Lynwood Post Acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lynwood, California.
- Location
- 3611 East Imperial Highway, Lynwood, California 90262
- CMS Provider Number
- 056415
- Inspections on file
- 58
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Lynwood Post Acute Care Center during CMS and state inspections, most recent first.
Insufficient Privacy Curtains in Multiple Resident Rooms: Surveyors observed that 17 of 33 rooms lacked enough privacy curtains to provide full visual privacy for all occupants, with several multi-occupancy rooms having only one or two curtains on the track at the foot of the beds. CNA and HS interviews confirmed that privacy curtains are essential for resident dignity during care, and the HS stated the facility was aware the rooms did not have enough curtains to ensure each resident full visual privacy.
A resident with anemia, dementia, syncope, and muscle wasting had a physician-ordered CBC that was scheduled but not collected after repeated refusals. The DON stated the record did not show the physician was notified of the refusals, even though facility policy required prompt notification of treatment refusal on two or more consecutive times.
Use of Bed Items as a Physical Restraint: A resident with legal blindness, muscle weakness, and severely impaired cognition was observed in bed with linen, towels, and pillows positioned to create a barrier that limited movement and getting out of bed without staff assistance. The resident stated the items restricted turning, repositioning, and exiting the bed, and the CNA and DON both acknowledged the setup was used to keep the resident positioned and prevent falls, functioning as a physical restraint.
PRN Ativan Continued Beyond 14-Day Limit: A resident with psychosis, dementia, and depression had a PRN Ativan order for anxiety that was written for 30 days. The DON confirmed the PRN psychotropic order exceeded the 14-day limit, and there was no documented physician reevaluation or clinical justification for continuing the medication beyond 14 days, despite the facility policy limiting PRN psychotropics to 14 days unless the attending physician documents the rationale and new duration.
MDS Did Not Match PASRR Status: A resident with depression had an MDS that marked PASRR as “No” for serious mental illness, even though the PASRR Level I screening and Level II determination identified a serious mental illness and need for a Level II mental health evaluation. The MDS Nurse confirmed the MDS was completed incorrectly and did not accurately reflect the resident’s PASRR status or mental health needs.
The facility failed to develop and implement individualized care plans for two residents with identified needs. One resident was receiving Apixaban and had multiple diagnoses, moderate cognitive impairment, and dependence on staff for ADLs, but no care plan addressed bleeding monitoring, fall precautions, or related oversight. Another resident had muscle weakness, dysphagia, GERD, protein calorie malnutrition, type 2 DM, moderate cognitive impairment, dependence on staff for ADLs, blanchable redness to the coccyx, and Braden scores showing moderate to high pressure injury risk, but no care plan addressed skin protection measures such as repositioning, pressure relief, and skin monitoring.
Untrimmed and Dirty Fingernails: A resident with severe cognitive impairment, legal blindness, muscle weakness, and dependence for ADLs was observed with long, untrimmed fingernails and black debris under the nail beds. CNA staff confirmed the nails were dirty and needed cleaning and trimming, and the DON and IPN stated nail care was part of routine ADL care and should be assessed daily.
A resident at high fall risk was observed with only one floor mat in place at the bedside during multiple observations, despite a physician order for bilateral floor mats and a care plan for fall precautions. In a separate incident, two used IV starter needles with visible blood were found on top of another resident’s blanket after an IV start, and the resident, RN, and DON all stated the contaminated sharps should have been immediately disposed of in a sharps container.
Missed Nutritional Supplements: A resident with dysphagia, protein-calorie malnutrition, cachexia, and adult failure to thrive did not receive ordered nutritional supplements. Observations and interviews showed a Magic Cup was missing from the lunch tray and a scheduled high-protein nourishment was not provided, despite care plan directions and physician orders for supplements to be served as ordered.
An LVN failed to properly identify medications, inform a resident of what was being given, or accurately document and communicate the resident’s refusal of several meds; the DON stated the charting did not reflect the care provided. In a separate event, staff were observed using a saline flush attached to a resident’s G-tube instead of the facility’s required warm purified water/water flushing practice, and the RN and DON stated this was not in accordance with protocol.
Opioid Given Outside Ordered Pain Parameters: A resident with hemiplegia, gout, DM, and ESRD was ordered Hydrocodone-Acetaminophen 5-325 mg PRN for severe pain rated 7-10, but the MAR showed it was administered multiple times when pain was documented at 5 or 6 out of 10. The LVN and DON both acknowledged the medication was given outside the physician’s ordered parameters and not in accordance with the order.
A resident with depression, DM2, HTN, hyperlipidemia, BPH, and moderate cognitive impairment was observed during medication pass receiving three tablets without being told what they were. The LPN then attempted to give more meds after the resident declined, told him he had to take them, and did not explain the names, risks, or benefits of the remaining medications. The LPN later stated she did not know which meds had been given or refused, while the EMAR documented refusals and claimed risks and benefits were explained.
Improperly Stored Unlabeled and Undated Food Items: In the kitchen, open bags of hamburger buns and wheat bread, along with ground Italian seasoning, plain salt, soy sauce, and powdered thickener, were observed unlabeled and undated. An aide stated the items were improperly stored, and the RD noted that unlabeled and undated or poorly stored food may lead to salmonella. The facility policy stated dry food storage items are to be labeled and dated.
Kitchen Trash Containers Left Open: Two large trash containers in the kitchen were observed uncovered and filled to capacity with open fruit cans, empty bottles, soiled paper towels, and wet meat bags. A DA stated trash containers must remain closed when not in use, and the RD and IPN stated open bins can attract pests and germs and increase cross contamination risk. The facility policy required waste to be placed in closable leak-proof containers and not allowed to overfill.
Two residents’ records did not contain readily available PASRR Level I and Level II documentation. One resident had depression, anxiety, and severely impaired cognitive skills with dependence for ADLs, while the other had depression, intact cognition, and required moderate ADL assistance. The MDS Nurse stated PASRR documents should be maintained in the chart and available upon request, but both records were incomplete.
Staff failed to wear required gowns during high-contact care for three residents on EBP. A CNA provided a bed bath to a resident with immunodeficiency and a gastrostomy while wearing gloves but no gown, two CNAs performed a linen change and assisted another resident with dressing without gowns, and an LVN checked a resident’s gastrostomy tube and gave meds while wearing gloves but no gown.
A resident with left-sided hemiplegia, cortical blindness, and severely impaired cognition was repeatedly observed in bed with the call light attached to the left side and out of reach. The resident stated he could not activate the call light with his left hand and needed staff help for pain medication, while an LVN stated the call light should have been placed on the resident’s right, stronger side so he could request assistance.
A facility failed to maintain a safe environment when a hallway floor drain cover near the kitchen door was cracked, uneven, and chipped with an irregular edge. The MS stated the condition posed a tripping risk, and the DON stated uneven flooring could cause residents to trip and fall. The facility also failed to post oxygen signage for a resident with COPD, acute and chronic respiratory failure with hypercapnia, severe cognitive impairment, dependence for all ADLs, and continuous O2 therapy; no oxygen sign was posted outside the room or at the bedside, and the DON stated the signage was needed due to fire risk.
Room Size Below Required Standard: The facility failed to meet the required 80 sq. ft. per resident in two multi-resident rooms. Census and accommodation records showed Rooms 3 and 4 each had capacity for four residents, and the Client Accommodation Analysis measured each room at 272 sq. ft. During a tour, the ADM confirmed the rooms were below the required space per resident and stated the reduced room size could decrease space for residents, staff, and equipment.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Staff failed to timely report a resident-to-resident altercation to the facility Administrator/Abuse Coordinator and CDPH as required by policy. One resident with anxiety disorder and dementia, but assessed as cognitively intact and independent in self-care, initiated an unprovoked physical and verbal aggression episode toward another cognitively intact, functionally independent resident with COPD and CHF. The RN on duty documented the incident in a Change of Condition assessment and separated the residents but did not notify the ADM or state agency, and the ADM later confirmed she was unaware of the event until the survey. Facility abuse policies required immediate reporting of suspected abuse to the ADM and to the state agency within specified timeframes, which did not occur, delaying the investigation.
Two residents with no documented cognitive impairments and independent ADL function were involved in a documented resident-to-resident altercation in which one resident displayed verbal and physical aggression and attempted to strike another without provocation, leading staff to separate them to minimize escalation. Despite this, the ADM later reported being unaware of the incident, and no investigation was initiated, contrary to facility abuse and investigation policies requiring the ADM to investigate all abuse allegations within required timeframes.
