Glendora Grand, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendora, California.
- Location
- 805 W. Arrow Hwy., Glendora, California 91740
- CMS Provider Number
- 056079
- Inspections on file
- 48
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Glendora Grand, Inc during CMS and state inspections, most recent first.
A resident with a history of stroke, mobility impairment, and cognitive deficits did not receive physician-ordered ambulation five times per week as part of a restorative nursing program. Despite orders and facility policy, documentation and staff interviews confirmed that the ambulation was not provided, resulting in decreased mobility for the resident.
A CNA and an LVN documented inaccurate information in a resident's medical record regarding the level of assistance needed for bed mobility and transfers. Both staff members later acknowledged the documentation was incorrect, as the resident required only limited assistance rather than being fully dependent. The resident had a history of stroke, difficulty walking, and traumatic brain disorder, and was assessed as moderately cognitively impaired.
A resident with a history of stroke and traumatic brain disorder was discharged without adequate arrangements for enteral feeding formula and without assessment or training of the caregiver in safe transfer techniques. Facility staff did not verify the caregiver's ability to provide necessary care, and essential supplies were not provided at discharge.
Four residents with cognitive and/or physical impairments were found without accessible call lights, despite facility policy and care plans requiring call lights to be within reach. Observations showed call lights placed out of reach—such as behind headboards or on the non-functional side—while staff interviews confirmed the importance of accessibility and acknowledged the lapses.
Ten residents reported not knowing where to find the facility's latest survey results or how deficiencies had been corrected. Interviews with the DON and Administrator revealed that the responsibility for posting survey results was with the Administrator, who was unaware of the residents' lack of knowledge. Facility policy states residents have the right to access survey results and plans of correction, but this information was not effectively communicated.
Two residents with indwelling Foley catheters and severe cognitive impairment were not properly assessed or monitored for sediments, hematuria, or cloudy urine as ordered by physicians and outlined in care plans. Nursing staff failed to document required shift assessments, and in one case, visible white sediments were present in the catheter tubing without evidence of timely intervention. Facility policy required such monitoring and reporting, but these procedures were not followed.
Licensed staff did not follow physician orders for a resident's gastrostomy tube feeding rate, administering a higher rate than prescribed, and failed to implement or communicate an RD's recommendation for multivitamins and minerals for another resident. Both deficiencies involved residents with significant care needs and were not in accordance with facility policy or physician directives.
Three residents receiving oxygen therapy did not receive care in accordance with professional standards: one resident lacked a required oxygen concentrator in the room for PRN use, another had nasal cannula tubing improperly stored when not in use, and a third was administered oxygen without a physician's order or required cautionary signage. These deficiencies were confirmed by staff and were not in line with facility policy.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Surveyors observed that six large trash bins in multiple facility buildings were left uncovered and overfilled, contrary to facility policy. Staff interviews, including with the KM, MS, DON, and IPN, confirmed that trash bin lids should remain closed at all times for infection control and sanitation, but space limitations and overfilling led to open lids.
A nurse failed to perform required hand hygiene during medication administration for a resident with neurological conditions, and another resident with a G-tube had a feeding valve that was left uncapped and visibly dirty, contrary to facility policy. Staff interviews and policy reviews confirmed that proper infection control procedures were not followed, placing both residents at risk for infection.
The facility did not promote or facilitate resident self-determination by failing to support resident choice, as required by regulation.
A deficiency was cited for not ensuring a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and to formulate an advance directive. The report does not provide further details about the specific circumstances or individuals involved.
A resident with impaired cognition and incontinence was exposed when an RN failed to close the privacy curtain while checking a foley catheter, leaving the resident's upper legs visible to others. Both the RN and DON confirmed that privacy should have been maintained according to facility policy.
A registered nurse was hired before the required OIG background check was completed, as facility staff followed a practice of conducting background checks after hiring, contrary to facility policy. Interviews with the DSD, DON, and ADM confirmed that background checks should be completed prior to employment to screen for abuse or criminal history.
Two residents with dementia and schizophrenia experienced significant behavioral changes resulting in psychiatric hospitalization and readmission, but the facility did not complete required MDS comprehensive assessments within 14 days as mandated. Documentation and staff interviews confirmed these were significant changes in condition, yet the assessments were not updated or reported to CMS in a timely manner.
A resident with severe cognitive impairment and multiple medical conditions was observed with unkempt hair and dirty feet, despite a care plan requiring assistance with ADLs and scheduled showers. Staff confirmed the resident's disheveled state, and facility policy required regular hygiene support, but the necessary care was not provided.
A resident with cognitive impairment and behavioral risks was found with unsupervised cigarettes in their room, despite facility policy requiring nursing staff to control smoking materials for residents needing supervision. Staff interviews revealed inconsistent enforcement of the smoking policy, resulting in a potential fire hazard.
A resident with severe cognitive impairment and behavioral risks was not provided with the required 1:1 supervision as outlined in their care plan. The assigned staff left the resident unsupervised in their room, resulting in a fall from a wheelchair and injuries that required emergency medical attention. Facility records and staff interviews confirmed the supervision requirement was known but not followed at the time of the incident.
Two residents with diabetes had care plans that included blood glucose monitoring and specific glycemic targets, but there were no corresponding physician orders for routine bedside blood sugar checks. Nursing staff and the DON confirmed the care plans' requirements, yet the lack of physician orders meant the interventions could not be properly implemented.
A resident with a history of suicidal ideation was readmitted from a hospital without proper assessment, documentation, or care planning for their mental health needs. The Social Services Director did not record the resident's recent suicidal thoughts or notify nursing staff, and no care plan or monitoring was initiated, despite facility policy requiring these actions for residents with such risk factors.
A resident with cognitive impairment developed an infected wound on the wrist due to embedded bracelets after nursing staff failed to perform a full body skin assessment, despite noticing a foul odor. The wound was only discovered when EMS arrived and removed the bracelets, revealing the infection. Facility policy requiring skin assessments after changes in condition was not followed by the LVN and RN.
A resident with intellectual disabilities and limited mobility did not receive daily body checks as required by their care plan and facility policy. Staff failed to identify the source of a foul odor, and a full body assessment was not performed, resulting in an infected wound on the resident's wrist caused by an embedded rubber band.
A resident with intellectual disabilities and mobility limitations developed an infected wound on the left wrist that went unnoticed and untreated after an LVN and RN failed to perform a full body assessment or escalate concerns when a persistent foul odor was detected. Facility policy required such assessments and reporting, but these were not followed, resulting in the wound only being discovered after hospital transfer.
A resident with Parkinson's and dementia repeatedly refused podiatric care, leading to osteomyelitis and hospitalization. The facility failed to notify the resident's physician or family and did not implement alternative interventions as per the care plan. Staff were unaware of the ongoing refusals, and a change in condition was not documented promptly, contributing to the resident's preventable condition.
A resident with Parkinson's and dementia repeatedly refused podiatric treatment, leading to hospitalization for osteomyelitis. The facility failed to notify the physician and family as required by policy, despite the resident's inability to make medical decisions and documented refusals throughout the year.
A resident with Parkinson's and dementia repeatedly refused podiatric treatment, but the facility failed to notify the physician or implement alternative interventions as required by the care plan. Despite documented refusals over a year, the Social Service Director and DON were unaware, and no actions were taken to address the refusals, violating the facility's policy for comprehensive care plans.
A resident with Parkinson's disease and dementia repeatedly refused podiatry care, and the facility failed to communicate this to the resident's physician and family. The care plan addressing refusal of care was not implemented, and licensed nurses did not inform the physician about the resident's toenail condition during weekly assessments. This led to the resident being hospitalized for right toe osteomyelitis.
A resident with schizophrenia and anxiety disorder, assessed as at risk for elopement, was transferred from a secured to an unsecured unit. The resident went missing after being last seen in the hallway and was not found despite extensive searches. The unsecured unit had multiple exit doors, some of which were not alarmed or locked, allowing the resident to potentially exit undetected.
A resident with a history of wandering and confusion left a secured unit unsupervised due to a janitor unlocking the door, allowing the resident to leave with a rideshare driver without a staff chaperone. The resident, who was scheduled for an ophthalmologist appointment, did not check in and was reported missing. The facility failed to follow its policy requiring staff accompaniment for residents at risk of elopement.
The facility failed to provide adequate pressure ulcer care for three residents, leading to the development and worsening of ulcers. A resident at risk for ulcers did not receive prescribed treatments, resulting in new and worsening ulcers. Another resident's low air loss mattress was incorrectly set, risking skin breakdown. A third resident did not receive consistent treatment for a stage 4 ulcer, potentially delaying healing.
