Channel Islands Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Barbara, California.
- Location
- 3880 Via Lucero, Santa Barbara, California 93110
- CMS Provider Number
- 555875
- Inspections on file
- 32
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Channel Islands Post Acute during CMS and state inspections, most recent first.
A resident with a documented high fall risk score and multiple falls had a fall care plan that was not revised despite repeated incidents and an increased fall risk assessment score. The original fall care plan interventions, initiated shortly after admission, remained unchanged even after three subsequent falls and a later assessment showing a higher risk score. After a fourth fall that caused a left periprosthetic femoral fracture, the care plan interventions still mirrored the original plan. During interviews, the MDS coordinator, ADM, and ADON acknowledged that the care plan had not been updated after each fall, after the score increase, or during quarterly reviews, contrary to facility P&P requiring care plan revision with significant changes and at regular intervals.
The facility did not consistently provide the required nursing staff hours, with several days falling below mandated DHPPD and CNA minimums. During this period, multiple residents experienced falls and two were transferred to the hospital. The DON and DSD confirmed staffing shortages, which were sometimes addressed by using staff from a sister facility or administrative staff with CNA licenses.
Staff failed to promptly communicate a resident's significant change in condition, including increased fatigue, confusion, and decreased food intake, to the appropriate licensed nurse and physician. Despite CNAs observing and attempting to report these changes, inconsistencies and incomplete communication led to a delay in treatment, and the resident was ultimately sent to the hospital after further decline.
A resident with anxiety disorders and altered mental status did not have their dentures, delivered by a dental provider, documented in the inventory records, nor was their loss recorded in the theft and loss log. Staff interviews and record reviews confirmed that the inventory list was not updated and required procedures for tracking personal items were not followed, despite facility policies mandating such documentation.
Surveyors found expired medications and products available for use, improper medication administration by nursing staff, and inconsistent medication re-ordering processes. Multiple residents did not receive their prescribed medications due to pharmacy delivery delays and missing cycle medications. Additionally, the contents of an IV emergency kit did not match its label, with staff acknowledging these discrepancies and failures to follow facility policy.
A resident with a history of suicidal ideations, alcohol abuse, and opioid use was found self-administering multiple supplements without a documented assessment, care plan, or interdisciplinary team notes, contrary to facility policy requiring evaluation and documentation for self-administration of medications.
Two residents were found to be living in rooms with environmental deficiencies, including a loose floor tile creating a raised gap, cobwebs on the ceiling, wall scratches with exposed underlayer, and missing bathroom tiles. Maintenance and housekeeping logs showed no entries for these issues, and staff confirmed the problems had not been addressed as required by facility policy.
Three residents were inaccurately assessed in the MDS, with one receiving insulin injections, another taking an anticoagulant, and a third using tobacco, but these were not properly documented in their assessments. Clinical records, medication administration, and direct observations confirmed the use of these treatments and behaviors, while MDS entries failed to reflect the actual care and status of the residents.
The facility did not complete required PASRR Level I and Level II screenings for two residents with mental health diagnoses. One resident was admitted with schizophrenia and bipolar disorder but had no PASRR Level I screening on file, while another resident with psychosis had a positive Level I screening for serious mental illness but no Level II evaluation was completed. The DON confirmed these omissions during interviews.
Medications requiring refrigeration, such as PPD, insulin, and hepatitis vials, were found stored in a medication refrigerator at 32°F, which is below the facility's policy range of 36°F to 46°F. An RN confirmed the out-of-range temperature and that the medications were not stored as required.
Dietary staff did not label or date several food items in storage, including stuffing packets, bread buns, and hamburger patties, as required by facility policy. The Assistant Administrator confirmed these deficiencies during an inspection.
A resident with multiple medical conditions was discharged home with the expectation of receiving home health services, but the facility did not confirm that these services were in place before discharge. The resident did not receive the needed care, contacted the facility for assistance, and reported a fall after discharge. Facility staff did not follow up with the home health agency or the resident to ensure continuity of care, and authorization from the VA was still pending.
A resident's personal belongings, including a cell phone and reading glasses, were mistakenly relocated to another room due to staff miscommunication about the resident's COVID-19 isolation status. The resident, who has COPD, CHF, and pneumonia, experienced agitation and accused staff of taking his phone. The items were later found and returned.
A facility failed to implement a comprehensive care plan for a resident with an ADL self-care deficit, despite the resident's diagnoses of COPD, CHF, and pneumonia. The care plan did not adequately address the resident's need for assistance with tasks like toileting, as required by the facility's policy, placing the resident at risk of unmet care needs.
