Napa Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Napa, California.
- Location
- 705 Trancas St., Napa, California 94558
- CMS Provider Number
- 056153
- Inspections on file
- 32
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 29 (1 serious)
Citation history
Health deficiencies cited at Napa Post Acute during CMS and state inspections, most recent first.
A resident with moderately impaired cognition and documented partial dentures on admission lost those dentures while in the facility, reportedly after they were placed on a meal tray and likely discarded by staff. Instead of assuming financial responsibility or timely initiating a facility-based replacement process, staff had the facility dentist submit a claim to the resident’s dental insurance, which was denied and appealed, without offering the family other payment options. There was no dental documentation in the medical record regarding the missing dentures or updated consent discussions about recommended extractions, even though the resident later stated willingness to proceed. The resident became self-conscious, wore a mask to hide the absence of teeth, and experienced a 3% weight loss over one month after the dentures were lost, while the facility’s policy provided to surveyors did not address financial responsibility for resident property and the report noted the situation had the potential to result in dental insurance fraud.
The facility failed to maintain an effective infection prevention and control program, resulting in a C. diff outbreak affecting multiple residents and significant lapses in basic infection control practices. The IP could not describe a communicable disease surveillance system or produce tracking logs, and the infection control manual lacked a specific C. diff policy or national standards references. Staff interviews and observations showed inconsistent and often incorrect use of disinfectants and shared vital sign equipment in isolation rooms, absence of dedicated BP cuffs, improper or omitted hand hygiene, and direct care to residents on contact precautions without appropriate PPE. Residents with C. diff shared bathrooms with non-infected residents without a defined process for bleach cleaning after each use, and leaders could not explain how bedside commodes would be safely managed. Record reviews revealed delays in initiating isolation for residents with suspected or confirmed C. diff despite documented loose stools and positive lab results. Separately, water testing showed very high levels of Legionella with documented immediate risk, yet there was no functioning water management program, no ongoing monitoring, and no ICC or QAPI follow-up. An open sewage pipe area in a communal shower room, stuffed with wet paper towels and used to store medical equipment, was identified by the IP as an infection risk, further evidencing environmental control failures.
The facility’s QAPI Committee did not identify or address multiple quality of care issues, including systemic infection control and prevention problems, despite a written plan stating that data from various sources would be used to monitor care and services in areas such as infections and medications. The Administrator reported that the QAPI Committee met monthly and relied on input from department heads, grievances, the resident council, staff meetings, and an anonymous suggestion box, and that only ongoing struggles were escalated for QAPI monitoring. A performance improvement project for infection prevention was initiated only after surveyors were already on-site, and no other quality of care issues later found by surveyors had been captured by the QAPI Committee as areas for improvement, resulting in a systemic breakdown of the infection control and prevention program with potential for resident harm.
Surveyors found that residents’ rights to dignity, communication, and access to assistance and visitors were not honored. A cognitively intact resident reported night staff yelling profanities outside his room and staff frequently speaking a foreign language in front of him, while a nurse was repeatedly observed vaping at the main entrance despite prior discipline for unprofessional behavior. The grievance log documented numerous complaints about unprofessional staff conduct, but Social Services, the DON, and the Administrator reported being unaware of such issues and did not review the log for trends as required by policy. Three residents were observed without accessible call lights—one with left-sided weakness after a stroke and others reporting long waits for toileting care—while a nurse confirmed none of them could reach their call systems. Another resident, who depended on substantial ADL assistance, tearfully expressed a desire to see her daughter, but the facility blocked the daughter’s visits based on DPOA instructions. Multiple cognitively intact residents also reported staff speaking foreign languages in hallways, shared rooms, and during direct care, making them uncomfortable because they could not understand what was being said, despite facility expectations that staff use a language understood by residents.
Surveyors found widespread environmental disrepair and unsanitary conditions, including cracked and missing floor tiles, chipped paint, exposed plaster, unsealed concrete, and damaged wood and laminate surfaces in resident rooms, nursing stations, utility rooms, and laundry areas. Hand-washing sinks at both nursing stations had exposed, damaged plaster behind faucets, and a medication cart had a cracked surface with exposed wood. In the laundry area, only one washer and two of three dryers were functional, with the operating washer showing corrosion and the room containing rusty fixtures, broken tiles, and exposed plaster. A red hose was plumbed through a wall opening to the outside, leaving a visible gap and causing water to pool on the exterior cement. Staff, including an LPN, the IP, the DON, and department heads, acknowledged these conditions, expressed uncertainty about disinfecting damaged and corroded surfaces, and confirmed that leadership was aware of many of the unresolved environmental issues.
Surveyors found that the medical director failed to provide effective oversight of infection prevention and control, informed consent for psychotropic medications, and diagnostic evaluation for serious mental illness. The Infection Prevention and Control Program, including antibiotic stewardship and monitoring for C. diff and Legionella, lacked active medical director oversight. Two residents receiving psychotropic medications had informed consent forms that were unsigned by their representatives and lacked documentation of verbal consent, while their representatives reported not being contacted about these medications. In addition, two residents were newly assigned diagnoses of schizophrenia or schizoaffective disorder based largely on medication use and behavior, without documentation of comprehensive, evidence-based assessments as required by facility policy, and without consistent confirmation of these diagnoses in behavioral health or psychology notes.
A resident with multiple neurologic and swallowing impairments, fed via G-tube and assessed as high risk for constipation, was care planned to have bowel movements every 1–3 days with medications per physician order, yet no routine bowel regimen was ordered or provided, and only PRN MiraLax was obtained and given after five days without a documented BM. Bowel records showed a small stool followed by no further BMs, and the resident was later hospitalized with findings of no BM for several days, feculent G-tube output, abdominal distention, and imaging suggesting ileus versus bowel obstruction. The DON reported that nurses were expected to monitor last BMs via the eMR alert, initiate bowel care after three days without a BM, and secure routine bowel care orders when a constipation care plan is developed, consistent with facility policy requiring assessment and documentation of lower GI symptoms including fecal impaction and abdominal status.
A resident with heart disease, muscle weakness, need for assistance with personal care, and unspecified psychosis eloped from the facility through front doors that opened onto a busy street. Staff believed the resident was in his room, and an RN later reported she was at lunch when he went missing and that he did not have a wander alarm in place despite an assessment indicating one was indicated. The resident’s elopement risk score was documented as low, the DON later called the wander-alarm recommendation a mistake, and the care plan included a wander alarm but no specific supervision or monitoring interventions beyond a falls care plan instruction to keep the resident within supervised view as much as possible. The resident left the building unnoticed and was found and returned by police.
The facility failed to provide adequate nursing staff and services to ensure residents’ hydration, toileting, and skin care needs were met. Several cognitively intact residents with conditions such as heart failure, ESRD, DM, metabolic encephalopathy, and hemiplegia had care plans requiring encouragement of fluids, frequent fluid offerings, incontinence care, and assistance with repositioning and transfers, yet reported that water was only changed once daily, left from the prior evening, warm, or out of reach, and that they received additional water only if they specifically asked. Multiple residents described waiting 30–60 minutes for call lights to be answered, particularly on swing and night shifts, resulting in them remaining in soiled briefs with associated skin burning and redness and feelings of lost dignity. Resident Council minutes documented ongoing concerns about insufficient CNAs, night shift staff not answering call lights, and CNAs sleeping or using phones in rooms. A surveyor directly observed a call light remaining on for 20 minutes while staff passed by or briefly entered only to take supplies without addressing the resident’s need, despite facility policy and leadership statements that staffing and timely call-light response should be adequate to meet residents’ needs.
A resident was admitted with multiple conditions, including obstructive/reflux uropathy and urinary retention, and had an indwelling urinary catheter in place after a failed voiding trial. Despite this, licensed nurses did not initiate a baseline, person-centered care plan addressing UTI risk related to the catheter, and the MDS later confirmed the presence of the catheter and stool incontinence. The resident subsequently developed fever and hypoxia and was sent to the ED, where sepsis due to UTI was diagnosed based on vital signs, elevated WBC, and urinalysis showing many bacteria and large leukocyte esterase. The DON acknowledged there was no catheter-related care plan or documentation of catheter care, while the DSD stated catheter care was not charted because it was considered standard of care, contrary to facility policy requiring care plan review and detailed documentation of catheter care and assessments.
The facility failed to ensure the most recent survey results were accessible to residents, as required by policy. The survey results binder was not found during observations, and staff interviews revealed a lack of awareness and communication about its location. The DON admitted to taking the binder to update it and forgot to return it, resulting in its unavailability for a week.
The facility failed to allow residents to file grievances anonymously, contrary to its policy. Grievance forms were not publicly accessible, requiring residents to request them from staff, compromising anonymity. Interviews with the grievance officer and observations confirmed that forms were stored in non-public areas, and residents had to ask for assistance to access them. The Administrator and DON acknowledged the need for anonymous grievance filing.
