Park Anaheim Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 3435 W Ball Road, Anaheim, California 92804
- CMS Provider Number
- 555035
- Inspections on file
- 23
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Park Anaheim Healthcare Center during CMS and state inspections, most recent first.
Kitchen sanitation deficiencies were identified when surveyors observed two heavily marred cutting boards, a thick ice buildup inside the ice cream freezer, and a Dietary Aide with uncovered facial hair in the food prep area. Staff verified the findings, and the report cited food safety guidance and facility policy requiring cleanable cutting surfaces, freezer maintenance, and hair restraints for facial hair.
The facility failed to maintain infection control practices when an LVN did not change PPE or perform hand hygiene between caring for two residents on EBP, a CNA did not perform hand hygiene after removing gloves before entering another resident’s room, the lint trap log had multiple missing entries, and a resident’s electric fan was observed covered in dust. The residents involved had orders for EBP related to trach, GT, wounds, and MDRO colonization.
Unsanitary Ice Machine and Countertop Oven: The facility failed to maintain an ice machine and a [NAME] Spunkmeyer countertop oven in sanitary condition. Surveyors observed black buildup residue on the ice machine’s water curtain and brown residue on the oven’s inside metal panel. The Maintenance Supervisor was unaware of the buildup, and the Maintenance Assistant stated staff should have cleaned the oven after every use.
The facility failed to complete a bed entrapment assessment before a resident used bilateral upper bed rails and failed to document monthly inspections for all beds in use. A resident who had capacity to make decisions and needed partial/moderate assistance with mobility was observed using elevated side rails, and RN and Maintenance staff confirmed the rails were in use and that maintenance was responsible for the zone assessment. The February bed safety checklist did not show the required entrapment measurement for that resident, and the monthly bed maintenance log listed only a few rooms rather than all resident beds.
Failure to inform a resident of a urine culture result: A resident who was alert, oriented, and cognitively intact had a urine culture positive for ESBL reviewed by nursing and the physician with no new order, but the record did not show that the resident was told the result. During interview, the resident indicated she had not been informed, and an RN confirmed the chart lacked documentation that the resident was notified of the abnormal lab result.
A resident's call light was found on the floor beside the bed and not within reach while the resident was lying in bed. The resident stated she did not know where the call light was, could not see or reach it, and would not be able to call for help if needed. The record showed a care plan to keep the call light within reach, and the DON later confirmed the call light should be accessible to allow the resident to communicate with staff.
Advance Directive Not Maintained in Resident Record: A resident had an executed advance directive, and the record also showed the resident had capacity to make medical decisions. However, the facility did not maintain a copy of the advance directive in the medical record or EHR, and the SSD verified it was not readily retrievable by staff. The record also showed the family reported the resident had an advance directive but did not provide a copy to the SSD.
A resident with a trach and ventilator support was observed wearing a blue right hand mitten even though the MD order required the mitten to be off on Sunday. The resident had been ordered the mitten due to attempts to pull out life-sustaining tubes, and an LVN verified the order but found the mitten still in place during Sunday observations.
Psychotropic Medication Documentation and Monitoring Deficiencies: Surveyors found that one resident receiving PRN lorazepam had no documented nonpharmacological interventions before administration and no documentation tied to multiple anxiety-related behaviors, while another resident receiving escitalopram had no documented nonpharmacological interventions for episodes of hopelessness and helplessness and incomplete orthostatic BP monitoring. The DON, RN, and an LVN verified the missing documentation during record review.
A facility failed to develop person-centered care plans for three residents. One resident had a positive ESBL urine culture after a change in condition, another used bilateral upper bed rails for turning and transfers, and a third had DM II with orders for basal and sliding-scale insulin. RN review confirmed that no care plans were in place to guide monitoring, interventions, or goals for these issues.
A resident’s activity care plan was not revised to reflect current needs after the resident was no longer on mechanical ventilation. The care plan still described the resident as ventilator dependent and needing social and sensory stimulation related to the subacute unit, while the Activity Director confirmed the resident was no longer on a vent and the record did not show mechanical ventilation. The resident was observed in bed, nonverbal, with GT feeding off, and the H&P noted the resident could make simple needs known but had no capacity to report subjective complaints.
The facility failed to follow an ordered orthostatic BP check for one resident, as the MAR showed identical lying, sitting, and standing readings that RN staff and the DON acknowledged were not accurate. The facility also failed to continuously monitor another resident after a positive ESBL urine culture, despite staff stating that abnormal lab results are a change in condition and that monitoring should occur every shift for 72 hours or more as needed. Interviews and record review confirmed the lack of documented ongoing assessment after the lab result and the inaccurate BP documentation.
Low Air Loss Mattress Set Incorrectly for a Resident With Pressure Injury. A resident with a sacrococcyx pressure injury was ordered a low air loss mattress for wound care management, but staff observed the mattress set at the 400-pound mark even though the resident weighed 82 pounds. An LPN verified the incorrect setting and stated the mattress should be based on the resident's weight to help prevent skin breakdown or worsening of the wound; the DON later acknowledged the finding.
Failure to Provide Required Two-Person Assistance During ADL Care: A dependent resident with TBI, tracheostomy, bed confinement, and contractures was repositioned by one CNA instead of two, fell from the bed, and sustained a right first metatarsal fracture. Staff interviews confirmed the resident required two-person assistance for turning and repositioning, and the same issue was identified for two other residents who were dependent for rolling and ADL care. Observations and interviews showed one-person assistance was sometimes used during cleaning, turning, and repositioning despite the residents’ dependent status.
GT Feeding Orders Not Fully Followed: The facility did not provide ordered enteral feeding care for several residents. A resident receiving GT feeding was not kept at the ordered head-of-bed elevation and the feeding was not held as ordered before phenytoin administration. Several other residents had tube feeding bags still full or nearly full when observed, and pump histories showed they did not receive the full ordered amounts of formula.
A resident with hypoxic ischemic encephalopathy and no full medical capacity was ordered oxygen at 3 LPM via NC, with titration up to 5 LPM for low O2 sats. Staff observed and verified the resident was actually receiving only 2 to 2.5 LPM, below the physician’s order, and an RN stated it should have been 3 liters based on the resident’s orders and shift report review.
A resident receiving dialysis had a dialysis center instruction to remove the old left arm graft dressing after treatment to avoid clotting of the access site, but the record did not show the instruction was addressed. The resident returned from dialysis with stable VS and a functioning access site, yet there was no documentation that the physician was informed, the instruction was carried out by nursing staff, or the event was recorded in the progress notes.
A resident was observed using bilateral upper bed rails with green tape indicating they were elevated. The record did not show a physician order, informed consent, a restraint assessment, or documentation of the medical symptoms supporting bed rail use, and there was no evidence that less restrictive alternatives were tried first. RN confirmed the resident was using the rails and that the required order, consent, assessment, and prior alternatives had not been completed.
Daily nurse staffing information was not kept current at Station A, where the posted census and DHPPD sheet showed an outdated date instead of the current day. Facility policy required daily posting of nurse staffing data with the current date, and the DSD verified the SNF-side posting was not current; the DON and Administrator acknowledged the finding, and the DON stated the posting should be updated at the beginning of the shift.
A resident's GT feeding was left unattended at the bedside instead of being stored until use. Surveyors observed the Glucerna tube feeding at the bedside during multiple checks, and an LVN confirmed it had been left there for the next shift. The resident had no capacity to understand and make decisions, and the feeding was labeled with the resident's name, room number, and rate.
Delayed Reporting of Abnormal UA C&S Result: A resident's UA C&S final result showed >100,000 colonies of Enterococcus faecalis, but the abnormal lab result was not reported to the MD until four days after it was available. RN documentation later noted new orders for Amoxicillin 500 mg TID for 10 days, and the facility policy required timely nurse review and communication of lab results based on the seriousness of the abnormality and the resident's condition.
Incomplete Documentation of Tube Feeding Intake: The facility failed to document the amount of GT feeding formula administered to a resident on the Intake record. The resident had physician orders for enteral feeding with VITAL AF and for I&O monitoring every shift, but the record showed multiple missing tube feeding intake entries across several shifts. RN verified the omissions during a concurrent record review, and the DON acknowledged the findings.
A resident on a ventilator did not have their suction canister changed in accordance with facility policy, resulting in the canister becoming full before it was replaced. Staff confirmed the canister had not been changed as required, and acknowledged it should have been replaced when 3/4 full or as needed.
A resident's room contained an air fryer and Keurig coffee machine that had not been approved or inspected according to facility policy. Staff, including LVNs and CNAs, had not received training on the safe use or maintenance of these appliances, and the Maintenance Director was unaware of their presence. The appliances were used by the resident with staff assistance, but no procedures were in place to ensure their safe operation.
A facility failed to document and monitor a resident's change in condition as per protocol. The resident, who had a physician's order for Levofloxacin due to fever and cough, lacked proper documentation for the change in condition, an updated care plan, and nurse progress notes. Interviews with staff confirmed the oversight, highlighting a failure to adhere to facility policies.
