Riverbank Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverbank, California.
- Location
- 2649 Topeka Street, Riverbank, California 95367
- CMS Provider Number
- 055084
- Inspections on file
- 38
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Riverbank Post-acute during CMS and state inspections, most recent first.
A resident admitted with bilateral nephrostomy tubes and an abdominal accordion drain was not accurately assessed or documented by nursing staff on admission. The admission and skin assessments did not identify the nephrostomy tubes or drain, and no related problems, goals, or interventions were added to the care plan. CNAs reported emptying the nephrostomy tubes and noted the presence of the drain, but the Treatment Nurse only became aware of these devices days later when family requested dressing changes. Review of the EMR showed no physician orders for nephrostomy or drain site care or monitoring until several days after admission, contrary to facility policies and professional standards that require comprehensive admission assessment, timely physician notification, and routine nephrostomy tube and drain care.
The facility did not ensure that licensed nurses had documented competency in nephrostomy tube assessment and care, despite having residents with nephrostomy tubes. Nursing staff, including an LVN, a treatment nurse, and an RN, reported participating in annual competencies covering the genitourinary system and catheter care but were unsure if nephrostomy care was included. The Director of Staff Development confirmed that the Licensed Nurse Competency Checklist addressed urethral and suprapubic catheters and genitourinary assessment but omitted nephrostomy care, and stated that topics not on the template were not evaluated. This omission conflicted with the facility’s own policy requiring sufficient and competent nursing staff to meet resident needs, including complex genitourinary care.
A resident admitted with bladder cancer, a psoas abscess, and artificial urinary openings had bilateral nephrostomy tubes and an abdominal accordion drain that were present on admission but not documented on the admission assessment, catheter/ostomy section, or skin assessment. Nursing staff did not obtain timely MD orders for dressing changes or site monitoring, and the Treatment Nurse only became aware of the devices after a CNA paged her at the family’s request for dressing changes. Review of the EMR showed that orders to assess the nephrostomy stoma sites each shift and to cleanse and dress the nephrostomy and drain sites every other day and PRN were not entered until several days after admission, and no care plan was developed to address these devices, their related problems, goals, or interventions, contrary to facility policy and nurse job expectations.
The facility failed to maintain its ice machine in safe operating condition, resulting in no ice being available to residents for two days. Two cognitively intact residents, one with an indwelling catheter, neuromuscular bladder dysfunction, pressure ulcer, protein-calorie malnutrition, and paraplegia, and another with cerebral palsy, breast cancer, bipolar disorder, and a recent UTI, reported they had no ice and drank less because they preferred ice-cold fluids. CNAs, an LVN, dietary staff, and the Director of Maintenance confirmed the ice machine’s dispenser repeatedly came off track, that no ice was available on the units or in kitchen freezers, and that the usual process of stocking ice chests at the nurses’ station was not followed. The MDS coordinator, DON, administrator, and other department heads either were not notified in a timely manner or did not follow up after receiving notice, despite facility policy and manufacturer guidelines requiring proper maintenance and operation of the ice machine to assure a safe supply of ice.
Three residents with dysphagia, G-tubes, neurologic conditions, and complex medical needs had physician-ordered Modified Barium Swallow (MBS) studies and ENT or Barium Swallow consults that were not properly scheduled or documented by the Social Services Director (SSD). Nursing staff documented that the physician issued the orders and that Social Services was notified, and the ST confirmed that the residents and responsible parties had agreed to the testing. The SSD acknowledged receiving the orders, attempting to contact responsible parties, and working on insurance authorization, but kept notes on paper in a personal folder and used a temporary EMR communication board instead of documenting referrals, scheduling efforts, refusals, or delays in the permanent EMR. Facility policy required Social Services to coordinate physician-ordered referrals and document them in the medical record, but there was no EMR evidence that the ordered tests and consults were completed, scheduled, or appropriately followed up, resulting in delayed care and unmet medically related social service needs.
The Administrator failed to provide effective oversight of social services and referral processes, resulting in multiple physician-ordered consultations and diagnostic tests not being timely scheduled or properly documented in the EMR for several residents with dysphagia, neurologic conditions, and G-tubes. An LVN documented that social services was notified of orders for Modified Barium Swallow and Barium Swallow studies, but the Social Services Director (SSD) and assistant did not ensure appointments were scheduled or that refusals, barriers, or follow-up efforts were entered into the medical record, instead relying on paper folders and a temporary communication board that was not part of the permanent record. One resident with a history of stroke and dysphagia had ENT and MBS orders that were not fully acted upon or documented, another resident reportedly refused an MBS without any EMR note of the refusal, and another resident’s swallow study was delayed while the SSD attempted but did not document contact with the responsible party and hospital. The facility’s own policies required Social Services to coordinate referrals and document them in the medical record, and the Administrator, as the SSD’s direct supervisor, did not identify or correct these documentation and follow-through failures.
The facility failed to maintain complete and accurate EMR documentation for three residents when the Social Services Director and social services staff did not record scheduling attempts, responsible party contacts, refusals, or follow-up related to physician-ordered EENT consults and Modified/Barium Swallow studies. Nursing notes showed that physicians ordered these consults and that social services was notified, and staff described residents with G-tubes, NPO status, and swallowing issues requiring these tests. However, the SSD kept paper notes in a personal folder and used a temporary EMR communication board that auto-deleted, rather than entering permanent progress notes as required by facility policies, resulting in no documented evidence in the medical record that the ordered referrals and diagnostic tests were scheduled or followed up.
Two residents did not receive comprehensive, person-centered care plans addressing their refusal of nail care, and required notifications to responsible parties and physicians were not documented or implemented. Staff interviews and record reviews confirmed that care plans were either not initiated in a timely manner or not followed, resulting in unmet requirements for individualized care planning and documentation.
Two residents who refused nail care did not have their refusals properly documented, and neither the physician nor the responsible party were notified as required. One resident with severe cognitive impairment and another who was cognitively intact both had long, untrimmed nails observed by staff, and interviews confirmed that notifications and documentation were not completed according to professional standards.
Two residents with complex medical needs were found to have long, untrimmed toenails despite repeated documentation of the need for nail care. Staff acknowledged the issue, and records showed that the process for reporting and addressing nail care was not followed, resulting in the residents not receiving appropriate foot care.
Surveyors identified that the facility did not maintain its fire alarm system as required, with ongoing trouble signals on the fire alarm control panel and missing records for annual battery discharge and charger tests. Staff were unaware of the trouble signals until the survey, and no documentation of required battery testing was provided.
The facility did not complete required weekly inspections, monthly load and battery conductance tests, or the triennial four-hour load tests for its emergency generators, with staff unable to confirm if these tasks were performed and missing documentation for multiple months. These failures affected all residents and smoke compartments in the facility.
Surveyors found that the facility did not maintain or update its Emergency Preparedness Plan as required, with no documentation of an annual review and staff confirming the plan had not been updated, affecting all residents.
Surveyors found that the facility did not maintain or update its Emergency Preparedness Plan (EPP) policies and procedures as required, with no documentation available to show annual review or updates. Staff confirmed the EPP had not been updated, affecting all residents in the facility.
The facility did not maintain or update its Emergency Preparedness Plan's Communication Plan as required, with no documentation of an annual review and staff confirming the update had not occurred. This deficiency could impact the health and safety of all residents during an emergency.
Surveyors found that the facility did not provide documentation showing that its Emergency Preparedness (EP) training and testing program for staff had been reviewed or updated on an annual basis. Staff confirmed that the EP training and testing had not been updated, and the last review date was unknown, affecting all residents.
Surveyors found that the facility's automatic sprinkler system was not properly maintained, with dust and debris present on sprinkler components and missing required signage for the fire department connection and control valve. These deficiencies were confirmed by staff and affected all residents and smoke compartments.
Surveyors found an orange extension cord powering fan components in the Human Resources Office and a missing faceplate on a receptacle in the Director of Staff Development's Office. Staff confirmed both issues, which did not comply with electrical safety standards and affected multiple residents and smoke compartments.
A penetration in the wall near the kitchen entrance, measuring about an inch and a half in diameter and located 18 inches from the ceiling, was observed during a facility tour. This breach affected one of six smoke compartments and 27 residents, compromising the required fire barrier integrity.
Surveyors found that emergency exit signs above the southeast fire doors and northwest corridor by Nurse Station A did not remain illuminated when tested, and staff were unaware of the issue. This deficiency affected 27 residents and one smoke compartment.
Surveyors found that the door to a Shower Room used for storing soiled linen containers was obstructed by equipment and lacked a self-closing mechanism. Staff confirmed the storage practices and the absence of the required door hardware, impacting one smoke compartment and 27 residents.
The facility did not provide complete semi-annual inspection records for the kitchen's hood fire suppression system, with one required record missing and staff unable to confirm when the service was conducted. This deficiency affected the nutritional services area and one smoke compartment.
