Maywood Skilled Nursing & Wellness Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Maywood, California.
- Location
- 6025 Pine Ave, Maywood, California 90270
- CMS Provider Number
- 555130
- Inspections on file
- 35
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Maywood Skilled Nursing & Wellness Centre during CMS and state inspections, most recent first.
Ombudsman Contact Information Not Posted: The facility failed to keep the State LTC Ombudsman program’s contact information posted in a visible area for residents. An alert resident with COPD, HTN, and dysphagia stated he did not know where to find the information, and the IPN and DON confirmed it was not posted after being removed during repainting. The facility policy stated the Ombudsman and CDPH contact details were to be posted on the consumer board.
An LVN did not administer a resident’s ordered cholecalciferol and documented it incorrectly on the MAR. For another resident with a change in condition, a UA with C&S order was not properly entered, endorsed, or followed up, so assigned nurses were not aware of the pending lab work. A third resident receiving haloperidol 4 mg BID was not monitored for sedation or other psychotropic side effects, and the MAR did not show the required monitoring.
Failure to submit accurate PBJ staffing data: Surveyors found the facility did not submit quarter one direct care staffing information to CMS, even though the ADM said a third-party company handled quarterly submissions and the data should have been sent. The CPD stated the submission database changed the quarter selection from Q1 to Q2, so Q1 data was submitted under the wrong quarter and the error went unnoticed. The DON stated staffing hours were important for meeting required hours and identifying staffing issues.
Call Light Not Within Reach: A resident with falls, muscle weakness, dysphagia, schizoaffective disorder, COPD, and bilateral knee contractures was observed lying in bed with the call light hanging behind and under the bed, out of reach. A photo confirmed the call light was not accessible, and an LVN stated call lights should always be within reach and verified during routine safety checks; the facility policy stated the call alert device will be placed within the resident’s reach.
Failure to Notify Physician of Resident’s Medication Preference: An LVN administered Depakote Sprinkle capsules whole to a resident with epilepsy, bipolar disorder, and schizophrenia even though the order directed the medication to be mixed with applesauce. The LVN stated the resident usually preferred to take the capsules whole, but she did not notify the physician of that preference. The DON stated the physician should have been informed because the order was intended to reduce choking risk.
Exposed Resident Belongings in Room Closets: Three residents with severely impaired cognition had their clothing and personal belongings left visible when all closet doors were missing in their shared room. One resident stated they did not want people seeing their belongings, and the DON acknowledged the missing doors left items exposed and at risk for potential theft. The facility policy called for a safe, clean, comfortable, and homelike environment.
A resident admitted from a GACH had schizophrenia, bipolar disorder, depression, cognitive impairment, and psychotropic medication use, but the PASRR Level 1 screening incorrectly stated the resident did not have a serious mental illness and was not taking psychotropic medication. The MDS nurse and DON stated the screening should have been reviewed for accuracy and that a new PASRR Level 1 should have been submitted so a PASRR Level 2 assessment could be completed.
Delayed Care Planning for Dentures and Sedating Medication: The facility did not timely develop and implement individualized care plans for a resident who was edentulous and refused to wear dentures, another resident whose full dentures were received by social services but not communicated to nursing, and a third resident who was frequently asleep in bed and receiving Haloperidol. Records, observations, and staff interviews showed the residents had identified needs, but care planning was delayed or omitted, including denture-related needs and daytime bedrest concerns.
A resident with epilepsy, bipolar disorder, and schizophrenia had a physician order for Depakote Sprinkle to be mixed with applesauce, but staff observed an LVN giving the capsules whole with water. The LVN stated she knew the resident did not like it mixed with applesauce and did not follow the order. The DON stated the resident’s care plans should have been updated to reflect the resident’s preference to take the medication whole if safe.
Failure to orient a legally blind resident to his meal tray during lunch. The resident had severely impaired vision, needed supervision or touching assistance while eating, and his care plan called for assistance with ADLs, including eating. During observations, he was eating by himself and could not find his spoon, and he stated staff did not orient him to the tray. CNA 2 said she placed the tray but did not give a detailed orientation, and the DON stated the resident should receive coaching when a meal tray is provided.
Medication administration errors were observed involving two residents. One resident received a regular multivitamin instead of the ordered multivitamin-minerals, had cholecalciferol documented as given when it was not administered, and had a Colace refusal inaccurately charted on the MAR. Another resident with epilepsy was given Depakote Sprinkle whole instead of being opened and mixed with applesauce as ordered. The DON and LVNs acknowledged the incorrect administration and documentation.
Improper cleaning of resident dishware and failure to label/store visitor food were observed. Clean water pitchers had sticky residue and old labels, and breakfast bowls had dried food residue. A resident with intact cognition and orders for NAS/CCHO diet had grapes from a family member left at the bedside without a date label, and the DS stated visitor food should be labeled and stored in the refrigerator.
Inaccurate fall risk records and missing denture documentation: The facility documented one resident’s vision status as adequate even though records and staff interviews showed impaired vision, and another resident’s post-fall evaluations were left incomplete with missing contributing factors after two falls. The facility also failed to update a resident’s special needs and belongings records to show upper and lower dentures had been received, and the dentures later could not be located.
Undated oxygen tubing and humidifier bottle. A resident with COPD, respiratory failure, diabetes, and heart failure was receiving O2 via NC, with an order for tubing changes every 7 days. During observation, the tubing and humidifier bottle were not dated, and an RN stated both items should be labeled with a date.
The facility failed to maintain appropriate food temperatures during lunch service, with quesadillas and lasagna found at 120°F and 126°F, below the required 140°F. The dietary staff placed these items away from the stove due to space constraints, leading to inadequate temperatures. The Dietary Supervisor confirmed these temperatures were unacceptable, potentially affecting 112 residents' food intake and posing a risk of unplanned weight loss.
The facility failed to maintain safe food temperatures, with quesadillas and lasagna measuring below the required 140°F. This deficiency affected 112 of 115 medically compromised residents, posing a risk of bacteria growth and foodborne illness. The issue arose due to inadequate space on the stove and steam table, leading to improper food storage.
