Delta View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Antioch, California.
- Location
- 1210 A Street, Antioch, California 94509
- CMS Provider Number
- 056381
- Inspections on file
- 18
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Delta View Post Acute during CMS and state inspections, most recent first.
The facility failed to prevent physical abuse when two residents were left unsupervised in an activity room and one resident, with a history of cerebral infarct, struck another resident with a cognitive communication deficit on the back of the head twice. The assigned activity assistant left the room for about ten minutes with no other staff present, during which the incident occurred. An LVN later assessed the injured resident and noted a visible swollen bump and redness on the head. The DON reported that video confirmed the hitting, and the facility’s investigation identified one resident as the perpetrator and the other as the victim, contrary to the facility’s abuse prevention policy that requires residents be free from physical abuse.
A resident with dementia and documented impaired vision had an active physician order for an eye health and vision consult and a care plan intervention to arrange an eye care practitioner consultation, but no optometry appointment or exam was ever documented during the entire stay. The resident’s responsible party reported the resident had not had an eye exam and could not see with their glasses, and the ADON confirmed there was no record of any eye exam. The resident’s prescription glasses were found in a bedside drawer, and the DON acknowledged the resident should have had an optometry appointment. This occurred despite facility policy requiring social services and nursing to arrange ordered medical referrals.
The facility failed to implement an effective infection prevention and control program during an RSV outbreak, including proper isolation, monitoring, and reporting. A resident with COPD and pneumonia who tested RSV-positive in the hospital was readmitted and placed in a shared room without transmission-based precautions because the admitting nurse did not fully review the hospital discharge summary and the RSV result was not recognized until later. Another resident with cerebral infarction and Alzheimer’s disease who tested RSV-positive had no documented assessments, monitoring, progress notes, or care plan interventions related to RSV, and there was no evidence of physician or responsible party notification. The facility’s RSV line list omitted at least one RSV-positive resident, and there was no documented communication with public health authorities despite multiple confirmed RSV cases, contrary to facility policies requiring surveillance, contact precautions, outbreak management, and reporting.
A resident's legal representative did not receive requested medical and billing records until 22 working days after submitting a written request. The facility's process involved legal review and subsequent release by the DMR, but the records were not provided within the expected timeframe.
A resident's representative requested daily nurse staffing data for an 18-month period, but the facility only released medical, billing, and therapy records. The request for staffing data was forwarded to the Administrator and legal team, but was not processed or fulfilled, as the Administrator was unaware of the requirement to release such information. This resulted in the representative not receiving the requested nurse staffing data.
A resident's legal representative submitted a written request for the facility's required Policies and Procedures, but the request was not fulfilled. The Director of Medical Records forwarded the request to the Administrator and legal team, but no action was taken to provide the documents, and the Administrator was unaware of the requirement to release them outside of a court order. This was not in accordance with the facility's own policy for handling such requests.
Surveyors identified that three residents had inaccurate MDS assessments, including errors in coding PASRR Level II status, functional limitations, discharge dates, and medication administration. These inaccuracies were confirmed through record review, staff interviews, and direct observation, with staff acknowledging mistakes and lack of proper auditing.
A resident with non-Alzheimer's dementia who was able to communicate reported ongoing gum pain and eating discomfort. Although an LVN was aware of the issue and a dentist had provided an order for oral gel, there was no care plan developed to address the resident's gum pain. The DON confirmed the absence of a care plan for this concern.
Two residents did not receive appropriate care: one was given an improperly sized hand roll for a contracture, causing frustration and difficulty, while another experienced swelling, discoloration, and pain in both feet that went unaddressed for at least two days, with no documentation or timely assessment by nursing staff.
A resident with hypertension did not receive prescribed lisinopril due to the medication being unavailable, with nursing staff unable to locate it or ensure timely re-ordering. Additionally, an IV drug emergency kit was found opened without accurate documentation of medication removal or timely replacement, contrary to facility policy.
