Pine Creek Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Roseville, California.
- Location
- 1139 Cirby Way, Roseville, California 95661
- CMS Provider Number
- 555801
- Inspections on file
- 30
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pine Creek Care Center during CMS and state inspections, most recent first.
Surveyors found that three residents at risk for falls and requiring varying levels of assistance with ADLs and transfers did not have accessible, functional call light systems as required by their care plans and facility policy. Two residents were observed awake in bed with their call light buttons on the floor under the bed and out of reach, and CNAs confirmed the lights should have been placed within reach. Another resident reported that his call light had been broken for several days, staff interviews indicated the call light frequently malfunctioned, and observation with staff confirmed the system was broken with no alternative call system provided and no documentation in the maintenance log.
Three residents did not receive care and services as ordered, including the application of TED stockings and lymphatic compression devices. One resident with endocarditis and muscle weakness was not provided with TED hose or offered the compression device as ordered, while two other residents with conditions such as congestive heart failure and multiple sclerosis were not provided with TED hose or daily weights as prescribed. Staff and nursing leadership confirmed these orders were not followed, and facility policy required adherence to physician orders.
Two residents who required staff assistance for ADLs were found with untrimmed, dirty fingernails, dry and scaly feet, and old food residue in their beards. Staff confirmed these hygiene deficiencies and acknowledged that the residents should have been properly cleaned and groomed, in accordance with their care plans and facility policy.
The facility did not consistently document the administration of hydrocodone-acetaminophen for three residents with orthopedic and spinal injuries, resulting in discrepancies between the Controlled Drug Record and the Medication Administration Record. The DON acknowledged the importance of accurate documentation for controlled drug accountability, but the facility's policy was not followed.
Surveyors found that medication carts contained a loose, unlabeled tablet and were left unlocked and unattended, contrary to facility policy. Additionally, a discontinued medication for a resident with respiratory conditions remained in the medication refrigerator with active medications days after discharge, instead of being promptly removed and stored for disposal as required.
Staff did not deliver bedside water pitchers for two days, resulting in four residents—each at risk for dehydration due to medical conditions and not on fluid restrictions—being left without consistent access to water. Observations and interviews confirmed the absence of water pitchers, with some residents only receiving water at mealtimes. Both nursing and CNA staff acknowledged that water pitchers should have been provided, and facility policy required monitoring and supporting resident hydration.
Licensed nursing staff documented treatments and medications as provided when they were not administered, including TED hose and IV antibiotics, and failed to accurately complete informed consent for a psychotropic medication. Additionally, meal tickets containing resident-identifiable information were disposed of in regular garbage instead of confidential shredding, breaching confidentiality protocols.
A resident with dysphagia and partial paralysis had a G-tube in place, but there was no current physician order or care plan addressing the device. Multiple staff, including an LPN, NP, and DON, confirmed the absence of required documentation and care planning for the G-tube, despite facility policy requiring comprehensive care plans for all medical devices.
A resident with dysphagia and partial paralysis had a physician order for 1:1 supervision and assistance during meals, including cues to slow eating and pre-cut food. Staff were observed leaving the resident unattended during meals, and there was no documentation of required supervision for the past month. Facility policies required following physician orders and providing meal assistance based on individual needs, but these were not followed.
The facility failed to meet professional standards for food storage and service practices, including unlabeled opened food packages, improperly stored food items, and ineffective sanitizer solution. These deficiencies were acknowledged by the Food and Nutrition staff and were in violation of the facility's policies and the U.S. Food and Drug Administration's Food Code.
The facility failed to follow infection control standards, including improper sanitation of a shower chair, washing machine, and vital signs machine, as well as inadequate hand hygiene and labeling of oxygen tubing, nebulizer equipment, and urinals. These failures decreased the facility's potential to prevent the spread of infection.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their MDS. One resident's MDS inaccurately indicated one-sided impairment despite both knees being contracted, while another resident's MDS incorrectly noted intermittent catheterization without physician orders. These inaccuracies were confirmed by the MDS Coordinator and nursing staff.
