Highland Palms Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Highland, California.
- Location
- 7534 Palm Ave, Highland, California 92346
- CMS Provider Number
- 056024
- Inspections on file
- 32
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Highland Palms Healthcare Center during CMS and state inspections, most recent first.
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.
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.
An LVN left a resident’s EHR open on a computer atop a med cart and unattended in the hallway while administering meds in the resident’s room. The resident’s health information remained visible and accessible, and the Administrator agreed the confidentiality policy was not followed.
A resident with diagnoses of schizophrenia and bipolar disorder had a PASARR Level I screen documented incorrectly by an RN, who marked the serious mental illness question as negative and indicated that a Level II screen was not needed. The RN acknowledged the error, and the DON verified that the PASARR was documented incorrectly and that the facility’s PASARR policy was not followed.
Unattended medication cart left unlocked in accessible common area. Medication cart 1 was observed unattended and unlocked in front of Nurses' Station I near the main entrance, where residents, staff, and visitors could access it. The cart contained eight drawers and a binder labeled Station I Narcotic & Antibiotic Record. An LVN was administering medications elsewhere, and a consultant confirmed the cart had been left unsecured. The LVN acknowledged the cart may have been left open after medication administration, and the DON reviewed policy stating medication carts must be locked when not in use.
A resident with acute respiratory failure, DM, and HTN left AMA after an out-on-pass during which she told a family member she had been sexually abused by staff. The family member reported the allegation to law enforcement and then took the resident home. The DON acknowledged that police came to the facility regarding the allegation but stated the facility did not initiate an investigation or report the allegation to CDPH because the resident had already been discharged, despite facility policy requiring identification, investigation, and timely reporting of all abuse allegations.
The facility failed to investigate or report an allegation of sexual abuse made by a resident with acute respiratory failure, DM, and HTN, who later left AMA. The resident’s family member reported that during an out-on-pass, the resident alleged sexual abuse by a staff member and that he notified law enforcement before taking the resident home. The DON confirmed that police came to the facility regarding the allegation but stated no internal investigation was initiated and no report was made to the state agency because the resident had already been discharged, despite facility policy requiring identification, investigation, and timely reporting of all abuse allegations.
A resident with a history of stroke, diabetes, and benign prostatic hyperplasia experienced moisture-associated skin damage (MASD) but the facility failed to document this change in condition. Despite new physician orders for treatment, the Director of Nursing confirmed the absence of documentation in the resident's records, violating the facility's policy on recording changes in a resident's condition.
A resident with multiple diagnoses, including schizophrenia and anxiety disorder, was found to smoke regularly without a comprehensive care plan in place. The resident kept smoking supplies and a lighter, but the facility failed to document a smoking care plan, as confirmed by the DON. This oversight was contrary to the facility's policy requiring evaluation and documentation of smoking-related concerns.
A resident's enteral feeding was administered at 65 mL/hr instead of the prescribed 60 mL/hr, as observed by surveyors. The discrepancy was confirmed by the DON, who acknowledged that the facility's policy for implementing physician orders was not followed. This failure could result in the resident receiving more calories than ordered.
A resident with a tracheostomy was not monitored for redness, discharge, and discoloration every shift as ordered by the physician. Instead, the monitoring was documented only once per day for two months. The DON confirmed the oversight, which contradicted the facility's policy on ostomy site care, potentially delaying the identification and treatment of complications.
The facility failed to follow its medication disposal policy when six tablets were found on top of the medication waste receptacle instead of inside it. An LVN and an RN confirmed the improper disposal, and the DON acknowledged that the facility's procedures were not followed, as per the 2019 policy on discarding and destroying medications.
An expired IV antibiotic was found in a medication supply room, still available for use. A nurse and the DON confirmed the oversight, acknowledging that expired medications should have been removed according to facility policy.
A CNA failed to don a gown when entering the room of a resident on contact precautions for MRSA, despite clear signage and facility policy requiring it. This breach in infection control was confirmed by the facility's IP and DON, highlighting a potential risk of spreading infectious disease.
A resident with multiple health conditions, including diabetes and HIV, was found to have medications stored unlocked at his bedside, contrary to the facility's policy. The medications, Genvoya and Ozempic, were confirmed by both the LVN and DON to be kept at the bedside, although administered by a nurse. The facility's policy requires medications to be stored in locked compartments, which was not adhered to, potentially risking the resident's health.
A facility failed to follow a physician's order to cover a resident's surgical site with a dry dressing, as the wound treatment nurse did not apply the dressing due to the resident's reported tape allergy. The resident had a history of orthopedic aftercare, alcoholic cirrhosis, a left artificial hip joint, and osteoarthritis. The DON confirmed that nurses are expected to follow orders, and the facility's wound care policy emphasized adherence to physician's orders.