Surveyors found that two residents experienced medication errors, including administration of the wrong multivitamin, crushing of an extended-release blood pressure medication, and a missed dose of lisinopril due to unavailability. These events resulted in a medication error rate above five percent, in violation of facility policy and physician orders.
Surveyors found that food waste trash was not disposed of in a sanitary manner when the outside trash container behind the kitchen was overflowing and its lid was left open. The DM confirmed the trash was food waste, and a cook acknowledged that the lid should be closed at all times, as required by facility policy.
Staff documented the administration of a lidocaine patch in the E-MAR before it was actually given to a resident, and a social services assistant created and backdated multiple discharge planning notes for another resident, resulting in medical records that did not accurately reflect the care provided.
Three residents experienced lapses in infection control, including urinary drainage bags placed on the floor and a tube feeding pole with dried formula residue. Staff interviews confirmed awareness of proper procedures, and facility policies required keeping catheter bags off the floor and cleaning equipment daily.
A resident with cellulitis received a lidocaine 5% patch that was not removed according to the physician's order, resulting in the patch remaining on for longer than the prescribed 12-hour period. A nurse confirmed the patch should have been removed the previous evening, but it was still in place the following morning, leading to excessive lidocaine exposure.
A resident with mild cognitive impairment and muscle weakness was served a meal while reclined in a wheelchair, despite requesting to be seated upright. An activity aide provided the meal tray without repositioning the resident, resulting in the resident eating in an improper position until nursing staff later intervened.
The facility did not provide at least 80 sq. ft. per resident in several shared rooms, as confirmed by room measurements and record review. Although staff and residents reported being able to manage within the available space and no complaints or negative outcomes were noted, the rooms did not meet regulatory size requirements.
Failure to Supervise Residents Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when two residents were left unsupervised in the activity room and one resident struck the other. Resident 1, admitted in 2025 with a diagnosis of cognitive communication deficit, was in the activity room with Resident 2, who was admitted in 2024 with a diagnosis of other cerebral infarct. Activity Assistant 1, who was assigned to the activity room on the day of the incident, left the residents alone in the room for about ten minutes with no other staff present. During this period without staff supervision, Resident 2 tapped Resident 1 on the back of the head two times because Resident 1 would not stop backing up into them. Following the altercation, LVN 1 assessed Resident 1 and observed swelling and redness on Resident 1’s head, documented as a visible swelling bump in the nurse’s note, which stated the resident had been involved in a verbal altercation and sustained a minor injury after bumping their head. Resident 2 confirmed that there were no staff in the activity room for about ten minutes and stated that staff could have intervened if they had been present. The DON reported that video of the incident showed Resident 2 hitting Resident 1 in the activity room and acknowledged that staff should have been present in the activity room during the altercation. The facility’s investigation summary concluded there was thorough evidence of Resident 2, identified as the perpetrator, hitting Resident 1, identified as the victim, in violation of the facility’s abuse prevention policy, which states residents have the right to be free from physical abuse.
Failure to Arrange Timely Optometry Services for Resident With Impaired Vision
Penalty
Summary
The facility failed to assist a resident with impaired vision in obtaining timely optometry care despite documented need and physician orders. The resident, admitted in 2020 with dementia and documented impaired vision on the MDS dated 3/15/20, had corrective lenses and an order dated 3/5/20 for an eye health and vision consult with follow-up treatment as indicated. The resident’s care plan dated 11/11/22 identified impaired visual function and included an intervention to arrange consultation with an eye care practitioner as required, with a goal for the resident to maintain optimal quality of life within the limitations of visual function. During interviews, the resident’s responsible party reported that the resident had not had an eye exam and could not see with their glasses. The ADON confirmed there was no documentation or proof that the resident had an eye exam during their entire stay. Observation showed the resident’s prescription glasses stored in the bedside drawer rather than in use. The DON stated the resident should have had an optometry appointment during their stay and that this was important for safety. The facility’s policy on social services referrals required that referrals for medical services be based on physician evaluation or resident need and that social services collaborate with nursing or other disciplines to arrange ordered services, but this process was not carried out for the resident’s ordered eye care consult.
