Veterans Home Of California - Chula Vista
Inspection history, citations, penalties and survey trends for this long-term care facility in Chula Vista, California.
- Location
- 700 East Naples Court, Chula Vista, California 91911
- CMS Provider Number
- 555795
- Inspections on file
- 38
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Veterans Home Of California - Chula Vista during CMS and state inspections, most recent first.
A resident with nicotine dependence and a PRN order for nicotine lozenges was found in bed with a medication cup containing a white tablet left unattended on the bedside drawer, with no staff present. The resident reported it was a nicotine wafer left by the nurse and ingested it, hoping it was the nicotine lozenge. The RN reported having given two lozenges but only saw the resident take one and believed direct observation was unnecessary for PRN doses. Review showed no evaluation or MD order for the resident to self-administer medications, despite facility policy requiring medications to be promptly administered as part of the complete act of administration.
A resident was readmitted with an order for IV Zosyn to treat an abdominal infection, but the facility did not have the medication available and could not obtain it from their contracted after-hours pharmacy. This resulted in delayed treatment and the resident being transferred to another facility for care.
Staff, including CNAs and an LVN, did not wear surgical masks as required in a unit with active Covid-19 cases, despite the facility's mitigation plan mandating source control masking during outbreaks. Interviews confirmed staff were aware of the policy, but masks were not consistently worn, increasing the risk of viral transmission.
The facility failed to maintain food safety and sanitation in the kitchen, with unlabeled and undated food items, expired meat substitute, and broken tiles creating unsanitary conditions. These deficiencies could expose residents to contaminated food and unsanitary practices.
The facility failed to notify the ombudsman of the transfer of three residents to the hospital, as required. One resident with diabetes and skin damage, another with a recent amputation, and a third with osteomyelitis were transferred without notification. The ADON was unaware of the requirement, and the facility's policy did not address notifying the ombudsman.
A facility failed to provide a written bed hold policy notification to a resident and/or his representative upon transfer to a hospital. Despite the facility's policy requiring such notification, there was no evidence of it in the resident's medical records. Interviews with RNs confirmed the oversight, potentially leaving the resident uninformed about their rights to return.
A resident experienced significant weight loss, and the facility failed to update the nutrition care plan to reflect necessary interventions. Despite the resident's moderate impairment and awareness of weight loss, the care plan was not revised to include dietary needs and preferences. The facility's policies on care plan updates were not followed, leading to a deficiency in providing appropriate nutrition interventions.
A resident experienced significant unintentional weight loss due to the facility's failure to implement a comprehensive approach for monitoring nutrition interventions. The RD did not update the care plan to address the resident's ongoing weight loss, and there was a lack of communication between dietary and nursing teams, hindering effective intervention.
The facility failed to ensure safe pharmaceutical services, with expired medications found in medication rooms and carts, and inadequate controlled drug records for a resident. Expired Procrit, Mantoux, insulin, and nitroglycerin were available for use, violating facility policy. Additionally, mismatched prescription numbers for a resident's narcotic medication indicated poor record-keeping, risking drug diversion or misuse.
A LTC facility experienced a medication error rate of 7.14% due to errors involving two residents. One resident received glipizide without the required 30-minute pre-meal interval, and another resident was given fexofenadine with fruit juice, contrary to guidelines. Additionally, a medication was omitted for the second resident. The errors occurred due to non-adherence to the facility's medication administration policies and guidelines.
The facility failed to ensure proper labeling and storage of medications. An outdated insulin vial was found in the Unit 700 Medication Room, and a bulk bottle of atovaquone oral suspension was improperly stored in the Unit 300 Medication Room. The pharmacist acknowledged these issues, which were contrary to the facility's policy and manufacturer's instructions.
A resident with dysphagia was not scheduled for a dental appointment despite a physician's order and facility policy requiring an initial dental screening upon admission. The resident had not seen a dentist since October 2023 and reported discomfort with ill-fitting dentures. The charge nurse failed to notify the office assistant to arrange the appointment, and there was no documentation of a request for dental evaluation.