The facility failed to ensure accurate MDS assessments for three residents, leading to incorrect discharge statuses and unrecorded use of a WanderGuard device. One resident was incorrectly documented as discharged to a hospital instead of home, another was inaccurately recorded as discharged home instead of to a hospital, and a third resident's use of a WanderGuard device was not reflected in their MDS despite being at risk for elopement.
A facility failed to ensure a resident's PASRR accurately captured their diagnosis of unspecified psychosis, an SMI. The resident's PASRR Level I Screening incorrectly indicated no SMI, despite the facility's policy requiring accurate screening for mental disorders. Staff interviews revealed the PASRR process should have addressed discrepancies upon admission, but the issue was only corrected after a survey identified the deficiency.
A resident with limited ROM did not receive ordered passive ROM therapy due to a lack of communication and follow-through by facility staff. Despite a doctor's order for rehabilitation services, there was no documentation of the order being completed, and the resident expressed a desire for therapy to aid mobility. Interviews revealed that staff were unaware of the order, leading to the resident not receiving necessary care.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to improper application of a WanderGuard device, which was attached to the metal part of their wheelchair, potentially interfering with its function. The staff failed to monitor the resident adequately and did not follow the manufacturer's guidelines for the device. Additionally, a supply closet containing medical supplies was found unlocked, posing a risk to wandering residents.
A medication cart was found unlocked and unattended outside a room, contrary to the facility's policy requiring secure storage of medications. An RN confirmed she was out of eyesight from the cart and acknowledged the oversight. The DON reiterated that medication carts should not be left unlocked and unattended.
A resident's medication order for Pred Forte was not discontinued in their clinical record despite a physician's directive. The resident, with a history of type two diabetes, had a follow-up appointment where the discontinuation was noted. However, the facility staff failed to review and update the order, leaving it active in the records. The oversight was confirmed by the LVN and Medical Records Director, who noted the physician's note was not reviewed before being scanned into the EMR.
A facility failed to provide adequate oral care for three residents, leading to poor oral hygiene and malodorous breath. One resident's daughter reported neglect, noting her father's mouth appeared to be rotting. Another resident did not receive oral care supplies for nine days, despite requests. A third resident received inadequate oral care, which was not documented. The facility's policy requires assistance with ADLs, including oral hygiene.
Expired medications and supplies were found in the treatment cart of an LTC facility, including silver nitrate applicators, barrier cream, and Providone Iodine solution. The charge treatment nurse responsible for checking the cart was on leave, and the facility's policy for handling expired items was not followed.
A resident reported a broken bed frame and damaged electronic tablet, but the facility failed to resolve these grievances, leading to discomfort and frustration. The Social Services staff did not follow up on the complaints, violating the facility's grievance policy.
A resident was unable to receive private phone calls due to a malfunctioning phone system and staff inaction, leading to a family member calling the police for a wellness check. The facility's phone issues were known to staff and the administrator, affecting communication and violating residents' rights.
A resident with anxiety disorder and alcohol dependence did not receive five doses of Chlordiazepoxide due to a delay in reordering the medication. The facility's policy required timely reordering to ensure an adequate supply, but the medication was not reordered in time, leading to missed doses.
A resident experienced severe weight loss and dehydration during a 3.5-week stay at the facility. Nursing staff and the RD failed to notify the physician, NP, or family about the weight loss, did not document it, and did not discuss it during relevant meetings. The resident's family removed him AMA, and he was admitted to the ICU with severe dehydration, malnutrition, and other complications.
A resident experienced a severe weight loss of 30.8 pounds within 18 days of admission, and the facility staff failed to notify the physician or implement interventions. The resident's family took him to a hospital, where he was admitted to the ICU in critical condition. Despite the weight loss being documented and presented at a QAPI meeting, it was not addressed, preventing the facility from identifying system failures and implementing necessary changes.
Failure to Assume Responsibility for Lost Dentures and Improper Use of Resident Insurance
Penalty
Summary
The deficiency involves the facility’s failure to assume financial responsibility and timely initiate replacement or reimbursement for a resident’s dentures that were lost while in the facility, instead pursuing the resident’s own dental insurance for coverage. The resident was admitted with partial dentures documented on her inventory sheet and had moderately impaired cognition per an MDS BIMS score of 12. The resident and her responsible party reported that the dentures were last seen on a meal tray and were believed to have been inadvertently discarded by staff during tray collection. The facility informed the responsible party that a dental insurance claim for replacement dentures had been submitted, denied, and appealed, but did not offer the option for the family to pay directly or indicate that the facility would bear the cost despite the dentures being lost at the facility. The Social Services Director stated that the facility’s dentist evaluated the resident after the dentures were lost and submitted a claim to the resident’s dental insurance, which was denied, and that an appeal was in process. The Social Services Director also reported that the dentist had indicated extractions of remaining natural teeth would be needed to fabricate functional dentures, and that the case was complicated because the resident was initially reluctant to have extractions. However, there was no documentation from the dentist in the resident’s medical record regarding the missing dentures or these clinical discussions, and the Social Services Director was unsure whether the resident or responsible party had been consulted again about extractions after the dentures were lost. The Social Services Director acknowledged that facility policy required initiation of the replacement or reimbursement process within three days of dentures being reported missing, but the documentation did not show that this process, with the facility assuming responsibility, had been initiated. The resident was observed consistently wearing a face mask, including in the activities room, and stated she wore it because she felt self-conscious about not having teeth. She reported that a staff member had thrown her dentures away and confirmed that she needed her dentures, which had not yet been replaced. The responsible party reported that the facility did not present an option other than using the resident’s dental insurance and that she had not been re-approached about extractions after the dentures went missing, although she now consented to extractions if needed for new dentures. Weight records showed the resident lost 9.6 pounds (3% of body weight) in the month after the dentures were lost, compared to a one‑pound loss in the prior month when she still had her dentures. The facility’s provided policy on theft and misappropriation of resident property did not address the facility’s financial responsibility for resident possessions lost during the stay, and the facility’s actions resulted in a claim being filed with the resident’s dental insurance for replacement of dentures that had been lost at the facility, with the report noting this had the potential to result in dental insurance fraud.