Surveyors found that two corridor doors with self-closing mechanisms, one to a Shower Room and another to a Salon, failed to latch after multiple tests. Staff attributed the issues to a need for lubrication and air pressure. This deficiency affected 34 residents and two smoke compartments, as the doors did not properly resist the passage of smoke.
Surveyors found an unsealed two-inch penetration containing a metal conduit in a smoke barrier wall above fire doors near a resident room. This breach, confirmed by staff, compromised the smoke integrity required by NFPA 101 and affected 27 residents and one smoke compartment.
An electrical panel in the Biohazard Storage Room was found with an exposed opening due to a missing cover on one of the breaker spaces. Staff confirmed the issue and were previously unaware of the gap, which affected a portion of the facility and did not comply with required electrical safety codes.
A resident with severe cognitive impairment continued to smoke unsupervised in a facility, despite having a care plan that required supervision and protective measures. The facility failed to enforce its smoking policy, allowing the resident to smoke outside designated times and areas, and did not remove the resident's lighter. Staff interviews revealed inadequate communication and documentation regarding the resident's smoking behavior and necessary interventions.
A resident undergoing dialysis did not receive prescribed medications on dialysis days, and the facility failed to notify the physician. The resident had a history of serious medical conditions and required medications like fluoxetine, Lasix, Eliquis, and metoprolol. Staff interviews revealed a lack of documentation and policy regarding physician notification, despite expectations to inform the physician of missed medications.
The facility failed to complete new Level I PASARRs for two residents with mental health diagnoses who stayed beyond 30 days. Both residents, admitted with conditions like bipolar disorder and anxiety, did not receive the required screenings due to oversight. The MDS Coordinator and DON acknowledged the necessity of these screenings, but they were not conducted. The Administrator was not involved in the PASARR process.
A resident with severe cognitive impairment and a history of nicotine dependence refused to sign the facility's smoking policy. The care plan did not include interventions for staff to obtain the resident's cigarette lighter, despite the facility's policy requiring such measures. Interviews revealed a lack of coordination among the interdisciplinary team to address the issue.
A resident's Albuterol inhaler was not accounted for as active medication and was kept on her overbed table without a physician's order or monitoring for side effects. The resident, who was cognitively intact and had multiple diagnoses, used the inhaler daily without the facility's knowledge, contrary to the facility's policy requiring medications to be administered only upon a written order. This oversight increased the risk of adverse side effects and potential drug interactions.
A facility failed to maintain a medication error rate of 5% or less, resulting in a 7.69% error rate. A resident with muscle weakness and osteoporosis was given incorrect dosages of medications due to the facility only having incorrect stock medications. The LVN did not follow prescriber orders, and although staff were trained to notify physicians if medications were unavailable, this procedure was not followed.
A resident with multiple health conditions missed critical medications on dialysis days due to a failure in the facility's medication administration process. The resident did not receive fluoxetine, Lasix, Eliquis, and metoprolol as prescribed, and there was no documentation of physician notification. Staff interviews revealed a lack of awareness and communication regarding the missed doses, and the DON emphasized the expectation to administer medications before dialysis.
A resident's oxygen concentrator filter was found covered with dust and lint, compromising the effectiveness of supplemental oxygen and potentially increasing the risk of respiratory infections. The facility's policies required weekly cleaning of the filter, but this was not adhered to, as confirmed by the DON and other staff.
A resident was subjected to repeated verbal abuse by a roommate who used racial slurs. Despite reporting the abuse to the Social Services Department, the facility failed to move the offending roommate as promised, allowing the abuse to continue. Staff and another resident confirmed the abuse, but the facility's administration claimed ignorance of the specific allegations, and no documentation was found. The facility did not report the abuse or investigate, violating its policies on resident protection.
A resident reported verbal abuse involving racial slurs by a roommate, but the LTC facility failed to investigate or document the allegations. Despite corroborating statements from another resident and a CNA, the facility's staff, including the Administrator and DON, were unaware of the specific complaints, leading to continued abuse without intervention.
A resident in an LTC facility was subjected to racial epithets by his roommate, which was reported to the Social Services Department but not to the California Department of Public Health. Despite staff awareness and facility policies requiring immediate reporting and investigation, the incident went unreported and uninvestigated, allowing the abuse to continue.
A resident with multiple medical conditions, including diabetes and dementia, was discharged to an ALF without an interdisciplinary team meeting or involvement of the Public Guardian Conservator. The facility failed to document discussions or provide a discharge plan, leading to the resident being placed in an ALF that could not meet their medical needs.
Two residents with severe cognitive impairments were at risk due to the facility's failure to ensure the functionality of Wander guard bracelets and exit door alarms. One resident eloped and crossed a busy highway, while another was found without a Wander guard. Staff did not perform required checks, and the facility lacked proper policies for Wander guard and alarm testing.
A facility failed to maintain a functional exit door alarm, leading to a resident with severe cognitive impairment eloping undetected. The alarm next to a specific room did not sound, and staff were unaware of its malfunction. The resident, known for exit-seeking behavior, was found offsite, highlighting the alarm's failure. Interviews revealed a lack of policy for testing alarms, contributing to the deficiency.
The facility failed to maintain effective infection control during wound care for two residents. The Treatment Nurse did not follow proper precautions, such as sanitizing hands between glove changes and using barriers for supplies, leading to potential risks of wound infections.
The facility failed to develop and implement a person-centered comprehensive care plan for a resident who tested positive for COVID-19 and required oxygen therapy. The care plan was initiated three days late and was not personalized to meet the resident's needs, potentially leaving their care needs unmet.
A resident with multiple health issues, including COVID-19, was administered oxygen using a non-rebreather mask by an LVN without a physician's order. The facility's policies and professional standards were not followed, placing the resident at risk.
Failure to Assess and Document Nephrostomy Tubes and Abdominal Drain on Admission
Penalty
Summary
Licensed nurses failed to complete an accurate admission physical assessment and documentation for a resident admitted with bilateral nephrostomy tubes and an abdominal accordion drain. The resident’s admission record showed diagnoses including psoas muscle abscess, malignant neoplasm of the bladder, surgical aftercare following genitourinary surgery, and artificial openings of the urinary tract system. Despite these conditions, the admission assessment dated 3/21/26 did not indicate the presence of an ileostomy/urostomy, nephrostomy/urostomy, or other relevant diagnoses/concerns, and additional nurses’ notes only stated the resident was voiding well and using a bedpan. The skin assessment dated 3/20/26 also failed to specify any special equipment or to identify the nephrostomy tubes or drain, leaving the “other” fields blank. Certified Nursing Assistant 5 reported remembering that the resident had bilateral nephrostomy tubes and an accordion drain and that she frequently emptied the nephrostomy tubes. However, these devices and their care needs were not reflected in the resident’s medical record or care plans. The Treatment Nurse stated she first became aware of the nephrostomy tubes and abdominal drain on 3/26/26 when a CNA paged her at the request of the resident’s family to have the dressings changed. Upon assessing the resident, the Treatment Nurse observed bilateral nephrostomy tubes exiting from the resident’s back with split gauze and tape at the exit sites, and an accordion drain in the lower abdomen, but found no existing physician orders in the electronic medical record for dressing changes or site monitoring. The Treatment Nurse and the Director of Staff Development both confirmed that the resident had bilateral nephrostomy tubes and a drain on admission, yet no orders for site care, dressing changes, or monitoring were obtained until 3/26/26. The resident’s care plans contained no problems, goals, or interventions addressing the nephrostomy tubes or the drain site. The Director of Nursing stated that the usual process involves the interdisciplinary team reviewing the electronic medical record, hospital records, and admission assessment to identify needed treatments and ensure they are incorporated into the plan of care, but this resident’s IDT meeting was delayed. Facility policies required nurses to conduct a comprehensive admission assessment, document all relevant findings, contact the attending physician to review assessment results, and obtain and document necessary orders, as well as to provide nephrostomy tube care including regular assessment, dressing changes, and monitoring. These required steps were not followed from admission on 3/20/26 until 3/26/26, resulting in the resident’s nephrostomy tubes and abdominal drain not being documented or addressed in the medical record or care plan during that period. A professional reference cited in the report indicated that nephrostomy tube management includes routinely checking tube patency, monitoring for pain, leakage, bleeding, and fever, and inspecting the tube and surrounding skin daily for breakdown, soiled dressings, kinks, or blockage, with dressing changes at least every other day or when soiled. The facility’s own nephrostomy tube care policy required assessment for bleeding every eight hours, checking tubing placement and integrity, ensuring proper drainage, changing dressings every one to three days or as ordered, and reporting signs of infection or dislodgement to the physician. Despite these standards and policies, the resident’s nephrostomy tubes and abdominal drain were not identified, assessed, or incorporated into orders and care plans upon admission, and no site care or dressing changes were provided or documented for six days until the Treatment Nurse’s assessment on 3/26/26.
