Hi-desert Medical Center D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Joshua Tree, California.
- Location
- 6601 White Feather Rd, Joshua Tree, California 92252
- CMS Provider Number
- 555443
- Inspections on file
- 49
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Hi-desert Medical Center D/p Snf during CMS and state inspections, most recent first.
The facility did not meet its required CNA nursing hours per patient day over a three-day period, as staffing records reviewed with the DON showed CNA hours consistently below the policy and state-required minimums. A resident reported delaying use of the call light due to long response times, while CNAs and an LVN stated they had been working short-staffed. The DON acknowledged ongoing staffing problems and confirmed that required staffing levels for dozens of residents were not achieved during the identified days.
A resident with paraplegia and multiple sclerosis, who was cognitively intact, was noted in nursing documentation to be acting impaired after returning from smoking, prompting a physician order for a UA and drug screen that later returned positive for cannabis. The resident reported occasional, non-prescribed marijuana use in the designated smoking area and stated staff were unaware of this use. Despite a corporate policy requiring investigation of illegal substance use to determine who brought the substance into the facility and whether patients used or had access to it, the facility, as confirmed by the DON, did not investigate or search the resident’s room after the positive drug test.
Two cognitively intact residents reported that an RN responded to a resident’s question about the timeliness of pain medication by yelling, speaking aggressively, and stating she did not have to deal with his medication at that time. One resident described withdrawing, hearing the RN bad-mouthing him in the hall, and feeling anxious and distressed, while another resident went to calm him. A third resident, about four doors away, reported clearly hearing the RN yelling, described her behavior as unprofessional and disrespectful, and later felt anxious about interacting with her. CNAs relayed these reports to the DON, and Social Services staff confirmed that residents described the RN’s tone as loud, dismissive, and lacking composure, consistent with the facility’s policy definition of verbal abuse based on tone of voice.
An allegation of psychological/mental abuse toward a resident was identified but not reported to the Ombudsman and CDPH within the required 24-hour timeframe. Instead, the concern was initially documented as a grievance by a Dietary Supervisor and handed to a social worker, who placed it in the DON’s mailbox while the DON was out of town. The DON later reviewed the grievance, recognized it as an abuse allegation, and filed the SOC 341 several days after the incident, contrary to facility policy and mandated reporter requirements.
A resident with a tracheostomy and PEG tube, documented as comatose and with a history of multiple cerebral infarctions, had a physician’s order for continuous enteral nutrition at a set rate via PEG. For approximately 48 hours, only water was infused through the PEG tube instead of the ordered tube feeding, as later identified in nursing documentation and staff interviews. Although the RN, LVN, and unit monitoring practices required verification of correct formula, labeling, infusion status, and intake at specific times each shift, these checks did not prevent or detect that the pump was continually flushing with water rather than delivering formula. Weight records showed a small weight loss over the review period, and the DON acknowledged that the facility’s enteral nutrition management policy, which required formula at goal rate when appropriate, was not followed.
A resident with multiple medical conditions, including a tracheostomy and recent fractures, was left soiled and did not receive timely assistance with activities of daily living when an RN failed to respond appropriately to the call light and did not notify a CNA or provide care, as confirmed by interviews, record review, and observation.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with a history of depression and paraplegia reported being hit by a CNA during care. The DON confirmed that, during the subsequent abuse investigation, the care plan was not updated and enhanced monitoring was not implemented, contrary to facility policy.
A resident with a history of neurological and cognitive conditions exhibited increased aggressive behaviors, but staff failed to update the care plan or document these changes as required by facility policy. Staff interviews confirmed that documentation and care plan updates were not completed despite clear changes in the resident's condition.
The facility failed to develop and implement comprehensive care plans for four residents, lacking measurable objectives and timeframes. A resident on a ventilator with a sacral wound had no re-evaluated care plan. Two residents with contractures lacked care plans for prescribed Passive Range of Motion exercises. Another resident only had a nutritional care plan, with other necessary plans discontinued. The DON confirmed these deficiencies, which contradicted the facility's care planning policy.