A resident with COPD and CHF, cognitively intact and independent with ADLs, was involved in a resident-to-resident altercation in which another resident attempted to strike him. The RN involved did not notify the resident’s physician or document the incident in the EMR, and the Administrator was unaware the altercation had occurred. As a result, there was no documentation of physician notification or development of a care plan with interventions to address possible psychosocial needs, contrary to the facility’s resident-to-resident altercation policy requiring physician notification, care plan updates, and documentation of all interventions.
A resident with iron deficiency anemia, hypothyroidism, hyperparathyroidism, a history of PCM, multiple food allergies, and limited food preferences was not provided palatable, properly prepared meals. The care plan documented that the resident had multiple food complaints and would only eat requested items, including double portions of fish or chicken and eggs at breakfast. Surveyors observed overcooked, mushy broccoli and strawberries that appeared old, and the resident reported routinely receiving burnt eggs, burnt chicken and broccoli, and old, moldy strawberries, even when trays were returned and replaced. A cook stated he boiled eggs for 15 minutes and then held them in a warmer for over an hour without following the facility’s recipe, and acknowledged the eggs appeared oxidized and firmer than expected. The dietary supervisor agreed that the broccoli and eggs served were overcooked, contrary to facility policies requiring palatable, attractive food and adherence to the hard-boiled egg preparation procedure.
A resident with DM, HTN, and chronic kidney disease was admitted with documented personal clothing and footwear, but the belongings inventory was not completed or updated at discharge, and progress notes did not describe what items were returned. The resident’s family later reported missing shirts and pants and stated they had notified Social Services, yet the Social Services Director was unaware of the issue and could not confirm whether belongings were provided at discharge. The DON confirmed that policy requires completion of an inventory list on admission, readmission, and discharge, and acknowledged it was not done, while the RN who discharged the resident could not recall which belongings were given or whether the discharge inventory was completed, preventing proper accounting of the resident’s property.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to have an RN on duty for at least eight consecutive hours on several occasions due to the regular weekend RN being on sick leave. Attempts to cover the shifts with MDSNs resulted in insufficient coverage, as they worked only partial shifts. The DON acknowledged that this deficiency could lead to delays in assessments and compromised care during emergencies.
The facility failed to monitor and document the use of psychotropic medications for two residents, leading to potential mismanagement of their conditions. One resident was administered PRN lorazepam without documented behaviors warranting its use, and nonpharmacological interventions were not attempted. Another resident's behavior of poor regard to health was not monitored, despite being treated with olanzapine. The facility did not follow the consultant pharmacist's recommendations for monitoring, resulting in deficiencies in care.
A facility failed to label and store nebulizer solutions properly, affecting five residents. The Ipratropium and Albuterol combination was found outside its protective foil pouch without open dates, contrary to manufacturer's instructions. This oversight was noted in two medication carts, with staff unaware of the importance of proper storage, potentially compromising medication effectiveness.
The facility was found deficient in food storage practices when surveyors observed unlabeled containers of apple sauce, jelly, and chocolate creme pie in the kitchen. The Dietary Supervisor confirmed the lack of labeling, which is required to ensure food freshness and safety. The facility's policy mandates proper labeling and monitoring of food items, which was not followed.
A resident with diabetes and dysphagia was not assisted with grooming or fed before a medical appointment, despite being dependent on staff for feeding. Staff interviews revealed a lack of communication about the appointment, leading to the resident leaving the facility hungry. The facility's policy on dignity was not upheld.
A facility failed to obtain informed consent for a resident's psychotropic medication and for the use of physical restraints by placing beds against the wall for three residents. Despite policies requiring informed consent, the residents or their responsible parties were not informed about the risks and benefits, leading to violations of residents' rights to make informed decisions.
A resident's call light was repeatedly found on the floor, out of reach, despite their need for assistance due to limited mobility and chronic pain. Staff interviews confirmed the importance of the call light for safety and communication, aligning with the facility's policy that was not followed.
A facility failed to obtain a copy of a resident's Advance Directive, despite the resident having the capacity to make decisions and having formulated the directive previously. The Social Services Director confirmed that no follow-up was conducted to secure the document, which is required by the facility's policy to ensure the resident's medical care wishes are upheld.
A facility failed to accurately code a resident's MDS, leading to incorrect data being sent to CMS. The resident, with a history of dementia, COPD, DM, and HTN, was observed to have dentures, which were not documented in the MDS. The MDS Nurse admitted the error, acknowledging the importance of accurate assessments for quality measures.
The facility failed to develop person-centered care plans for three residents, impacting their care. A resident using side rails for mobility lacked a care plan to ensure safety and appropriateness. Another resident with dentures had no care plan for their use, affecting oral health management. A third resident in a Restorative Nurse Assistant program had no care plan to guide their mobility exercises. These deficiencies highlight a lack of communication and coordination among staff.
A resident with end-stage renal disease and other conditions was found with long, dirty fingernails, indicating a failure by the facility to maintain personal hygiene. Staff interviews confirmed that CNAs were responsible for daily nail care, as supported by facility policies, but this was not followed, leading to the deficiency.
A resident with a fracture and osteoarthritis used quarter side rails for mobility assistance without a physician's order, as required by facility policy. Despite the resident's intact cognition and request for side rails, the facility did not secure the necessary order, risking potential injury. Interviews confirmed the need for a physician's order to ensure safety and compliance with the facility's policy.
A resident did not receive the prescribed Lidocaine patch 4% due to a nurse's failure to administer and reorder the medication. Instead, the nurse falsely documented the administration and used another resident's Lidocaine patch 5%. The nurse did not inform the RN supervisor or the resident's doctor, leading to unmanaged pain and potential medication errors.
A facility failed to implement a pharmacist's recommendation to monitor a resident for bleeding risk due to the use of blood thinners, Apixaban and aspirin. The resident, with severe cognitive impairment and dependency on staff for daily activities, had no order in their electronic medical record or MAR to monitor for bleeding, despite the pharmacist's recommendation. A nurse confirmed the oversight, acknowledging the importance of monitoring for bleeding to ensure necessary care is provided.
The facility failed to document resident leave of absence accurately, affecting three residents. A resident left for appointments without staff checking on return, another's outing plans were undocumented, and a third left without nurse clearance. Staff interviews confirmed the need for complete documentation to ensure safety.
The facility failed to follow infection control practices, risking resident safety. A resident's oxygen therapy equipment was not changed weekly, and multiuse blood glucose test strips were improperly handled during monitoring for several residents. The DON confirmed these practices violated facility policies, increasing infection risk.
A resident with Alzheimer's and dementia, prone to crawling and climbing out of bed, was found on the floor due to the facility's failure to implement a care plan intervention. The care plan required a mattress to be placed on the floor for safety, but it was not followed, posing a risk of injury. The DON confirmed the oversight, which contradicted the facility's policy on fall risk management.
The facility failed to report a COVID-19 positive case to the California Department of Public Health (CDPH) as required by their policy and state regulations. A resident tested positive for COVID-19, but the case was not reported, as confirmed by the Infection Preventionist and Director of Nursing. This oversight delayed CDPH's investigation and increased the risk of virus spread within the facility.
Insufficient Privacy Curtains in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure there were adequate privacy curtains available in 17 of 33 rooms, including Rooms 2, 3, 4, 7, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31. During observations, surveyors found multiple rooms with only one or two privacy curtains on the horizontal track along the foot of residents' beds, which did not provide full visual privacy for all occupants in those rooms. In several rooms with three occupants, the curtains only covered one or two residents, and in one room with two occupants, only one privacy curtain was present, providing full visual privacy for only one resident. During interviews, CNA 6 stated privacy curtains were essential for residents' dignity during care, including dressing, bathing, and treatments, and said the curtains should always be fully functional. The Housekeeping Supervisor stated privacy curtains protected residents' dignity and comfort and that without them, residents may feel uneasy receiving care, affecting their emotional well-being. The Housekeeping Supervisor also stated the facility was aware there were not enough privacy curtains in place to allow each resident full visual privacy and that the concern had been brought to the Administrator. The facility policy on Resident Rights stated residents were to be treated with respect and dignity and were guaranteed rights including privacy and a dignified existence.
Failure to Notify Physician of Repeated Lab Refusals
Penalty
Summary
The facility failed to ensure the physician was notified in a timely manner when Resident 13 refused a physician-ordered CBC laboratory draw. Resident 13 was admitted and later readmitted to the facility with diagnoses including anemia, dementia, syncope, and muscle wasting. The Minimum Data Set dated 1/21/2026 indicated Resident 13 had severely impaired cognition and was dependent on staff for activities of daily living. A physician order dated 4/13/2026 directed staff to collect a CBC. The laboratory requisition form showed the CBC was scheduled for collection on 4/13/2026, but the specimen was not collected on 4/20/2026 and 4/21/2026 due to patient refusal. During interview and record review, the DON stated the medical record did not show documented evidence that the physician was notified of the refusals on 4/13/2026, 4/20/2026, or 4/21/2026. The DON stated the physician should have been notified each time the resident refused the ordered laboratory test, and the facility policy required prompt notification of treatment refusal on two or more consecutive times.