A facility failed to implement proper infection control practices for a resident with an indwelling suprapubic urinary catheter. Despite signage indicating the need for Enhanced Barrier Precautions (EBP), a CNA was observed changing the resident's brief while only wearing gloves, failing to don a gown as required. The Infection Preventionist confirmed the expectation for staff to wear both gloves and a gown during high-contact care activities, acknowledging the lapse in following infection prevention protocols.
The facility failed to ensure the DSS was competent in supervising kitchen operations, leading to potential foodborne illness risks for residents. The DSS used raw shelled eggs that were not fully cooked, demonstrated incorrect thermometer calibration, and was unaware of health shake guidelines. Additionally, worn equipment was not replaced, and beard coverings were unavailable for staff with facial hair. The Administrator did not evaluate the DSS's competency, relying on the RD, who had not conducted a formal evaluation.
The facility failed to ensure kitchen staff competence, leading to unsafe food handling practices. Cook 1 did not follow hand hygiene protocols, inaccurately took food temperatures, and did not follow recipes or test sanitizing solutions correctly. DA 1 was unable to read the dish machine temperature dial, posing a risk for improper dishwashing procedures.
The facility did not adhere to the prescribed recipes for pureed diets, affecting the nutritional needs of 15 residents. Observations revealed that pureed sweet and sour chicken, vegetables, and noodles were not prepared according to the recipes, with incorrect consistencies and high sodium content due to the use of unmeasured thickeners and inappropriate broth. The RD and DSS confirmed the necessity of following recipes to meet residents' nutritional needs.
The facility failed to meet food safety and sanitation standards, with issues such as undercooked eggs, improper hand hygiene, and inadequate food storage and preparation procedures. Kitchen equipment was not maintained in a sanitary condition, and staff did not use hair restraints. A resident's personal refrigerator was not kept at the correct temperature, with no corrective actions documented. These deficiencies posed a risk of foodborne illnesses to residents.
The facility failed to maintain the dignity and privacy of two residents. A resident with an indwelling urinary catheter had an uncovered drainage bag, compromising dignity. Another resident was exposed during a transfer to a shower bed, with the door left open, violating privacy. Staff acknowledged these oversights, which were against facility policies.
The facility failed to ensure informed consents were properly completed for several residents, as required by policy. Informed consents for treatments, including the use of gerichairs, side rails, and medications, were not signed and dated by physicians for multiple residents, some of whom lacked decision-making capacity. These deficiencies were confirmed by nursing staff and acknowledged by the administration.
A facility failed to maintain a copy of a resident's advance directive in their medical record, as required by the facility's policies. Despite the resident having an advance directive, confirmed by a POLST and an Advance Directive Acknowledgement, the document was not found in the medical record. The Social Service Director verified the absence, and the Director of Nursing acknowledged the deficiency.
The facility failed to manage and document the use of restraints for three residents, leading to potential risks of injury and decreased range of motion. A resident had an elbow splint without a current physician's order or documentation of removal and assessment. Two other residents had hand mitten restraints without proper documentation of removal and assessment every two hours, as required by facility policy. Staff interviews confirmed the lack of adherence to restraint policies.
A facility failed to develop a comprehensive care plan for a resident, omitting details about nighttime ventilator use and an elbow splint. Observations and interviews revealed the resident regularly used an elbow splint, which was not documented in the care plan. Additionally, the care plan did not reflect the resident's current ventilator schedule, as confirmed by the Respiratory Lead.
A resident at high risk for falls did not have their tab alarm properly applied as ordered by the physician. Observations showed the alarm was not consistently attached, and staff interviews confirmed the improper application. This failure placed the resident at risk for serious injuries.
A facility failed to verify the placement, patency, and gastric residuals of a GT before starting enteral feeding for a resident. The LVN connected the feeding formula and water flush tubing without performing the necessary checks, contrary to the facility's protocol and physician's orders. The ADON confirmed the protocol required these checks to prevent potential adverse outcomes.
The facility failed to provide appropriate respiratory care for three residents. Two residents had unlabeled oxygen tubing, which is required for infection control, and staff could not confirm when it was last changed. Another resident received oxygen at a rate higher than the physician's order. The DON acknowledged these deficiencies.
A resident experiencing pain did not receive non-pharmacological interventions as outlined in the facility's pain management policy. Despite having a care plan that included non-pharmacological methods like positioning, hot packs, and massage, these interventions were not documented or provided when the resident reported significant pain levels. The RN confirmed the oversight, and the DON acknowledged the findings.
A facility failed to ensure licensed staff were competent in assessing a resident's hemodialysis access site, leading to inadequate care. Despite a policy requiring training for staff caring for residents with ESRD, interviews revealed inconsistencies in understanding how to check for bruit and thrill. The deficiency was identified through medical record reviews and staff interviews, with the DON acknowledging the need for further training.
The facility failed to document attempts of alternative measures before applying side rails for several residents, despite policy requirements. Residents with varying cognitive and physical abilities were subjected to side rail use without proper assessments or documentation, potentially exposing them to risks associated with side rails.
The facility failed to ensure physician's orders matched medication labels and administered medications as ordered for two residents. One resident received digoxin with a label discrepancy, while another was given metoprolol tartrate without food, contrary to physician's orders. Staff acknowledged the errors, and the administration was informed.
The facility failed to properly store and separate medications, maintain clean medication carts, and accurately document blood glucose meter serial numbers for two residents. Medications were improperly mixed in storage areas, and multiple medication carts were found with unsanitary residues. Additionally, discrepancies in serial numbers for blood glucose meters were identified, indicating lapses in record-keeping.
The facility failed to preserve the nutrient content of pureed vegetables for 15 residents on a pureed diet. Pureed vegetables were prepared over an hour before meal service and stored in an oven at 500°F, which was not ideal for nutrient preservation. This practice was confirmed by the RD and posed a risk to the residents' nutritional needs.
Two residents were not provided with meals that met their specific dietary needs, risking aspiration or choking. One resident, awaiting oral surgery, received improperly minced chicken, while another was given inappropriate snacks contrary to her mechanical soft diet order. Staff confirmed the discrepancies, highlighting a failure in adhering to dietary orders.
A resident's request for collard greens was not honored by the facility, despite being documented in a Resident Council meeting. The Dietary Services Supervisor acknowledged the request but did not purchase the item or follow up with the resident. The resident's care plan indicated a risk for nutritional issues, yet the facility failed to accommodate the dietary preference, potentially affecting the resident's wellbeing.
The facility failed to ensure safe storage and handling of food brought in by visitors for three residents, potentially exposing them to foodborne illnesses. Despite a policy discouraging outside food, residents received food without proper guidance on safe handling. Staff interviews revealed a lack of procedures and training, with no refrigeration for outside food and unclean microwaves used for heating. The Director of Staff Development confirmed no staff training on safe food handling guidelines.
The facility failed to properly dispose of garbage and refuse, with open dumpsters and improper handling of organic and recyclable waste. Observations showed trash bags and cardboard boxes stored improperly, leading to potential unsanitary conditions. The Maintenance Director and Administrator confirmed these findings.
The facility failed to maintain accurate medical records and assess entrapment risks for residents using side rails. A resident was incorrectly documented as being on a ventilator, and multiple residents had inaccurate side rail assessments, with all zones marked despite not all being applicable. These inaccuracies were confirmed by staff interviews, posing potential risks to resident care.
The facility failed to maintain infection control practices, with used items found in clean areas, improper maintenance of a water feature, and inaccurate infection surveillance. An LVN used enteral tubing from the floor for a resident's GT feeding, and another did not perform hand hygiene before medication administration. Unlabeled basins were improperly stored in shared restrooms. These issues were confirmed by staff and management.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen during survey observations and interviews. During the initial kitchen tour, two cutting boards were observed heavily marred with chipped areas, and the Dietary staff member present verified the finding. The report cited USDA Food Code guidance stating that scratched and scored cutting surfaces may be difficult to clean and sanitize and may allow pathogenic microorganisms to build up or transfer to foods prepared on those surfaces. The survey also found the ice cream freezer had a thick ice buildup on the plastic lining of the right interior side near the door, which was verified by the Dietary staff member. In addition, a Dietary Aide was observed in the food preparation area with uncovered facial hair and stated he needed to use a beard net. The DSS verified that facial hair needed to be covered, and the facility’s policies referenced maintaining sanitary conditions and using hair restraints for facial hair.
