Heritage Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Monterey Park, California.
- Location
- 610 North Garfield Avenue, Monterey Park, California 91754
- CMS Provider Number
- 055989
- Inspections on file
- 35
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Heritage Manor during CMS and state inspections, most recent first.
Surveyors found multiple food safety deficiencies during meal service in a conference room used as a temporary tray line area. An expired, ready-to-eat turkey sandwich remained in the refrigerator past its labeled use-by date, contrary to facility policy and FDA Food Code requirements. Staff serving food in the conference room did not have hair nets readily available, and a staff member wiped food contact surfaces with a kitchen towel that was then left on the counter instead of being stored in a sanitizer solution, with no sanitizer bucket or test strips present in the room. In addition, milk served during lunch was measured at 52.5°F, above the required 41°F or below for TCS foods, and staff reported there was no ice available in the conference room to maintain proper cold holding temperatures.
The facility failed to use its QAA/QAPI process to monitor and manage a temporary food service system put in place after the kitchen elevator became inoperable. Staff began transporting food and beverages by stairwell and using a conference room as a serving area, but no performance improvement project or monitoring was implemented for sanitation, infection control, or staff safety. Surveyors found expired food in the conference room refrigerator and cold beverages held above required temperatures, while the conference room lacked proper means to keep items cold. Food deliveries were left in the parking lot and carried by staff down the stairs to the basement kitchen. The RD’s sanitation audits did not include the conference room, and staff did not receive routine training or evaluation on safe food transport, fall prevention, or injury risk related to the new procedures, despite QA meetings discussing the elevator outage.
The facility failed to maintain a functional kitchen elevator, leaving it inoperable for an extended period despite prior maintenance recommendations, and did not notify the district office about the ongoing outage. As a result, dietary staff were required to carry all food, beverages, and supplies up and down stairs between the basement kitchen and an upstairs conference room used as a temporary meal staging and service area, with staff observed making multiple trips, becoming visibly fatigued, and one staff injury reported. Surveyors found cold beverages held above 41°F in a warm conference room without ice, and staff reported that vendor deliveries were left in the parking lot and then manually transported to the kitchen over a prolonged period, potentially delaying refrigeration. These practices were inconsistent with the facility’s own food safety and storage policies and FDA Food Code requirements for proper hot and cold holding and prompt refrigerated storage.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their documented preferences and goals, resulting in care that was not individualized or consistent with regulatory requirements.
A resident with type 2 DM was admitted with no orders for insulin or hypoglycemic medications, yet the care plan included interventions for diabetes medication administration and blood sugar monitoring. Staff confirmed the care plan was not tailored to the resident's actual needs and was initiated before a full IDT review, leading to inaccurate and non-resident-specific interventions.
A licensed nurse responsible for MDS assessments did not complete required annual competency evaluations for two consecutive years. The nurse was unaware of the facility's comprehensive care plan policy, a key aspect of their role. The DON confirmed the lapse, and facility records showed that annual competency checks, including care planning, are mandated to ensure staff maintain necessary skills and knowledge.
A resident with a history of type 2 diabetes and cognitive impairment did not receive a comprehensive monthly medication regimen review by the consultant pharmacist. The pharmacist failed to review the full diagnoses, previous medication orders, and relevant records, resulting in the omission of diabetes medication and subsequent hyperglycemia.
A resident with acute respiratory failure, COPD exacerbation, and pulmonary hypertension experienced a significant decline in respiratory status. Despite physician orders for close monitoring, oxygen titration, and immediate notification of the physician and emergency services, staff failed to assess, document, and respond appropriately when the resident's oxygen saturation dropped. The LVN did not follow orders to increase oxygen, did not notify the physician or call 911, and did not implement the resident's POLST. The resident's condition worsened and resulted in death, with facility policies and procedures not followed throughout the event.
Staff failed to maintain privacy for multiple residents during personal care by not closing privacy curtains or providing alternative visual barriers when curtains were removed for cleaning. In several cases, residents were exposed during care without their consent, and staff did not follow facility policy to ensure privacy and dignity.
Dietary staff, including the Dietary Manager and Facility Cook, did not follow required recipes or measure ingredients when preparing pureed foods for residents on modified diets. Instead, staff estimated thickener amounts and did not verify food texture, resulting in inconsistent and inappropriate food consistencies. Facility policies and recipes required specific measurements and procedures, but these were not followed, and there was no system to check the final product before serving.
The facility did not follow its own food safety policies by failing to properly store a flour scoop to prevent contamination and by not calibrating a food thermometer according to established procedures. The scoop was left exposed on top of the flour container instead of being stored in a plastic bag, and the thermometer was incorrectly calibrated, with staff accepting an inaccurate temperature reading. These actions did not meet professional standards for food safety and equipment handling.
The facility did not have effective systems in place to ensure dietary staff followed pureed food recipes, resulting in improper food texture for all residents on pureed diets. Additionally, the facility failed to identify, investigate, and respond to an adverse event involving a resident who expired from respiratory distress, with staff not documenting vital signs, notifying the physician, or following POLST preferences. These deficiencies were not addressed by the QAPI committee, despite repeated concerns.
A resident with cognitive impairment and respiratory conditions was not served a meal at the same time as other residents in the dining room, resulting in the resident waiting at least 17 minutes and feeling disrespected and frustrated while watching others eat. Staff interviews indicated a lack of communication regarding the resident's presence in the dining room, leading to the delay.
A resident with acute respiratory failure and COPD exacerbation experienced a significant drop in oxygen saturation, but staff failed to immediately notify the physician or follow emergency protocols as required by facility policy and physician orders. The resident's condition deteriorated rapidly, and the physician was only contacted after the resident had expired. Documentation and interviews confirmed that vital signs were not properly recorded, and appropriate interventions were not initiated in a timely manner.
Two residents experienced an unclean and unsafe environment due to unresolved maintenance issues, including a broken sliding screen door with holes and tears and missing floor tiles under a bed following a water leak. Despite repeated notifications and existing preventative maintenance policies, the facility did not repair these issues for over a month, impacting the comfort and quality of life for the affected residents.
A resident with hypertension and hyperlipidemia was discharged home with home health services, but the MDS assessment was incorrectly coded as a discharge to an acute hospital. The error was identified during a review of records and acknowledged by the MDS Nurse, who confirmed the MDS did not accurately reflect the resident's actual discharge disposition.
A resident with impaired vision and multiple medical conditions did not have a care plan addressing his need for new eyeglasses, despite an optometrist's recommendation and the resident's reports of worsening vision. Staff were unaware of the resident's vision concerns, and there was no documentation or tracking of the eyeglasses order, resulting in unmet care needs.
A resident with severe cognitive impairment developed a pressure injury on the left big toe that progressed from partial-thickness to full-thickness loss while in the facility. Despite wound care notes recommending new footwear and the care plan identifying improper footwear as a risk, there was no assessment or intervention regarding the resident's shoes. The resident continued to wear tight, uncomfortable sneakers, and staff did not evaluate footwear as a contributing factor, contrary to facility policy.
A nurse failed to check a resident's heart rate before administering antihypertensive medications and did not provide food with Metoprolol and Metformin as ordered, resulting in a medication error rate above 5%. The resident, who had diabetes and hypertension and was dependent on staff, received medications contrary to physician orders and facility policy.
A nurse failed to check a resident's heart rate before administering Metoprolol and Amlodipine, as required by physician orders and facility policy. The nurse only checked blood pressure and was about to give the medications when prompted by a surveyor to check the heart rate, which was then found to be within the safe range. The resident had cognitive impairment and was dependent on staff, and the omission was confirmed as a significant medication error.
A resident with dysphagia and cognitive impairment was repeatedly served pureed food that was too thick and lumpy, contrary to physician orders and care plan requirements for a thin consistency. The resident's family member reported having to bring in homemade food due to the facility's failure to provide the correct texture, and direct observations confirmed the food did not meet prescribed standards. The dietary manager and registered dietician acknowledged the inconsistency, and the cook admitted to not following facility recipes.
A dirty and rusty commode was discovered in a shared bathroom used by six residents. Housekeeping staff were unaware of the issue and could not confirm if the restroom had been checked for cleanliness. The maintenance supervisor confirmed the commode had been in poor condition for several days, despite facility policies requiring sanitary equipment and regular preventative maintenance.
A resident's responsible party reported aggressive and rude behavior by a nurse to the Social Service Assistant (SSA), who failed to initiate a grievance process or inform the Social Service Director (SSD). The facility's policy requires prompt grievance resolution, but the SSD was unaware of the issue, and the Director of Nursing (DON) was not informed. This failure increased the risk of negative psychosocial impact on the resident.
A resident with dementia and osteoporosis fell from a shower chair in an LTC facility when a CNA left her unattended. The resident, who was dependent on staff for bathing, opened the armrest and fell, resulting in a fractured humerus. The CNA did not report the fall immediately and moved the resident without a nurse's assessment, violating facility policy. The resident was later transferred to a hospital for non-operative treatment.