The facility failed to ensure call lights were within reach for two residents, both at high risk for falls due to conditions like dementia and muscle weakness. Observations revealed that the call lights were inaccessible, contrary to the care plans and facility policy. Staff interviews confirmed the oversight, indicating a lapse in maintaining safety and accessibility for residents needing assistance.
The facility failed to implement its smoking policy for a resident identified as an unsafe smoker, who was found with cigarettes despite requiring supervision. Additionally, the facility did not ensure proper positioning for another resident with dysphagia during meals, as observed when the resident's neck was hyperextended contrary to physician orders. These deficiencies highlight lapses in policy adherence and communication among staff.
The facility failed to prevent UTIs in two residents with Foley catheters. One resident's urine output was not monitored for UTI signs, and the physician was not notified of changes. Another resident's catheter bag was improperly positioned on the floor, risking contamination. Staff acknowledged these oversights, which contradicted the facility's catheter care policy.
The facility failed to follow its respiratory care procedures for two residents. A resident with respiratory failure had a suction canister with sputum that was not replaced, risking inaccurate monitoring. Another resident with COPD had an undated humidifier bottle, risking reduced oxygen therapy effectiveness. Both instances reflect non-compliance with facility policies.
The facility failed to implement gradual dose reductions and monitor psychotropic medication use for three residents. A resident on Risperdal and Lexapro did not have a GDR attempted since the medications were ordered, and another resident on Lexapro did not have a GDR attempted despite limited social interaction not being an adequate indication for continued use. Additionally, a resident's target behavior and side effects for Ativan use were not monitored every shift as required.
The facility failed to ensure kitchen staff were trained and evaluated for competency in following guidelines for chlorine paper testing and sanitizer use. Staff did not adhere to correct procedures, leading to potential unsanitized dishware and ineffective surface sanitization. There was no competency evaluation for key staff, and not all attended training sessions.
The facility's kitchens were found to have multiple sanitation and food safety deficiencies, including dust and dirt buildup in freezers and refrigerators, rusted storage racks, improper storage of dented cans, and inadequate cleaning of equipment. Staff practices, such as wearing inappropriate jewelry and not following sanitizer guidelines, further contributed to the potential health risks for residents.
The facility failed to properly dispose of garbage and refuse, with overflowing and uncovered trash bins observed outside Kitchens 1 and 3. The Dietary Area Manager noted the health risks posed by exposed trash, while the Environmental Services Manager confirmed that trash pickup was insufficient to prevent overflow. Facility policies and the Food Code 2017 require covered receptacles to prevent contamination.
The facility failed to provide Speech Therapy (ST) evaluations as ordered for three residents with swallowing, communication, and cognitive concerns. Despite physician's orders, these residents only received Therapy Screens, which are not comprehensive evaluations. The Director of Rehabilitation and the Speech Therapist confirmed the oversight, highlighting the importance of following physician's orders to ensure residents receive necessary care.
The facility did not ensure its arbitration agreements included a venue selection convenient for both the facility and residents, affecting three residents with cognitive impairments. The facility's policy lacked this regulatory requirement, acknowledged by the administrator.
A facility failed to document and implement hospice services for a resident with severe cognitive impairment. The Hospice Health Aide did not document care provided, and the Licensed Vocational Nurse visits were not accurately recorded or completed according to the physician's orders. The facility's policy required proper communication and documentation of hospice interventions, which was not adhered to.
The facility failed to maintain three laundry dryers in a safe and sanitary condition, with thick patches of brown/black material observed on the dryers' drums. This posed a risk of cross-contamination and potential fire hazard due to obstructed ventilation. The Environmental Service Manager acknowledged the issue, which was contrary to the facility's maintenance policies requiring daily inspection and cleaning.
The facility failed to properly dispose of soiled gauze, adhere to PPE protocols for Contact Isolation Precautions, and follow COVID-19 guidance in yellow zones. A soiled gauze was left in a resident's room, an RNA did not change PPE after exiting a resident's room, and staff did not wear full PPE, including face shields, in yellow zones. These actions were confirmed through observations and interviews with staff.
A resident's room in an LTC facility was found to have peeling paint and a black stain on the floor, which were not reported to maintenance until a surveyor's visit. The resident had moderately impaired cognition and lacked decision-making capacity. The facility's policy required staff to report such issues, but the Director of Maintenance was unaware of the problem until informed by the DON during the survey.
A resident with anxiety and dementia, prescribed Ativan, did not have an individualized care plan developed by the LTC facility. Despite the resident's impaired cognition and need for assistance with daily activities, the facility failed to create a care plan addressing the use of Ativan, as confirmed by the RN Supervisor and DON. This was contrary to the facility's policy requiring a person-centered care plan within seven days of the MDS assessment.
A resident with a history of diabetes and renal disease had a care plan for hip scratches that was not updated when the condition worsened. Despite facility policy requiring care plan revisions after assessments, the plan was not revised when the scratches became macerated and white, potentially delaying treatment. The DON acknowledged the oversight.
A resident was nearly given contaminated medications after an LVN dropped pills on the floor and returned them to the medication cup. The incident was stopped by a surveyor. The resident had heart failure and a malignant kidney tumor, requiring partial assistance. The facility's policy mandates discarding dropped medications to prevent contamination.
A resident with chronic conditions and impaired cognition was found to have unclean, yellow, and long toenails, indicating a failure in timely foot care. Despite being seen by a podiatrist in May, the resident's toenails were not trimmed as needed, and the Social Services Designee was not informed until late July. The facility's policy required nail care to be provided as needed, but this was not adhered to, leading to a deficiency in care.
Failure to Implement Physician-Ordered Ambulation for Resident
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve a resident's range of motion and mobility by not implementing a physician's order for ambulation. The resident, who had a history of cerebral infarction, difficulty walking, and traumatic brain disorder, was admitted and later readmitted to the facility. Assessment records indicated the resident required supervision or assistance for daily activities and had moderate cognitive impairment. A physician's order was in place for a Restorative Nursing Assistant (RNA) to ambulate the resident five times a week using a front wheel walker, as part of a restorative nursing program following discharge from rehabilitation services. Despite the physician's order, record reviews and staff interviews confirmed that the resident did not receive the prescribed ambulation in the hallway five times a week. Documentation for August, September, and October did not show evidence that the ambulation was provided as ordered. The RNA confirmed that the ambulation was not performed as required. The facility's policy stated that restorative services should be provided to maintain or improve residents' abilities, but this was not followed for the resident in question, resulting in a decrease in the resident's ability to walk.
Inaccurate Documentation of Resident Assistance Needs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one of two sampled residents when both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) documented inaccurate information regarding the resident's level of assistance needed for bed mobility and transfers. Specifically, the CNA documented that the resident was dependent on staff for transfers, mobility, getting up in a chair, and ambulation on several dates, but later admitted that this was inaccurate and that the resident actually required only limited assistance for these activities. Similarly, the LVN documented in the resident's discharge summary that the resident was dependent on staff for bed mobility and transfers, but also acknowledged this was inaccurate. The resident involved had a history of cerebral infarction, difficulty walking, and a traumatic brain disorder, and was assessed as moderately impaired in cognitive skills. The Minimum Data Set indicated the resident required supervision or touch assistance for activities such as dressing, bathing, toileting, and personal hygiene. The facility's policy required that all medical records be complete and accurate to reflect the care and services provided, but this was not followed, resulting in incomplete and inaccurate documentation in the resident's medical record.
Failure to Ensure Safe Discharge Preparation and Caregiver Training
Penalty
Summary
The facility failed to ensure adequate preparation and orientation for a safe and orderly discharge of a resident who required enteral feeding and assistance with transfers. Specifically, the facility did not arrange for the resident's enteral feeding formula to be readily available upon discharge, providing only a one- to two-day supply and leaving the caregiver to obtain additional formula independently. Additionally, the facility did not assess or verify the caregiver's ability to safely transfer and care for the resident, nor did it provide training or instruction on safe transfer techniques. The resident's caregiver reported not being aware of the resident's inability to get out of bed without assistance and did not receive training or incontinence supplies upon discharge. Interviews with facility staff confirmed that there was no assessment of the caregiver's competence in transferring the resident, and discharge instructions did not include necessary training or arrangements for ongoing care needs. The facility's policy required orientation and documentation to ensure safe discharge, but this was not followed in this case. The resident had a history of cerebral infarction, traumatic brain disorder, and required assistance with activities of daily living, making these omissions significant in the context of the resident's care needs.