Infection Control Lapses in PPE Use, Hand Hygiene, Documentation, and Environmental Cleanliness
Penalty
Summary
The facility failed to maintain infection prevention and control practices during care provided to Residents 4 and 6 in an Enhanced Barrier Precautions room. Resident 4 had an order for enhanced barrier precautions related to a tracheostomy tube and GT, and Resident 6 had a similar order related to a tracheostomy tube and GT. During observation, LVN 14 was wearing gown and gloves while assisting Resident 6, then removed Resident 6’s left hand mitten while making contact with the resident’s bed linen. The LVN then assisted Resident 4 remove her hand mittens and made contact with Resident 4’s bed linen after readjusting the bed sheets without changing PPE or performing hand hygiene. The LVN acknowledged not changing PPE or performing hand hygiene between residents and stated she should have done so. The facility also failed to maintain required documentation for the lint trap log. Review of the March 2026 lint trap log showed multiple missing entries across several dates and times, including repeated omissions for afternoon, evening, and overnight checks. The Maintenance Assistant verified that the log was missing multiple dates and times the lint trap was monitored and stated staff forgot to sign. The Maintenance Assistant stated the lint trap was checked to prevent fires. In addition, CNA 1 was observed providing personal care to Resident 13, who had enhanced barrier precautions for a tracheostomy tube, GT, wound, and colonization of C. auris. After doffing PPE, CNA 1 did not perform hand hygiene and went directly to Resident 106’s room, where he pulled up the blanket to cover the resident. Resident 106 had enhanced barrier precautions for a GT, tracheostomy, colostomy, and history of CRAB colonization. The facility also observed Resident 31’s green electric fan on the nightstand with dust on the front and rear grills and blades. The Maintenance Director and LVN 9 both verified the fan was dusty, and the Maintenance Director stated it should have been cleaned if staff knew about it.
Unsanitary Ice Machine and Countertop Oven
Penalty
Summary
The facility failed to maintain essential equipment in clean and safe operating condition. During observation and interview, the ice machine in the kitchen was found with the top front cover removed, and when it was wiped with a clean white towel, a black buildup residue was removed from the water curtain adjacent to the ice bin. The Maintenance Supervisor stated the ice machine was cleaned every month but was not aware of the black buildup that was identified during the inspection. The facility also failed to keep the [NAME] Spunkmeyer countertop oven in a sanitary condition. During observation in the main dining area, the oven was seen with brown residue on the right inside metal panel. The Maintenance Assistant verified the residue and stated staff should have cleaned it after every use. The DSS, Administrator, and DON were informed and acknowledged these findings.
Missing Bed Entrapment Assessment and Incomplete Bed Inspection Logs
Penalty
Summary
The facility failed to ensure that bed entrapment inspections were completed for all beds in use and failed to complete an entrapment assessment for one resident before bilateral upper bed rails were used. The facility’s Bed Safety and Entrapment policy stated that all bed frames, mattresses, and bed rails would be inspected to identify possible entrapment areas, and the Bed Safety and Bed Rails policy stated that bed frames, mattresses, and bed rails were to be checked for compatibility and size prior to use, with maintenance staff routinely inspecting beds and related equipment for potential entrapment risks. Resident 20 was observed in bed with bilateral upper bed rails elevated and green tape around the rails, and the resident stated he had been using the bed rails since admission and used them to turn in bed and transfer to a wheelchair. The resident’s record showed he had been readmitted to the facility, had capacity to understand and make decisions, and required partial/moderate assistance with mobility. RN 1 confirmed the resident was using the bilateral upper bed rails and stated maintenance staff completed the bed rail entrapment assessment and measurement during bed inspection. The Maintenance Supervisor stated the maintenance department was responsible for completing the zone assessment and measurement to ensure residents would be free of possible entrapment while using bed rails, and that monthly inspections were to be completed for all beds used by residents. However, the February 2026 Bed Safety Checklist for Residents with Side Rails did not show an entrapment assessment or zone measurement for Resident 20. The Monthly Bed Maintenance Checklist also did not reflect inspections of all beds used by residents, showing only a few rooms documented for January, February, and March 2026, and the Maintenance Supervisor stated the log only included beds they had fixed rather than a monthly inspection of all beds.
Failure to Inform Resident of Urine Culture Result
Penalty
Summary
The facility failed to ensure that Resident 13 was informed of the result of a urine culture test. The facility’s policy stated that the resident is to be promptly notified of changes in medical or mental condition or status and that, regardless of the resident’s condition, a nurse or healthcare provider will inform the resident of any changes in medical care or nursing treatments. Review of the record showed Resident 13 was readmitted to the facility, was alert and oriented to person, place, and time on H&P examination, and was cognitively intact on MDS assessment. Resident 13’s urine culture collected on 3/10/26 resulted on 3/14/26 as positive for ESBL and was reviewed by RN 6, with a handwritten note indicating the physician saw the result and no new order was given. The medical record did not show documentation that Resident 13 was informed of the urine culture result. During interview, Resident 13 indicated she had not been told the result. RN 4 confirmed that an abnormal laboratory result was considered a change in condition, that the resident or responsible party should be notified, and that the record did not show Resident 13 was informed of the urine culture result. The DON was also informed of and acknowledged the findings.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to provide a reasonable accommodation for one resident by not keeping the call light within reach. During an observation, the resident was lying in bed and the call light was found on the floor on the left side of the bed, far from the resident's reach. The resident stated she did not know where the call light was, said she would use it to call staff when she needed assistance, and attempted to reach for it but stated she was unable to see and reach it. She also stated that if she needed help, she would not be able to reach the call light to get help. The resident's record showed a care plan addressing self-care deficits with interventions to keep the call light within reach and attend to needs promptly. The resident's H&P stated she was able to make decisions for ADLs, and the MDS showed a BIMS score of 12, indicating moderate cognitive impairment. On follow-up observation with the DON, the resident was again observed in bed with the call light hanging and on the floor on the left side of the bed, not within reach. The DON stated the call light should be within the resident's reach to ensure safety and allow communication with staff when assistance was needed, and acknowledged the findings.
Advance Directive Not Maintained in Resident Record
Penalty
Summary
The facility failed to maintain a copy of Resident 42’s advance directive in the medical record so it was readily retrievable by facility staff. Facility policy stated that if a resident or representative had executed an advance directive, copies were to be obtained and maintained in the same section of the resident medical record and be readily retrievable by any facility staff. Review of Resident 42’s record showed an IDT Advance Directives for Care note dated 3/7/24 stating that, according to the resident’s family member, Resident 42 had an advance directive but did not have a copy to provide to the SSD. Resident 42’s Advance Healthcare Directive Acknowledgment form dated 2/28/25 showed that an advance directive had been executed, and an H&P dated 9/23/25 showed the resident had capacity to make medical decisions. However, further review of the medical record did not show a copy of the advance directive, and on 3/23/26 the SSD verified that no copy was in the medical record or uploaded in the EHR. The SSD stated the follow-up with the family member should have been documented and a copy obtained and placed in the record; the DON was later informed and acknowledged the findings.
Failure to Remove Ordered Hand Mitten on Sunday
Penalty
Summary
The facility failed to ensure that one sampled resident was free from an unnecessary physical restraint. The resident had a tracheostomy tube connected to a ventilator and was observed sleeping in bed with a blue right hand mitten in place. The resident's history and physical noted respiratory failure with full ventilatory support and that the resident turned head to tactile stimuli. The resident's physician ordered the right hand mitten to be applied because the resident was attempting to pull out life-sustaining tubes, with the mitten to be used daily and off on Sunday, and hand hygiene to be provided during release of the mitten. During multiple observations on Sunday, the resident was still wearing the right hand mitten. The LVN verified the order required the mitten to be off on Sunday and acknowledged that the mitten remained on when it should have been removed.
Psychotropic Medication Documentation and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure two sampled residents were free from unnecessary psychotropic medication use and related documentation gaps. The facility’s Psychotropic Medication Use policy stated residents would not receive medications that were not clinically indicated and that non-pharmacological approaches would be used unless contraindicated to minimize the need for medication and allow discontinuation when possible. Surveyors reviewed records, observed documentation, and interviewed staff regarding the use and monitoring of lorazepam for one resident and escitalopram for another resident. For one resident, the record showed a physician’s order for lorazepam 0.5 mg via GT every six hours as needed for anxiety manifested by attempting to pull out life-sustaining tubes and getting out of bed, with monitoring of anxiety episodes for use of the medication. The record did not show what nonpharmacological interventions would be attempted before giving the medication. The MAR showed lorazepam was administered on three occasions, but there was no documentation of any nonpharmacological intervention provided before administration. The MAR also did not show documented evidence of nonpharmacological interventions or whether lorazepam was given during multiple documented episodes of the resident attempting to pull out life-sustaining tubes and get out of bed. An LVN and the DON verified the order and documentation gaps during interview. For the other resident, the record showed orders to monitor episodes of hopelessness, helplessness, abandonment, worthlessness, and similar statements related to escitalopram use, to administer escitalopram 15 mg daily for depression, to document every shift the nonpharmacological interventions attempted or used with the psychotherapeutic medication, and to monitor orthostatic hypotension. The MAR documented several episodes of verbalization of hopelessness and helplessness, but there was no documentation of what nonpharmacological interventions were attempted. The MAR also showed only lying blood pressure readings on weekly dates and did not document sitting and standing readings, and there was no physician order or documented evidence that orthostatic blood pressure was monitored in those positions. An RN verified the missing blood pressure documentation and the lack of documentation of nonpharmacological interventions, and the Administrator and DON acknowledged the findings.
