A Grace Sub Acute & Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 1250 S. Winchester Boulevard, San Jose, California 95128
- CMS Provider Number
- 056376
- Inspections on file
- 24
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at A Grace Sub Acute & Skilled Care during CMS and state inspections, most recent first.
The facility did not conduct fire drills at varied times as required, with records showing that drills for both PM and NOC shifts repeatedly occurred at the same times. This issue was confirmed through record review and staff interview, affecting all residents and smoke compartments.
A power strip not meeting required UL standards was found in use at a bedside, resulting in an electrical fire. The device had been brought in by a family member for charging a phone, and the facility could not verify its compliance with safety standards. This deficiency affected multiple residents and a smoke compartment.
A resident with a history of traumatic brain injury and epilepsy did not receive prescribed anti-seizure medications as ordered due to delays in pharmacy delivery. The delays were caused by the need for triplicate prescriptions for controlled substances and a lack of timely delivery authorization for a high-cost medication, with required documentation not provided promptly by the facility and physician. Facility policies requiring timely medication receipt and administration were not followed.
The facility failed to follow professional standards for several residents, including incomplete physician orders for insulin and lorazepam, lack of hypoglycemic protocols, and improper blood pressure monitoring on an arm with an AV fistula. Additionally, a resident on fluid restriction due to renal disease was not monitored for fluid intake and output, contrary to facility policy.
The facility failed to attempt alternatives before using side rails for numerous residents, as observed and documented in their care plans and assessments. Despite having physician orders for side rails for positioning and mobility, there was no evidence of alternative measures being considered. Interviews with the DON confirmed that alternatives were not deemed necessary, contradicting the facility's policy requiring less restrictive interventions to be documented and attempted first.
The facility failed to document the administration of controlled drugs for three residents, leading to unaccounted medications and potential errors. The nursing staff signed out medications from the Controlled Drug Record but did not record their administration on the Medication Administration Record, as required by facility policy. This issue was confirmed by the Minimum Data Set Coordinator.
The facility failed to maintain food safety standards, with undated and expired food items found in storage, and improper sanitization practices observed. Spoiled produce and expired test strips were noted, and a dietary supervisor used a contaminated thermometer without sanitizing it, risking foodborne illness for 44 residents.
The facility failed to follow infection prevention protocols, including dirty oxygen concentrator filters, improper PPE use by a nurse during medication administration to a resident with CP-C.R.E, and incorrect placement of a urinary drainage bag by a CNA, risking infection.
A resident with quadriplegia was not provided with an appropriate call device, relying instead on yelling for assistance. Despite the availability of alternative devices, the resident had not been assessed for a suitable option, contrary to the facility's policy on assistive devices.
The facility failed to complete baseline care plans within 48 hours of admission for two residents, as required by policy. Critical information was missing from the care plans, including therapy services, safety details, completion dates, review dates, and necessary signatures. This was confirmed by interviews with the Nurse Supervisor, MDS Coordinator, and DON, who acknowledged the plans should have been completed within 72 hours.
The CP failed to identify and report medication irregularities for two residents. One resident had an unclear and potentially unsafe insulin order, while another resident with CKD received Calcium Acetate at incorrect times, not aligned with meals, affecting its efficacy. The CP did not address these issues during monthly reviews.
Two residents in the facility were affected by medication mismanagement. One resident received warfarin for an incorrect indication, as the orders specified pulmonary edema instead of the correct condition, pulmonary embolism. Another resident had a lidocaine patch applied continuously without the required 12-hour off period, contrary to the manufacturer's instructions. These errors were confirmed by the DON and a Consultant Pharmacist.
A survey found a medication error rate of 5.56% in an LTC facility. One error involved an LVN not allowing the required interval between puffs of an asthma inhaler for a resident, contrary to facility policy. Another error involved an RN failing to flush a gastrostomy tube with water between medications for a resident, as per policy.
The facility did not adhere to the meal preferences of two residents, as observed during a survey. One resident preferred a cheeseburger daily, which was not provided, and another was served rice despite disliking it. The dietary supervisor confirmed these discrepancies, which were against the facility's policy to honor food preferences.
A resident in a room was unable to reach the call button, which was observed hanging on the wall above the bed, out of reach. The resident confirmed the inability to reach the button, and it remained out of reach during multiple observations until an RN handed it to the resident. The facility's policy indicated that call light devices should be accessible to assist with resident safety and independence.