Failure of Infection Control Program Leading to C. diff Outbreak, Legionella Risk, and Environmental Contamination
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain an effective infection prevention and control program, resulting in a C. difficile (C. diff) outbreak and multiple lapses in basic infection control practices. Eight residents were confirmed positive for C. diff between 11/12/25 and 1/24/26, and three residents had active C. diff infections on the survey entrance date. The Infection Preventionist (IP) could not describe the facility’s surveillance program for communicable diseases and was unable to provide a tracking log for such infections. The facility’s Infection Prevention Policy and Procedure Manual lacked a specific policy or protocol for C. diff and did not cite national standards for infection control, despite referencing regulatory requirements that call for written standards, policies, and procedures, including when and how isolation should be used and what hand hygiene procedures staff must follow. Staff interviews and observations showed widespread confusion and inconsistency regarding appropriate disinfectants and equipment use for C. diff. Multiple unlicensed staff and housekeeping personnel reported or were observed using products not effective against C. diff, such as Clorox disinfectant spray and Medline MicroKill One alcohol-based wipes with violet or lavender tops, instead of bleach-based products labeled as killing C. diff spores. Some staff stated that residents on C. diff precautions should have dedicated vital signs equipment, but in practice, shared vital sign towers and reusable stethoscopes were routinely brought into isolation rooms and then wiped down, often with non-bleach products. In several C. diff isolation rooms, no dedicated blood pressure cuffs or vital sign equipment were present, and staff acknowledged that there were only a few vital sign towers in the facility, preventing them from being left in isolation rooms as dedicated equipment. Hand hygiene and isolation practices were also deficient. Staff were observed exiting resident rooms, including those on contact precautions, without performing hand hygiene, and some staff admitted forgetting to wash their hands or not knowing that soap and water for 20 seconds were required for contact precautions. A nurse was observed attempting to wash hands at a nurses’ station sink that did not have warm water or paper towels, and a nurse practitioner stated she did not wash hands in a contact precaution room’s bathroom because she considered it contaminated, without being able to state the facility’s hand hygiene policy. Staff were observed providing direct care to residents on contact precautions without gowns, and bedside care staff could not consistently verbalize appropriate PPE use or the correct disinfectant for shared equipment in C. diff rooms. Resident placement and bathroom use for C. diff-positive residents were not managed according to the facility’s own written expectations for individualized room placement and dedicated equipment. Two residents with C. diff shared a bathroom with residents who did not have C. diff, and the DON and IP could not describe a clear process for ensuring the bathroom was cleaned with bleach after each use or how staff would monitor and document such cleaning, especially when residents used the bathroom independently. The DON stated she was not concerned about a C. diff resident sharing a bathroom with non-C. diff residents and acknowledged there was no process to ensure cleaning after each use. When discussing the use of bedside commodes for C. diff residents, both the DON and IP were unable to explain how staff would empty the commodes if the shared bathroom was not to be used, and there was no clear plan for preventing cross-contamination in these scenarios. Medical record reviews showed delays and inconsistencies in initiating isolation precautions for residents with suspected or confirmed C. diff. For one resident, a positive C. diff result was obtained on 11/6/25, but the resident was not moved to an isolation room until 11/10/25. Another resident had loose stools documented on CNA task sheets, with a stool specimen collected and later confirmed positive for C. diff, and contact precautions were not initiated until days after the specimen was sent and the positive result obtained. For another resident, documentation indicated multiple episodes of loose, foul-smelling stools and a positive C. diff result, with contact precautions initiated only after the result was received, despite CDC guidance that patients with three or more stools in 24 hours should be isolated immediately when C. diff is suspected. These delays occurred in the context of a documented outbreak, with 11 C. diff cases identified over a one-year period on the facility’s surveillance log. The facility also failed to implement an effective water management program for Legionella as part of its infection control system. The water system was tested in February 2025, and 9 of 10 samples were positive for Legionella, with documentation describing excessively high levels of Legionella, low to zero chlorine residuals, very high occupant susceptibility, and an immediate risk to patient health. The testing company strongly recommended immediate implementation of a water management program and noted that such a program is mandated by CMS. However, the IP could not fully describe the facility’s Legionella prevention program or monitoring activities, did not know the test results, and confirmed that Legionella monitoring and prevention were not discussed in Infection Control Committee (ICC) meetings. The Administrator and Regional Corporate Director acknowledged that the water system had not been retested for Legionella between February 2025 and early 2026, and QAPI minutes showed that although a performance improvement plan was initiated in March 2025 to monitor weekly hot water flushing and implement a water management program, there was no further documented follow-up, discussion, or recommendations through the end of 2025. In addition, environmental infection control in a communal shower room was deficient. During an observation of the northwest resident shower room, the IP noted that the room appeared dim and that a large diameter pipe near the floor, in an area where a toilet might have been, was stuffed with wet paper towels. The IP stated it was an infection risk to have wet paper towels in that location. The shower room was also used to store medical equipment, compounding the concern about contamination from an open sewage pipe area that had been plugged with wet paper products. This condition existed in a shared space used for resident hygiene and equipment storage, further demonstrating the facility’s failure to maintain a sanitary environment as part of its infection prevention and control program.
Removal Plan
- Update the C. Diff policy and procedure to include bathroom use and the frequency of cleaning and disinfecting equipment, rooms, and bathrooms.
- Train the Infection Preventionist on the infection surveillance program for monitoring and tracking and on the facility's Infection Control and Prevention Program.
- Provide in-services to all Licensed Nurses and Certified Nursing Assistants on the C. diff policy and procedure, including appropriate use of personal protective equipment.
- Ensure every isolation room has dedicated vital signs equipment and cleaning solution.
- Review all residents' medical records to determine whether they have had any change of condition that would indicate C. diff infection.
- Have the Medical Director provide solutions and measures to prevent the spread of infections.
Failure of QAPI Committee to Identify Systemic Infection Control and Quality of Care Issues
Penalty
Summary
The facility’s Quality Assurance Performance Improvement (QAPI) Committee failed to identify multiple quality of care issues, including systemic infection control and prevention problems, despite having a written QAPI plan stating that the facility would monitor care and services using data from multiple sources and consider areas such as infections and medications. During interview, the Administrator reported that the QAPI Committee met monthly and relied on information from department heads, grievances, the resident council, monthly all-staff meetings, and an anonymous suggestion box, and that issues considered ongoing struggles would be taken to QAPI for monitoring. The Administrator further stated that a performance improvement project for infection prevention was only initiated after the survey had already begun, and confirmed that none of the other quality of care issues identified by the survey team had been captured by the QAPI Committee as areas needing improvement. This failure of the QAPI and Quality Assessment and Assurance (QAA) processes to detect and address multiple quality of care concerns, including infection prevention and control, was cited as resulting in a systemic breakdown of the infection control and prevention program, which potentially could have led to harm of vulnerable residents and other poor outcomes for residents in the facility’s care.
Failure to Honor Resident Rights to Dignity, Communication, Call-Light Access, and Visitation
Penalty
Summary
The deficiency involves multiple failures to honor resident rights to dignity, self-determination, communication, and access to persons and services. A cognitively intact resident with chronic ulcer, cellulitis, dialysis, and diabetes reported that night nurses yelled profanities such as "F**k you" outside his room and that staff frequently spoke Spanish or another foreign language in front of him, which he felt was unprofessional and made him feel staff did not care. The same nurse was later observed multiple times exiting through the main lobby and exhaling vapor from a device immediately outside the main entrance where residents and families enter, and was described by the Administrator as having prior disciplinary action for being loud and lacking professionalism. The Activity Director stated staff were not supposed to be on the phone during patient care hours or speak a foreign language in front of residents or families, and Social Services stated she handled grievances but reported she had not heard of unprofessional staff behavior, despite a grievance log documenting 25 instances of unprofessional staff behavior, including 13 related to staff tone, HIPAA issues, inappropriate bedside manner, and lack of professionalism. The DON and Administrator both stated they were unaware of grievances about unprofessional behavior and did not review the grievance log for trends, even though the facility’s grievance policy required the Administrator to review findings with the grievance officer. The deficiency also includes failures to ensure residents had access to call lights for assistance and emergencies. One resident stated staff moved his call light away, forcing him to yell for help, and his call light was not visible near his bed. Another resident’s call light was observed on the floor on the far side of his bedside table, out of his reach; he reported having a bowel movement and waiting two hours to be changed and said this happened frequently and made him feel staff did not want to help him. A third resident with left-sided weakness after a stroke had his call light pinned to the wall on his affected side, far out of reach, and he believed staff pinned it away on purpose so he could not call for help. A nurse confirmed that none of the residents in the room had access to their call lights and acknowledged this could lead to delays in care and be dangerous in an emergency. The DON stated call lights should always be within reach and that having them anchored out of reach or on the floor did not meet her expectations, and the facility’s call system policy required each resident to have a means to call staff directly from bed and that calls be answered immediately. Another component of the deficiency concerns denial of access to visitors and communication practices that affected residents’ sense of dignity. A resident with osteoarthritis, heart disease, chronic pain, glaucoma, degenerative nerve syndrome, cognitive impairment, and substantial ADL assistance needs expressed a clear desire to see her daughter, stating her daughter helped her get out of bed, clean, and eat, and she cried and pleaded for her daughter to be brought back. Social Services and the Administrator stated they were following the guidance of the resident’s DPOA, who instructed the facility to prevent the daughter from visiting due to alleged interference with care and detriment to the resident’s well-being, and the facility was not allowing the daughter to visit. Additionally, four cognitively intact residents reported that staff frequently spoke foreign languages in hallways, in shared rooms, and during direct care, which made them uncomfortable and, in some cases, bothered them especially when it occurred during their own care because they did not know what staff were saying or whether they were being talked about. A nurse acknowledged staff occasionally spoke foreign languages and that there had been an in-service on the issue, and the DON stated staff were expected to speak the same language as the resident, especially around resident care areas. An in-service record documented that staff were expected to speak only in a language recognized and understood by residents after the training.
Environmental Disrepair and Unsanitary Surfaces in Resident Care and Laundry Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, sanitary, and homelike environment in multiple resident care and support areas. Surveyors observed chipped and cracked floor tiles and chipped paint on doors and door jambs in several resident rooms on different hallways, as well as exposed plaster and unsealed surfaces in high-touch areas. At both the east and west nursing station hand-washing sinks, there was exposed and damaged plaster behind the faucets and handles. In the clean and soiled utility rooms, surveyors noted chipped paint, exposed plaster, unsealed concrete, and visibly dirty, sticky high-touch areas, including black and grey residue around door handles and jambs. The medication cart at the west nursing station was observed to have a crack and open area on the work surface with exposed wood, and staff, including a licensed nurse and the Infection Preventionist, stated they were unsure whether such exposed wood and damaged surfaces could be disinfected. In the laundry area, only one of two washing machines was functioning, and the operating machine had a heavy band of white, rusty, powdery material resembling corrosion. The ceiling in the washing room had a rough, rusty metal box that had been painted over, and the dryer area had broken floor tiles, scratched walls with exposed plaster, and a ceiling with a large rough area of exposed plaster. The folding table used for clean resident laundry had exposed unsealed wood edges and a cracked, bubbled laminate surface. Surveyors also observed a red hose and spigot plumbed through a hole in the wall from the laundry room to the outside dirty laundry sorting area, with a visible gap around the hose allowing sunlight into the room and a steady drip of water forming a pool on the outside cement. Staff, including the Housekeeping Director and Infection Preventionist, repeatedly stated they did not know if exposed plaster, chipped paint, rust, corrosion, unsealed wood, or exposed concrete could be disinfected or sanitized. The Administrator, DON, and Maintenance Director acknowledged awareness of various environmental issues, including non-functioning equipment, damaged floors, chipped paint, exposed plaster, and a non-functioning shower room light, while also indicating that repairs were delayed or pending, and that resident rooms were often occupied, making floor repairs difficult. These conditions were cited as creating an environment that did not appear homelike and increased the risk of cross contamination and spread of contagious disease.