Missing Care Plans for Change in Condition, Bed Rail Use, and Insulin Therapy
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents when their conditions or treatments required plan-of-care updates. Facility policy stated that the interdisciplinary team develops and implements a comprehensive care plan for each resident, that care plans include measurable objectives and timeframes, and that care plans are revised when a resident’s condition changes or after a hospital readmission. For Resident 13, who was readmitted to the facility and was described in the record as alert, oriented, and cognitively intact, a urine culture collected on 3/10/26 resulted positive for ESBL on 3/14/26 and was reviewed by an RN the same day. The record showed a physician note of no new orders, but it did not show that a care plan was developed in response to the positive ESBL urine culture. During interview and record review, an RN stated that an abnormal lab result was considered a change in condition and verified that no care plan had been developed for this resident after the positive result. For Resident 20, who had decision-making capacity and was observed awake in bed with bilateral upper bed rails elevated and marked with green tape, the resident stated he had been using the bed rails since admission to hold on when turning and transferring to a wheelchair. The medical record did not show a care plan addressing the use of the bilateral upper bed rails. For Resident 102, who had diabetes mellitus type II and orders for insulin glargine at bedtime and regular insulin on a sliding scale before meals and at bedtime, the record did not show a care plan addressing insulin use for diabetes. An RN confirmed that a care plan should guide staff on monitoring, interventions, medication effectiveness, and goals, and verified that no care plan had been developed for the insulin therapy.
Care Plan Not Updated for Current Condition
Penalty
Summary
The facility failed to ensure Resident 54’s care plan was revised and updated to reflect the resident’s current condition and needs. The care plan report showed an activity care plan problem dated 9/16/25 that described the resident as a younger resident with activity participation challenged by the need for social and sensory stimulation related to being a sub-acute unit resident and ventilator dependent. During the initial tour on 3/22/26, Resident 54 was observed lying in bed with GT feeding off and was nonverbal. Review of the medical record showed the resident was admitted and later readmitted to the facility, and an H&P dated 1/29/26 stated the resident could make simple needs known and had no capacity to report subjective complaints. The medical record failed to show the resident was on mechanical ventilation, and the Activity Director verified on 3/16/26 that Resident 54 was no longer on mechanical ventilation and was on the subacute unit, while also confirming the care plan did not reflect the resident’s current condition and needs.
Failure to Follow Ordered BP Monitoring and Monitor Resident After Positive Urine Culture
Penalty
Summary
The facility failed to provide necessary care and services for two sampled residents. For one resident, the physician ordered orthostatic blood pressure monitoring in standing, sitting, and lying positions on a weekly basis, with notification to the MD if there was a 20 mmHg systolic drop or a 10 mmHg diastolic drop between readings. The resident’s March 2026 MAR documented blood pressure values that were the same across all three positions on multiple dates, and the readings did not show the expected positional differences. During interview, RN 1 verified the findings and stated the results should have changed, and the DON acknowledged the readings were not accurate. For another resident, the facility did not continuously monitor the resident after a urine culture was positive for ESBL. The resident was alert and oriented per the H&P and cognitively intact per the MDS, and the urine culture result was reviewed by RN 6 with a handwritten note indicating the physician was seen and no new orders were given. However, the medical record did not show documented ongoing monitoring for the resident’s condition after the positive urine culture. Facility staff stated that a change in condition includes abnormal lab results and that monitoring should occur every shift for 72 hours or more as needed, but RN 4 verified there was no documented evidence that the resident was monitored continuously after the positive ESBL result. Interviews with CNA 1, LVN 7, RN 4, and the DON described the resident’s condition and the facility’s expectations for monitoring when a change in condition occurs. CNA 1 reported the resident was incontinent and at times had dark, foul-smelling urine and occasional lower abdominal pain, while LVN 7 stated the resident did not show signs of infection. RN 4 confirmed that abnormal laboratory results are a change in condition and that the resident should have been monitored to determine response to interventions or decline, but the record lacked such documentation.
Low Air Loss Mattress Set Incorrectly for Resident With Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was cited after the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries or worsening of existing pressure injuries for one of two residents reviewed for pressure injuries. Resident 40 had physician orders dated 3/11/26 for a low air loss mattress for wound care management and for treatment of a sacrococcyx pressure injury extending to the left and right buttock, with cleansing, zinc oxide application, and border gauze. The resident's medical record showed a weight of 82 pounds on 3/17/26. On 3/22/26, Resident 40 was observed lying in bed on a low air loss mattress with the weight setting at the 400-pound mark. During a concurrent interview, LVN 2 verified the mattress setting was at 400 pounds and confirmed the resident did not weigh 400 pounds, stating the mattress setting should be based on the resident's weight to prevent skin breakdown or worsening of the wound. The DON was later informed of the findings and acknowledged that the low air loss mattress should be set based on the resident's current weight.
Failure to Provide Required Two-Person Assistance During ADL Care
Penalty
Summary
The facility failed to ensure that necessary care and services were safely provided using two-person assistance for dependent residents during ADL care and repositioning. The report states that Resident 12, who had diagnoses including traumatic brain injury, tracheostomy, bed confinement, and multiple contractures, was dependent for functional abilities and had no capacity to understand and make decisions. His MDS coded rolling left and right as dependent, requiring two or more helpers. Despite this, CNA 6 repositioned Resident 12 alone on the bed, lost her grip when the resident turned and moved, and the resident fell from the bed during the care activity. After the fall, Resident 12 was documented with swelling and bruising of the right metatarsal, and x-ray findings showed concern for an impacted fracture of the head/neck of the first metatarsal. Interviews confirmed that Resident 12 required two-person assistance for turning, repositioning, and other ADL care. CNA 6 acknowledged she performed the repositioning alone and stated she thought one person was enough, while also acknowledging that she made a mistake and should have asked for extra help. RN, LVN, DOR, and DON interviews all confirmed that Resident 12 was dependent and should have had two-person assistance during care. The same issue was also identified for three nonsampled residents. Resident 49 stated he needed help to turn and reported that only one person usually assisted him during cleaning or repositioning. Resident 22 stated that two staff should assist her with changing, turning, and repositioning, but sometimes only one person did. For Resident 70, staff were observed cleaning and changing the resident without another staff member present, and CNA 7 later confirmed he had cleaned and changed the resident by himself before asking for help to pull the resident up. LVN 12 verified Resident 70’s MDS showed dependent rolling ability and stated the resident required two-person assistance for repositioning and care.
GT Feeding Orders Not Fully Followed
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for five sampled residents with enteral feeding orders. The report states that Residents 8, 12, 42, and 104 did not receive the total amount of enteral feeding ordered by the physician, and Resident 54 was not positioned at the ordered head-of-bed elevation during feeding and did not have feeding held as ordered before phenytoin administration. The residents involved had varying levels of decision-making capacity, with some documented as having no capacity to understand and make decisions and others able to make simple needs known or understand and make decisions. For Resident 54, the physician ordered Nutren 2.0 via GT at 60 ml per hour for 20 hours, head of bed elevation between 30 and 45 degrees during feeding, and phenytoin via GT with feeding held one hour before and after the medication. During observation, the resident was in bed receiving GT feeding while the head of bed was not elevated to 30 to 45 degrees, and the LVN stated there was no measuring device to ensure the correct elevation. On another observation, the resident was receiving GT feeding when the LVN stated he had just administered medications and verified that the feeding was not held one hour before the phenytoin was given, despite the physician’s order. For Resident 8, the ordered Glucerna 1.2 feeding was observed hanging with the pump off and the bag still full, even though the label indicated it had been started hours earlier at the ordered rate. For Resident 42, the Nepro 1.8 bottle was observed still full after being hung the prior day, and the pump was off, with the LVN verifying that zero milliliters of the prescribed volume had infused. For Resident 12, the Jevity 1.5 feeding was documented as hung and later turned off, but the bag remained full and the pump history showed the resident had received less than the ordered amount. For Resident 104, the Glucerna 1.2 feeding was hung at a time that did not match the order, the pump was turned off before the full ordered amount could be delivered, and the bag still contained nearly all of the formula, with pump history showing the resident did not receive the full dose.
Oxygen Not Administered at Ordered Rate
Penalty
Summary
The facility failed to provide respiratory care and services for one of two nonsampled residents reviewed for respiratory care by not administering oxygen at the physician-ordered rate. Resident 84 was admitted with a history of hypoxic ischemic encephalopathy and was described in the H&P as too ill to make simple needs known and without full medical capacity to make decisions. The physician’s order directed oxygen at 3 LPM via nasal cannula, with titration up to 5 LPM for oxygen saturation less than 92% every shift. During the initial tour, Resident 84 was observed receiving oxygen via nasal cannula at between 2 and 2.5 LPM using an oxygen concentrator. Later, LVN 9 verified the oxygen was being delivered at 2 to 2.5 LPM and stated he checked the oxygen rate that morning but did not realize it was set below the ordered rate. RN 2 also verified the oxygen rate was below the physician’s order and stated it should have been 3 liters based on the resident’s orders and shift report review. The Administrator and DON were informed of the findings.
