Berkley East Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 2021 Arizona Ave, Santa Monica, California 90404
- CMS Provider Number
- 555748
- Inspections on file
- 75
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Berkley East Healthcare Center during CMS and state inspections, most recent first.
A CNA recorded and posted a video of a cognitively impaired resident on social media without obtaining consent, violating facility policies and the resident's rights to privacy and dignity. The resident and responsible party were unaware of the recording and posting, and staff confirmed that no consent was documented. Facility policies prohibit such actions, and the incident was confirmed through interviews and record review.
A resident with multiple comorbidities and cognitive impairment was discharged home alone without sufficient follow-up on interdisciplinary team recommendations for a caregiver or consideration of assisted living, despite documented safety concerns and family input. The facility provided brochures for caregiver agencies, but did not ensure necessary post-discharge care or document adequate discharge planning as required by policy.
A resident with severe cognitive impairment and chronic wounds repeatedly removed their own wound dressings due to itchiness, but staff did not develop an individualized care plan to address this behavior. Facility staff and the DON acknowledged the lack of a care plan, despite policy requirements for comprehensive, person-centered care planning.
A resident with diabetes, peripheral vascular disease, and a chronic non-pressure ulcer did not receive a wound consultation from a Wound Provider Specialist, and staff failed to consistently monitor and maintain wound dressings as ordered. The resident frequently removed dressings due to discomfort, and no care plan was developed to address this behavior. Additionally, the Treatment Administration Record was inaccurately documented, including entries for care provided after the resident had been transferred out of the facility.
A high fall-risk resident with dementia and impaired cognition experienced two unwitnessed falls while attempting to ambulate to the bathroom without assistance. Despite a care plan that included using call lights and providing assistance, the resident's cognitive impairments and tendency to overestimate their abilities were not adequately addressed. Facility staff acknowledged the need for more direct supervision, such as a sitter, only after the falls occurred, highlighting a gap in proactive fall prevention strategies.
A breach of resident confidentiality occurred when a family member found medical records of other residents in a resident's room. The documents included sensitive information such as medical, demographic, and financial details, violating HIPAA and the facility's privacy policy. The Case Manager and Facility Administrator confirmed the breach, acknowledging that such records should not be accessible to unauthorized individuals.
The facility failed to manage its Cubex medication dispensing system properly, as the DON did not review daily reports for 11 months. Additionally, non-controlled drug dispositions were not recorded by two nurses as required, and outdated medications were found in a medication cart. These deficiencies could lead to medication errors and discrepancies.
The facility did not follow standardized recipes for residents on mechanical soft and dysphagia diets, serving incorrect food textures that could pose a choking risk. Observations showed that residents received sliced turkey instead of ground turkey and regular rice instead of pureed rice, contrary to the menu and food production guide. The Dietary Supervisor and Registered Dietitian confirmed the importance of adhering to texture-modified diets.
The facility failed to clean and sanitize an ice scooper daily, as required by its policy, leading to unsanitary conditions with red stains and sticky residue. The Dietary Supervisor admitted the lack of a cleaning log, and the Dishwasher confirmed no record of cleaning times. This oversight risked cross-contamination for 101 out of 102 residents receiving ice.
A facility failed to label a resident's enteral feeding bottle, which was required by policy to ensure correct administration and infection control. The resident, with severe cognitive impairment and total dependence on staff, was receiving Glucerna 1.5 via a gastrostomy tube. The LVN could not confirm when the bottle was first administered, and the DON confirmed the labeling requirement. This oversight posed a potential risk for complications.
A facility failed to obtain a physician's order for CPAP use for a resident with obstructive sleep apnea upon admission, delaying the order by two days. Additionally, staff lacked training on CPAP/BIPAP machines, with no documented competency checks or in-service training. The Director of Staff Development had not conducted necessary training, and the Director of Nursing acknowledged the risks of inadequate training.
A facility failed to provide a hemodialysis (HD) emergency kit at the bedside for a resident with end-stage renal disease (ESRD), risking delayed intervention during emergencies like bleeding. The resident, dependent on staff and cognitively impaired, did not have the kit due to family members taking them home, as confirmed by an LVN. The DON stated the kit is essential for managing bleeding emergencies, aligning with facility policy requiring kits at the bedside and on crash carts.
The facility failed to ensure staff competency in using CPAP/BIPAP machines, crucial for residents with respiratory conditions. A resident with sleep apnea did not have a CPAP order on admission, and staff interviews revealed a lack of training. The Director of Staff Development had not conducted training, and employee files lacked competency records, despite facility policy requiring trained personnel for CPAP use.
A facility failed to verify informed consent for psychotropic medications Lexapro and Seroquel for a resident with impaired cognitive skills. The resident, unable to make medical decisions, was administered these medications without proper consent from a representative. Staff interviews revealed that the informed consent process was not followed, as the consent should have been obtained from the resident's representative.
A discrepancy was found in the labeling of a controlled medication at a facility, where a bottle of morphine sulfate was labeled as containing 15 ml, but the packaging indicated 30 ml. This inconsistency was discovered during an inspection of discontinued medications meant for destruction. The facility's policy requires such discrepancies to be addressed, but this was not done, posing a potential risk for medication diversion.
The facility failed to maintain a reach-in freezer, resulting in significant ice buildup that affected food quality. The ice accumulation made it difficult to open the freezer door and compromised the storage conditions of food items, as observed with a discolored package of plant-based turkey alternative. Despite the Dietary Supervisor's request for maintenance over a month prior, the issue persisted, potentially impacting 101 out of 102 residents who consume meals from the facility's kitchen.
A resident's ring, documented on the inventory list upon admission, was not reimbursed after it went missing. The Social Services Assistant was informed by the resident's representative and completed a theft loss form, but the issue remained unresolved. The Administrator questioned the facility's responsibility due to the delayed report and lack of a receipt, and the facility's policy on lost property was not fully executed.