Failure of Medical Director Oversight for Infection Control, Informed Consent, and Serious Mental Illness Diagnoses
Penalty
Summary
The deficiency involves the failure of the designated medical director, Physician R, to effectively participate in and oversee resident medical care, including infection prevention and control, informed consent for psychotropic medications, and appropriate diagnostic evaluation for serious mental illness. Surveyors determined that the Infection Prevention and Control Program for a census of 116 residents did not receive oversight by Physician R for antibiotic stewardship and monitoring of infectious diseases, including measures designed to slow and prevent the spread of C. difficile and to address waterborne illness risks related to positive Legionella results. This lack of medical director oversight was cross-referenced to F880. For informed consent, the facility’s own policy titled “Psychotropic: Medication Use,” revised 02/25, required that prior to initiating, increasing, or switching psychotropic medications, staff and the physician review non-pharmacological alternatives, indications and rationale, potential risks and benefits (including side effects, adverse consequences, and black box warnings), and the resident or representative’s right to accept or decline treatment. Record review showed that Resident 12 had an informed consent form dated 3/16/25 for Risperidone for visual hallucinations that was not signed by the resident’s representative and did not indicate verbal consent. A second informed consent form dated 9/11/25 for Mirtazapine for depression and Risperidone for visual hallucinations was also not signed by the representative and did not indicate verbal consent. Resident 10’s representative reported never hearing from the medical doctor and not signing any forms concerning psychotropic medications, stating she felt she was not kept informed. Resident 12’s representative stated she had not spoken to anyone about psychotropic medications and would have declined them because she felt they made Resident 12 less functional. The DON stated her expectation was that Physician R would contact representatives for education and treatment planning before nurses obtained confirmation and signatures, and she was surprised the representatives had not heard from him. In contrast, Physician R stated he could not do all the education and depended on nurses to teach and notify him if representatives had concerns. The deficiency also included inadequate diagnostic evaluation for new diagnoses of serious mental illness, specifically schizophrenia and schizoaffective disorder, for two residents. Resident 10 was admitted with dementia, major depressive disorder (MDD), and unspecified psychosis, and had severe cognitive impairment per an MDS dated 12/22/25. Her physician order summary listed Seroquel for schizoaffective disorder manifested by visual hallucinations. However, a CHE Behavioral Health psychiatry note dated 9/13/23 listed active diagnoses of dementia and MDD with no auditory hallucinations, and a SOAP note by Physician R dated 10/12/23 listed no new diagnosis of schizoaffective disorder. On 10/16/23, facility staff faxed Physician R noting Resident 10 was taking Seroquel without an assigned diagnosis and requested an updated diagnosis list; schizoaffective disorder was added that same day by Physician R. Subsequent CHE psychiatry notes, including 12/27/23 and 12/24/25, continued to list dementia and MDD, recommended a Seroquel dose decrease, and did not mention schizoaffective disorder. The DON stated a serious mental illness diagnosis should not be added solely for medication and should be properly diagnosed by behavioral health, and that mislabeling could inappropriately label residents. Resident 10’s representative stated the resident had no history of schizoaffective disorder and she had never spoken to a medical doctor about this diagnosis. Physician R stated residents with schizoaffective disorder are referred to psychiatry and, if psychiatry did not confirm the diagnosis, it should have been removed; he further stated he may have added the diagnosis based on evolving symptoms. Resident 2’s record showed admission with cerebral infarction with right-sided weakness, epilepsy, diabetes, anxiety, and psychotic disorder with delusions. On 2/6/24, a schizophrenia diagnosis was entered. A behavioral health note dated 11/29/23 by NP LL recommended starting Risperdal 0.25 mg daily for delusions and paranoia but did not list schizophrenia. Review of physician and behavioral health notes from November 2023 through May 2024 revealed no mention of schizophrenia. NP KK, from the behavioral health group, confirmed that NP LL’s notes did not mention schizophrenia at the time Risperdal was prescribed and that her own December 2024 note was the first documentation of schizophrenia as a diagnosis. A fax dated 2/6/24 from MDS Nurse NN to Physician R asked if the diagnosis list could be updated to include schizophrenia for a resident on Risperdal; Physician R responded “Yes” with his signature. NP KK stated the schizophrenia diagnosis was based on delusions, a BIMS score of 3, and symptom improvement on Risperdal. Psychologist MM, Resident 2’s psychologist, stated his notes documented a delusional disorder, not schizophrenia, and that the two diagnoses are not interchangeable; his progress notes did not mention schizophrenia. MDS Nurse NN stated she sent the fax because the MDS system required a matching diagnosis for the antipsychotic and that she was not aware of any clinician documentation diagnosing schizophrenia at that time. MDS Nurse OO similarly stated there was no documentation that a clinician had diagnosed schizophrenia when the diagnosis was entered in February 2024. The facility’s “Schizophrenia and Related Disorders – Clinical Protocol,” revised 3/2025, required that practitioners not newly diagnose serious mental illness without evidence-based criteria documented in the record, including comprehensive assessment findings, DSM-consistent symptoms and duration, exclusion of other causes, and documentation of the effect on function. These requirements were not met in the documentation surrounding the new schizophrenia diagnoses for Residents 2 and 10.
Failure to Implement Bowel Regimen for High-Risk Tube-Fed Resident
Penalty
Summary
A resident in their 70s with traumatic subdural hemorrhage, facial fractures, aphasia, dysphagia, and a G-tube was assessed on admission as high risk for constipation and care planned on 1/10/26 with a goal of having satisfactory bowel movements every 1 to 3 days, including an intervention to administer medications per physician order. Despite this, the physician orders contained no routine bowel regimen (such as laxatives or stool softeners) other than a PRN MiraLax order obtained on 1/26/26 after the resident had already gone five days without a bowel movement. Bowel movement documentation showed a small, putty-like stool on 1/21/26 with no subsequent BMs recorded, and the resident had no bowel care medications in place during this period, contrary to the care plan focus on constipation risk. On 1/26/26, after recognizing that the resident had not had a BM for five days and had no bowel care orders, a nurse contacted the physician and obtained a PRN MiraLax order, which was administered on 1/26/26 and 1/27/26. The nurse acknowledged that going five days without a BM was significant and could lead to serious complications. The resident, who had been readmitted from the hospital on 1/21/26, was transferred back to the hospital on 1/27/26 when he became unresponsive. Hospital records from 1/30/26 documented no BM since 1/21/26, black/feculent G-tube output, a distended and tense abdomen, and imaging showing a large amount of gas and fecal material in the colon suggesting an ileus, with notes indicating bowel obstruction versus ileus. The DON stated her expectation that nurses monitor last BMs using the eMR alert, initiate bowel care if more than three days pass without a BM, and obtain routine bowel care orders when a constipation care plan is developed, and facility policy required assessment and documentation of lower GI symptoms including fecal impaction and abdominal assessment.
Failure to Adequately Supervise Resident Leading to Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and monitoring to prevent an elopement for one resident. The resident was admitted with diagnoses including heart disease, aftercare following circulatory surgery, muscle weakness, need for assistance with personal care, and unspecified psychosis. The facility’s front doors opened onto a busy street with consistent traffic. On the date of the incident, the resident left the facility unnoticed by staff and was later found outside the facility by police, who returned him. The resident’s public guardian reported being informed by facility staff that the resident had eloped over a weekend. According to the guardian, a licensed nurse had believed the resident was in his room with the door shut and did not know he was actually missing. The Infection Preventionist stated she saw a group text message indicating the resident was missing, that staff had looked for him, and that police had been called. Another licensed nurse stated she was at lunch when the resident went missing, confirmed the resident did not have a wander alarm at that time, and stated that if a wander alarm had been recommended on the wandering and elopement assessment, it should have been applied right away and would have prevented the elopement. The DON stated the resident’s original elopement and wandering assessment score was 8, which the facility considered low risk, and that a score above 10 was considered high risk. The DON also stated that the assessment dated the day of the incident recommended a wander alarm, but she characterized that recommendation as a mistake. She reported that the nurse assigned to the resident had observed him in his room after morning medications and did not notice when he left his room and exited the facility, and acknowledged there was not enough supervision to prevent the elopement. The Administrator similarly stated that staff did not see the resident exit his room and leave the facility and that the facility did not supervise the resident closely enough to prevent him from leaving. The facility’s wandering and elopement policy required that residents identified as at risk have care plan strategies and interventions to maintain safety. The resident’s elopement and wandering risk assessment scored him as low risk but indicated that a wander alarm was indicated, and his care plan included a wander alarm intervention without any specific supervision or monitoring interventions, while a separate falls care plan instructed staff to keep him within supervised view as much as possible.