A facility failed to maintain a safe environment for a resident due to cracked walls near the bathroom door and toilet, which were reported but not fully repaired. The resident, who is cognitively intact, confirmed the facility's awareness of the issue since the previous year. The maintenance director acknowledged that repairs were started but incomplete, contrary to the facility's maintenance policy.
A resident with hemiplegia and muscle weakness experienced a witnessed fall in the facility. Despite being at moderate risk for falls, the facility failed to complete a Morse Fall Scale assessment after the incident, as required by their policy. This deficiency was confirmed through interviews and record reviews.
Failure to Conduct Fire Drills at Varied Times
Penalty
Summary
The facility failed to conduct fire drills at varied times as required by regulation. Record review showed that fire drills for both the PM and NOC shifts were conducted at the same times on multiple occasions within the last 12 months, specifically with PM drills at 4:00 p.m. and NOC drills at 2:30 a.m. This deficiency was identified during a review of fire drill records and confirmed in an interview with the Administrator, who stated that the drills were conducted by the Director of Staff Development. The failure to vary the timing of fire drills affected all 116 residents and all four smoke compartments in the facility.
Plan Of Correction
by the deficient practice. Missing Fire Drill was completed on 12/24/2025 and education was provided to The Maintenance Director and designee. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A: The Maintenance Director or designee will maintain Fire drills according to regulation quarterly and be held at different times during the day, with a coded announcement being completed instead of audible alarms. Record keeping of quarterly tests to be gathered in a fire drill binder for reference and evidence of completion and compliance. Any updates necessary will be completed timely and reported to the Safety and QA Committee. Include dates when corrective action will be completed. The corrective action completion dates must be acceptable by the State Agency: Completion date: 12/24/25 K0712
Unapproved Power Strip Causes Electrical Fire at Bedside
Penalty
Summary
A deficiency was identified when a power strip was found in use at a patient bedside location that did not meet the required approval standards. During a facility tour, it was observed that a power strip was located approximately one foot away from a resident's bed on the ground in Resident Room 34. The Maintenance Supervisor confirmed that an electrical fire had occurred at this location in the early morning hours, and the resident occupying the bed reported that the power strip had been brought in by a family member for charging a phone. The facility was unable to verify whether the power strip in question met the necessary UL 1363A or UL 60601-1 standards required for use with patient-care-related electrical equipment in a patient care vicinity. This deficiency affected 47 out of 116 residents and one of four smoke compartments, as noted during the survey. The report does not provide additional details regarding the medical history or condition of the resident at the time of the incident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: A: Power strips and extension cords were immediately removed from the rooms. Both family and resident were notified of power cord safety and the importance of using medical-grade approved cords and safety of surroundings around the power cords. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: A: All residents have the potential to be affected by the deficient practice. Facility-wide audit conducted on 12/08/25 and all other power cords identified were noted and removed. Education was provided on 12/08/25 to the Maintenance Director on appropriate power cords within the facility. Facility-wide audit to be completed weekly for 12 weeks and then PRN as needed. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A: 1) Resident education on proper equipment usage (i.e., hospital graded extension cords only) 2) Staff In-Serviced on fire safety and prevention in regards to outlets and proper power cord identification—importance of keeping residents' belongings away from outlets and bringing concerns related to storage of belongings to facility leadership team 3) Daily resident room round sheet updated and to be conducted by assigned department managers. Weekly facility rounds will be conducted and every room and common area checked to ensure approved hospital grade extension cords are in place and outlet integrity is compliant by the maintenance supervisor or designee. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: A: Room round sheets will be turned in weekly. The Maintenance Director or designee will complete a facility-wide audit weekly for 12 weeks and report the results of the audit to the Safety Committee and QA meeting for compliance evaluation x4 months and then PRN as needed. Include dates when corrective action will be completed. The corrective action completion dates must be acceptable by the State Agency: Completion date: 12/11/2025
Failure to Provide Timely Pharmacy Services Resulting in Missed Medication Administration
Penalty
Summary
The facility failed to provide necessary pharmacy services to meet the needs of a resident who was readmitted with diagnoses including traumatic brain injury and epilepsy. Upon review, it was found that the resident had physician orders for multiple anti-seizure medications, including Clobazam, Lacosamide, and Zonisamide, all to be administered via gastrostomy tube. However, the medication administration record showed that these medications were not given on several days following the resident's readmission. Progress notes confirmed that the medications were not available at the facility and were pending delivery from the pharmacy. Interviews with facility staff and the consultant pharmacist revealed that delays occurred due to the need for triplicate prescriptions for controlled substances and a lack of timely delivery authorization for a high-cost medication. The pharmacy had requested the necessary documentation and authorizations from both the physician and the facility, but did not receive them in time to ensure the medications were available as ordered. Facility policies required timely receipt and administration of medications, but these were not followed, resulting in the resident not receiving prescribed anti-seizure medications as ordered.