A resident with severe cognitive impairment and multiple diagnoses was transferred to a hospital without their representative being informed in writing about the bed-hold policy. The facility's policy requires written notification prior to transfers, but no bed-hold order or notice was documented. The DON confirmed the oversight.
A resident was not readmitted to the facility after hospitalization, despite the facility's policy allowing for such returns. The resident, with conditions like hypertensive heart disease and emphysema, was sent to a hospital due to low blood oxygen levels. Upon discharge, the facility's clinical staff decided not to readmit the resident, citing an inability to meet their needs, without providing the required notice or documentation.
Two residents experienced significant weight loss, but their care plans were not updated to address this issue. One resident lost 5.6% of their weight, and another lost 10.4%, yet the Registered Dietitian's recommendations for appetite stimulants were not incorporated into their care plans. Interviews revealed confusion over responsibility for care plan updates, with the Director of Nursing indicating that any licensed staff could revise them, while the RD believed it was the nursing staff's duty.
A resident with conditions including cellulitis, diabetes, and Parkinson's experienced confusion and hallucinations. Despite family concerns and a physician's order for a urinalysis, the facility failed to document the change in condition or conduct the test. The DON confirmed the lack of documentation and test execution, indicating a breach in facility policies.
A facility failed to provide a BIPAP machine for a resident who required continuous oxygen therapy. The resident, with a history of respiratory failure and COPD, was admitted without a BIPAP machine, and the facility did not follow its process for reviewing pre-admission documents. Attempts to use the resident's home BIPAP machine were unsuccessful due to missing parts, and a new machine ordered by the facility was incompatible. This oversight placed the resident at risk for inadequate oxygenation.
The facility failed to document glucometer QC results on multiple days and did not secure the medication disposal bin, risking inaccurate blood sugar readings and medication diversion. The DON confirmed the lapses, which violated the facility's policies on glucometer testing and medication disposal.
The facility failed to implement its infection control policy, as staff members did not perform hand hygiene after resident contact, and visitors were not screened before entry. Observations showed staff moving between resident rooms without washing hands, and visitors entering without masks or temperature checks. The absence of staff at the front desk during lunch breaks left visitors unscreened, despite an active COVID-19 outbreak.
A power outage in an LTC facility left 88 residents without power for over 30 minutes due to a delayed generator start. A resident was unable to use their CPAP machine and had to sleep on a deflated mattress. The delay was caused by a breaker switch not being in the 'ON' position, which was discovered after a significant delay.
A resident with COPD and asthma was found with an albuterol inhaler at their bedside, which they used without facility authorization. The resident required assistance for daily activities and had not been assessed for self-medication. An LVN confirmed that the facility was administering the inhaler and expressed concern about potential double dosing, as the resident was not allowed to self-administer medications according to facility policy.
A resident with a history of falls and cognitive impairment was left unattended in the bathroom, resulting in a fall and a mild displaced fracture of the right femoral neck. Despite being assessed as high risk for falls, the resident was left alone, leading to the incident. Staff interviews revealed a lack of communication regarding the resident's needs, contributing to the deficiency.
A resident with a history of falls and multiple medical conditions experienced a fall and was not properly assessed for injuries by an LVN. The LVN failed to perform a thorough neuro check, relying only on the resident's verbal denial of pain. This oversight delayed the diagnosis of a right hip fracture, as the resident later expressed pain during a physical therapy session. The facility's policy required a comprehensive assessment after falls, which was not followed.
A resident with a history of falls and multiple medical conditions fell and sustained a hip fracture due to inadequate staffing at a facility. The resident required assistance with toileting, which was not provided due to CNA shortages. On the day of the incident, only three CNAs were available for a shift, each responsible for 14-15 residents, leading to delays in care and the resident being left unattended.
A resident with hypertension and other medical conditions did not receive her antihypertensive medications on time, as observed during a survey. The LVN responsible admitted to administering the medications late, beyond the facility's policy of within one hour of the prescribed time. The delay was attributed to the time taken by residents to take their medications, despite the LVN starting the medication pass on time.
A resident experienced respiratory distress due to the facility's failure to correctly apply a non-rebreather oxygen mask (NRBM) in an emergent situation. The NRBM was set to an insufficient oxygen flow, and the reservoir bag was not fully inflated, leading to inadequate oxygen delivery.
The facility failed to ensure that licensed nurses had the skills and knowledge to correctly apply a non-rebreather oxygen mask (NRBM) in an emergent situation for a resident. The resident was found with low oxygen saturation, and the staff set the oxygen flow incorrectly, leading to inadequate oxygen delivery. The facility's training on oxygen use was based on personal experience rather than a structured curriculum, and staff did not adhere to the facility's policy for using the NRBM.
The facility failed to develop a discharge care plan for a resident with multiple diagnoses and severely impaired cognition. Despite the issuance of eviction notices, the care plan was not initiated or updated in a timely manner, as required by facility policies.
Violation of Resident Privacy and Dignity Through Unauthorized Social Media Posting
Penalty
Summary
Certified Nursing Assistant (CNA) 1 violated a resident's rights to privacy, dignity, and respect by recording a video of the resident without obtaining consent from either the resident or the resident's responsible party. The resident, who had severe cognitive impairment and required moderate to maximal assistance with activities of daily living, was not aware that a video was being taken or that it would be posted on social media. The facility's policies explicitly prohibit staff from taking or releasing images or recordings of residents without explicit written consent, except under specific circumstances such as investigations or emergencies. Despite these policies, CNA 1 admitted to posting a video of the resident on her personal Instagram story and to FaceTiming friends while in the resident's room. The Director of Nursing (DON) and other staff confirmed that the images and video were of the resident and that no consent had been obtained. The resident's responsible party expressed shock and concern over the incident, emphasizing the resident's desire for privacy and the lack of understanding or consent regarding the sharing of images. The responsible party also highlighted the resident's vulnerability and the potential for harm to the resident's dignity and self-esteem. Interviews with facility staff, including social services and nursing leadership, confirmed that taking photos or videos of residents without proper consent is a violation of both facility policy and resident rights. The facility's review of records found no documentation of consent for the images or video. The incident was reported to the district office, and the facility's policies regarding privacy, use of personal devices, and protection of protected health information were reviewed and found to have been violated by CNA 1's actions.