Failure to Ensure Call Lights Were Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four sampled residents, as required by its own policy and care plans. Observations and interviews revealed that residents with significant cognitive and physical impairments did not have access to their call lights, which are essential for requesting assistance. For example, one resident with severely impaired cognition and high fall risk was found unable to reach the call light, which was stuck behind the headboard. Nursing staff confirmed the call light was not accessible and acknowledged the importance of keeping it within reach. Another resident with hemiplegia and severely impaired cognition was observed unable to reach the touch call light, which was placed above the resident's non-functional side. Staff interviews confirmed that the call light should have been placed near the resident's dominant, functional hand. Similarly, a resident with a left hand contracture and severe cognitive impairment had the call light placed on the side of the contracted hand, making it inaccessible. Staff confirmed the resident could only use the right hand and that the call light should have been placed accordingly. A fourth resident, with moderate cognitive impairment and mobility issues, was found sitting in a wheelchair with the call light wedged behind the bed and out of reach. The resident stated they could not access the call light when not in bed and would have to yell for help. Staff interviews consistently indicated that call lights should always be within reach, and the facility's policy required staff to ensure accessibility with each interaction. The failure to follow these procedures was observed across all four cases.
Failure to Inform Residents of Survey Results and Corrections
Penalty
Summary
Ten residents who attended a resident council meeting reported being unaware of the availability and location of the facility's latest survey results, as well as how the facility addressed previously identified deficiencies. During interviews, both the DON and the Administrator acknowledged that posting the survey results was the Administrator's responsibility. The Administrator was unaware that residents did not know where to find the survey results or how to access them, despite stating that the results were discussed during resident council meetings. A review of the facility's policy and procedure on Resident Rights confirmed that residents have the right to examine the most recent survey results and any plan of correction in effect. However, all ten residents interviewed indicated they had not been informed about the location or availability of these documents, nor about the facility's corrective actions following the last survey. This lack of communication resulted in residents not being fully informed of the facility's survey findings or the steps taken to address deficiencies.
Failure to Monitor and Document Catheter Assessments for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that residents with indwelling urinary catheters were properly assessed and monitored for the presence of sediments, hematuria, and cloudy urine as required by physician orders and the residents' care plans. For two residents with significant cognitive impairment and dependence on staff for activities of daily living, there was no documentation that licensed staff assessed or monitored the catheter tubing and drainage bags for signs of infection or complications every shift, as ordered. One resident with a history of obstructive uropathy, benign prostatic hyperplasia, and prior urinary tract infection had a physician order to monitor the Foley catheter tubing and bag for sediments, hematuria, and cloudy urine every shift. However, review of the medical record and interviews with nursing staff confirmed that there was no documentation of these assessments being performed. The care plan for this resident also required staff to observe for signs and symptoms of UTI, but this was not carried out as documented. Another resident with chronic kidney disease and BPH had a Foley catheter in place and was similarly dependent on staff. During observation, white sediments were noted in the catheter tubing, which staff acknowledged could indicate infection. Despite this, there was no evidence that regular monitoring and assessment were documented as required. Facility policy and procedure required observation for complications and reporting of findings, but these were not followed for the residents in question.
Failure to Administer Tube Feeding as Ordered and Implement Dietitian Recommendations
Penalty
Summary
Licensed nursing staff failed to administer gastrostomy tube (GT) feeding to a resident as ordered by the physician and as outlined in the facility's policy and procedure for enteral nutrition. The resident, who had diagnoses including Parkinson’s disease and dysphagia, was dependent on staff for all activities of daily living and required continuous GT feeding at a specific rate. Observations revealed that the feeding was administered at 65 ml/hr instead of the ordered 60 ml/hr. Both the LVN and DON confirmed that the physician’s order was not followed, and the RD noted that the resident had experienced significant weight gain over the past six months, with the feeding rate being a contributing factor. In a separate incident, the facility did not implement or communicate the registered dietitian’s (RD) recommendation for another resident to start multivitamins and minerals. The resident, who had severe cognitive impairment and was dependent on staff for daily care, had a nutrition screening indicating the need for multivitamins. However, this recommendation was not included in the dietary recommendations form, nor was it communicated to the resident’s physician. Interviews with nursing staff and the DON confirmed that the RD’s recommendation was not followed up, and there was no documentation that the physician had been notified. The facility’s policies and procedures required that enteral nutrition be provided as ordered by the physician and that all dietary recommendations from the RD be reviewed by the physician and documented by nursing staff. In both cases, the required processes were not followed, resulting in deficiencies related to the administration of nutrition and communication of dietary recommendations.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary care and services for three residents receiving oxygen therapy by not adhering to professional standards of practice. For one resident with a PRN oxygen order due to COPD and other chronic conditions, there was no oxygen concentrator machine set up in the room, despite the order requiring oxygen to be available as needed. Both the CNA and RN Supervisor confirmed the absence of the equipment, and the DON stated that all residents with continuous or PRN oxygen orders should have a concentrator set up and a cautionary sign posted outside the room, as per facility policy. Another resident, with a history of pneumonia and asthma, had a physician's order for PRN oxygen therapy. During observation, the resident's nasal cannula tubing was found hanging on the oxygen concentrator with the prongs touching the handle, rather than being stored in a plastic bag when not in use. Both the RN and DON confirmed that the tubing should be stored in a bag for infection control, in accordance with the facility's policy and procedure for oxygen administration. A third resident, diagnosed with COPD and anemia, was observed receiving oxygen at 2.5 liters per minute via nasal cannula. However, there was no physician's order for this oxygen administration, and no sign was posted outside the resident's door to indicate oxygen was in use or to prohibit smoking. The RN confirmed the absence of a physician's order and signage, both of which are required by the facility's policy to ensure safe and accurate oxygen therapy.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Noncompliance with Drug Labeling and Storage Requirements
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in noncompliance with regulations regarding the proper labeling and secure storage of medications and biologicals within the facility.
Improper Disposal of Garbage and Refuse Due to Uncovered Trash Bins
Penalty
Summary
The facility failed to properly cover six out of ten large trash bins with lids as required by its own policy and procedure on garbage disposal. During a facility tour and observation, surveyors found two large trash bins in the Lodge Building, three in the Manor Building, and one in the Center Building area outside in the parking lot with open lids, all of which were full of trash bags. Staff interviews confirmed that the trash bin lids should be kept closed at all times to maintain sanitation and prevent cross contamination. The Kitchen Manager stated that the kitchen area in the Center Building had insufficient space for daily trash, leading to overfilled bins and open lids. The Maintenance Supervisor also acknowledged that overfilled bins prevented lids from closing, which could attract rodents and flies. Further interviews with the DON and Infection Prevention Nurse confirmed that trash bins should be covered with lids at all times for infection control, to prevent bad odors, and to keep out rodents and other animals. The facility's policy and procedure on garbage disposal specifies that refuse containers and dumpsters kept outside should have tightly fitting lids and be kept covered when not being loaded. The failure to keep trash bin lids closed was directly observed and confirmed by multiple staff members as not sanitary and not in compliance with facility policy.
Failure to Follow Infection Control Protocols During Medication Administration and G-Tube Care
Penalty
Summary
A deficiency was identified when a Licensed Vocational Nurse (LVN) failed to perform proper hand hygiene during medication administration for a resident with multiple diagnoses, including dry eye syndrome, epilepsy, and Parkinson’s disease. The LVN did not sanitize or wash hands before entering the resident’s room, after exiting the room, before donning gloves, or after removing gloves, despite handling medications and administering eye drops. The LVN acknowledged the lapse in hand hygiene during an interview, and the facility’s policies clearly required hand hygiene at these points to prevent infection. Another deficiency was observed with a different resident who had a gastrostomy tube (G-tube) for enteral feeding and was dependent on staff for all activities of daily living. The resident’s [NAME] valve, used to maintain a closed system for tube feeding, was found to be uncapped, with visible dry, black, and brown crust and formula residue inside the connector port. The valve was only wrapped with a towel rather than being properly covered with a cap. Staff interviews confirmed that the valve should have been kept clean and covered, and that the facility had replacement covers available. The facility’s policies required proper cleaning and maintenance of medical devices to minimize infection risk. Both deficiencies were confirmed through direct observation, staff interviews, and review of facility policies and procedures. The failures to follow established infection prevention and control protocols placed the residents at risk for the spread of infection and cross-contamination. The facility’s own policies outlined the necessary steps for hand hygiene and device maintenance, which were not followed in these instances.
Failure to Support Resident Self-Determination
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support residents in making their own choices regarding their care or daily life, as required by regulation. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions of staff, the events that occurred, or the medical history or condition of the resident(s) involved. No further factual observations or resident-specific information are included in the report.
Failure to Provide Privacy During Catheter Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to provide privacy for a resident during a foley catheter check. The RN did not close the privacy curtain while pulling up the resident's gown to check the catheter securement device, resulting in the resident's upper legs being exposed to a roommate and the hallway. The RN acknowledged that the privacy curtain should have been closed prior to providing care and treatment to maintain the resident's privacy. The resident involved had chronic kidney disease, benign prostatic hyperplasia, and was incontinent of bowel and bladder due to impaired cognition. The care plan for this resident specifically indicated that nursing staff should provide privacy during activities of daily living. Both the RN and the Director of Nursing confirmed during interviews that the privacy curtain should be closed to protect the resident's dignity and bodily privacy during care, as outlined in the facility's policy.
