Santa Fe Lodge
Inspection history, citations, penalties and survey trends for this long-term care facility in El Monte, California.
- Location
- 5053 Peck Rd., El Monte, California 91732
- CMS Provider Number
- 555106
- Inspections on file
- 25
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Santa Fe Lodge during CMS and state inspections, most recent first.
Staff interviews and record review showed that multiple CNAs and an LVN did not know who the facility’s Abuse Coordinator was or which external agencies must receive abuse allegations within the required two-hour timeframe. The DSD stated that the Administrator is the Abuse Coordinator and that all staff are expected to know to report suspected abuse to the Administrator, who then reports to the state survey agency, APS, law enforcement, and the Ombudsman. The facility’s written abuse prevention policy confirms these responsibilities and timelines, yet interviewed staff were unable to identify the Abuse Coordinator or the mandated reporting entities.
A resident with schizophrenia, impulse disorder, and HTN, who lacked decision-making capacity, allegedly yelled "rape" when a CNA entered the room. The CNA delayed reporting the allegation to an LVN, and the LVN further delayed notifying the DON and did not immediately inform the administrator. As documented on an SBAR form, the allegation of physical and sexual abuse by staff was not reported to law enforcement, the Ombudsman, or the state agency until several hours later, exceeding the facility’s policy requirement to report abuse allegations within two hours.
A resident with dementia, impaired cognition, gait and mobility issues, and a known fall risk experienced a fall that triggered an alarm, after which an LVN found the resident on the floor with an abrasion and notified the primary nurse. Despite facility policy requiring prompt assessment, documentation of a change of condition (COC), and physician notification for injuries and falls, no post-fall assessment, COC documentation, or MD notification was found in the record. The DON and nursing staff later confirmed that a fall is considered a change of condition and that the charge nurse was responsible for completing the COC, but this was not done.
A resident with severe cognitive impairment was placed on bed and wheelchair alarms and started on Lexapro and Remeron without documented informed consent from the resident or their representative. Staff confirmed that required consents were not obtained prior to implementing these interventions, contrary to facility policy.
The facility did not ensure that executed advance directives were obtained and maintained in the medical records for three residents, despite documentation indicating that these legal documents existed. For two residents with severe cognitive impairment and one with intact cognition, the actual ADs were missing from their files, and the Social Services Assistant confirmed the documents could not be found. Facility policy required that ADs be readily retrievable, but this was not followed.
Three residents with significant medical conditions did not have weekly weights obtained or documented as required by physician orders and facility policy. Staff responsible for weighing residents lacked access to the electronic record system and relied on others to enter data, resulting in missing documentation for required weekly weights. This failure occurred despite clear orders and care plans indicating the need for close monitoring due to recent weight loss.
Surveyors found that food items in the kitchen walk-in refrigerator, including sliced cheese, a jar of pickles, and whipping cream, were not labeled with required open or received dates. Both the Certified Dietary Manager and Registered Dietitian confirmed that labeling is necessary to track food quality and freshness, and facility policy requires all items to be properly dated and labeled.
Two residents with significant medical and mental health conditions signed binding arbitration agreements that did not include a provision allowing them or their representatives to communicate with federal, state, or local officials. The Admission Coordinator confirmed the omission during interviews and record reviews.
Multiple infection control lapses were observed, including unlabeled and improperly stored personal care items in a shared restroom, a resident with severe cognitive impairment independently accessing communal drink pitchers, uncleaned dryer lint traps, soiled bed linens with suspected fecal matter, and a used cup left on a hallway handrail. Staff interviews confirmed these practices did not follow facility policy and posed risks for cross-contamination.
A resident with severe cognitive impairment and mental health conditions was left exposed while sitting in a shower chair, with privacy curtains only partially drawn and the room door open as a CNA prepared for care. This exposure was visible to others in the hallway, and both the CNA and RN Supervisor acknowledged the lapse in maintaining the resident's privacy and dignity, contrary to the care plan and facility policy.