Failure to Ensure Safe and Adequate Discharge Planning
Penalty
Summary
The facility failed to provide sufficient preparation and orientation for a safe and orderly discharge for one resident. The interdisciplinary team (IDT) did not follow up on the care conference recommendations regarding discharge planning during the resident's admission. Although the care plan and discharge planning review identified that the resident lived alone and would require a caregiver (CG) for safety, there was no documented evidence that these recommendations were fully implemented or followed up. The resident had multiple diagnoses, including infrarenal abdominal aortic aneurysm, type II diabetes mellitus, muscle weakness, and major depressive disorder, and was noted to have moderately impaired cognitive skills and fluctuating capacity to make decisions. The resident's family expressed concerns about his safety living alone, and the general acute care hospital social worker recommended discharge to an assisted living facility (ALF) due to the resident's comorbidities and home situation. Despite these concerns, the resident was discharged home alone with home health services, and there was no documentation confirming that a caregiver was arranged or that ALF was presented as an option. Interviews with staff revealed that while the resident was provided with brochures for caregiver agencies, he stated he could not afford a caregiver, and no information about ALF was given. The facility's policy required documentation of discharge planning and arrangements for post-discharge care, but the medical record did not reflect adequate follow-up or evidence that the necessary care and services were provided upon discharge.
Failure to Develop Individualized Care Plan for Wound Dressing Removal Behavior
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive, individualized care plan addressing a resident's behavior of removing their own wound dressings. The resident, who had a history of surgical aftercare, Type II diabetes mellitus, peripheral vascular disease, and a chronic non-pressure ulcer on the right ankle, was assessed as having severely impaired cognitive skills and required moderate to maximal assistance with activities of daily living. Despite these needs and the resident's behavior of removing wound dressings due to itchiness, there was no care plan in place to address this specific behavior. Interviews with facility staff confirmed that the behavior was known, as the resident would often be found with dressings removed, and staff acknowledged that a care plan should have been developed to address this issue. The Director of Nursing stated that the absence of a care plan for this behavior could put the resident at risk, and that such incidents should have been documented and communicated to the physician. Review of facility policies confirmed the requirement for comprehensive, person-centered care plans with measurable objectives and timeframes for each resident.
Failure to Obtain Wound Consultation, Maintain Wound Care, and Ensure Accurate Documentation
Penalty
Summary
The facility failed to obtain a wound consultation and assessment by a Wound Provider Specialist (WPS) for a resident admitted with multiple risk factors for poor wound healing, including Type II diabetes mellitus, peripheral vascular disease, and a chronic non-pressure ulcer of the right ankle. Despite the resident's complex medical history and the presence of surgical and arterial wounds, there was no documentation of a WPS evaluation from admission through the resident's discharge. Nursing staff noted that the resident was supposed to be seen by the WPS, but the consultation did not occur, and the resident's wounds and skin integrity were not evaluated by a specialist. Additionally, the facility did not ensure that wound dressings were monitored and maintained according to physician orders. The resident exhibited behaviors such as removing wound dressings due to discomfort, leaving wounds exposed. Nursing staff acknowledged that dressings were often found removed during their shifts, and there was no care plan developed to address the resident's behavior of removing dressings. The facility's Director of Nursing confirmed that staff should have reapplied dressings to keep wounds clean and dry as ordered, but this was not consistently done. The facility also failed to maintain accurate and objective documentation in the Treatment Administration Record (TAR). The TAR indicated that all skin treatments were documented as given, even on dates when the resident was no longer present in the facility due to transfer to an acute care hospital. The Director of Nursing identified this as fraudulent documentation, as it did not reflect the resident's actual presence or care provided. These deficiencies were contrary to the facility's policies and procedures regarding wound care, documentation, and consulting physician practices.
Inadequate Supervision Leads to Recurrent Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a high fall-risk resident, resulting in two unwitnessed falls. Resident 1, who has a history of falls, dementia, and impaired cognition, experienced falls on 2/5/2025 and 3/19/2025 while attempting to ambulate to the bathroom without assistance. Despite being identified as a high fall risk, the resident was not adequately supervised, leading to these incidents. Resident 1's care plan included interventions such as using call lights for assistance and providing help with activities of daily living. However, the resident's cognitive impairments and tendency to overestimate their abilities were not sufficiently addressed, as evidenced by the resident's repeated attempts to ambulate independently. Interviews with facility staff revealed that the resident often did not ask for assistance and had a history of frequent falls, indicating a need for more direct supervision. Observations and interviews highlighted the resident's confusion and reluctance to seek help, as well as the facility's lack of effective fall prevention measures, such as bed alarms or a consistent one-to-one observation. The facility's policy on fall risk management was not effectively implemented, as the resident continued to experience falls despite being identified as high risk. The staff's acknowledgment of the need for a sitter or other interventions came only after the falls occurred, indicating a gap in proactive fall prevention strategies.