Lack of Nephrostomy Care Competency for Licensed Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nurses had documented competency in the assessment and care of nephrostomy tubes for residents who had these devices. During interviews, a licensed vocational nurse stated there were residents with nephrostomy tubes and that annual skill competencies were conducted, but could not recall if nephrostomy care was included. The treatment nurse similarly reported that annual competencies covered the genitourinary system, including urethral and suprapubic catheters, but was unsure whether nephrostomy tube care was part of that training. A registered nurse also confirmed participation in in-services and annual competency checks related to the urinary system but was unsure if nephrostomies were addressed. The Director of Staff Development reported that the facility used a Licensed Nurse Competency Checklist updated in July 2023, which included urethral catheterization (female and male), catheter insertion and removal, suprapubic catheter daily care, insertion and removal, and genitourinary assessment, but did not include nephrostomy care. The Director of Staff Development stated that if a topic was not on the template, it was not evaluated, and acknowledged that nurses had not been assessed for nephrostomy care despite the presence of residents with nephrostomy tubes. The facility’s policy on sufficient and competent nursing, dated August 2022, stated that the facility would provide sufficient nursing staff with appropriate skills and competency to meet resident needs, including genitourinary care and managing complex care needs, but the actual competency process did not include nephrostomy care even though such care was being provided in the facility.
Failure to Care Plan and Timely Identify Nephrostomy Tubes and Abdominal Drain
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan for a resident with bilateral nephrostomy tubes and an abdominal accordion drain. The resident was admitted with diagnoses including a psoas muscle abscess, malignant neoplasm of the bladder, surgical aftercare following genitourinary surgery, and artificial openings of the urinary tract system. The resident’s MDS showed a BIMS score of 14, indicating the resident was cognitively intact. Despite these conditions and devices being present on admission, the nephrostomy tubes and abdominal drain were not documented on the admission assessment, catheter/ostomy section, or skin assessment, and no related concerns were recorded. Following admission, nursing staff did not identify or document the nephrostomy tubes and drain, and no physician orders for dressing changes or site monitoring were obtained at that time. The Treatment Nurse later reported being called to the resident’s room by a CNA at the request of the resident’s family for dressing changes, at which point she first became aware of the bilateral nephrostomy tubes and abdominal accordion drain. Review of the resident’s orders showed that treatment orders for assessing the nephrostomy stoma sites every shift and for cleansing and dressing the nephrostomy and drain sites every other day and as needed were not in place until several days after admission. Facility leadership, including the Director of Staff Development and the DON, confirmed that the admission nurse had not documented the tubes and drain or contacted the physician for necessary orders at the time of admission. Care plan review revealed that no care plans addressed the resident’s nephrostomy tubes or abdominal drain site. The Treatment Nurse, Director of Staff Development, and DON each acknowledged that there were no care plan entries identifying these devices, their associated problems, treatment goals, or required interventions. They stated that care plans are intended to direct care, ensure staff are aware of resident needs, and include instructions such as dressing changes and monitoring for signs of infection or dislodgement. The facility’s baseline care plan policy and the licensed nurse job description both require that baseline plans and care plans be developed from admission orders and assessments to meet immediate health and safety needs, but this was not done for the resident’s nephrostomy tubes and abdominal drain.
Failure to Maintain Ice Machine and Provide Ice for Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain essential equipment in safe operating condition when the only ice machine malfunctioned and residents were left without ice for two consecutive days. Staff interviews and observations on 3/23/26 confirmed that the ice machine stopped dispensing ice on Friday 3/20/26 and that no ice was available for residents on 3/21/26 and 3/22/26. The facility’s own policy stated that ice machines and ice storage/distribution containers would be used and maintained to assure a safe and sanitary supply of ice, and the manufacturer’s guidelines specified that equipment should not be operated when damaged or not in original manufactured condition. Despite these requirements, the ice chute/dispenser on the aging ice machine repeatedly came off track, preventing ice from being dispensed, and no alternative ice supply was provided over the weekend. Two cognitively intact residents reported not having ice and described how this affected their fluid intake. One resident with an indwelling catheter, neuromuscular dysfunction of the bladder, pressure ulcer, protein-calorie malnutrition, and paraplegia stated she had not received any ice since Friday and that she preferred ice-cold drinks; her cup was observed to be empty, and she reported she did not consume as much fluid as usual because there was no ice. Her roommate, who had diagnoses including cerebral palsy, malignant neoplasm of the breast, and bipolar disorder, also reported there was no ice to drink over the weekend, stated she had a recent UTI and needed to drink fluids to help prevent another infection, and requested a soda with ice when ice finally became available. Both residents’ MDS assessments showed BIMS scores in the cognitively intact range. Multiple staff members confirmed the lack of ice and described the usual process and the breakdown in communication and follow-up. CNAs reported there was no ice over the weekend, that residents complained about the lack of ice, and that ice was normally kept in chests at the nurses’ station and changed once per shift. An LVN stated there was no ice available when she passed medications on Saturday and emphasized that some residents would not drink as much fluid if it was not cold. Dietary staff, including the Certified Dietary Manager and cooks, stated the ice machine dispenser had come off track, that there was no ice in the kitchen freezers, and that no one contacted dietary leadership over the weekend. The Director of Maintenance acknowledged the ice machine was old and had acted up off and on, that he had previously realigned the dispenser on 3/19/26, and that he received a text on 3/20/26 about the machine not working but assumed the issue was resolved because he received no further communication. The Administrator, DON, MDS Coordinator, and payroll staff each reported they were not effectively notified or did not follow up after receiving notice, resulting in residents having no access to ice for two days and the facility failing to maintain the ice machine in safe operating condition. The facility’s own documentation from 3/19/26 noted that the ice chute had fallen off track, likely due to pushing too hard on the lever, and the manufacturer’s manual described that ice falls from the paddle wheel to the ice chute opening of the dispenser bin and that damaged or altered equipment should not be operated. Despite this known, recurring problem with the dispenser coming off track, the ice machine remained the sole source of ice, and no interim measures were implemented when it failed again over the weekend. Staff interviews, resident statements, and record review collectively demonstrate that the facility did not ensure continuous availability of ice or timely repair/alternative provision when the ice machine malfunctioned, creating a lapse in maintaining essential equipment in safe operating condition as required by facility policy and manufacturer guidelines.
Failure to Schedule and Document Physician-Ordered Swallow Studies and Consults
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services by not ensuring that physician-ordered consultations and diagnostic tests were scheduled and properly documented for three residents. For one resident with COPD, dysphagia, and altered mental status, a physician ordered a Modified Barium Swallow (MBS) to rule out silent aspiration. Nursing notes documented that the physician made rounds, examined the resident, and issued the MBS order, and that Social Services was notified. The assigned LVN stated that the Social Services Director (SSD) was responsible for scheduling the MBS after receiving the order and that nursing did not typically follow up once the order was handed off. However, there was no documentation in the electronic medical record (EMR) that the MBS was scheduled, completed, refused, or that any follow-up attempts or contacts with the resident or responsible party occurred. Another resident with seizures, dystonia, a history of traumatic brain injury, and a gastrostomy tube had a physician’s order dated 7/22/25 for a Barium Swallow consult. Nursing notes indicated that the physician examined the resident and issued a new order for the Barium Swallow consult and that the Social Services Assistant was notified. The LVN stated that the resident had swallowing issues and received nutrition and medications via G-tube because he was not safe to eat or drink by mouth, and that Social Services should have scheduled the appointment and documented follow-up in the EMR. The Speech Therapist (ST) confirmed that this resident had an MBS ordered to assess whether he could tolerate an oral diet and reported that she followed up with the SSD months later and was told the SSD was still working on scheduling the test. The SSD later stated she had contacted the resident’s sister because the hospital required the responsible party to attend the appointment, and that she called the sister several times but did not document any of these attempts or contacts in the EMR. A third resident with hemiplegia and hemiparesis following cerebral infarction, dysphagia, aphasia, and a G-tube had physician’s orders dated 12/10/25 for an ENT consult to assist with vocal cord mobility and for an MBS to rule out silent aspiration and determine if a by-mouth diet was possible. The LVN stated this resident had been dependent on G-tube feeding on admission and had progressed to an oral diet while in the facility, and that the MBS was ordered to ensure he could safely tolerate oral intake. The ST stated she was treating this resident and that he needed an MBS to confirm he could tolerate an oral diet without aspirating and also needed an ENT consultation to help with communication. The SSD stated the resident had been scheduled for an in-house ENT consultation but discharged before the appointment, and that the MBS had not been scheduled because they were waiting for the ENT consult and insurance authorization. The SSD acknowledged she did not document the appointment, her attempts to obtain authorization, or any notifications to the ST or primary physician in the EMR. Across these three residents, the SSD described a process in which physician orders were delivered to her, sometimes placed under her office door, and she would then begin scheduling. She admitted she did not document attempts to schedule appointments or follow-up notes in the EMR, instead keeping papers with orders and handwritten notes in a folder in her office, and that when she did enter information into the EMR it was in a communication section that was automatically cleared and not part of the permanent medical record. The SSD stated that if something was not documented, it was considered not done, and acknowledged she should have documented her efforts in the EMR. The facility’s policy and procedure for Social Services referrals required Social Services to collaborate with nursing and other disciplines to arrange physician-ordered services and to document the referral in the resident’s medical record. The DON and Administrator both stated that the SSD was responsible for scheduling such appointments and that appointment scheduling and follow-up notes needed to be part of the resident’s medical record, but they were unaware that the SSD had not scheduled the ordered tests and consultations or documented her actions in the EMR. The surveyors concluded that these failures caused a delay in care and had the potential for the residents’ needs to go unmet.