Failure to Provide Adequate Nursing Staff, Timely Call-Light Response, and Hydration Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff and services to meet residents’ hydration, skin care, toileting, and safety needs, despite care plans and policies requiring such care. Multiple residents with intact cognition and documented risks for dehydration, skin breakdown, and falls reported that water was not refreshed regularly and that they had to wait extended periods for call lights to be answered, particularly on night and swing shifts. Care plans for several residents required staff to encourage fluids, offer fluids between meals and at snack times, provide additional fluids during activities, and keep water within reach, as well as to monitor for incontinence and provide pericare after each incontinent episode, but observations and interviews showed these expectations were not consistently met. One resident with acute on chronic heart failure, end stage renal disease, and diabetes, who had a care plan for dehydration risk and skin breakdown, stated that her water was from the previous evening, was room temperature, and that she had to ask staff for fresh water. She reported needing assistance with toileting and that call lights, especially at night, took about 30 minutes to be answered, resulting in her sitting in her own bowel movement long enough for it to burn her skin and cause pain. Another resident with cholecystitis, cystitis, and hemiplegia, who was care planned for dehydration, skin breakdown, and falls, reported that on swing shift his call light had once been answered an hour after activation when he had an incontinent bowel movement, and that similar events had occurred two or three additional times in recent months. He described his skin turning red and his groin burning, and his water bottle was observed nearly full but placed out of his reach, requiring him to call a CNA for help. A third resident with metabolic encephalopathy, care planned for dehydration, skin breakdown, and falls, reported being dependent on staff for brief changes and stated she removed her own brief when soiled because staff took too long to respond to call lights, estimating a 15‑minute wait, which she felt was too long when needing a bowel movement. At her bedside, one water bottle was empty and another contained only a small amount of room‑temperature water, which she stated was from the previous evening, and she reported that residents only received additional water if they asked. A fourth resident with hemiplegia, care planned for dehydration, bowel incontinence, and skin breakdown, stated his water bottle was only changed and filled once per day, that the water present had been brought the previous night, and that he would not drink it when it was warm because it tasted bad. He reported that staff sometimes took up to an hour to answer call lights, especially on the graveyard shift, and that he had to sit in his own bowel movement and urine on several occasions, too many times to count. Additional evidence of inadequate staffing and delayed response to resident needs was documented through Resident Council minutes and direct observation. Resident Council minutes over several months reflected repeated resident concerns about CNAs, including CNAs going into rooms to sleep or charge phones, questions about when facility CNAs would replace registry staff, reports that night shift CNAs did not answer call lights, and repeated requests to hire more CNAs and to have CNAs available to help. During one observation, a surveyor heard a call light sounding and saw the corresponding light illuminated above a resident’s doorway; one staff member entered the doorway only to take gloves and left without entering the room or addressing the resident’s need, and multiple staff walked past without checking on the resident. The call light remained on for 20 minutes before a staff member finally responded. Interviews with CNA staff and the DON confirmed that residents should have water refreshed every shift, fluids offered with each care intervention, and call lights answered quickly, and that leaving residents in soiled briefs was unacceptable, while the Administrator in Training confirmed there were no staffing waivers on file, despite the facility’s policy stating it would maintain adequate staffing on each shift to meet residents’ needs.
Failure to Initiate Baseline Care Plan and Document Care for Indwelling Urinary Catheter
Penalty
Summary
The deficiency involves the facility’s failure to initiate a baseline, person-centered care plan addressing an indwelling urinary catheter for one newly admitted resident. The resident was admitted with multiple diagnoses, including obstructive and reflux uropathy and a need for assistance with personal care, and had an indwelling urinary catheter in place for urinary retention following a failed voiding trial. Review of the resident’s care plans dated several days after admission showed there was no care plan addressing the risk of UTI related to the indwelling catheter. The SNF admission History & Physical documented that the catheter was in place and that a voiding trial would be considered the following week, and the MDS assessment confirmed the presence of an indwelling catheter and that the resident was always incontinent of stool. Subsequently, the resident developed a fever and low oxygen saturation, prompting a physician order for oxygen and transfer to the hospital. At the emergency department, the resident was found to have an elevated temperature, tachycardia, tachypnea, low-normal blood pressure, tacky mucous membranes, and an elevated white blood cell count consistent with infection. Urinalysis showed many bacteria and large leukocyte esterase, and the resident was admitted with sepsis due to a UTI. During interviews, the DON stated she could not find documentation of catheter care and confirmed there was no documented evidence of a person-centered care plan for the indwelling catheter, despite stating that a UTI risk care plan should be in place for all residents with indwelling catheters. The DSD reported that catheter care was not documented in residents’ charts because it was considered a standard of care. Facility policy on urinary catheter care required review of the resident’s care plan for special needs and detailed documentation of catheter care and related assessments, which was not reflected in this resident’s record.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible for all residents to review, as required by their policy. The policy, revised in April 2017, stated that a copy of the most recent survey report and any plans of correction should be kept in a binder in the residents' dayroom. However, during observations on March 5, 2025, the survey results could not be found in the facility. Interviews with various staff members revealed a lack of awareness and communication regarding the location of the survey results binder. The Activities Director was unaware of the requirement for the survey results to be available without asking, and the Social Services Director last saw the binder three weeks prior when the state surveyors were present. Further interviews indicated that the Administrator and the Director of Nursing (DON) were also unaware of the binder's current location. The DON admitted to taking the binder on March 3, 2025, to update it with the most recent survey and forgot to return it to its designated location. This oversight resulted in the survey results binder not being available in its usual location for that week. The Administrator and DON both confirmed that the survey results binder should be accessible to all residents, highlighting a breakdown in the facility's process for maintaining compliance with their policy on survey result accessibility.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were affected by the deficient practice. Within 5 minutes the survey binder was located and put in the correct position. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Once we were notified that the survey binder was missing, it was located within two minutes and returned to the front desk of the facility. The survey binder had only been away from the front for less than 24 hours. It was temporarily taken to the copier for updates following a deficiency received through RSS on February 28th. During the rush of the survey, the facility inadvertently forgot to place it back at the front. To prevent recurrence of this issue, we have placed a laminated sign that reads "DO NOT REMOVE SURVEY BINDER FROM TABLE FOR ANY REASON." In instances where the survey binder needs updating, staff will ensure it is promptly returned to the front desk. In addition, the facility educated all staff in-service on 3/28/25, emphasizing where the survey binder is located and the importance of residents and residents' families having access to these results. How the facility plans to monitor its performance to make sure that solutions are sustained: For the next three months, the Activities Director will conduct a weekly audit to ensure that the survey binder is consistently located on the front table by the entrance of the building. Additionally, these audit findings will be discussed during monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvements are made as necessary. Include dates when corrective actions will be completed: All corrective actions will be completed by March 28, 2025.