Breach of Resident Confidentiality and Privacy
Penalty
Summary
The facility failed to protect and safeguard the personal and medical records of 11 out of 13 sampled residents, violating their rights to privacy. This deficiency was identified during a survey when a family member of a resident found a stack of documents in a resident's room that did not belong there. These documents contained sensitive medical and personal information of other residents, which should have been kept confidential according to the facility's policy and procedures. The documents found included other residents' medical records, demographics, financial information, insurance details, clinical information, and personal living information. The Case Manager confirmed that these documents were not supposed to be in the resident's room and acknowledged that their presence there was a violation of the Health Insurance Portability and Accountability Act (HIPAA). The exposure of these records to unauthorized individuals was a breach of confidentiality and privacy, as it made sensitive information accessible to other residents and their families. The Facility Administrator also confirmed that the presence of these documents in the resident's room was a violation of HIPAA. The facility's policy, titled 'Confidentiality of Information and Personal Privacy,' mandates that access to resident personal and medical records should be limited to authorized staff and business associates. The incident was reported to the facility's HIPAA compliance officer, and a case was opened to address the breach of privacy.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper management and oversight of its medication dispensing system, Cubex, for at least 11 months. The Director of Nursing (DON) was unable to access or review daily activity and discrepancy reports from the Cubex system, as required by facility policy. Despite the system being installed in the facility, the DON did not recall reviewing any reports, and it was discovered that the facility had not received any reports since the system's installation. The facility pharmacy corrected the email address in the system, which allowed the facility to start receiving autogenerated reports. This lack of oversight had the potential to lead to medication errors and discrepancies. Additionally, the facility did not adhere to its policy regarding the disposition of non-controlled drugs, which requires the presence and signatures of two licensed nurses. For at least 8 months, the medication disposition logs showed only one nurse's signature, except for one instance. Furthermore, outdated medications were found stored in a medication cart, specifically two inhalers with open dates indicating they should have been discarded. The failure to remove expired medications from the cart was confirmed by the DON, who acknowledged that the inhalers should have been disposed of according to the facility's policy.
Failure to Follow Dietary Guidelines for Texture-Modified Diets
Penalty
Summary
The facility failed to adhere to the standardized recipes for the lunch menu on 12/16/24, specifically for residents on mechanical soft and dysphagia diets. Observations revealed that 25 residents on a mechanical soft diet received Cajun country rice with sliced turkey instead of the prescribed ground turkey. Additionally, a resident on a dysphagia diet was served baked fish instead of ground fish and regular rice instead of pureed rice, contrary to the food production guide. These deviations from the menu were confirmed during interviews with Cook1, who acknowledged the mistake and the potential risk of choking due to incorrect food textures. The Dietary Supervisor and Registered Dietitian confirmed that the menu should have been followed, emphasizing the importance of texture-modified diets to prevent choking. The facility's policy and procedures, as well as specific recipes, indicated that meats for mechanical soft diets should be ground, and for dysphagia diets, the fish should be ground and rice pureed. The failure to follow these guidelines was observed during a taste test, where the food served did not meet the required texture modifications, posing a risk to the residents' safety.
Failure to Maintain Sanitary Conditions for Ice Scooper
Penalty
Summary
The facility failed to ensure safe food handling practices by not cleaning and sanitizing an ice scooper daily as per the facility's policy and procedure titled 'Ice Procedures.' During an observation, the ice scooper was found stored in an unsanitary condition with red stains and a sticky texture, which the Dietary Supervisor (DS) attributed to juice residue. The DS acknowledged that the ice scooper is used to transfer ice into water and juice pitchers for residents and admitted that the facility does not maintain a log or record of when the ice scooper is cleaned. This oversight had the potential to result in harmful bacteria growth and cross-contamination, affecting 101 out of 102 residents who received ice from the facility. The Dishwasher (DW), who works morning shifts, confirmed that he washed the ice scooper that morning but could not recall the exact time and also stated that no record is kept of the cleaning schedule. The facility's policy, dated 2018, requires that ice scoops be washed daily by the PM Dishwasher or specified on the daily cleaning schedule. The 2022 U.S. Food and Drug Administration Food Code mandates that surfaces of utensils and equipment contacting food be cleaned routinely to prevent the development of microorganisms. The facility's failure to adhere to these guidelines and maintain proper records contributed to the deficiency.
Failure to Label Enteral Feeding Bottle
Penalty
Summary
The facility failed to label the enteral feeding of Resident 141, who was admitted with diagnoses including tongue cancer, dysphagia, and endocarditis. The resident's Minimum Data Set indicated severe cognitive impairment and total dependence on staff for various activities, including feeding. The physician's orders specified the administration of Glucerna 1.5 via a gastrostomy tube at a controlled rate, with specific instructions for labeling and infection control. However, during an observation, it was noted that the enteral feeding bottle was not labeled, and the Licensed Vocational Nurse (LVN) present could not confirm when the bottle was first administered. The Director of Nursing confirmed that the facility's policy requires labeling of enteral feeding bottles with the resident's name, room number, and feeding rate to ensure correct administration and infection control. The facility's policy on enteral nutrition, revised in 2018, outlines the necessary components of complete orders, including labeling instructions. The failure to label the feeding bottle as per policy posed a potential risk for complications associated with enteral feeding, such as infection.
Failure to Obtain Physician's Order and Train Staff on CPAP/BIPAP Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of a CPAP machine for a resident diagnosed with obstructive sleep apnea upon their admission. The resident was admitted with a diagnosis that included obstructive sleep apnea and polyneuropathy, yet there was no physician order for CPAP use on the day of admission. The order was only documented two days later. The resident's care plan was initiated a day after admission, indicating the need for CPAP/BIPAP machine use, but the lack of timely physician orders posed a risk for respiratory distress. Additionally, the facility staff, including registered nurses and licensed vocational nurses, lacked training on the use of CPAP/BIPAP machines. Interviews with the staff revealed that they had not received any training on how to use these machines, and there was no documentation of annual skills competency checks or in-service training in their employee files. The Director of Staff Development acknowledged the importance of such training but had not yet conducted it. The Director of Nursing also noted the potential risks of inadequate training, such as increased carbon dioxide levels and respiratory distress, but could not provide evidence of previous training sessions.
Absence of Hemodialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to ensure that a hemodialysis (HD) emergency kit was available at the bedside for a resident with end-stage renal disease (ESRD), which is crucial for managing potential emergencies such as accidental bleeding. The resident, who was admitted and readmitted to the facility with diagnoses including ESRD, metabolic encephalopathy, and generalized muscle weakness, was dependent on staff for activities of daily living and had cognitive impairment. During an observation, it was noted that the HD emergency kit was not present at the bedside, and a Licensed Vocational Nurse (LVN) confirmed that the kits were no longer kept at the bedside due to family members taking them home. The Director of Nursing (DON) acknowledged that the HD emergency kit should be at the bedside for easy access in case of emergency bleeding, which could lead to hypovolemic shock if not promptly addressed. The facility's policy on the care of residents with ESRD, reviewed in January 2024, indicated that an emergency kit should be provided at the bedside and on crash carts. The absence of the HD emergency kit at the bedside had the potential to delay life-saving interventions during accidental bleeding, as stated by both the LVN and the DON.