Failure of Administrative Oversight for Physician-Ordered Consults and Diagnostic Tests
Penalty
Summary
The deficiency involves the Administrator’s failure to provide effective oversight and necessary resources to ensure that physician-ordered consultations and diagnostic tests were scheduled, carried out, and documented in the electronic medical record (EMR) for multiple residents. The Administrator was the direct supervisor of the Social Services Director (SSD) and was responsible, per the job description, for directing day-to-day operations, ensuring policies and procedures were implemented, and reviewing the competence of the workforce. Despite this, the Administrator was not aware that the SSD was not consistently scheduling ordered appointments or documenting referral activities in the EMR, and allowed the SSD to maintain paper records in a personal folder and use a temporary communication board that was not part of the permanent medical record. For one resident with COPD, dysphagia, and altered mental status, a physician ordered a Modified Barium Swallow (MBS) to rule out silent aspiration. Nursing documented that the SSD was notified of the order, and the expectation was that the SSD would schedule the test and document follow-up. However, there was no documentation in the EMR that the MBS was scheduled, completed, or refused, and the SSD later stated that the resident had refused the MBS and that the responsible party had also refused, but she had not documented this in the resident’s medical record. For another resident with seizures, dystonia, traumatic brain injury, and a gastrostomy, a physician ordered a Barium Swallow consult. Nursing notes indicated that the Social Services Assistant or SSD was notified, but the SSD acknowledged that although she contacted the resident’s sister and the hospital, she did not document her attempts to schedule the MBS or her contacts with the responsible party in the EMR, nor did she follow up with the speech therapist after being unable to schedule the test. A third resident with hemiplegia, hemiparesis following cerebral infarction, dysphagia, aphasia, and a gastrostomy had physician orders for an ENT consult to assist with vocal cord mobility and an MBS to rule out silent aspiration and determine if oral diet was possible. The SSD stated that an in-house ENT consult had been scheduled but not documented in the EMR and that the MBS had not been scheduled because they were waiting for the ENT consult and insurance authorization. The SSD did not document any attempts to obtain authorization, schedule the MBS, or notify the speech therapist or primary physician of delays. The SSD described a referral process in which orders were left under her office door when she was absent and acknowledged that she did not routinely document referral attempts or follow-up in the EMR, instead keeping papers in a folder and using a communication section of the EMR that was automatically cleared and not part of the permanent record. The facility’s policy required Social Services to collaborate with nursing to arrange ordered services and to document referrals in the resident’s medical record, but this was not done. The Administrator confirmed that he was aware the SSD was documenting on paper and in a non-permanent communication board, and that he expected physician orders to be followed and referrals documented, but he had not ensured that this occurred, resulting in ordered consultations and tests for several residents not being timely scheduled or properly documented. The surveyors also observed one resident with a gastrostomy lying in bed with an enteral feeding pump at bedside not connected to the gastrostomy tube, and this resident was verbally nonresponsive. While this observation did not directly reference a missed order, it occurred in the context of broader concerns about the facility’s management of residents requiring specialized nutritional support and diagnostic evaluation for swallowing. Across the reviewed cases, there was no evidence in the EMR of timely scheduling, follow-up, or clear documentation of refusals or barriers to completing ordered tests and consultations. The SSD herself stated that if something was not documented, it was considered not done, and acknowledged that she should have documented her attempts and follow-up in the EMR so they would be part of the medical record. The Administrator’s lack of effective oversight and failure to ensure adherence to the facility’s referral and documentation policies contributed to these gaps in care coordination and recordkeeping for multiple residents. The facility’s written policy on Social Services referrals required that referrals for medical services be based on physician evaluation, that Social Services collaborate with nursing and other disciplines to arrange ordered services, and that Social Services document the referral in the resident’s medical record. The Administrator’s job description required development and maintenance of policies and procedures, routine inspections to ensure implementation, consultation with department directors to correct problem areas, and review of staff competence. Despite these requirements, the Administrator did not detect or correct the SSD’s practice of using non-medical-record systems (paper folders and a temporary communication board) for tracking referrals, did not ensure that physician orders for MBS and ENT consults were carried out, and did not ensure that all referral-related activities were documented in the EMR. This lack of administrative oversight and failure to enforce established policies led to physician-ordered consultations and tests for several residents not being timely scheduled or properly documented in the medical record.
Failure to Document Social Services Referrals and Follow-Up in EMR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with professional standards and facility policy for three sampled residents. For one resident, a physician’s order dated 10/9/25 directed a Modified Barium Swallow (MBS) to rule out silent aspiration. Nursing documentation on that date showed the physician made rounds, examined the resident, and issued the new MBS order, and that the Social Services Director (SSD) was notified. An LVN stated it was important for this resident to have the MBS to evaluate swallowing and aspiration risk and that the SSD was responsible for scheduling the test and documenting follow-up in the EMR. However, there was no documentation in the EMR that the SSD scheduled the MBS or followed up on the order. For a second resident, a physician’s order dated 7/22/25 directed a Barium Swallow consult. Nursing notes from the same date documented that the physician examined the resident, issued the new order, and that the Social Services Assistant (SSA) was notified. The LVN reported that this resident had swallowing issues, had a G-tube, and an order for nothing by mouth, and that the SSA or SSD should have scheduled the appointment and documented follow-up in the EMR. The SSD later stated she had contacted the resident’s sister after the hospital indicated a responsible party (RP) needed to attend the appointment to sign consents, and that she called the RP several times. She acknowledged she did not document any of these attempts to schedule the MBS or contact the sister in the EMR. For a third resident, physician’s orders dated 12/10/25 included an EENT consult to assist vocal cord mobility and an MBS to rule out silent aspiration to help determine if a by-mouth diet was possible. An LVN stated this resident had been admitted with a G-tube and had progressed to an oral diet, and that the MBS was ordered to assess safe oral intake. The LVN was unable to locate any documentation that the SSD scheduled the appointment or followed up. The SSD stated this resident had been scheduled for an in-house ENT consultation but was discharged before the appointment and that she did not document the appointment or any follow-up calls in the EMR. The SSD explained that her practice was to keep paper notes and orders in a folder in her office and to enter appointment information in a temporary communication section of the EMR that was automatically cleared and not part of the permanent medical record. Facility policies required that all services provided, changes in condition, and referrals coordinated by social services be documented in the resident’s medical record, and the SSD acknowledged that if something was not documented, it was considered not done.
Failure to Develop and Implement Person-Centered Care Plans for Refusal of Care
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents regarding their refusal of care, specifically related to nail care and the required notifications to responsible parties and physicians. For one resident, who was cognitively intact and had multiple diagnoses including schizophrenia, pain, and depression, observations revealed long, jagged fingernails and toenails. Although the care plan indicated interventions such as notifying the physician and responsible party upon refusal of care, there was no documentation that these notifications occurred. Interviews with nursing staff and the interim director of nursing confirmed that refusals and notifications were not properly documented or followed up as required by the care plan and facility policy. Another resident, who was non-verbal and severely cognitively impaired with a history of traumatic brain injury and other significant medical conditions, was observed with long, thick, and untrimmed toenails. Staff interviews indicated that nail care should have been addressed and that a care plan for refusal of care should have been initiated when the resident first refused. However, the care plan for non-compliance was only started after the deficiency was identified, and there was no evidence that staff had previously communicated or documented the resident's refusals or the necessary notifications to the responsible party or physician. Facility policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident, including documentation of refusals and notifications. The lack of timely care plan development, implementation, and documentation for both residents resulted in a failure to meet these requirements, as confirmed by staff interviews and record reviews.