A long-term care facility failed to administer medications as ordered for 23 residents, with nursing staff not notifying physicians or pharmacists of missed doses. Additionally, a resident with a PEG tube received medications through the tube without verifying the route with a physician. These actions violated the facility's medication administration policies, leading to unsafe practices.
A resident with complex medical needs was transferred to a hospital for a suprapubic catheter exchange without notifying their family, as required by facility policy. The absence of documentation confirming family notification was confirmed by the DON, highlighting a lapse in communication between the healthcare team and the resident's family.
The facility failed to provide and document Passive Range of Motion (PROM) services for two residents with contractures, as ordered by their physicians. Despite orders for PROM every Monday, Wednesday, and Friday, there was no evidence of these services being performed. Interviews with staff revealed that neither the Restorative Nurse Assistant nor the Certified Nurse Assistant provided the services, with the CNA stating she was not certified to perform ROM. The Director of Nursing confirmed the lack of documentation and service provision.
The facility failed to respond to call lights in a timely manner for two residents with significant health needs. One resident with paraplegia reported delays of up to two hours, while another with metastatic lung cancer experienced variable response times. Both residents were found to be fully dependent on staff for assistance. The facility lacked a specific policy on call light response times.
The facility failed to ensure accurate controlled medication verification for 17 residents, missing a second nurse's signature on drug count records over several days. Interviews revealed that the policy required two nurses to verify controlled drugs, but records showed only one signature on some occasions.
A resident's controlled medication was improperly removed and destroyed by an LVN, violating facility policies. The LVN took Norco from the medication cart without permission, leading to a discrepancy noted during verification. The facility's policies prohibit such actions, which resulted in the unauthorized diversion of medication.
Failure to Meet Required CNA Staffing Levels Over Multiple Days
Penalty
Summary
The facility failed to provide sufficient nursing staff in accordance with its own staffing policy and state-required nursing hours per patient day (NHPPD) over a three-day period from April 10, 2026, through April 12, 2026. Review of staffing assignments and NHPPD data with the DON showed that the required 3.5 nursing hours per patient day, including a minimum of 2.4 CNA hours per patient day, were not met on these dates. Specifically, the actual CNA NHPPD was 1.79 hours on April 10 (short by 1.71), 1.87 hours on April 11 (short by 1.63), and 2.03 hours on April 12 (short by 1.47). The DON acknowledged that the facility did not meet staffing requirements on these dates and stated that the facility has problems with staffing. During interviews, one resident reported usually not using the call light because it sometimes took a long time for staff to respond. Two CNAs stated that they usually worked with not enough CNAs and that they had been working short, although one noted it was better on the day of the interview. An LVN also reported that they had been working with short nurses lately. These interviews, combined with the staffing records, demonstrated that for three consecutive days the facility did not provide the required number of CNAs to meet its staffing guidelines for 78 residents, with the DON emphasizing the necessity of adequate staffing for patient safety.
Failure to Investigate Resident’s Positive Drug Screen for Marijuana
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to investigate and monitor the use of illegal substances after a resident tested positive for marijuana. The resident was admitted with diagnoses including paraplegia and multiple sclerosis, and had a BIMS score of 15, indicating intact cognition. A nurse’s note documented that the resident was acting impaired after returning from smoking, and a physician ordered a urinalysis with drug screen via straight catheter. Laboratory results from that testing showed the resident was positive for cannabis. Despite the positive drug screen and the facility’s corporate policy defining illegal substances and requiring an investigation to identify who brought the substance into the facility and whether a patient used or had access to it, no investigation was conducted. In an interview, the resident stated she occasionally used non-prescribed marijuana and had smoked it in the designated smoking area without staff awareness. During a subsequent interview and record review, the DON confirmed that no search of the resident’s room or investigation for illegal substances had been performed, and acknowledged that, per policy, an investigation should have occurred after the positive drug test.