Use of Bed Items as a Physical Restraint
Penalty
Summary
The nursing staff failed to ensure a resident was free from physical restraints when bed linen, towels, and pillows were used as a barrier to prevent the resident from falling out of bed. Resident 90 was admitted with diagnoses including legal blindness, muscle weakness, and metabolic encephalopathy. The resident's MDS dated 1/28/2026 indicated severely impaired cognition and dependence on staff for ADLs. During observation and interview on 4/20/2026, Resident 90 was lying in bed with bed linen covering and tightly positioned along the body and tucked under the mattress. The resident stated staff had placed pillows and towels on the bed, which restricted movement, turning, repositioning, and getting out of bed without staff assistance. CNA 1 stated the bed linen was tucked tightly along the resident's body to keep the resident properly positioned and prevent movement toward the edge of the bed. On 4/22/2026, the DON observed bed linen, towels, and pillows between the mattress and bed frame and stated these items created a barrier that limited the resident's ability to freely move or get out of bed without staff assistance and functioned as a physical restraint. The facility policy stated restraints should only be used to treat medical symptoms and never for discipline, staff convenience, or prevention of falls.
PRN Ativan Continued Beyond 14-Day Limit
Penalty
Summary
The facility failed to ensure that a PRN order for Ativan was not continued beyond 14 days for one resident with diagnoses including psychosis, dementia, and depression. The resident’s MDS dated 1/22/2026 indicated moderately impaired cognition and dependence on staff for ADLs. During a concurrent interview and record review on 4/23/2206 at 8:15 a.m., the DON reviewed a physician order dated 3/25/2026 for Ativan 0.5 mg by mouth every 8 hours PRN for anxiety, with a 30-day duration and stop date of 4/24/2026. The DON stated the PRN psychotropic order exceeded the 14-day requirement and that the resident should have been reevaluated every 14 days, with clinical justification documented if the medication was continued beyond that period. The DON stated there was no documented evidence that the physician completed the required reevaluation or documented clinical justification for continued PRN Ativan use beyond 14 days. The facility policy titled Psychotropic Medication Use, dated 7/2022, stated PRN psychotropic medications are limited to 14 days unless the attending physician documents the rationale and specifies a new duration.
MDS Did Not Match PASRR Status
Penalty
Summary
The facility failed to ensure that Resident 8’s MDS accurately reflected the resident’s PASRR status. Resident 8 was admitted and later readmitted to the facility and had diagnoses that included depression. In the MDS dated 1/8/2026, Resident 8 was documented as having intact cognitive skills for daily decision making and requiring moderate assistance with ADLs. A review of Resident 8’s PASRR Level I screening dated 6/15/2022 showed that the resident had a serious mental illness and required a Level II mental health evaluation. During interview and record review with the MDS Nurse on 4/21/2026, the MDS section A1500 for PASRR was marked “0 - No,” indicating the resident was not identified as having a serious mental illness. The MDS Nurse stated the MDS was completed incorrectly because the PASRR Level II determination report dated 6/27/2022 identified Resident 8 as having a serious mental illness, and that the MDS did not accurately reflect the resident’s PASRR Level II determination or serious mental illness.
Failure to Care Plan Anticoagulant Use and Pressure Injury Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents with identified needs related to Apixaban use and pressure ulcer prevention. For one resident, the record showed an order for Apixaban 5 mg twice daily, along with diagnoses including type 2 diabetes, muscle weakness, dysphagia, multiple rib fractures, hyperlipidemia, rhabdomyolysis, and cerebral infarction. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making and dependence on staff for ADLs. During interview, the DON stated that Apixaban requires an individualized care plan because it increases bleeding risk and that staff need direction for monitoring for signs and symptoms of bleeding, fall precautions, and prompt reporting of changes in condition. For the second resident, the record showed diagnoses including muscle weakness, dysphagia, GERD, protein calorie malnutrition, and type 2 diabetes. The H&P documented fluctuating capacity to understand and make decisions, and the MDS indicated moderately impaired cognitive skills and dependence on staff for ADLs. The initial skin assessment identified blanchable redness to the coccyx area. Braden Scale scores were documented as 14, then 13, then 12, reflecting moderate to high risk for pressure ulcer development. During interview, the DON stated that based on the resident’s diagnoses, skin findings, and Braden scores, the resident was already at risk for further skin impairment and required interventions such as frequent repositioning, pressure relief measures, skin monitoring, and prompt reporting of worsening areas. The facility’s policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is to be developed and implemented for each resident, with interventions based on data gathering and clinical decision making. Despite this, the facility did not develop care plans addressing Apixaban therapy for one resident or pressure ulcer risk for the other resident. The report states that this left both residents without individualized care plan direction for the identified issues.
Untrimmed and Dirty Fingernails
Penalty
Summary
The facility failed to keep one sampled resident's fingernails trimmed and clean. Resident 90 was admitted with legal blindness, muscle weakness, and metabolic encephalopathy, and the MDS dated 1/28/2026 indicated the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for ADLs. During an observation and interview on 4/20/2026, Resident 90's fingernails were observed to be long and untrimmed with black debris underneath the nail bed. During a concurrent observation and interview with CNA 1, the resident's fingernails were again observed to be long and untrimmed with black debris underneath the nail bed. CNA 1 stated the nails were dirty and required cleaning and trimming, and explained that nail care was part of CNA responsibilities and should be checked daily. The DON stated fingernail care was part of the resident's ADL routine and that dirty, long fingernails were not acceptable. The IPN stated nail care should be assessed daily and that residents needing help with cleaning or trimming nails should be assisted by CNAs or licensed nurses. The facility policy titled Fingernails/Toenails Care indicated nail care included daily cleaning and regular trimming.
Failure to Maintain Fall Protection and Dispose of Contaminated Sharps
Penalty
Summary
The facility failed to ensure bilateral floor mats were in place for a resident at risk for falls. Resident 13 had diagnoses including dementia, syncope, and muscle wasting, and the MDS indicated severely impaired cognition and dependence on staff for ADLs. The care plan identified the resident as at risk for falls with injury and directed staff to follow the facility’s fall precaution protocol. A physician order dated 11/3/2025 directed staff to apply bilateral floor mats for fall precaution. During observations on 4/20/2026 and 4/21/2026, Resident 13 was seen lying in bed with a floor mat on the right side of the bed and no floor mat on the left side. During a later observation with the DON on 4/22/2026, a floor mat was observed on the left side of the bed and the DON stated there was no floor mat on the right side. The DON stated the resident was at risk for falls and required interventions to reduce the risk of injury, and that the resident could sustain injuries such as bruising, skin tears, pain, or fracture if falling onto the floor without a floor mat in place. The facility also failed to ensure two used IV starter needles were properly disposed of for Resident 2. Resident 2 had diagnoses including muscle weakness, dysphagia, GERD, protein calorie malnutrition, and type 2 diabetes, and the H&P indicated fluctuating capacity to understand and make decisions; the MDS indicated moderately impaired cognitive skills for daily decision making and dependence on staff for ADLs. During observation, two used IV starter needles with visible blood were found on top of the resident’s blanket while the resident was lying in bed. Resident 2 stated a nurse had started an IV earlier that morning and that the dirty needles should have been thrown away. RN 2 stated the used needles should not have been left on the resident and that the licensed nurse performing the procedure was responsible for immediate disposal in an approved sharps container. The DON stated used sharps should never be left in a resident’s immediate environment and that the contracted IV specialist reportedly left the needles on the blanket instead of disposing of them properly.
Missed Nutritional Supplements
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for a resident with dysphagia, moderate protein-calorie malnutrition, cachexia, and adult failure to thrive. The resident’s MDS indicated she had no cognitive impairment, required set-up/clean-up assistance to eat, and had sustained weight loss in the last six months. Her care plan directed staff to provide and serve her supplements as ordered, with a goal of consuming 100% of them. A physician order required a Magic Cup nutritional treat twice daily with lunch and dinner, but during observation the resident’s lunch tray did not include the supplement, and an LVN confirmed it was not provided. A separate physician order required a sugar-free high-protein nourishment three times daily, but during observation the resident did not have a supplement or snack available and stated she had not received one that morning; a CNA confirmed she did not provide the 10:00 a.m. nourishment. The RD stated tray ticket printing problems and delayed delivery of nourishment shakes may have contributed to the missed supplements, and confirmed the expectation was that the resident receive her supplements as ordered.