Failure to Implement Effective RSV Infection Control, Monitoring, and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program, including surveillance, during an RSV outbreak affecting multiple residents. Resident 1, admitted with diagnoses including pneumonia and COPD, tested positive for RSV in the hospital on 1/19/26 and was readmitted to the facility on 1/22/26. Upon readmission, Resident 1 was not placed on isolation precautions and was cohorted in a shared bedroom with two other residents during the RSV isolation period. The Infection Preventionist (IP) and DON stated the facility was unaware of the RSV diagnosis at the time of readmission because the hospital discharge documents were not uploaded into the EHR until 2/2/26, and the admitting nurse did not identify the RSV result, relying mainly on the nurse-to-nurse report and physician orders rather than reviewing the full discharge summary. The facility also failed to assess and monitor RSV-positive residents during the isolation period. Resident 2, admitted with cerebral infarction and Alzheimer’s disease, tested positive for RSV on 1/29/26. Review of Resident 2’s EHR showed no documentation of change in condition assessments, monitoring, progress notes, or care plan interventions related to RSV management. The IP confirmed there was no documentation that the physician or responsible party were notified after Resident 2’s positive RSV test, and that Resident 2 was not assessed or monitored to evaluate progression of symptoms or response to infection. For Resident 1, the IP stated the resident was not monitored for RSV after readmission, and LVN 1 confirmed Resident 1 was not placed in isolation upon the last two readmissions. The facility’s infection surveillance and reporting processes were also deficient. A facility-provided RSV record showed five residents tested positive for RSV within a 30-day period, but Resident 1, who was RSV-positive on 1/19/26, was not included on the RSV line list. The IP stated that more than two confirmed RSV cases should have been reported to public health authorities and acknowledged there was no formal or verifiable documented communication with local or state health departments regarding the RSV outbreak, recommendations, or guidance. The DON confirmed miscommunication among staff regarding RSV cases and acknowledged that nursing staff did not document Resident 2’s RSV status in the medical record. These practices were inconsistent with the facility’s written policies on RSV prevention, outbreak of communicable diseases, and infection prevention and control, which required monitoring for signs and symptoms, initiation of transmission-based precautions, surveillance and reporting of infectious diseases, and communication with public health authorities.
Delayed Release of Medical Records to Legal Representative
Penalty
Summary
The facility failed to provide a copy of requested medical records to the legal representative of a resident within the required timeframe. The legal representative submitted a written request for the resident's medical records, billing records, photography, charts, writings, admission agreements, utilization review committee records, and x-rays. The facility's records indicated that the request was received, but the records were not released until 22 working days after the request was made. The resident in question had been admitted to the facility and was later discharged to an acute care hospital. During interviews, the Director of Medical Records (DMR) stated that she believed the facility had 30 days to release medical records based on her training, though she could not recall the specifics of the training. The facility Administrator explained that medical record requests were first sent to the legal department for review, which typically took up to 24 hours, and that records should be released within 48 hours after the request. The facility's policy indicated that records may be released upon legal approval in accordance with the minimum necessary standard.
Failure to Provide Requested Nurse Staffing Data to Resident's Representative
Penalty
Summary
The facility failed to process a record request for nurse staffing data when a resident's representative requested this information. The request, dated 5/28/25, specifically asked for daily posted nurse staff data for each day of the 18 months prior to the request. Although the facility's log showed that the request was received, only the resident's medical records, billing, and therapy notes were released on 6/26/25. The Director of Medical Records stated that the request for nurse staffing data was forwarded to the facility's Administrator and legal team, but she did not process the request herself, as she was not responsible for releasing nurse staffing data. During an interview, the Administrator stated he was unaware of any requirement to release nurse staffing data to the public unless requested by a court, and confirmed that no staffing or policy information had been released to the requester. The facility's policy indicated that all requests for medical records, whether verbal or written, should be immediately forwarded to the Medical Records department or designated staff, but did not specify procedures for nurse staffing data requests. As a result, the requested nurse staffing data was not provided to the resident's representative.