Failure to Provide Anonymous Grievance Filing
Penalty
Summary
The facility failed to protect the rights of residents and their representatives to file grievances anonymously, as required by their own policy. The policy, dated 2001, stated that grievances could be submitted orally or in writing and could be filed anonymously. However, during observations, it was found that grievance forms were not available for public use, and there was no way for residents to take a grievance form anonymously to fill out and submit. The grievance forms were stored in locations that required residents to ask staff for access, which compromised anonymity. Interviews with the Social Worker (SW) #16, who was the grievance officer, revealed that the facility practice required residents to inform staff or the SW if they wished to file a grievance. The SW stated that grievances could not be addressed without knowing who made them, although she claimed to keep grievances confidential. Observations confirmed that grievance forms were kept behind nursing stations or in closed cabinets, requiring residents to request assistance to access them. Interviews with the Administrator and the Director of Nursing (DON) confirmed that there should be an option for residents and their families to file grievances anonymously, which was not being facilitated by the current practice.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were affected by the deficient practice. We have promptly implemented corrective actions for all residents in the facility to enhance the grievance process. This includes: **Increased Access to Grievance Forms:** Grievance forms are now readily available in public areas, allowing both residents and family members to easily access and submit their concerns anonymously. **Placement of Grievance Forms:** The forms are strategically posted at the reception desk, in front of the activities room, and at the East Social Service office for maximum visibility. **Secure Grievance Submission:** A locked grievance box has been installed at both the East and West Nurses stations, ensuring confidentiality. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. How the facility plans to monitor its performance to make sure that solutions are sustained: To ensure that the identified deficiencies do not recur, the facility will implement the following systemic changes: **Enhanced Accessibility to Grievance Forms:** Grievance forms are now readily available in public areas, ensuring both residents and family members can easily access them. **Strategic Placement:** Grievance forms have been posted in visible locations, including the reception desk, the activities room, and the East Social Service office, to facilitate convenient access. **Secure Submission Process:** Locked grievance boxes have been installed at both the East and West Nurses stations, ensuring that grievances can be submitted confidentially. **Education of Staff:** The Social Services and Activities Departments have been reeducated on 3/7/25 and 3/19/25 on residents' rights to file grievances anonymously, reinforcing the importance of this practice in supporting resident empowerment. **Communication:** The locations of the grievance forms and locked boxes were clearly communicated during the resident council meeting, ensuring that all residents are aware of how to voice their concerns. These measures aim to create a transparent and effective grievance process that empowers residents and their families, ultimately contributing to ongoing quality improvement within the facility. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: The grievance form clipboards and locked grievance boxes are monitored Monday-Friday by the social service director throughout the week to ensure that forms remain available and that any grievances submitted are promptly received and processed. Furthermore, the facility will implement a monthly review of the grievance logs as part of its Quality Assurance and Performance Improvement (QAPI) program. This proactive approach will help to ensure that the grievance management systems are functioning effectively and efficiently. Include dates when corrective actions will be completed: 3/24/2025 What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: The grievance form clipboards and locked grievance boxes are monitored Monday-Friday by the social service director throughout the week to ensure that forms remain available and that any grievances submitted are promptly received and processed. Furthermore, the facility will implement a monthly review of the grievance logs as part of its Quality Assurance and Performance Improvement (QAPI) program. This proactive approach will help to ensure that the grievance management systems are functioning effectively and efficiently. Include dates when corrective actions will be completed: 3/24/2025
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their discharge statuses and care plans. Resident #107 was inaccurately recorded as being discharged to a hospital, while the Post-Discharge Plan of Care indicated a discharge to home with home health services. Interviews with the MDS Nurse, Director of Nursing (DON), and Administrator confirmed the error, acknowledging that the MDS was incorrectly coded and did not reflect the resident's actual discharge status. Resident #106's MDS inaccurately documented a discharge to home/community, despite the resident being sent to a hospital due to breathing difficulties. The physician's order and progress notes confirmed the hospital discharge, but the MDS was signed off as accurate by LVN Manager #2, who later admitted the error. Both the MDS Nurse and the DON emphasized the expectation for MDS accuracy, which was not met in this instance. Resident #61's quarterly MDS assessments failed to indicate the use of a WanderGuard device, despite orders and care plans specifying its necessity due to the resident's risk of elopement. The device was ordered to be checked regularly, yet this was not reflected in the MDS. Interviews with the MDS Nurse and DON highlighted the oversight, with the DON reiterating the need for MDS assessments to accurately reflect the resident's condition and care requirements.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The MDS coding for Resident #107 has been corrected to accurately reflect that the resident discharged home from the facility on 3/07/25. The MDS updated coding for Resident #106 on 3/07/25 to correctly indicate the resident discharged to a hospital. The MDS coding for Resident #61 has been revised on 3/07/25 to ensure accurate documentation of the WanderGuard assessments. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents may potentially be impacted by this deficient practice. MDS Regional completed the review on 3/7-3/10/25 of all residents who had discharged assessment completed in the last 90 days for accuracy to ensure that assessments reflect the correct discharged status, and no residents' assessments were identified with the same deficient practice. RAI specialist completed the review on 3/26/25 of MDS assessments of all residents currently with a Wanderguard order; to verify coding accuracy of Wanderguard on section P and no other residents' assessments were identified with incorrect coding. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On March 19, 2025, an informative in-service training session was conducted specifically for the two MDS nurses at the facility. The primary objective of this in-service was to provide comprehensive reeducation on the critical importance of accurately coding Minimum Data Set (MDS) assessments. This training emphasized how precise MDS coding can significantly affect the quality of patient care and overall healthcare outcomes for residents. Lead MDS Nurse will cross-check all MDS completed to ensure accuracy of coding before letting the MDS regional know for a second review and signing of the MDS for completion and accuracy. The Regional Resident Assessment Instrument (RAI) Specialist, and MDS Coordinator developed a quarterly training program for the facility MDS Coordinators that complete MDS's for coding accuracy. RAI Specialist will complete a monthly MDS audit for accuracy to ensure compliance and that resident conditions are accurately captured on each MDS assessment. The results will be sent to the facility MDS, Admin, and DON. Any inaccuracies or coding errors will be discussed with the MDS, and follow-up training will be scheduled as needed. Ongoing training sessions will be organized for MDS nurses and relevant staff to reinforce best practices in coding, ensuring they stay updated on any changes in regulations or procedures. This commitment to continuous education will help maintain high standards of coding practice. How the facility plans to monitor its performance to make sure that solutions are sustained: QAPI will review monthly audits performed by the Regional RAI specialist for accuracy, completeness, and thoroughness. Include dates when corrective actions will be completed: March 19, 2025
Failure to Accurately Capture SMI in PASRR
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening and Resident Review (PASRR) accurately captured an admission diagnosis of a serious mental illness (SMI). Specifically, the PASRR for a resident admitted on November 1, 2024, did not reflect their diagnosis of unspecified psychosis, which was part of their medical history. The facility's policy required participation in or completion of a Level I screen for all potential admissions to determine if the individual met the criteria for mental disorder, intellectual disability, or related condition. However, the resident's PASRR Level I Screening, dated October 15, 2024, incorrectly indicated that the resident did not have an SMI. Interviews with facility staff revealed that the PASRR process should have started on admission, and any discrepancies should have been addressed by resubmitting the PASRR to the hospital for correction. The Director of Nursing acknowledged that if a resident had an SMI diagnosis not captured by their PASRR, a new resident review should have been conducted. The deficiency was identified during a survey, prompting the facility to resubmit the PASRR on March 5, 2025, to accurately reflect the resident's diagnosis of unspecified psychosis.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The Pre-Admission Screening and Resident Review (PASRR) for Resident #64 was promptly reviewed and updated. Upon further examination, it was determined that a correction was necessary, and a revised PASRR was resubmitted on March 5, 2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents within the facility have the potential to be affected by the deficient practice. Medical Records did a facility-wide audit of current residents' PASRR for accuracy on 3/21/25 and no additional deficient practice was noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A thorough audit of residents' PASRR was conducted by medical records to identify individuals who may have experienced any adverse effects on 3/21/2025, no additional issues were found. On 3/19/2025, an in-service was given by the Director of Nursing to all those involved in the PASRR screening process, including the medical records team, nursing management team, and admissions team. The purpose of this in-service was to reeducate those involved on the process and importance of PASRR screening regarding patient care and facility protocol. To ensure compliance with regulations, the facility will implement a system-wide change to improve the review process for all Pre-Admission Screening and Resident Review (PASRR) assessments. Going forward, the clinical team, including nurses, MDS, and other relevant healthcare professionals, will conduct a thorough review of the PASRR assessment upon each resident's admission to the facility. This review will verify that each resident's needs, including any mental health or specialized care requirements, are accurately identified and addressed in their individualized care plan. How the facility plans to monitor its performance to make sure that solutions are sustained: Upon admission, the admissions team will verify that a Pre-Admission Screening and Resident Review (PASRR) has been received, preferably via file exchange or, if necessary, as a paper copy. In cases where follow-up is required for file exchange completion, the clinical team will notify the hospital for review or a new PASRR. As part of the verification process, the clinical team immediately reviews the PASRR and checks for accuracy. A secondary screening will be performed before the PASRR is officially uploaded to the patient's chart by the medical records team. Additionally, the medical records department will review the PASRR for accuracy to ensure compliance with regulatory requirements. Furthermore, the unit manager will reassess any PASRRs requiring follow-up, with all follow-up actions being systematically tracked through the Interdisciplinary Plan of Care (IPOC) by medical records. To maintain accountability and ensure accuracy, the medical records department will conduct regular audits of PASRR. Additionally, when the facility does the resident review for new admits, if an inaccuracy is noted, a new PASRR/resident review assessment will be created to ensure the residents' PASRR is accurate according to their needs. This process will be monitored by and reported to our Quality Assurance and Performance Improvement (QAPI) monthly meeting. This will stay on our QAPI for 90 days and/or 3 QAPI meetings. Include dates when corrective actions will be completed: March 21st, 2025