Failure to Complete Pre-Employment OIG Background Check
Penalty
Summary
The facility failed to conduct a required Office of Inspector General (OIG) background check for one of four randomly selected employees, a registered nurse, prior to hire. According to interviews and record reviews with the Director of Staff and Development (DSD), the Director of Nursing (DON), and the Administrator (ADM), the facility's practice was to hire applicants before completing background checks, contrary to the facility's own policy and procedure. The DSD confirmed that the background check for the registered nurse was performed after the hiring date, following instructions from the previous DSD. Both the DON and ADM acknowledged during interviews that background checks should be completed prior to hiring to ensure applicants do not have a history of abuse or criminal records. Review of the facility's policy titled "Abuse, Neglect and Exploitation" indicated that screening for a history of abuse, neglect, exploitation, or misappropriation of resident property must be conducted on potential employees, contracted staff, students, volunteers, and consultants before hire. The policy specifies that background, reference, and credential checks are required prior to employment. The failure to follow this policy resulted in the hiring of an employee before confirming their eligibility through the OIG database.
Failure to Complete Timely MDS Assessments After Significant Change in Condition
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) comprehensive assessments within the federally required time frames for two residents who experienced significant changes in condition. Both residents had histories of dementia and schizophrenia, and each exhibited new or worsening behavioral symptoms that led to acute psychiatric hospitalizations and subsequent readmissions to the facility. Documentation, including SBAR forms and progress notes, indicated that these behavioral changes were significant departures from each resident's baseline condition. Despite this, the MDS assessments did not reflect a significant change of condition, and comprehensive assessments were not completed within 14 days of the residents' readmissions as required. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the changes in the residents' mental and behavioral status constituted significant changes in condition, necessitating timely MDS comprehensive assessments. The facility's own policy also required completion of such assessments within 14 days after determination of a significant change. The failure to complete and report these assessments in a timely manner resulted in inaccurate and delayed reporting of the residents' health status to CMS.
Failure to Maintain Resident Hygiene and Assistance with ADLs
Penalty
Summary
A deficiency occurred when a resident with diagnoses including type 2 diabetes mellitus, schizophrenia, and adult failure to thrive was not kept clean, as observed on 8/5/2025. The resident was found lying in bed with an oily, unkempt ponytail and the bottoms of both bare feet covered with black dirt. Multiple staff, including a CNA and an LVN, confirmed the resident's disheveled appearance and dirty feet during interviews and observations. The resident's care plan indicated a need for assistance with activities of daily living (ADLs), including personal hygiene and bathing, and interventions were in place to encourage participation and maintain cleanliness. Despite these documented needs and scheduled showers, the resident was not provided adequate hygiene, as evidenced by their appearance during the survey. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain grooming and personal hygiene, and the DON confirmed that staff were expected to provide hygiene every shift. The failure to ensure the resident was kept clean constituted a deficiency in providing care and assistance with ADLs.
Failure to Enforce Smoking Policy for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement its smoking policy and procedure for a resident with significant cognitive impairment and behavioral issues. The resident, who had diagnoses including schizoaffective disorder, schizophrenia, and traumatic brain injury, was assessed as having moderately impaired cognition and was determined to be a danger to self or others while smoking. The resident's care plan indicated a risk for self-injury related to smoking and a tendency to hoard cigarettes, with interventions requiring staff to explain and enforce the facility's smoking policy. Despite these documented risks and interventions, the resident was found with two cigarettes in their possession in their room, which was not in accordance with the facility's policy that required nursing staff to maintain control of smoking materials for residents needing supervision. Interviews with staff revealed inconsistent practices regarding the handling of cigarettes, with a certified nurse assistant stating that residents were usually given one cigarette per day and could keep cigarettes in their rooms, while a licensed vocational nurse and the director of nursing confirmed that residents were not allowed to keep cigarettes or lighters. The facility's written policy specified that smoking materials for residents requiring supervision should be maintained by nursing staff. The failure to follow this policy resulted in the resident having unsupervised access to cigarettes, creating a potential fire hazard within the facility.
Failure to Provide Required 1:1 Supervision Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with intellectual disabilities, autistic disorder, and schizoaffective disorder, who was assessed as having severely impaired cognitive skills and a history of impulsive and self-injurious behaviors, was not provided with the required one-on-one (1:1) supervision as indicated in their care plan. The care plan, established by the interdisciplinary team, specified that the resident should receive 1:1 supervision for 10 hours daily due to their impaired cognition and behavioral risks. On the day of the incident, the assigned staff member left the resident unsupervised in their room for approximately 30 seconds, during which time the resident fell from their wheelchair. As a result of being left unsupervised, the resident sustained a laceration above the left eyebrow, abrasions to the left elbow and forearm, and a bruise under the left eye. The injuries required emergency medical attention, and the resident was transferred to a general acute care hospital for further evaluation and wound management. Staff interviews confirmed that the resident was known to require constant supervision due to their behavioral tendencies and risk of harm, and that the assigned staff was aware of the supervision requirement but failed to maintain it at the time of the fall. Facility records, including progress notes, care conference documentation, and staff interviews, consistently indicated that the resident's need for 1:1 supervision was well established and communicated among the care team. The facility's policy on safety and supervision emphasized the importance of implementing and communicating specific interventions to prevent accidents, but in this instance, the intervention was not carried out as required, directly leading to the resident's fall and subsequent injuries.
Failure to Align Diabetes Care Plans with Physician Orders
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two of three sampled residents with diabetes mellitus, as required by physician orders and facility policy. For both residents, the care plans included goals to maintain blood glucose levels within a specified range and interventions such as monitoring blood glucose and observing for signs of hypo- or hyperglycemia. However, neither resident had an active physician's order for routine bedside blood sugar monitoring, which was a key component of the care plan interventions. Resident 4 was admitted and readmitted with a diagnosis of diabetes mellitus type 2 and diabetic polyneuropathy. The resident's care plan specified blood glucose monitoring and maintaining levels between 70 and 150 mg/dl, but the order summary report showed no physician order for routine blood sugar checks. Interviews with nursing staff confirmed that the care plan called for monitoring, but this was not supported by physician orders. Similarly, Resident 6, who had severe cognitive impairment and required assistance with activities of daily living, had a care plan with similar goals and interventions for diabetes management. The order summary report for this resident also lacked a physician order for routine blood glucose monitoring or for monitoring signs and symptoms of hypo- or hyperglycemia. Nursing staff and the DON acknowledged the importance of care plans in guiding resident care, but the necessary physician orders to implement the care plan interventions were not present.
Failure to Assess, Document, and Care Plan for Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a documented history of suicidal ideation. Upon readmission from an acute care hospital, the resident's prior episode of suicidal ideation, including a stated plan to overdose on medication, was not accurately assessed or documented by the Social Services Director (SSD) or the admitting licensed nurse. The resident's medical records from the hospital indicated recent suicidal thoughts, feelings of hopelessness, and a history of aggressive behavior, but this information was not incorporated into the facility's assessment or care planning process. The SSD conducted an interview with the resident after readmission and asked about current suicidal thoughts, to which the resident denied any intent. However, the SSD did not document this conversation or the resident's history of suicidal ideation in the Social Service History & Initial Assessment. The assessment form's section for history of suicidal ideation/gestures was left blank, and the SSD did not notify nursing staff or initiate an interdisciplinary team meeting as required by facility policy. The Director of Nursing (DON) confirmed that no assessment, care plan, or monitoring for suicidal ideation was completed for the resident, despite the documented history and recent hospital evaluation. Interviews with facility staff, including the DON, SSD, and a registered nurse, revealed a consensus that the lack of assessment, documentation, and care planning for suicidal ideation could result in potential or actual harm to the resident. Facility policies required assessment for suicidality upon admission, thorough documentation, and the development of a care plan with appropriate interventions for residents with a history of suicidal ideation. These steps were not followed, and the resident's risk factors were not addressed in the care plan or through ongoing monitoring.