The facility failed to serve food at acceptable temperatures, with observations showing meals below the required 130°F. Residents reported meals, especially breakfast, were often cold. The Director of Dietetics acknowledged the issue, and the facility's policy emphasized serving food at required temperatures.
The facility failed to follow Enhanced Barrier Precautions for two residents, leading to potential infection control issues. Staff did not wear required PPE during high-contact activities for residents with gastrostomy tubes. Additionally, improper storage of a single-use syringe and an unsealed saline spray in the medication room posed contamination risks. These actions were contrary to the facility's infection prevention policies.
A facility failed to implement a comprehensive care plan for a resident with mental health diagnoses, as their aggressive behaviors were not documented or communicated to the IDT. The resident's behavior towards staff was not monitored as required, leading to a lack of awareness among the care team until a meeting months later.
A resident with cognitive impairments eloped from an LTC facility, resulting in a fall and injury. The facility failed to assess the resident's supervision needs and did not conduct an Elopement Risk Assessment despite previous incidents. Staff did not adhere to monitoring protocols, leading to the resident being unsupervised for nine hours.
The facility failed to report suspected financial abuse within 24 hours for a resident with severe cognitive impairment. Despite multiple indications of delinquent payments by the resident's DPOA, the facility delayed reporting to APS and CDPH, resulting in a year-long delay in oversight and investigation.
Unattended Nicotine Lozenge Left at Bedside Without Self-Administration Authorization
Penalty
Summary
Nursing staff failed to ensure medications were properly administered and not left unattended at the bedside for a resident with an order for nicotine lozenges. The resident had a diagnosis of nicotine dependence and a physician’s order for nicotine 2 mg lozenges to be given as needed. During observation, the resident was found lying in bed with a clear plastic medication cup containing a single white circular tablet on the bedside drawer, with no nursing staff present. The resident stated the tablet was a nicotine wafer that the nurse had left there and then ingested the tablet, stating he hoped it was the nicotine lozenge. Further review showed that the MAR documented administration of one 2 mg nicotine lozenge earlier that morning, while the RN reported having given two lozenges and only witnessing the resident take one. The RN stated that because the lozenges were ordered as needed, she did not believe she had to see the resident take them. The supervising RN confirmed that medications should not be left unattended at the bedside and that the resident had not been evaluated for self-administration of medications. Another RN confirmed there was no physician order for the resident to self-administer medications. The facility’s medication administration policy required that medications be promptly given to the proper resident as part of the complete act of administration.
Failure to Provide Ordered IV Antibiotic Upon Readmission
Penalty
Summary
The facility failed to provide necessary treatment for a resident who was readmitted with an order for intravenous (IV) Zosyn, an antibiotic required for an abdominal infection following acute appendicitis with abscess. The hospital had communicated the need for IV Zosyn prior to the resident's transfer, and the facility staff, including the RN Case Manager and Director of Nursing, were aware of the requirement. However, upon the resident's arrival, the facility did not have IV Zosyn available, and the in-house pharmacy was closed. Attempts to obtain the medication from the contracted after-hours IV pharmacy were unsuccessful, as the pharmacy was not open during the weekend hours. The facility's process for reviewing new admissions or readmissions included determining whether the facility could meet the resident's care needs. Despite this, the staff did not verify the availability of IV Zosyn before accepting the resident for readmission. The emergency medication kit did not contain IV Zosyn, and the pharmacy manager was not informed in advance about the need for this medication. The facility's after-hours pharmacy contract indicated that emergency or expedited orders could be delivered on weekends and holidays upon mutual agreement, but this process was not successfully executed in this case. As a result of the facility's inability to provide the ordered IV antibiotic, the resident experienced a delay in receiving necessary medication and was subsequently transferred to another facility that could provide the required treatment. The failure to ensure medication availability prior to readmission directly led to the deficiency identified in the report.