The facility was found to have improper garbage storage practices, as two trash dumpster lids were not closed completely. This was observed during a survey and confirmed by the Dietary Supervisor and Infection Preventionist Nurse, who both stated that the lids should be closed to prevent flies and maintain infection control. The facility's Administrator acknowledged the lack of a specific policy requiring the lids to be closed, despite existing guidelines for covered food waste disposal.
The facility failed to report abuse allegations involving two residents to the State Agency, ombudsman, and police. One resident reported hurtful comments by a CNA, while another alleged inappropriate touching during care. Despite internal reporting, external agencies were not notified, delaying investigation and potentially exposing other residents to abuse.
Two residents reported abuse by a CNA, but the facility failed to conduct thorough investigations or suspend the CNA, leaving other residents at risk. Despite reports of hurtful comments and inappropriate touching, the facility only reassigned the CNA without further action, violating its abuse reporting policy.
The facility failed to respect the rights and dignity of two residents. One resident did not have a public guardian or IDT meeting to facilitate care, resulting in medical treatments without consent. Another resident's nephrostomy bags were not covered with a dignity bag, contrary to facility policy. These actions demonstrate a lack of adherence to policies ensuring resident rights and dignity.
A facility failed to obtain updated informed consents for psychotropic medications for a resident unable to make medical decisions. Despite severe cognitive impairment, the resident was administered Haloperidol, Buspirone Hydrochloride, and Sertraline Hydrochloride without consent from a responsible party or public guardian, nor was an IDT convened. The facility's policy required surrogate decision-making, which was not followed, as confirmed by an LVN.
A resident with aphasia in an LTC facility was not provided with a communication device at her bedside, hindering her ability to communicate effectively. Despite having a care plan that included the use of a communication board, the resident relied on gestures and writing, which were not always understood by staff and visitors. The facility's policy to provide adaptive devices for communication was not followed.
Three residents were found on low air loss mattresses (LALM) set incorrectly for their weights, risking the worsening of pressure ulcers. A resident with a resolved Stage III ulcer was on a LALM set for 300 lbs instead of 170 lbs. Another resident with a surgical wound was on a LALM set for 200 lbs instead of 147.8 lbs. A third resident with a Stage II ulcer was on a LALM set for 550 lbs instead of 190.2 lbs. The facility's policy to ensure proper LALM settings was not followed.
The facility failed to adequately monitor and care for a resident with a long-term indwelling urinary catheter, leading to septic shock, and another resident with nephrostomy tubes, risking urinary tract infections. The staff did not follow care plans or physician orders, failing to document and communicate changes in the residents' conditions.
A facility failed to check the gastrostomy tube (GT) placement and gastric residual volume (GRV) for a resident with severe cognitive impairment and multiple medical conditions. The care plan required checking these parameters every shift, but an LVN started the tube feeding without doing so, acknowledging the oversight. The DON highlighted the importance of these checks to prevent complications, as outlined in the facility's policy.
Two residents in the facility were found with unlabeled nebulizer masks, which lacked the resident's name and date of opening, posing an infection risk. Both residents had significant medical conditions, including COPD and dementia, and required assistance with daily activities. The facility's policy required masks to be changed and labeled every seven days, but this was not followed, as confirmed by staff interviews.
A resident with a history of UTI, sepsis, and diabetes reported feeling uncomfortable during a bed bath, alleging inappropriate touching by a CNA. Despite the resident's moderate cognitive impairment, he was capable of making decisions. The LVN reassigned the CNA but did not notify the physician, contrary to facility policy. The RN and DON acknowledged the physician should have been informed to assess and implement necessary interventions.
The facility failed to create care plans for two residents after allegations of inappropriate behavior by a CNA. One resident reported hurtful comments affecting her emotional state, while another alleged inappropriate touching during a bed bath. Despite investigations and reassignment of the CNA, care plans were not developed, contrary to facility policy.
A resident with dementia and known behavioral issues, including biting and elopement risk, did not have a comprehensive care plan in place. This led to an incident where the resident wandered into another resident's room, resulting in an altercation. The facility's policies on care planning and risk management were not followed.
A resident with dementia and behavioral issues was inadequately supervised, leading to an altercation with another resident. Despite care plans requiring frequent checks, staff were too busy to monitor the resident every 15 minutes, allowing them to wander into another resident's room and cause an incident.
Ombudsman Contact Information Not Posted
Penalty
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman program contact information was posted in a visible area for residents. During observation of the front lobby and the walls throughout the facility, no Ombudsman contact information was posted. The Infection Prevention Nurse stated the information was usually posted in the front lobby but was not posted at the time because it had been taken down when the walls were recently repainted. The nurse also stated the information should be posted in a visible place for residents so they could report concerns or make complaints to the Ombudsman. Resident 52, who was admitted and later readmitted to the facility, had diagnoses including COPD, HTN, and dysphagia. The resident’s H&P indicated he had the capacity to understand and make decisions, and the MDS described him as cognitively intact and needing staff supervision for eating and toileting, with partial assistance for bathing and personal hygiene. During interview, Resident 52 stated he did not know where to find the Ombudsman’s contact information in the facility. The DON stated the Ombudsman information was usually posted in the front lobby but had been removed during repainting, and the facility policy stated that addresses and telephone numbers for the local Long Term Care Ombudsman’s office and the California Department of Public Health were posted on the facility consumer board.