Failure to Provide Ordered Passive ROM for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received the necessary care and services to prevent further decline. The resident, who had a medical history of morbid obesity, unspecified joint contracture, rheumatoid arthritis, and difficulty in walking, had an order for rehabilitation services to perform passive ROM. However, there was no documentation that this order was completed. The resident expressed a desire for therapy to help with mobility, and although the doctor had ordered therapy, the resident had not received any services. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's care. The Physical Therapy Assistant indicated that the last documented visit with the resident was in 2023, and the Director of Staff Development and Human Resources was unaware of any order for restorative care. The Director of Nursing confirmed that staff should have communicated the doctor's order to the therapy department. A Certified Nursing Aide mentioned performing some passive ROM during transfers and showers but was unaware of the specific order for passive ROM. This lack of coordination and communication led to the resident not receiving the necessary care to maintain or improve their ROM.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #28 was evaluated by the therapy staff on 3/6/2025 and RNA program 3x a week or as tolerated for BUE/BLE PROM was started on 3/7/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: A comprehensive review of all residents' records performed by the Director of Nursing was started on 3/11/2025 to identify individuals with similar orders for restorative care that have not been followed. No other resident identified with the same findings/deficient practice. A weekly audit of MDS assessments and therapy orders will be implemented for all residents to ensure that any unaddressed restorative needs are promptly identified, and actions are taken. Affected residents will receive the necessary restorative interventions as determined by their care plans. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 3/21/2025, the Director of Nursing Services in serviced the Licensed nursing staff to enhance communication protocols between nursing and therapy departments to ensure that all restorative therapy orders are communicated to therapy department. Medical Record will do a daily audit for orders established to review therapy orders and restorative care compliance. This will allow the nursing manager to verify if communication was sent to therapy department. Any gaps in this communication will be flagged immediately and nursing will follow up with therapy to ensure orders are seen and acted upon. How the facility plans to monitor its performance to make sure that solutions are sustained: The Director of Nursing with the IDT will implement monthly reviews/monthly recaps of restorative care compliance, which will include tracking the timely execution of therapy orders and resident feedback on the effectiveness of interventions. Outcomes related to restorative nursing services will be discussed in monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvement. A designated staff member will be assigned to oversee the restorative nursing program and oversee continuous monitoring for adherence to policies and procedures. Include dates when corrective actions will be completed: March 21st, 2025
Resident Elopement and Unsecured Supply Closet
Penalty
Summary
The facility failed to ensure the safety of a resident who was at risk for elopement. The resident, who had a history of severe cognitive impairment and was using a WanderGuard device, managed to elope from the facility and was found in a parking lot approximately one block away. The WanderGuard device was not applied according to the manufacturer's instructions, as it was attached to the metal part of the resident's wheelchair, which could interfere with its function. Staff members, including a CNA and LVN, were unaware of how to properly check the functionality of the WanderGuard device, and the device did not alarm when the resident exited the facility. The resident had a medical history that included hemiplegia, schizophrenia, and epilepsy, among other conditions, and was known to wander frequently. Despite this, the facility's staff did not adequately monitor the resident or ensure the proper functioning of the WanderGuard device. The facility's policy on wandering and elopements was not effectively implemented, as staff failed to follow the manufacturer's guidelines for the WanderGuard device, and there was a lack of documentation and tracking of the resident's previous elopement attempts. Additionally, the facility failed to secure a supply closet containing medical supplies, which was observed to be unlocked. This posed a potential risk to residents, especially those who wandered, as they could access and potentially ingest harmful substances. The facility's policy on the storage of medications and supplies was not adhered to, as the supply closet was not locked, and staff were not aware of the importance of securing it.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/05/2025, the facility moved WanderGuard on resident #61's wheelchair to the back of the metal part of the wheelchair, away from metal or anything that could interfere with the system's function. The WanderGuard is secured and not easily movable. It is also visible to staff for licensed nurses to do placement and function checking. On 3/03/2025, maintenance switched the lock on the supply closet and converted it to auto-lock. This ensures that the door will have to be unlocked every time it is opened. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice of the storage of the supply closet. All residents exhibiting behaviors associated with elopement or wandering have the potential to be affected by the deficient practice. All residents exhibiting behaviors associated with elopement or wandering have been identified through a facility-wide assessment conducted on March 19, 2025. No other issues were found with the placement of the WanderGuard. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: All residents exhibiting behaviors associated with elopement or wandering have been identified through a facility-wide assessment conducted on March 19, 2025. All relevant care plans have been reviewed and adjusted to incorporate necessary interventions aimed at reducing elopement risks for these residents and ensuring WanderGuard is in proper placement. An in-service training and competency check related to the proper use and placement of WanderGuard devices has been conducted for all licensed nurses from March 4, 2025, to March 21, 2025. A facility-wide in-service for all nursing staff has been initiated from March 12, 2025, to March 28, 2025, to review elopement procedures and reinforce adherence to protocols. An in-service was done on 3/19/25 reeducating nurses on the importance of ensuring the supply closet stays locked when not in use. Additionally, a systemic change has been implemented requiring competency checks for all new hires as well as annual assessments for licensed nurses to ensure their understanding and ability to handle elopement concerns effectively. How the facility plans to monitor its performance to make sure that solutions are sustained: Competencies will be reviewed by the Director of Staff Development annually and upon hire on elopement prevention protocols and the effectiveness of WanderGuard device functioning and storage of medication/ensuring locked doors. All training sessions and competency checks will be documented, and return demonstrations will be done to verify understanding of the device and elopement protocol. The facility will bring forth all education done for new hires and annual competencies to its monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure continuous monitoring and improvement. This will stay in place for at least 90 days/3 QAPI meetings. An elopement drill will be conducted on different shifts twice a month for the next 3 months by the Director of Staff Development, and any findings will be reported to QAPI. Nursing management will perform twice-monthly audits for the next three months of medication storage areas to ensure they are all locked according to policy and procedure. Include dates when corrective actions will be completed: March 28, 2025.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that medication carts were locked when unattended, as observed during a survey. A policy titled 'Storage of Medications,' revised in April 2019, mandates that all drugs and biologicals be stored securely, and specifically states that unlocked medication carts should not be left unattended. During an observation, a medication cart was found unlocked and unattended outside a room, with no staff or residents nearby. A Registered Nurse confirmed she was in a resident's room and out of eyesight from the cart, acknowledging that she should have locked it. The Director of Nursing also confirmed that medication carts should not be left unlocked and unattended.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were affected by the deficient practice. Nurse was immediately informed she left her med cart unlocked and locked it right away. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice, and therefore, a comprehensive review will be initiated to assess any potential risks associated with the handling of medications. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On March 21, 2025, the Director of Nursing provided an in-service training for Licensed Nurses on the critical importance of ensuring that medication carts are locked when not in use. This training will reinforce the protocol that all medication carts must be secured properly when left unattended. How the facility plans to monitor its performance to make sure that solutions are sustained: Starting on March 21, 2025, Nursing Managers and Supervisors, including the Director of Nursing Services, Assistant Director of Nursing, Infection Preventionist, and Director of Staff Development, will begin conducting weekly audits at various times throughout the day to verify adherence to the policy requiring that medication carts are properly locked when not in use. The outcomes of these weekly audits will be discussed during monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvements are made as necessary. Include dates when corrective actions will be completed: March 21, 2025.