Failure to Enforce Masking Protocols During Covid-19 Outbreak
Penalty
Summary
Staff on Unit 300 failed to adhere to the facility's infection prevention and control program by not wearing surgical masks as required in an area where residents with active Covid-19 infections resided. During an observation, two CNAs were seen with their surgical masks around their necks, not covering their nose and mouth, while passing nourishments to residents. Additionally, an LVN was observed at the nurse's station without a mask. Interviews with the involved staff confirmed their awareness of the masking requirement, and the Infection Preventionist stated that surgical masks were required on the units, with N-95 masks needed for direct care of Covid-19 positive residents. The facility's mitigation plan, reviewed during the investigation, specified that source control masking is required during a VRI outbreak or surge in cases, which was the current situation with multiple residents and staff testing positive for Covid-19. Despite this, staff, including visiting hospice nurses, were not consistently following the masking procedures as outlined in the mitigation plan. The DON and Standard Compliance Coordinator acknowledged the expectation for all staff and visitors to adhere to the masking requirements during the outbreak.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain food safety and sanitation measures in the kitchen, as observed during a survey. A plastic bin containing a white powdered substance, identified as a thickening agent for pureed foods, was found unlabeled and undated under a food preparation counter. Additionally, a bag of opened frozen peanut butter cookies and three sandwiches in the refrigerator were also found without labels or dates. These items were not in compliance with the 2022 Federal Food and Drug Administration Food Code, which requires proper labeling and dating of food items to ensure safety and prevent foodborne illnesses. Further observations revealed a bag of meat substitute in the walk-in freezer that was past its expiration date, which should have been discarded according to the facility's policy and the FDA Food Code. Additionally, five broken tiles were found at the base of the wall next to the dish drying racks, creating unsanitary conditions. The facility's policy requires that kitchen areas be kept clean and in good repair, which was not adhered to in this instance. These deficiencies had the potential to expose residents to contaminated food and unsanitary practices, increasing the risk of foodborne illnesses.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the ombudsman of the transfer or discharge of three residents, which is a requirement to ensure residents' rights are protected. Resident 19, who had diabetes mellitus and sacral moisture-associated skin damage, was transferred to a hospital for further evaluation and treatment of buttocks wounds. There was no documented evidence that the ombudsman was notified of this transfer. Similarly, Resident 47, who was readmitted to the facility after a right above-knee amputation, was transferred to a hospital without the ombudsman being informed. Resident 99, diagnosed with osteomyelitis, was also transferred to a hospital for further evaluation and treatment without notifying the ombudsman. Interviews with the Assistant Director of Nursing (ADON) revealed that the facility did not have a practice of notifying the ombudsman when residents were transferred or discharged. The ADON was unaware of the requirement to notify the ombudsman, and the facility's policy and procedure on transfer/discharge did not address this requirement. This oversight in communication and policy led to the deficiency identified by the surveyors.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a written bed hold policy notification to a resident and/or his representative upon the resident's transfer to an acute care hospital. This deficiency was identified during a review of the resident's medical records and interviews with facility staff. The resident was transferred to the hospital on August 27, 2024, and was readmitted to the facility on December 7, 2024, after a prolonged hospitalization. Despite the facility's policy requiring a bed hold notification to be provided and documented, there was no evidence of such notification in the resident's medical records. Interviews with Registered Nurses 5 and 6 confirmed that a bed hold notification was not completed for the resident at the time of transfer. The facility's policy, dated January 29, 2025, mandates that a licensed nurse must notify the resident or their representative about the bed hold policy and document this in the medical record. The failure to adhere to this policy potentially left the resident and/or his representative uninformed about the resident's rights to return to the facility following hospitalization.