A resident with severe cognitive impairment was found with ecchymosis and a skin tear, but the facility failed to report the injury of unknown source within the required two-hour timeframe. The CNA noticed the discoloration but did not report it immediately, leading to a delay in notifying the DPH. The facility's policy mandates immediate reporting to ensure resident safety and compliance.
A facility failed to follow its wound care protocol when an LVN did not change gloves or wash hands after handling a soiled dressing on a resident with a Stage 4 pressure ulcer. The LVN continued to treat the resident's wounds without performing necessary hand hygiene, contrary to the facility's policy. The resident had a history of diabetes, hypertension, sepsis, and antibiotic-resistant bacteria, and was dependent on staff for daily activities.
The facility failed to implement an effective infection prevention and control program during a Covid-19 outbreak, leading to improper cohorting of residents. A resident who tested positive for Covid-19 was mistakenly moved into a room with negative residents due to the lack of a proper line listing and reliance on verbal reports. The IP nurse did not consult local health department or CDC guidelines, relying instead on online resources, which contributed to the deficiency.
A resident with cognitive impairments and mobility issues eloped from the facility without staff knowledge. Despite expressing a desire to go home earlier, the resident left unnoticed, and the facility was only informed of the elopement by a family member. The facility's policy on preventing elopements was not effectively implemented.
A CNA was observed standing while feeding three residents, contrary to facility policy requiring staff to be seated to maintain dignity and prevent choking. The residents, who have severe cognitive impairments and are dependent on staff for eating, were fed in a manner that could compromise their dignity and safety. Staff interviews and policy reviews confirmed the importance of seated feeding.
The facility failed to develop comprehensive care plans for three residents, leading to potential risks in their care. One resident lacked a care plan for oxygen therapy, another for sepsis and pneumonia, and a third for medication preferences. Staff confirmed the absence of necessary care plans, which are essential for consistent and effective care.
The facility failed to properly assess, monitor, and evaluate a resident's skin condition related to MASD and fungal infection. The care plan was not implemented, weekly skin assessments were not conducted, and the primary physician was not notified of the worsening condition. The resident experienced severe pain and distress due to the untreated skin condition.
The facility failed to provide appropriate pain management for a resident with severe MASD and fungal dermatitis, resulting in unrelieved severe pain. Despite the resident's complaints and visible signs of discomfort, the staff did not assess or manage her pain effectively, and no pain medication was administered.
The facility failed to complete performance reviews and Annual Core Clinical Competencies (ACCC) for eight of nine CNAs, potentially impacting the quality of care provided to residents. The new Director of Staff Development (DSD) confirmed that the previous DSD did not conduct the required competency checks for 2023, leaving the CNAs' skills assessments incomplete or not done since 2022. The Administrator acknowledged the issue, emphasizing the necessity of annual competency checks to ensure proper care for residents.
The facility failed to label and date food items in the kitchen, including chicken bouillon, rice, sliced peaches, tofu, and green peas, as required by their policy and professional standards. The DSS and DON acknowledged that these items should have been labeled and dated to ensure they were fresh and safe for consumption.
The facility failed to complete necessary documentation and monitoring as part of its Antibiotic Stewardship Program for two residents, leading to potential inappropriate antibiotic use and incomplete monitoring during therapy.
The facility failed to provide reasonable accommodation of needs for two residents. One resident's call light was out of reach, potentially delaying care, while another resident, who speaks little English, was not provided with appropriate communication tools or translation assistance, leading to confusion and frustration.
A facility failed to notify a physician and family of a significant change in a resident's condition, leading to worsened MASD and a fungal infection. Despite the resident's complaints and the Treatment Nurse's acknowledgment of the issue, proper documentation and timely assessments were not conducted. The Primary Medical Physician did not assess the wound and relied on second-hand reports, resulting in inadequate care.
A facility failed to ensure proper care for a resident with a Foley catheter, resulting in urine backflow due to kinked tubing. This oversight, confirmed by multiple staff members, contradicted the resident's care plan and facility policies, posing a risk of recurrent UTIs for the resident with severe cognitive impairment and a history of sepsis secondary to UTI.
The facility failed to label and date the gastrostomy tube for a resident, leading to potential infection control issues. The resident had severe cognitive impairment and was dependent on assistance for all ADLs. The facility's policies on feeding tube care and infection control were not followed.
The facility failed to ensure that a resident had their nasal cannula and humidifier bottle dated and changed weekly, and another resident had their plastic storage bag for oxygen equipment changed weekly per facility protocol. This led to potential contamination and infection risks.
The attending physician failed to supervise the care of a resident with severe MASD, fungal infection, and dermatitis. The physician did not assess the resident's skin condition or provide a pain medication regimen, despite the resident experiencing significant pain and worsening skin conditions. The facility's policy requiring active physician supervision was not followed.
The facility failed to ensure that two residents on blood thinners were adequately monitored for bleeding and bruising. One resident on Plavix had no physician order or documentation for monitoring, while another on Aspirin and Eliquis lacked routine lab tests. The DON confirmed these lapses, which were against the facility's policy for anticoagulant therapy.
The facility failed to maintain a medication error rate below five percent, with errors including not checking expiration dates and not administering medications with food as ordered, affecting three residents.
The facility failed to document that two residents were offered or declined the flu vaccine for the 2023-2024 season, despite having the capacity to make decisions. The Infection Preventionist confirmed the absence of necessary documentation in the residents' medical charts.
The facility failed to ensure employee personal items were not stored in a medication room and did not maintain a sanitary environment for a resident. A jacket was found in the medication room, and a resident's bedside commode was left uncleaned for hours, leading to a strong smell and potential infection risk. The facility's policies on sanitation and infection prevention were not followed.
Improper Food Storage, Sanitation, and Cold Holding Temperatures During Meal Service
Penalty
Summary
Surveyors identified deficiencies in food safety and sanitation practices related to food storage and handling in a conference room being used as a temporary food service area. During observation of the conference room refrigerator, one prepared turkey sandwich was found with a use-by date of 2/22/26–2/23/26 that had not been discarded after expiration. The Dietary Supervisor (DS) stated that sandwiches were prepared the day before, served the next day, and discarded if not used by the labeled date, and acknowledged that the sandwich in the refrigerator was expired and should have been discarded. Facility policy and the 2022 FDA Food Code require ready-to-eat, time/temperature control for safety (TCS) foods to be labeled, dated, monitored, and used, frozen, or discarded by the use-by date. Additional deficiencies were observed in hygienic practices and surface sanitation in the same conference room tray line area. There were no hair nets readily available in the conference room, even though it was being used as a temporary food serving area. The DS stated that staff wore hair nets from the basement kitchen but confirmed that hair nets should be readily available in the conference room to prevent hair from contacting food. A staff member was observed wiping food contact surfaces with a kitchen towel and then placing the towel on the counter instead of storing it in a sanitizer solution between uses. The staff member stated that kitchen towels should be stored in sanitizer solution when not in use and that there was no sanitizer solution available in the conference room. The DS confirmed that a sanitizer solution bucket should have been present and that there were no sanitizer test strips in the conference room to verify sanitizer effectiveness, despite facility policy and FDA Food Code requirements for wiping cloths to be held in appropriate sanitizer solution. Surveyors also found improper cold holding temperatures for TCS beverages during lunch service in the conference room. Using the facility’s thermometer, the temperature of milk held for cold storage and served during lunch was measured at 52.5°F, above the required 41°F or below. The dietary aide reported that beverages were stored in the kitchen freezer to make them very cold before being brought to the conference room, and the DS stated that the conference room became warm during meal service, causing cold beverage temperatures not to remain at or below 41°F. The DS also stated there was no ice available in the conference room to keep beverages cold before service. Facility policy and the 2022 FDA Food Code require monitoring and maintaining proper hot and cold holding temperatures for TCS foods and beverages to keep them out of the danger zone.
Failure to Use QAPI to Monitor Temporary Food Service After Elevator Outage
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a QAA/QAPI plan to monitor and manage changes in food service operations after the kitchen elevator became inoperable. The elevator, which connected the basement kitchen to upper floors, had been broken since the last quarter of 2024, and staff began transporting food and beverages via the stairwell and using the conference room as a food distribution and serving area. Despite this significant operational change, the facility did not establish a performance improvement project or monitoring system under QAPI to oversee sanitation, infection control, or safety related to this temporary food service arrangement. Surveyors observed multiple issues in the temporary conference room service area and in the process of transporting and receiving food. In the conference room, a sandwich with an expiration date of 2/22/26–2/23/26 was found stored in a reach-in refrigerator past its use-by date. During lunch service, cold beverages were out of temperature range, with apple juice at 46.9°F and milk at 52.5°F, while the Dietary Supervisor acknowledged that cold foods and beverages should be at 41°F or below and that the conference room was warm and lacked ice for proper cold holding. The Registered Dietitian’s monthly sanitation audits were limited to the kitchen and did not include the conference room where food was being temporarily served. Additional observations and interviews showed that staff were manually carrying beverages and large pans of food up the stairs from the basement kitchen, and food vendors were leaving deliveries in the parking lot for staff to bring down the stairwell to the kitchen. The Dietary Supervisor reported that only one staff member had been injured during this period and acknowledged that no in-services on fall injuries or fall prevention had been provided, and that staff were not routinely trained in injury risk prevention while delivering food via the stairwell. The Administrator confirmed that while the elevator outage was discussed in monthly QA meetings, there was no documentation of a performance improvement project or monitoring of sanitation and infection control in the conference room, nor ongoing training and evaluation of staff skills and knowledge related to the new food transport and service procedures, despite facility policy requiring the QAA committee to identify quality issues, implement corrective plans, and monitor performance.