A resident with severe cognitive impairment and multiple mental health diagnoses was observed sitting in a wheelchair with the call light secured to the bed's grab bar, out of reach. Staff confirmed the call light was not accessible, despite facility policy requiring call lights to be within reach for all residents.
A resident was readmitted with multiple diagnoses and a new order for Depakote to treat bipolar disorder, but the facility failed to update the MDS and admission records to reflect the new diagnosis. Despite documentation in physician orders and progress notes, the bipolar disorder was not included in the resident's official records, contrary to facility policy requiring current and detailed health records.
A resident with a history of traumatic subdural hemorrhage, seizures, and hypertension was admitted and had a positive PASARR Level I screening for SMI, but the facility did not complete or document the required Level II evaluation, as confirmed by interviews and record review.
A resident was readmitted with a new diagnosis of bipolar disorder, but the facility did not update the MDS or develop a care plan to address this condition. Interviews confirmed that staff were aware a care plan was needed for the new diagnosis, but it was not completed, contrary to facility policy requiring care plan updates after significant changes or hospital readmissions.
The facility did not meet the required minimum of 80 square feet per resident in multiple-occupancy rooms, as shown by facility records and room measurements. Despite a waiver request and staff reporting no issues providing care in the available space, the documented room sizes for 20 rooms were below regulatory standards.
A resident with dementia and major depressive disorder eloped from an LTC facility due to inadequate supervision. The resident left through an exit door that was not properly monitored or secured during mealtime, as staff were occupied with feeding other residents. The resident was found with a skin tear upon return. Facility policy emphasized continuous supervision to prevent such incidents, which was not followed.
The facility failed to maintain an acceptable temperature range, affecting several resident rooms, a dining room, and a hallway. The air conditioning unit malfunctioned, leading to temperatures exceeding the facility's acceptable range. The Director of Nursing acknowledged the issue, and the Maintenance Director confirmed the malfunction, stating that the HVAC technician was working on repairs. The facility's policy emphasized maintaining comfortable and safe temperatures, which was not adhered to during the malfunction.
Staff Lack Knowledge of Abuse Reporting Roles and Requirements
Penalty
Summary
The facility failed to ensure that staff understood and followed its abuse reporting policies and procedures. During interviews, three of six sampled staff members (two CNAs and one LVN) were unable to identify the facility’s Abuse Coordinator and did not know the external agencies to which allegations of resident abuse must be reported. Specifically, these staff members did not know that allegations of abuse must be reported to the California Department of Public Health, the Ombudsman, adult protective services, and local law enforcement within two hours when abuse is suspected. The Director of Staff Development stated that the Administrator is the Abuse Coordinator and that all staff are expected to know this and to understand the reporting requirements. The record review included an admission record and history and physical for a resident admitted with schizophrenia, impulse disorder, and hypertension, with documentation that the resident lacked capacity to understand and make decisions due to schizophrenia. The facility’s written policy, “Abuse Prevention and Prohibition Program,” revised 11/28/2022, states that the Administrator or designee serves as Abuse Coordinator and is responsible for reporting known or suspected abuse to proper authorities, and that staff must report suspected abuse to the Administrator or designee. The policy further specifies that allegations of abuse must be reported immediately, but no later than two hours after suspicion is formed, to the state survey agency, adult protective services, law enforcement, and the Ombudsman. Despite these written requirements, interviewed staff demonstrated a lack of knowledge of both the designated Abuse Coordinator and the mandated external reporting entities and timelines.