Failure to Update Nutrition Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a person-centered care plan for weight loss was updated for a resident, identified as Resident 20, who experienced significant weight loss. Resident 20 was admitted with diagnoses including hypertension, rheumatoid arthritis, and chronic obstructive pulmonary disease. The resident had a BIMS score indicating moderate impairment and experienced a weight loss of over 7% from August 2024 to January 2025, without being on a physician-prescribed weight-loss regimen. Despite the resident's awareness of his weight loss and food preferences, the care plan was not updated to reflect necessary nutrition interventions. Observations and interviews revealed that Resident 20 consumed less than 55% of meals on average, and although there was an order for a Prostat supplement, it was not consistently administered. The Registered Nurse confirmed that the supplement was not given on a specific date, and the Registered Dietitian acknowledged that the care plan was not updated to include additional food items recommended. The care plan had not been revised to reflect the resident's ongoing weight loss and dietary needs, despite the dietitian's awareness and quarterly assessments. The facility's policies required care plans to be reviewed and updated quarterly or as necessary, but this was not adhered to in Resident 20's case. The Assistant Director of Nursing stated that dietary notes were separate from nursing notes, which may have contributed to the lack of communication and updates in the care plan. The failure to update the care plan as per the facility's policy and the resident's needs led to a deficiency in providing appropriate nutrition interventions for Resident 20.
Failure to Monitor Nutrition Interventions Leads to Significant Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive systematic approach for monitoring nutrition interventions for a resident, leading to significant unintentional weight loss. The resident, who had a history of hypertension, rheumatoid arthritis, and chronic obstructive pulmonary disease, experienced a weight loss of 10.84% from July 2024 to January 2025. Despite the resident's weight loss being documented, the facility did not adequately update or follow through with the nutrition care plan to address the issue. The Registered Dietitian (RD) was responsible for updating the nutrition care plans and attending Nutritional At Risk (NAR) meetings. However, the RD did not consistently update the care plan to reflect the resident's ongoing weight loss and failed to implement recommended interventions such as a fortified diet. The RD acknowledged that the resident's nutrition assessment did not include additional foods recommended, and the care plan lacked a weight loss goal. Interviews with facility staff revealed a lack of communication and coordination between the dietary and nursing teams. The Assistant Director of Nursing (ADON) stated that dietary notes were separate from nursing notes, hindering the nursing staff's ability to carry out interventions. The facility's policies required the RD to monitor significant weight changes and update care plans, but these actions were not effectively executed, contributing to the resident's continued weight loss.
Expired Medications and Inadequate Drug Records Found in Facility
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for its residents, as evidenced by the presence of expired medications in the medication rooms and carts. During an inspection of the Unit 300 Medication Room, outdated Procrit, Mantoux vial, and insulin pen were found stored and available for resident use. The pharmacist acknowledged that these medications were expired and should have been removed from the medication refrigerator. The facility's policy clearly stated that drugs should not be kept in stock after their expiration date, yet these expired medications were still present. In another instance, an expired nitroglycerin vial was found in the Unit 700 Medication Cart. The Assistant Director of Nursing confirmed the expiration and acknowledged that the vial should have been removed according to the facility's policy. This oversight in managing medication expiration dates posed a risk of residents receiving outdated and potentially ineffective medications. Additionally, the facility failed to maintain organized and orderly controlled drug records for Resident 5. The prescription numbers on the resident's PRN hydrocodone/acetaminophen did not match the corresponding Controlled Drug Record, leading to discrepancies in narcotic accountability. The Director of Pharmacy and Supervising Registered Nurse acknowledged the mismatch and the delay in the use of the narcotic supply. This lack of proper record-keeping could result in drug diversion, abuse, or misuse, further compromising resident safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate due to three medication errors