A resident in a LTC facility, requiring assistance with ADLs due to conditions like COPD and CHF, was left waiting for over an hour for a urinal, resulting in urination on himself. The resident's care plan highlighted the need for staff assistance due to muscle weakness and a deep tissue injury. Other residents reported similar delays in staff response, indicating a broader issue with call light wait times.
The facility failed to ensure that residents with a positive Level I PASRR received a Level II evaluation. Two residents with significant mental health histories did not have their cases reopened for Level II evaluations as directed by the Department of Health Care Services. The DON was unaware of the need to resubmit Level I PASRRs after the initial cases were closed.
The facility failed to ensure a safe environment by leaving unsecured medications in resident rooms without proper assessment or authorization for self-administration. This affected two residents, one with diabetes and another with spinal stenosis, who had medications left at their bedside without staff supervision.
Failure to Revise Fall Care Plan After Increased Fall Risk and Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s comprehensive fall care plan in response to increased fall risk scores and multiple subsequent falls. The resident had an initial fall risk score of 10 on admission, categorizing them as high risk, and a fall care plan for falls was initiated on 8/20/25 and revised on 8/30/25. Despite this, there was no documentation of updated interventions after the resident experienced falls on 10/17/25, 11/27/25, and 12/11/25. A follow-up Fall Risk Evaluation on 2/25/26 showed the resident’s score had increased to 17, still indicating high risk, and the facility’s own Fall Risk Evaluation Form stated that a score of 10 or greater requires immediate initiation and documentation of preventive protocols. However, the comprehensive care plan interventions remained unchanged from the original 8/20/25 plan. The resident subsequently experienced a fourth fall on 3/31/26, which resulted in a left periprosthetic femoral fracture. While this fall was addressed, the interventions in the care plan still remained identical to those originally established on 8/20/25. During interviews and concurrent record reviews, the MDS coordinator confirmed the history of four falls and acknowledged that the care plan had not been revised following the increased fall risk score, each fall, or during quarterly reviews, and could not explain the lack of updates. The Administrator and ADON also acknowledged that facility policies and procedures were not followed, despite written policies stating that care plans must be revised quarterly, annually, and upon significant changes in condition, and that comprehensive assessments and significant changes require IDT review and/or revision of the care plan.
Failure to Maintain Sufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days where the Direct Care Service Hours Per Patient Day (DHPPD) and Certified Nursing Assistant (CNA) hours fell below the required minimums. Record review showed that on several dates, the actual DHPPD and CNA hours did not meet the 3.5 and 2.4 minimums, respectively, as mandated by state guidelines. The Director of Nursing (DON) validated these findings during a concurrent interview and record review. The Director of Staff Development (DSD) confirmed that the facility has implemented CNA classes and occasionally receives staffing support from a sister facility or administrative staff who are licensed CNAs, but last-minute call-ins due to family emergencies have contributed to staffing shortages. A review of facility fall logs during the period of insufficient staffing revealed multiple resident falls and two hospital transfers. Specifically, one resident fell on one date, two residents fell on another, and two residents fell on a subsequent date, with two hospital transfers occurring during the same timeframe. There were no reported missed or medication errors within the period reviewed. The facility's policy on adequate staffing states that sufficient staff must be maintained on each shift to meet resident needs, but the documented staffing levels did not consistently meet this standard.
Failure to Communicate Change in Condition Resulting in Delay of Treatment
Penalty
Summary
Facility staff failed to ensure prompt communication of a significant change in condition for one resident, resulting in a delay in treatment. The resident, who had a history of alcohol cirrhosis with ascites, hepatic encephalopathy, pleural effusion, heart failure, and generalized swelling, experienced increasing fatigue, confusion, and difficulty eating. Certified Nursing Assistants (CNAs) observed these changes, including the resident becoming more tired, needing assistance with meals, eating less, and displaying confusion and altered speech. Although CNAs reported some changes to licensed nurses, there were inconsistencies in communication, with one CNA later admitting to the Assistant Administrator that she had not reported the change in condition to the nurse as initially claimed. Licensed nurses did not receive complete or timely information about the resident's altered mental status and physical decline. As a result, the resident's significant change in condition, including weakness, dysphagia, and altered level of consciousness with abnormal vital signs, was not promptly communicated to the physician. The delay in recognizing and reporting these changes led to a delay in treatment, and the resident was eventually sent to the hospital after further decline was noted. Review of facility policy confirmed that staff were required to report such changes to licensed nurses, but this procedure was not followed.