Failure to Notify Physician and Responsible Party of Residents' Refusal of Nail Care
Penalty
Summary
The facility failed to meet professional standards of practice for two residents when staff did not notify the physician or the resident's responsible party (RP) after the residents refused nail care. In the case of one resident with severe cognitive impairment and multiple complex medical diagnoses, including traumatic brain injury and major depressive disorder, the resident was observed with long, thick, and jagged toenails with a dark crusted substance underneath. Staff interviews revealed that although the need for nail care was identified, there was no documentation of refusal or notification to the physician or RP, and the resident's care plan for non-compliance was not initiated until months after the initial refusal. Another resident, who was cognitively intact and had a history of schizophrenia, pain, muscle weakness, anxiety, and depression, was also observed with long, jagged fingernails and toenails. The care plan for this resident included interventions for notifying the physician and RP in the event of non-compliance, but there was no documentation that these notifications occurred following the resident's refusal of nail care. Staff interviews confirmed that refusals and notifications were not consistently documented, and the only recorded attempt to notify the RP was from a previous year. Throughout the investigation, staff including CNAs, nurses, the Director of Staff Development, and the Interim Director of Nursing acknowledged that proper nail care is important for resident comfort and infection prevention, and that refusals of care should be documented and communicated to the physician and RP. However, the records reviewed showed a lack of documentation and follow-through on these procedures, resulting in the deficiency.
Failure to Provide Timely and Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care and treatment in accordance with professional standards of practice for two of four sampled residents. Both residents were observed to have long, overgrown, and untrimmed toenails, with one resident's toenails described as yellow, thick, jagged, and with a dark crusted substance under the big toenail. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) acknowledged that the residents' toenails needed trimming and confirmed that the process for reporting and addressing nail care needs was not followed as required. Record reviews revealed that both residents had been identified on multiple occasions as needing toenail care, as documented on their shower sheets. However, the necessary follow-up actions, such as logging the residents for podiatry appointments or ensuring nail care was performed by nursing staff, were not completed. The Social Services Director's log, which should have included these residents for podiatry referral, had not been updated to include them, and the last entry was several months prior. Staff interviews confirmed that the expected process for addressing nail care needs was not adhered to, and there was no documentation of refusals or completed care for these residents during the relevant period. Both residents had significant medical histories, including severe cognitive impairment, traumatic brain injury, and physical disabilities for one, and schizophrenia, pain, and muscle weakness for the other. Observations and interviews with staff and review of facility policies confirmed that the facility's procedures for nail care, including daily cleaning, regular trimming, and prompt reporting of issues, were not followed. The deficiency was further substantiated by photographic evidence and staff admissions that the residents' nail care needs had not been addressed as required.
Failure to Maintain and Test Fire Alarm System and Batteries
Penalty
Summary
The facility failed to maintain its Fire Alarm System (FAS) in accordance with NFPA 101, NFPA 70, and NFPA 72 requirements. During a tour and document review, surveyors observed a trouble signal on the Fire Alarm Control Panel (FACP) at Nurse Station A, which was initially attributed by staff to a smoke detector being accidentally hit by equipment in a resident room. Upon resetting the FACP, the panel began displaying a cycle of trouble signals for various devices throughout the facility, with a new trouble signal appearing approximately every two seconds. A monitoring report confirmed this ongoing cycle of trouble signals, and the FAS vendor indicated that a technician would be needed to diagnose the issue. Testing of the water flow device, two smoke detectors, and a tamper switch showed that notification devices activated and signals were received by the monitoring company. Additionally, the facility failed to conduct required annual testing of the FACP batteries, specifically the discharge and charger tests. The dates of the last tests were unknown, and no records of these tests were provided when requested by surveyors. Staff confirmed the lack of testing and indicated they would follow up with their vendor, but no documentation was submitted by the deadline. These deficiencies affected all residents and smoke compartments in the facility.
Plan Of Correction
K 345 - Fire Alarm System Testing and Maintenance How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The facility immediately contacted its fire alarm system vendor to diagnose and address the ongoing trouble signals. The vendor completed necessary repairs on 4/4/25, and all alarms are now fully operational. 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. On 4/4/25, the facility performed a comprehensive assessment of all fire alarm system components to identify any additional deficiencies. No other deficiencies were 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: The EVS Director will perform a monthly check for 3 months then semi-annually to ensure semi-annual and annual fire alarm testing is completed on time. The EVS Director was trained by the Administrator on 4/9/25 on the importance of fire alarm testing and functionality. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: The EVS Director will perform a monthly check for 3 months then semi-annually to ensure semi-annual and annual fire alarm testing is completed on time. Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance 4/18/25
Failure to Maintain and Test Emergency Power Supply System
Penalty
Summary
The facility failed to maintain its Emergency Power Supply System (EPSS) as required by NFPA 101, NFPA 110, and related standards. Specifically, the facility did not conduct the required weekly visual inspections for both its 10-kW and 25-kW propane generators, missing 10 out of 52 inspections for each generator. Additionally, the facility did not perform three of the required 12 monthly load tests for each generator, with missing records for March, April, and September of the specified year. Staff interviewed during the survey were unable to confirm whether these inspections and tests had been completed, citing lack of employment at the facility during the relevant periods and uncertainty regarding missing records. The facility also failed to conduct three of the required 12 monthly conductance tests for the batteries of both generators, with missing documentation for the same months as the load tests. Staff were again unable to verify if these tests had been performed, and no explanation was provided for the missing records. Furthermore, the facility did not provide evidence of having conducted the mandatory four-hour load tests for either generator, which are required every three years. The date of the last such test was unknown, and no records were submitted by the deadline given by surveyors. These deficiencies affected all 92 residents and all six smoke compartments in the facility. The lack of required inspections, testing, and documentation for the emergency generators and their batteries was confirmed through document review, staff interviews, and the absence of records during the survey. No information was provided regarding the medical history or condition of individual residents at the time of the deficiency.
Plan Of Correction
K 918 - Essential Electrical Systems How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Finding 1: On 3/18/25, the current EVS Director performed and documented a visual inspection of the 10kW generator to confirm it is functional. No issues were found. • Finding 2: On 3/20/25, the EVS Director inspected the 25kW generator. No issues were found. • Finding 3: Load test completed on 10kW generator on 3/28/25. • Finding 4: Load test completed on 25kW generator on 3/28/25. • Finding 5: Conductance test completed for 10kW generator on 3/18/25; batteries confirmed to be within operational parameters. • Finding 6: Conductance test completed for 25kW generator on 3/20/25; batteries confirmed to be within operational parameters. • Finding 7: Facility contracted with vendor to conduct 4-hour load test for the 10kW generator on 1/8/25. • Finding 8: Facility contracted with vendor to conduct 4-hour load test for the 25kW generator on 1/8/25. 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. The EVS Director conducted a full generator inspection on 3/18/25 to verify the emergency power system's functionality. No other issues were identified. The EVS Director conducted an additional inspection on 3/27/25 to verify the emergency power system's functionality. No other issues were identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: • EVS Director will conduct a weekly non-load test for both the 10kW and 25kW generators. • EVS Director will conduct a monthly load test for both the 10kW and 25kW generators. • EVS Director will conduct battery conductance tests on both the 10kW and 25kW generators. • Our vendor will conduct a 4-hour load test for both the 10kW and 25kW generators. • A new EVS Director has been hired, and we will continue to monitor and support ongoing compliance. • The EVS Director was trained by the administrator on 3/9/25 on the importance of proper testing, documentation, and reporting of generator inspections and load tests. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • EVS Director will conduct weekly and monthly tests for both the 10kW and 25kW generators. • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance: 4/18/25 K 919 Electrical Equipment - Other How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • The circuit breaker filler plate was ordered on 3/31/25 and is scheduled to arrive 4/10/25. • The missing cover for the breaker space labeled "24" will be replaced on the arrival of the breaker cover by 4/11/25. 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: • EVS director conducted a facility-wide inspection on 3/19/25 of all electrical breaker panels to ensure all available spaces are sealed and covered properly. • Did not find any other open breaker slots. 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 facility will conduct quarterly inspections of all electrical panels and wiring to ensure compliance. These inspections will be documented, and corrective actions will be taken as necessary.
Failure to Maintain and Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to maintain and update its Emergency Preparedness Plan (EPP) as required by federal regulations. During a document review and staff interview, surveyors found that there was no documentation to show that the EPP had been reviewed or updated at least annually. The date of the last review was unknown, and staff confirmed that the EPP had not yet been updated. This deficiency affected all 92 residents in the facility, as the lack of an updated EPP could impact the facility's ability to protect their health and safety during emergencies. The findings were based on direct document review and staff interviews conducted by surveyors.
Plan Of Correction
E 004 Develop EP Plan, Review, and Update Annually How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The facility initiated a review and update of the Emergency Preparedness Plan (EPP) upon identification of the deficiency. The facility's leadership and emergency preparedness team have reviewed the updated plan on 4/9/25. 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. The facility will update the EPP to ensure all protocols for the protection of all residents during emergencies. A facility-wide audit will be conducted on 4/10/25 to verify that all emergency preparedness procedures and documentation are up to date. 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 facility has established a process to review and update the EPP annually. The policy now requires the administrator or designee to document the annual review in a designated log. A calendar reminder has been set for December 1st of each year to ensure timely review and update of the EPP by the new year. The facility's emergency preparedness committee will convene quarterly to review emergency protocols and make any necessary revisions. Maintenance director was retrained on the importance of maintaining an updated EPP, by the Administrator on 4/9/25. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system.