Failure to Protect Residents From Verbal Abuse by RN
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively intact residents from verbal abuse by a registered nurse (RN 1). One resident with multiple sclerosis and chronic pain due to trigeminal neuralgia, and another resident admitted after an accident with bone fractures, both had Brief Interview for Mental Status (BIMS) scores of 15, indicating normal cognition. According to interviews, when the resident with multiple sclerosis questioned RN 1 about the timeliness of his medications for chronic pain, RN 1 began yelling and “freaking out.” The resident reported withdrawing from the area, hearing RN 1 “bad mouthing” him in the hallway, and then blocking it out by putting on headphones. He stated that the interaction made him feel “like shit,” “crazy,” and anxious because he needed his pain medication. Another resident reported that RN 1 was yelling at the first resident, saying she did not have to deal with administering his medication at that time and that she was already late, and described RN 1 as aggressive and yelling, which upset the first resident enough that the second resident went to calm him down. A third resident, located approximately 40 feet and four doors down from the first resident’s room, reported overhearing the incident and stated that RN 1 was yelling at the first resident about the timing of his pain medication, describing RN 1 as very unprofessional and disrespectful. This resident emphasized that RN 1’s yelling was audible from his room and reported feeling anxiety about any potential interactions with her afterward. Social Services staff, after meeting with the involved residents, stated that the residents reported RN 1’s tone as loud, that she may not have maintained her composure in a stressful situation, and that she was loud talking and dismissive toward the first resident. The DON reported that CNAs 1 and 2 had brought forward the incident, and the DON characterized the behavior as verbal abuse based on yelling that could be heard down the hallway. CNAs 1 and 2 confirmed that the third resident reported RN 1 was irritated and yelling at the first resident about medication, and one CNA noted having previously heard RN 1 talk “a little loud” toward others. The facility’s abuse policy defines verbal abuse to include use of a tone of voice that causes a resident to feel frightened or threatened, and notes behavioral indicators such as fear, withdrawal, anger, and anxiety.
Failure to Timely Report Allegation of Psychological Abuse
Penalty
Summary
The facility failed to timely report an allegation of psychological/mental abuse toward one resident within the required 24-hour timeframe. Review of a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) dated January 21, 2026, showed that the allegation of psychological/mental abuse was identified on January 13, 2026, but was not reported to the Ombudsman and the California Department of Public Health (CDPH) until January 21, 2026, eight days after the incident. The SOC 341 documented that the allegation involved psychological/mental (mind, emotion, and behavior) abuse toward the resident. During an interview, the DON stated they had been out of town when the incident was initially documented. The DON explained that the Dietary Supervisor wrote the concern as a grievance and gave it to the Social Worker, who then placed it in the DON’s mailbox. The DON reported that on January 21, 2026, they read the grievance, recognized it should have been treated as an allegation of abuse, and then filed the SOC 341. The DON acknowledged there was a delay in reporting and stated that the facility’s policy, "Resident Abuse, Neglect Prevention, Investigation and reporting," requires all mandated reporters to report any allegation of abuse, and that all allegations of abuse not resulting in serious bodily injury must be reported within 24 hours to the facility administrator, CDPH, and the Ombudsman. The DON stated the policy was not followed because mandated reporters did not report the suspected abuse within 24 hours as required.