Failure to Document and Track Resident's Dentures
Penalty
Summary
The facility failed to ensure that a resident's right to retain and use personal possessions was honored when a set of dentures delivered to the resident was neither documented in the inventory records nor subsequently located. The resident, who had diagnoses including anxiety disorders and altered mental status, was admitted with a process in place for documenting personal belongings. However, review of the resident's records showed that the dentures, delivered by a dental provider, were not entered into the inventory of personal effects, and there was no record of their loss in the theft and loss log. Multiple staff interviews confirmed that the inventory list had not been updated since admission, and the required procedures for documenting and tracking personal items were not followed. Observations of the resident revealed a sunken facial appearance, and staff interviews indicated that packages and personal items are typically logged, labeled, and added to the inventory list. Despite these procedures, the dentures were not accounted for, and staff responsible for maintaining these records were unaware of the missing item. Review of facility policies confirmed that all personal items, especially those affecting health and safety, should be documented and tracked, but these policies were not adhered to in this case.
Expired Medications, Missed Doses, and Medication Management Failures
Penalty
Summary
The facility failed to adhere to its pharmaceutical services policies in several key areas. Surveyors observed that expired medications and products, including a nutritional shake, sodium chloride, acetic acid, estradiol cream, and an inhaler, were available for resident use. Nursing staff acknowledged the presence of these expired or improperly stored items and confirmed that they should have been discarded according to facility policy. Additionally, a nurse administered more eye drops than ordered by the physician to a resident, contrary to the documented medical order and facility procedures for medication administration. The facility did not maintain a consistent medication re-ordering process, as evidenced by multiple entries in the re-ordered medication binder showing that numerous residents were either out of medications or had only a few doses left. Nursing staff stated that medications were supposed to be ordered five days in advance, but this was not consistently done. Furthermore, the facility did not ensure timely and consistent availability of resident medications. Several residents did not receive their prescribed medications due to delays in pharmacy delivery or missing cycle medications, and staff interviews confirmed that this was a recurring issue. The facility's agreement with the pharmacy for monthly cycle medication refills was not being fulfilled as planned. Surveyors also found discrepancies in the contents of the intravenous emergency kit, where two bags of sodium chloride were present but not listed on the kit's label. Nursing staff acknowledged that the kit contents did not match the label and stated that the pharmacy was responsible for ensuring accuracy. These failures collectively had the potential to negatively impact resident care and safety, as the facility did not follow its own policies for medication storage, administration, re-ordering, and emergency kit management.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
A resident was found with multiple self-administered medications, including Primal Harvest Hair Growth Complex, Immuneti Advanced Immune Defense, and Primal Multivitamins, at their bedside. The resident reported self-administering these supplements since admission. The resident's medical record indicated a history of suicidal ideations, alcohol abuse, and opioid use. No self-administration assessment was completed for the resident, and there was no documentation of the resident's desire to self-administer medications. Additionally, there were no interdisciplinary team notes or care plan entries regarding self-administration, despite facility policy requiring assessment, documentation, and care planning for residents who wish to self-administer medications. Nursing staff and facility leadership confirmed the absence of required documentation and assessments.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents. In one instance, a resident's room was observed to have a loose floor tile that was partially lifted, creating a raised gap. Review of the maintenance logbook for the relevant section of the facility showed no requests or entries for floor tile repairs in this resident's room or bathroom. During an interview and observation with the Maintenance Supervisor, the issue was confirmed, and it was acknowledged that the problem existed. In another case, a different resident's room was found to have cobwebs hanging from the ceiling above the bed, visible scratches with paint coming off the wall behind the headboard, and missing tiles around the bathtub in the bathroom, exposing residue on the wall. The maintenance logbook for this section also showed no entries for maintenance work in this room. The Maintenance Supervisor confirmed the presence of these issues and stated that repairs had not yet been completed. The Laundry and Housekeeping Supervisor and District Manager of Laundry and Housekeeping Services acknowledged that the room had been overlooked. Facility policy requires housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, and staff are expected to report findings directly or add them to the maintenance logbook.