Failure to Maintain Functional Kitchen Elevator Resulting in Unsafe Food Handling and Staff Strain
Penalty
Summary
Facility staff and leadership failed to maintain a safe and functional environment by allowing the kitchen elevator, which connects the basement kitchen to the main floor, to remain inoperable for an extended period. The Assistant Administrator and Maintenance Supervisor reported that the elevator had been broken since the last quarter of 2024, with documented elevator company recommendations for maintenance and replacement that were not completed after early September 2024. The Administrator stated the elevator ultimately was deemed not repairable and needed replacement, and that the facility notified the state construction authority about the replacement project but did not notify the district office about the existing inoperable elevator. Because the elevator was not functioning, the facility relocated food distribution and tray set-up to an upstairs conference room and required dietary staff to transport all food, beverages, and supplies via the stairwell. Surveyors observed the conference room being used as a food distribution and serving area, containing a steam table, plate warmer, refrigerator, meal carts, and a fan. Dietary staff were seen repeatedly carrying trays of beverages and large pans of food up and down the stairs from the basement kitchen, with one dietary aide observed making multiple trips, breathing heavily, and sweating. The Dietary Supervisor confirmed that since the elevator failure, staff had been using the stairwell for food delivery and vendor deliveries, and reported that one staff member had been injured during this period and that the facility had not provided in-services on safe food delivery or fall prevention related to this change in process. Surveyors also identified failures in maintaining proper food temperatures and timely refrigerated storage under these altered conditions. During lunch service in the conference room, cold beverages such as apple juice and milk were measured at 46.9°F and 52.5°F, respectively, while the Dietary Supervisor acknowledged the room was warm during service, there was no ice available in the conference room, and that cold foods should be held at 41°F or below. In the basement, staff and the Dietary Supervisor described that food and supplies were now left by vendors in the parking lot and then carried down the stairs by kitchen staff, with one dietary aide stating it could take about two hours to bring supplies when working alone and acknowledging that dairy products left outside for a long time could spoil. These practices conflicted with the facility’s own food safety and storage policies and the FDA Food Code requirements for hot and cold holding and immediate refrigeration upon receipt.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Develop Resident-Specific Diabetes Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with type 2 diabetes mellitus. Upon admission and readmission, the resident's records indicated diagnoses including diabetes, hyperglycemia, gastrostomy, and dysphagia, with the resident being dependent on staff for multiple activities of daily living. The Minimum Data Set (MDS) assessment showed the resident had moderately impaired cognitive skills and was not prescribed insulin or any hypoglycemic medications. Despite this, the care plan initiated for the resident included interventions such as administering diabetes medications as ordered and monitoring for signs and symptoms of hyperglycemia and hypoglycemia, which were not applicable to the resident's current orders and condition. Interviews with nursing staff and review of the care plan revealed that the care plan was initiated before a full interdisciplinary team (IDT) care conference and did not accurately reflect the resident's needs or current medical orders. Staff confirmed that the interventions listed were not resident-specific and could cause confusion in care delivery. The facility's policy required the development of a comprehensive, person-centered care plan with measurable objectives and timeframes based on the resident's assessment, which was not followed in this instance.
Failure to Complete Annual Licensed Nurse Competency for MDS Nurse
Penalty
Summary
The facility failed to ensure that a licensed nurse specializing in Minimum Data Set (MDS) assessments completed the required annual competency evaluations for both 2023 and 2024. During interviews, the nurse admitted to not knowing the facility's policy and procedure for comprehensive care plans, which are essential for outlining all aspects of a resident's care. Another MDS nurse confirmed that developing comprehensive care plans is a key responsibility and that all MDS nurses should be familiar with the relevant policies. The Director of Nursing (DON) verified that the nurse had not completed the annual competency, which is intended to keep staff updated on necessary knowledge and skills. A review of facility records and policies showed that annual competency evaluations are part of the facility's training program for licensed nurses, with specific skills such as care planning included in the checklist. The facility's policies require ongoing training and competency assessments to ensure staff are equipped to provide person-centered care, including care planning, documentation, and communication with residents and families. The DON acknowledged the importance of these competencies for safe and effective resident care, and confirmed the deficiency in the nurse's training record.
Failure to Perform Comprehensive Medication Regimen Review for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a licensed pharmacist performed a comprehensive monthly medication regimen review (MRR) for a resident with a diagnosis of type 2 diabetes mellitus. The resident, who had moderately impaired cognitive skills and was dependent on staff for daily activities, was admitted and readmitted with a history of diabetes and hyperglycemia. Despite this, the MRR for the relevant month only included a recommendation regarding gabapentin and did not address the absence of diabetes medication. The pharmacist did not review the resident's full list of diagnoses, previous medication orders, hospital records, or laboratory results, and therefore did not identify the lack of diabetes medication. Interviews revealed that the consultant pharmacist did not have access to the resident's complete diagnoses and only reviewed certain records if clarification was needed, rather than as a standard practice. The Director of Nursing confirmed that the pharmacist did not conduct a comprehensive review as required by facility policy, which mandates access to residents' medical records and a thorough monthly review. As a result, the resident did not receive necessary diabetes medication, leading to an episode of hyperglycemia.
Failure to Provide Timely and Appropriate Respiratory Care and Emergency Response
Penalty
Summary
The facility failed to provide necessary respiratory care and interventions for a resident diagnosed with acute respiratory failure with hypoxia, COPD exacerbation, and pulmonary hypertension. The resident had physician orders and a care plan requiring close monitoring of respiratory status, titration of oxygen therapy to maintain oxygen saturation at or above 94%, and immediate notification of the physician and emergency services in the event of significant changes. Despite these orders, when the resident was found with weakness, labored breathing, and an oxygen saturation of 88% while on oxygen via nasal cannula, the findings were reported to an LVN, but appropriate actions were not taken. The LVN did not follow physician orders to increase oxygen therapy or switch to a mask as required when the resident's oxygen saturation dropped further to 70%. There was no documentation of vital signs, treatments rendered, or timely notification to the physician. The LVN also failed to implement the resident's Physician Orders for Life-Sustaining Treatment (POLST), which included specific interventions for respiratory distress, and did not call 911 or escalate the situation as required by facility policy. The resident's condition continued to deteriorate, and the resident expired at the facility with the cause of death listed as cardiac dysrhythmia, acute respiratory distress, and pulmonary hypertension. Interviews and record reviews confirmed that the required assessments, documentation, and interventions were not performed. The facility's policies on oxygen administration, notification of changes, and medical emergency response were not followed. The failure to monitor, document, and respond appropriately to the resident's change in condition resulted in a delay in diagnosis, care, and respiratory services, ultimately leading to the resident's death.
Removal Plan
- The Director of Nursing (DON) and Registered Nurse (RN) supervisor evaluated current residents with oxygen order and/or with diagnosis of COPD for appropriate assessment and interventions.
- The Regional Nurse Consultant (RNC) provided one on one education to DON and Director Staffing Development (DSD) related to respiratory care, assessment and documentation, monitoring for any change of condition, oxygen administration as ordered by the physician, notification of the physician, escalation of emergent medical services (911) if needed, and implementation of POLST per resident preference.
- The Regional Nurse Consultant (RNC) conducted an interview with LVN 1 and CNA 1 regarding the death incident of Resident 98. The RNC investigated for the licensed nurse documentation, monitoring of change of condition and the reason for not calling 911 and for the possible root cause.
- The RNC provided one on one education to LVN 1 related to respiratory care, assessment and documentation, monitoring for any change of condition, oxygen administration as ordered by the physician including skills competency, notification of the physician, escalation of emergent medical services (911) if needed, and implementation of POLST per resident preference.
- The DON or designee conducted re-education for licensed nursing staff on the following topics: documentation, oxygen administration, compliance with individualized interventions in each resident's care plan, implementation of POLST and notification of the physician and following physician orders.
- The DON or designee started auditing residents with COPD and or Oxygen order 3 times weekly to ensure physician's orders were carried out, resident specific care plans were implemented, and necessary respiratory equipment/supplies were in place, and monitor if change of condition occurred. Upon identification, the DON or designee would immediately address concerns and remedy any audit deficiencies with the licensed nursing staff immediately.
- A Quality Assurance and Performance Improvement (QAPI) Plan was implemented to track and report on above audit findings. The findings will be presented for the monthly Quality Assessment and Assurance (QAA) meeting for a minimum of three months. After the initial three months, the QAA Committee will decide regarding the continued frequency of audits and subsequent reporting, with audits continuing at least monthly to sustain compliance.