The facility failed to develop and implement accurate baseline care plans for three residents within the required 48-hour timeframe after admission. The residents had various medical devices and needs, including urinary catheters, a PICC line, an abdominal binder, and TED hose, but there were no documented care plans for these items. The Director of Nursing confirmed the omissions, and the facility could not provide a policy for Baseline Care Plans.
The facility failed to update a resident's care plan to include the use of an elopement management bracelet, despite multiple observations of the resident wearing the bracelet. Both the ADON and DON confirmed the care plan was not revised, contrary to facility policy.
The facility failed to implement physician's orders for a resident's use of TED hose and an abdominal binder, and did not properly assess and cover a PICC line. Additionally, an elopement management bracelet was applied to another resident without a physician's order, with no documented communication between staff and the physician.
The facility failed to ensure that a resident with a history of stroke and dysphagia was assisted to an upright position while eating, increasing the risk of aspiration. The resident was observed lying in bed while eating, and staff acknowledged the need for the resident to be sitting up to prevent choking. Interviews with staff confirmed the importance of proper positioning during meals.
The facility failed to ensure all drugs were properly labeled, as an aerosol medication used to treat breathing problems was found inside a disposable plastic cup without any identifying labels in a medication cart. Staff confirmed the medication lacked identification labels and was unable to determine which resident the medication belonged to. The facility's policy requires medications to be labeled with specific information, which was not followed in this instance.
Failure to Maintain Accessible and Functional Call Light Systems for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents had access to functioning call light systems within reach, as required by their care plans and facility policy. For one resident with a neck fracture, dementia, and no capacity to make decisions, the care plan identified risk for falls and directed staff to keep the call light within reach. During observation, this resident was found awake in bed with a neck brace, and the call light button was on the floor under the bed. The resident stated he did not know where his call light was, and a CNA confirmed its location and acknowledged it should have been placed where the resident could reach it. A second resident, with diabetes, polyneuropathy, retinopathy, gait and mobility abnormalities, and muscle weakness, had an MDS showing intact cognition but required varying levels of assistance with ADLs and transfers. The care plan for this resident, which addressed fall risk, included interventions to keep the call light within reach and to educate/remind the resident to call for assistance with all transfers. During observation, this resident was also found awake in bed with the call light button on the floor under the bed and the cord stuck on the bed frame. The resident reported being unable to reach the call light, and a CNA confirmed the situation and stated the call light should always be within the resident’s reach. A third resident, with a history including a left upper arm fracture, diabetes, muscle weakness, and congestive heart failure, had an MDS indicating mostly substantial/maximal assistance needs for ADLs and supervision or assistance for bed mobility and transfers. The care plan for this resident, addressing fall risk, included instructions to educate/remind the resident to call for assistance with all transfers and to keep the call light within reach. Staff interviews revealed that this resident’s call light “usually gets broken” and that staff would try to fix it, but it would break again. The resident reported feeling annoyed and uncomfortable in the room because the call light had been broken for several days and stated that staff were aware but had not fixed it. Observation with a CNA and the Maintenance Supervisor confirmed the call light system was broken, there was no alternative call system in place, and there was no entry in the maintenance logbook documenting the broken call light. The DON stated she expected residents to have working call lights within reach and acknowledged safety concerns when call lights are not working or not within reach.