Medication Administration Documentation Errors and Improper G-Tube Flushing
Penalty
Summary
The facility failed to ensure an LVN demonstrated appropriate medication administration, documentation, and communication with the healthcare team for a resident with depression, DM II, HTN, hyperlipidemia, BPH, a broken left leg bone, and muscle wasting and atrophy. The resident’s MDS indicated moderate cognitive impairment and that he required set-up/clean-up assistance to eat and drink. During medication administration, the LVN dispensed 10 medications into one cup, then used a plastic spoon to give the resident three tablets without telling him what they were. When the resident declined more medication, the LVN told him, “You have to take your medicine,” and offered the remaining medication with chocolate pudding, but did not identify the medications or explain the risks of refusal. The LVN later left the room with five tablets and two capsules still in the cup. The LVN told surveyors she did not know which three medications she had administered or which seven remained in the cup, and stated she had not informed the resident of the medications, their names, or their risks and benefits. She also stated she could not explain the risks and benefits because she could not identify the tablets and capsules once they were placed in the medication cup. The LVN said she would need to compare the remaining pills to the resident’s blister packs and multi-dose bottles to identify what had been refused. However, the EMAR notes documented that the LVN explained the risks and benefits for seven refused medications, and the progress note stated the resident refused medication after three offers and that the LVN explained the medications’ uses. The LVN also told the NP that the resident had been educated on the risks and benefits of the seven refused medications. In interview, the LVN acknowledged that the resident was not informed of the medications during administration and was not given the opportunity to make an informed decision to accept or refuse them, and that her documentation and communication did not accurately reflect the care provided. The DON stated the LVN was to separate each medication into a separate cup, identify each medication, explain its indication before administration, and document only care that was actually provided. The facility also failed to ensure licensed nursing staff used warm purified water when flushing a G-tube for another resident with muscle weakness, dysphagia, GERD, protein calorie malnutrition, and type 2 diabetes. The resident’s physician ordered the tube feeding to be flushed with 30 ml before and after medication. During observation, a saline flush was attached to the Lopez valve of the resident’s G-tube. The RN stated the saline flush should not have been attached and that using a saline flush to irrigate the G-tube after feedings or medication administration was not in accordance with facility protocol. The DON stated facility protocol required flushing G-tubes with the appropriate prescribed solution, typically water, before and after feedings and medication administration, and that attaching a saline flush for routine flushing was not in accordance with facility policy or accepted standards of nursing practice.
Opioid Given Outside Ordered Pain Parameters
Penalty
Summary
The facility failed to ensure Hydrocodone-Acetaminophen was administered according to the physician-ordered parameters for one sampled resident. Resident 7 was admitted and later readmitted to the facility and had diagnoses including hemiplegia, gout, diabetes mellitus, and end stage renal disease. The resident’s MDS dated 2/26/2026 indicated cognition was intact and the resident was independent on staff for ADLs. The care plan for pain, revised 7/11/2025, directed staff to administer Hydrocodone-Acetaminophen as ordered by the physician. The physician order dated 3/30/2026 directed Hydrocodone-Acetaminophen 5-325 mg, one tablet by mouth every 8 hours as needed for severe pain rated 7-10. Review of the MAR from 4/1/2026 through 4/22/2026 showed the medication was administered on multiple dates when the documented pain level was 5 or 6 out of 10, which was below the ordered parameter for severe pain. During interview, the LVN stated the medication should have been given only within the ordered parameters and acknowledged it was administered when the resident’s pain level did not meet the order. The DON also stated the medication was given outside the ordered parameters and was not consistent with the physician’s order.
Medication Administration Errors and Failure to Inform Resident of Medications
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors observed 10 medication errors out of 29 opportunities for error, resulting in an observed medication administration error rate of 34.48% for one of five randomly selected residents. Resident 57 was admitted with diagnoses including depression, type 2 DM, HTN, hyperlipidemia, BPH, a broken left leg bone, and muscle wasting and atrophy. The resident’s MDS dated 4/2/2026 indicated moderate cognitive impairment, with no disorganized thinking or acute change in mental status, and that the resident required set-up/clean-up assistance to eat and drink. During medication administration observation, LVN 2 removed 10 medications from the cart and gave the resident three tablets without telling him what they were. When the resident declined additional medication, LVN 2 told him, “You have to take your medicine,” and offered the remaining medications with chocolate pudding. LVN 2 did not tell the resident the names of the seven remaining medications or the risks of refusing them. LVN 2 later stated she did not know which three medications had been administered or which seven remained in the cup, and that she did not inform the resident of the medications he received or refused. The EMAR notes documented refusal of seven medications and stated the LVN explained the risks and benefits of all seven, which conflicted with the observation and interview findings.
Improperly Stored Unlabeled and Undated Food Items
Penalty
Summary
The facility failed to store food properly in the kitchen when one bag of hamburger buns, two bags of wheat bread, ground Italian seasoning, plain salt, soy sauce, and powdered thickener were observed unlabeled and undated. During observations in the kitchen, the hamburger buns and wheat bread were open, and the seasoning, salt, soy sauce, and powdered thickener were also found without labels or dates. During interview, a Dietary Aide stated the items were improperly stored and that proper labeling and dating were important to prevent foodborne illness among residents. The Registered Dietician stated that unlabeled and undated or poorly stored food may lead to salmonella in residents. The facility policy for food receiving and storage stated that dry food storage follows safe handling practices, with all items labeled and dated.
Kitchen Trash Containers Left Open
Penalty
Summary
The facility failed to ensure two large trash containers in the kitchen were maintained in a closed position. During observations on 4/20/2026 at 8:15 a.m. and 12:02 p.m., two uncovered trash containers were seen in the kitchen and were filled to capacity with open fruit cans, empty bottles, soiled paper towels, and wet meat bags. During a concurrent observation and interview on 4/20/2026 at 12:06 p.m., a Dietary Aide stated kitchen trash containers must remain closed when not in use at all times to prevent pests and keep the facility safe. The RD later stated that open trash cans in the kitchen could attract pests, promote bacterial growth, and increase the risk of cross contamination that could lead to foodborne illness among residents with low immune systems. The IPN also stated trash bins must stay closed at all times to prevent pests and germs. The facility policy titled Waste Disposal indicated regulated waste disposal shall be placed in closable leak proof containers and that waste containers should be replaced routinely and not allowed to overfill.
Missing PASRR Documentation in Resident Records
Penalty
Summary
The facility failed to ensure PASRR documentation was maintained and readily available in the medical records for two sampled residents. Resident 1 was originally admitted and later readmitted to the facility, and had diagnoses including depression and anxiety. A review of Resident 1’s MDS dated 1/12/2026 showed severely impaired cognitive skills for daily decision making and dependence on staff for ADLs. During record review on 4/21/2026 with the MDS Nurse present, Resident 1’s medical record did not include evidence that the PASARR Level I screening and Level II determination were maintained and readily available for review. Resident 8 was originally admitted and later readmitted to the facility and had a diagnosis of depression. A review of Resident 8’s MDS showed intact cognitive skills for daily decision making and moderate assistance needed for ADLs. During a concurrent interview and record review on 4/21/2026 with the MDS Nurse, Resident 8’s medical record also did not include evidence that PASRR Level I and Level II determination documentation was maintained and available for review. The MDS Nurse stated PASRR documentation should be maintained in the resident’s record and available upon request, and stated he was responsible for maintaining complete resident records and ensuring required documents, including PASRR information, were available in the medical record.
Failure to Use Required PPE During High-Contact Care
Penalty
Summary
The facility failed to ensure required PPE was worn during high-contact care for three residents on enhanced barrier precautions. Resident 6 was admitted with immunodeficiency due to drugs, a gastrostomy, muscle wasting and atrophy, and generalized weakness, and was dependent on staff for all ADLs. Although the care plan directed staff to wear a gown and gloves during high-contact care such as dressing and hygiene, CNA 2 was observed at the bedside preparing to give a bed bath while wearing gloves but no gown. Resident 94 had diagnoses including muscle wasting and atrophy, generalized weakness, and dementia, with severe cognitive impairment and dependence on staff for lower body dressing and substantial to maximal assistance for rolling in bed. His care plan required gown and glove use during high-contact care including dressing and linen changes, but CNA 7 and another unidentified CNA were observed performing a linen change, removing his pants, repositioning him, and assisting him into a new pair of pants without wearing disposable gowns. Resident 103 had dysphagia with gastrostomy and severely impaired cognition, was fully dependent on staff for all ADLs, and had care plans requiring enhanced barrier precautions and appropriate PPE during high-contact care. LVN 1 was observed checking the gastrostomy tube placement and administering medications while wearing gloves but no gown.