- The RNC discussed regarding Chronic Obstructive Pulmonary Disease (COPD) and pulmonary hypertension with post-test to LVN 1 to ensure understanding of the medical condition.
- The DON or designee provided education to licensed nurses regarding COPD and pulmonary hypertension with post-test to ensure understanding of the medical condition.
Failure to Provide Privacy During Personal Care and Absence of Privacy Curtains
Penalty
Summary
The facility failed to ensure the privacy and dignity of four residents during the provision of personal care. In one instance, a certified nurse assistant (CNA) changed a resident's brief without closing the privacy curtain, leaving the resident exposed from the waist down. The CNA later stated that the curtain was left open because the room was hot, but acknowledged that the curtain should have been closed to maintain privacy. The resident was non-verbal and unable to communicate, and a family member indicated that exposure to strangers would upset the resident. The Director of Staff Development confirmed that privacy should always be maintained during care. In another case, a CNA cleaned and changed a resident's gown without drawing the privacy curtain, exposing the resident from the waist down. The CNA claimed the curtain was left open so the resident could watch TV, but the resident reported not requesting this and expressed being upset about the exposure. The resident had intact cognition and was dependent on staff for personal hygiene and dressing. The Director of Staff Development reiterated that privacy should always be provided during such care. Additionally, two residents in a shared room were left without privacy curtains when the curtains were removed for washing. Both residents were present in the room during this time, and the door was left open. The maintenance supervisor stated the curtains would be reinstalled later, and a CNA indicated that care would be delayed or the door closed until privacy was restored. The Director of Nursing stated that it was not acceptable to leave residents without privacy curtains and that temporary measures should be used to maintain privacy. Facility policies reviewed indicated that residents have a right to personal privacy and dignity during care.
Failure to Follow Pureed Diet Recipes and Measurement Protocols by Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff, including the Dietary Manager and Facility Cook, demonstrated appropriate competencies and skill sets in preparing pureed diets for residents. Observations revealed that staff did not measure or follow recipes when preparing pureed foods such as chicken, noodles, vegetables, rice porridge, and desserts. Instead, staff added thickener powder by estimation, without referencing the required recipes or measuring the ingredients, resulting in inconsistent food textures. The recipes and policies required specific measurements and procedures to ensure the correct texture and nutritional content, but these were not followed during food preparation. During multiple observations, staff prepared pureed foods by blending unmeasured amounts of ingredients and adding thickener powder without using the prescribed measurements. The Dietary Manager and other dietary staff did not check or follow the recipes, and there was no system in place to verify the final texture of the pureed foods before serving. The Dietary Manager acknowledged that the pureed chicken and noodles were too sticky and did not meet the required consistency, and also stated uncertainty about who was responsible for checking the final product. There was no log or documentation of texture checks being performed. Interviews with staff confirmed that recipes were not followed, and thickener was added based on experience rather than measurement. The Registered Dietitian stated that following recipes is necessary to ensure both nutritional adequacy and safe texture for residents with swallowing difficulties. Review of facility policies and recipes confirmed the requirement to follow specific procedures and measurements for pureed food preparation, which were not adhered to by the dietary staff.
Failure to Follow Safe Food Handling and Thermometer Calibration Procedures
Penalty
Summary
The facility failed to adhere to proper sanitation and safe food handling practices as outlined in its own policies and procedures. During an observation in the kitchen dry storage room, a scoop used for flour was found resting on top of the flour container and not stored in a plastic bag as required. The Dietary Manager confirmed that the scoop should have been placed in a plastic bag to prevent potential contamination, but it was left exposed, likely due to staff oversight. Additionally, the facility did not ensure that dietary staff correctly calibrated the food thermometer used to check food temperatures. The Dietary Manager demonstrated the calibration process by submerging the thermometer in ice water and accepting a reading of 39°F as accurate, whereas the facility's policy specifies that the correct reading should be 32°F. The Dietary Manager Assistant confirmed that the thermometer was not calibrated correctly, which could result in inaccurate temperature measurements for food served to residents. Review of facility policies confirmed the requirements for both food handling and thermometer calibration were not followed.
Failure to Systematically Identify and Address Adverse Events and Dietary Protocols
Penalty
Summary
The facility failed to implement a systematic approach to identifying, investigating, analyzing, and utilizing data related to monitoring and preventing adverse events, as required by its own Quality Assurance and Performance Improvement (QAPI) policy. Specifically, the QAPI committee did not address or develop a written plan to ensure dietary staff followed pureed food recipes for all residents prescribed a pureed diet. Observations revealed that dietary staff did not measure thickener powder when preparing pureed foods, instead relying on estimation and taste, and there was no documentation or log verifying the correct texture of the food. The Dietary Manager and Registered Dietitian confirmed that recipes were not consistently followed, and the Administrator acknowledged that concerns about food texture had been raised multiple times but were not discussed or addressed in QAPI meetings. Additionally, the facility did not have a system in place to identify and investigate adverse events, as demonstrated by the handling of a resident who expired from respiratory distress related to COPD and pulmonary hypertension. The charge nurse on duty did not document vital signs, failed to notify the physician or RN of the resident's significant change in condition, and did not follow physician orders regarding oxygen administration. The Director of Nursing did not investigate the possible cause of death until prompted by surveyors, and the Administrator was not informed of the resident's death or the circumstances surrounding it, indicating a lack of oversight and failure to recognize and respond to adverse events as required by facility policy. Furthermore, the facility did not ensure that the resident's Physician Orders for Life-Sustaining Treatment (POLST) were implemented according to the resident's preferences. The charge nurse did not notify the physician or call for emergency assistance when the resident's condition deteriorated, and the death was not reported or investigated in a timely manner. The facility's own QAPI policy requires systematic identification, reporting, investigation, and prevention of adverse events, as well as documentation and monitoring, but these procedures were not followed in the cases observed.
Resident Not Served Meal Timely in Dining Room
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease and pulmonary edema, who also had moderately impaired memory and cognition, did not receive his meal tray at the same time as other residents dining in the communal dining room. During lunch, staff served meal trays to 11 out of 14 residents, leaving the resident in question waiting and observing others eat. The resident, seated at a corner table, waited at least 17 minutes before receiving his meal tray, during which time he ate a bread bun he had brought with him. The resident expressed feeling disrespected and frustrated by the delay and by having to watch others finish their meals before he was served. Staff interviews revealed that the resident typically did not eat lunch in the dining room, which may have contributed to the dietary staff not preparing his tray with the others. The treatment nurse acknowledged noticing the delay and stated that staff should have communicated the resident's presence to dietary staff to ensure all residents received their meals simultaneously. The facility's policy requires staff to protect and promote resident dignity, which was not upheld in this instance.
Failure to Notify Physician and Follow Emergency Protocols for Resident with Acute Respiratory Decline
Penalty
Summary
The facility failed to follow its policy and procedure regarding the notification of changes in a resident's condition, as well as professional standards of practice and physician orders, for a resident with acute respiratory failure, COPD exacerbation, and pulmonary hypertension. The resident had specific physician orders to monitor oxygen saturation and to notify the physician if the saturation dropped below 91% or was significantly lower than baseline. On the day of the incident, the resident's oxygen saturation was observed to decrease to 88% and then to 70%, but the physician was not notified immediately as required. CNA 1 reported to LVN 1 that the resident was experiencing labored breathing and a drop in oxygen saturation. LVN 1 assessed the resident, confirmed the low oxygen saturation, but did not document the vital signs, did not notify the physician, did not inform the RN on duty, and did not titrate the oxygen as per the physician's order. Instead, LVN 1 only called the physician after the resident had already passed away. Interviews with staff and review of documentation confirmed that the required notifications and interventions were not performed in a timely manner. The facility's policies required immediate action and notification of the physician in the event of significant changes in a resident's condition, including life-threatening situations. The failure to follow these policies and physician orders resulted in a delay in diagnosis, care, and services for the resident, who ultimately expired shortly after the onset of symptoms. Documentation and interviews confirmed that the expected standards of care and facility protocols were not followed during this critical event.
Failure to Maintain Safe and Homelike Resident Environments
Penalty
Summary
The facility failed to provide a homelike, safe, and clean environment for two residents by not addressing maintenance issues in their rooms. For one resident with dementia and hypertension, the sliding screen door in the room was out of track and had multiple holes and tears for over a month. The resident reported discomfort due to bugs, dirt, and leaves entering the room and stated that maintenance staff had been notified multiple times, but the issue remained unresolved. The Maintenance Supervisor confirmed that routine checks on screen doors were not conducted and that he was unaware of the problem until the survey, relying instead on staff reports that were not received. Another resident, who had severe cognitive impairment and was dependent for mobility, had unrepaired missing floor tiles below the bed due to a water leak that occurred about a month prior. The Certified Nurse Assistant confirmed the floor had not been repaired since the leak, and the Maintenance Supervisor acknowledged that, although the water pipe had been fixed, the floor remained unrepaired. Both staff members agreed that the resident should have a functional and homelike environment, but the necessary repairs had not been completed. Review of the facility's policies indicated that a preventative maintenance program was in place, requiring the maintenance of a safe, functional, and comfortable environment for residents. The policies also specified that the Maintenance Director was responsible for ensuring that the physical environment did not pose a safety risk and that all areas frequented by residents, including their rooms, should be maintained accordingly. Despite these policies, the facility did not address the reported maintenance issues in a timely manner, resulting in an unclean and unsafe environment for the affected residents.