Medication administration, lab order follow-up, and psychotropic monitoring failures
Penalty
Summary
The facility failed to ensure a resident received cholecalciferol as ordered when an LVN did not clarify the medication during administration and then documented it as given on the MAR even though it was not administered. The resident had diagnoses including protein-calorie malnutrition, generalized muscle weakness, and generalized osteoarthritis, and was cognitively intact with capacity to understand and make decisions. During the observed medication pass, the LVN prepared and administered other medications but did not give the cholecalciferol. She later stated she was confused by the order and the house supply medications, did not want to risk giving the wrong medication, and documented incorrectly. The DON stated the medication should have been clarified during the medication administration timeframe and that the resident did not receive the daily dose. The facility also failed to carry out a physician order for a UA with C&S for a resident with diabetes, Alzheimer’s disease, muscle weakness, and neuromuscular dysfunction of the bladder. The resident had a change in condition with getting up unassisted, yelling, and combative and aggressive behaviors, and the physician ordered the urine testing. The order was not properly entered into the physician orders, was not visible to assigned nurses, and there was no documentation showing endorsement, attempts to obtain the specimen, or follow-up. RN staff stated they were not made aware of the pending order because it was not endorsed or documented in a way that allowed follow-up, and the DON stated the order was not properly inputted and should have had an end date to ensure awareness. The facility further failed to monitor a resident receiving haloperidol 4 mg twice daily for sedation and related side effects. The resident had COPD, muscle weakness, dysphagia, and dementia, and was severely cognitively impaired and dependent on staff for toileting, bathing, and dressing. The care plan and psychotropic risk form identified sedation as a risk and indicated monitoring for adverse reactions such as sedation and dizziness, but the MAR did not show monitoring for sedation. During observation, the resident was found asleep in bed and did not respond to verbal stimuli until repeated attempts and tactile stimulation, including a sternal rub. The DON stated monitoring for sedation was important due to the risk for falls or excessive sedation and to allow the physician to be notified if medication adjustments were needed.
Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to ensure direct care staffing information was submitted to CMS based on payroll and other verifiable and auditable data. During review of the PBJ Staffing Data Report dated 3/19/2026, surveyors found the facility had not submitted data for quarter one (10/1/2025-12/31/2025). In a concurrent interview and record review with the ADM, the CMS Submission Report dated 2/13/2026 showed direct care staffing information was submitted for quarter two (1/1/2026-3/31/2026) on 2/13/2026. The ADM stated the facility used a third-party company to submit the quarterly staffing information and acknowledged that quarter one data should have been submitted. During interviews, the CPD stated the database used to submit staffing information changed the selection for submission from quarter one to quarter two, and that quarter one's data had been submitted but the error in quarter selection went unnoticed. The CPD stated this error caused the facility to be triggered for failing to submit data for quarter one. The DON stated submitting direct care staffing hours was important because it ensured the facility met required hours and helped identify staffing issues, and that staffing hours helped indicate the level of care being provided to residents. The facility policy titled Electronic Staffing Data Submission Payroll-Based Journal stated direct care staffing and census data would be collected quarterly and was required to be timely and accurate.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure the call light was readily accessible and within reach for one sampled resident, Resident 112. Resident 112 was admitted with diagnoses including falls, muscle weakness, dysphagia, schizoaffective disorder, COPD, and contractures of both knees. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated mildly impaired cognitive skills for daily decision making and moderate assistance needed for ADLs. During an observation at the resident’s bedside, Resident 112 was lying in bed and the call light was hanging behind and under the bed, out of reach. A concurrent review of a photo taken at the time of the observation confirmed the call light was behind the bed and not accessible. LVN 1 stated that call lights should always be within reach, including after care, repositioning, toileting, and transfers, and that staff were expected to verify accessibility as part of routine safety checks. The facility policy titled Communication- Call System stated that the call alert device will be placed within the resident’s reach.
Failure to Notify Physician of Resident’s Medication Preference
Penalty
Summary
The facility failed to notify Resident 91’s physician of the resident’s preference to take Depakote Sprinkle capsules whole. Resident 91 was admitted and readmitted to the facility with diagnoses including epilepsy, bipolar disorder, and schizophrenia. The resident’s MDS indicated cognition was intact and that the resident required supervision or touching assistance with several activities of daily living. The resident’s H&P stated the resident had the capacity to understand and make decisions, and the care plan for risk of aspiration/choking directed staff to crush medications and mix with applesauce if indicated. During observation, LVN 5 prepared Resident 91’s routine medications and administered the Depakote Sprinkle capsules whole along with the resident’s other medications. During interview, LVN 5 stated the Depakote Sprinkle was supposed to be administered with applesauce, that the capsule should be opened and the beads poured over applesauce, and that she did not follow the physician’s order. LVN 5 also stated the resident’s usual preference was to take the capsules whole, but she should still have asked the resident before administering them and did not notify the physician of the preference. The DON stated licensed nurses were responsible for following medication administration instructions and that the physician should have been notified because the order was to mix the medication with applesauce to reduce the risk of choking.
Exposed Resident Belongings in Room Closets
Penalty
Summary
The facility failed to ensure residents' clothing and personal belongings were protected from view and potential loss when closet doors were left uncovered without doors or adequate protective measures for three sampled residents. Resident 11 was admitted and readmitted to the facility with diagnoses including pneumonia, COPD, Alzheimer's disease, and muscle weakness. The MDS dated 3/4/2026 indicated the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for oral hygiene, bathing, toileting, and dressing. Resident 25 was admitted and readmitted with diagnoses including diabetes, Alzheimer's, muscle weakness, and neuromuscular dysfunction of the bladder, and the MDS indicated severely impaired cognitive skills and need for moderate assistance with oral hygiene, toileting, and dressing. Resident 116 was admitted and readmitted with diagnoses including COPD, muscle weakness, and dysphagia, and the MDS indicated severely impaired cognitive skills and dependence on staff for oral hygiene, toileting, bathing, and dressing. During observations in Room A, all three closet doors were missing, leaving the clothing and personal belongings of Residents 11, 25, and 116 exposed. Resident 116 stated that the closets were not supposed to be like that and that they did not want people seeing their belongings. The DON stated that the absence of closet doors made the residents' personal belongings exposed and at risk for potential theft, and stated the facility was aware of the issue. The facility policy on Resident Rooms and Environment stated that the facility was to ensure a safe, clean, comfortable, and homelike environment and to provide a pleasant environment that emphasized residents' comfort, independence, and personal needs and preferences.