Failure to Provide Policies and Procedures to Resident's Legal Representative
Penalty
Summary
The facility failed to comply with state regulations by not providing copies of its Policies and Procedures (P&P), as required by Title 22 California Code of Regulations section 72523, to the legal representative of a resident upon written request. The resident had been admitted and later discharged to an acute care hospital. A review of the admission record and the release of record log confirmed that the legal representative submitted a written request for all required administrative, management, personnel, and patient care policies. The Director of Medical Records (DMR) acknowledged receipt of the request and stated it was forwarded to the facility's Administrator (ADM) and legal team, but did not process the request for policy information. During interviews, the ADM stated unawareness of any requirement to release the facility's P&P to the public unless the request came from a court. The facility's own Medical Record Request Policy indicated that all requests for medical records, whether verbal or written, must be immediately forwarded to the Medical Records department or designated staff, including requests from residents or their personal representatives. Despite this policy, the facility did not release the requested P&P to the resident's legal representative.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three sampled residents, resulting in discrepancies between documented assessments and residents' actual clinical conditions. For one resident with diagnoses including bipolar disorder, schizophrenia, and a right foot contracture, the MDS was not coded accurately in Section A to reflect a positive Preadmission Screening and Resident Review (PASRR) Level II evaluation for mental illness. Additionally, Section GG of the same resident's MDS incorrectly indicated impairment in both lower extremities, despite observation and staff interview confirming limitation only in the right foot. Another resident, admitted with myeloid leukemia and discharged against medical advice after one day, had an inaccurately coded discharge assessment. The MDS discharge date did not match the actual date the resident left the facility, as confirmed by the MDS coordinator, who acknowledged the error in the assessment reference date. A third resident, with a history of stroke, atrial fibrillation, and major depressive disorder, had inaccuracies in MDS Section N regarding medication administration. The MDS assessment failed to accurately reflect the administration of anticoagulant, anticonvulsant, and antidepressant medications, and incorrectly indicated the use of antibiotics during the observation period. Staff interviews revealed that the MDS coordinator responsible for the assessment was new to the role and that no audit of the assessment was conducted by supervisory staff.
Failure to Develop Care Plan for Resident's Gum Pain
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan addressing a resident's gum pain and discomfort, as required by its Care Planning - Interdisciplinary Team policy. The resident, who had a diagnosis of non-Alzheimer's dementia and was able to communicate her needs, reported ongoing gum pain and discomfort with eating, and stated she had not seen a dentist. Although a licensed vocational nurse confirmed awareness of the resident's painful gum and noted that the resident had been seen by a dentist with an order for oral gel as needed, there was no care plan in place to address the gum pain. The director of nursing also confirmed that no care plan existed for this issue after reviewing the resident's records.
Failure to Provide Proper Supportive Devices and Timely Assessment of Circulatory Issues
Penalty
Summary
Two deficiencies were identified involving the care of two residents. One resident with a history of stroke and right-sided hemiplegia had a right hand contracture and was provided with a hand roll that was too large and had a loose elastic band. The resident reported that the hand roll frequently fell out of place and was difficult to keep positioned correctly, leading to frustration and emotional distress. Staff interviews confirmed that the hand roll was not the correct size, and the rehabilitation department was aware of the issue but had not yet provided an appropriately sized device. Another resident with diagnoses including peripheral vascular disease, peripheral arterial disease, renal insufficiency, and end-stage renal disease experienced swelling, black/bluish discoloration, and pain in both feet. The resident reported these symptoms, and observations confirmed the presence of discoloration and pain. Nursing staff assigned to the resident had not assessed the feet until at least two days after the symptoms began, and there was no documentation of the skin issues in the resident's electronic health record during the relevant period. These deficiencies were based on direct observations, resident interviews, and record reviews, which showed that the facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals. The lack of timely and suitable interventions for both residents resulted in unaddressed discomfort and risk of further complications.