Plan Of Correction
F 740 Behavioral Health Services 483.40 Resident 1 was discharged to acute hospital for evaluation of his aggressive behavior on 5/6/25. All residents in house census as of 5/16/25 were reviewed by the DON and RN/LVN supervisors. Review was initiated on 5/16/25 to ensure that residents with a history of suicidal ideations have been assessed, care planned, and monitored. Review was completed on 5/22/25. NO other residents were affected. Social services department and licensed nurses were in serviced by the DON on 5/15 and 5/19/25 regarding Behavioral Health Services; Social services and licensed nurses are to accurately assess and document suicidal ideation upon admission; develop a care plan, and monitor the suicidal ideation behavior. Every other month, licensed staff and Social services department will be given an in-service regarding Behavioral Health Services by the DON. RN/LVN supervisors will monitor compliance during weekly admissions review using the suicidal ideation admission review log to ensure that residents' suicidal ideations have been assessed upon admission, care planned, and behavior is being monitored. Any findings will be corrected immediately and will be given to the DON for follow-up. Any significant findings will be reported by the DON during the quarterly QA&A meetings for discussion and recommendation for 6 months.
Failure to Assess Resident's Skin Leads to Infected Wound from Embedded Bracelets
Penalty
Summary
Licensed nursing staff failed to perform a full body skin assessment on a resident who had a history of mild intellectual disabilities and moderate cognitive impairment. The resident required partial to moderate assistance with activities of daily living and had no documented skin conditions prior to the incident. On one occasion, a Licensed Vocational Nurse (LVN) noticed a foul odor coming from the resident but did not identify its source, did not conduct a full body assessment, and did not notify a supervisor or Registered Nurse (RN) about the issue. The following day, the LVN again noticed the odor and informed the RN, who instructed the LVN to provide the resident with another shower, despite the resident having already received one the previous day. Neither the LVN nor the RN performed a full body skin assessment as required by facility policy, which mandates such assessments after a change in condition or when a new wound is identified. The facility's Director of Nursing confirmed that the staff did not follow the established policy for skin assessments. Emergency medical services were called, and upon their arrival, EMTs discovered that the resident had bracelets, including a hospital band and beaded bracelets, embedded in the left wrist, causing a wound that was infected and emitting a strong odor. The bracelets were removed by the EMTs, and the wound was noted to be infected with discharge. The failure of the nursing staff to assess the resident's skin and identify the embedded bracelets led to the development of the infected wound.
Plan Of Correction
F 684 Quality of Care CFR(s): 483.25 Resident 1 was re-admitted back to our facility on 3/28/25. He was assessed by the RN supervisor on 3/28/25. Left wrist noted with dry scab with no signs of infection. RN1 and LVN 1 were given a one-on-one in-service and 1:1 Skills and Policy review by the DON on 4/11/25. Disciplinary action was given by the DON to the RN1, LVN1, and the CNAs who were assigned to Resident 1. DON, RN/LVN supervisors performed body/skin checks to the current residents on census as of 4/10/25 to identify any residents affected with the findings. Skin/Body checks were completed on 4/30/25. No other residents were affected. DON in-serviced licensed nurses on 4/9/25, 4/11/25, and 4/28/25 regarding Skin assessment Policy upon admission/readmission, change of condition, and as needed. DSD in-serviced CNAs on 4/9/25 regarding skin and body assessment including reporting to licensed nurses for any changes. A follow-up in-service to CNAs, LVNs, and RNs was given on 4/25/25 by the DSD. To monitor compliance, the DON and/or Designee will conduct random skin assessment reviews to licensed nurses on a weekly basis. Any issues will be addressed and corrected immediately. Findings will be reported by the DON during quarterly QA&A meetings for 6 months.
Failure to Implement Comprehensive Care Plan and Daily Body Checks
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident by not performing daily body checks as required by the resident's care plan and the facility's own policies. The resident had a history of mild intellectual disabilities, limited mobility, and was at risk for developing pressure ulcers, as documented in the care plan and Minimum Data Set (MDS). The care plan specifically included interventions such as daily body checks for redness and open areas, keeping the skin clean and dry, and protecting the skin from moisture. Despite these documented needs and interventions, staff did not consistently perform or document daily body checks. A Licensed Vocational Nurse (LVN) assigned to the resident noticed a foul odor but did not conduct a full body assessment, stating it was outside their scope of practice. The LVN reported the odor to a Registered Nurse (RN), but the only action taken was to provide another shower, even though the odor persisted. The Director of Nursing (DON) confirmed that the facility's policy required full body skin assessments by licensed or registered nurses, particularly for residents at risk of pressure ulcers, and that this protocol was not followed in this case. As a result of the failure to follow the care plan and perform required skin assessments, the resident developed an infected wound on the left wrist, which was later identified at an acute care hospital as an embedded rubber band causing infection. The lack of adherence to the care plan and facility policy directly contributed to the development and delayed identification of the wound.
Plan Of Correction
F 656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) Resident 1 was re-admitted back to our facility on 3/28/25. He was assessed by the RN supervisor on 3/28/25. Left wrist noted with dry scab with no signs of infection. Care plan reviewed and revised by the RN supervisor on 3/28/25. DON, RN/LVN supervisors performed body/skin checks to the current residents on census as of 4/10/25 to identify any resident affected with the findings. Body/skin checks were completed on 4/30/25. No other residents were affected. DON in-serviced licensed nurses regarding Comprehensive Care Plan Implementation on 4/9, 4/11, and 4/28. At least quarterly, every 10th, DON will in-service regarding Comprehensive Care Plan Implementation. Weekly, during IDT care plan meetings, MDS nurse, RN/LVN supervisors assigned, and Social Services designee will review the care plan of residents on schedule to ensure that body/skin assessment was performed as written in the care plan. Findings will be corrected and will be reported to the DON for follow-up. Any significant findings will be reported by the DON during the quarterly QA&A meetings for discussion and recommendation for 6 months.
Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
Licensed nursing staff failed to properly assess and respond to a foul odor detected from a resident on two consecutive days. An LVN assigned to the resident noticed a foul smell but did not perform a full body assessment, citing it as outside their scope of practice, nor did they notify a supervisor or RN on the first day. The following day, after the smell persisted, the LVN informed an RN, who instructed the LVN to give the resident another shower, despite the LVN's report that a shower had already been given and the odor remained. The resident in question had a history of mild intellectual disabilities and mobility issues, and required varying levels of assistance with daily activities. The resident's most recent assessment did not indicate any skin conditions. However, when the resident was later evaluated at a hospital, a rubber band embedded in the left wrist was found to be infected, which had gone unnoticed and untreated by facility staff. Facility policy required licensed or registered nurses to perform full body skin assessments upon admission, readmission, and as needed, including after a change in condition or the identification of new skin issues. The Director of Nursing confirmed that LVNs are expected to report unusual findings to RNs for further assessment, but was unaware of the wound until the resident was transferred to the hospital. The failure of both the LVN and RN to assess the resident's skin condition and follow facility policy led to the deficiency.
Plan Of Correction
Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c) Resident 1 was re-admitted back to our facility on 3/28/25. He was assessed by the RN supervisor on 3/28/25. Left wrist noted with dry scab with no signs of infection. RN1 and LVN 1 were given a one-on-one in-service and 1:1 Skills and Policy review by the DON on 4/11/25 regarding Skin assessment Policy. Disciplinary action was given by the DON to the RN1, LVN1, and the CNAs who were assigned to Resident 1. DON, RN/LVN supervisors performed body/skin checks to the current residents on census as of 4/10/25 to identify any residents affected with the findings. Skin/Body checks were completed on 4/30/25. No other residents were affected. Monthly, Skin assessment in-service will be given by the DON and DSD to licensed nurses and CNAs. To monitor compliance, the DON and/or designee will conduct random Skin assessment reviews to licensed nurses on a weekly basis. Any issues will be addressed and corrected immediately. Skills competency training and evaluation by return demonstration will be done annually and as needed by the DON and/or designee and DSD to the licensed nurses and CNAs. Findings will be reported by the DON during quarterly QA&A meetings for 6 months.
Failure to Provide Adequate Foot Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate foot care and treatment to a resident, leading to a significant health issue. The resident, who had a history of Parkinson's disease and dementia, repeatedly refused podiatric treatment throughout 2024. Despite these refusals, the facility did not notify the resident's physician or family, nor did they implement alternative interventions as outlined in the resident's care plan. This lack of action resulted in the resident developing osteomyelitis, a serious bone infection, which required hospitalization and intravenous antibiotics. The resident's care plan indicated that staff should monitor for noncompliance and notify the physician for possible treatment, as well as refer the resident for psychological consultation if necessary. However, the facility's staff, including licensed nurses and the Social Service Director, failed to follow these protocols. The resident's toenails were noted to be mycotic and hypertrophic, yet no treatment was provided due to the resident's refusal. The facility's policies required notification of the physician and family after repeated refusals, but this was not done. Interviews with staff revealed a lack of communication and awareness regarding the resident's condition. The Director of Nursing was unaware of the resident's year-long refusal of podiatric care, and the Social Service Director did not inform the nursing staff of the ongoing refusals. Additionally, a change in the resident's condition was not documented in a timely manner, delaying necessary medical intervention. This series of inactions and communication failures contributed to the resident's hospitalization for a preventable condition.