Lack of Staff Competency in CPAP/BIPAP Use
Penalty
Summary
The facility failed to ensure that nursing staff were competent in the use of CPAP/BIPAP machines, which are critical for treating residents with sleep apnea and other respiratory conditions. Resident 191, who was admitted with a diagnosis of obstructive sleep apnea, did not have a physician order for CPAP use on the day of admission, although it was later added. Interviews with staff, including a Registered Nurse and two Licensed Vocational Nurses, revealed that they had not received training on the use of CPAP/BIPAP machines at the facility, despite the potential for serious consequences such as respiratory distress if the machines are not used correctly. The Director of Staff Development, who had been employed for one month, acknowledged the importance of staff being knowledgeable about CPAP/BIPAP use but had not yet conducted relevant training. The Director of Nursing mentioned that a previous in-service training had been conducted but could not provide documentation. A review of employee files confirmed the absence of annual skills competency checklists or in-service training records for CPAP/BIPAP use. The facility's policy stated that only qualified and properly trained personnel should administer oxygen through a CPAP mask, highlighting a gap between policy and practice.
Failure to Verify Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to properly verify informed consent before administering psychotropic medications Lexapro and Seroquel to a resident. The resident, who was admitted with diagnoses including encephalopathy, sepsis, and heart failure, was found to have severely impaired cognitive skills and required total assistance with daily activities. Despite this, the facility's records indicated that informed consent was verified directly with the resident, who lacked the capacity to make medical decisions. The sections of the informed consent forms that should have indicated the resident's capacity to consent were left blank. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Nursing, revealed that the informed consent process was not properly followed. The RN Supervisor acknowledged that the consent should have been obtained from the resident's representative, given the resident's inability to make medical decisions. The Director of Nursing explained that informed consent is crucial to ensure that residents or their representatives are aware of the risks and benefits of medications. The facility's policy required that a surrogate decision maker be identified if a resident lacks capacity, but this was not adhered to in this case.
Discrepancy in Controlled Medication Labeling
Penalty
Summary
The facility failed to ensure that the label on a controlled medication matched the correct quantity received, which had the potential for diversion of controlled medications. During an observation at Nursing Station 1, a bundle of discontinued controlled medications was found wrapped together in a locked compartment. A Licensed Vocational Nurse (LVN) stated these medications were to be brought to the Director of Nursing (DON) for disposition. However, the DON was in a meeting, and the medications were handed off to a Registered Nurse (RN) for later destruction with the facility pharmacist. Among these medications was a bottle of morphine sulfate labeled as containing 15 ml, but the prints on the box and bottle indicated 30 ml, creating a discrepancy. The Quality Assurance nurse and the DON confirmed that the quantity sent by the pharmacy did not match the label and the delivery receipt, which indicated a delivery of 15 ml. The facility's policy and procedures require that improperly or inaccurately labeled medications be rejected and returned to the pharmacy, but this was not adhered to in this instance. The incident was identified as having the potential for diversion, as the accountability record showed no indication of use, and the bottle was reportedly unopened.
Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the reach-in freezer in good operating condition, leading to significant ice buildup inside and outside the freezer. This ice accumulation was observed on the ceiling, walls, door, and gasket of the freezer, making it difficult to open the door. The ice buildup had the potential to affect the quality of food stored within, as evidenced by a package of plant-based turkey alternative food that showed frost buildup and discoloration. The freezer's condition was noted during an observation in the kitchen, and the Dietary Supervisor acknowledged awareness of the issue, having requested maintenance to address it over a month prior. The Maintenance Supervisor indicated that an outside vendor had serviced the freezer over a year ago, but was unaware of the current ice issue until the observation. The facility's policies from 2018 emphasize the importance of maintaining kitchen equipment in good working order and ensuring the cleanliness and functionality of refrigerators and freezers. Despite these policies, the freezer's condition was not addressed in a timely manner, resulting in the potential for compromised food quality for 101 out of 102 residents who rely on the facility's kitchen for meals.
Failure to Reimburse Missing Ring
Penalty
Summary
The facility failed to protect a resident from potential misappropriation of property by not reimbursing a missing ring that was included on the resident's inventory list upon admission. The resident, who was admitted with multiple health conditions including metabolic encephalopathy and chronic respiratory failure, had an inventory list that documented two yellow rings with an emerald. Upon a subsequent admission, only one ring was listed, and the facility did not resolve the issue of the missing ring. The Social Services Assistant (SSA) was informed by the resident's representative (RR) about the missing ring and was shown a picture of a similar ring from the internet. The SSA completed a theft loss form and submitted it to the Administrator for reimbursement. However, the SSA did not document an unknown staff member's statement that the resident was wearing the ring when transferred to a General Acute Care Hospital (GACH), nor did they update the RR with this information. The Director of Social Services confirmed that the issue was unresolved. The Administrator acknowledged the missing ring was reported two months after the resident's transfer to the GACH, which led to questions about the facility's responsibility. The facility's policy required documentation and investigation of lost or stolen property worth $100 or more, but the lack of a receipt for the ring and the delayed report complicated the situation. The facility did not report the incident to the police due to the time lapse, and communication with the RR ceased, leaving the issue unresolved.