A facility failed to create a care plan for a resident who tested positive for methamphetamine, despite being informed by the hospital. The resident had a history of stroke and drug abuse, and was admitted with multiple health issues. Interviews with staff revealed a lack of communication and care planning, contrary to the facility's policies on behavioral health services.
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.
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.
EHR Left Open and Visible on Medication Cart
Penalty
Summary
The facility failed to keep Resident 132’s electronic health record secure when an LVN left the resident’s health information open on a computer screen on top of a medication cart and unattended in the hallway. During observation on April 29, 2026, the LVN logged into the computer, reviewed Resident 132’s EHR, prepared the medication, and then went into the resident’s room to administer the medications without logging off the computer. Resident 132’s information remained visible and accessible on the medication cart. When asked, the LVN stated she was not supposed to keep the computer unattended. During review of the facility’s Confidentiality Information and Personal Property policy with the Administrator on April 30, 2026, the Administrator agreed the policy was not followed.
Incorrect PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to follow its policy and procedure for PASARR when RN 1 completed the Level I screening for one resident and documented the screening incorrectly. The resident’s PASARR dated December 20, 2025, indicated a negative Level I screen for serious mental illness and intellectual/developmental disability or related conditions, and stated that a Level II screening was not required. A review of the resident’s admission record showed diagnoses of schizophrenia and bipolar disorder. During interview, RN 1 stated he was responsible for completing PASARR screenings for admitting residents and acknowledged that he incorrectly marked “no” for the question regarding serious mental illness. The DON also reviewed the policy titled admission Criteria PASARR and verified that the PASARR was documented incorrectly and that the policy was not followed because RN 1 did not complete the Level I screening correctly.
Unattended medication cart left unlocked in accessible common area
Penalty
Summary
Medication cart 1 was observed unattended and unlocked in a common area directly in front of Nurses' Station I near the main entrance, where it was accessible to residents, staff, and visitors. The cart contained eight drawers, and a binder labeled Station I Narcotic & Antibiotic Record was on top of it. At the time of the observation, LVN 1 was down the hallway administering medications, leaving the cart unsecured. During a concurrent observation and interview, Consultant 1 noted that the lock on Medication cart 1 was dislodged from its secured position, leaving the cart unsecured and accessible, and manually pushed the lock back into place. Consultant 1 confirmed the cart had been left unlocked and stated it should not be left unlocked because it can be accessible to anyone, including residents and visitors. LVN 1 acknowledged that leaving the cart unattended and unlocked was not safe and stated the cart may have been left open after medication administration. The DON reviewed the facility policy stating that compartments containing drugs and biologicals must be locked when not in use and that carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.
Failure to Report and Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse and to initiate an investigation as required by its abuse, neglect, exploitation, and misappropriation prevention program. Resident 1 was admitted with diagnoses including acute respiratory failure, diabetes mellitus, and hypertension, and later left the facility against medical advice on February 17, 2026. During an out-on-pass with a family member on February 15, 2026, Resident 1 allegedly reported that she had been sexually abused by a staff member in the facility. The family member stated that he reported the allegation to the sheriff and police department and then took Resident 1 home after discharging her AMA on February 17, 2026. The DON confirmed that law enforcement came to the facility in response to the resident’s allegation of abuse. However, the DON stated that the facility did not initiate its own investigation or report the allegation to CDPH because Resident 1 had already been discharged when the facility became aware of the alleged abuse. A subsequent review of the facility’s policy and procedure on Abuse, Neglect, Exploitation and Misappropriation Prevention Program showed that the facility was required to identify and investigate all possible incidents of abuse and to investigate and report any allegations within timeframes required by federal requirements. Despite this policy, the facility did not investigate or report the allegation involving Resident 1.
Failure to Investigate Allegation of Sexual Abuse After Resident Discharge
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving one of four sampled residents. The resident was admitted with diagnoses including acute respiratory failure, diabetes mellitus, and hypertension. According to the resident’s AMA (against medical advice) Release Form, the resident left the facility against medical advice on February 17, 2026. During a telephone interview on February 23, 2026, the resident’s family member reported that during an out-on-pass on February 15, 2026, the resident alleged she had been sexually abused by a staff member at the facility. The family member stated he reported the allegation to the sheriff’s and police departments and then took the resident home after discharging her AMA on February 17, 2026. In a subsequent interview, the DON stated that law enforcement came to the facility in response to the resident’s allegation of abuse. The DON acknowledged that the facility did not initiate an internal investigation or report the allegation to the California Department of Public Health because the resident had already been discharged when the facility became aware of the allegation. During a later record review, the DON reviewed and acknowledged the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, which requires the facility to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property, and to investigate and report any allegations within timeframes required by federal requirements.