Incomplete Physician Orders and Improper Monitoring in LTC Facility
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for several residents, leading to potential unsafe implementation of medical orders and unmonitored medical conditions. For Residents 25, 35, 93, and 98, there were incomplete physician orders. Resident 93 had an unclear insulin order with an incorrect dosage and no specified frequency or parameters for administration. Resident 35's lorazepam orders lacked dosing frequency, yet the medication was administered multiple times without clarification from the physician. Resident 98's insulin orders referenced a hypoglycemic protocol that was not present in the clinical record, leaving staff without guidance for managing low blood sugar levels. Resident 25 also had insulin orders that referred to non-existent hypoglycemia orders, which were only clarified with the physician shortly before the surveyor's interview. These deficiencies in medication orders and protocols could lead to inappropriate medication administration and inadequate response to residents' medical needs. The facility's policies required medication orders to include dosage, frequency, and clinical conditions, but these were not consistently followed. Additionally, Resident 75, who had an AV fistula for dialysis, had blood pressure readings taken on the arm with the fistula, contrary to care plan instructions and facility policy. This practice could cause injury or bleeding. Furthermore, Resident 75 was on a fluid restriction due to end-stage renal disease, but there was no monitoring of fluid intake and output, which is crucial for dialysis patients. The facility's policy required monitoring of fluid balance, but this was not implemented for Resident 75.
Failure to Attempt Alternatives Before Using Side Rails
Penalty
Summary
The facility failed to offer and/or attempt alternatives before using side rails for 18 of 22 sampled residents and 77 non-sampled residents. This deficiency was identified through observations, interviews, and record reviews. The residents involved had physician orders for side rails for positioning, mobility, or postural support, but there was no documentation that alternatives were considered or attempted prior to their use. The facility's policy required less restrictive interventions to be incorporated into care planning, but this was not followed. During observations, it was noted that residents had side rails or grab bars in use without documented attempts of alternative measures. For instance, Resident 66 had side rails for positioning and mobility, but the care plan and assessments lacked evidence of alternative attempts. Similar findings were noted for other residents, such as Resident 38, Resident 75, and Resident 77, among others. Informed consents for the use of bed rails indicated that alternatives were not attempted, and in some cases, were deemed not appropriate due to the use of specific mattresses like low air loss mattresses. Interviews with the Director of Nursing (DON) revealed that the facility did not consider alternatives necessary, as side rails were used for support, mobility, and positioning. The DON confirmed that most residents had side rails and that the facility used them if deemed beneficial. The facility's policy on the proper use of side rails, revised in 2016, stated that less restrictive interventions should be documented and attempted before considering side rails, but this was not adhered to, leading to the deficiency.
Failure to Document Controlled Drug Administration
Penalty
Summary
The facility failed to ensure accurate accountability and documentation of controlled drug administration for three residents, leading to potential medication errors and drug diversion. During an interview with the Director of Nursing (DON), it was explained that the facility's policy requires nurses to assess residents, review physician orders, sign out medications from the Controlled Drug Record (CDR), administer the medication, document the administration on the Medication Administration Record (MAR), and reassess the resident within one hour. However, discrepancies were found in the records of three residents, indicating that the nursing staff signed out medications from the CDR but failed to document their administration on the MAR. For Resident 39, there were five occasions where diazepam was signed out but not documented on the MAR. Resident 35 had nine instances where lorazepam was signed out without documentation on the MAR. Similarly, Resident 85 had four instances where oxycodone was removed without proper documentation. The Minimum Data Set Coordinator (MDSC) confirmed these findings and acknowledged that the medications were unaccounted for, as the nursing staff did not document the administration as required by the facility's policy.