Failure to Provide Ordered Medication and Maintain Emergency IV Kit Documentation
Penalty
Summary
The facility failed to provide routine medication as ordered and did not ensure pharmaceutical services were delivered in accordance with prescriber orders and facility policy. Specifically, a resident admitted with essential hypertension had a physician's order for daily lisinopril, but the medication was not available for administration on multiple occasions. Nursing staff were unable to locate the medication in the medication cart and confirmed that the resident had not received the prescribed doses. Documentation in the Medication Administration Record showed missed doses, and staff reported contacting the pharmacy to re-order the medication, but the medication remained unavailable for at least two consecutive days. Additionally, the facility did not maintain accurate records or timely replacement of intravenous (IV) drug emergency kits. One of two IV drug emergency kits was found opened, but the associated utilization log did not accurately reflect what medication was removed or the date of removal. Staff were uncertain about the accuracy of the log, and the required documentation on the IV Drug Emergency Kit Use Form was incomplete. The facility's policy required that any medication removed from the emergency kit be documented and replaced promptly, but this was not done, potentially affecting the availability of emergency IV medications for all residents.
Medication Error Rate Exceeds Five Percent Due to Administration and Availability Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 10.71% during the observed medication administration. For one resident with chronic obstructive pulmonary disease (COPD), a nurse administered a multivitamin with minerals instead of the prescribed multivitamin, contrary to the physician's order and the facility's medication administration policy. This error was directly observed during a medication pass and confirmed through review of the resident's orders and medication administration record. For another resident admitted with essential hypertension, a registered nurse crushed and administered an extended-release (ER) blood pressure medication (toprol xl ER), despite manufacturer instructions and the medication label stating it should not be crushed. The nurse acknowledged during interview that crushing the ER medication was inappropriate and could have adverse effects. Review of the medication label and manufacturer's specifications confirmed the medication should not be crushed or chewed. Additionally, the same resident did not receive a scheduled dose of lisinopril, another blood pressure medication, because the medication was not available in the facility. Multiple staff confirmed the medication was missing and had not been delivered by the pharmacy, resulting in the resident missing at least one scheduled dose. Facility policy requires medications to be administered as prescribed and within a specified timeframe, which was not followed in this instance.
Improper Disposal of Food Waste Trash
Penalty
Summary
Surveyors observed that the facility failed to dispose of food waste trash and garbage in a sanitary manner. During an observation at the dumpster area behind the kitchen, the trash container was found overflowing with bags of trash, and the lid was not closed. The Dietary Manager confirmed that the trash consisted of food waste. In a subsequent interview, a cook stated that food waste is disposed of into the trash can after each shift and acknowledged that the trash container lid is expected to be closed at all times. Review of the facility's sanitation and infection control policy indicated that outside trash compactors require a protective cover to prevent pests, animals, or debris from entering, and that lids should remain closed.
Inaccurate Medical Record Documentation and Backdating of Progress Notes
Penalty
Summary
The facility failed to maintain accurate and timely medical records for two residents. For one resident with a diagnosis of cellulitis of the left lower limb, a registered nurse documented the administration of a lidocaine patch in the Electronic Medication Administration Record (E-MAR) before actually administering the medication. The nurse stated that she documented the administration early to prevent the E-MAR from indicating a late administration, even though the medication was given at a later time as requested by the resident. Facility policy required that medication administration be documented immediately after it is given. In a separate incident, a social services assistant created and backdated multiple discharge planning progress notes for another resident, entering them on a single day but assigning dates spanning several months prior. The assistant admitted to routinely backdating notes and stated that this practice had not previously been questioned. Facility policy specified that late entries should be dated at the time of entry and clearly noted as late entries. These actions resulted in medical records that did not accurately reflect the timing and content of care provided.