Incorrect PASRR Screening for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure that the correct PASRR Level 1 screening was received and reviewed for a resident admitted from a general acute care hospital. The resident had diagnoses of schizophrenia and major depressive disorder on the admission record, and the MDS also identified bipolar disorder, moderate cognitive impairment, and use of antipsychotic and antidepressant medications. The resident’s H&P indicated the resident could make needs known but could not make medical decisions, and the hospital H&P listed bipolar disorder and schizophrenia. The hospital discharge reconciliation directed continuation of aripiprazole, fluoxetine, and mirtazapine after discharge. The facility’s physician orders also included aripiprazole for schizophrenia with aggressive behavior, fluoxetine for depression with refusal to participate in previously enjoyed activity, and later mirtazapine for depression with poor oral intake. A psychiatric evaluation documented diagnoses of schizophrenia, bipolar disorder, and depression with psychotropic medication use. During interview and record review, the facility’s MDS nurse stated the PASRR Level 1 from the hospital was reviewed on admission to determine whether a Level 2 assessment was needed, but the resident’s PASRR Level 1 incorrectly indicated the resident did not have a serious mental illness and was not taking psychotropic medication. The MDS nurse stated the screening was not accurate because the resident had schizophrenia, bipolar disorder, and psychotropic medication use, and that a new PASRR Level 1 should have been submitted so a Level 2 assessment could be completed. The DON stated the PASRR Level 1 should have been reviewed by nursing and admissions staff for accuracy and that the inaccurate screening should have been identified on admission.
Delayed Care Planning for Dentures and Sedating Medication
Penalty
Summary
The facility failed to develop and implement comprehensive care plans in a timely manner for three residents who had specific care needs related to dentures and use of Haloperidol. The report states that the deficient practice involved Resident 22, Resident 28, and Resident 4, and that the care plans were not developed when the residents’ conditions and needs were identified through assessment, observation, and record review. Resident 22 was admitted and later readmitted to the facility with diagnoses including COPD, diabetes mellitus, and dementia. The MDS indicated the resident was moderately impaired in daily decision-making, dependent on staff for multiple ADLs, and edentulous. Dental notes showed dentures were delivered to the facility, and the resident was observed without natural teeth and stated she had dentures but did not know where they were. Staff interviews confirmed the resident refused to wear her dentures. The MDS nurse stated the care plan for the resident’s edentulous status was developed only after the annual MDS was completed, and that a care plan addressing refusal to wear dentures should also have been developed sooner. Resident 28 was admitted with diagnoses including COPD, anemia, muscle weakness, GERD, and diabetes. The resident’s H&P stated she could make needs known but could not make medical decisions, and the MDS showed mild impairment in daily decision-making and need for supervision with ADLs. A dental evaluation report showed the facility received the resident’s full upper and lower dentures, and the resident stated she needed her dentures to eat. The SSD and DON stated the dentures were received by social services, but nursing was not informed, and the dentures were omitted from the special needs list and belongings record. The DON stated the resident needed an individualized care plan for denture care, including cleaning, storage, fit monitoring, and assessment for discomfort or oral breakdown, and that this did not occur because of a communication breakdown. Resident 4 was admitted and readmitted with diagnoses including COPD, muscle weakness, dysphagia, and dementia. The MDS showed severe impairment in daily decision-making, dependence on staff for toileting, bathing, and dressing, and the H&P stated the resident lacked capacity to understand and make decisions. A physician order directed Haloperidol 4 mg by mouth twice daily. Observations showed the resident asleep in bed, slow to respond to verbal prompts, and on another occasion unresponsive to verbal and tactile stimulation until a sternal rub was performed. LVN 6 stated the resident had been napping extensively and keeping his eyes closed for approximately one to two months before the care plan was initiated, and that the care plan should have been started sooner.
Care Plan Not Revised to Reflect Resident’s Medication Preference
Penalty
Summary
The facility failed to revise one sampled resident’s care plan to reflect the resident’s preference for taking Depakote Sprinkle capsules whole. Resident 91 was admitted and readmitted to the facility with diagnoses including epilepsy, bipolar disorder, and schizophrenia. The resident’s MDS dated 2/16/2026 indicated cognition was intact, and the H&P dated 11/11/2025 stated the resident had the capacity to understand and make decisions. A physician order dated 11/9/2025 directed Depakote Sprinkle 500 mg by mouth twice a day for epilepsy and to mix it with applesauce. Resident 91’s care plan for aspiration/choking, initiated 11/10/2025, directed staff to crush medications and mix with applesauce if indicated, and the seizure-related care plan directed staff to administer Depakote Sprinkle 500 mg by mouth twice a day. During observation on 3/24/2026, an LVN prepared and administered the resident’s medications, keeping the capsules whole and giving them with water. During interview, the LVN stated she did not follow the physician’s order and said she knew the resident did not like to take it mixed with applesauce. The DON stated the resident had the right to take medications however preferred as long as it was safe, and that the care plans should have been updated to reflect the resident’s preference to take Depakote Sprinkle capsules whole if there were no safety concerns.
Failure to Orient a Legally Blind Resident to Meal Tray
Penalty
Summary
The facility failed to ensure that Resident 94, who was legally blind and had severely impaired vision, was oriented to his meal tray during lunch. Resident 94's admission record showed diagnoses including legal blindness, COPD, muscle weakness, and hypertension. His MDS indicated he needed supervision or touching assistance while eating, and his care plan stated that he was legally blind and needed assistance with activities of daily living, including eating, to maintain a hazard free and safe environment. During a concurrent observation and interview on 3/23/2026 at 12:24 p.m., Resident 94 was sitting on his bed with his lunch tray in front of him and was eating by himself. He stated he could not find his spoon on the meal tray and that staff did not orient him to the tray. During another observation on 3/24/2026 at 12:20 p.m., he was again eating by himself with no utensil in his hand and could not find his spoon on the tray. CNA 2 stated she placed the tray on the table but did not provide a detailed orientation of the meal tray, and the DON stated that Resident 94 should receive coaching when a meal tray is provided so he knows where each item is located.