Call Light Left Out of Reach for Resident With Left-Sided Weakness
Penalty
Summary
The facility failed to ensure a working call system was available and within reach for one resident with left-sided weakness. Resident 40 had diagnoses including left-sided hemiplegia and cortical blindness, and the MDS indicated severely impaired cognition and dependence on staff for ADLs. The care plan for ADLs self-care and mobility deficit stated staff would ensure the resident's call light was within reach and available for use when assistance was needed. During observations on 4/20/2026, 4/21/2026, and 4/23/2026, Resident 40 was found lying in bed with the call light attached to the left side of the bed and out of reach. The resident stated he could not reach or activate the call light and needed staff assistance for pain medication, and that he used his right hand more effectively because of left-sided weakness. An LVN stated the resident required the call light to be placed within reach on the right, stronger side, and that if it was placed on the left side or not within reach, the resident would not be able to use it to request staff assistance. The facility policy titled Answering the Call Light stated staff would ensure the resident's call light was within reach when the resident was in bed and ensure residents were able to use it.
Unsafe hallway flooring and missing oxygen signage
Penalty
Summary
The facility failed to maintain a safe environment when a circle floor drain cover in the hallway by the kitchen door was observed cracked, uneven, and chipped with an irregular edge. The condition was observed on multiple occasions, and during a concurrent observation and interview, the Maintenance Supervisor stated the cracked and uneven flooring near the drain posed a tripping risk for residents and that delayed repair could allow the damage to worsen and lead to serious injury. The Director of Nursing stated uneven flooring could cause residents to trip and fall, resulting in injuries such as bruises or fractures. The facility policy on falls identified obstacles in the walking path as environmental factors that increase fall risk. The facility also failed to post oxygen signage for Resident 99, who had COPD, acute and chronic respiratory failure with hypercapnia, severely impaired cognitive skills for daily decision making, dependence on staff for all ADLs, and continuous oxygen therapy. Observations showed Resident 99 receiving oxygen via nasal cannula at 2 liters per minute in bed, but no oxygen signage was posted outside the room or at the bedside. The DON stated oxygen signage was to be posted for safety purposes due to the risk of fires related to oxygen use. The facility policy on oxygen administration required no smoking signage on the outside of the room entrance door and an Oxygen in Use sign in a designated place on or over the resident's bed.
Room Size Below Required Standard
Penalty
Summary
The facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. A review of the facility census dated 4/20/2026 showed that Rooms 3 and 4 each had the capacity for four residents. During observations made from 4/20/2026 through 4/23/2026, no adverse effects were observed related to residents' care, privacy, health, or safety in connection with the living space provided. A review of the facility's Client Accommodation Analysis form dated 4/23/2026 showed that two rooms did not meet the 80 square foot requirement, with each room measured at 272 square feet. During a facility tour observation and concurrent interview on 4/23/2026 at 11:25 a.m., the Administrator observed Rooms 3 and 4 and stated that they measured less than 80 square feet per resident. The Administrator also stated that the reduced room size could create a risk of decreased space for residents, staff, and equipment, and could cause residents to feel uncomfortable if the rooms were not properly arranged and monitored.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Failure to Timely Report Resident-to-Resident Altercation to Administrator and CDPH
Penalty
Summary
The facility failed to timely report a resident-to-resident altercation involving two residents to the Abuse Coordinator/Administrator and to the California Department of Public Health (CDPH). One resident, with diagnoses including anxiety disorder and dementia but assessed on the MDS as having no cognitive impairments and being independent with oral hygiene and dressing, initiated a physical altercation without provocation and attempted to strike another resident. The second resident, with diagnoses including COPD and CHF, was also assessed on the MDS as having no cognitive impairments and being independent with ADLs. A Change of Condition assessment documented that staff observed the first resident displaying verbal and physical aggression and initiating the altercation, and that both residents were separated to minimize escalation. The RN on duty at the time of the incident acknowledged in interview that she did not report the altercation to the Administrator, who is the facility’s Abuse Coordinator, and did not recall reporting the incident to CDPH, despite stating she was required to report such altercations to the Administrator and CDPH right away for resident safety. The Administrator stated she was not aware of the altercation until a later survey interview and confirmed that the RN should have reported the incident to her immediately, or to the DON if she was unavailable. Review of facility policies on abuse, neglect, exploitation, and misappropriation showed that suspected resident abuse was to be reported to the Administrator immediately and to the state licensing/certification agency immediately or within two hours, and that the facility was to report any allegations of abuse within the timeframes required by federal requirements. These policies were not followed in this incident, resulting in a delay in investigation by the Abuse Coordinator and CDPH and a potential for further abuse.
Plan Of Correction
F609 - 483.12 (b)(5)(i)(A)(B)(c)(1)(4) Reporting of Alleged Violations Corrective Actions taken for those residents alleged to have been affected by the deficient practice are: . Resident 4's physician was notified on 3/19/26 . Resident 4's plan of care was reviewed and revised on 3/19/26 Actions taken to identify other residents that may have the potential to be affected by the same deficient practice: . Documentation authored by R1 was reviewed by the DON and Administrator on 3/19/26 with no other instances of unreported events noted. The measures the facility will take to ensure the problem will be corrected and will not recur. . RN 1 and all staff were in-serviced beginning on 3/23/26 by the DSD and DON related to: o Timely reporting within 2 hours; all staff are mandated reporters o Any suspicion of abuse should be reported to the Administrator immediately o Any suspicion of abuse should be reported to the Department of Public Health, the Ombudsman and the local police department. o If two residents are involved in an altercation, staff are to notify each resident's attending physician. o Staff are to update each resident's plan of care o Staff are to document all interventions in the clinical record Quality Assurance plans to monitor facility performance to make sure corrections are achieved. - A QA/QI Tool was developed and initiated by Administrator/Designee to ensure the process for the following: o Ensuring alleged violations are reported. o QA will be completed 5times a week for 2 weeks. o QA will be completed 3 times a week for 2 weeks. - The Administrator or Designee will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this Plan of Correction will be
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to investigate a resident-to-resident altercation that occurred on 1/31/2026 involving Resident 2 and Resident 4. Resident 2, who had diagnoses including anxiety disorder and dementia, had an MDS dated 1/8/2026 indicating no cognitive impairments and independence with oral hygiene and dressing. Resident 4, with diagnoses including COPD and CHF, also had an MDS indicating no cognitive impairments and independence with ADLs. A Change of Condition Assessment for Resident 2 dated 1/31/2026 documented that on the morning of that date, Resident 2 displayed verbal and physical aggression with an anger outburst and initiated a physical altercation with Resident 4 without provocation, attempting to strike him for no apparent reason. Staff separated the residents to minimize escalation. Despite this documented altercation, the Administrator stated in an interview on 3/18/2026 that she was not aware of the incident and that it was not investigated. Facility policies titled “Abuse, Neglect, Exploitation, and Misappropriation Prevention Program” and “Abuse, Neglect, Exploitation, and Misappropriation – Reporting and Investigating” required that any allegations of abuse be thoroughly investigated within required federal timeframes and that the investigation be initiated by the Administrator. The lack of any investigation into the documented resident-to-resident physical altercation constituted the cited deficiency.
Plan Of Correction
submitted monthly to the QAPI committee for review and further follow up. The QA/QI tool will continue until the QAPI committee deems it is no longer necessary. Completion Date: 04/01/2026 F610 - 483.12 (c)(2)-(4) Investigate/Prevent/Correct Alleged Violation Corrective Actions taken for those residents alleged to have been affected by the deficient practice are: Post Event Assessment completed for Resident 4 on 3/19/26 Resident 4's physician was notified on 3/19/26 Resident 4's plan of care was reviewed and revised on 3/19/26 Actions taken to identify other residents that may have the potential to be affected by the same deficient practice: Documentation authored by R1 was reviewed on 3/19/26 by the DON and Administrator with no other instances of uninvestigated events noted. The measures the facility will take to ensure the problem will be corrected and will not recur. RN 1 and all staff were in-serviced beginning on 3/23/26 by the DSD and DON related to: - Timely reporting within 2 hours; all staff are mandated reporters - Any suspicion of abuse should be reported to the Administrator immediately so that a timely investigation can be completed. - Any suspicion of abuse should be reported to the Department of Public Health, the Ombudsman and the local police department. - If two residents are involved in an altercation, staff are to notify each resident's attending physician. - Staff are to update each resident's plan of care - Staff are to document all interventions in the clinical record Quality Assurance plans to monitor facility performance to make sure corrections are achieved. A QA/QI Tool was developed and initiated by Administrator/Designee to ensure the process for the following: - Ensuring alleged violations are investigated.