Dialysis Instructions Not Documented or Addressed
Penalty
Summary
The facility failed to ensure dialysis instructions from the dialysis center were addressed for a resident receiving dialysis care. Resident 10 had no capacity to understand and make decisions, and the dialysis communication record for 11/27/25 instructed staff to remove the old/previous left arm graft dressing at 5 PM after dialysis to avoid clotting of the access site. The resident returned from the dialysis center on 11/27/25, and the progress note documented that the dialysis site had bruit and thrill and that vital signs were stable and within normal range. However, there was no documented evidence that the dialysis center’s instructions were addressed in the progress notes, that the physician was informed, or that the instructions were carried out by licensed nurses. During interview, LVN 8 stated the recommendation was addressed but could not show documentation that it was done. The ADON verified there was no documentation showing the instructions received from the dialysis center were addressed and stated the dialysis communication record should have been checked, the physician informed, an order obtained, the family called, the progress notes documented, the care plan updated, and the team notified using the PCC communication board.
Bed Rail Use Without Required Order, Consent, or Assessment
Penalty
Summary
The facility failed to ensure the necessary care and services were provided for the use of side rails for one resident. The report states that before using bed rails, the facility’s policy required staff to inform the resident or representative about the benefits and potential hazards, obtain informed consent, and document the assessed medical needs, risks, alternatives attempted, and alternatives considered but not attempted. The policy also required an interdisciplinary evaluation, a physical restraint assessment, and documentation of the proper medical symptoms that warranted bed rail use. Resident 20 was observed awake and lying in bed with bilateral upper bed rails elevated, with green tape around each rail. The resident stated he had been in the facility for almost a month and had been using the bed rails since admission, and that he held onto the rails when turning on his sides or transferring to a wheelchair. The resident’s H&P dated 3/1/26 showed he had the capacity to understand and make decisions, and the MDS showed he needed partial/moderate assistance with mobility. Review of the medical record failed to show a physician’s order, informed consent, a physical restraint assessment, or documentation of the medical symptoms warranting bed rail use. The record also did not show that less restrictive alternatives were attempted before the bed rails were used. During interview, RN 1 stated the resident was being evaluated for bed rail use, that alternatives such as lowering the bed, placing pillows at the side, or frequent checks would be used before bed rails, and that the physician would be informed after alternatives failed; RN 1 also verified that the order, informed consent, assessment, and prior alternatives were not completed for Resident 20. The DON was later informed and acknowledged these findings.
Daily Nurse Staffing Posting Not Updated
Penalty
Summary
The facility failed to ensure that accurate nurse staffing information was posted daily for residents and visitors to view at one of three nursing stations, Station A. On 3/22/26, the Daily Nurse Staffing information posting observed on the bulletin board in front of Station A on the SNF side, next to the storage room, displayed the date of 3/18/26 instead of the current date. Facility policy titled Posting Direct Care Daily Staffing Numbers, revised 8/2022, stated that the facility would post nurse staffing data on a daily basis for each shift and that the information record would include the current date for which the information was posted. During interview, the DSD stated he posted the new Census and DHPPD daily and that on weekends the Manager of the Day would post it. The DSD verified that the staffing information on the SNF side was not posted for the current date, and the DON and Administrator acknowledged the findings. The DON stated the staffing posting should be posted daily at the beginning of the shift.
Unattended Tube Feeding Left at Bedside
Penalty
Summary
The facility failed to ensure drugs, biologicals, or medical supplies were stored in a safe manner when Resident 104's GT feeding was left unattended at the bedside. Resident 104 was admitted and later readmitted to the facility, and the H&P dated 12/1/25 stated the resident had no capacity to understand and make decisions. The physician's orders in the resident's record included Glucerna 1.2 at 72 ml per hour for 20 hours via pump to provide 1440 ml/1728 kcal per day, with the pump to be turned on at 12 PM and off at 8 AM or when the dose was completed. During the initial tour on 3/22/26, surveyors observed one Glucerna with Carbsteady 1.2 tube feeding left unattended at the resident's bedside, with the label showing the resident's name, room number, and feeding rate. A later observation showed the tube feeding was still left at the bedside while multiple staff, residents, and visitors passed by the room. In a concurrent interview, an LVN confirmed the tube feeding had been left at bedside for the next shift to use and stated it should not be left unattended there because it could be contaminated or used inappropriately. The DON later stated the tube feedings should not be kept unattended at the bedside and should be stored until ready to use, and the Administrator, DON, and Regional Director of Operations acknowledged the findings.
Delayed Reporting of Abnormal UA C&S Result
Penalty
Summary
The facility failed to ensure nursing staff reported laboratory results to the physician in a timely manner for one sampled resident. Resident 20 had a UA C&S final report showing a colony count of greater than 100,000 of Enterococcus faecalis, and the final laboratory results were available to the facility on 3/15/26 at 1643 hours. The resident's medical record showed a history and physical examination dated 3/1/26 indicating the resident had the capacity to understand and make decisions. The abnormal UA C&S result was not documented as being reported to MD 1 until 3/19/26 at 1645 hours, when RN 2 noted the result was reported and new orders for Amoxicillin 500 mg three times daily for 10 days were received and carried out. Review of the medical record did not show MD 1 was notified of the abnormal result on 3/15/26, and RN 2 later verified the result was reported four days after it became available. The facility's policy stated a nurse would review lab results and identify the urgency of communicating with the attending physician based on the seriousness of any abnormality and the individual's current condition.
Incomplete Documentation of Tube Feeding Intake
Penalty
Summary
The facility failed to ensure complete and accurate medical records for one of 23 sampled residents, Resident 7, by not documenting the amount of GT feeding formula administered on the resident’s Intake record. Facility policy required intake or output to be monitored as ordered and the amount of intake and output to be measured and recorded for every 24-hour period, and the charting policy required documentation to be objective, complete, and accurate. Resident 7 was admitted and later readmitted to the facility, and the H&P dated 3/2/26 stated the resident had the capacity to understand and make decisions. The physician’s orders included enteral feeding with VITAL AF at 50 ml/hr for 24 hours via pump, later changed to 65 ml/hr for 20 hours via pump, and an order to monitor intake and output every shift for 30 days. Review of the Intake Record for February through March 2026 showed missing tube feeding intake documentation on multiple shifts, including 2/27/26, 2/28/26, 3/2/26, 3/3/26, 3/5/26, and 3/6/26. During interview and concurrent record review, RN 1 verified the missing entries and stated licensed nurses should record the intake of tube feeding every shift per physician’s order and as required. The DON was later informed and acknowledged the findings.
Failure to Timely Change Suction Canister for Resident on Ventilator
Penalty
Summary
The facility failed to provide necessary respiratory care and services for one resident by not ensuring that the resident's suction canister was changed according to facility policy. The policy required suction canisters to be changed weekly, when 3/4 full, or as needed (PRN). Medical record review showed the suction canister was last changed on 5/2/25, and on 5/7/25, the canister was observed to be full while the resident was on a ventilator. The respiratory therapist (RT 1) confirmed the canister had not been changed since 5/2/25 and stated it was scheduled to be changed later that day, but acknowledged it should be changed when full. Further interview with the RT Supervisor confirmed that the canister should be changed when full, and failure to do so could result in the equipment being unable to suction and posed a potential for infection. The RT Supervisor acknowledged that the canister should have been changed when it was 3/4 full, as per policy. The resident involved was on a ventilator and had the capacity to make and understand their own decisions at the time of the deficiency.
Failure to Maintain Safe Resident Equipment and Ensure Staff Training
Penalty
Summary
The facility failed to ensure that resident equipment was maintained in a safe operating condition, as required by its own policy. An air fryer and a Keurig coffee machine were observed in a resident's room, both of which had not been approved by the administrator or designee as stipulated in the facility's electrical appliance policy. Staff interviews revealed that the appliances had been present in the room prior to the current staff's employment, and no staff had received training or in-service on the safe use or maintenance of these appliances. The resident reported using the air fryer to heat food and the coffee machine for personal use, with facility staff assisting in their operation. Further investigation showed that the Maintenance Director was unaware of the presence of these appliances and had not inspected them, although he did check the resident's refrigerator daily. The Maintenance Director stated that he relied on notification from Social Services to inspect resident equipment and only checked electrical outlets for compatibility, not the appliances themselves. The Director of Nursing and Administrator confirmed the presence of multiple personal appliances in the resident's room and acknowledged the lack of staff training regarding their safe use and maintenance.