Failure to Notify Physician and Family of Treatment Refusal
Penalty
Summary
The facility failed to notify the physician and responsible party of a resident's repeated refusal of podiatric treatment, as required by their policies and procedures. The resident, who was diagnosed with Parkinson's disease and dementia, was unable to make medical decisions and had a history of refusing treatment and medications. Despite the resident's refusal of podiatric care throughout 2024, the licensed nurses did not inform the resident's physician or family, which was a requirement under the facility's policy. The resident's condition deteriorated, leading to a transfer to a General Acute Care Hospital for intravenous antibiotics to treat osteomyelitis in the right toe. The resident's toenails were noted to be mycotic, hypertrophic, and painful, with repeated refusals for toenail debridement documented. The facility's staff, including the Social Services Designee and Director of Nursing, were unaware of the resident's continued refusal of podiatric care, and the necessary notifications to the physician and family were not made. Interviews with staff revealed that the facility's policy required notification of the physician and family after three refusals of treatment, but this was not followed. The Director of Nursing acknowledged the lack of awareness and communication regarding the resident's refusal of care. The facility's policies clearly outlined the need for notification in cases of significant changes in a resident's condition, but these were not adhered to, resulting in the resident's hospitalization.
Failure to Implement Care Plan for Resident's Podiatric Treatment Refusals
Penalty
Summary
The facility failed to implement the care plan for a resident, identified as Resident 4, by not notifying the resident's physician about repeated refusals to receive podiatric treatment. Resident 4, who was admitted with diagnoses including Parkinson's disease and dementia, was noted to refuse treatment and medications, including podiatric care, as per the care plan. The care plan required staff to monitor for noncompliance and notify the physician for possible treatment, but this was not done. Resident 4's nursing assessments and podiatric consultation notes indicated repeated refusals of toenail debridement over a year, resulting in untreated mycotic and hypertrophic toenails. Despite the care plan's directive to notify the physician and involve family or staff in decision-making, the Social Service Director and Director of Nursing were unaware of the ongoing refusals, and no alternative interventions were attempted. The facility's policy required comprehensive care plans to include measurable objectives and timeframes, with attempts to address treatment refusals documented. However, the licensed nurses were not informed of Resident 4's refusals, and the necessary notifications to the physician and other relevant parties were not made, leading to a failure in implementing the care plan as required.
Failure to Address Resident's Refusal of Podiatry Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide necessary care and services to a resident, identified as Resident 4, by not implementing its policies and procedures regarding changes in a resident's condition or status and comprehensive care plans. Resident 4 repeatedly refused treatment by a podiatrist, and this refusal was not communicated to the resident's physician or family. The care plan addressing the refusal of care and treatment was not implemented, and licensed nurses did not inform the resident's physician about the condition of the resident's toenails during weekly nursing assessments. Resident 4, who was admitted with diagnoses including Parkinson's disease and dementia, was at risk for clinical or social decline due to refusals of care, including podiatry treatment. The resident's care plan indicated that family members and staff should assist in decision-making and inform the resident of the risks and consequences of their choices. Despite this, the facility did not take appropriate actions when the resident refused podiatry care throughout 2024, leading to a lack of communication with the resident's physician and family. The failure to address Resident 4's refusal of podiatry care resulted in the resident being transferred to a General Acute Care Hospital for treatment of right toe osteomyelitis. The facility's policies required that significant changes in a resident's condition be communicated to the physician and family, but this was not done. The Director of Nursing and Social Service Director were unaware of the resident's repeated refusals, and the necessary interventions were not implemented, leading to the resident's hospitalization.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as at risk for wandering and elopement. The resident, who had a history of schizophrenia and anxiety disorder, was initially admitted to a secured unit due to wandering behavior. However, the resident was later transferred to an unsecured unit, Station 6, which had multiple exit doors, some of which were not alarmed or locked. This transfer occurred despite the resident's known risk factors and a physician's order to admit the resident to a secured unit. On the evening of the incident, the resident was last seen walking in the hallway by the nurses' station and later listening to the radio in their room. The staff, including a CNA and LVN, noticed the resident's absence at 8:45 pm and initiated a search within the facility and surrounding areas. Despite these efforts, the resident was not found, and a missing person report was filed with the local police department. The facility's emergency code for a missing resident was activated, and staff searched extensively, but the resident remained missing. Interviews with staff revealed that the kitchen exit door, located near a vending machine frequently used by the resident, was not alarmed at the time of the incident. This door was not visible from the main hallway or the nurses' station, potentially allowing the resident to exit the facility undetected. The facility's policy on elopement and wandering residents emphasized the need for adequate supervision and systematic monitoring, which was not effectively implemented in this case, leading to the resident's elopement.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as at risk for elopement. The incident involved a resident with a history of diabetes mellitus and schizophrenia, who was admitted to the secured unit due to wandering behavior and confusion. Despite being scheduled for an ophthalmologist appointment, the resident left the facility unsupervised with a rideshare driver, without the presence of a staff chaperone as required by the facility's policy. The deficiency occurred when a janitor unlocked the door of the secured unit, allowing the resident to leave with the rideshare driver. The staff responsible for accompanying the resident to the appointment was not present at the scheduled pick-up time. The facility's policy required that residents in the secured unit be accompanied by a staff member for any outside appointments, but this protocol was not followed, leading to the resident's unsupervised departure. The facility's failure to ensure that the resident was accompanied by a staff chaperone resulted in the resident not checking in at the ophthalmologist's office and subsequently being reported missing. The facility's staff, including the Administrator and Director of Nursing, were unable to locate the resident, prompting the filing of a missing person report with the local police department. The incident highlighted a lapse in the facility's supervision and monitoring procedures for residents at risk of elopement.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to the development and worsening of pressure ulcers. Resident 228, who was at risk for pressure ulcers due to limited mobility and moist skin, did not receive the prescribed treatments for open wounds and unstageable pressure ulcers on multiple occasions. The treatment nurses failed to notify the medical doctor of the development of new pressure ulcers and did not implement the care plan for impaired skin integrity. As a result, Resident 228 developed an avoidable unstageable pressure ulcer on the right hip and a worsening ulcer on the left hip. Resident 231 was at risk for pressure ulcers due to severe cognitive impairment and required substantial assistance with daily activities. The facility staff failed to set the low air loss mattress to the correct setting based on the resident's weight, which could potentially lead to skin breakdown. The mattress was set at 325 pounds, while the resident weighed 158 pounds, indicating a lack of adherence to the manufacturer's recommendations and facility policy. Resident 80, who had severe cognitive impairment and was dependent on all activities of daily living, did not receive the prescribed treatment for a stage 4 pressure ulcer on the sacrococcyx for several days. The treatment administration record was left blank for multiple days, indicating missed treatments. The failure to provide consistent wound care had the potential to delay the healing of the pressure ulcer.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in care. Resident 81, who was admitted with osteoarthritis, muscle weakness, and dementia, had a care plan indicating a high risk for falls and required assistance with activities of daily living. During an observation, it was noted that Resident 81's call light was dangling and out of reach, which the resident confirmed, stating they could not access it without assistance. Staff interviews corroborated that the call light should have been clipped to the bed for easy access, as per the facility's policy. Similarly, Resident 25, who was admitted with muscle weakness and unspecified dementia, was also identified as high risk for falls. The care plan for Resident 25 included ensuring the call light was within reach. However, during an observation, the call light was found on the floor, out of reach, and not accessible to the resident. Staff interviews confirmed that the call light should have been within reach to allow the resident to call for assistance promptly. The facility's policy on call light accessibility was not adhered to, as evidenced by the observations and staff interviews. Both residents were at high risk for falls, and the failure to ensure call lights were within reach could lead to delayed assistance and potential harm. The deficiency was identified through observations, interviews, and a review of the residents' records, highlighting a lapse in maintaining safety and accessibility for residents in need of assistance.
Failure to Implement Smoking Policy and Ensure Proper Positioning During Meals
Penalty
Summary
The facility failed to implement its smoking policy for Resident 100, who was observed with a pack of cigarettes despite being identified as an unsafe smoker requiring supervision. Resident 100, diagnosed with schizophrenia, schizoaffective disorder, and anxiety, had a care plan indicating a risk for self-injury related to smoking. The care plan required that smoking materials be maintained by nursing staff, yet during an observation, the resident was found with cigarettes in their possession. Interviews with staff confirmed that cigarettes should be kept by LVNs and only provided to residents during supervised smoking times. The facility also failed to ensure proper positioning for Resident 80 during meals, which is crucial to prevent aspiration. Resident 80, who has dementia and dysphagia, was observed with their neck hyperextended while eating, contrary to physician orders requiring the head of the bed to be elevated at 90 degrees during feeding. A registry CNA assisting the resident was unaware of this requirement, and the care plan for dysphagia did not include specific instructions for proper positioning during meals. Interviews with nursing staff highlighted the importance of correct positioning and the need for this information to be communicated to all staff, including registry staff. These deficiencies indicate a lack of adherence to established policies and procedures, potentially compromising resident safety. The facility's failure to supervise Resident 100's smoking and to ensure Resident 80's proper positioning during meals could lead to significant health risks, as noted in the observations and interviews conducted during the survey.