Failure to Follow Resident-to-Resident Altercation Policy and Update Care Plan
Penalty
Summary
The facility failed to follow its policy and procedure for resident-to-resident altercations after an incident involving Resident 4 on 1/31/2026. Resident 4, who had diagnoses of COPD and CHF and was assessed on the MDS as having no cognitive impairment and being independent with ADLs, was involved in an altercation in which another resident attempted to strike him. Registered Nurse 1 reported that this altercation occurred but stated she did not recall notifying Resident 4’s physician or documenting the incident in Resident 4’s electronic medical record. The Administrator stated she was not aware that the altercation had occurred and confirmed there was no documentation in Resident 4’s EMR indicating that his attending physician had been notified or that a care plan with interventions had been developed to address possible psychosocial needs following the incident. The facility’s policy on Resident-to-Resident Altercations, revised 9/2022, required staff to notify each resident’s attending physician, make necessary changes to the care plan for all residents involved, and document all interventions in the clinical record. These required actions were not carried out for Resident 4 after the altercation.
Plan Of Correction
o Ensuring alleged violations are investigated. QA will be completed 5times a week for 2 weeks. o QA will be completed 3 times a week for 2 weeks. The Administrator or Designee will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this Plan of Correction will be submitted monthly to the QAPI committee for review and further follow up. The QA/QI tool will continue until the QAPI committee deems it is no longer necessary. Completion Date: 04/01/2026 F684 - 483.25 Quality of care Corrective Actions taken for those residents alleged to have been affected by the deficient practice are: Resident 4's physician was notified on 3/19/26 Resident 4's plan of care was reviewed and revised on 3/19/26 Actions taken to identify other residents that may have the potential to be affected by the same deficient practice: Documentation authored by R1 reviewed by the DON and Administrator on 3/19/26 with no other instances of resident to resident altercations noted. The measures the facility will take to ensure the problem will be corrected and will not recur. RN 1 and all staff were in-serviced beginning on 3/26/26 by the DSD and DON related to: o Timely reporting within 2 hours; all staff are mandated reporters o Any suspicion of abuse should be reported to the Administrator immediately o Any suspicion of abuse should be reported to the Department of Public Health, the Ombudsman and the local police department. o If two residents are involved in an altercation, staff are to notify each resident's attending physician. o Staff are to update each resident's plan of care o Staff are to document all interventions in the clinical record Quality Assurance plans to monitor facility performance to make sure corrections are achieved. A QA/QI Tool was developed and initiated by Administrator/Designee to ensure the process for the following: o Ensuring residents receive the care and interventions needed after an altercation. o QA will be completed 5times a week for 2 weeks. o QA will be completed 3 times a week for 2 weeks. The Administrator or Designee will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this Plan of Correction will be submitted monthly to the QAPI committee for review and further follow up. The QA/QI tool will continue until the QAPI committee deems it is no longer necessary. Completion Date: 04/01/2026
Failure to Provide Palatable, Properly Prepared Food to a Resident With Nutritional Risks
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide palatable, properly prepared food to a resident with documented nutritional and hydration problems, a history of protein calorie malnutrition, multiple food allergies, and limited food choices. The resident’s care plan stated that the resident had multiple food complaints, would only eat requested items, and was to receive specific food items as requested. Physician orders included a regular diet with regular texture, thin liquids, and double portions of fish or chicken and eggs at breakfast. The resident’s MDS showed independence with eating but a need for setup or clean-up assistance. During kitchen observation, surveyors noted a container of strawberries on the counter with an open date several days earlier. In interviews, the resident reported receiving burnt hard-boiled eggs daily, burnt chicken and broccoli, and old, moldy strawberries, and stated that when trays were sent back, replacement meals were also overcooked. Surveyors directly observed the resident eating broccoli that was mushy and overcooked and strawberries that appeared acceptable on top but looked old when turned in the container. On another observation, the resident had a hard-boiled egg that was green in color, rubbery, and peeling in layers, and stated the food that morning was not good. The cook who prepared breakfast reported boiling the eggs for 15 minutes, then holding them in a warmer for over an hour before service, and acknowledged not following any instructions or recipes for cooking hard-boiled eggs. The cook agreed that the egg shown looked oxidized and firmer than expected and stated that residents would be disappointed, possibly angry, and would not like the food, with the potential to be undernourished with possible weight loss when food is overcooked. The dietary supervisor acknowledged that the broccoli and eggs served to the resident were overcooked. These findings conflicted with the facility’s policies requiring that each resident receive a nourishing, palatable, well-balanced diet, that food appear palatable and attractive, and that staff follow the facility’s hard-boiled egg preparation procedure.
Plan Of Correction
potential to be affected by the same deficient practice: All residents have the potential to be affected by the alleged deficient practice. The measures the facility will take to ensure the problem will be corrected and will not recur. On 3/11/26 DSD in-serviced all staff on reporting to Dietary Supervisor if an incorrect meal is served, or if a meal does not appear palatable so that a new food tray can be issued. On 3/11/26 Dietary supervisor in-serviced kitchen staff on the procedure for cooking hard boiled eggs. On 3/11/26 Dietary Supervisor in-serviced kitchen staff on the procedure for cooking broccoli. On 3/11/26 Dietary Supervisor in-serviced kitchen staff on the procedure for discarding spoiled foods (strawberries). On 3/11/26 Dietary Supervisor in-serviced kitchen staff on P&P titled, "Food and Nutrition Services" Quality Assurance plans to monitor facility performance to make sure corrections are achieved. A QA/QI Tool was developed and initiated by Dietary Supervisor/Designee to ensure the process for the following: Ensuring that the food is palatable, pleasant to taste, not overcooked and appetizing. QA will be completed daily for 2 weeks. QA will be completed 3 times a week for 2 weeks. QA will be completed random check for 2 weeks. The Dietary Supervisor or Designee will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this Plan of Correction will be submitted monthly to the QAPI committee for review and further follow-up. The QA/QI tool will continue until the QAPI committee deems it is no longer necessary. Completion Date: 3/12/2026
Failure to Account for Resident Belongings at Discharge
Penalty
Summary
The facility failed to protect a resident’s personal property by not completing and updating the resident’s belongings inventory at discharge and not accounting for missing clothing. The resident was admitted with diagnoses including diabetes mellitus, hypertension, and chronic kidney disease, and had fluctuating capacity to understand and make decisions per the History and Physical, while the MDS indicated no cognitive impairment and a need for partial to moderate assistance with ADLs. On admission, the Clothing and Possessions Inventory List documented two shirts, one pair of slippers, and one pair of pants, but there was no documentation that these belongings were accounted for or reconciled at the time of discharge. Progress notes from the discharge date did not describe what personal belongings were provided to the resident or family. The resident’s family member reported that the resident’s shirts and pants were lost at the facility and stated that Social Services had been informed and had said they would look for the missing clothes, but the items were not returned. The Social Services Director stated she was not aware of the lost belongings and did not know if the resident’s belongings were given to the resident or family at discharge. The DON confirmed that the inventory list should be completed on admission, readmission, and discharge, and acknowledged that the resident’s discharge inventory list was not completed, contrary to facility protocol and the Personal Property policy. The RN who completed the discharge instructions stated that she gave belongings to the resident and family but could not recall which items were given and could not remember completing the discharge inventory list, acknowledging that failure to complete the list prevents the facility from accounting for what belongings were provided at discharge.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for at least eight consecutive hours on specific dates, namely 12/7/2024, 12/8/2024, 12/15/2024, and 1/4/2025. This deficiency was identified through a review of the facility's Licensed Nurse Staffing records, which showed no RN was scheduled for any shift on these dates. Interviews with staff, including a Licensed Vocational Nurse (LVN) and Minimum Data Set Nurses (MDSNs), revealed that the RN who typically worked weekends was on sick leave, and attempts to cover the shifts with MDSNs resulted in insufficient RN coverage. The MDSNs worked only partial shifts, ranging from 4 to 5.97 hours, failing to meet the required eight-hour coverage. The Director of Nursing (DON) acknowledged the deficiency, noting that having an RN on duty for eight consecutive hours is crucial for timely assessments upon admission and for providing experienced leadership during emergencies. The absence of an RN for the required duration could lead to delays or missed assessments and potentially compromise the quality of care during emergencies. The facility's Job Description for the RN Supervisor emphasized the importance of supervising day-to-day activities in compliance with federal, state, and local standards, which was not adhered to on the specified dates.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free of unnecessary medications. For one resident, the facility did not monitor specific target behaviors associated with the use of multiple psychotropic medications, including Zyprexa, Ativan, Desyrel, Cymbalta, and Depakene. The facility also failed to attempt nonpharmacological interventions prior to the initiation and during the use of these medications. The resident's records showed a lack of documentation regarding the effectiveness of nonpharmacological interventions, and the resident was administered PRN lorazepam multiple times without documented episodes of restlessness or other behaviors that warranted its use. The facility's records indicated that the resident was often sleeping during the day, and there was no documentation of monitoring for hours of sleep, which was the targeted behavior for the use of trazodone. Despite the absence of documented behaviors, the resident's trazodone dosage was increased. Interviews with staff revealed that nonpharmacological interventions were not documented or attempted prior to administering PRN medications, and the resident's care plan did not include such interventions. The Director of Nursing acknowledged the lack of documentation and monitoring for the resident's behaviors and side effects of psychotropic medications. For the second resident, the facility failed to monitor for specific behaviors of poor regard to health while the resident was receiving olanzapine. Although the resident was being treated for delusional thinking and poor regard to health, only behaviors of agitation and delusional thinking were monitored. The facility did not follow the consultant pharmacist's recommendations to monitor all indicated behaviors, resulting in the resident's behavior of poor regard to health being undetected and potentially mismanaged. The Director of Nursing confirmed that all indicated behaviors must be monitored to ensure the effectiveness of the medication and to allow for dosage adjustments if needed.