Inaccurate MDS Discharge Coding for Resident Discharged Home
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident who was discharged home with home health services. Specifically, the MDS was incorrectly coded to indicate that the resident had been discharged to an acute hospital, rather than to their home under the care of a home health agency. This discrepancy was identified during a review of the resident's records, which included physician orders clearly stating the discharge to home with home health services. The error was acknowledged by the MDS Nurse during a concurrent interview and record review, confirming that the MDS did not accurately reflect the resident's actual discharge disposition. The CMS Resident Assessment Instrument (RAI) Manual requires that MDS discharge assessments accurately document the resident's discharge location and care needs, which was not met in this instance. The resident involved had a medical history of hypertension and hyperlipidemia and was admitted to the facility prior to the discharge event.
Failure to Develop and Implement Vision Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with impaired vision who required new eyeglasses. Despite the resident's report of worsening vision and inability to read due to outdated eyeglasses, there was no care plan addressing his visual impairment. The resident had been seen by an optometrist, who recommended new prescription glasses, but the care plan and clinical records did not reflect this need or the optometry visit. Additionally, there was no documentation or tracking of the eyeglasses order by social services, and nursing staff were unaware of the resident's vision concerns until informed by the resident himself. The resident's medical history included intervertebral disc degeneration, diabetes mellitus, and a below-knee amputation. The Minimum Data Set indicated moderate cognitive impairment and a need for partial assistance with personal hygiene. Despite these complexities, the facility did not assess or document the resident's sensory changes or coordinate care following the optometry visit. Interviews with staff confirmed a lack of awareness and communication regarding the resident's vision needs, and the facility's policy required interdisciplinary care planning that was not followed in this case.
Failure to Assess and Address Footwear Contributing to Pressure Injury Progression
Penalty
Summary
A resident with chronic atrial fibrillation, dementia, and spinal stenosis was admitted and later readmitted to the facility. Upon admission, the resident's skin was noted to be warm and dry, with some discoloration but no pressure injuries (PIs) documented. On a later date, redness was observed on the left big toe, but no staging or detailed wound description was recorded at that time, and no change in condition documentation was created when the skin condition worsened. Over the following months, wound progress notes indicated the development and progression of a pressure injury on the resident's left big toe, advancing from partial-thickness tissue loss to a Stage 3 PI with full-thickness tissue loss. Despite recommendations in the wound notes for new footwear, there was no documented assessment or evaluation of the resident's shoes to determine their effectiveness in preventing further injury. The care plan identified improper footwear as a predisposing factor but did not include any interventions related to footwear. Observations and interviews revealed that the resident preferred to wear older, tighter white sneakers, which caused discomfort due to the wound, even though a newer pair of shoes had been provided by family. The treatment nurse was unaware of the footwear issue and had not assessed whether the shoes contributed to the pressure injury. The facility's policy required individualized interventions based on risk and skin assessments, but these were not implemented or documented in relation to the resident's footwear.
Medication Error Rate Exceeds 5% Due to Missed Vital Checks and Food Administration
Penalty
Summary
A medication pass observation revealed that a nurse failed to maintain a medication error rate of 5% or less, with three errors identified out of 29 opportunities, resulting in a 10.34% error rate. Specifically, the nurse did not check the resident's heart rate prior to administering Amlodipine and Metoprolol, as required by the physician's order, and also failed to provide food during the administration of Metoprolol and Metformin, both of which were ordered to be given with food. The nurse acknowledged forgetting to check the heart rate and not providing food at the time of administration. The resident involved had diagnoses of diabetes mellitus and hypertension, lacked the mental capacity to make medical decisions, and was dependent on staff for activities of daily living. Physician orders specified that Amlodipine and Metoprolol should be held if the systolic blood pressure was below 110 or heart rate below 60, and that Metoprolol and Metformin should be administered with food. The facility's medication administration policy required obtaining and recording vital signs as ordered and providing food and fluids as appropriate, but these procedures were not followed during the observed medication pass.
Failure to Check Heart Rate Before Administering Antihypertensive Medications
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow physician orders and facility policy by not checking a resident's heart rate prior to administering Metoprolol tartrate and Amlodipine, both medications prescribed for hypertension. The physician's order specifically required that these medications be held if the resident's systolic blood pressure was less than 110 or if the heart rate was less than 60. During a medication pass observation, the LVN prepared and was about to administer the medications after checking only the resident's blood pressure, omitting the required heart rate check. When questioned by the surveyor, the LVN acknowledged forgetting to check the heart rate and subsequently measured it, finding it to be 65 beats per minute before proceeding with administration. The resident involved had a history of diabetes mellitus and hypertension, was cognitively impaired, and dependent on staff for activities of daily living. The facility's policy required obtaining and recording vital signs as per physician orders, and the Director of Nursing confirmed the necessity of checking heart rate before administering these medications. The failure to check the heart rate as required constituted a significant medication error, as it did not comply with the physician's order or facility policy.
Failure to Provide Prescribed Pureed Diet Consistency for Resident with Dysphagia
Penalty
Summary
A deficiency was identified when a resident with a history of dysphagia, dementia, and recent pneumonia was not provided with food in the prescribed consistency. The resident had a physician order and care plan specifying a regular diet with pureed texture and thin consistency due to significant swallowing difficulties and risk for aspiration. Multiple assessments, including those by speech therapy and the registered dietician, emphasized the need for moist, thin pureed foods and close supervision during feeding. Despite these documented needs, the resident was repeatedly served pureed food that was too thick and contained lumps, as observed by both the resident's family member and facility staff. Observations revealed that the resident's family member had been bringing in homemade food and feeding the resident daily, stating that the facility's pureed food was too thick and caused the resident to gag and cough. During direct observation, the facility-provided pureed food was seen sticking to the spoon and not sliding off, with visible lumps, and the resident was observed coughing and unable to swallow the food. The dietary manager confirmed through a spoon test that the food did not meet the required thin consistency and acknowledged that the food was too thick, which could cause it to get stuck in the resident's mouth. Further investigation found that the facility's cook did not follow the facility's recipe for preparing pureed food, instead relying on personal experience and taste to determine texture. The registered dietician confirmed the importance of following recipes to ensure correct consistency, especially for residents at risk of aspiration and choking. The facility's policy required that foods be provided in the appropriate form as prescribed by the physician and assessed by the interdisciplinary team, but this was not followed in the resident's case.
Unsanitary Commode Found in Shared Resident Bathroom
Penalty
Summary
A deficiency was identified when a dirty and rusty commode was found in the shared bathroom between two rooms, used by six residents. During an observation, the unsanitary condition of the commode was noted. The housekeeper interviewed was unaware of the issue and stated she had not received any report about the commode's condition. She also could not recall if she had checked the shared restroom to ensure all equipment was clean and functional. The maintenance supervisor, upon concurrent observation, confirmed the commode was dirty and rusty and estimated it had been in that state for at least a few days. He acknowledged responsibility for ensuring all facility equipment was sanitary, clean, and functional. A review of the facility's policies and procedures revealed that maintaining a sanitary environment includes keeping resident care equipment clean and properly stored, and that a preventative maintenance program should be in place to ensure a safe, sanitary, and comfortable environment. The failure to identify and address the dirty and rusty commode resulted in an unsanitary environment for the residents using the shared bathroom.
Failure to Address Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances verbalized by a resident's responsible party (RP) and did not issue a written grievance decision in accordance with the facility's policy. The RP reported that during a visit, the admitting nurse was aggressive and rude to both the resident and the RP. This concern was communicated to the Social Service Assistant (SSA), who noted the issue but did not initiate a grievance process or inform the Social Service Director (SSD) responsible for handling grievances. The SSA only informed the Director of Nursing (DON) about the concern without further action. The facility's grievance policy requires prompt acknowledgment and resolution of grievances, but the SSD was unaware of the RP's concerns due to a lack of communication from the SSA. The SSD stated that if informed, she would have initiated a formal grievance process. The DON also stated she was unaware of any complaints and would have started an investigation if informed. The failure to address the grievance promptly and according to policy increased the risk of negative psychosocial impact on the resident's quality of life.