Failure to Administer Ordered PEG Tube Feeding for 48 Hours
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving enteral nutrition via PEG tube was provided tube feeding according to the physician’s order. The resident was admitted with a tracheostomy and PEG tube and had a history of hypertension, hyperlipidemia, and multiple cerebral infarctions. The MDS documented the resident as comatose with no discernible consciousness. Physician orders dated January 19, 2026, directed continuous tube feeding at 60 ml/hr via PEG tube. However, the resident did not receive the ordered enteral formula for approximately 48 hours, during which only water was infused through the PEG tube instead of the prescribed tube feeding. Interviews with staff described how tube feedings were expected to be managed and monitored. RN 1 stated that RNs and LVNs were responsible for managing tube feedings, including checking them at the start of each shift, during designated shut-off times, and at the end of the shift to document intake. The Clinical Coordinator reported that tube feedings were to be monitored during rounds to verify the correct formula, proper labeling, and that the feeding was infusing, and that feeding and water were to be changed every 24 hours. Despite these stated practices, the nursing narrative documented that when the resident was reconnected to enteral feeding, it was discovered that only water had been running through the system and that the pump appeared to be continually flushing with water instead of delivering the ordered formula. Further record review showed that the resident’s weights decreased from 87.2 kg to 85.4 kg over an 11-day period. The nursing narrative documented that the physician was notified that the resident’s tube feeding had not been administered for 48 hours and that only water had been infused via the PEG tube during that time. RN 1 acknowledged that nursing staff should have checked the feeding to ensure it was being administered as ordered and stated that it was important for residents to receive needed nutrition. Review of the facility’s policy, “Guidelines for Management of Enteral and Parenteral Nutrition,” indicated that enteral formula should be initiated at full strength at goal rate if there was no GI compromise. The DON stated that this policy was not followed and confirmed that it was important to meet each resident’s nutritional needs.
Failure to Provide Timely Assistance with Activities of Daily Living
Penalty
Summary
A resident with a complex medical history, including blunt abdominal trauma, non-displaced C5 and C7 fractures, anxiety, a right upper arm partial thrombus, and a tracheostomy, was admitted to the facility. The resident was left soiled and their activities of daily living were not met in a timely manner. The incident occurred when a registered nurse failed to respond to the resident's call light and did not provide assistance when the resident attempted to communicate her needs. The nurse initially believed the call light was for another patient and, upon realizing it was for this resident, asked her to write down her request when she could not speak clearly. When the resident did not write down her needs, the nurse did not pursue further assistance and continued with other tasks until a respiratory therapist informed him that the resident needed to be changed. Interviews and record reviews confirmed that the nurse did not notify a CNA or provide timely care, resulting in the resident remaining soiled. The facility's policy requires that residents receive good personal hygiene and timely care to prevent bedsores and incontinence. The Director of Nursing acknowledged that there was no justification for the nurse's failure to assist or communicate the resident's needs to other staff. This lapse in care was identified through interviews, record reviews, and direct observation.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the required reporting process for such incidents. The report indicates that when an event involving suspected abuse, neglect, or theft occurred, the facility did not fulfill its obligation to promptly notify the appropriate authorities or provide the outcomes of its internal investigation as required.
Failure to Update Care Plan and Implement Monitoring During Abuse Investigation
Penalty
Summary
The facility failed to follow its policy and procedure for resident abuse in the case of one resident. After an allegation was made that a Certified Nurse Assistant (CNA) hit the resident on the buttocks and thighs while assisting with dressing, the resident expressed concern that the incident could recur if not reported. The Director of Nursing (DON) confirmed that, during the investigation, no interventions were added to the resident's care plan, and enhanced monitoring was not implemented as required by facility policy. Record review showed that the resident had a history of depression, paraplegia due to a self-inflicted gunshot wound, and left-sided weakness. The facility's policy stated that during an abuse investigation, actions such as assessment, care planning, supervision, staff assignment, and monitoring should be taken to ensure the resident's health and safety. The DON acknowledged that the care plan was not updated or revised following the incident, and the required monitoring was not put in place during the investigation process.