Failure to Follow Physician Orders for Compression Devices and Stockings
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for three residents by not following physician orders for the application of Thrombo-Embolic Deterrent (TED) stockings and lymphatic compression devices. One resident, admitted with endocarditis and generalized muscle weakness, had physician orders for TED hose to be applied every morning and removed in the evening, as well as for a lymphatic compression device to be offered after meals. During observation and interview, the resident was found wearing regular socks instead of TED stockings and reported that the compression device had not been offered. The assigned nurse confirmed the devices were not applied as ordered and that the compression device was stored out of sight in the resident's room. Another resident, admitted with congestive heart failure and muscle weakness, had an order for compression stockings to be worn during the day and removed at night, as well as an order for daily weights. Observations revealed the resident was not wearing compression stockings, and record review showed daily weights were not completed as ordered. The Director of Staff Development confirmed the omission of daily weights and the absence of compression stockings during review of the resident's records. A third resident, admitted with muscle weakness and multiple sclerosis, had an order for TED hose to be applied in the morning and removed at bedtime. During observation and interview, the resident was not wearing TED hose and stated she had never been fitted for them while at the facility. The physical therapy assistant and licensed nurse confirmed that TED hose were not available among the resident's belongings and had not been applied. The Director of Nursing and Nurse Practitioner both stated their expectation that staff follow physician orders as written. Facility policy also required that prescribed medication and treatment orders be carried out as prescribed.
Failure to Provide Adequate Hygiene and Grooming for Two Dependent Residents
Penalty
Summary
Two residents who required assistance with activities of daily living (ADLs) were observed to have untrimmed, jagged fingernails with black substances underneath, dry and scaly skin on their feet, and traces of colored-liquid and old, dry food residue in their beards. These findings were confirmed during multiple observations and interviews with facility staff, including the Treatment Nurse, Assistant Director of Nursing, and Director of Nursing. Both residents had documented medical conditions—one with osteoarthritis, generalized muscle weakness, and a left below-knee amputation, and the other with Parkinson's disease and dementia—that necessitated staff assistance for ADLs, as reflected in their care plans. Despite these documented needs, the residents were not provided with adequate hygiene and grooming, as evidenced by their physical condition during the survey. Staff interviews confirmed that the residents should have been cleaned and groomed, and that the lack of hygiene could lead to discomfort, skin irritation, and affect their dignity. Facility policy required appropriate care and services for residents unable to perform ADLs independently, but this was not followed for the two residents in question.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled medications for three residents who were prescribed hydrocodone-acetaminophen for pain management following orthopedic and spinal injuries. For one resident, the Controlled Drug Record (CDR) indicated a dose was administered, but this was not reflected in the Medication Administration Record (MAR). For another resident, multiple instances were found where the CDR showed administration of the medication, but the MAR did not document these doses. In a third case, there was a discrepancy between the administration times recorded in the CDR and the MAR for the same dose. Interviews with the Director of Nursing confirmed the importance of correct documentation for controlled drug accountability and acknowledged that incorrect records could be associated with medication misuse and drug diversion. The facility's policy required immediate and accurate documentation of controlled medication administration on both the accountability record and the MAR, including date, time, amount administered, and the nurse's signature, but this procedure was not consistently followed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of medications. During an inspection of a medication cart, a loose, unlabeled white tablet was found at the bottom of a drawer containing blister packs. The nurse present acknowledged that medication carts should not contain loose or unlabeled medications. Additionally, a medication cart was found unlocked and unattended at a nursing station, which was confirmed by both a licensed nurse and the Director of Nursing (DON) as a safety concern and contrary to facility policy. The facility's policy requires all drugs and biologicals to be stored in their original packaging and for medication carts to be locked when not in use. Another deficiency was identified regarding the handling of discontinued medications. A prescription drug belonging to a discharged resident, who had a history of acute respiratory failure with hypoxia and chronic obstructive pulmonary disease, was found stored in the medication refrigerator alongside active medications several days after the resident's discharge. The nurse and DON confirmed that discontinued medications should be removed immediately upon discharge and stored separately for disposal. Facility policy also states that discontinued, outdated, or deteriorated drugs must be placed in designated bins for destruction, which was not followed in this instance.