Medication Administration Errors and Inaccurate Documentation
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent during a medication administration observation involving two residents. Surveyors identified four medication errors out of 27 opportunities, resulting in a 14.81% error rate. The errors involved one resident receiving a multivitamin instead of the ordered multivitamin-minerals, cholecalciferol being documented as given when it was not administered, and Colace refusal being inaccurately documented on the MAR. One resident had diagnoses including protein-calorie malnutrition, generalized muscle weakness, and generalized osteoarthritis. Her MDS indicated intact cognition and that she required supervision or touching assistance with several activities of daily living. Her physician orders included cholecalciferol 1000 units daily, Colace 100 mg daily with instructions to hold for loose stools, and multivitamin-minerals daily. During observation, an LVN prepared and administered medications but gave a regular multivitamin instead of the ordered multivitamin-minerals and did not prepare the cholecalciferol capsule. The LVN later stated she administered the wrong multivitamin and that the cholecalciferol was not given, although it was documented on the MAR as administered. The same resident refused Colace during the observed medication pass, but the MAR was documented as if the medication had been given. The DON stated the refusal should have been accurately documented because it was needed to track bowel movements. Another resident had diagnoses including epilepsy, bipolar disorder, and schizophrenia, with intact cognition and a care plan directing that medications be crushed and mixed with applesauce if indicated. During observation, an LVN removed Depakote Sprinkle capsules from the blister pack and divided them into medication cups, then administered them whole rather than opening the capsules and mixing the beads with applesauce as ordered. The LVN stated she did not follow the physician’s order and acknowledged the medication was supposed to be administered with applesauce to reduce the risk of choking.
Improper Cleaning of Dishware and Unlabeled Visitor Food
Penalty
Summary
The facility failed to ensure resident-use dining equipment was properly cleaned and sanitized. During a concurrent observation and interview in the kitchen, six water pitchers labeled as clean were observed on the clean storage rack with sticky residue and previously dated labels dated 3/21/2026 and 3/22/2026 on the lids. The staff member present stated the residue showed the pitchers had not been thoroughly cleaned before being placed in clean storage, and that labels should have been removed before washing. A dishwasher stated that dining equipment must be inspected after removal from the dishwasher and any items with residual food or debris must be rewashed and sanitized before being placed in clean storage. During another observation, multiple breakfast bowls were seen with dried food residue remaining on their surfaces. The Dietary Supervisor stated that all resident-use dishware, including bowls and water pitchers, must be thoroughly washed, rinsed, and sanitized before reuse, and that kitchen staff should report dirty dishware so proper washing can occur. The supervisor stated the observed condition did not meet facility expectations for safe food handling and sanitation practices. The facility policy titled Dietary Assistant/Dishwasher indicated maintaining a safe and sanitary work environment. The facility also failed to properly label and store food brought in from outside for a resident with type 2 diabetes mellitus, COPD, and major depressive disorder. The resident’s record showed intact cognition, capacity to make decisions, and an order for a NAS and CCHO diet. An opened bag of green grapes was observed on the resident’s nightstand and later a cup of grapes was observed on the bedside table; neither was labeled with the date brought into the facility. The resident stated the grapes were brought by a family member and had been at the bedside for about two days before being placed in the cup. The Dietary Supervisor stated food brought in by visitors had to be labeled with the resident’s name and date received, and that the grapes should have been stored in the refrigerator. The facility policy for food brought in by visitors required food to be labeled with the resident’s name and date received and stored in the designated refrigerator.
Inaccurate fall risk records and missing denture documentation
Penalty
Summary
The facility failed to keep resident records accurate for fall risk and resident property documentation. For Resident 105, the admission record showed diagnoses including COPD, diabetes mellitus, and schizophrenia, and the H&P stated the resident had capacity to understand and make decisions. However, the MDS dated 12/16/2025 indicated moderate cognitive impairment and moderately impaired vision. During review of the Fall Risk Evaluation dated 3/18/2026, the vision status was documented as adequate even though LVN 2 stated the resident was visually impaired and required orientation to objects in the environment. RN 1 also reviewed the ophthalmology note dated 3/3/2026, which indicated the resident was blind in the right eye, and stated the fall risk evaluation was inaccurate because it should have reflected poor vision instead of adequate. For Resident 82, the admission record listed diagnoses including history of falling, diabetes, muscle weakness, and hypertension. The MDS indicated a history of fall and a history of fracture prior to admission. Fall Risk Evaluations dated 1/20/2026 and 2/28/2026 both identified the resident as high risk for falls. The post-fall evaluation dated 2/28/2026 did not indicate the contributing factors for the fall, and the post-fall evaluation dated 3/5/2026 also did not include all contributing factors. LVN 1 stated she completed the post-fall evaluation for the 3/5/2026 fall and acknowledged that several contributing factors were left blank and should have been documented. The DON stated the resident had two falls and that the post-fall evaluation needed to be fully completed so all factors contributing to the falls could be identified. For Resident 28, the admission record listed diagnoses including COPD, anemia, muscle weakness, GERD, and diabetes. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated mildly impaired cognitive skills for daily decision making and supervision needed for ADLs. During observation and interview, Resident 28 stated she wore upper and lower dentures and needed them to eat, but said they had gone missing. The dental evaluation report dated 12/30/2025 showed the resident received full upper and lower dentures, yet the List of Residents with Special Needs did not identify the resident as having dentures. The SSD confirmed the list was not updated after the dentures were received, and the resident's belongings list dated 10/17/2025 was also not updated to reflect the dentures. The DON confirmed the belongings list was not updated and stated the omission reflected a breakdown in facility policy and procedure.
Undated oxygen tubing and humidifier bottle
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure that Resident 55’s nasal cannula oxygen tubing and humidifier bottle were labeled with a date. Resident 55 was a [AGE]-year-old female admitted on [DATE] with diagnoses including COPD, respiratory failure, diabetes, and heart failure. Her MDS dated 2/27/2026 indicated she was on oxygen therapy, and a physician’s order dated 2/20/2026 directed oxygen at 2 liters per minute via nasal cannula as needed and that the oxygen tubing be changed every 7 days. During an observation on 3/23/2026 at 11:18 a.m., Resident 55 was lying on her bed wearing her nasal cannula, and the oxygen tubing and humidifier bottle did not have any dates on them. During a concurrent observation and interview on 3/24/2026 at 10:30 a.m., RN 1 observed that both items were still not dated and stated they should be labeled with a date. RN 1 also stated the oxygen tubing must be changed every 7 days. The facility’s policy titled Oxygen Therapy, dated 10/31/2025, indicated oxygen tubing should be changed at least every 7 days and labeled with the date of change.