Failure to Document Change in Condition for Resident with MASD
Penalty
Summary
The facility failed to document a significant change in condition for one of its residents, identified as Resident 42, who experienced moisture-associated skin damage (MASD). On October 30, 2024, new physician orders were issued for Resident 42 to treat MASD on the right buttocks, which included cleansing with normal saline, applying calcium alginate, and covering with a dry dressing daily for 14 days. However, the Director of Nursing (DON) confirmed that there was no documented evidence of this change in condition in Resident 42's clinical records, indicating a lapse in following the facility's policy and procedure for documenting changes in a resident's condition. Resident 42, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, type 2 diabetes mellitus, and benign prostatic hyperplasia, reported discomfort and redness in the genital area to a nurse on October 28, 2024. Despite this report, the nurse did not document the change in condition, as confirmed by the DON during a review of the facility's policy titled 'Change in a Resident's Condition or Status.' This policy mandates that any change in skin integrity should be recorded in the resident's medical record, which was not adhered to in this case.
Failure to Develop Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was identified as a smoker. The resident, who had been admitted with diagnoses including muscle wasting, schizophrenia, anxiety disorder, and major depressive disorder, reported smoking regularly and keeping smoking supplies, including cigarettes and a lighter, in his possession. Despite these circumstances, there was no evidence of a smoking care plan in the resident's medical record. During an interview, the Director of Nursing confirmed the absence of a smoking care plan for the resident, acknowledging that such a plan should have been created. The facility's smoking policy requires an evaluation of a resident's smoking status upon admission and mandates that any smoking-related privileges, restrictions, and concerns be documented in the care plan. The lack of a care plan for the resident's smoking habits was a deviation from the facility's established policies and procedures, which aim to ensure safe smoking practices and address the resident's needs comprehensively.
Failure to Follow Physician Orders for Enteral Feeding
Penalty
Summary
The facility failed to adhere to physician orders for a resident's enteral feeding, resulting in a discrepancy in the feeding rate. Specifically, Resident 44 was observed to have their enteral feeding running at 65 mL/hr instead of the prescribed 60 mL/hr. This deviation from the physician's order was noted during an observation on October 31, 2024, and was confirmed by the Director of Nursing (DON) during a concurrent observation and interview. The physician's order, dated July 13, 2024, clearly specified that the enteral feeding should be administered at 60 mL/hr for 20 hours, totaling 1200 mL and 1440 calories. The facility's policy and procedure for accepting, transcribing, and implementing physician orders were not followed, as acknowledged by the DON. The policy mandates that licensed nursing personnel ensure all physician orders are accurately recorded and implemented. Despite this, the enteral feeding for Resident 44 was not administered according to the specified rate, potentially leading to the resident receiving more calories than ordered. The failure to follow the physician's order was identified through observations and interviews conducted over several days, highlighting a lapse in the facility's adherence to its own procedures.
Failure to Monitor Tracheostomy as Ordered
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with a tracheostomy, as specified by the physician's orders. The resident, who had a tracheostomy due to conditions such as muscle wasting, asthma, dysphagia, and immunodeficiency, was supposed to have their tracheostomy site monitored for redness, discharge, and discoloration every shift. However, the Treatment Administration Records for September and October showed that the monitoring was only documented once per day instead of the required three times per day. During an interview and record review, the Director of Nursing confirmed that the physician's orders were not followed, emphasizing the importance of monitoring to promptly identify and address potential infections. The facility's policy on ostomy site care also highlighted the need for regular assessment to prevent irritation, breakdown, and infection. This oversight in monitoring had the potential to delay the identification and treatment of complications, affecting the resident's health and safety.
Improper Disposal of Medications
Penalty
Summary
The facility failed to adhere to its policies and procedures for the destruction and disposal of medications, as evidenced by the discovery of six medication tablets on top of the medication waste receptacle. During an observation and interview, a Licensed Vocational Nurse (LVN) acknowledged that the tablets, which were not narcotics, were improperly placed on the lid of the receptacle instead of being disposed of inside it. This was confirmed by a Registered Nurse (RN) who also observed the tablets and stated that they should have been properly disposed of within the receptacle. Further investigation with the Director of Nurses (DON) revealed that the facility's policy and procedure, titled "Discarding and Destroying Medications" and revised in 2019, was not followed. The policy mandates that both controlled and non-controlled substances be disposed of in the authorized onsite receptacle and documented on the medication disposition record. The DON confirmed that the facility's procedures were not adhered to, as the tablets were left accessible on top of the waste receptacle, contrary to the established guidelines.