Failure to Provide Bedside Water Pitchers Results in Hydration Deficiency
Penalty
Summary
The facility failed to provide sufficient hydration to four residents when staff did not deliver bedside water pitchers for two consecutive days. Observations and interviews revealed that these residents, all of whom had medical conditions placing them at risk for dehydration, did not have water pitchers at their bedside tables during multiple checks. Instead, some residents only had partially filled cups or received water only at mealtimes, which was inconsistent with their care plans and facility policy. Resident records indicated that none of the affected residents were on fluid restrictions, and their care plans specifically identified them as being at risk for dehydration. For example, one resident with a history of urinary tract infection, type 2 diabetes, and high blood pressure, who was also prescribed a diuretic, had significantly reduced fluid intake on the days in question compared to her average intake for the month. Other residents with moderate cognitive impairment also lacked bedside water pitchers, and staff interviews confirmed that water pitchers should have been provided regardless of fluid restriction status. Staff interviews further clarified that the night shift was responsible for providing fresh water pitchers, and the day shift was expected to replace any missing pitchers. However, both nursing and CNA staff acknowledged that the absence of water pitchers could lead to adverse outcomes, and the facility's own hydration policy required staff to monitor hydration status and provide supportive measures, including supplemental fluids. The deficiency was directly linked to the failure of staff to ensure water pitchers were consistently available at residents' bedsides.
Inaccurate Documentation and Breach of Resident Confidentiality
Penalty
Summary
Licensed nursing staff documented the administration of treatments and medications that were not actually provided to several residents. For example, one resident with orders for TED hose and a lymphatic compression device was not wearing the devices as ordered, and the nurse confirmed she had not applied them despite documenting otherwise. Similarly, two other residents with orders for TED hose were not wearing them, and the responsible nurse admitted to documenting their application on the MAR when she had not performed the task. In another case, a resident's intravenous antibiotics were documented as administered by a nurse not authorized to do so, and the nurse acknowledged the documentation was inaccurate. The facility also failed to safeguard resident-identifiable information. Meal tickets containing residents' names, room numbers, dietary information, and allergies were disposed of in the regular garbage rather than in a confidential shredding bin. This practice was confirmed by both the dietary worker and the dietary manager, who acknowledged that the tickets contained confidential information and should not have been discarded with regular waste. Additionally, the facility did not accurately complete informed consent documentation for the administration of a psychotropic medication. The consent form for a resident receiving brexpiprazole was signed and witnessed by two nurses, but the section indicating the name of the person giving verbal or phone consent was left blank. The assistant director of nursing confirmed that the consent was incomplete and inaccurate, as the responsible party's name was not documented as required.
Failure to Develop and Implement Care Plan for G-Tube
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who was admitted with diagnoses including dysphagia and partial paralysis to the left side, and who had a G-tube in place. Upon review of the resident's admission record, order summary report, and care plan documentation, it was found that there was no current physician's order or care plan addressing the G-tube, despite its presence. The resident expressed a desire to have the G-tube removed, and during multiple interviews and record reviews with facility staff, it was acknowledged that the necessary documentation and care planning for the G-tube were missing. Further interviews with a licensed nurse, nurse practitioner, and the director of nursing confirmed that there was no current order for the G-tube and no care plan developed, revised, or resolved for its care and treatment. The facility's own policy requires a comprehensive care plan that includes measurable objectives to meet the resident's needs, including medical devices. The lack of a care plan for the G-tube meant the resident's specific needs related to this device were not formally addressed.