Failure to Maintain and Update Emergency Preparedness Policies and Procedures
Penalty
Summary
The facility failed to maintain and update its Emergency Preparedness Plan (EPP) as required. During a document review and staff interview, it was found that there were no documents available to show that the Emergency Preparedness (EP) policies and procedures had been reviewed or updated at least annually. The date of the last review was unknown, and staff confirmed that the EPP policies and procedures had not yet been updated. This deficiency affected all 92 residents in the facility, as the lack of updated EP policies and procedures could result in a delay in protecting their health and safety during emergencies. The findings were based on direct document review and staff interviews conducted during the survey.
Plan Of Correction
The EVS Director or designee will conduct quarterly audits of the EPP to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented. **Date of Compliance: 4/18/25** **E 013: Development of EP Policies and Procedures** How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The facility initiated a review and update of the Emergency Preparedness (EP) Policies and Procedures upon identification of the deficiency. The facility's leadership and emergency preparedness team have reviewed the updated plan on 4/9/25. 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. The facility will update the Emergency Preparedness (EP) Policies and Procedures to ensure all protocols for the protection of all residents during emergencies. An audit will be conducted on 4/10/25 to verify that all Emergency Preparedness (EP) Policies and Procedures are up to date. 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 facility has established a process to review and update the Emergency Preparedness (EP) Policies and Procedures annually. The policy now requires the administrator or designee to document the annual review in a designated log. A calendar reminder has been set for December 1st of each year to ensure timely review and update of the Emergency Preparedness (EP) Policies and Procedures by the new year. The facility's emergency preparedness committee will convene quarterly to review emergency protocols and make any necessary revisions. The EVS Director was retrained on the importance of maintaining an updated Emergency Preparedness (EP) Policies and Procedures by the Administrator on 4/9/25. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director or designee will conduct quarterly audits of the Emergency Preparedness (EP) Policies and Procedures to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented.
Failure to Maintain and Update Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain and update its Emergency Preparedness Plan (EPP), specifically the Communication Plan component, as required by federal regulations. During a document review and staff interview, it was found that there were no records indicating the Communication Plan had been reviewed or updated at least annually. The last review date of the Communication Plan was unknown, and staff confirmed that the update had not yet occurred. This deficiency could affect all 92 residents in the facility, as the lack of an updated Communication Plan may delay the protection of their health and safety during an emergency. The findings were based on direct document review and staff interviews, with no evidence provided to show compliance with the annual review and update requirement for the Communication Plan.
Plan Of Correction
E 029: Development of Communication Plan How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The facility initiated a review and update of the Communication Plan upon identification of the deficiency. The facility's leadership and emergency preparedness team have reviewed the updated plan on 4/9/25. 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. • The facility will update the Communication Plan to ensure all protocols for the protection of all residents during emergencies. An audit will be conducted on 4/10/25 to verify that the Communication Plan is up to date. 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 facility has established a process to review and update the Communication Plan annually. The policy now requires the administrator or designee to document the annual review in a designated log. • A calendar reminder has been set for December 1st of each year to ensure timely review and update of the Communication Plan by the new year. • The facility's emergency preparedness committee will convene quarterly to review the Communication Plan and make any necessary revisions. • The EVS Director was retrained on the importance of maintaining an updated Communication Plan, by the Administrator on 4/9/25.
Failure to Annually Update Emergency Preparedness Training and Testing
Penalty
Summary
The facility failed to maintain its Emergency Preparedness Plan (EPP) as required by federal regulations. During a document review and staff interview, it was found that there were no documents available to show that the Emergency Preparedness (EP) training and testing program for new and existing staff had been reviewed or updated at least annually. The last date of training and testing review was unknown, and staff confirmed that the EP training and testing had not yet been updated. This deficiency was identified during a review of the facility's documentation and through interviews with staff. The lack of updated EP training and testing could affect all 92 residents in the facility, as there was no evidence that staff were adequately prepared according to the required schedule. The findings are based on direct observations and interviews conducted by surveyors.
Plan Of Correction
How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director or designee will conduct quarterly audits of the Communication Plan to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented. Date of Compliance 4/18/25 E 036: EP Training and Testing How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The facility initiated a review and update of the Training and Testing Plan upon identification of the deficiency. The facility's leadership and emergency preparedness team have reviewed the updated plan on 4/9/25. The testing was conducted on 4/10/25 by the EVS Director. A training was done on 4/10/25 by the EVS Director. 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. The facility will update the Training and Testing Plan to ensure all protocols for the protection of all residents during emergencies. An audit will be conducted on 4/10/25 to verify that the Training and Testing Plan is up to date. 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 facility has established a process to review and update the Training and Testing Plan annually. The policy now requires the administrator or designee to document the annual review in a designated log. An emergency plan test will be conducted twice a year by the EVS Director. A training will be done once a year by the EVS Director. A calendar reminder has been set for December 1st of each year to ensure timely review and update of the Training and Testing Plan by the new year. The facility's emergency preparedness committee will convene quarterly to review the Training and Testing Plan and make any necessary revisions. The EVS Director was retrained on the importance of maintaining an updated Training and Testing Plan, by the Administrator on 4/9/25. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director or designee will conduct quarterly audits of the Training and Testing Plan to ensure it remains updated. The results of these audits will be reported during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. Any deficiencies identified during audits will be addressed immediately, and corrective actions will be documented.
Deficient Sprinkler System Maintenance and Missing Signage
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 13 standards. During a tour and document review, surveyors observed that two sprinklers located at the front entrance of the facility had accumulated dust and debris on their bodies and deflectors. Staff confirmed that these components were typically cleaned on a monthly basis. Additionally, the annual sprinkler system testing record indicated a failed test due to missing required signage for the control valves and the fire department connection (FDC) servicing the building. Further observations revealed that the FDC on the riser along the southwest side of the building was missing identification signage, and the control valve in the same area also lacked the necessary signage. Staff confirmed these findings and stated that the facility was in the process of obtaining new signs. These deficiencies affected all 92 residents and all six smoke compartments within the facility.
Plan Of Correction
K 353 - Sprinkler System Maintenance and Testing How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • The facility has immediately removed dust and debris on the exterior sprinklers. • The required signage for the fire department connection and control valve were installed on 4/2/25 by the EVS Director. 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. • A full facility-wide sprinkler system inspection has been conducted to identify any additional deficiencies. No other deficiencies have been identified. 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 monthly maintenance checklist will be completed by the EVS Director to ensure that all sprinkler system components are clean and free of debris. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • A monthly maintenance checklist will be completed by the EVS Director to ensure that all sprinkler system components are clean and free of debris. • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance 4/18/25
Improper Use of Extension Cord and Missing Receptacle Faceplate
Penalty
Summary
During a facility tour and staff interviews, surveyors observed that an orange extension cord was in use along the northeast wall of the Human Resources Office. The extension cord was placed on top of wall cabinets and was powering fan components. Staff confirmed the presence of the extension cord but were unsure how long it had been in use. The use of extension cords as a substitute for fixed wiring is not permitted under NFPA 70, and the cord's placement and use did not comply with regulatory requirements. Additionally, a receptacle along the west wall of the Director of Staff Development's Office was found to be missing a faceplate. Staff confirmed that the faceplate was likely removed accidentally. The absence of a faceplate on a receptacle is a violation of electrical safety standards, as receptacle faceplates are required to completely cover the opening and seat against the mounting surface. These deficiencies affected a significant portion of the facility, including 52 of 92 residents and two of six smoke compartments.
Plan Of Correction
K 920 - Electrical Equipment - Power Cords and Extension Cords Plan of Correction: How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; • The orange extension cord found in the Human Resources Office was removed on 3/18/25 and replaced with a fixed, properly installed electrical setup. • The missing receptacle faceplate in the Director of Staff Development's Office was replaced on 3/18/25, ensuring that it fully covers the opening and is seated correctly against the mounting surface. 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; The EVS Director conducted a facility-wide inspection of resident rooms and offices on 3/19/25 to ensure there's no other improper use of extension cords. No other issues were identified. 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 monthly inspection will be conducted by the EVS Director or designee to ensure that all receptacles are covered with faceplates and that no extension cords are used improperly. The EVS Director was trained by the Administrator on 4/9/25 on the importance of faceplates and avoidance of improper extension cables. The Human Resource Director was trained by the EVS Director on 3/18/25. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; • A monthly inspection will be conducted by the EVS Director or designee to ensure that all receptacles are covered with faceplates and that no extension cords are used improperly. Results will be reviewed in the QAPI meetings for ongoing compliance oversight.