Failure to Provide Bed-Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to inform a resident's representative in writing about the bed-hold and return policy when the resident was transferred to a General Acute Care Hospital. This deficiency was identified during a review of the facility's policy and procedures, which require that residents or their representatives be informed in writing of the bed-hold and return policy prior to transfers and therapeutic leaves. The policy outlines the rights and limitations regarding bed-holds, the reserve bed payment policy for Medicaid residents, the facility per diem rate for non-Medicaid residents, and details of the transfer. The resident involved had been admitted to the facility with diagnoses including hypertensive heart disease, emphysema, and dysphagia, and had severely impaired cognitive skills requiring moderate assistance for daily activities. The resident was transferred to the hospital due to low blood oxygen levels, but there was no documentation of a bed-hold order or notice in the resident's medical records. The Director of Nursing confirmed that there was no bed-hold notice completed, which should have been provided to the resident's responsible party.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident following hospitalization, contrary to its policy and procedure for transfer or discharge. The resident, who had been admitted with conditions including hypertensive heart disease, emphysema, and dysphagia, was sent to a general acute care hospital due to low blood oxygen levels. After the hospital indicated the resident was ready for discharge, the facility's business development team received the referral for readmission. However, the clinical staff, including the Director of Nursing (DON) and the Administrator, decided not to readmit the resident, citing an inability to accommodate the resident's needs. The DON stated that the facility could meet the resident's post-hospitalization care plan but was unaware of the hospital's referral. The facility did not provide reasonable and appropriate notice or documentation explaining why they could not accommodate the resident after hospitalization. The facility's policy requires that residents sent to an acute care setting be permitted to return unless the facility cannot meet their needs, in which case written notification and appeal rights must be provided. The facility did not follow this procedure, resulting in the resident remaining in the hospital.
Failure to Revise Care Plans for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to revise the care plans for two residents who experienced significant weight loss. Resident 1, admitted with conditions such as hypertensive heart disease, emphysema, and dysphagia, showed a weight decrease from 107 pounds to 100 pounds over a short period. Despite the Registered Dietitian (RD) noting a 5.6% weight loss and recommending an appetite stimulant, the care plan initiated on 7/10/2024 was not updated to reflect these changes. Similarly, Resident 2, with diagnoses including respiratory failure and Type II Diabetes Mellitus, experienced a weight drop from 132 pounds to 121 pounds, equating to a 10.4% loss within a month. The RD also suggested an appetite stimulant for Resident 2, but the care plan remained unchanged since its initiation. Interviews with the RD and the Director of Nursing (DON) revealed a lack of clarity regarding responsibility for updating care plans. The RD believed it was the nursing staff's duty to revise care plans, while the DON stated that any licensed staff, including the RD, could make revisions. The facility's policy indicated that care planning for weight loss should be a multidisciplinary effort, involving the physician, nursing staff, dietitian, consultant pharmacist, and the resident or their legal surrogate. The failure to update the care plans for these residents placed them at risk for further weight loss.
Failure to Document Change in Condition and Execute Physician's Order
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident by not ensuring proper documentation and execution of medical orders. The resident, who was admitted with conditions including cellulitis, diabetes mellitus, and Parkinson's Disease, experienced a change in condition characterized by confusion and hallucinations. Despite the family's concerns and a physician's order for a urinalysis to investigate these symptoms, there was no documentation of the change in condition or the physician's order in the resident's medical record. Additionally, the urinalysis was not conducted as ordered, which was confirmed by the Director of Nursing during a review of the resident's records. The facility's policies and procedures require documentation of changes in condition and the processing of test requisitions, but these were not followed. Interviews with the Director of Nursing and the Licensed Vocational Nurse involved revealed a lack of documentation and failure to carry out the physician's order, highlighting deficiencies in the facility's adherence to its own policies.
Failure to Provide BIPAP Machine for Oxygen-Dependent Resident
Penalty
Summary
The facility failed to ensure the availability of a BIPAP machine for a resident who was oxygen-dependent and required continuous oxygen therapy. The resident, a female with a history of respiratory failure, COPD, and dependence on supplemental oxygen, was admitted to the facility without a BIPAP machine from 6/21/2024 to 6/25/2024. Despite the physician's order for the family to bring the home BIPAP machine, the machine was not available, and the resident was placed on a nasal cannula instead. The Director of Nursing (DON) admitted that the facility's process for reviewing pre-admission documents was not followed, as the necessary paperwork was not reviewed before the resident's admission. This oversight led to the absence of a BIPAP order in the resident's physician orders from 6/21/2024 to 7/3/2024. The facility's staff attempted to use the resident's home BIPAP machine, but it was missing a part, and efforts to contact the family for the missing part were unsuccessful. The facility's central supply ordered a new BIPAP machine, but it was not compatible with the resident's needs, lacking a tube to connect to the oxygen. The resident's original machine was eventually made operational, but the resident frequently removed the mask, leading to decreased oxygen saturation levels. The facility's failure to ensure the availability and proper setup of the BIPAP machine placed the resident at risk for shortness of breath and inadequate oxygenation.
Failure to Document Glucometer QC and Secure Medication Disposal
Penalty
Summary
The facility failed to document Quality Control (QC) results for the glucometer on multiple days, as required by their policy. This deficiency was identified during an interview and record review with the Director of Nursing (DON), where it was found that the Daily Quality Control Record for Blood Glucose Testing had blank entries on several dates. The DON acknowledged that QC for the glucometer should be conducted every night during the 11 p.m. to 7 a.m. shift and documented accordingly. The absence of these records could lead to inaccurate blood sugar readings and subsequent incorrect insulin administration. Additionally, the facility did not adhere to its medication disposal policy. During an observation and interview with the DON in the medication storage room, it was noted that the medication disposal bin was not secured properly, allowing easy access to intact pills of various colors and sizes. The DON confirmed that the bin's top should be closed, and pills should be destroyed by adding hot water. The unsecured bin posed a risk of medication diversion, where medications could be removed and reused. The facility's policy on medication disposal, revised in 2019, outlines specific procedures for the secure disposal of unused medications, including controlled substances. These procedures include retaining unused controlled substances in a locked area, disposing of non-controlled substances according to state and federal guidelines, and ensuring that controlled substances are rendered non-retrievable. The failure to follow these procedures could lead to unauthorized access and potential misuse of medications, compromising resident safety.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to implement its infection control policy to prevent the spread of COVID-19 and other diseases. Observations revealed that several staff members, including a Licensed Vocational Nurse (LVN 1), a Certified Nursing Assistant (CNA 1), and Central Supply staff (CS 1 and CS 2), did not perform hand hygiene after contact with residents and their environment. LVN 1 and CNA 1 acknowledged the need for hand hygiene to prevent infection spread, yet were observed entering and exiting resident rooms without washing hands or using hand sanitizer. Similarly, CS staff were seen moving between resident rooms and touching equipment without performing hand hygiene, despite acknowledging the potential for infection transmission. Additionally, the facility failed to ensure visitors were screened before entry. Observations in the lobby showed no staff present to conduct screenings, allowing visitors to enter without masks, temperature checks, or completing COVID-19 questionnaires. The Admissions Coordinator and Administrator confirmed the absence of staff at the front desk during lunch breaks, leaving visitors unscreened. The Director of Nursing and Infection Preventionist Nurse emphasized the importance of hand hygiene and visitor screening, especially during an active COVID-19 outbreak, to prevent further spread of infection.