Failure to Discontinue Medication Order
Penalty
Summary
The facility failed to ensure that an order to discontinue a medication was properly transcribed into the clinical record for a resident. The resident, who was admitted with a medical history of type two diabetes mellitus, had a follow-up appointment with an outside physician who noted that the resident's prescription for Pred Forte should be discontinued. Despite this, the medication order remained active in the resident's records, indicating a failure to update the clinical documentation as per the physician's instructions. Interviews with facility staff revealed that the physician's note regarding the discontinuation of the medication was not reviewed by nursing staff before being scanned into the resident's electronic medical record. The Licensed Vocational Nurse and the Medical Records Director confirmed that the note was not marked as reviewed, which is a necessary step before scanning. The Director of Nursing also stated that nursing staff should have checked for new orders and updated the resident's records accordingly upon their return from the appointment, which did not occur in this instance.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 03/05/25, Resident #84 had the order for Pred Forte (prednisolone acetate) immediately discontinued in the clinical record. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice, as the failure to document and discontinue medication orders can occur for any resident with outside medical appointments. On 03/19/25, medical records conducted a comprehensive review of all appointment/consult notes for each resident to ensure they are consistent with the most recent provider instructions. No further discrepancy noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 03/21/25, the nursing and medical records staff were in-serviced on the facility's policies for reviewing, documenting, and transcribing medication orders, particularly those issued by outside providers. A new process has been implemented to ensure that all outside provider notes are promptly reviewed by nursing staff upon receipt. Nurses will be responsible for identifying and entering any new orders, including medication discontinuations, into the EMR. Medical records staff will ensure that all physician progress notes are not scanned into the EMR until they have been reviewed and acted upon by nursing staff. Before scanning and uploading to the resident's documents, Medical Records will make sure it is noted and verified by nursing staff. How the facility plans to monitor its performance to make sure that solutions are sustained: Regular audits will be conducted by Medical Records to review compliance with the new procedures. These audits will focus on ensuring that all provider orders, including medication discontinuations, are accurately documented in the clinical record and MAR. Outcomes related to restorative nursing services will be discussed in monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvement. Include dates when corrective actions will be completed: Completion date March 28th, 2025
Failure to Provide Adequate Oral Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL), specifically oral care, for three residents. Resident 1, who had been admitted with hemiplegia and hemiparesis following a cerebral infarction, was found to have a gray-white residue inside his oral cavity and malodorous breath. His daughter reported that his mouth appeared to be rotting, with broken teeth and gray saliva, indicating a lack of oral care. She expressed concerns about neglect and decided not to return him to the facility. Resident 2, also admitted with hemiplegia and hemiparesis, was observed with a significant amount of grayish-white residue on his teeth and malodorous breath. He stated that he was capable of brushing his own teeth but required staff to provide the necessary supplies, which had not been done for nine days. Despite his requests, staff failed to provide the supplies, and the assigned CNA admitted to not providing them, citing unfamiliarity with the resident. Resident 3, diagnosed with Parkinsonism and pneumonia, was observed with excessive yellow-white residue on his lips, teeth, and tongue, and malodorous breath. He reported not receiving oral care that day and expressed a desire for more frequent assistance. The assigned CNA claimed to have provided oral care using only a swab, but this was not documented. The Director of Staff Development confirmed the lack of documentation, indicating that oral care was not properly provided or recorded, contrary to the facility's policy on supporting ADLs.
Expired Medications Found in Treatment Cart
Penalty
Summary
The facility failed to ensure that expired medications were discarded from the treatment cart, which was the only cart containing supplies and treatments for resident wounds. During an interview, Licensed Staff E, a treatment nurse, confirmed that the charge treatment nurse, who was responsible for regularly checking the cart for expired medications or supplies, was on leave of absence. Upon inspection of the treatment cart, several expired medications and supplies were found, including silver nitrate applicators, a bottle of barrier cream, and bottles of Providone Iodine 10% solution. Some of these items had expiration dates that had been erased, indicating a lack of proper management and oversight. Licensed Staff E acknowledged the presence of expired products and stated she would discard them immediately. The Director of Staff Development (DSD) confirmed that the treatment nurse was responsible for checking the treatment cart for expired items and that the facility had a designated receptacle for discarding such products. The facility's policy on Medication Labeling and Storage, dated 2001, indicated that the dispensing pharmacy should be contacted for instructions regarding the return or destruction of discontinued, outdated, or deteriorated medications or biologicals. However, this policy was not followed, leading to the deficiency.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to address grievances reported by a resident, leading to unresolved issues that affected the resident's quality of life. The resident, who had medical diagnoses including hemiplegia, hemiparesis, and insomnia, reported a broken bed frame and a damaged electronic tablet to the Social Services Department. Despite these reports, the facility did not take timely action to resolve the grievances. The resident's bed frame remained broken, causing discomfort and difficulty sleeping, while the electronic tablet, essential for entertainment, was not replaced, resulting in boredom and frustration. The Social Services staff acknowledged receiving the complaints but did not follow up to ensure the issues were resolved. The facility's grievance policy requires that all grievances be investigated and resolved promptly, with the resident informed of the findings and corrective actions. However, the staff failed to adhere to this policy, as evidenced by the unresolved grievances and the lack of follow-up with the resident. The facility's inaction in addressing these grievances highlights a deficiency in ensuring residents' rights to voice grievances without discrimination or reprisal.
Deficiency in Resident Phone Access and Privacy
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to and privacy in their use of communication methods, specifically telephone calls. This deficiency was identified through observations, interviews, and record reviews. A family member of the resident was unable to contact the resident by phone, prompting them to call the police for a wellness check. The family member, who lived out of state, reported that calls to the resident went unanswered, and voicemails were not returned. The resident confirmed that the facility's phones did not work properly, and staff did not answer calls, which led to missed communication with a visitor. Further investigation revealed that the facility's phone system was problematic, with staff acknowledging that phones were not answered after certain hours due to the absence of a receptionist. Additionally, many phones in residents' rooms and the facility's overhead pager were not functioning. The facility's staff and visitors frequently complained about these issues, and the administrator was aware of the problem. This deficiency was in violation of the residents' rights to make and receive private phone calls as outlined by CMS.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, specifically Chlordiazepoxide, which is used to treat anxiety and symptoms of alcohol withdrawal. The resident, who was admitted with diagnoses of anxiety disorder and alcohol dependence with withdrawal, did not receive five scheduled doses of this medication. The resident's Minimum Data Set indicated intact cognition, and the care plan required the administration of anti-anxiety medication as ordered. However, the Medication Administration Record showed missed doses on specific dates, and notes indicated the medication was awaiting delivery from the pharmacy. The Director of Nursing confirmed that the medication was reordered after the last available dose was administered, which did not allow enough time for the order to be completed before the next dose was due. The facility's policy required medications to be given at the specified date and time in the physician's order. The policy also stated that routine medications should be reordered by the re-order date on the label to ensure an adequate supply. The failure to reorder the medication in a timely manner led to the resident missing multiple doses, potentially causing anxiety and symptoms of alcohol withdrawal.
Failure to Ensure Adequate Hydration and Nutrition
Penalty
Summary
The facility failed to ensure adequate hydration and nutrition for a resident during his 3.5-week stay. The resident, who required assistance for eating and drinking and was at risk for dehydration and malnutrition, experienced a significant weight loss of 30.8 pounds within 18 days of admission. Nursing staff and the Registered Dietitian (RD) did not notify the resident's physician, Nurse Practitioner (NP), or family about the severe weight loss, nor did they document it in the medical record or discuss it during the Weight Committee or interdisciplinary team (IDT) meetings. Additionally, Certified Nursing Assistants (CNAs) did not consistently and accurately document the resident's oral fluid intake. The resident's medical records indicated that he was admitted to the facility after a hospital stay for a right toe amputation and was at risk for dehydration and malnutrition. Despite this, the facility did not implement a Change of Condition (COC) in response to the severe weight loss. The resident's family, upon observing his deteriorated condition, removed him from the facility against medical advice (AMA) and took him to the hospital, where he was admitted to the Intensive Care Unit (ICU) with severe dehydration, malnutrition, acute kidney injury, and other complications. Interviews with facility staff revealed that the RD and nursing staff failed to take appropriate actions to address the resident's weight loss and poor fluid intake. The RD admitted that the weight loss was missed and that no interventions were implemented. The Director of Nursing (DON) confirmed that the medical record did not contain evidence of rechecked weights, notifications to the RD or DON, or documentation of the weight loss. The facility's failure to monitor and intervene in the resident's fluid status and weight loss contributed to his severe decline in health.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Committee (QAPI) failed to identify and act upon significant quality deficiencies, as evidenced by the case of a resident who experienced a severe weight loss of 30.8 pounds within 18 days of admission. The facility staff did not notify the resident's physician or nurse practitioner of the severe weight loss, nor did they implement any interventions to address the decline. The resident's family eventually took him from the facility against medical advice and transported him to a hospital, where he was admitted to the ICU in critical condition. Despite the resident's weight loss being documented and presented at a QAPI meeting, it was not addressed or discussed, preventing the facility from identifying potential system failures and implementing necessary changes to prevent similar harm to other residents. The resident's medical records from the hospital indicated that he was admitted with a right foot diabetic ulcer and had undergone a right fifth toe amputation. Upon discharge to the facility, he was placed on a pureed diet and required daily dressing changes. However, during his stay at the facility, the resident's condition deteriorated significantly, leading to severe dehydration, acute kidney injury, severe malnutrition, and other critical health issues. The facility's records showed that the resident's weight was documented multiple times, but no actions were taken to address the significant weight loss. The facility's policies on weight assessment and intervention, as well as change in a resident's condition, were not followed, and the necessary notifications and interventions were not made. Interviews with facility staff, including the Registered Dietitian (RD), Licensed Nurses (LNs), and the Director of Nursing (DON), revealed that the weight loss was missed, and no interventions were implemented. The facility's documentation showed incomplete and low fluid intake records for the resident, which were not properly monitored or addressed. The facility's administrator confirmed that the QAPI team did not conduct a root cause analysis to determine the cause of the resident's severe weight loss or the family's decision to remove him from the facility. The facility's failure to monitor and intervene in the resident's condition contributed to his severe decline and hospitalization in the ICU.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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