Wall Penetration Compromises Fire Barrier Integrity
Penalty
Summary
A deficiency was identified when a penetration, approximately an inch and a half in diameter, was observed on the east wall by the main entrance to the kitchen, about 18 inches from the ceiling. This breach in the wall's integrity was noted during a facility tour and interview with staff. The penetration could potentially compromise the building's construction standards as required by 42 CFR §483.90 and NFPA 101, specifically regarding the containment of smoke in the event of a fire. The deficiency affected 27 of 92 residents and one of six smoke compartments. No information was provided about the medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
Date of Compliance 4/18/25 Tag K 161: Building Construction Type and Height How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The EVS Director fixed the identified penetration on 4/9/25. Maintenance staff have been retrained on monitoring and promptly repairing any penetrations in fire-rated walls. 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: No additional residents have the potential to be affected. This penetration affected one smoke compartment which contains no resident space. A facility-wide inspection was conducted to identify and seal any additional penetrations in fire-rated walls. No other unsealed penetrations were found. 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 quarterly wall inspection program has been implemented. Maintenance staff were trained on 4/9/25 by the administrator on fire-rated wall requirements and the importance of preserving wall integrity. Any new penetrations discovered will be fixed immediately. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the
Failure to Maintain Illuminated Emergency Exit Signage
Penalty
Summary
The facility failed to maintain emergency exit signage as required by NFPA 101, specifically section 19.2.10.1, which mandates that exit and directional signs be continuously illuminated and served by the emergency lighting system. During a facility tour and staff interviews, surveyors observed that the battery-backup emergency exit signs above the southeast fire doors and the northwest wall of the corridor by Nurse Station A did not remain illuminated when tested. Staff present at the time confirmed the findings and indicated they were not aware of the non-functioning exit signs. This deficiency affected 27 of 92 residents and one of six smoke compartments within the facility. The lack of illuminated exit signage was directly observed during the survey, and no information was provided regarding the medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
Corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director or designee will conduct quarterly fire barrier inspections, with results reviewed in QAPI meetings. Any deficiencies identified will be corrected immediately and documented. Date of Compliance 4/18/25 Tag K 293: Exit Signage How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The facility replaced the batteries in the emergency exit signs above the southeast fire doors and the northwest wall of the corridor by Nurse Station A on 4/21/25. The signs are now fully operational and compliant with NFPA 101 requirements. 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 facility-wide audit was conducted to check all emergency exit signs. No additional faulty signs were identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur.
Hazardous Area Enclosure Deficiencies in Shower Room
Penalty
Summary
Surveyors observed that the facility failed to maintain proper enclosures for hazardous areas, specifically in the Shower Room located by Room 22. The corridor door to this Shower Room was obstructed from closing by a wheeled shower bed and three soiled linen containers, each with a capacity of approximately 40 gallons. These soiled linen containers were normally stored in the Shower Room, as confirmed by staff during the survey. The obstruction prevented the door from closing, compromising the required separation of hazardous areas. Additionally, the same Shower Room door was found to be missing a self-closing mechanism. The room, measuring approximately 60 square feet, was used to store three soiled-linen containers. Staff confirmed the absence of the self-closing device and indicated they were unaware that such a mechanism was required for the door. These deficiencies affected 27 of 92 residents and one of six smoke compartments in the facility.
Plan Of Correction
* A monthly inspection of all emergency exit signage has been implemented. * Maintenance staff was trained on 4/9/25 by the Administrator on emergency lighting requirements and proper testing procedures. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; * The Maintenance Director or designee will conduct monthly tests of all exit signage and document findings. * Any malfunctioning exit signs will be immediately repaired or replaced. * The results of inspections will be reviewed in QAPI meetings to ensure ongoing compliance. Date of Compliance 4/18/25 Tag K 321: Hazardous Areas - Enclosure How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; * The wheeled shower bed and soiled linen containers obstructing the Shower Room door by Room 22 have been removed. * A self-closing mechanism was purchased on 3/28/25. * The self-closing mechanism will be installed on the door by 4/11/25 to ensure compliance with fire safety regulations. On 4/9/25 Housekeeping and maintenance staff were trained by the Administrator on hazardous area storage regulations. 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 facility-wide inspection was conducted by the EVS Director to ensure all hazardous area doors are unobstructed and self-closing where required. * No other issues were identified. 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 monthly inspection schedule has been established to verify compliance with hazardous area enclosure requirements. * The inspection will be done by the EVS director. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; * The EVS Director or designee will perform monthly inspections of hazardous area enclosures. On 4/9/25 Housekeeping and maintenance staff were trained by the Administrator on hazardous area storage regulations. 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 facility-wide inspection was conducted by the EVS Director to ensure all hazardous area doors are unobstructed and self-closing where required. * No other issues were identified. 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 monthly inspection schedule has been established to verify compliance with hazardous area enclosure requirements. * The inspection will be done by the EVS director. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; * The EVS Director or designee will perform monthly inspections of hazardous area enclosures.
Incomplete Kitchen Hood Fire Suppression System Maintenance Records
Penalty
Summary
The facility failed to maintain complete records for the kitchen's hood fire suppression system, as required by NFPA 101 and NFPA 96 standards. During a document review and interview, it was found that one of the two required semi-annual inspection records for the kitchen's hood fire suppression system was missing. The last available record was dated 11/13/24, and staff interviewed were unable to provide the missing documentation or confirm when the previous service had been conducted. This deficiency affected the nutritional services area and one of six smoke compartments in the facility. The absence of the required maintenance record was confirmed by a staff member, who stated that the missing record pertained to a period before their employment and that they did not have access to it. No information was provided regarding any specific residents or their conditions in relation to this deficiency.
Plan Of Correction
The EVS Director or designee will perform monthly inspections of hazardous area enclosures. Any deficiencies will be corrected immediately and documented. Findings from inspections will be reviewed in QAPI meetings to ensure continued compliance. Date of Compliance 4/18/25 K 324 - Cooking Facilities How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The facility has immediately scheduled a semi-annual inspection of the kitchen's hood fire suppression system to ensure compliance with NFPA 96. The inspection is scheduled to be completed by the end of April. 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 potentially to be affected. The facility has immediately scheduled a semi-annual inspection of the kitchen's hood fire suppression system to ensure compliance with NFPA 96. The inspection is scheduled to be completed by the end of April. 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 EVS Director will conduct a quarterly audit to ensure all fire suppression system maintenance occurs at the required intervals. The EVS Director was trained by the Administrator on the importance of safety documentation and maintaining and verifying inspection records. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; The EVS Director will conduct a quarterly audit to ensure all fire suppression system maintenance occurs at the required intervals. Findings will be reported to the Quality Assurance and Performance Improvement (QAPI) committee by the EVS Director for continued oversight. Date of Compliance 4/18/25
Non-Latching Corridor Doors Compromising Smoke Compartment Integrity
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with regulatory requirements. Specifically, during a facility tour, two corridor doors—one to the Shower Room by Room 6 and another to the Salon by Room 13—were found to have self-closing mechanisms but did not latch when tested for closure. Each door was tested approximately three times and failed to latch on each attempt. Staff interviews indicated that the Shower Room door may have required lubrication, while the Salon door's failure to latch was attributed to air pressure in the room. This deficiency affected 34 of 92 residents and two of six smoke compartments within the facility. The non-latching doors could allow the passage of smoke between compartments, as the doors did not resist the passage of smoke as required. No specific resident medical histories or conditions at the time of the deficiency were mentioned in the report.
Plan Of Correction
K 363 - Corridor Doors How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Maintenance staff lubricated and adjusted the self-closing mechanisms on the Shower Room door by Room 6 and the Salon door by Room 13 to ensure proper latching. • The EVS Director replaced both door handles on 4/10/25 to ensure proper latching. • Both doors were tested three times and successfully latched upon closure. 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: • No additional residents have the potential to be affected. This latching concern only affects the two smoke compartments and cannot affect the other smoke compartments. • On 4/10/25 a facility-wide inspection was conducted to identify any other door latching issues. No other issues were found. 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 4/10/25 a facility-wide inspection was conducted to identify any other door latching issues. No other issues were found. • The maintenance team has implemented a monthly inspection schedule to ensure all corridor doors latch properly and self-closing mechanisms function as required. • The EVS Director was trained by the Administrator on the importance of proper door maintenance, including lubrication, alignment, and troubleshooting air pressure issues that may affect door closure. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • The maintenance team has implemented a monthly inspection schedule to ensure all corridor doors latch properly and self-closing mechanisms function as required. • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance 4/18/25
Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
During a facility tour and staff interview, surveyors observed that the smoke barrier wall above the fire doors near Room 12 had an unsealed penetration measuring approximately two inches in diameter, which contained a metal conduit. This condition was confirmed by a staff member, who acknowledged that he had not yet inspected the smoke barrier walls. The unsealed penetration compromised the smoke integrity of the barrier wall, which is required to have a minimum 1/2-hour fire resistance rating according to NFPA 101, Life Safety Code, 2012 Edition. This deficiency affected 27 out of 92 residents and one of six smoke compartments in the facility. The report does not mention any specific medical history or condition of the residents involved, but it directly states that the unsealed penetration could result in the spread of smoke in the event of a fire. The deficiency was identified through direct observation and staff confirmation during the survey.