Resident Falls from Shower Chair Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident who was at risk for falls and had a history of dementia and osteoporosis. The resident, who was totally dependent on staff for bathing, fell from a shower chair when a Certified Nursing Assistant (CNA) left the resident unattended to adjust her own clothing. The resident opened the armrest of the shower chair and fell to the floor, resulting in a fracture of the left humerus. The CNA did not immediately report the fall to a Registered Nurse (RN) and instead moved the resident back to the shower chair without a licensed nurse's assessment, contrary to the facility's policy. The resident was later found by an RN with swelling and pain in the left arm, and an X-ray confirmed a fracture. The resident was transferred to a general acute care hospital for further treatment, where it was determined that surgery was not an option due to the resident's comorbidities. The resident received non-operative treatment, including pain management and a splint for the fracture. Interviews with facility staff revealed that the CNA did not follow the facility's policy on incidents and accidents, which requires that a resident not be moved after a fall until assessed by a licensed nurse. The CNA admitted to not reporting the fall due to fear. The facility's policies on accidents and supervision, as well as fall prevention, were not adhered to, leading to the resident's injury.
Delayed Reporting of Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source within the required timeframe, as per their policy and procedure on Abuse, Neglect, and Exploitation. The incident involved a resident who was found with ecchymosis on both arms and a skin tear on the left forearm. The allegation of abuse was made at 8:30 AM, but the facility reported it to the Department of Public Health (DPH) at 1:23 PM, five hours later, instead of within the mandated two-hour window. The resident involved had been admitted to the facility with diagnoses including dementia, anemia, and lack of coordination. The resident was assessed to have severe cognitive impairment and was dependent on facility staff for daily activities. During an interview, the resident initially claimed someone had grabbed and hit her but later retracted the statement, appearing confused and disoriented. The facility's Social Services Director assured the resident of her safety, but the delay in reporting the incident was a breach of protocol. Interviews with facility staff revealed that a Certified Nursing Assistant (CNA) noticed discoloration on the resident's arm during morning care but did not report it immediately, as the resident was not in pain. The discoloration was later reported by the resident's family member. The Director of Staff Development confirmed that CNAs were trained to report any changes in a resident's condition immediately, which did not occur in this case. The facility's policies required immediate reporting of such incidents to ensure resident safety and compliance with state and federal regulations.
Failure to Follow Wound Care Protocol
Penalty
Summary
The facility failed to adhere to its policy and procedure for clean dressing changes, which led to a deficiency in the care of a resident with a Stage 4 pressure ulcer. During an observation, a Licensed Vocational Nurse (LVN) did not change gloves or wash hands after handling a soiled dressing while providing wound care to a resident. The LVN continued to use the same soiled gloves to clean and treat the resident's wounds, including a Stage 4 pressure ulcer on the right mid-back, without performing hand hygiene or changing gloves as required by the facility's protocol. The resident involved had a medical history that included diabetes, hypertension, sepsis, and antibiotic-resistant bacteria, and was dependent on staff for various activities of daily living. The facility's policy required handwashing and glove changes between handling soiled dressings and applying clean ones, which the LVN did not follow. This failure was confirmed through interviews with the LVN and the Infection Prevention Nurse, who emphasized the importance of hand hygiene in preventing infection spread.
Inadequate Infection Control and Cohorting During Covid-19 Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program during a Covid-19 outbreak, as evidenced by the lack of a proper line listing and inadequate cohorting of residents. The Infection Preventionist (IP) nurse did not create a line listing for residents who tested positive for Covid-19 or were exposed, due to being occupied with testing and moving residents. This led to confusion and improper room assignments, such as moving a Covid-19 positive resident into a room with negative residents, increasing the risk of virus transmission. Resident 1, who tested positive for Covid-19, was mistakenly moved from Room A to Room B, where they were placed with Residents 3 and 5, both of whom tested negative. This error occurred because the facility's nurses began moving residents based on verbal reports without formal documentation or a line listing. The IP nurse later confirmed Resident 1's positive status and had to move them again to another room, as their original room was occupied by another positive resident. The IP nurse relied on online resources for guidance during the outbreak, neglecting to consult local health department or CDC guidelines. The facility's policy required heightened surveillance during periods of transmission, but the IP nurse was unable to track the necessary information due to the lack of a structured system. This deficiency in infection control practices had the potential to spread Covid-19 among residents, staff, and the community.
Resident Elopement Due to Insufficient Supervision
Penalty
Summary
The facility failed to provide sufficient monitoring and supervision to a resident who eloped from the facility. The resident, who had diagnoses including metabolic encephalopathy and chronic obstructive pulmonary disease (COPD), was admitted on 3/27/24. The resident's assessments indicated that he did not have the capacity to understand and make decisions for himself and required substantial assistance when walking. On 4/20/24, the resident was found missing at around 8 PM when a family member called the facility to inform them that the resident had gone home. The facility staff were unaware that the resident had left the premises or was missing until the family member's call. Interviews with the staff revealed that the resident had expressed a desire to go home earlier in the evening but was told he could not leave without a physician's order. Despite this, the resident managed to leave the facility unnoticed. The Director of Nursing (DON) confirmed that the resident left the facility without notifying the staff and that the facility was informed of the resident's departure by a family member. The facility's policy on elopements and wandering residents, dated 12/19/22, indicated that residents at risk for elopement should receive adequate supervision and have preventive measures in place, such as door locks and alarms, to help avoid elopements and prevent accidents. However, the staff interviews and the incident itself suggest that these measures were either not in place or not effectively implemented, leading to the resident's unsupervised departure from the facility.
Failure to Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA) was seated while assisting with feeding during meal times for three residents. During meal observations, the CNA was seen standing while feeding Residents 25, 33, and 388, which is against the facility's policy. This policy mandates that staff should be seated at eye level with residents during feeding to maintain their dignity and prevent choking hazards. The CNA admitted to standing due to a lack of available chairs and personal preference, despite knowing the protocol required her to be seated. Resident 25, who has severe cognitive impairments and requires supervision for eating, was observed being fed by the standing CNA. Similarly, Resident 33, who is dependent on staff for eating and has severe decision-making impairments, was also fed by the standing CNA. Resident 388, who is also dependent on staff for eating and has severe cognitive impairments, was observed in the same situation. All three residents have significant medical conditions, including dementia and dysphagia, which necessitate careful and respectful feeding practices. Interviews with other staff members, including another CNA and the Director of Staff Development (DSD), confirmed that the facility's policy requires staff to be seated while feeding residents to maintain their dignity and prevent choking. The DSD emphasized that standing while feeding can make residents feel rushed and emotionally distressed, and it poses a safety risk. The facility's policies and procedures were reviewed and confirmed to support these practices, highlighting the importance of treating residents with respect and dignity during mealtimes.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to potential risks in their care. Resident 12, who was admitted with acute respiratory failure, COPD, and other conditions, did not have a care plan for oxygen therapy despite having an order for oxygen via nasal cannula. Interviews with staff confirmed the absence of a care plan, which is essential for consistent and effective care. The facility's policy mandates that care plans include specific details about oxygen therapy, but this was not followed for Resident 12. Resident 2, who was readmitted with sepsis, pneumonia, and other serious conditions, also lacked a care plan addressing these diagnoses. Despite being treated for these conditions, there was no care plan outlining the necessary interventions and goals. Staff interviews revealed that the absence of a care plan posed a risk to Resident 2's health, as it left staff without clear guidance on how to manage and monitor the resident's conditions. Resident 31, who preferred to take medications at different times than the facility's usual schedule, did not have a care plan or physician's order to accommodate this preference. Medications were found left on the resident's bedside table, which is against the facility's policy. Staff confirmed that there should have been a care plan and physician's order to address the resident's medication preferences, and the lack of these documents could reduce the effectiveness of the medications and pose a risk to other residents.
Failure to Assess and Monitor Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that Resident 81 was properly assessed, monitored, and evaluated for skin breakdown related to moisture-associated skin damage (MASD) and fungal infection. The resident's care plan, which included specific interventions for monitoring and treating the skin condition, was not implemented effectively. The Treatment Nurse (TN) did not conduct weekly skin assessments as required, and Resident 81's name was not listed in the facility's computerized charting system to prompt these assessments. Additionally, the TN did not inform the physician or document a Change of Condition (COC) report when the resident's wound worsened, and the primary physician was not consulted before the Wound Consultant was involved in the resident's care. The physician order to leave the perineal area open to air at bedtime was also not implemented, and the primary physician did not physically assess the resident's skin condition to ensure the treatment was effective. Resident 81 was admitted to the facility with multiple diagnoses, including Type 2 Diabetes Mellitus, urinary tract infection, sepsis, immunodeficiency, adult failure to thrive, and pressure ulcer. The resident was cognitively intact but dependent on assistance for personal hygiene and toileting. Despite the care plan indicating the need for regular skin assessments and monitoring, the facility failed to document and follow through with these interventions. The TN admitted to forgetting to assess the resident's skin condition due to the resident not being listed in the assessment history report. The resident's condition worsened, with severe pain and increased skin breakdown, which was not adequately addressed by the facility staff. Interviews with the resident, TN, and other staff members revealed a lack of communication and documentation regarding the resident's skin condition. The primary physician was not notified of the worsening condition, and the Wound Consultant was consulted without the physician's prior assessment. The resident expressed significant pain and distress due to the untreated skin condition, which impacted her ability to move and participate in activities. The facility's policies and procedures for skin assessment, incontinence-associated dermatitis, and notification of changes were not followed, leading to a delay in appropriate treatment and care for Resident 81.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to ensure that Resident 81 was assessed and provided with appropriate pain management and interventions to relieve severe pain in the perianal and perineal areas due to severe Moisture Associated Skin Damage (MASD) and fungal dermatitis. Despite the resident's complaints of severe pain and visible signs of discomfort during wound care and hygiene activities, the staff did not take adequate measures to address her pain. The resident's care plan did not include specific interventions for pain management in the affected areas, and no pain medication was ordered or administered to the resident during the observed period. Resident 81, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, urinary tract infection, sepsis, immunodeficiency, adult failure to thrive, and pressure ulcer, was cognitively intact and able to communicate her pain. Despite this, the staff failed to recognize and manage her pain effectively. The resident reported experiencing the worst pain she had ever felt, particularly during brief changes and wound treatments, yet the CNAs and nurses did not stop to assess her pain or provide pain relief. The resident's Medication Administration Record (MAR) showed no record of pain medication being administered, and the CNAs did not report the resident's pain to the charge nurse. Interviews with the staff revealed a lack of communication and awareness regarding the resident's pain. CNAs assumed that the charge nurse was already aware of the resident's pain, and the Treatment Nurse did not confirm whether pain medication was given before wound treatment. The Director of Nurses (DON) acknowledged that the resident should not have been left to suffer from pain and that the staff should have taken immediate action to provide pain relief. The facility's policy on pain management emphasized the importance of recognizing and managing pain, but this was not followed in the case of Resident 81.