Failure to Maintain Infection Control for Catheter and Feeding Equipment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections for three residents. In one instance, a resident with an indwelling suprapubic catheter was observed with their urinary drainage bag lying on the floor. The resident reported placing the bag on the floor for ease of mobility, as staff response to call lights was delayed, and staff confirmed the resident preferred the bag on the floor. The care plan for this resident indicated the need to keep the catheter below the bladder, and facility policy required catheter tubing and drainage bags to be kept off the floor. Another resident, newly admitted with multiple serious diagnoses including acute kidney failure and urinary retention, was observed with their urinary catheter drainage bag touching the floor and lacking a privacy cover. The resident was in a multi-bed room, and staff interviews confirmed the bag should not be on the floor due to infection control concerns. Facility policy also specified that catheter tubing and drainage bags must be kept off the floor to prevent complications such as urinary tract infections. A third resident, who was nonverbal and severely cognitively impaired, was observed with a tube feeding pole that had dried brown matter, identified as feeding formula, stuck to it. The primary nurse acknowledged the residue and stated the pole should be cleaned as needed. The infection preventionist confirmed that a dirty pole could increase infection risk, especially for a resident with a surgical opening, and stated that feeding poles should be cleaned daily and as needed. Facility policy required daily and as-needed cleaning and disinfection of durable medical equipment.
Failure to Remove Lidocaine Patch as Ordered
Penalty
Summary
A resident with a diagnosis of cellulitis of the left lower limb was admitted to the facility and had a physician's order for a lidocaine 5% patch to be applied daily at 9:00 a.m. and removed at 9:00 p.m. During a medication administration observation, a registered nurse removed a lidocaine patch from the resident's back that had been applied the previous morning, as indicated by the nurse's initials and the date written on the patch. The nurse confirmed that the patch should have been removed the previous evening according to the physician's order and the facility's medication administration policy, which requires medications to be administered in accordance with orders and specified time frames. Review of the resident's medication administration record confirmed the patch was applied in the morning but not removed at the scheduled time. Manufacturer's guidelines for the lidocaine patch specify that it should be worn for no more than 12 hours within a 24-hour period, as excessive dosing can result in increased absorption and high blood concentrations. The failure to remove the patch as ordered resulted in the resident receiving an excessive dose of lidocaine in a 24-hour period.
Failure to Properly Position Resident Before Meal Service
Penalty
Summary
A deficiency occurred when a resident with mild cognitive impairment, muscle wasting, and a need for assistance with personal care and positioning was not properly positioned in the dining room prior to eating lunch. The resident was observed lying in a high-rise wheelchair with the head of the wheelchair at about a 45-degree angle. Despite the resident's request to be seated upright before receiving the meal tray, the activity aide served the lunch tray without adjusting the resident's position. As a result, the resident ate lunch while reclined, causing food to drop onto his chest area. The activity aide stated she did not reposition the resident because she was not a nurse and did not want to return the lunch tray, so she left the tray in front of the resident. The nurses later repositioned the resident, allowing him to finish his lunch. The Director of Nursing confirmed that the facility's expectation was for both activity and nursing staff to assist with resident positioning before serving meal trays.
Failure to Meet Minimum Square Footage Requirements in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms, as mandated by regulations. During observations, interviews, and a review of the Client Accommodations Analysis, it was found that numerous rooms with two or three beds each did not meet the 80 square feet per resident requirement. Specific measurements taken by maintenance staff confirmed that several rooms had as little as 70.26 to 79.76 square feet per resident. Despite this, observations showed that there was sufficient space for care provision, no heavy equipment obstructed movement, and residents had adequate personal space and privacy. Interviews with residents and staff indicated that, while some staff found the rooms somewhat small, they were able to manage care tasks without significant difficulty. Residents did not report any complaints regarding insufficient space for their belongings or movement. No negative outcomes or safety concerns were attributed to the decreased space in the identified rooms during the survey period.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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