involving two residents. For one resident, the medication glipizide, which is used to manage blood sugar levels, was not administered 30 minutes before meals as required. The Licensed Vocational Nurse (LVN) prepared and administered the medication without adhering to the timing guidelines specified in both the facility's drug handbook and Lexi-comp, the facility's reference for drug information. The Director of Pharmacy confirmed that the medication should be given 30 minutes before the first main meal, but this protocol was not followed. Another resident experienced two medication errors. One medication was omitted, and the allergy medication fexofenadine was administered with fruit juice, contrary to the guidelines in Lexi-comp, which state that fexofenadine should not be given with fruit juices. The Registered Nurse (RN) responsible for administering the medications acknowledged the omission and the incorrect administration method. The facility's policy and procedure for medication pass and administration were not adhered to, as special considerations and timing were not properly noted or followed in the Medication Administration Record (MAR). The facility's policies, including those for medication pass and drug administration, emphasize the importance of administering medications as prescribed and noting special considerations in the MAR. However, these policies were not followed, leading to the medication errors. The Director of Pharmacy and nursing staff acknowledged the discrepancies between the facility's practices and the established guidelines, which contributed to the increased medication error rate.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were labeled and stored according to accepted standards and manufacturer's instructions. During an inspection of the Unit 700 Medication Room, an outdated insulin vial was found stored in the refrigerator, despite a pharmacy label indicating it should not be used after January 22, 2025. The pharmacist acknowledged the outdated insulin vial and stated it should not have been returned to the medication room refrigerator. The facility's policy, reviewed with the Director of Pharmacy, indicated that drugs should not be kept in stock after their expiration date, and no contaminated or deteriorated drugs should be available for use. In another instance, during an inspection of the Unit 300 Medication Room, a bulk bottle of atovaquone oral suspension for a resident was stored in the medication refrigerator at 38 degrees Fahrenheit, contrary to the manufacturer's instructions to store it at room temperature between 68 to 77 degrees Fahrenheit. The pharmacist acknowledged the discrepancy between the storage conditions and the manufacturer's labeling. The facility's policy, reviewed with the Director of Pharmacy, stated that nursing staff should review manufacturer's recommendations to ensure drugs are stored at appropriate temperatures.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to ensure a dental appointment was scheduled for a resident, identified as Resident 72, who was admitted with a diagnosis of dysphagia. During an observation and interview, it was noted that Resident 72 was without teeth or dentures and expressed discomfort with wearing dentures due to their fit. The resident had not been seen by a dentist since October 2023, despite a physician's order from November 2024 for a dental evaluation and treatment. The registered nurse confirmed that the charge nurse should have notified the office assistant to arrange a dental appointment and documented this in the resident's record, which was not done. The facility's policy required an initial dental screening examination upon admission, which was not adhered to in this case.
Failure to Serve Food at Acceptable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at an acceptable temperature, which could affect the meal and food intake of residents, potentially impairing their nutritional status. During a test tray observation, it was noted that the entree of carne with tortilla was served at 128 degrees Fahrenheit, and the milk was at 50.8 degrees Fahrenheit, both below the acceptable temperature as per the FDA Food Code, which requires food to be held at 130 degrees Fahrenheit or above. Additionally, the beans served as a side item were dried out, indicating a lack of proper food handling and temperature maintenance. Interviews with residents and observations further confirmed the issue, as nine residents reported that meals, particularly breakfast, were often served cold. One resident specifically mentioned that his food was often cool and expressed a preference for hotter meals. The Director of Dietetics acknowledged the low food temperatures and stated that food should be served at an acceptable temperature and palatability. The facility's policy on food preparation also emphasized the importance of serving food at required temperatures to conserve nutrients, flavor, and appearance.