Failure to Complete Annual Competency Checks for CNAs
Penalty
Summary
The facility failed to complete a performance review for eight of nine Certified Nurse Assistants (CNAs) based on the outcome of the review for each of the CNAs. The CNAs did not have a completed Annual Core Clinical Competencies (ACCC), which is an assessment and training on the CNAs' ability to perform clinical nursing care. This failure had the potential to result in the facility's CNAs not being able to provide quality care to the resident population based on the Facility Assessment. The Director of Staff Development (DSD) confirmed that the previous DSD did not use the CNA Core Clinical Competencies checklist for any of the 2023 competency skills checks, leaving all the facility's CNAs' skills checks either incomplete or not done. During a review of the binder containing all the staff's annual competency checklists, it was found that nine full-time CNAs had no ACCC done since 2022. The DSD confirmed that the previous DSD did not conduct any ACCC with all nine CNAs. The Administrator (ADM) also confirmed the issue and stated that it was unacceptable for the CNAs not to have their annual competency skills check since 2022, as their skills needed to be refreshed yearly to take care of the facility's residents. The facility's policy and procedure indicated that competencies and skill sets for all new and existing staff must be consistent with their expected roles and that training requirements should be met annually and as necessary based on the facility assessment.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to implement its policy and procedure on food storage and professional standards of practice for food service safety. During an initial kitchen observation, a brown powdery substance identified as chicken bouillon was found in a clear plastic container without a label or date of when it was opened or used by. Additionally, the facility's refrigerator contained rice, sliced peaches, tofu, and green peas in clear plastic containers, all without use-by dates or preparation dates. The Dietary Service Supervisor (DSS) acknowledged that these items should have been labeled and dated to ensure they were still fresh and safe for consumption. The Director of Nurses (DON) confirmed that food in the kitchen should be labeled and dated to prevent spoilage and ensure resident safety. The facility's policy and procedure on food storage, revised on a specific date, indicated that all food products should be inspected for safety and quality, dated upon receipt, when opened, and when prepared. The Food Code 2022 also requires ready-to-eat, time/temperature control for safety food to be clearly marked with the date or day by which the food should be consumed, sold, or discarded. The failure to label and date food items had the potential to result in food contamination or growth of microorganisms, posing a risk to residents' health.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to complete the Surveillance Data Collection (SDC) form, a part of its Antibiotic Stewardship Program, before administering antibiotics to Resident 30. Resident 30, who had moderate cognitive impairment and required assistance with daily activities, was prescribed Ciprofloxacin for a urinary tract infection. However, the SDC form lacked documented evidence that the resident met the criteria for antibiotic use, as neither signs and symptoms of infection nor lab results were marked. The Infection Preventionist Nurse (IPN) confirmed that the SDC form was not completed, which is crucial for ensuring the appropriate prescription of antibiotics. Similarly, the facility did not implement its Antibiotic Stewardship Program for Resident 2, who had severe cognitive impairment and multiple diagnoses, including sepsis, COPD, UTI, pneumonia, and dementia. Resident 2 was prescribed Ceftriaxone and Metronidazole for pneumonia and UTI, but there was no documentation in the Antibiotic Stewardship Binder or the resident's medical chart to indicate that the resident was screened prior to antibiotic use. Additionally, an Antibiotic Time Out was not completed for either antibiotic, which is necessary to assess the ongoing need for the medication. The facility's policy on the Antibiotic Stewardship Program, which aims to optimize infection treatment and reduce adverse events related to antibiotic use, was not followed. The policy requires the Infection Preventionist to coordinate all stewardship activities, maintain documentation, and serve as a resource for clinical staff. The lack of adherence to these protocols resulted in the potential for unnecessary or inappropriate antibiotic use for both residents, as well as incomplete monitoring during antibiotic therapy.
Failure to Provide Reasonable Accommodation of Needs
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents. For Resident 30, the facility did not ensure the call light was within reach. Resident 30, who has a traumatic brain injury and moderate cognitive impairment, was observed lying in bed with the call light hanging on an IV pole, out of reach. The CNA admitted to placing the call light on the IV pole after stripping the bed and forgetting to return it to the resident's bedside. Both the LVN and DON confirmed that the call light should always be within reach to allow the resident to request assistance. The care plan for Resident 30 also indicated that the call light should be kept within easy reach, and the facility's policy supported this requirement. However, this was not adhered to, leading to a potential delay in care for Resident 30. For Resident 81, the facility failed to use appropriate communication tools or seek assistance from a translator. Resident 81, who has mild cognitive impairment and speaks little English, was observed getting frustrated when a CNA communicated with her in English. The CNA did not use the communication board available in the room or seek help from a staff member who spoke Resident 81's native language. Resident 81 expressed that she often felt confused and frustrated due to the language barrier. The DON stated that the CNA should have used the communication board or asked for translation assistance. The facility's policy indicated that information should be provided in a manner that the resident can understand, including using communication boards or writing materials, but this was not followed. These deficiencies had the potential to delay or prevent the provision of necessary care and services for both residents. Resident 30's inability to reach the call light could result in unmet needs, while Resident 81's communication issues could lead to confusion and frustration, impacting her overall well-being. The facility's failure to adhere to its policies and care plans contributed to these deficiencies, highlighting a need for better compliance with established procedures to ensure resident safety and satisfaction.
Failure to Notify Physician and Family of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to ensure the physician and responsible party were notified of a significant change in condition for a resident with severe MASD and a fungal skin infection. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, urinary tract infection, and sepsis, experienced worsened skin breakdown and recurrent sepsis due to inadequate care and communication. Despite the resident's capacity to understand and make decisions, and her complaints of increased pain and delayed diaper changes, the facility did not take timely action to address her condition or notify her physician and family members appropriately. The Treatment Nurse (TN) acknowledged that the resident had severe MASD upon admission and that the condition initially improved but worsened again. The TN informed the Primary Medical Physician (PMP) about the change in the resident's wound condition but failed to document this communication in the nursing progress notes. The PMP did not assess the resident's wound and relied on the TN's report and a Wound Consultant's (WC) recommendations without direct evaluation. The PMP admitted to signing the treatment orders without assessing the wound, as he did not receive any images or reports about the wound condition. The Director of Nursing (DON) stated that the facility's policy requires notifying physicians and family members of any significant changes in a resident's condition. The DON emphasized the importance of documentation and regular assessments to ensure proper care. However, the facility's failure to follow these protocols resulted in the resident's condition worsening, as the necessary notifications and assessments were not conducted in a timely manner.
Failure to Prevent Urine Backflow in Foley Catheter
Penalty
Summary
The facility failed to ensure that a resident with a Foley catheter received appropriate care to prevent urine from flowing back into the bladder, which could cause urinary tract infections. Resident 76 was observed with the Foley catheter tubing kinked on the bedrail, causing urine to flow back towards the bladder instead of freely into the drainage bag. This observation was confirmed by a Registered Nurse, the Infection Preventionist nurse, and the Director of Nurses, all of whom acknowledged that the catheter should not be kinked and that backflow of urine could lead to recurrent UTIs. The resident's care plan and the facility's policy and procedure both indicated that the catheter bag and tubing should be positioned below the level of the bladder to prevent backflow, but this was not adhered to in Resident 76's case. Resident 76 had a history of severe cognitive impairment, was dependent on assistance for all activities of daily living, and had been diagnosed with sepsis secondary to a urinary tract infection. The resident's medical records indicated that they had a Foley catheter for neurogenic bladder management and had been prescribed antibiotics for an abnormal urinalysis. Despite these precautions, the facility's failure to ensure proper catheter care as per their own policies and procedures resulted in a significant risk of recurrent urinary tract infections for Resident 76.