Failure to Prevent UTIs in Residents with Foley Catheters
Penalty
Summary
The facility failed to provide necessary care to prevent urinary tract infections (UTIs) for two residents with Foley catheters. For one resident, the licensed staff did not monitor urine output for signs of UTI, such as cloudy urine and sediments, and failed to notify the physician promptly. This oversight was acknowledged by a registered nurse who admitted to being too busy to inform the physician. Additionally, a certified nursing assistant focused only on the urine output amount and did not check for changes in color or sediments until instructed by the nurse. For the second resident, the facility did not ensure proper positioning of the Foley catheter bag, which was observed on the floor. A certified nursing assistant was unsure about the correct positioning, and a licensed vocational nurse confirmed that the bag should not be on the floor due to infection risks. The facility's policy and procedure for catheter care also indicated that the catheter bag should be kept off the floor to prevent contamination and infection.
Failure to Follow Respiratory Care Procedures
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding respiratory care for two residents, leading to potential health risks. For Resident 67, who was admitted with respiratory failure and dysphagia, the facility did not remove or replace the suction canister after use, leaving a moderate amount of thick, yellow sputum in the canister. This oversight was observed by a Licensed Vocational Nurse (LVN) who acknowledged the need for the canister to be emptied after use. The failure to do so could result in inaccurate monitoring of the resident's secretions, as staff would not know how long the sputum had been in the container. The facility's policy required the suction bottle to be cleaned every shift and changed weekly or as needed. For Resident 653, who had chronic obstructive pulmonary disease and asthma, the facility did not date the humidifier bottle used with the resident's oxygen machine. This was observed by an LVN, who noted that the absence of a date could lead to the use of an old humidifier bottle, potentially reducing the effectiveness of the oxygen therapy. The facility's policy required the humidifier bottle to be changed every 72 hours or as recommended by the manufacturer. Both instances reflect a failure to follow established procedures, which could compromise the residents' respiratory care.
Failure to Implement Gradual Dose Reductions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents on psychotropic drugs were free from unnecessary medication. For Resident 198, the licensed staff did not attempt a gradual dose reduction (GDR) for Risperdal and Lexapro since the medications were ordered on 6/8/21. The resident was readmitted with the same medication orders, and there was no documented evidence of a past or recent failed attempt of GDR to justify that it would be clinically contraindicated. For Resident 210, the staff did not attempt a GDR for Lexapro since it was ordered on 3/27/23. The resident was readmitted with diagnoses including dementia and diabetes mellitus. The staff believed that GDR was not indicated after several psychotropic medications had been discontinued, but acknowledged that limited social interaction was not an adequate indication for continued use of Lexapro. Resident 22's target behavior and side effects for Ativan use were not monitored every shift as required. The resident was admitted with diagnoses including anxiety and dementia, and the physician order required monitoring for adverse side effects and target behavior every shift. However, there was no documented monitoring for specific shifts, and the Director of Nurses confirmed the lack of documentation, emphasizing the need for monitoring to assess medication effectiveness and potential harm.
Deficiencies in Kitchen Staff Training and Sanitization Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in following manufacturer's guidelines for chlorine paper testing and smartpower sink and surface cleaner sanitizer. Two staff members, a Dietary Aide and the Dietary Account Manager, did not adhere to the correct procedures for testing chlorine sanitizer concentration. The Dietary Aide incorrectly shook the test strip for 4 seconds and compared it to the color chart, while the Dietary Account Manager placed the test strip on wet trays instead of dipping it in water, as per the manufacturer's guidelines. This deviation from the guidelines could result in inaccurate readings of chlorine concentration, potentially leading to unsanitized dishware. Additionally, the facility did not follow the manufacturer's guidelines for the smartpower sink and surface cleaner sanitizer. The staff failed to check the temperature of the testing solution, which should be above 65°F, as required by the guidelines. The Director of Maintenance confirmed that water temperature checks were not conducted daily, and the Maintenance Worker did not record the results of temperature checks in the log. This oversight could lead to ineffective sanitization of kitchen surfaces, increasing the risk of cross-contamination. The report also highlighted that there was no competency evaluation for the Dietary Aide and the Dietary Account Manager, despite their job descriptions requiring them to maintain sanitation and safety standards. The Registered Dietitian confirmed that the Dietary Account Manager had not been evaluated for competency because she had not been in the facility for a year. Furthermore, the facility's in-service lesson plan indicated that staff were instructed on testing procedures, but attendance records showed that not all staff, including the Dietary Aide, attended these sessions.
Sanitation and Food Safety Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in both of its kitchens, leading to potential health risks for residents. Observations revealed that Freezer A and B in Kitchen 1 had significant dust and dirt buildup, with food debris present on the bottom shelves and vents. The reach-in refrigerator in Kitchen 1 also had dirt buildup on its vents. Additionally, stainless steel racks used for kitchen utensil storage and in the dry storage area were found to be rusted, which could contribute to foodborne illnesses. Dented cans were improperly stored with non-dented cans in both kitchens, and bulk condiment containers had dirt buildup on their lids. Further issues were identified with the equipment and utensils used in the kitchens. The reach-in refrigerator in Kitchen 2 had ice buildup and dirt debris, while the dry storage wooden racks had cereal debris. The ice machine in Kitchen 1 had hard water buildup, and its internal parts had a slimy brownish buildup. The resident's refrigerator was not maintained at the correct temperature, and pans in Kitchen 2 had burned dirt debris. Kitchen utensils storage also had food debris, and staff were not following the manufacturer's guidelines for testing chlorine concentration for the dish machine. Staff attire and practices also contributed to the deficiencies. A dietary aide was observed wearing dangling and beaded bracelets while handling food, which is against the facility's policy. The facility's policy on jewelry was not adhered to, as staff were only allowed to wear plain bands. Additionally, the facility did not have a proper cleaning schedule for some equipment, such as the plate warmer, and staff were not following the manufacturer's guidelines for the use of sanitizers, which could lead to inaccurate readings and ineffective disinfection of kitchen surfaces.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed in the dumpster areas outside Kitchen 1 and Kitchen 3. Four gray trash bins outside Kitchen 1 were overflowing and not completely closed, while one of two black trash bins outside Kitchen 3 was also not fully covered. The Dietary Area Manager (DAM) acknowledged that the trash bins should be completely covered and expressed concerns about the health implications for residents. The DAM indicated that it was the janitor's responsibility to maintain the cleanliness of the dumpster areas. Additionally, the dumpster areas outside Kitchens 1 and 3 were not maintained free from trash, soiled gloves, and other debris. The DAM noted the presence of a trash bag on the ground, soiled gloves, and other trash in the surrounding areas, emphasizing the importance of cleanliness to prevent the spread of infections. The Environmental Services Manager (EVSM) confirmed that trash was picked up daily except Sundays, but acknowledged that the bins should not be overflowing to avoid attracting insects and rodents. The facility's policies and procedures, as well as the Food Code 2017, require that trash receptacles be covered with tight-fitting lids to prevent contamination.
Failure to Provide Speech Therapy Evaluations as Ordered
Penalty
Summary
The facility failed to provide Speech Therapy (ST) evaluations as ordered by physicians for three residents with swallowing, communication, and cognitive concerns. Resident 147, who was readmitted with diagnoses including encephalopathy, cirrhosis, and COPD, had a physician's order for an ST evaluation upon readmission. However, the resident only received a Therapy Screen, which is not equivalent to a comprehensive ST evaluation. The Director of Rehabilitation (DOR) and the Speech Therapist (ST 1) confirmed that the ST evaluation was not conducted as ordered, which could potentially result in negative outcomes for the resident. Similarly, Resident 198, who was readmitted with dysphagia and a G-tube malfunction, also had a physician's order for an ST evaluation. Despite this, the resident did not receive the evaluation, only a Therapy Screen. Both the DOR and ST 1 acknowledged the oversight, emphasizing the importance of following physician's orders to ensure residents receive necessary care and services to reach their highest functional level. Resident 280, admitted with dysphagia, metabolic encephalopathy, and COPD, was also supposed to receive an ST evaluation as per physician's orders. However, the evaluation was not performed, and the order was discontinued by a Registered Nurse without notifying the physician. ST 1 admitted to not conducting the evaluation and failing to inform the physician about the discontinuation. The facility's policy requires that ST services follow physician's orders, which was not adhered to in these cases.