Inaccurate MDS Assessments for Injections, Anticoagulant, and Tobacco Use
Penalty
Summary
The facility failed to accurately assess and document the clinical status of three residents in the Minimum Data Set (MDS) assessments. One resident with a diagnosis of Type 2 Diabetes was prescribed and administered insulin injections as documented in the Medication Administration Record and physician's notes, but the MDS assessment incorrectly indicated that the resident did not receive any injections during the observation period. Another resident was prescribed and received Apixaban, an anticoagulant, as confirmed by physician orders and the Medication Administration Record, yet the MDS assessment inaccurately recorded that the resident did not receive any anticoagulant medication during the look-back period. In both cases, the MDS coordinator acknowledged the discrepancies between the clinical records and the MDS entries during interviews and record reviews. A third resident, who was documented as a smoker in the physician's notes and a smoking evaluation, and was observed both with a vaping device and smoking cigarettes on facility grounds, was incorrectly assessed in the MDS as not using any form of tobacco. The MDS coordinator confirmed the inaccuracy after reviewing the resident's records and observations. These failures to accurately assess and document the residents' clinical statuses in the MDS have the potential to result in care needs not being properly identified or addressed.
Failure to Complete Required PASRR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that required PASRR (Preadmission Screening and Resident Review) Level I and Level II screenings were completed for two residents with mental health diagnoses. For one resident admitted with diagnoses including unspecified schizophrenia and bipolar disorder, there was no evidence of a PASRR Level I screening in the medical record from the time of admission through the date of review. The Director of Nursing confirmed that the PASRR Level I screening was missed for this resident. For another resident admitted with a diagnosis of unspecified psychosis, the pre-admission PASRR Level I screening indicated a positive result for serious mental illness, which required a Level II mental health evaluation. However, there was no documentation of a Level II PASRR evaluation in the medical record from the time of the positive Level I screening through the date of review. The Director of Nursing confirmed that the PASRR Level II evaluation was not completed for this resident. The facility's policy requires Level I screenings for all admissions and Level II evaluations when indicated, but these procedures were not followed in these cases.
Improper Refrigeration of Medications
Penalty
Summary
Surveyors observed that medications requiring refrigeration, including Tuberculin (PPD), insulin, and hepatitis vials, were stored in a medication refrigerator with a temperature reading of 32°F, which is below the facility's policy requirement of 36°F to 46°F (2°C to 8°C). During the observation, a registered nurse confirmed the temperature was outside the acceptable range and acknowledged that the medications were not stored according to policy. The facility's policy specifies that medications needing refrigeration must be kept within the specified temperature range and monitored with a thermometer, with maintenance notified if temperatures are out of range. The improper storage temperature was directly observed and confirmed by staff during the survey.
Failure to Label and Date Stored Food Items
Penalty
Summary
The facility failed to ensure that dietary staff properly labelled and dated food items in storage, as observed during a kitchen inspection. Specifically, three packets of traditional stuffing were found with only a date received and no indication of the date opened or expiry date. Additionally, an open bag of bread buns and a bag containing four hamburger patties were found in the freezer section without any date markings or expiry dates. The Assistant Administrator acknowledged these findings during the observation. A review of the facility's policy on labeling and dating foods indicated that staff are responsible for marking the date at the time of processing and/or storage, and that a use-by date must be provided for all food items.
Failure to Ensure Home Health Services in Place Prior to Discharge
Penalty
Summary
The facility failed to ensure adequate discharge planning for a resident who was discharged home with the expectation of receiving home health services. The resident, who had a history of a right acetabulum and pubis fracture, Type 2 Diabetes Mellitus, and long-term insulin use, was discharged with arrangements for physical therapy, occupational therapy, and nursing services through a home health agency (HHA). Although the facility's social services staff faxed referral documents to the HHA, there was no evidence that the facility confirmed receipt of the referral or that services were in place prior to discharge. After discharge, the resident contacted the facility to report that he had not received the expected caregiver services and had already experienced a fall at home. Interviews with facility staff revealed that the social services department did not typically follow up with HHAs or discharged residents unless notified by the HHA of an issue. The HHA reported they had not seen the resident because they were awaiting VA authorization and had been unable to contact the resident. Documentation showed that the VA had not processed the authorization request in a timely manner, and the HHA had not received the necessary information to proceed. The facility's policy required social services to ensure continuity of care during discharge, but in this case, the lack of confirmation and follow-up resulted in the resident not receiving needed home health services.
Resident's Personal Belongings Misplaced Due to Staff Miscommunication
Penalty
Summary
The facility failed to honor a resident's right to retain and use personal possessions, resulting in a deficiency. This incident involved a resident who was admitted with chronic obstructive pulmonary disease, congestive heart failure, and pneumonia. The resident's personal belongings, including a cell phone, charger, and reading glasses, were mistakenly relocated to another room. This occurred due to a miscommunication among staff regarding the resident's COVID-19 isolation status. The resident experienced agitation and made verbal accusations towards the staff, claiming that his phone was taken away. A licensed nurse confirmed the resident's complaint and explained that the certified nursing assistant had transferred the resident's belongings to another room due to the misunderstanding about the resident's isolation status. The items were eventually found and returned to the resident. The facility's policy on resident rights emphasizes the importance of allowing residents to keep and use personal possessions unless it infringes on the rights or safety of others.