Failure to Timely Report Allegation of Abuse to Required Authorities
Penalty
Summary
The facility failed to timely report an allegation of abuse involving Resident 1 to the California Department of Public Health, the Ombudsman, and local law enforcement within the two-hour timeframe required by its Abuse Prevention and Prohibition Program policy. Resident 1, who had been admitted with schizophrenia, impulse disorder, and hypertension, and was documented in a History and Physical as lacking capacity to understand and make decisions due to schizophrenia, allegedly yelled "rape, rape" when CNA 2 entered the room around 1 PM on 4/4/2026. CNA 2 did not report this allegation until approximately 2:45 PM, when CNA 2 informed LVN 2 that Resident 1 had alleged CNA 2 raped and touched the resident. LVN 2 stated that CNA 2 reported the allegation at 3 PM and acknowledged not reporting the allegation to the Administrator, instead waiting until 5 PM to inform the DON, and stated that the allegation should have been reported right away. Review of Resident 1's Change of Condition/Interact Assessment Form (SBAR) dated 4/4/2026 showed that the resident made an allegation of physical and sexual abuse by unidentified staff, and that the RN supervisor reported the allegation to local law enforcement at 8:30 PM. The SBAR further indicated the Administrator reported the allegation to the Ombudsman at 8:24 PM and to the Department at 8:25 PM. The DON confirmed these reporting times were greater than two hours from when the allegation was made and acknowledged that the allegation was not reported to the Department, the Ombudsman, and local law enforcement in accordance with the facility's Abuse Prevention and Prohibition Program policy, which requires allegations of abuse to be reported immediately, but no later than two hours after forming the suspicion, to the state survey agency, adult protective services, law enforcement, and the Ombudsman.
Failure to Assess and Notify Physician After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its Change of Condition policy after a fall experienced by Resident 1. Resident 1 had multiple diagnoses including abnormalities of gait and mobility, unspecified dementia, and a history of falling, and had been assessed as a fall risk on a Fall Risk Evaluation that directed staff to alert the physician if a fall occurred. An MDS assessment indicated Resident 1 had moderately impaired cognition and was dependent for ADLs, requiring supervision or touching assistance. Despite these identified risks, when Resident 1 fell, the required assessments and notifications were not completed. On 1/9/2026 at approximately 3 AM, LVN 2 heard an alarm from the back hallway, entered Resident 1’s room, and found Resident 1 sitting on the floor in front of the roommate’s bed. Resident 1 stated, “I do not know, I just fell.” LVN 2 noted an abrasion on Resident 1’s mid-back on the right side and notified Resident 1’s primary nurse, LVN 3, who stated LVN 2 would resume follow-up. There was no documented evidence that a post-fall assessment was completed, that the physician was notified, or that a Change of Condition (COC) form was initiated for this event, despite the facility’s policy requiring prompt handling, documentation, and physician notification for changes such as bruises, lacerations, and other injuries. During subsequent interviews and record reviews, the DON confirmed that the progress note from 1/9/2026 indicated a fall and that LVN 2, as charge nurse, was responsible for completing the COC, which was not found in the record. The DON also confirmed there was no documentation that the physician was notified or that an assessment was completed after the fall. LVN 1 and LVN 3 both acknowledged that a fall constitutes a change of condition and that it is important to assess the resident and notify the physician and family, yet LVN 3 stated they did not assess Resident 1 after the fall and relied on LVN 2 to “take care of the incident.” The facility’s Change of Condition policy required proper assessment, prompt handling, licensed nurse documentation, completion of a COC, and prompt physician notification with daily assessments, which were not carried out in this case.
Failure to Obtain Informed Consent for Alarms and Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of bed and wheelchair alarms, as well as for the administration of two anti-depressant medications, Lexapro and Remeron, for one resident. The resident, who had diagnoses including Alzheimer's disease, dementia, and muscle weakness, was assessed as having severely impaired cognition. Despite facility policy requiring informed consent prior to the use of safety devices and psychotherapeutic medications, there was no documentation of consent being obtained from the resident or their responsible party before implementing these interventions. Observations confirmed that the resident was using bed and wheelchair pad alarms, and physician orders for both the alarms and the medications specified that informed consent should be obtained. Interviews with facility staff, including a CNA, LVN, and RN Supervisor, confirmed that the required consents were not present in the resident's records. Facility policies reviewed also indicated that informed consent must be obtained and documented prior to the use of such interventions, but this process was not followed for the resident in question.