Inadequate Infection Control Practices and Medication Storage Issues
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for two residents, leading to potential infection control issues. Resident 84, who was admitted with dysphagia and a gastrostomy tube, was observed receiving perineal hygiene care, medication administration, and tube feeding without the staff wearing the required personal protective equipment (PPE). Despite the presence of EBP signage, both a Certified Nursing Assistant and a Licensed Vocational Nurse did not wear gowns during these high-contact activities, which are essential to prevent the spread of multidrug-resistant organisms. Similarly, Resident 25, diagnosed with multiple sclerosis and dysphagia, was also subject to inadequate infection control practices. During medication administration via a gastrostomy tube, a Licensed Vocational Nurse failed to wear a gown, contrary to the EBP requirements indicated by the signage outside the resident's room. The Infection Control Nurse confirmed that gowns and gloves should have been worn to prevent the transmission of multidrug-resistant organisms. Additional deficiencies were noted in the medication room, where a single-use syringe labeled as sterile was improperly stored attached to a medication bottle, and an unsealed bottle of saline spray was found without its printed neckband. These practices posed a risk of contamination and were acknowledged by the facility's pharmacist and infection control nurse. The facility's policies on drug storage and infection prevention were not followed, contributing to the potential spread of infections and use of compromised medical supplies.
Failure to Document and Monitor Resident's Aggressive Behavior
Penalty
Summary
The facility failed to implement an accurate comprehensive person-centered care plan for a resident, who was admitted with diagnoses including Major Depressive Disorder, Panic Disorder, and Post-Traumatic Stress Disorder. The resident exhibited aggressive behaviors towards staff, which were not monitored or documented as required. The Director of Physical Therapy reported being verbally harassed by the resident over the past two years but did not document these behaviors in the medical record or notify the Interdisciplinary Team (IDT) until July 2024. This lack of documentation and communication resulted in the IDT being unaware of the resident's behavior issues until a meeting on July 22, 2024. The Social Services Director and Supervising Registered Nurse were also unaware of the resident's aggressive behavior until shortly before the IDT meeting. The facility's policy required behavior monitoring to be documented every shift, but this was not done. The Medical Doctor emphasized the importance of documentation for accurate assessment and treatment planning. The failure to document and communicate the resident's behaviors compromised the ability to address the resident's mental health needs effectively.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident, resulting in injury. The resident, who had a history of dementia and paranoid schizophrenia, left the facility unsupervised and was missing for approximately nine hours. During this time, the resident fell and sustained a two-centimeter forehead laceration that required five sutures. The facility staff did not assess the level of supervision required for the resident's safety, despite previous incidents indicating a risk of elopement. The resident had a documented history of attempting to leave the facility unsupervised, as evidenced by a previous fall at the facility's back gate. Despite this, the facility did not conduct an Elopement Risk Assessment or update the resident's care plan to address the risk of elopement. The facility's policy required staff to monitor residents' whereabouts every two hours, but this was not adhered to, as the resident's location was documented without direct visualization. Interviews with facility staff revealed a lack of adherence to established protocols for monitoring residents. The Certified Nurse Assistant (CNA) responsible for the resident's care did not visually confirm the resident's location, relying instead on routine assumptions. The Director of Nursing acknowledged the failure to conduct an Elopement Risk Assessment and the absence of policies to prevent elopements, citing the facility's status as an unlocked facility where residents have the right to leave.
Failure to Report Suspected Financial Abuse in a Timely Manner
Penalty
Summary
The facility failed to implement their policy and procedure for reporting suspected financial abuse within 24 hours for a resident with severe cognitive impairment. The resident's Durable Power of Attorney (DPOA) had not paid the monthly residential fees for an extended period, leading to a significant outstanding balance. Despite multiple indications and internal communications about the delinquent payments, the facility did not report the suspected financial abuse to Adult Protective Services (APS) or the California Department of Public Health (CDPH) in a timely manner. The Financial Case Worker (FCW) and other staff members were aware of the issue but did not take the necessary steps to report it immediately, resulting in a year-long delay in oversight and investigation. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, was financially dependent on the DPOA. The facility's internal records showed multiple attempts to contact the DPOA and discussions about the need to report the suspected abuse. However, the actual report to APS was not made until much later, despite clear signs of financial mismanagement. The Facility Administrator acknowledged the oversight and confirmed that the suspected abuse should have been reported immediately as per the facility's policy and state law.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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