Improper Storage and Labeling of Nebulizer Solution
Penalty
Summary
The facility failed to ensure that opened boxes of nebulizer solution, specifically Ipratropium and Albuterol combination, were labeled with an open date and stored according to the manufacturer's specifications. This deficiency was observed in two medication carts, affecting five residents. The medication was found stored outside of its protective foil pouch, which is against the manufacturer's instructions that require the solution to be protected from light and used within two weeks once removed from the pouch. During an inspection of Medcart Station 1, it was found that two boxes of the inhalation solution for two residents were not labeled with an open date, and vials were stored outside the foil pouch. The prescription fill dates were noted, but the lack of proper labeling and storage could compromise the medication's effectiveness. Similarly, at Medcart Station 2, three boxes of the inhalation solution for three residents were found with vials stored loosely and without foil pouches, lacking open dates, and with unknown storage durations. Interviews with the nursing staff revealed a lack of awareness regarding the importance of proper storage and labeling. The Director of Nursing confirmed that the manufacturer's instructions were not followed, which could affect the medication's potency. The failure to adhere to these guidelines increased the risk of residents receiving ineffective medication, potentially leading to health complications.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices in the kitchen, as observed during a survey. Specifically, a container of apple sauce and jelly were found unlabeled in Refrigerator 5, lacking the product name, open date, and use-by date. The Dietary Supervisor (DS) confirmed that these items had been transferred from their original packaging into kitchen-safe containers without proper labeling, leaving no indication of how long they had been stored. Additionally, an opened container of chocolate creme pie in Freezer 1 was also found without an open date or use-by date, despite being served the previous day. The DS acknowledged that proper labeling is required when food items are transferred to another container or when opened in their original packaging. This ensures the freshness of the food and prevents the use of items beyond their use-by date, which could lead to bacterial growth and food safety hazards. The facility's policy and procedure on Food Receiving and Storage, revised in November 2022, mandates that all refrigerated or frozen foods be covered, labeled, and dated, with monitoring to ensure they are used, frozen, or discarded by their use-by date. The lack of adherence to these procedures was identified as a deficiency during the survey.
Failure to Assist Resident with Grooming and Feeding Before Appointment
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident, identified as Resident 9, by not assisting with grooming and feeding prior to a medical appointment. On the day of the appointment, Resident 9 was observed being picked up without having eaten, as his food tray was untouched. Resident 9, who has diabetes mellitus and dysphagia, was dependent on staff for feeding and other daily activities due to severely impaired cognitive skills. The facility's records indicated that Resident 9 required feeding assistance for every meal, yet he was not fed before leaving for his appointment. Interviews with staff revealed a breakdown in communication and procedure adherence. CNA 3 and CNA 4 were unaware of Resident 9's appointment, which led to the failure to prepare him adequately. CNA 3 stated that the charge nurse did not inform her of the appointment, and CNA 4, who was assigned to feed Resident 9, did not have the opportunity to do so before he was picked up. RN 1 confirmed that staff should have been informed during morning huddles about the appointment, and that residents like Resident 9, who require feeding assistance, should be prioritized to eat before leaving the facility. The facility's policy on dignity emphasizes care that promotes residents' well-being and self-esteem, which was not upheld in this instance.
Failure to Obtain Informed Consent for Medications and Restraints
Penalty
Summary
The facility failed to obtain informed consent for the continuation of olanzapine for a resident after readmission from a general acute care hospital. The resident, who had intact cognition and the capacity to make decisions, was not informed about the risks, benefits, and indications of the medication. Despite the facility's policy requiring informed consent for psychotropic medications, the resident was administered olanzapine for approximately three months without being informed, as confirmed by interviews with the resident and a licensed vocational nurse. Additionally, the facility did not obtain informed consent from residents or their responsible parties before using physical restraints, specifically by placing beds against the wall for three residents. One resident, who had intact cognitive skills, stated that the facility did not discuss the risks and benefits of this action. Another resident, also with intact cognitive skills, was unaware of the reason for the bed placement and expressed dissatisfaction. The third resident, with moderately impaired cognitive skills, had their bed placed against the wall without informed consent from the responsible party, who confirmed that no explanation was provided by the facility. The facility's policies on psychotropic medication use and restraint use were not followed, as evidenced by the lack of documented informed consent in the residents' medical records. Interviews with nursing staff and the Director of Nursing revealed that the facility failed to ensure residents were informed and consented to their care and treatment, resulting in violations of residents' rights to make informed decisions.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident by not ensuring the call light was within reach. During multiple observations, the resident was found lying in bed with the call light on the floor, out of reach. The resident, who was admitted with diagnoses including a collapsed vertebra, depression, and chronic pain, required supervision or assistance for activities of daily living. The resident's care plan, which focused on fall risk due to limited mobility and impaired function, specified that staff should ensure the call light was within reach. Interviews with staff, including a CNA and the DON, confirmed that the call light should have been attached to the resident's bed and within reach. The DON emphasized the importance of the call light for resident communication and safety, noting that its absence could prevent residents from calling for help, thereby increasing the risk of falls and injury. The facility's policy indicated that the call light system should enable residents to alert nursing staff and be placed within reach, which was not adhered to in this case.
Failure to Obtain Advance Directive for Resident
Penalty
Summary
The facility failed to follow up and obtain a copy of an Advance Directive for a resident, which is a legal document indicating the resident's preferences on end-of-life treatment decisions. This deficiency was identified during a review of the resident's records and interviews with the Social Services Director (SSD). The resident, who had been admitted and readmitted to the facility with diagnoses including heart failure, type two diabetes mellitus, and major depressive disorder, had an intact cognition and the capacity to understand and make decisions as per the Minimum Data Set and History and Physical records. Despite this, the facility did not have a copy of the resident's Advance Directive, which was formulated on a previous date, and there was no documentation of follow-up to obtain it. The SSD acknowledged that upon admission, residents are asked about their Advance Directives, and if one is in place, the facility should request a copy to ensure the resident's wishes are respected. However, the SSD confirmed that no follow-up occurred to obtain the resident's Advance Directive, as indicated by the absence of documentation in the resident's Progress Notes. The facility's policy and procedure on Advance Directives, revised in September 2023, requires that copies of these documents be obtained and maintained in the resident's medical record, but this was not adhered to in this case.
Inaccurate MDS Coding for Resident's Oral Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident, leading to incorrect data being transmitted to the Centers for Medicare and Medicaid Services (CMS). The deficiency was identified during a review of the resident's MDS, which inaccurately indicated that the resident had no oral and/or dental issues, despite the presence of dentures observed in the resident's room. The MDS Nurse responsible for completing the assessment acknowledged the error, stating that the resident's use of dentures should have been documented. The resident involved had a medical history that included dementia, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and hypertension (HTN). The MDS indicated that the resident was dependent on staff for activities of daily living (ADLs) and had intact cognitive skills for daily decision-making. The facility's policy required qualified professionals to certify the accuracy of the MDS assessments, but this was not adhered to in this instance, resulting in the deficiency.