Failure to Label and Date Gastrostomy Tube
Penalty
Summary
The facility failed to implement its policy and procedure on the care and treatment of feeding tubes for Resident 72. Specifically, the gastrostomy tube (GT) for Resident 72 was not labeled with the date when the tubing was last changed or when it was due to be changed. This oversight was observed during a concurrent observation and interview with a registered nurse (RN), who acknowledged that the tubing should have been dated to determine the last time it was changed. The RN stated that undated tubing could lead to an infection control issue due to potential bacteria buildup. The Infection Preventionist (IP) nurse and the Director of Nurses (DON) also confirmed that the tubing should have been labeled and dated to prevent infection risks. Resident 72 was admitted with diagnoses including gastrostomy infection, other complications of gastrostomy, sepsis, and atherosclerosis of the aorta. The resident's cognitive status was severely impaired, and they were dependent on assistance for all activities of daily living (ADLs). The facility's policy on the care and treatment of feeding tubes, as well as its infection prevention and control program, emphasized the importance of using infection control precautions and maintaining a safe environment to prevent contamination and infection. However, the facility failed to adhere to these policies, resulting in a potential risk of complications for Resident 72.
Failure to Adhere to Oxygen Equipment Maintenance Protocols
Penalty
Summary
The facility failed to ensure that Resident 12 had their nasal cannula and humidifier bottle dated and changed weekly in accordance with the facility's protocol for oxygen administration. Resident 12, who was admitted with acute respiratory failure, COPD, and other conditions, was observed receiving oxygen via nasal cannula tubing without a current date. The humidifier bottle had a handwritten label dated 3/31/24 to 4/6/24, indicating it had not been changed for three days past the due date. The Director of Nurses confirmed that the nasal cannula and humidifier bottle should be dated and changed weekly to prevent lung infections, as per facility protocol and policy on oxygen administration dated 12/19/22. The facility also failed to ensure that Resident 59 had their plastic storage bag for oxygen equipment changed weekly per the facility's standard of practice. Resident 59, who was admitted with acute respiratory failure, COPD, emphysema, dementia, and quadriplegia, was observed with a plastic storage bag dated 3/30/24 attached to their oxygen concentrator machine. The bag contained a nebulizer mask and had not been changed for more than the required seven days. Registered Nurse 2 confirmed that the facility's standard practice was to change the plastic storage bags weekly and label them with the replacement date to prevent contamination and infection. The Infection Preventionist stated that the facility's infection control protocol required the plastic storage bag to be changed weekly every Sunday and labeled accordingly. Failure to change the bag weekly could lead to bacterial contamination, causing symptoms such as shortness of breath, respiratory infection, and potentially sepsis. The facility's policy on oxygen administration, revised on 2/23/24, indicated that oxygen equipment should be kept in a plastic bag when not in use and cleaned according to facility policy.
Physician's Failure to Supervise Resident Care
Penalty
Summary
The attending physician failed to take an active role in supervising the total program of care for Resident 81, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, urinary tract infection, sepsis, immunodeficiency, adult failure to thrive, and pressure ulcer. The physician did not physically assess, evaluate, or document the resident's skin condition during admission or subsequent visits, despite the resident suffering from severe MASD, fungal infection, and dermatitis. The physician also did not assess the resident's skin condition before ordering a skin treatment, nor did they provide a medication regimen for the resident's pain due to severe MASD. Resident 81 reported having redness of the buttocks upon admission, which worsened over time, causing significant pain. The resident stated that staff took a long time to change her diaper at night, contributing to the worsening of her condition. Despite requesting to see a doctor, Resident 81 had not seen any physician since her admission. Observations revealed multiple open lesions, redness, dry skin peeling, and rashes on the resident's perineal and perianal areas, causing severe pain rated between eight to ten on a pain scale. The Primary Medical Physician admitted to not assessing Resident 81's wound, relying instead on pictures sent by the facility's nurses, which he did not receive. The physician signed a skin treatment order without assessing the wound and did not order any pain medication for the resident. The Director of Nursing confirmed that physicians are supposed to assess all residents during their visits and that Resident 81 should not have suffered from pain without timely pain interventions. The facility's policy requires physicians to take an active role in supervising resident care, which was not followed in this case.
Failure to Monitor Residents on Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that two residents, who were at risk for bleeding and bruising, were free of unnecessary medication while receiving blood thinners. Resident 2 was readmitted with multiple diagnoses including hemiplegia, hemiparesis, and dementia, and was prescribed Plavix. However, there was no physician order to monitor Resident 2 for bleeding and bruising, and no documentation indicated that such monitoring was performed. The Director of Nursing (DON) confirmed the absence of monitoring orders and documentation, acknowledging the risks associated with not monitoring for side effects of anticoagulants. Resident 50, who had diagnoses including end-stage renal disease and acute respiratory failure, was prescribed Aspirin and Eliquis. The resident's care plan indicated the need for monitoring for adverse side effects of anticoagulant therapy every shift. However, there were no physician orders for routine laboratory tests to monitor for complications. The DON confirmed the lack of routine lab orders, which was against the facility's policy for anticoagulant therapy, and acknowledged the importance of such tests to detect bleeding. The facility's policy on high-risk medications, including anticoagulants, required routine lab orders and monitoring for adverse consequences such as bleeding and hemorrhage. The failure to adhere to this policy for both residents had the potential to result in undetected side effects or adverse effects related to anticoagulant therapy, which could lead to a decline in the residents' health and wellbeing.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate was less than five percent. During a medication administration observation, four out of 30 medications administered resulted in an overall medication error rate of 13.33%, affecting three residents. The errors included administering medications without checking expiration dates and not following physician orders to administer certain medications with food. For Resident 37, the medication nurse attempted to administer Calcitriol and Folic Acid without checking the expiration dates on the bottles. The nurse admitted to forgetting to check the expiration dates, which is crucial to avoid the risk of using expired medications. Resident 37 had diagnoses including hypokalemia and hyperlipidemia and required substantial assistance with daily activities. For Residents 28 and 69, the medication nurse administered Metoprolol without offering food as ordered by the physician. Resident 28 had severe cognitive impairment and was totally dependent on staff for daily activities, while Resident 69 had moderate cognitive impairment and required partial assistance. The nurse confirmed the oversight and acknowledged the importance of administering Metoprolol with food to prevent potential side effects. The Director of Nursing also emphasized the importance of checking expiration dates and following physician orders to ensure resident safety.
Failure to Document Flu Vaccine Offer and Declination
Penalty
Summary
The facility failed to provide documented evidence that two residents, identified as Resident 53 and Resident 390, were offered or declined the influenza vaccine for the 2023-2024 flu season. Despite the facility's policy requiring annual flu vaccine offers and documentation of acceptance or declination, there was no record in the medical charts of these residents indicating that the vaccine was offered, administered, or declined. This deficiency was identified through a review of the residents' medical records and interviews with the Infection Preventionist (IP), who confirmed the absence of necessary documentation. Resident 53, admitted with diagnoses including hyperthyroidism, anemia, and mobility issues, and Resident 390, admitted with acute respiratory failure, congestive heart failure, type 2 diabetes, and immunodeficiency, both had the capacity to understand and make decisions. However, their medical charts lacked any documentation regarding the flu vaccine for the specified season. The IP acknowledged that the facility's policy was not followed, which required offering the vaccine and documenting the resident's decision, thus failing to ensure the residents were protected against the flu as per the facility's infection prevention and control program.
Failure to Maintain Sanitary Environment and Proper Storage in Medication Room
Penalty
Summary
The facility failed to ensure that employee personal items were not stored in one of the medication rooms. During an inspection, a black jacket was found hanging on the back of the door in the medication room at Nursing Station 2. The Registered Nurse (RN) acknowledged that the jacket should not be there and mentioned that employees have a designated lounge for their personal belongings. The Director of Nursing (DON) confirmed that personal belongings should not be stored in the medication room due to the risk of infection. The facility's policy on medication storage and infection prevention was reviewed, indicating that medications should be stored properly to ensure sanitation and security, and that the facility should maintain a safe and sanitary environment to prevent infections. The facility also failed to maintain a sanitary environment for one of the residents, Resident 6. Resident 6, who has chronic obstructive pulmonary disease (COPD), asthma, dementia, and lack of coordination, was found with a bedside commode full of feces and urine. The commode had not been cleaned for two and a half hours, resulting in a strong smell of urine and feces in the room. The RN and Certified Nurse Assistant (CNA) acknowledged that the commode should have been cleaned immediately after use to prevent the spread of infection and maintain a sanitary environment. Resident 6's family member also reported finding the commode full of feces and urine on multiple occasions during visits. The facility's policy on providing a safe and homelike environment was reviewed, which indicated that the facility should ensure a clean, comfortable, and sanitary environment for residents. The Infection Control Nurse (IPN) and DON both stated that an unclean bedside commode could lead to the spread of bacteria and infection, negatively affecting the resident's health. The failure to clean the commode in a timely manner was not in accordance with the facility's policies and procedures, leading to an unsanitary environment for Resident 6.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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