Inadequate Food Temperature Management
Penalty
Summary
The facility failed to maintain appropriate food temperatures during lunch service, as observed on December 17, 2024. During the tray line service, quesadillas and lasagna were found to be at temperatures of 120°F and 126°F, respectively, which are below the facility's required temperature of greater than 140°F for hot foods. The dietary staff placed these food items on a shelf away from the stove and steam table due to a lack of space, leading to the inadequate temperatures. The Dietary Supervisor confirmed that these temperatures were unacceptable and acknowledged that the food would not be palatable for residents, potentially affecting their food intake. The facility's Policy and Procedure on food temperatures, revised on July 1, 2024, was reviewed and indicated that hot food should be maintained above 140°F. However, there was no policy addressing food palatability or menu planning, which the Dietary Supervisor noted should be in place if there were concerns. The deficient practice had the potential to affect 112 of 115 residents who received food from the kitchen, posing a risk of unplanned weight loss due to poor food intake.
Deficient Food Temperature Control in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Specifically, the temperatures of quesadillas and lasagna were found to be below the required safe temperature of 140 degrees Fahrenheit. The quesadillas measured 120 degrees Fahrenheit, and the lasagna measured 126 degrees Fahrenheit. These food items were placed on a shelf away from the stove and steam table due to a lack of space, which contributed to the inadequate temperatures. The dietary staff, including Cook 1, acknowledged the temperature readings and the Dietary Supervisor confirmed that these temperatures were unacceptable according to the facility's policy. The deficiency had the potential to affect 112 of 115 medically compromised residents who received food from the kitchen. The Infection Preventionist Nurse indicated that hot food below 140 degrees Fahrenheit could lead to bacteria growth, potentially causing foodborne illness. The quesadillas were intended for residents on regular and mechanical soft diets, while the lasagna was for those on a liquid diet. The failure to maintain appropriate food temperatures posed a risk of cross-contamination and foodborne illness among the residents.
Improper Garbage Storage Practices
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary manner, as observed during a survey. Two trash dumpster lids were not closed completely, which was confirmed during an observation and interview with the Dietary Supervisor (DS). The DS acknowledged that the lids should be closed to prevent flies, which can transport bacteria and potentially cause illness among residents. The Infection Preventionist Nurse (IPN) also confirmed that the lids should be closed for infection control purposes. The facility's Administrator (ADM) admitted that there was no existing policy requiring the lids to be closed, although the facility's policy on garbage and trash can use indicated that food waste should be placed in covered containers.
Failure to Report Abuse Allegations to Authorities
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the appropriate authorities, including the State Agency, ombudsman, and police department. Resident 88, who had a history of urinary tract infection, type two diabetes mellitus, and major depressive disorder, was reported by her Responsible Party to have been subjected to hurtful comments by a Certified Nursing Assistant (CNA). Despite the report, the Registered Nurse (RN) involved did not notify the external agencies, believing that informing the Director of Nursing (DON) was sufficient. The Director of Staff Development (DSD) confirmed that the CNA had not been assigned to Resident 88 for over a month, but the lack of external reporting delayed further investigation. In a separate incident, Resident 259, who had diagnoses including urinary tract infection, sepsis, and type two diabetes mellitus, reported feeling uncomfortable with the care provided by the same CNA during a bed bath. The resident alleged inappropriate touching, which was communicated to a Licensed Vocational Nurse (LVN) and the DSD. Although the CNA assignment was changed to ensure the resident's comfort, the allegations were not reported to the necessary external agencies. The LVN assumed that reporting to the DSD would suffice, but the DSD acknowledged that the allegations should have been reported due to the nature of the claims. Interviews with facility staff, including the DON and Administrator, revealed a misunderstanding of the reporting responsibilities. The facility's policy required that all abuse allegations, regardless of perceived validity, be reported to the Administrator and external agencies within two hours. The failure to adhere to this policy resulted in a delay of an onsite inspection by the State Agency and potentially exposed other residents to ongoing abuse.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, which led to a deficiency in protecting residents from potential abuse. Resident 88, who had a history of urinary tract infection, type two diabetes mellitus, and major depressive disorder, was reported by her Responsible Party to have been subjected to hurtful comments by a Certified Nursing Assistant (CNA 2). Despite the report, the facility did not conduct a thorough investigation, as CNA 2 was not suspended, and no further actions were taken after confirming that CNA 2 had not been assigned to Resident 88 for over a month. In another incident, Resident 259, who had diagnoses including urinary tract infection, sepsis, and type two diabetes mellitus, reported feeling uncomfortable during a bed bath provided by CNA 2. The resident alleged inappropriate touching, which was reported to a Licensed Vocational Nurse (LVN 3) and the Director of Staff Development (DSD). However, the facility only changed the CNA assignment without conducting a thorough investigation or suspending CNA 2, which left other residents potentially vulnerable to similar incidents. The Director of Nursing (DON) and the Administrator (ADM) acknowledged that the facility's policy required immediate reporting and suspension of the alleged perpetrator pending investigation, but these steps were not followed. The facility's failure to adhere to its policy and procedure for abuse reporting and investigation resulted in a lack of protection for residents and a deficiency in addressing the allegations appropriately.