Failure to Ensure Convenient Venue in Arbitration Agreements
Penalty
Summary
The facility failed to ensure its Resident-Facility Arbitration Agreement (AA) included the selection of a venue convenient to both the facility and the residents or their responsible parties. This deficiency was identified for three residents, each with moderately impaired cognitive skills and requiring varying levels of assistance for daily activities. The facility's policy and procedure for the Binding Arbitration Agreement did not include a provision for selecting a mutually convenient venue, which is a regulatory requirement. During the review, it was found that the arbitration agreements for the residents did not have written language providing for the selection of a convenient venue. The facility's administrator acknowledged this omission and stated that the facility's policy did not require the selection of a convenient venue for both parties involved in the arbitration agreement. This oversight placed the residents at risk for unjust arbitration and potential delays in arbitration hearings.
Deficiency in Hospice Service Documentation and Implementation
Penalty
Summary
The facility failed to ensure proper documentation and implementation of hospice services for a resident on hospice care. The resident, who had severe cognitive impairment and was dependent on all activities of daily living, did not have documented services provided by the Hospice Health Aide (HHA) during visits. The Hospice and Nursing Facility Services Agreement required the HHA to document care provided, but the flow sheet for the resident only indicated a regular visit without details of the care given. This lack of documentation was confirmed by a registered nurse, who stated that the Hospice Book should contain all relevant documents and communication between the hospice and the facility. Additionally, the facility did not accurately document hospice Licensed Vocational Nurse (LVN) visits. The LVN flow sheet showed a visit on one date, but there were four undocumented vital signs without dates, making it impossible to verify additional visits. The registered nurse confirmed that the LVN visits were not completed according to the hospice visit calendar or the physician's orders, which required skilled nurse visits twice a week. The facility's policy indicated the need for communication and documentation of hospice interventions, but this was not followed, leading to the deficiency.
Deficient Laundry Dryer Maintenance
Penalty
Summary
The facility failed to maintain three laundry dryers in a safe, operating, and sanitary condition, which was observed during a survey. The Environmental Service Manager (EVSM) noted multiple thick patches of brown/black material on the inner walls of the dryers' drums. The EVSM acknowledged that these patches were dirty and did not know their origin. The presence of these patches was identified as a potential source of cross-contamination and infection risk when drying residents' clothes. Additionally, the EVSM recognized that the patches could pose a fire hazard by obstructing the drum holes, which are essential for heat and moisture ventilation. The facility's policies and procedures for washer and dryer maintenance, as well as laundry maintenance, were reviewed and indicated the need for daily inspection and cleaning of laundry equipment to prevent such hazards. However, these procedures were not followed, leading to the observed deficiencies.
Infection Control Deficiencies in PPE Usage and Disposal
Penalty
Summary
The facility failed to properly dispose of soiled gauze in a resident's room, which was observed during a concurrent observation and interview with a Licensed Vocational Nurse (LVN). The soiled gauze dressing was left next to the resident's head on the bed, potentially causing the spread of infection. The LVN acknowledged that the gauze should have been disposed of and suggested it might have been left by the wound doctor. The Infection Prevention Nurse (IPN) confirmed that the failure to clean up after wound care could spread infection and emphasized the expectation for staff to follow proper infection control protocols. In another incident, a Restorative Nursing Aide (RNA) failed to remove an isolation gown and gloves and perform hand hygiene after exiting a resident's room who was on Contact Isolation Precautions. The RNA transported the resident into the hallway without changing PPE, which was confirmed during an interview. The Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) both stated the importance of following proper infection control procedures to prevent cross-contamination and the spread of infection. The facility's policy on Transmission-Based Precautions was reviewed, indicating the need for PPE to be donned upon room entry and discarded before exiting. Additionally, the facility did not adhere to the Public Health Nurse's guidance for COVID-19 precautions in yellow zones. Observations revealed that PPE carts lacked face shields, and staff were not wearing full PPE, including face shields, when entering rooms in these zones. Interviews with staff confirmed the absence of face shields in PPE carts and the incorrect PPE usage. The facility's policy on COVID-19 prevention was reviewed, which required full PPE, including face shields, for staff entering rooms of residents with suspected or confirmed SARS-CoV-2 infection.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident by not addressing peeling paint on the walls and a black stain on the floor in the resident's room. The resident, who was admitted with diagnoses including muscle weakness, anxiety disorder, and insomnia, had moderately impaired cognition and lacked the capacity to make decisions. During an observation, the Director of Nursing (DON) confirmed the presence of peeling paint and a black stain on the floor, acknowledging that these issues had not been reported to the Maintenance Department until the surveyor's visit. Interviews with the DON and the Director of Maintenance (DM) revealed that the facility's policy required staff to report environmental issues, such as peeling paint and stains, to the Maintenance Supervisor. However, the DM was unaware of the issues in the resident's room until informed by the DON during the survey. The facility's policy and procedure emphasized the importance of maintaining a safe, clean, and homelike environment, which was not upheld in this instance.
Failure to Develop Individualized Care Plan for Resident on Ativan
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan for a resident who was prescribed Ativan for anxiety. The resident, who had diagnoses of anxiety and dementia, was admitted and readmitted to the facility with severely impaired cognition affecting daily decision-making. The Minimum Data Set (MDS) assessment indicated the resident required varying levels of assistance with daily activities, including eating, hygiene, and dressing. Despite these needs and the prescription of Ativan to manage anxiety symptoms such as yelling and screaming, the facility did not create a care plan to address the use of Ativan and ensure appropriate care and interventions. During a review of the resident's medical records, it was confirmed by the Registered Nurse Supervisor that no care plan had been developed for the management of Ativan. The Director of Nursing also acknowledged the absence of a comprehensive care plan tailored to the resident's specific needs. The facility's policy on Comprehensive Care Plans, revised in March 2023, mandates the development of a person-centered care plan within seven days of completing the comprehensive MDS assessment, which was not adhered to in this case.
Failure to Revise Care Plan for Resident's Skin Injury
Penalty
Summary
The facility failed to revise the care plan for Resident 228 when a change in the condition of a skin injury was observed. Resident 228, who has a medical history including type two diabetes mellitus, end-stage renal disease, and dependence on renal dialysis, was readmitted to the facility with mild cognitive impairments. The resident's care plan, initially addressing open scratches on the right hip, included an intervention for staff to notify the Medical Doctor if treatment was ineffective. However, when the scratches appeared macerated and white in color, indicating a change in condition, the care plan was not updated. During a review of the Non-Pressure Sore Skin Problem Report, it was noted that the change in the condition of the scratches occurred on 7/24/2024. The Director of Nursing confirmed that the care plan should have been revised to ensure appropriate treatment was provided. The facility's policy on comprehensive care plans requires that they be reviewed and revised after each comprehensive and quarterly MDS assessment, with objectives and timeframes to meet the resident's needs. The failure to update the care plan potentially delayed necessary care and treatment for Resident 228's skin injury.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the safe administration of medications during an observation involving a resident. During the medication administration, a Licensed Vocational Nurse (LVN) prepared 13 medications for a resident and accidentally dropped three pills on the floor. Instead of discarding the contaminated pills, the LVN picked them up and placed them back into the medication cup, which was then handed to the resident. The surveyor intervened before the resident could consume the contaminated medications. The resident involved had been admitted to the facility with diagnoses including heart failure and a malignant neoplasm of the right kidney. The resident required partial assistance for personal hygiene and transfers. The Director of Nursing confirmed that the facility's policy required nurses to discard any medications that fell on the floor to prevent contamination, aligning with professional standards of practice. The facility's policy on medication administration emphasized the importance of preventing contamination or infection during the process.
Failure to Provide Timely Foot Care
Penalty
Summary
The facility failed to provide timely foot care for a resident, identified as Resident 42, who was observed to have unclean, yellow, and long toenails on both feet. This deficiency was noted during an observation and interview conducted on July 30, 2024, where the resident expressed a desire for shorter toenails, indicating that no one had trimmed them. The resident's toenails were described by a Licensed Vocational Nurse (LVN) as yellow, thick, long, and surrounded by dry skin. The resident had been seen by a podiatrist on May 21, 2024, but the facility's policy required nail care to be provided as needed between scheduled visits. The resident, who had diagnoses including Chronic Kidney Disease, dementia, and schizophrenia, was noted to have moderately impaired cognition and required assistance with personal hygiene. Despite the facility's policy and the resident's needs, the Social Services Designee (SSD) was not informed by the nursing staff about the resident's long toenails until July 30, 2024. The Director of Social Services confirmed that the last podiatry consult was in May, and the facility's policy indicated that nail care should be provided as needed, highlighting a lapse in communication and care coordination within the facility.
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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