Failure to Document and Monitor Change in Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained the highest practicable physical well-being. Specifically, the facility did not complete proper documentation as per their protocol for a resident who experienced a change in condition. The resident, who was admitted to the facility in November 2024, had a physician's order for Levofloxacin due to fever and cough, along with a chest x-ray and various tests. However, the medical record review revealed a lack of documentation for the change in condition, an updated care plan, and nurse progress notes to monitor the resident's condition. Interviews with facility staff, including an LVN and the ADON, confirmed that the resident should have had a change of condition report, an updated care plan, and 72-hour monitoring as per the facility's protocol. The absence of these critical documentation and monitoring steps indicates a failure to adhere to the facility's policies and procedures, potentially impacting the resident's care and monitoring during their change in condition.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control practices as outlined in their policies and procedures, specifically regarding the use of Enhanced Barrier Precautions (EBP) during high-contact resident care activities. This deficiency was observed in the care of a resident who had an indwelling suprapubic urinary catheter, which required the use of gown and gloves during care activities to prevent the transmission of multi-drug resistant organisms (MDROs). Despite the presence of signage indicating the need for EBP, a Certified Nursing Assistant (CNA) was observed changing the resident's brief while only wearing gloves, failing to don a gown as required. The Infection Preventionist (IP) confirmed the expectation that staff should perform hand hygiene and wear both gloves and a gown during high-contact care activities for residents on EBP. The failure to adhere to these precautions was verified during an interview with the IP, who acknowledged the lapse in following the facility's infection prevention protocols. This oversight posed a risk for the transmission of diseases and infections within the facility.
Incompetence in Dietary Supervision Poses Risk to Residents
Penalty
Summary
The facility failed to ensure the Dietary Services Supervisor (DSS) was competent in supervising the kitchen operations, which posed a risk to the residents. The DSS was unable to order pasteurized eggs due to an egg shortage, resulting in the use of raw shelled eggs that were not fully cooked, as observed in the breakfast meal of a resident. The DSS also demonstrated a lack of knowledge in calibrating thermometers correctly, leading to inaccurate temperature readings of food items, which could potentially expose residents to foodborne illnesses. Additionally, the DSS was unaware of the manufacturer guidelines for health shakes, leading to expired products being stored in the refrigerator. The DSS also failed to replace worn food preparation equipment, such as a can opener blade and a Robot Coupe blade assembly, which were observed to be excessively worn and had residue that could not be cleaned off. Furthermore, the DSS did not ensure that beard coverings were available for kitchen staff with facial hair, as required by the facility's policy and USDA Food Code. The Administrator did not evaluate the DSS's competency, relying instead on the Registered Dietitian (RD) to assess the DSS. However, the RD had only been with the facility for two weeks and had not conducted a formal competency evaluation. The lack of a written competency evaluation for the DSS by the Administrator further highlights the facility's failure to ensure that the DSS was competent in managing the dietary department, thereby putting residents at risk of exposure to foodborne illnesses.
Incompetence in Kitchen Staff Leads to Unsafe Food Handling Practices
Penalty
Summary
The facility failed to ensure that two kitchen employees, Cook 1 and Dietary Aide 1 (DA 1), were competent in their daily job duties, which posed a risk for unsafe food handling practices. Cook 1 did not follow proper hand hygiene protocols, as observed when he touched a trash can lid and then proceeded to wash a dirty peeler without changing gloves or washing hands. Additionally, Cook 1 did not take food temperatures correctly during meal service, as he used an analog thermometer that touched the hot pan, and he was unable to read the temperature on the thermometer dial. Further observations revealed that Cook 1 did not prepare resident meals according to the facility recipes, as he failed to follow the recipes for puree sweet and sour chicken, puree stir fry vegetables, and puree sesame noodles. Cook 1 also inaccurately tested the sanitizing solution used to sanitize food preparation surfaces, as he did not follow the correct procedure for testing the ppm of the sanitizing solution. Moreover, Cook 1 did not utilize the manual dishwashing process correctly, as he dipped a dirty peeler in a cleaning solution and rinsed it off with a faucet before drying it with a paper towel, instead of following the manual dishwashing procedure. DA 1 was unable to read the temperature dial of the dish machine, which was located under the machine near the floor. During an observation, DA 1 was unable to stoop down to read the dish machine temperature dial, and the temperature of the wash water was found to be 100 degrees F, which was too low. The facility's dish machine temperature log showed that the automatic dishwashing machine temperature was consistently between 120-123 degrees F, which was within the required range, but DA 1's inability to read the temperature dial posed a risk for improper dishwashing procedures.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to adhere to the prescribed recipes for pureed diets, which are essential for meeting the nutritional needs of residents on such diets. During an observation, it was noted that the preparation of pureed sweet and sour chicken did not follow the specified recipe, resulting in an incorrect consistency. The staff member responsible for the preparation used an unmeasured amount of thickener to adjust the consistency, which was not in accordance with the recipe guidelines. This inconsistency in preparation could potentially affect the nutritional intake of the 15 residents who were prescribed a pureed diet. Additionally, the preparation of pureed vegetables and starches also deviated from the established recipes. The vegetables were cooked in high-sodium chicken broth instead of water or low-sodium broth, as preferred by the Registered Dietitian (RD). Similarly, the pureed noodles were prepared using chicken flavored bouillon with high sodium content, contrary to the recipe's requirement for low-sodium broth or milk. These deviations from the recipes were confirmed by the RD and Dietary Services Supervisor (DSS), who acknowledged that all recipes should be strictly followed to ensure the nutritional needs of the residents are met.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure food safety and sanitary requirements were met in the kitchen, leading to potential foodborne illnesses for residents. Observations revealed that eggs served were not fully cooked, and there were no pasteurized eggs available, which is a requirement in licensed healthcare facilities to prevent Salmonella infections. Additionally, hand hygiene protocols were not followed during food preparation, as staff members were observed not washing hands or changing gloves after handling trash or switching tasks, increasing the risk of cross-contamination. The facility also failed to adhere to proper food storage and preparation procedures. Fish thawing processes were not followed, as there was no indication of when the fish was removed from the freezer to thaw. The dishwashing machine did not reach the required temperature, and manual dishwashing procedures were not properly executed, with staff not following the correct steps for sanitizing utensils. Refrigerated food items were not stored properly, with some items being kept beyond their safe usage dates, and the ice storage was found to be unsanitary. Furthermore, the facility did not maintain kitchen equipment in a sanitary condition, with observations of unclean utensils and equipment. Hair restraints were not worn by staff, and food items in the walk-in freezer were not properly labeled or sealed. Resident 7's personal refrigerator was not maintained at the appropriate temperature, with logs showing temperatures outside the acceptable range, and there was no documentation of corrective actions taken. These deficiencies highlight significant lapses in the facility's adherence to food safety and sanitation standards, posing a risk to resident health.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents, leading to deficiencies in care. Resident 84, who was cognitively intact and required extensive assistance with activities of daily living, had an indwelling urinary catheter with a drainage bag that was not fully covered. This was observed on multiple occasions, and the facility's policy on dignity, which requires urinary bags to be covered, was not followed. The Infection Preventionist (IP) and Director of Nursing (DON) acknowledged the oversight, confirming that the uncovered drainage bag compromised the resident's dignity. In another incident, Resident 71, who had the capacity to understand and make decisions and was diagnosed with unspecified depression, was transferred from a bed to a shower bed using a Hoyer lift. During the transfer, the resident's abdomen and legs were exposed, and the door to the room was left open, allowing visibility from the hallway. Both the Speech-Language Pathologist (SLP) and a Licensed Vocational Nurse (LVN) involved in the transfer acknowledged that the door should have been closed to maintain the resident's privacy. The resident expressed disappointment over the lack of privacy, indicating a failure to uphold the resident's right to dignity and privacy as per the facility's policies.
Informed Consent Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that informed consents were properly completed for several residents, as per the facility's policies and procedures. Specifically, the informed consents for four sampled residents and one non-sampled resident were not signed and dated by the physician, which is a requirement according to the facility's policy. This oversight was identified through interviews, medical record reviews, and facility document reviews. Resident 10, who had the capacity to understand and make decisions, had informed consents for treatments that were not signed and dated by the physician. These treatments included the use of a gerichair for socialization and activities, and the use of bilateral upper half side rails for positioning and mobility. Similarly, Resident 72, who lacked the capacity to make decisions, had informed consents for various treatments, including the use of a hand mitten and side rails, that were not signed and dated by the physician. Additionally, Resident 20, who also lacked decision-making capacity, had informed consents for treatments such as the use of side rails and a gerichair that were not properly signed and dated. Resident 85, with no capacity to understand and make decisions, had similar issues with unsigned informed consents for treatments involving side rails and a gerichair. Lastly, Resident 44, who was moderately cognitively impaired, had an informed consent for the use of Abilify that was not signed or dated by the physician. These deficiencies were verified by nursing staff and acknowledged by the facility's administration.