Food Safety Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by several observations in the kitchen. Undated food items, food past their use-by date, and spoiled produce such as bananas with black spots, partially soft tomatoes, and dry green onions were found in the refrigerator and on the shelves. Additionally, a tube of Auto-Chlor test strips, essential for ensuring proper chemical concentration in cleaning solutions, was expired. The dietary supervisor confirmed these findings and acknowledged that expired food should not be on the shelves and should have been discarded. The facility's policies on labeling, dating, and storing produce were not followed, contributing to these deficiencies. Furthermore, during a tray line observation, the dietary supervisor failed to sanitize a contaminated thermometer before using it to check the temperature of lemonade. The thermometer was handled improperly, touching the bin several times before being dipped into the lemonade. This action was contrary to the facility's policy on thermometer use and calibration, which requires cleaning and sanitizing the thermometer before use. These lapses in food safety practices had the potential to cause foodborne illness and cross-contamination, affecting the 44 residents eating at the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention techniques in several instances. Two oxygen concentrators in different rooms were observed with dirty filters, indicating a lack of adherence to the facility's policy for weekly cleaning by the assigned environmental services staff. The Assistant Director of Nursing acknowledged the need for cleaning and checking the policy for frequency, while the Administrator later confirmed the filters had been cleaned. A registered nurse did not follow enhanced barrier precautions while administering medication to a resident who tested positive for CP-C.R.E, a multi-drug resistant organism. Despite clear signage indicating the need for gowns and gloves during high-contact care activities, the nurse entered the resident's room twice without wearing a gown, although gloves and a mask were used. The nurse admitted to the oversight after being shown the precautionary posters. Additionally, a certified nursing assistant placed a urinary drainage bag on a resident's bed during personal care, causing urine to flow back toward the resident. This action was confirmed by the treatment nurse and the infection preventionist, who both stated that the drainage bag should be kept below the bladder to prevent infection. The facility's policy also supports this practice, emphasizing the need to position the drainage bag lower than the bladder at all times.
Failure to Provide Appropriate Call Device for Resident with Quadriplegia
Penalty
Summary
The facility failed to accommodate the needs of a resident with quadriplegia by not providing an appropriate staff call device. The resident, who was admitted with diagnoses including respiratory failure and quadriplegia, was observed with hand splints and a call button placed next to her on the bed. However, due to her condition, she was unable to use the call button effectively and instead had to yell out for assistance. Interviews with staff, including a registered nurse and the maintenance director, revealed that the resident had not been assessed for an appropriate call device, despite the availability of alternative devices that could be activated by other means, such as a head-activated call device. The facility's policy on assistive devices and equipment indicated that call light devices should be appropriate for the resident's condition. Despite this, the resident's needs were not adequately assessed or met, as confirmed by the nurse supervisor and the Director of Nursing. Both acknowledged the availability of other call devices that could be more suitable for the resident's condition, yet no action had been taken to provide such a device. This oversight had the potential to delay necessary care and services for the resident.
Failure to Complete Baseline Care Plans Within Required Timeframe
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for two residents, Resident 66 and Resident 25, as required by their policy. For Resident 66, the baseline care plan was missing critical information such as therapy services, completion date, review date with the resident or representative, and signatures from both staff and the resident or representative. Similarly, Resident 25's baseline care plan lacked details on safety, completion date, review date, and necessary signatures. These omissions were confirmed during interviews with the Nurse Supervisor, MDS Coordinator, and Director of Nursing, who all acknowledged that the baseline care plans should have been completed within 72 hours of admission. The facility's policy, dated December 2016, mandates that a baseline care plan be developed within 72 hours to ensure the resident's immediate care needs are met. This includes reviewing healthcare practitioner orders and implementing a plan covering initial goals, physician orders, dietary needs, therapy services, and social services. The policy also requires that a summary of the baseline care plan be provided to the resident and their representative. The failure to adhere to this policy resulted in the potential for residents and their responsible parties to be unaware of the care plan, as evidenced by the incomplete documentation for Residents 66 and 25.
Consultant Pharmacist Fails to Identify Medication Irregularities
Penalty
Summary
The consultant pharmacist (CP) failed to identify and report medication irregularities during the monthly drug regimen review for two residents. For one resident, an order for Admelog insulin was issued without specifying the frequency or parameters for administration, and the dose was incorrectly set at 3 ml, equating to 300 units, which is excessively high. Despite the order being unclear and potentially unsafe, the CP did not identify or report this irregularity during the monthly reviews since July 2024. For another resident with chronic kidney disease, the CP did not ensure that the medication Calcium Acetate was administered in accordance with the manufacturer's specifications, which require it to be taken with meals. The facility's administration schedule did not align with meal times, resulting in the medication being given at incorrect times on 35 out of 39 occasions. The resident's phosphorous levels were high, indicating the medication was not optimally effective. The CP did not make any recommendations to correct the administration timing after June 2024.