Delayed Generator Start Causes Power Outage
Penalty
Summary
The facility failed to ensure that the emergency generator started and transferred power within 10 seconds after a power outage, resulting in a lack of power for over 30 minutes for all 88 residents. On the night of the incident, the generator did not start promptly due to a breaker switch not being in the 'ON' position, which was discovered by the Maintenance Assistant after a delay. This delay in power restoration affected the residents, including one who was unable to use their CPAP machine and had to sleep on a deflated low-air loss mattress, causing discomfort. The Director of Maintenance and the Maintenance Assistant provided conflicting accounts of the generator's usual start time, with the Assistant indicating a delay of 20-30 minutes on the night of the outage. The facility's policy required the generator to operate as designed, but the maintenance records did not indicate that critical equipment like the CPAP machine and mattress were connected to generator-powered outlets. The Director of Maintenance was responsible for maintaining the generator, but the incident revealed a lapse in ensuring the generator's readiness and the staff's ability to manage the situation effectively.
Medication Management Deficiency
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that a resident's albuterol sulfate medication was not left unattended. The resident, who was admitted with diagnoses including emphysema, COPD, and asthma, had mildly impaired cognitive skills and required moderate to maximal assistance for activities of daily living. Despite this, the resident's albuterol inhaler was found at their bedside, labeled with their name, and was reportedly brought from home. The resident stated they used the inhaler themselves whenever needed, indicating a lack of assessment for self-administration of medication. During an observation and interview, a Licensed Vocational Nurse (LVN) confirmed that residents should be assessed for their ability to self-administer medications. The LVN noted that the facility was administering the albuterol inhaler for the resident and had their own medication supply. The presence of the resident's personal inhaler at the bedside was against the facility's policy, which requires medications to be administered as prescribed and only by authorized personnel. The LVN expressed concern that the resident might be at risk of respiratory issues due to potential double dosing, as the facility had not authorized the resident to self-administer medications.
Resident Left Unattended Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident assessed as high risk for falls, resulting in the resident being left unattended in the bathroom. This oversight led to the resident falling and sustaining a mild displaced comminuted subcapital fracture of the right femoral neck. The resident, who had a history of falls and cognitive impairment, was found on the bathroom floor by staff after being left alone in his room. The resident's medical history included atrial fibrillation, congestive heart failure, cervical fractures, and repeated falls, which necessitated the use of a neck brace and increased supervision. The resident's care plan specifically indicated the need for assistance with toileting and not leaving the resident unattended. Despite these precautions, the resident was left alone, leading to the fall and subsequent injury. Interviews with staff revealed a lack of communication and understanding of the resident's needs. The CNA assigned to the resident was not fully aware of the resident's fall risk and required level of assistance, partly due to a lack of a proper handover and being short-staffed. The facility's policy on fall management was not adequately followed, as the resident's supervision needs were not communicated effectively to all staff members, contributing to the incident.
Failure to Perform Accurate Neuro Check After Resident Fall
Penalty
Summary
The facility failed to accurately perform a neuro check on a resident after a fall, which could have delayed necessary medical intervention. The resident, who had a history of falls and was at high risk for recurrent falls, was found on the bathroom floor but initially denied any pain. The resident had multiple medical conditions, including atrial fibrillation, congestive heart failure, and a history of falls, which made him dependent on assistance for daily activities and decision-making. On the morning following the fall, an LVN conducted a neuro check but did not properly assess the resident's leg strength or pain, relying solely on the resident's verbal denial of pain. This oversight was significant because later that morning, the resident expressed pain during a physical therapy session, leading to a delayed diagnosis of a right hip fracture. The LVN admitted to not performing a thorough assessment, which could have identified the resident's pain earlier. The facility's policy required a comprehensive assessment following a fall, including checking for changes in consciousness, range of motion, and functional mobility. However, the LVN did not adhere to these protocols, as confirmed by the Director of Nursing, who stated that proper neuro checks involve assessing limb strength and not just asking about pain. This failure to follow established procedures contributed to the delay in identifying the resident's injury.
Inadequate Staffing Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate certified nursing assistants (CNAs) to meet the needs of its residents, specifically impacting one resident who required assistance with toileting. This deficiency resulted in the resident falling while unattended in the bathroom, leading to a right hip fracture. The resident, who had a history of falls and was at high risk for recurrent falls, was admitted with multiple medical conditions, including atrial fibrillation, congestive heart failure, and a recent cervical fracture. The resident's care plan included fall precautions and assistance with toileting, which were not adequately provided due to staffing shortages. On the day of the incident, the facility was short-staffed, with only three CNAs available for the 3:00 p.m. to 11:00 p.m. shift, each responsible for 14-15 residents. This was due to two CNA call-offs, and the facility attempted to cover the shortage by calling in additional CNAs who arrived later in the shift. The CNAs on duty were unable to attend to all residents promptly, leading to delays in responding to call lights and providing necessary assistance. The resident in question was left unattended, resulting in a fall and subsequent injury. Interviews with staff revealed that the facility's staffing projections were based on the previous day's census and anticipated admissions. However, the actual staffing levels were insufficient to meet the needs of high-acuity residents, such as the one involved in the incident. The facility's policy required sufficient staffing to provide care according to residents' care plans, but this was not achieved, contributing to the resident's fall and injury.