Failure to Provide Required Supervision and Assistance During Meals
Penalty
Summary
A resident with diagnoses including dysphagia and partial paralysis to the left side was admitted to the facility and had a physician order for 1:1 supervision during meals, cues to slow eating, and pre-cut food into bite-sized pieces. Observations revealed that the resident was left unattended during meal times, with staff delivering meal trays, positioning the resident, and then leaving. On two separate occasions, the resident was found alone with her meal tray, without the required supervision or assistance. A review of the resident's electronic record showed no documentation of 1:1 supervision for meals over the past 30 days, despite the physician's order. When requested, the facility was unable to provide a policy and procedure defining levels of meal assistance. The facility's existing policies indicated that residents should receive meal assistance according to their individual needs and that physician orders should be followed as prescribed. The nurse practitioner confirmed that staff are expected to follow orders for resident safety.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to meet professional standards for food storage and service practices, as observed during a survey. Opened food packages, such as a bottle of barbecue sauce and various seasonings, were found without labels indicating the date they were opened. This lack of labeling was acknowledged by the Food and Nutrition Assistant (FNA) and the Food and Nutrition Director (FND), who both stated that opened food items should be labeled with the date to determine their shelf life based on storage guidelines. The facility's policy and procedure, as well as posted guidelines, were not followed in these instances. Additionally, several food items, including frozen waffles and bins of sugar and brown rice, were found removed from their original packaging without proper labels identifying the contents. The FNA confirmed that these items should have been labeled to indicate what the product was. This practice is in violation of the facility's policy and the U.S. Food and Drug Administration's Food Code, which requires that food storage containers be identified with the common name of the food to prevent contamination. Furthermore, opened and unsecured packages of meatless meatballs, meatless breaded wings, and oatmeal cookie dough were found in the freezer. The FNA and FND both acknowledged that these bags should be securely closed to prevent cross-contamination and freezer burn. The facility also failed to maintain the proper concentration of quaternary ammonium sanitizer solution, as observed during multiple tests where the solution was found to be below the effective range of 200 to 400 parts per million (ppm). The FND and Dietary Aide (DA) confirmed that the solution needed to be changed more frequently to ensure its effectiveness, as per the facility's policy and procedure.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection control standards of practice in several instances. A shower chair with a brown substance was observed stored in the hallway, and staff did not follow the recommended minimum disinfectant contact time for sanitation of the chair. Additionally, staff did not sanitize the exterior surface of the washing machine, including the door handle, after loading dirty laundry. Staff also failed to perform hand hygiene prior to donning and after doffing personal protective equipment during medication administration. Furthermore, staff did not disinfect the vital signs machine between resident use and after use. Oxygen tubing for three residents was not labeled with a date, and nebulizer equipment for one resident was not labeled with a date or stored in an anti-microbial bag. Lastly, urinals for two residents were not labeled with resident identifiers. These failures decreased the facility's potential to prevent the spread of infection.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, resulting in discrepancies in their Minimum Data Sheets (MDS). Resident 15, who was admitted with multiple diagnoses including hemiplegia and hemiparesis, was observed with both knees contracted and experiencing significant pain. However, the MDS inaccurately indicated impairment on only one side. This inaccuracy was confirmed by the MDS Coordinator, who acknowledged that the assessment should have reflected impairment on both sides, potentially affecting the resident's plan of care. Similarly, Resident 301's MDS inaccurately indicated that the resident was receiving intermittent catheterization, despite no physician orders for such a procedure. This discrepancy was confirmed during a review of the resident's MDS and Order Summary Report (OSR) by the MDS Coordinator and a Licensed Nurse. The Director of Nursing stated that resident assessments are expected to be accurate, as per the facility's policy and procedure on resident assessments.
Failure to Implement Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement accurate baseline care plans for three residents within the required 48-hour timeframe after admission. Resident 297, admitted with diagnoses including fractures and muscle weakness, had a urinary catheter in place due to urinary retention, but there was no care plan documented for the catheter. Similarly, Resident 301, readmitted with muscle weakness, a fracture, and chronic respiratory failure, also had a urinary catheter without a corresponding care plan documented. These omissions were confirmed during a review of their care plans and physician orders, which indicated the presence of urinary catheters without associated care plans. Resident 307, admitted with lymphoma, benign prostatic hyperplasia, and muscle weakness, had multiple medical devices and needs, including a urinary catheter, a PICC line, an abdominal binder, and TED hose. However, there was no documented care plan for any of these items. During an observation and interview, Resident 307 confirmed the presence of these devices and the lack of use of the abdominal binder and TED hose. The Director of Nursing confirmed the missing care plans for all three residents and acknowledged that the baseline care plans should have included these essential details within the first 24-48 hours of admission. The facility was also unable to provide a policy and procedure for Baseline Care Plans when requested.