Failure to Ensure Resident Rights and Dignity
Penalty
Summary
The facility failed to respect the rights and provide dignity to two residents, Resident 75 and Resident 95. For Resident 75, the facility did not obtain a public guardian or conduct an interdisciplinary team (IDT) meeting to facilitate the care and medical treatments. Resident 75 was admitted with diagnoses including schizophrenia disorder, depressive disorder, and anxiety, and was found to have severely impaired cognitive skills for daily decision-making. Despite this, there was no documentation indicating efforts to find a surrogate decision-maker or apply for public guardianship, resulting in medical treatments and antipsychotics being administered without consent from an appointed decision-maker. For Resident 95, the facility failed to follow its policy and procedure regarding catheter care by not providing a dignity bag for the resident's nephrostomy bags. Resident 95, who had chronic kidney disease and other related conditions, was observed with nephrostomy bags lying uncovered on the bed, which was against the facility's policy. The Licensed Vocational Nurse (LVN) acknowledged the inappropriate handling of the nephrostomy bags and the lack of documentation regarding any refusal of a dignity bag by Resident 95. The Treatment Nurse (TN) later provided education to Resident 95 about the importance of using dignity bags, but initially, there was no documentation or care plan addressing the issue. These deficiencies highlight the facility's failure to ensure the rights and dignity of its residents, as evidenced by the lack of appropriate decision-making support for Resident 75 and the failure to maintain dignity for Resident 95 by not covering the nephrostomy bags. The facility's policies and procedures were not adequately followed, leading to these oversights in resident care.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain updated informed consents for the administration of psychotropic medications to Resident 75, who was unable to make medical decisions. Resident 75 was admitted with diagnoses including schizophrenia, depressive disorder, and anxiety, and was assessed as having severely impaired cognitive skills for daily decision-making. Despite this, the facility administered Haloperidol, Buspirone Hydrochloride, and Sertraline Hydrochloride to Resident 75 without obtaining consent from a responsible party or public guardian, nor did they convene an interdisciplinary team to make medical decisions on behalf of the resident. The facility's policy required that if a resident lacked capacity to provide informed consent, a surrogate decision-maker should be involved, or an interdisciplinary team should be convened if no surrogate was available. However, the facility did not follow this policy, as evidenced by the lack of documentation for obtaining consent from a responsible party or public guardian. This oversight was confirmed during an interview with LVN 4, who acknowledged the importance of obtaining informed consent and the facility's failure to act promptly in securing a public guardian or conducting an IDT meeting for Resident 75.
Failure to Provide Communication Device for Resident with Aphasia
Penalty
Summary
The facility failed to provide a communication device at the bedside for a resident with aphasia, which hindered the resident's ability to communicate effectively. The resident, who had multiple diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, schizophrenia, paraplegia, dysphasia, and aphasia, was observed without a communication board or device in her room. Despite being alert and oriented, the resident was unable to orally communicate and relied on gestures and writing to express her needs. However, her handwriting was not legible, and not all staff and visitors were aware of her communication methods. The resident's care plan, which aimed to improve her communication abilities, included interventions such as allowing time to talk, using a communication board, and providing a pencil and paper. However, these interventions were not fully implemented, as evidenced by the absence of a communication board at the resident's bedside. Interviews with staff revealed that not everyone was aware of the resident's communication methods, and there was a lack of signage to inform visitors. The facility's policy required staff to provide adaptive devices to enable effective communication, but this was not adhered to in the resident's case.
Failure to Properly Set Low Air Loss Mattresses for Residents
Penalty
Summary
The facility failed to implement appropriate interventions to prevent the formation and worsening of pressure ulcers for three residents. Resident 15 was observed lying on a low air loss mattress (LALM) set for a weight of 300 pounds, despite weighing 170 pounds. The resident had a history of chronic obstructive pulmonary disease, generalized muscle weakness, a resolved Stage III pressure ulcer, and schizophrenia. The care plan for Resident 15 indicated the use of a LALM for skin maintenance and wound management, with orders to monitor the settings every shift. However, the LALM was not set correctly, potentially compromising the resident's skin integrity. Resident 94 was also found lying on a LALM set for 200 pounds, while the resident's actual weight was 147.8 pounds. The resident had diagnoses of COPD, malnutrition, generalized muscle weakness, diabetes mellitus, and anemia, with a significant surgical wound on the lower back extending to the buttocks and thighs. The resident's care plan included the use of a LALM for wound management, with instructions to verify its functioning every shift. The incorrect setting of the LALM could have affected the healing of the surgical wound and increased the risk of pressure injuries. Similarly, Resident 36 was observed on a LALM set for 550 pounds, although the resident weighed 190.2 pounds. The resident had a Stage II pressure ulcer, generalized muscle weakness, COPD, and obesity. The care plan required the use of a pressure-reducing device for the bed and chair, with orders to check the LALM settings every shift. The incorrect LALM setting could delay the healing process of the existing pressure ulcer. The facility's policy required staff to ensure the air mattress was inflating properly and to check it routinely, which was not adhered to in these cases.
Inadequate Monitoring and Care of Urinary Catheters and Nephrostomy Tubes
Penalty
Summary
The facility failed to provide adequate care for a resident with a long-term indwelling urinary catheter, leading to the development of septic shock. The resident's urinary drainage was not monitored for sediment, abnormal color, or foul odor for six months, as required by the facility's policies and the resident's care plan. Despite a urine analysis indicating a urinary tract infection, a urine culture was not performed, delaying the identification and treatment of the infection. This oversight resulted in the resident being admitted to the intensive care unit with septic shock secondary to a urinary tract infection. Another resident with nephrostomy tubes also received inadequate care, as the nephrostomy bags were not positioned to gravity, and sediment in the tubing was not documented or reported to the physician. The nursing staff failed to monitor the nephrostomy bags for signs of infection, as required by the resident's care plan and physician orders. This lack of monitoring and documentation had the potential to cause avoidable urinary tract infections and delay treatment for the resident. Interviews with facility staff revealed a lack of adherence to care plans and physician orders, as well as a failure to document and communicate changes in the residents' conditions. The Director of Nursing acknowledged the importance of monitoring urine output and nephrostomy care to prevent infections and sepsis. The facility's policy on catheter care emphasized the need for regular assessment of urinary drainage and prompt notification of physicians in case of infection signs, which was not followed in these cases.