Medication Mismanagement for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, leading to a deficiency in medication management. Resident 35 was administered warfarin, a blood thinner, for an incorrect indication. The resident's clinical record showed a diagnosis of chronic embolism and thrombosis, as well as a saddle embolus of the pulmonary artery with acute cor pulmonale. However, the physician's orders incorrectly indicated that warfarin was prescribed for pulmonary edema, rather than the appropriate condition of pulmonary embolism. This error was confirmed during an interview with the Director of Nursing, who acknowledged the incorrect diagnosis in the warfarin orders. Resident 98 was affected by improper administration of a lidocaine patch, which was not used according to the manufacturer's specifications. The resident's physician's orders specified the application of a lidocaine patch for back pain management, but the patch was applied continuously without the required 12-hour off period. The Licensed Vocational Nurse confirmed the incorrect application schedule, and the Director of Nursing verified that the facility's template for lidocaine patch application was not followed. The Consultant Pharmacist also confirmed the correct usage instructions for the lidocaine patch, highlighting the deviation from proper medication administration practices.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 5.56% during a survey, with two errors occurring out of 36 opportunities. One error involved a Licensed Vocational Nurse (LVN) administering an asthma medication, Alvesco, to a resident without allowing the recommended 1-2 minute interval between puffs. The LVN was unaware of the need to space out inhalations, which was contrary to the facility's policy and procedures that required a minimum of one minute between inhalations of the same medication. The second error involved a Registered Nurse (RN) administering medications via a gastrostomy tube to another resident. The RN failed to flush the tube with water between administering each of the ten medications, as required by the facility's policy. The policy specified that the tube should be flushed with 10 mL of water between medications and a final flush of 50 mL after the last medication. The RN acknowledged the oversight during an interview, confirming that he did not follow the correct procedure.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to provide meals according to the preferences and dislikes of two residents, which was identified during a survey. Resident 55, who was admitted to the facility on an unspecified date, preferred to have a cheeseburger every day, but this preference was not honored during a lunch service observed on October 15, 2024. Similarly, Resident 67, admitted on an unspecified date, was served rice despite her documented dislike for it. These discrepancies were confirmed during an interview with the dietary supervisor, who acknowledged that meals should have been served according to the residents' preferences and dislikes. The facility's 2023 policy on food preferences states that residents' food preferences will be adhered to within reason, and substitutes for disliked foods will be provided from the appropriate food group.
Resident's Call Button Out of Reach
Penalty
Summary
The facility failed to ensure that a resident had access to a staff call device, which is essential for requesting help or in case of an emergency. During multiple observations in Room R3, the call button for bed A was found hanging on the wall above the head of the bed, out of reach of the resident. The resident confirmed that she could not reach the call button and expressed a desire to be able to call for assistance. Despite being observed at different times throughout the day, the call button remained out of reach until a registered nurse noticed the issue and handed the call button to the resident. The facility's policy and procedure on assistive devices and equipment, revised in January 2020, indicated that call light devices should be provided to assist with resident mobility, safety, and independence.
Facility Fails to Repair Cracked Walls in Resident's Bathroom
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment for one of the sampled residents due to cracked walls near the bathroom door and at the bottom left side of the toilet in the bathroom. This issue was observed during an interview with the resident, who confirmed that the facility was aware of the damage since the previous year. The resident, who was cognitively intact with a BIMS score of 15, expressed that the walls were damaged and needed repair. During a review of the maintenance log with the maintenance director, it was confirmed that the maintenance staff had started repairs but missed the areas near the bathroom door and the bottom of the toilet. The facility's policy on maintenance service, revised in 2009, indicates that the maintenance department is responsible for maintaining the building in good repair and free from hazards. However, the failure to address the cracked walls in a timely manner represents a deficiency in maintaining a safe environment for residents.
Failure to Complete Morse Fall Scale After Resident Fall
Penalty
Summary
The facility failed to complete a Morse Fall Scale assessment after a witnessed fall involving a resident, which is a requirement according to the facility's policy. The resident, who had diagnoses including hemiplegia, disorientation, and muscle weakness, was admitted on an unspecified date and was identified as being at moderate risk for falls based on a previous Morse Fall Scale assessment. On a specific date, the resident was seen scooting out of bed by a licensed nurse (LN A) and another staff member. Despite attempts to assist, the resident slid onto the ground, which was documented as a witnessed fall. Upon review of the resident's medical record, it was found that there was no documentation of a Morse Fall Scale assessment being completed after the fall. This was confirmed during an interview with another licensed nurse (LN B), who acknowledged that the facility's protocol required a Morse Fall Scale assessment to be completed after each fall. The facility's policy and an undated fall checklist both indicated the necessity of conducting a Morse assessment following a fall, highlighting the deficiency in adhering to established procedures.
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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