Failure to Maintain Advance Directives in Resident Medical Records
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were obtained and maintained in the medical records for three of five sampled residents. For each of these residents, documentation indicated that an AD had been executed, as shown by their Advance Healthcare Directive Acknowledgement (AHDA) forms. However, during record review, the Social Services Assistant (SSA) was unable to locate copies of the actual ADs in the residents' medical records, despite facility policy requiring that such documents be readily retrievable. Resident 14 and Resident 145 both had severe cognitive impairment and lacked capacity to make decisions, as documented in their History and Physicals and Minimum Data Sets. Their care plans referenced respecting the wishes specified in their ADs, but the actual AD documents were not present in their records. Resident 38, who had intact cognition and capacity, also had an AHDA indicating an executed AD, but the AD itself was missing from the file. In all three cases, the POLST forms on file noted that the POLST was not a substitute for an AD and should complement, not replace, the AD. The SSA confirmed responsibility for obtaining and filing ADs upon admission and acknowledged that the facility had not followed through in securing and maintaining these documents in the residents' records. Facility policy required that executed ADs be obtained and kept in a specific section of the medical record, but this was not done for the three residents in question.
Failure to Obtain and Document Weekly Weights as Ordered
Penalty
Summary
The facility failed to obtain and document weekly weights for three residents as required by physician orders and the facility's own policy. For one resident with heart failure and dementia, the weight was not taken upon readmission or on the date specified by the physician order. The Restorative Nurse Assistant (RNA) reported weighing the resident upon return but did not have access to the electronic documentation system and provided the weight to the Infection Preventionist (IP) on paper. The IP did not enter the weight into the system and had no documentation to confirm the weight was taken. Another resident with dysphagia, hypertension, and acute kidney failure experienced significant weight loss, and a physician order was in place for weekly weights. However, the medical record showed no weights were recorded on two consecutive weeks as required. Both the Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RNS) confirmed that weights were missing and acknowledged the importance of monitoring weight for residents experiencing weight loss. A third resident with multiple diagnoses, including dementia and anxiety disorder, also had a physician order for weekly weights due to recent weight loss. The care plan and nutritional assessment indicated the need for close monitoring, but the weekly weight for one of the required weeks was not documented. The RNA, responsible for weighing residents, stated that weights were sometimes taken on different days depending on workload and that the Director of Nursing (DON) was responsible for entering weights into the electronic record. The facility's policy required weekly weights for all residents for four weeks after admission or readmission, but this was not consistently followed or documented.
Failure to Label and Date Food Items in Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to ensure proper food storage practices in the kitchen's walk-in refrigerator. Specifically, a transparent container with sliced cheese was not labeled with an open date, a halfway-filled jar of hamburger pickles was not labeled with an open date, and two unopened plastics of whipping cream were not labeled with a received date. These observations were made during a walkthrough with the Certified Dietary Manager, who confirmed that food items should be labeled with open and receive dates to monitor quality and freshness. Further interview with the Registered Dietitian confirmed that all items in the refrigerator should be labeled with open and receive dates to track when food items arrived, determine when to discard them, and ensure the highest quality of food served to residents. Review of the facility's policy and procedure on Refrigerator/Freezer Storage indicated that leftover food or unused portions of packaged foods should be covered, dated, and labeled, and that all items should have appropriate delivery, open, and thaw dates. The facility's failure to follow these procedures led to the cited deficiency.
Arbitration Agreements Lacked Required Communication Provision
Penalty
Summary
The facility failed to ensure that its binding arbitration agreements included a provision allowing residents or their representatives to communicate with federal, state, or local officials. This deficiency was identified during interviews and record reviews for two residents. In both cases, the Admission Coordinator confirmed that the arbitration agreements signed by the residents' responsible parties did not contain a selection or statement affirming the right to communicate with authorities such as surveyors or the Ombudsman. One resident had a history of schizophrenia, bipolar disorder, and anxiety, while the other had chronic obstructive pulmonary disease, major depressive disorder, and psychosis, with documented intact cognition and partial assistance needs for daily activities. The omission in the arbitration agreements was acknowledged by the Admission Coordinator, who stated the importance of allowing such communication to honor residents' rights.
Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
The facility failed to adhere to infection prevention and control practices for six sampled residents, as evidenced by multiple observations and staff interviews. Personal toiletries and resident care items belonging to four residents were found unlabeled and improperly stored in a shared restroom, with items such as an opened cleanser, uncapped shaving cream, and a wash basin left accessible. Staff confirmed these items should have been labeled and secured in residents' closets to prevent cross-contamination, especially since some residents were ambulatory and could access items not belonging to them. Additionally, a resident with severe cognitive impairment was observed independently pouring water from a communal pitcher on a medication cart in the hallway, with no staff intervention. Staff interviews confirmed that residents should not be allowed to serve themselves from communal drink pitchers due to infection control concerns, as residents could contaminate the pitchers with dirty hands or by returning unwanted liquid. Facility policy also required measures to prevent the transmission of communicable diseases, which were not followed in this instance. Further deficiencies included a heavy accumulation of lint in two out of three dryer lint traps in the shared laundry room, contrary to the facility's schedule requiring frequent cleaning. Staff acknowledged the risk and admitted to not cleaning the lint traps as often as required. In another instance, a resident's bed sheets and room wall were observed with brown streaks suspected to be stool, and staff confirmed the resident had a history of handling feces and was unable to clean their own hands. Lastly, a used cup with leftover liquid was found on a hallway handrail, and staff stated that such items should not be left unattended as they could be used by other residents, posing an infection risk.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple mental health diagnoses was not provided adequate privacy and dignity during personal care. The resident was observed sitting in a shower chair at the bedside with the right flank and thigh exposed. The privacy curtains were only partially drawn, and the room door was propped open while a CNA was outside the room donning PPE. During this time, several male residents were walking in the hallway, making the resident's exposure visible to others. The resident's care plan specifically included interventions to maintain privacy and respect the resident's rights. Facility policy and procedures also required staff to close the room entrance door and ensure bodily privacy during personal care. Both the CNA and the RN Supervisor acknowledged that the resident's body was exposed and should have been covered for dignity and privacy. The failure to follow these protocols resulted in the resident being exposed in a manner inconsistent with facility policy and the resident's care plan.
Call Light Not Within Reach for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as observed during a survey. The resident, who had a history of unspecified dementia, psychotic and mood disturbances, and anxiety, was assessed as having severely impaired cognition and required varying levels of assistance with activities of daily living. During the observation, the resident was seated in a wheelchair in the middle of the room, facing away from the bed, while the call light was secured around the right-side grab bar of the bed, making it inaccessible to the resident. A Certified Nursing Assistant confirmed that the call light was not within the resident's reach and acknowledged that it should have been accessible in case the resident needed help. The Registered Nurse Supervisor also stated that call lights must be within reach for all residents, including those who are confused, to allow them to call for assistance. The facility's policy and procedure on call lights required staff to ensure that call lights are within reach when residents are in their rooms or on the toilet.
Failure to Update Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to complete a required assessment following a significant change in condition for a resident who was readmitted with multiple diagnoses, including dementia and major depressive disorder. Upon review, it was found that the resident's Minimum Data Set (MDS) did not reflect a new diagnosis of bipolar disorder, despite the presence of a physician's order for Depakote to treat this condition. The MDS Coordinator confirmed that the resident's hospital records, which should have been reviewed upon readmission, indicated treatment for bipolar disorder, and that this diagnosis should have been documented in both the Admission Record and the MDS. Further review of the resident's active orders and physician progress notes confirmed ongoing treatment for bipolar disorder, yet the diagnosis was not included in the facility's official records. The facility's policy requires that health records be current and detailed, consistent with good medical and professional practice. The omission of the bipolar disorder diagnosis in the resident's records and assessment tools represented a failure to update documentation after a significant change in the resident's condition.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete a required Level II Pre-Admission Screening and Resident Review (PASARR) evaluation for a resident who had a positive Level I PASARR screening for serious mental illness (SMI). The resident was initially admitted with diagnoses including traumatic subdural hemorrhage, seizures, and hypertension. The Level I PASARR screening, conducted after admission, indicated the need for a Level II evaluation, but there was no documentation that this evaluation was ever completed. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that there were no records of a Level II PASARR evaluation for the resident, despite facility policy requiring such an evaluation for residents with a positive Level I result. The facility's policy also required staff to review PASARR information regularly, follow up with the appropriate contractors, and maintain documentation, none of which was evidenced in this case.