Failure to Update Care Plan for Elopement Management Bracelet
Penalty
Summary
The facility failed to revise the care plan for Resident 310 to reflect the placement of an elopement management bracelet. Resident 310, who was admitted with diagnoses including a left hip fracture, dysphagia, and dementia without behavioral disturbance, was observed wearing the bracelet on multiple occasions. However, the care plan dated from 4/4/24 to 4/18/24 did not include this critical update. Certified Nursing Assistant 5 was unaware of the bracelet's purpose, indicating a lack of communication and documentation regarding the resident's care needs. The Assistant Director of Nursing and the Director of Nursing both confirmed that the care plan had not been updated to include the elopement management bracelet, despite the facility's policy requiring care plans to be revised to meet residents' individual needs. This oversight was acknowledged during interviews and record reviews, highlighting a failure to provide consistent nursing interventions for Resident 310.
Failure to Implement Physician's Orders and Unauthorized Use of Elopement Bracelet
Penalty
Summary
The facility failed to ensure services provided met nursing professional standards for two residents. For Resident 307, the physician's orders for the use of thrombo-embolic deterrent hose (TED hose) and an abdominal binder to prevent orthostatic hypotension were not implemented. Additionally, Resident 307's peripherally inserted central catheter (PICC) was not assessed for patency and was not covered with an appropriate dressing. The Assistant Director of Nursing (ADON) confirmed that there were multiple shifts where the orders for TED hose were not documented as executed, and the PICC dressing was observed to be not intact and needed changing. For Resident 310, an elopement management bracelet was applied without a physician's order. The resident's records indicated no risk for elopement, and there was no documented communication between the nursing staff and the physician regarding the application of the bracelet. The Medical Doctor (MD) and Nurse Practitioner (NP) confirmed that there was no documentation or communication about the order for the bracelet in the communication binder, and the MD was unaware of the order. These failures decreased the facility's potential to ensure physician's orders were carried out for residents, as evidenced by the lack of implementation and documentation of prescribed treatments and the application of an elopement management bracelet without proper authorization.
Failure to Assist Resident to Upright Position While Eating
Penalty
Summary
The facility failed to ensure that Resident 28 was assisted to an upright position while eating lunch, which decreased the potential to prevent food aspiration and aspiration pneumonia. Resident 28, who had a history of stroke, dysphagia, and generalized muscle weakness, was observed lying in bed while eating a bowl of soup. When asked, Resident 28 indicated that lying down was not the best position to eat. A Certified Nursing Assistant (CNA) acknowledged that the resident was lying back too much and should be sitting up to eat, and subsequently raised the head of the bed to an upright position. The resident did not express any discomfort with sitting upright. Interviews with the Director of Staff Development (DSD), the Restorative Nursing Assistant Supervisor (RNAS), and the Director of Nursing (DON) confirmed that residents should be sitting up while eating to prevent choking. The facility's policy on Activities of Daily Living (ADLs) indicated that residents who are unable to carry out ADLs independently should receive appropriate support and assistance with dining. A review of a research article highlighted the importance of appropriate posture to prevent aspiration in older adults with dysphagia, emphasizing that the head of the bed should be raised by at least 30 degrees for those who cannot get out of bed.
Failure to Properly Label Medications
Penalty
Summary
The facility failed to ensure all drugs were properly labeled, as observed during a survey at nursing station 1. An aerosol medication used to treat breathing problems was found inside a disposable plastic cup without any identifying labels in medication cart 1. Licensed Nurse 3 confirmed the medication lacked identification labels and was unable to determine which resident the medication belonged to. The Regional Nurse Consultant also confirmed the medication should have been labeled. The Assistant Director of Nursing stated that unlabeled medications should be discarded due to safety issues, as nurses would not be able to identify which resident the medication was intended for. A review of the facility's policy and procedure on medication labeling, revised in February 2023, indicated that medications should be labeled in accordance with federal and state requirements. The policy specifies that labels must include the resident's name, medication name, prescribed dose, route of administration, and appropriate instructions and precautions. The failure to adhere to this policy reduced the facility's potential to ensure safe medication administration for its residents.
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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