Failure to Implement Comprehensive Care Plan for Resident with ADL Deficit
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for a resident with an activities of daily living (ADL) self-care deficit. This deficiency was identified during a review of the resident's clinical record, which revealed that the resident was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and pneumonia. The comprehensive care plan dated 6/10/24 indicated that the resident had an ADL self-care deficit related to muscle weakness and unsteady gait, requiring staff assistance for various tasks such as washing hands, adjusting clothing, and using the toilet. However, the facility's policy and procedure for care planning, revised in 11/2023, mandates that the interdisciplinary team (IDT) implement a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident's needs. The review of the resident's admission Minimum Data Sheet (MDS) dated 6/16/24 showed that the resident had moderate cognitive impairment and required assistance for ADLs, but the care plan did not adequately address these needs. This oversight placed the resident at risk of not having their care needs met due to the lack of a proper plan.
Delayed Assistance with Toileting Leads to Resident Incident
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident 1, who required help with activities of daily living, specifically toileting. Despite the resident's request for a urinal, staff did not respond for over an hour, resulting in the resident urinating on himself. This incident was documented in a complaint report, where the resident expressed concerns about staff not listening to his needs, including issues with his mattress, toothbrush, and television, in addition to the delayed response for toileting assistance. Resident 1 had been admitted for post-acute care therapy with multiple diagnoses, including COPD, CHF, pneumonia, muscle weakness, and unsteadiness on feet, necessitating assistance with personal care. The resident's care plan indicated a need for staff assistance with various ADLs due to an ADL self-care deficit and a deep tissue injury requiring protection from excessive moisture. Interviews with other residents revealed that call light response times were often delayed, with one resident stating an average wait time of 15 minutes or more, and another reporting waits of 20 minutes or longer for assistance, including pain medication.
Failure to Ensure Level II PASRR Evaluations
Penalty
Summary
The facility failed to ensure that residents with a positive Level I Preadmission Screening and Resident Review (PASRR) received a Level II evaluation. Specifically, after the cases for two residents were closed, the facility did not resubmit Level I PASRRs to reopen the cases as directed by the Department of Health Care Services. This failure was identified during interviews, record reviews, and policy reviews conducted by surveyors. Resident #80, who had a medical history including bipolar disorder, major depressive disorder, anxiety disorder, PTSD, and paranoid schizophrenia, was readmitted to the facility. Despite having a positive Level I screening, the Level II evaluation was not scheduled due to the resident being isolated as a health or safety precaution. The Director of Nursing (DON) was unaware that a new Level I should have been completed to reopen the case after the Level II evaluation was closed. Similarly, Resident #5, who had a medical history including bipolar disorder, major depressive disorder, anxiety disorder, hydrocephalus, traumatic brain injury, and schizoaffective disorder, also had a positive Level I screening. The Level II evaluation was not scheduled because the resident was unable to participate. The DON did not review the reason for the evaluation's non-completion and was unaware that a new Level I should have been completed to reopen the case.
Unsecured Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure the residents' environment remained as free of accident hazards as possible when unsecured medications were observed in residents' rooms without staff present. This deficiency affected Resident #33, who had a medical history including type two diabetes mellitus and gastro-esophageal reflux disease, and Resident #65, who had a medical history including spinal stenosis and depression. Both residents had medications left unsecured in their rooms without proper assessment or authorization to self-administer their medications. Resident #33 was observed with two medications on their bedside table, which they stated were for their stomach and diabetes. The nurse had left the medications in the room, and the resident indicated they would take them when ready. The nurse confirmed that medications should not be left at the bedside and admitted not knowing if the resident had been assessed to self-administer. Further interviews revealed that the nurse did not stay with the resident to ensure the medications were taken, contrary to facility policy. Resident #65 was found with a bottle of Osteo-Biflex on their bedside table, which was not included in their medical orders. The resident stated they had been taking the supplement since admission and had informed their physician, who approved its use. However, there was no documentation or assessment for self-administration. The DON and Administrator confirmed that medications should be securely stored and inaccessible to residents unless they had been assessed and authorized to self-administer, which was not the case for Resident #65.
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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