Failure to Verify GT Placement and Residuals for a Resident
Penalty
Summary
The facility failed to properly check the gastrostomy tube (GT) placement and gastric residual volume (GRV) for Resident 12, who was dependent on tube feeding due to dysphagia and other medical conditions. Resident 12's medical history included type 2 diabetes mellitus, chronic kidney disease, dysphagia, Alzheimer's disease, and dementia, with severely impaired cognition and a lack of capacity to make decisions. The care plan for Resident 12 required checking the GT placement and GRV every shift, with specific instructions to hold feeding if the residual was above 100 ml. During an observation, Licensed Vocational Nurse (LVN) 5 was seen connecting and starting Resident 12's tube feeding without checking the residuals or GT placement, contrary to the care plan and facility policy. LVN 5 acknowledged the oversight and the importance of checking these parameters to ensure proper digestion and prevent complications. The Director of Nursing (DON) also emphasized the necessity of verifying GT placement to avoid potential issues such as peritonitis. The facility's policy outlined specific steps for verifying GT placement, which were not followed in this instance.
Unlabeled Nebulizer Masks Pose Infection Risk
Penalty
Summary
The facility failed to implement proper infection control practices for two residents, Resident 52 and Resident 310, as observed during a survey. In both cases, the nebulizer masks used by the residents were found to be unlabeled, lacking the resident's name and the date of opening. This oversight was noted during observations conducted on December 16, 2024, at different times in the residents' rooms. The absence of labeling on the nebulizer masks posed a risk of infection, as it was unclear when the masks were last changed or to whom they belonged. Resident 52, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, generalized muscle weakness, schizophrenia, and dementia, was observed to have an unlabeled nebulizer mask at their bedside. The resident's medical records indicated that they required supervision and partial assistance with various activities of daily living. The order summary report for Resident 52 included an order for albuterol sulfate via nebulizer, highlighting the importance of proper labeling and infection control practices. Similarly, Resident 310, who also had diagnoses of COPD, generalized muscle weakness, schizophrenia, and dementia, was found with an unlabeled nebulizer mask. The resident's medical records showed severe cognitive impairment and a need for assistance with daily activities. The facility's policy and procedure for oxygen therapy, which was also applied to nebulizer masks, required that masks be changed every seven days and labeled with the resident's name and date. The failure to adhere to these procedures was confirmed through interviews with the Licensed Vocational Nurse and the Infection Preventionist Nurse, who acknowledged the potential for infection due to the lack of labeling.
Failure to Notify Physician of Abuse Allegation
Penalty
Summary
The facility failed to notify the physician of an abuse allegation made by a resident, identified as Resident 259, against a Certified Nursing Assistant (CNA). Resident 259, who had a history of urinary tract infection, sepsis, and type two diabetes mellitus, reported feeling uncomfortable during a bed bath when CNA 2 allegedly touched him inappropriately. Despite Resident 259's moderate cognitive impairment, he was deemed capable of understanding and making decisions. The incident was reported to a Licensed Vocational Nurse (LVN), who reassigned the CNA but did not notify the physician, believing the issue was resolved. The Registered Nurse (RN) and Director of Nursing (DON) both stated that the physician should have been informed of the abuse allegation to assess and implement necessary interventions for Resident 259. The facility's policy required immediate notification of the attending physician upon receiving allegations of sexual abuse. The failure to notify the physician resulted in a delay in any necessary care for Resident 259, as the physician was unaware of the situation and could not determine if further assessments or interventions were needed.
Failure to Develop Care Plans for Abuse Allegations
Penalty
Summary
The facility failed to develop person-centered care plans for two residents, Resident 88 and Resident 259, after allegations of inappropriate behavior by a Certified Nursing Assistant (CNA 2). For Resident 88, the Responsible Party (RP 1) reported to a Registered Nurse (RN 1) that CNA 2 had said hurtful things to the resident, which affected her emotional state and eating habits. Despite an investigation confirming that CNA 2 had not been assigned to Resident 88 for over a month, no care plan was developed to address the resident's psychosocial needs or to monitor for any further issues. Resident 259 reported feeling uncomfortable during a bed bath given by CNA 2, alleging inappropriate touching. A Licensed Vocational Nurse (LVN 3) reassigned CNA 2 to another resident and did not develop a care plan, believing it was unnecessary since the issue was resolved by the reassignment. However, the Director of Nursing (DON) stated that a care plan should have been developed for any abuse allegation to outline the necessary care based on the specific incident. The facility's policy on Comprehensive Person-Centered Care Planning, revised in August 2023, requires updates to the care plan based on assessed needs. The failure to develop care plans for these incidents indicates a deficiency in adhering to this policy, potentially impacting the residents' physical, mental, and psychosocial well-being.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with known behavioral issues and risk factors. Specifically, the facility did not create a care plan for a resident's known behavior of biting and did not timely implement a care plan for the resident's risk of elopement. This oversight resulted in an incident where the resident wandered into another resident's room, leading to an altercation where the resident hit, attempted to bite, and threw water on the other resident. The resident involved in the incident had a history of dementia, anxiety, and mobility issues, with severely impaired cognitive skills as noted in their Minimum Data Set (MDS). Despite being monitored for biting and identified as an elopement risk, the necessary care plans were not in place. The facility's policies required comprehensive person-centered care planning and specific measures for wandering and elopement risks, which were not adhered to in this case.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to adequately monitor a resident with a known history of wandering, aggression, and other behavioral issues, leading to an incident involving another resident. Resident 1, who has dementia, anxiety, and mobility issues, was not properly supervised despite care plans indicating the need for frequent visual checks and one-to-one supervision. This lack of supervision allowed Resident 1 to wander into Resident 2's room, resulting in an altercation where Resident 1 hit Resident 2, attempted to bite them, and threw water at them. Interviews with staff revealed that Resident 1 was known to enter other residents' rooms and take items, and that staff were often too busy to monitor Resident 1 every 15 minutes as required. The facility's policy required resident checks every two hours, but Resident 1's care plan necessitated more frequent monitoring due to their behavioral risks. The failure to adhere to these monitoring requirements led to the altercation between the two residents, highlighting a deficiency in the facility's supervision and safety protocols.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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