Failure to Maintain Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to maintain a copy of an advance directive in the medical record for one of the six sampled residents, specifically Resident 34, who was reviewed for advance directives. This oversight was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P). According to the facility's P&P, revised in September 2022, the Social Service Director (SSD) or designee is responsible for inquiring about the existence of any written advance directives upon a resident's admission. If an advance directive exists, it should be obtained and maintained in the resident's medical record, ensuring it is readily retrievable by facility staff. During the review, it was found that Resident 34, who was readmitted to the facility, had an advance directive as indicated by the Physician Orders for Life-Sustaining Treatment (POLST) dated February 24, 2025, and an Advance Directive Acknowledgement dated the same day. Despite this, a copy of the advance directive was not found in Resident 34's medical record. The SSD confirmed the absence of the document in both the physical and electronic medical records (EMR) during an interview on March 12, 2024. The Director of Nursing (DON) was informed of these findings on March 14, 2025, and acknowledged the deficiency.
Failure to Document and Manage Restraint Use
Penalty
Summary
The facility failed to ensure the appropriate use of physical restraints for three residents, leading to potential risks of skin and soft tissue injury and decreased range of motion. Resident 100 was observed with an elbow splint on the left arm without a current physician's order or consent. There was no documentation of the splint's removal or any assessment and exercise of the arm every two hours as required by the facility's policy. Interviews with staff revealed that the splint was typically removed by the resident's family, but there was no formal documentation of this process. Residents 41 and 72 were both subjected to hand mitten restraints without proper documentation of their removal and assessment every two hours. Resident 41's medical records showed a physician's order for a right hand-mitten restraint, but the Medication Administration Record (MAR) lacked specific times and outcomes of the restraint's removal and the necessary assessments. Similarly, Resident 72 had a physician's order for a left hand mitten restraint, but the MAR did not document the removal times or the condition of the resident's hand, despite multiple observations of the restraint being in place. Interviews with various staff members, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), confirmed the lack of documentation and adherence to the facility's policy on restraint use. The DON acknowledged the absence of records showing the required two-hourly removal and assessment of the restraints. The facility's failure to document and follow proper procedures for restraint use was acknowledged by the Administrator and DON, indicating a systemic issue in maintaining compliance with restraint policies.
Care Plan Deficiency for Ventilator and Elbow Splint Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 100, which did not address the resident's use of a ventilator at night and the application of an elbow splint. This deficiency was identified through observations, interviews, and medical record reviews. On multiple occasions, Resident 100 was observed with an elbow splint on the left arm, which was not documented in the care plan. Interviews with CNA 6 and RN 3 confirmed that the elbow splint was applied regularly, yet there was no corresponding care plan to guide its use. Additionally, the care plan did not reflect the resident's current ventilator use, as per the physician's orders. The resident was supposed to be on a ventilator at night and on supplemental oxygen during the day, but this was not documented in the care plan. The Respiratory Lead confirmed that the resident's care plan failed to address the current ventilator schedule, which had been adjusted from 24-hour use to nighttime use only. This lack of documentation could lead to miscommunication among the interdisciplinary team regarding the resident's care needs.
Failure to Properly Apply Fall Prevention Device
Penalty
Summary
The facility failed to ensure that a tab alarm, a fall prevention device, was properly applied for one of the residents, identified as Resident 47. The physician had ordered the use of a tab alarm to monitor the resident every shift due to their high risk of falls, as evidenced by multiple falls on previous dates. Despite this order, observations revealed that the tab alarm was not consistently applied as required. On one occasion, the resident was observed sitting in a wheelchair without the tab alarm attached, and on another occasion, the tab alarm was not clipped onto the resident's clothing as it should have been. Interviews with facility staff, including an LVN and a CNA, confirmed the improper application of the tab alarm. The LVN acknowledged that the tab alarm was not correctly applied, as it should have been hung on the wheelchair handle and clipped onto the resident's clothing. Similarly, the CNA admitted to not clipping the tab alarm onto the resident after assisting them, despite knowing the resident's high fall risk status. These lapses in following the physician's order and the facility's policy for alarm monitors contributed to the deficiency in ensuring the resident's safety from accident hazards.
Failure to Verify GT Placement and Residuals Before Feeding
Penalty
Summary
The facility failed to adhere to its protocol for verifying the placement, patency, and gastric residuals of a gastrostomy tube (GT) before initiating enteral tube feeding for Resident 100. The facility's policy, revised in March 2023, requires verification of GT placement and flushing the tubing with at least 30 ml of water before starting the feeding. However, during an observation on March 11, 2025, LVN 5 was seen connecting the enteral feeding formula and water flush tubing to Resident 100's GT and starting the feeding pump without checking the GT for placement, patency, or residuals. LVN 5 confirmed that these checks were not performed, stating that they were done earlier in the shift during the administration of morning medications. Resident 100 had specific physician's orders to check the GT feeding residual every shift and to hold the enteral feeding for one hour if residuals exceeded 100 ml. Additionally, the orders included running 40 ml of water every hour to provide 800 ml/day and administering Peptamen AF 1.2 at 70 ml/hr for 20 hours daily via GT. The Assistant Director of Nursing (ADON) confirmed that the protocol was to check tube placement using a stethoscope and an air bolus into the GT, as well as checking gastric residuals before starting the feeding. The failure to follow these procedures had the potential for adverse outcomes related to a dislodged GT or increased gastric residuals.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as observed during a survey. For two residents, the oxygen tubing was not labeled and dated, which is a requirement for infection prevention and control. During observations, it was noted that the nasal cannulas for these residents were unlabeled, and the staff member interviewed was unable to confirm when the tubing was last changed. The Director of Nursing (DON) acknowledged that the tubing should have been labeled and dated. Additionally, another resident was not administered oxygen according to the physician's order. The resident was observed receiving oxygen at a rate of 3 LPM, contrary to the physician's order of 2 LPM continuously. The Licensed Vocational Nurse (LVN) confirmed the discrepancy and acknowledged that the physician's order was not followed. The DON emphasized the importance of adhering to physician's orders and acknowledged the findings.
Failure to Provide Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to provide non-pharmacological interventions for pain management to a resident, identified as Resident 34, who was experiencing pain. According to the facility's policy and procedure (P&P) titled Pain - Clinical Protocol, dated March 2018, the physician is responsible for ordering appropriate non-pharmacologic and medication interventions to address an individual's pain. The P&P also states that staff should provide elements of a comforting environment and appropriate physical and complementary interventions, such as positioning/repositioning, local heat or ice, and opportunities to discuss chronic pain. However, during an observation on March 11, 2024, Resident 34 reported pain on the right side of her body to RN 1, who only checked for pain medication and did not offer any non-pharmacological interventions. A review of Resident 34's medical records revealed a care plan problem addressing her pain, with goals to reduce episodes of pain or discomfort through appropriate interventions daily, including non-pharmacological methods like positioning for comfort, hot packs, cold packs, massage, and distraction. Despite this, there was no documented evidence that these interventions were provided when Resident 34 reported a pain level of 7 on multiple occasions. RN 1 confirmed the lack of documentation and stated that non-pharmacological interventions should have been provided. The Director of Nursing (DON) was informed and acknowledged these findings.
Inadequate Hemodialysis Care Due to Staff Competency Issues
Penalty
Summary
The facility failed to provide adequate hemodialysis care for a resident with End-Stage Renal Disease (ESRD), specifically in assessing the hemodialysis access site. The facility's policy and procedure for the care of residents with ESRD required staff to be trained in the care and special needs of these residents, including the assessment of grafts and fistulas. However, interviews with licensed staff revealed a lack of competency in assessing the hemodialysis access site, as there were inconsistencies in their understanding of how to check for bruit and thrill, which are critical indicators of the functionality of the access site. The deficiency was identified during a review of Resident 10's medical records and interviews with staff. Resident 10, who was cognitively intact and capable of making decisions, had a physician's order to monitor the shunt or graft for bruit and thrill every shift. Despite this, interviews with three licensed nurses showed a lack of proper understanding of the assessment process. The Director of Nursing (DON) acknowledged the findings and indicated a need for further in-service training for the licensed nurses on the proper assessment of hemodialysis access sites.
Failure to Document Alternatives Before Side Rail Use
Penalty
Summary
The facility failed to ensure that seven out of eight residents reviewed for side rail use were free from the accident hazards associated with elevated side rails. The facility's policy requires that alternatives to side rails be attempted, an interdisciplinary evaluation be conducted, a resident assessment be completed, and informed consent be obtained before using side rails. However, these steps were not adequately documented or followed for the residents in question. For Resident 51, the facility did not document any attempts to use alternatives before applying bilateral half upper side rails, despite the resident being cognitively intact and capable of making decisions. Similarly, Resident 52, who had severe physical impairments and was unable to use the side rails, was still subjected to their use without documented attempts of alternative measures. The Director of Nursing acknowledged that Resident 52 was not appropriate for side rail use and planned to inform the physician to discontinue them. Other residents, including Residents 45, 47, 9, 99, and 89, also had side rails applied without documented evidence of alternative measures being attempted. In some cases, such as with Resident 45, the facility's documentation indicated that alternatives were considered, but there was no evidence that they were actually attempted. The lack of proper assessments and documentation for these residents indicates a systemic failure to adhere to the facility's policy on side rail use, potentially putting residents at risk for entrapment and serious injuries.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that the physician's orders matched the medication labels provided by the pharmacy and that medications were administered as ordered by the physician for two residents. For Resident 18, there was a discrepancy between the physician's order and the medication label for digoxin. The physician's order specified two tablets of 125 mcg digoxin, while the pharmacy label indicated one tablet of 250 mcg. This inconsistency was verified by LVN 8 during a medication administration observation, who acknowledged that the orders and instructions did not match, and there was no evidence of a change of direction label on the medication bubble pack. For Resident 48, the facility failed to administer metoprolol tartrate with food as ordered by the physician. The physician's order required the medication to be given with food, but during a medication administration observation, LVN 1 was seen administering the medication without food. LVN 1 confirmed the oversight and acknowledged that food should have been provided with the medication. Both the Administrator and DON, along with the Regional Director of Operations, were made aware of these findings.