Failure to Develop Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents, leading to deficiencies in their care. Resident 42, who was admitted with a fracture of the right femur, osteoarthritis of the left knee, and a history of embolism and thrombosis, used side rails as a mobility aid. Despite the resident's intact cognition and the need for side rails being documented, there was no care plan developed to address the use of side rails, which is essential for assessing the necessity, appropriateness, and safety of the resident's use of these aids. Resident 40, who had diagnoses including dementia, COPD, diabetes mellitus, and hypertension, was observed to have dentures but lacked a care plan for their use. The absence of a care plan for dentures meant that the facility staff did not have a structured approach to ensure the resident's oral health needs were met, which is crucial for maintaining overall health and quality of life. Resident 24, diagnosed with diabetes mellitus, muscle weakness, depression, difficulty walking, and anxiety, was enrolled in a Restorative Nurse Assistant (RNA) program for ambulation and exercise. However, there was no care plan in place to guide the RNA program, which is vital for ensuring the resident receives the necessary care and services to maintain or improve mobility. The lack of care plans for these residents indicates a failure in communication and coordination among the facility staff, potentially impacting the residents' well-being.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to maintain appropriate grooming and personal hygiene for a resident, identified as Resident 18, by not keeping their fingernails clean and neat. Resident 18, who was dependent on staff for activities of daily living due to conditions such as end-stage renal disease, muscle weakness, and hypertension, was observed with long fingernails that had a black substance underneath. The resident expressed uncertainty about the last time their fingernails were cleaned or cut and indicated a desire for staff assistance in maintaining their nails. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), revealed that it was the responsibility of CNAs to clean and trim residents' fingernails daily. The facility's policy and procedure documents supported this responsibility, indicating that nails should be cleaned daily and trimmed regularly to prevent potential injuries and maintain personal hygiene. Despite these guidelines, the facility did not adhere to its policies, resulting in the observed deficiency.
Failure to Obtain Physician's Order for Side Rail Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of quarter side rails for a resident who used them for transfer assistance and bed mobility. The resident, who had a fracture of the right femur, osteoarthritis of the left knee, and a history of acute embolism and thrombosis, was observed using bilateral quarter side rails. Despite the resident's intact cognition and request for side rails, the facility did not secure a physician's order, which is necessary to ensure the safety and appropriateness of side rail use. Interviews with the LVN and the DON confirmed that a physician's order is required before installing side rails to ensure the physician's awareness and approval of their use. The absence of such an order for the resident meant there was no documented proof that the physician deemed the side rails safe, putting the resident at risk of injury from potential entrapment or physical harm. The facility's policy mandates that bed rails should not be used unless specific criteria, including obtaining a physician's order, are met.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure safe and effective medication administration practices for Resident 90, as observed during a survey. Licensed Vocational Nurse 3 (LVN 3) did not administer the prescribed Lidocaine patch 4% to Resident 90 as ordered by the doctor. Instead, LVN 3 falsely documented that the medication was administered, which was not the case. This resulted in Resident 90 experiencing unmanaged pain and requesting assistance due to discomfort. Further investigation revealed that LVN 3 did not reorder the necessary medication for Resident 90, leading to the use of another resident's Lidocaine patch 5%, which was not prescribed for Resident 90. LVN 3 failed to notify the Registered Nurse (RN) supervisor or Resident 90's doctor about the medication not being administered as ordered and the subsequent use of an incorrect medication. This practice exposed Resident 90 to potential medication errors and adverse effects. Interviews with LVN 4 and RN 1 confirmed the inappropriate actions taken by LVN 3, including the failure to follow proper procedures for medication administration and documentation. The facility's policy and procedure for administering medications were not adhered to, as medications were not administered in a safe and timely manner, and the required documentation was not completed accurately. This deficiency highlights a significant lapse in the facility's medication management practices.
Failure to Implement Pharmacist's Recommendation for Monitoring Bleeding Risk
Penalty
Summary
The facility failed to implement the pharmacist's recommendation from the Medication Regimen Review (MRR) for a resident, which had the potential to place the resident at risk for complications due to bleeding. The resident, who was admitted with diagnoses of diabetes mellitus and dysphagia, had fluctuating capacity to understand and make decisions, and was severely impaired in cognitive skills for daily decision-making. The resident was dependent on staff for various activities of daily living. The resident's medication orders included Apixaban and aspirin, both of which are blood thinners, but there was no order to monitor the resident for signs of bleeding in the electronic medical record or the Medication Administration Record (MAR). During an interview and record review, a registered nurse confirmed that the pharmacist's recommendation to monitor for bleeding was not included in the resident's electronic medical record, although it should have been. The nurse acknowledged that it was important to monitor for bleeding when administering blood thinners, as failure to do so could result in missed signs of bleeding, such as in feces or urine, and the resident not receiving necessary care. The facility's policy and procedure for Medication Regimen Reviews emphasized the goal of promoting positive outcomes while minimizing adverse consequences and potential risks associated with medications.
Incomplete Documentation of Resident Leave of Absence
Penalty
Summary
The facility failed to ensure complete and accurate documentation of clinical records for three residents, leading to potential miscommunication and safety concerns. For Resident 1, the facility did not document the dates and times the resident left and returned, nor were there nursing progress notes indicating these movements. Resident 1, who had fluctuating capacity to understand and make decisions, reported leaving the facility for appointments and errands without staff checking on him upon return. Resident 143's records also lacked documentation of the resident's outings, including who they left with and their outing plan. The Leave of Absence forms for two separate days were incomplete, and there were no nursing progress notes indicating the resident's departure and return. Resident 143 had intact cognitive skills for daily decision-making and required assistance with activities of daily living. Resident 144's Leave of Absence form was missing a nurse's signature, indicating the resident was not cleared to leave the facility. The electronic medical record also lacked documentation of the resident's departure. Interviews with staff revealed that the Leave of Absence forms must be fully completed and signed by a licensed nurse to ensure residents are cleared to leave, and the absence of such documentation is considered unsafe.
Infection Control Lapses in Oxygen Therapy and Blood Glucose Monitoring
Penalty
Summary
The facility failed to adhere to proper infection control practices for several residents, leading to potential risks of infection. For Resident 19, the nasal cannula and humidifier used for oxygen therapy were not changed every seven days as required. Observations revealed that the oxygen humidifier was dated over a month old, and the nasal cannula and tubing were undated and found touching the floor. The Director of Nursing confirmed that these supplies should be changed weekly to prevent respiratory infections, as per the facility's policy. Additionally, the facility did not follow proper procedures for blood glucose monitoring for Residents 8, 76, 90, and 15. A multiuse bottle of blood glucose test strips was taken into each resident's room during testing, which is against infection control protocols. The Licensed Vocational Nurse (LVN) involved in the testing was observed placing the test strips on bedside tables and returning the unused strips to the medication cart, increasing the risk of cross-contamination. The Director of Nursing acknowledged that the test strips should remain on the medication cart to prevent infection spread. The facility's policies on infection control and blood glucose monitoring were not followed, as evidenced by the improper handling of medical supplies and equipment. The Centers for Disease Control and Prevention guidelines emphasize maintaining unused supplies in clean areas and performing hand hygiene to prevent the spread of infections. The facility's failure to comply with these guidelines and its own policies placed residents at risk for infections, including hepatitis and other bloodborne pathogens.
Failure to Implement Care Plan Intervention for Resident Safety
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with excessive tendencies of crawling and climbing out of bed, which posed a risk of injury. The resident, who was admitted with diagnoses including cerebral infarction, Alzheimer's disease, and dementia, had a care plan that required placing a mattress on the floor next to the bed for safety precautions. However, during an observation, the resident was found on the floor underneath a bed, and the mattress was not placed as required but was instead leaning against a curtain. The Director of Nursing (DON) acknowledged that the care plan intervention was not followed, which was intended to prevent falls and ensure the resident's safety. The facility's policy and procedure on managing falls and fall risks emphasized the need to implement relevant interventions to minimize serious consequences of falling. Despite this, the care plan intervention was not executed, leaving the resident at risk of harm.
Failure to Report COVID-19 Case to CDPH
Penalty
Summary
The facility failed to report a COVID-19 positive case to the California Department of Public Health (CDPH), which was a requirement as per their policy and state regulations. Resident 4, who was admitted with diagnoses including epilepsy and muscle weakness, tested positive for COVID-19. Despite having the mental capacity to understand and make medical decisions, the facility did not report this case to the CDPH, as confirmed by the Infection Preventionist (IP) during an interview. The facility's policy, dated May 2023, clearly stated that the health department should be notified of any residents or staff with suspected or confirmed COVID-19 infection. The Director of Nursing (DON) also acknowledged that COVID-19 outbreaks and other unusual occurrences should be reported to the CDPH. A review of the All Facilities Letter (AFL) 23-08 confirmed that COVID-19 is categorized as an unusual infection that requires reporting. The facility's policy on unusual occurrence reporting, dated December 2007, indicated that such events should be reported via telephone to appropriate agencies within 24 hours. The failure to report resulted in a delay in investigation by the CDPH and had the potential for the virus to spread within the facility.
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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