Failure to Develop Care Plan for New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to develop a care plan addressing bipolar disorder for a resident who was readmitted following a hospital stay. The resident's admission record indicated multiple diagnoses, including dementia and major depressive disorder, and hospital records obtained during the recent hospitalization included a new diagnosis of bipolar disorder. However, the Minimum Data Set (MDS) completed after readmission did not list bipolar disorder as an active diagnosis, and no care plan was created to address this new condition. Interviews with the Minimum Data Set Coordinator (MDSC) revealed that the resident's medical record should have reflected the new bipolar disorder diagnosis and that a care plan should have been developed upon admission to ensure staff awareness and appropriate interventions. The facility's policy required the interdisciplinary team to review and update care plans when there is a significant change in a resident's condition or upon readmission from a hospital stay, but this was not done for the resident in question.
Resident Rooms Below Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 20 out of 23 resident rooms met the minimum required space of 80 square feet per resident in rooms with more than one occupant. Documentation from the Resident Listing Report and Client Accommodation Analysis showed that multiple rooms, each housing two residents, measured only 140 square feet, resulting in less than the required space per resident. Additionally, one room with four residents measured 308 square feet, also falling short of the standard. These findings were based on a review of facility records and room measurements. A waiver request letter from the facility stated that reasonable privacy, closet, and storage space were provided, and that there was sufficient room for nursing care and resident equipment. During an observation and interview, a CNA was able to move freely and provide care in a room with two wheelchairs present, and reported no issues with space when attending to residents. However, the documented room sizes did not meet the regulatory requirements for square footage per resident.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident at risk for elopement, leading to the resident leaving the facility unnoticed. The resident, who had diagnoses of dementia and major depressive disorder, was identified as having moderately impaired cognition and required supervision for daily activities. Despite these needs, the resident was able to elope from the facility without staff noticing, as staff were occupied with assisting other residents during mealtime. The incident occurred when a CNA and a Dietary Aide entered the hallway from the exit door and failed to ensure the door was closed or locked. The resident was seen on surveillance video holding the door open and subsequently leaving the facility. Interviews with staff revealed that during mealtimes, there was no one monitoring the exit door, as staff were busy feeding residents. This lack of supervision allowed the resident to leave the facility unnoticed. Upon the resident's return, it was noted that the resident had sustained a skin tear on the left arm. The facility's policy and procedure emphasized the importance of continuous supervision and redirection to prevent accidents and elopements, which was not adhered to in this case. Staff interviews confirmed that there was a lapse in monitoring and that the exit door was not properly checked, contributing to the resident's elopement.
Facility Fails to Maintain Acceptable Temperature Range
Penalty
Summary
The facility failed to maintain an acceptable temperature range as per its policy, affecting six resident rooms, one dining room, and one hallway. The air conditioning unit for the middle part of the nursing unit malfunctioned, leading to temperatures ranging from 84.4 to 97 degrees Fahrenheit, which exceeded the facility's acceptable range of 71 to 81 degrees Fahrenheit. The Director of Nursing acknowledged the issue, stating that the air conditioner had been broken since the previous day, and fans were being provided to residents as a temporary measure. The Maintenance Director confirmed the malfunction and stated that the HVAC technician was working on replacing the condenser. The air conditioning unit was reportedly fixed later that day. The facility's policy, titled 'Homelike Environment,' emphasized maintaining comfortable and safe temperatures, which was not adhered to during the malfunction. The Maintenance Supervisor's job description highlighted the responsibility for maintaining the facility in good repair, including mechanical systems, which was not fulfilled in this instance.
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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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