Medication Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and separation of medications, as observed in Medication Storage Room A and Medication Cart G. In Medication Storage Room A, boxes of bisacodyl stimulant laxative suppositories were stored together with artificial tears lubricant eyedrops, which was acknowledged by RN 1 as inappropriate. Similarly, Medication Cart G contained a mix of loperamide tablets, fluticasone nasal spray, and artificial tears, which LVN 6 confirmed should not be stored together. The facility also failed to maintain cleanliness and sanitation of medication carts, as evidenced by observations of sticky and dried medication residues on various carts. Medication Carts A, B, C, D, E, G, and H were found with residues and spills, which were verified by the respective nursing staff. These unsanitary conditions were noted to potentially compromise infection prevention and control measures. Additionally, there were discrepancies in the documentation of serial numbers for blood glucose monitoring systems for two residents. Resident 98's and Resident 19's Assure Platinum Blood Glucose Meter Machines had incorrect serial numbers recorded in their medical records, which were verified by LVNs 7 and 8. The Director of Nursing confirmed these findings, indicating a lapse in accurate record-keeping for medical equipment used by the residents.
Improper Storage of Pureed Vegetables Affects Nutrient Preservation
Penalty
Summary
The facility failed to ensure the nutrient content of pureed vegetables was preserved for 15 residents on a pureed diet. The deficiency was identified when it was observed that pureed vegetables were prepared more than one hour prior to meal service and held in an oven at 500 degrees Fahrenheit. This method of storage was not ideal for preserving nutrients, as confirmed by the Registered Dietitian (RD). The observation and interview with a staff member revealed that 13 portions of pureed stir fry vegetables were blended to a pudding consistency and stored in the oven until the lunch meal tray line began. The RD agreed that this practice was not suitable for maintaining the nutritional value of the pureed vegetables, posing a risk to the residents' nutritional needs.
Failure to Provide Appropriate Dietary Needs
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual dietary needs of two residents, placing them at risk for aspiration or choking. Resident 11, who was edentulous and awaiting oral surgery, was supposed to receive a minced and moist diet as per her physician's order. However, during an observation, it was noted that her meal included chicken pieces that were not finely minced and moist, making it difficult for her to swallow. This was confirmed by the Director of Staff Development (DSD) and the Dietary Services Supervisor (DSS), who acknowledged the meal did not meet the required dietary specifications. Resident 85, who had a physician's order for a puree texture diet with occasional mechanical soft snacks, was observed eating saltine crackers, which were not appropriate for her dietary needs. The Licensed Vocational Nurse (LVN) and the Registered Dietitian (RD) confirmed that the saltine crackers were not suitable for a mechanical soft snack diet. The Speech-Language Pathologist (SLP) mentioned that the crackers could be consumed if dipped in water, but this instruction was not included in the diet order, leading to confusion among the staff. Both residents were at risk due to the facility's failure to adhere to their specific dietary requirements. The deficiencies were acknowledged by the Director of Nursing (DON) and the facility's administration, indicating a lapse in ensuring that dietary orders were properly followed and communicated among the staff.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 10, which was documented as a deficiency. Upon admission and periodically, the facility's policy requires the Dietary Services Supervisor (DSS) to meet with residents to discuss and ensure their food preferences are honored. However, despite Resident 10's request for collard greens during a Resident Council meeting, the facility did not fulfill this request. The DSS acknowledged receiving the request but confirmed that the collard greens were not purchased, and there was no documentation of follow-up with the resident regarding the request. Resident 10's medical records indicated a risk for alteration in nutritional status, weight loss, and malnutrition, with specific dietary preferences and restrictions documented. Despite these risks, the facility did not provide the requested food item, potentially impacting the resident's nutritional intake and psychosocial wellbeing. Interviews with the resident and facility staff, including the Administrator and Director of Nursing (DON), confirmed the oversight and lack of communication regarding the resident's food preference request.
Failure to Ensure Safe Handling of Outside Food
Penalty
Summary
The facility failed to ensure proper storage and handling of food brought in by visitors for three nonsampled residents, potentially exposing them to foodborne illnesses. The facility's policy discourages outside food due to safety and infection control concerns, yet it allows residents to consume such food at their own risk. Observations revealed that Resident 70, who was on a No Added Salt diet, received a piece of cake from a family member who was unsure about safe food handling guidelines. Resident 65, with diabetes and liver disease, was observed eating BBQ ribs and macaroni salad brought by a friend, who had not received any information from the facility regarding safe food handling. Resident 57, with hemiplegia and diabetes, received pureed chicken and rice from a family member who had only been informed about the resident's diet. Interviews with facility staff highlighted a lack of proper procedures and training regarding the handling of outside food. RN 1 stated that outside food must be consumed in one sitting as there was no refrigeration available for storage, and the facility did not allow storage of such food. Additionally, the microwave used for heating outside food was found to be unclean, with excess food debris inside. The Director of Staff Development confirmed that no staff training had been provided on safe food handling guidelines, further contributing to the facility's failure to ensure the safety of food brought in from outside sources.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by several observations of open and improperly closed waste dumpsters. During an initial tour, one of four dumpsters was found with its lid open, and another was propped open by garbage, preventing it from closing fully. These observations were verified by the Maintenance Director through photographs. Additionally, organic waste was not being collected as required by state mandate SB1383, with regular trash found in an organic waste barrel. The Administrator and DSS confirmed that the facility was not collecting organic waste, and the kitchen was also not participating in organic waste collection. Furthermore, the facility did not comply with the Mandatory Commercial Recycling Regulation, as it was not collecting recyclable trash. Observations revealed trash bags and cardboard boxes stored improperly on the ground and on hand carts, with the Maintenance Director acknowledging that the dumpsters were full. These actions and inactions led to the potential for unsafe sanitary conditions and the harboring of pests and rodents, as the refuse was not stored in a manner that made it inaccessible to insects and rodents.
Inaccurate Medical Records and Entrapment Risk Assessments
Penalty
Summary
The facility failed to maintain accurate medical records for eight residents, leading to potential risks in their care. For Resident 72, the medical records inaccurately documented the resident as being on a ventilator, despite the ventilator orders being discontinued months prior. This discrepancy was confirmed through interviews with the LVN, RT, and DON, who all verified that Resident 72 was not on a ventilator, highlighting a significant lapse in accurate documentation. Additionally, the facility did not accurately assess the risk of entrapment for residents using side rails. Residents 9, 40, 45, 47, 51, 52, 89, and 99 had their side rail assessments marked inaccurately, with all seven zones being checked despite not all zones being applicable due to the absence of split bed rails. This was confirmed through interviews with various nursing staff, including RN 2 and the MDS RN, who acknowledged the inaccuracies in the assessments. The inaccurate documentation and assessments posed a risk to the residents, as their medical records did not reflect their actual care needs and conditions. The facility's failure to adhere to its policies and procedures for charting and documentation, as well as bed safety and side rail assessments, could lead to residents not receiving the necessary care and services, as their medical records were not accurate.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several observations and interviews. In the laundry room, used mugs and a utensil were found on a clean sink, and personal belongings were stored on clean linen shelves, which is against the facility's policy. The Maintenance Director confirmed these items should not be in clean areas. Additionally, the facility did not properly maintain its decorative water feature or keep logs as required by the water management program. The Maintenance Director admitted to not testing the water fountain or maintaining logs for HVAC and water systems. The facility's infection surveillance was also found to be inaccurate. The Infection Preventionist (IP) incorrectly reported infections for four residents as meeting McGeer's criteria when they did not. This misreporting was acknowledged by the IP during a review of the facility's monthly infection surveillance report. Furthermore, an LVN failed to maintain infection control practices by using enteral tubing that had been on the floor for a resident's GT feeding, which the LVN admitted should have been discarded and replaced. Hand hygiene practices were not followed by an LVN during medication administration, as observed in Resident 6's room. The LVN confirmed the oversight and acknowledged the importance of hand hygiene in preventing contamination. Additionally, unlabeled basins were found in shared restrooms, which were not stored properly, as verified by CNAs and the DON. These deficiencies in infection control practices were confirmed by the Administrator and DON during an interview with the Regional Director of Operations present.
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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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