Failure to Update and Document Changes in Resident's Care Plan
Penalty
Summary
The facility failed to follow its policy and procedure for care plan documentation for one resident when the care plan was not updated to reflect changes in the resident's condition and behaviors. Specifically, a resident with a history of subdural hemorrhage, aphasia, and dementia exhibited increased aggressive behaviors, including yelling, slamming doors, and inappropriate interactions with another resident. Despite these changes, the care plan was not updated, and nursing staff did not document the resident's outbursts or aggressive behaviors as required by the facility's policy. The last documented update in the care plan was several weeks prior to the observed incidents. Interviews with staff confirmed that the resident's care plan should have been updated to reflect the recent behavioral changes, and that documentation of each outburst or aggressive behavior was not completed as per policy. The Director of Nursing acknowledged that the policy regarding care plan documentation was not followed, emphasizing the importance of timely updates and documentation to ensure effective communication among staff.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four of five sampled residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. For Resident 24, who was on a ventilator and had a sacral wound, the care plan lacked measurable goals and timeframes, and there was no re-evaluation of the care plan since its initiation. The Director of Nursing confirmed that the care plan should have been initiated and re-evaluated as needed. Resident 61, who had anoxic brain injury and contractures, did not have a care plan developed for the prescribed Passive Range of Motion exercises. The Director of Nursing verified that a care plan should have been initiated the same day the physician order was received. Similarly, Resident 67, who also had contractures and required Passive Range of Motion exercises, did not have a care plan developed and implemented, as confirmed by the Director of Nursing. Resident 50, with a history of cerebral vascular accident and other conditions, only had an active care plan for nutritional status, while other necessary care plans were discontinued. The Director of Nursing was unable to provide documented evidence of the required care plans for Resident 50, confirming that the nursing staff should have documented the care plan. The facility's policy and procedure on care planning emphasized the need for documentation and consideration of individualized patient needs, which was not adhered to in these cases.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff administered medications as ordered for 23 out of 41 sampled residents. On December 1, 2024, medications were not administered to 22 residents, and the responsible physician or pharmacist was not notified of the missed doses. This included critical medications such as levetiracetam and apixaban, which are essential for managing conditions like seizures and preventing blood clots. The Director of Nursing confirmed that the facility's policy and procedure for medication administration were not followed, as the nursing staff did not report the medication omissions or notify the appropriate medical personnel. In a separate incident, a resident with a PEG tube was administered medications through the tube without verifying the route of administration with a physician. The resident had orders for oral medications, but due to their inability to swallow, the medications were given via the G tube. The registered nurse responsible for administering these medications did not notice the discrepancy in the route of administration, and the physician was not informed of the change in administration method. The Interim Director of Nursing acknowledged that the nursing staff failed to adhere to the facility's policy, which requires validation of the six rights of medication administration, including the right route. These failures in medication administration resulted in unsafe practices that could potentially lead to adverse health outcomes for the residents involved. The facility's policy and procedure for medication administration were not followed, leading to a lack of communication with physicians and pharmacists regarding missed doses and changes in medication administration routes. This oversight highlights significant deficiencies in the facility's medication management processes.
Failure to Notify Family of Resident Transfer
Penalty
Summary
The facility failed to notify the family or emergency contact of a resident before transferring them to an acute care hospital for a suprapubic catheter exchange. This deficiency was identified during a review of the resident's emergency department physician note and interviews with facility staff. The resident, a male with a history of quadriplegia, tracheostomy, ventilator dependency, neurogenic bladder, and suprapubic catheter dependency, was transferred from the long-term care facility without documented evidence of family notification. Interviews with a Licensed Vocational Nurse and the Director of Nursing revealed that the facility's policy requires family notification upon any transfer, which was not adhered to in this case. The Director of Nursing confirmed the absence of documentation regarding family notification in the resident's medical record. The facility's policy and procedure for transferring residents requiring emergency or acute care also mandates notifying the resident's primary contact, which was not followed, leading to a lack of communication between the resident's family and the healthcare team.