Expired Medication Found in Supply Room
Penalty
Summary
The facility failed to ensure that expired medications were removed from one of its medication supply rooms. During an observation and interview, a registered nurse identified an expired intravenous antibiotic, Daptomycin, in the medication refrigerator. The medication had expired the previous day, yet it was still readily available for use. The registered nurse acknowledged that expired medications should have been removed and discarded. Further investigation with the Director of Nurses confirmed the oversight. The facility's policy and procedure, which mandates the removal and destruction of expired medications, was not followed. The Director of Nurses admitted that the nursing staff was responsible for maintaining medication storage and ensuring expired drugs were not used, highlighting a lapse in adherence to the facility's established protocols.
Infection Control Breach Due to Improper PPE Use
Penalty
Summary
The facility failed to maintain proper infection control practices when a Certified Nursing Assistant (CNA 1) did not don a gown upon entering the room of a resident on contact precautions. The resident, identified as Resident 391, was admitted with diagnoses including sepsis, a local infection of the skin and subcutaneous tissue, and a methicillin-resistant Staphylococcus aureus (MRSA) infection. The resident's care plan required contact isolation precautions due to the MRSA infection, which included the use of personal protective equipment such as gowns. Despite a sign at the entryway of the resident's room indicating the need for gowning, CNA 1 entered the room without a gown, touched the resident's phone, and handed it to the resident. The incident was observed on October 29, 2024, and was later discussed with the facility's Infection Preventionist (IP) and Director of Nursing (DON). Both confirmed that staff were expected to don gloves and gowns when entering the room of a resident on contact precautions. The facility's policy on transmission-based precautions, dated September 2022, also required staff and visitors to wear a disposable gown upon entering such rooms. The failure to adhere to these precautions had the potential to spread infectious disease to other residents and staff in the facility.
Improper Medication Storage at Resident's Bedside
Penalty
Summary
The facility failed to ensure medications were stored properly according to its policies and procedures and standards of practice. During an observation, a resident was found to have medications stored at his bedside unlocked, including an opened bottle of Genvoya and an injection pen of Ozempic. The resident, who has a medical history of type 2 diabetes mellitus, cirrhosis of the liver, chronic kidney disease, and is HIV positive, stated that he kept the medications with him at his bedside. Both the LVN and the DON confirmed that the resident kept these medications at his bedside, although a nurse administered them. The facility's policy and procedure for medication storage, dated November 2020, requires that all drugs and biologicals be stored in locked compartments under proper conditions. The DON acknowledged that the facility did not follow its policy, as the medications should have been stored in a locked compartment. This oversight had the potential to place the resident's health at risk for drug abuse and ingestion of unsanitary drugs.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the deficiency involved a failure to cover the surgical site on the resident's left hip with a dry dressing as per the physician's order. The resident had been admitted with diagnoses including orthopedic aftercare, alcoholic cirrhosis of the liver, a left artificial hip joint, and osteoarthritis. The physician's order clearly stated that the surgical site should be cleansed with normal saline, patted dry, and covered with a dry dressing daily. However, during a dressing change, the wound treatment nurse did not cover the surgical site because the resident reported an allergy to the tape. The Director of Nursing (DON) confirmed that licensed nurses are expected to verify and follow physician's orders for resident care, and expressed that the nurse should have adhered to the order to cover the surgical site with a dry dressing. The facility's policy and procedure for wound care, revised in October 2010, also emphasized the importance of following physician's orders and assessing any special needs of the resident. This oversight had the potential to delay and promote wound healing for the resident.
Failure to Implement Care Plan for Resident with Illicit Drug Use
Penalty
Summary
The facility failed to provide a comprehensive person-centered care plan for a resident who had tested positive for an illicit drug, specifically methamphetamine. The resident, who had a history of stroke and methamphetamine abuse, was admitted to the facility with diagnoses including shortness of breath, opioid use, respiratory failure, and major depressive disorder. Despite being informed by the hospital about the resident's positive drug test, the facility did not develop a care plan to monitor or provide treatment for the resident's condition. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed that there was no formal communication or care plan in place regarding the resident's illicit drug use. The facility's policies on Behavioral Health Services and Behavioral Assessment, Intervention, and Monitoring were reviewed, indicating that a care plan should have been implemented to address the resident's needs. However, the interdisciplinary team did not evaluate the resident's behavioral symptoms or develop a plan of care, leading to a deficiency in meeting the resident's health and safety needs.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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