Untimely Administration of Antihypertensive Medications
Penalty
Summary
The facility failed to administer antihypertensive medications timely for Resident 4, a [AGE] year-old female with a history of hypertension, COPD, diabetes mellitus, asthma, and aftercare following shoulder joint prosthesis. The resident was admitted on 5/15/2024, and her physician orders included Amlodipine Besylate, Lisinopril, and Metoprolol, all to be administered for hypertension with specific instructions to hold if the systolic blood pressure was less than 100. On 5/31/2024, during an observation and interview, LVN 4 was found administering these medications late, acknowledging that they were due at 9:00 a.m. but were being given after 10:45 a.m. The LVN noted that the resident's blood pressure was 141/71, taken at 7:00 a.m., and admitted to not rechecking it before administering the medication. The facility's policy, revised in 4/2019, requires medications to be administered within one hour of their prescribed time unless specified otherwise. LVN 4 cited that some residents take a long time to take their medications, which contributed to the delay, despite starting the medication pass at 8:00 a.m. This practice was in violation of the facility's policy and placed Resident 4 at risk of elevated blood pressure due to the untimely administration of her antihypertensive medications.
Failure to Apply Non-Rebreather Oxygen Mask Correctly
Penalty
Summary
The facility failed to correctly apply a non-rebreather oxygen mask (NRBM) in an emergent situation for a resident, leading to inadequate oxygen delivery. The resident, a male with multiple diagnoses including Parkinson's Disease, Asthma, and Heart Disease, was admitted on 4/27/2024. On 5/11/2024, the resident experienced anaphylaxis and was found with a red flushed face, low oxygen saturation (79%), and low blood pressure. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) initially administered oxygen via nasal cannula at 2 liters per minute (lpm), but the resident's oxygen saturation remained in the 80s. The RNS then received an order to use the NRBM but set the oxygen flow to only 5 lpm, which was insufficient to fully inflate the reservoir bag. The LVN placed the NRBM on the resident without fully inflating the bag, and although oxygen was flowing, the bag remained mostly flat. The resident's oxygen saturation improved to 94% but dropped if the mask was removed. The paramedics, upon arrival, noted that the bag was not adequately inflated and increased the oxygen flow, although the facility's oxygen regulators only went up to 10 lpm. The facility's policy and procedure for using a non-rebreather mask require the oxygen flow to be set between 10-15 lpm to ensure the reservoir bag is fully inflated during exhalation and only partially deflates during inspiration. The deficiency in applying the NRBM correctly could have caused the resident to remain in respiratory distress. The facility's failure to follow the proper procedure for using the NRBM, including not setting the oxygen flow to the required 10-15 lpm and not fully inflating the reservoir bag, led to inadequate oxygen delivery in an emergent situation. This incident highlights the importance of adhering to established protocols for respiratory care to ensure resident safety and effective treatment during emergencies.
Failure to Properly Apply Non-Rebreather Oxygen Mask
Penalty
Summary
The facility failed to ensure that licensed nurses had the skills and knowledge to correctly apply a non-rebreather oxygen mask (NRBM) in an emergent situation for one of three sampled residents. Resident 1, a male with multiple diagnoses including Parkinson's Disease, Asthma, and Heart Disease, was found with a red flushed face and an oxygen saturation (O2 sat) of 79% without supplemental oxygen. The Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RNS) initially placed the resident on 2 liters per minute (lpm) of oxygen via nasal cannula, which did not sufficiently improve the O2 sat. The RNS then received an order to use the NRBM but set the oxygen flow to only 5 lpm, which was insufficient to fully inflate the reservoir bag, leading to inadequate oxygen delivery. When the paramedics arrived, they noted that the bag on the mask was not inflated enough and increased the oxygen flow, which the facility's equipment could only support up to 10 lpm. The Director of Staff Development (DSD) demonstrated the use of the NRBM but also failed to fully inflate the reservoir bag before placing it on a mannequin. The DSD admitted to not having a lesson plan for the oxygen training conducted on 5/10/2024 and stated that the training was based on personal experience rather than a structured curriculum. Further observations revealed that another Registered Nurse (RN) also failed to fully inflate the reservoir bag before placing the mask on a resident. The facility's policy and procedure for using a non-rebreather mask clearly stated that the oxygen flow should be set to approximately 15 lpm and the bag should be fully inflated before placing the mask on the resident. The lack of proper training and adherence to the facility's policy led to the deficient practice, which could have caused Resident 1 to remain short of breath and potentially placed other residents at risk.
Failure to Develop Discharge Care Plan
Penalty
Summary
The facility failed to develop a care plan for discharge planning for a resident, which was identified during an interview and record review. The resident, a male with multiple diagnoses including Parkinson's disease, chronic kidney disease, dementia, anxiety, adult failure to thrive, and dysphagia, was admitted to the facility and had severely impaired cognition. The resident was totally dependent on staff for various activities of daily living and was under hospice care. Despite the resident's complex medical needs and the issuance of eviction notices, the facility did not develop or update a comprehensive discharge care plan in a timely manner, as required by their policies and procedures. During a review of the resident's care plan, it was found that the discharge planning care plan was initiated only after the second eviction notice, and it did not include information about the first eviction notice or the appealed discharges. The Director of Nursing (DON) acknowledged that discharge planning should have started at the first care plan meeting upon admission and should have been updated after each meeting with the family. The facility's policies indicated that a comprehensive care plan should be completed within seven days of the resident assessment and revised as needed, but this was not followed in the case of the resident, leading to a deficiency in discharge planning.
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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