Failure to Provide and Document PROM Services
Penalty
Summary
The facility failed to provide Passive Range of Motion (PROM) services as ordered for two residents, leading to a deficiency in care. Resident 61, who was observed on the sub-acute unit, had bilateral upper extremities contractures and was supposed to receive PROM services every Monday, Wednesday, and Friday. However, there was no documented evidence that these services were provided on the specified dates. Interviews with the Restorative Nurse Assistant (RNA) and Certified Nurse Assistant (CNA) revealed that neither provided the PROM services, with the CNA stating she was not certified to perform ROM. Similarly, Resident 67, who also had contracted upper extremities and was breathing via tracheostomy, was not provided with the ordered PROM services. The physician's order for Resident 67 also indicated PROM every Monday, Wednesday, and Friday, but there was no documentation of these services being performed. The RNA and CNA both confirmed they did not provide the services, and the Director of Nursing (DON) verified the lack of documentation and service provision. The facility's policy and procedure on Wound Care Management Pressure Wounds required turning with range of motion every two hours and as needed, along with appropriate documentation. However, the failure to provide and document PROM services for Residents 61 and 67 indicates a lapse in following these procedures, as confirmed by the DON during the review of the residents' records.
Delayed Call Light Response for Clinically Compromised Residents
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, affecting two residents who were clinically compromised. Resident 1, who has paraplegia and is totally dependent on staff for transfers, reported that it sometimes took up to two hours for staff to respond to calls for help. This was observed during an interview where Resident 1 was found seated in a wheelchair, indicating reliance on the wheelchair for mobility. Resident 1's clinical records confirmed a diagnosis of paraplegia and a Brief Interview for Mental Status (BIMS) score indicating no mental impairment. Similarly, Resident 2, who has lung cancer that has metastasized to the bone and is totally dependent on staff for assistance with activities such as using the commode, reported variable response times to call lights, ranging from prompt to delays of up to 45 minutes. During an interview, Resident 2 was found lying in her room, indicating reliance on staff for commode use. Resident 2's clinical records also showed a BIMS score indicating no mental impairment. Interviews with the Director of Nursing and the Administrator revealed that the facility lacked a specific policy on call light response times.
Controlled Medication Verification Deficiency
Penalty
Summary
The facility failed to maintain an accurate controlled medication verification process for 17 residents, as evidenced by missing signatures from two licensed nurses on the controlled drug count records. This deficiency was observed on seven out of 20 days between August 1, 2024, and August 20, 2024. The absence of a second nurse's signature was noted on specific shifts, including both AM and PM shifts on certain days. This lapse in procedure was identified during a review of the facility's control drug count records. Interviews conducted with the Director of Staff Development, the Pharmacist Consultant, and the Administrator revealed that the facility's policy required two nurses to verify controlled drugs at the beginning and end of each shift. However, the drug count sheets for August 2024 showed instances where only one nurse's signature was present. The Administrator acknowledged being recently informed of this issue. The facility's policy, dated March 15, 2017, mandates that high alert medications be checked by two licensed nurses, with both required to document the verification process in the Medication Administration Record (MAR).
Unauthorized Removal of Controlled Medication by LVN
Penalty
Summary
The facility failed to ensure the secure storage of controlled medications for a resident, leading to the wrongful use of the resident's belongings. A Licensed Vocational Nurse (LVN) took acetaminophen and hydrocodone (Norco) from the medication cart without permission, resulting in the diversion of controlled medication. This incident involved a resident who was admitted with a diagnosis of unspecified focal traumatic brain injury and had orders for Norco to be administered as needed for pain management. During a controlled medication verification, discrepancies were noted, and it was discovered that 18 tablets of Norco were missing. Interviews revealed that the LVN took the pill card and remaining medication home and destroyed them, admitting to the action but unable to explain the discrepancy. The facility's policies and procedures clearly state that controlled medications should not be surrendered to anyone other than specified parties, highlighting a breach in protocol. The incident was reported by a Registered Nurse (RN) who noticed the discrepancy and informed the facility's management. The LVN's actions resulted in the unauthorized removal and destruction of the resident's medication, violating the facility's medication storage policies.
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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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