Plan Of Correction
K 372 - Smoke Barrier Construction How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • The identified penetration was sealed using fire-rated caulking and fire-resistant materials in accordance with NFPA 101 and NFPA 8.5.6.2 standards. 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: • No other residents have the potential to be affected. The penetration was limited to its specified smoke compartment. • A comprehensive review of all smoke barrier walls was conducted to identify any other unsealed penetrations. No other issues were found. 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 quarterly smoke barrier inspection protocol has been implemented, with documentation maintained for compliance review. • The EVS Director was trained by the administrator on the importance of proper inspection and sealing of smoke barrier penetrations. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; • Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance 4/18/25
Exposed Opening in Electrical Panel
Penalty
Summary
During a facility tour and staff interview, an electrical panel located in the Biohazard Storage Room near Room 27 was observed to have an exposed opening. Specifically, one of the 42 breaker spaces, labeled as '24', was missing a cover, resulting in an open gap in the panel. Staff present at the time confirmed the observation and indicated they were unaware of the missing cover. This deficiency affected 27 out of 92 residents and one of six smoke compartments. The finding was cited as a failure to maintain electrical equipment in accordance with NFPA 101 and NFPA 70 requirements, which mandate that unused openings in electrical panels be properly closed.
Plan Of Correction
The EVS Director was trained by the Administrator on 4/9/25 on the importance of electrical panel safety. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The EVS Director will conduct quarterly inspections of all electrical panels and wiring to ensure compliance. These inspections will be documented, and corrective actions will be taken as necessary. Results will be reviewed in the QAPI meetings for ongoing compliance oversight.
Failure to Ensure Resident Safety in Smoking Practices
Penalty
Summary
The facility failed to ensure the safety and well-being of a resident who was reviewed for smoking. The resident, who had a medical history of dementia, delirium, and nicotine dependence, was admitted to the facility and was identified as a smoker. Despite the resident's severe cognitive impairment, the facility did not implement adequate interventions to ensure the resident's safety and compliance with the smoking policy. The resident continued to smoke unsupervised, refused to turn in their lighter, and smoked used cigarettes found on the ground, which posed a significant safety risk. The facility's smoking policy required that residents who smoked be assessed for their ability to smoke safely and that any smoking-related privileges, restrictions, and concerns be noted on the care plan. However, the facility failed to enforce these policies effectively. The resident's care plan included interventions such as applying a protective apron during smoking and keeping the resident's cigarettes and lighter, but these interventions were not adequately implemented. The resident was observed smoking outside designated times and areas, and staff failed to remove the lighter or provide necessary supervision. Interviews with facility staff revealed a lack of consistent communication and documentation regarding the resident's smoking behavior and the necessary interventions. The Director of Nursing and other staff members were aware of the resident's non-compliance with the smoking policy, but additional interventions were not implemented in a timely manner. The facility's failure to address the resident's smoking behavior and ensure compliance with the smoking policy resulted in a situation that was likely to cause serious harm to the resident and others.
Removal Plan
- Immediate Smoking Assessments: All identified residents who smoke were assessed for safety risks, including cognitive impairment and ability to handle smoking materials safely. Residents were identified based on their current desire to smoke. The resident smoking assessment titled, Resident Smoking Initial Assessment, was completed for the identified residents. The assessments were completed, and the residents' care plans were updated accordingly.
- The active smoker list was updated to include Resident #37.
- All residents were previously assessed on admission for a desire to smoke. All new residents will be assessed on admission if they have a desire to smoke. This will be completed by admitting nurse.
- All identified residents were re-educated on the risk vs benefit of following the smoking policy.
- All other necessary interventions including supervised smoking, appropriate storage of smoking materials, smoking in designated areas, and offering of aprons were implemented immediately.
- Immediate Supervision Implementation: The smoking program was reviewed for resident safety by the interdisciplinary team including the Administrator, Activities Director, Director of Nursing, Medical Records Director, Director of Staff Development, Social Services, and the Medical Director.
- Staff were educated by the Director of Staff Development. Staff education included nurses, nurse assistants, activity assistants, department heads, dietary, administration, and housekeeping. Education included how to ensure smoking activities occur in designated, supervised areas to prevent unsupervised smoking and reduce fire hazards. Additionally, staff were trained on the importance of supervision and monitoring of smoking residents, including the prevention of unsafe practices. Education will be ongoing with an expected completion of all staff. Education will be conducted by the Director of Staff Development or designee. Any additional staff or new staff will be given a one on one education prior to start of shift.
- Training on the importance of supervision and monitoring of smoking residents, including the prevention of unsafe practices will be provided for all new hires by Director of Staff Development as part of the orientation process.
- Restriction of Smoking Materials: Any potentially dangerous items, including lighters or cigarettes, have been removed from residents' rooms.
- A lighter was removed from Resident #37's room by CNA.
- All rooms were visually inspected, and residents were asked for any smoking paraphernalia. There was no additional smoking paraphernalia.
- The Activities Director will conduct a monthly sweep visually inspecting all resident rooms and asking for smoking paraphernalia. The Activity Director was educated to this responsibility by the Administrator and Director of Nursing.
- All Staff including nurses, nurse assistants, activity assistants, department heads, dietary, administration, and housekeeping educated by the Director of Staff Development that staff who identify smoking paraphernalia should report it to Administrator or designee. All staff off site were educated via phone by department heads, administrator or designee.
- Revised Smoking Policy and Agreement Enforcement: A smoking agreement has been reintroduced and enforced for all residents who smoke, with clear guidelines about safe smoking practices, supervision, and the need to follow all facility policies. The smoking agreement was revised to better match the facility's smoking policy and procedure. A revision was made indicating that aprons are offered and strongly encouraged based on assessment, instead of requiring an apron to be eligible for the smoking program.
- Residents have the right to refuse smoking apron. Staff will continue to offer and encourage the apron. In the event of a refusal, the resident will be educated on the risk vs. benefit of the apron use. The resident will be provided supervision during smoking by Activity aide or designee during smoke break. Fire blanket and fire extinguisher are available in smoking area.
- Staff assisting residents who refuse to wear apron will notify the Activity Director or designee. Activity aides were trained by Activity Director. The Activity Director or designee will bring this to the attention to the interdisciplinary team during the interdisciplinary team meeting. This will then be care planned by nursing during the interdisciplinary team meeting.
- Residents who refuse to sign the agreement will have their smoking materials stored securely and will only be allowed to smoke under direct supervision. Residents who refuse to sign will be asked to turn in any smoking paraphernalia. If resident refuses to voluntarily give up paraphernalia the interdisciplinary team including the administrator, director of nursing, activity director, medical record director, director of staff development, infection preventionist, social services or other designee, will confiscate smoking materials as per our policy or discharge the resident.
- Residents who refuse to sign will be placed on every shift visual monitoring for smoking paraphernalia. Monitoring will be done by licensed nurses. Licensed nurses were trained by Director of Staff Development and Director of Nursing.
- Staff Education and Training: Facility staff, including nurses, nurse assistants, activity assistants, department heads, dietary, administration and housekeeping, have been immediately educated on the updated smoking policy, the importance of smoking assessments, and how to ensure that all smoking activities are managed safely. The education was conducted by the Director of Staff Development.
- Environmental Safety Measures: Fire safety training was given by fire training vendor.
- Additionally, fire safety training was done by the Director of Staff Development. Staff educated included nurses, nurse assistants, activity assistants, department heads, dietary, administration and housekeeping. Training was completed, and additional fire safety measures, such as fire extinguishers and fire blankets near designated smoking areas, have been implemented. Staff not currently in facility were called and educated by the Director of Staff Development via phone.
- Safe smoking area training was done for the Activities Director and activity assistants. Training was done by the Director of Staff Development and Administrator.
- Activities and or designee will do a check after each smoke break to ensure that smoking areas are safe and free from hazards such as loose smoke buds. Aides will verify receptacle is in working order, fire extinguisher is in place and fire blanket is in present. Activity aides were trained by activity director and administrator.
- Activity aides will supervise that all cigarettes will be extinguished and disposed in proper receptacle of after each smoking break. Activity aides were trained by activity director and administrator.
- A weekly scheduled audit conducted by the Medical Records Director or designee to review and monitor compliance with safety procedures.
- Compliance of audits conducted by the Medical Records Director will be monitored for three months and will be added to the Medical Record Director's portion (or designee) for our QAPI meeting, quarterly thereafter.
Failure to Notify Physician of Missed Medications for Dialysis Resident
Penalty
Summary
The facility failed to notify the physician that a resident undergoing dialysis did not receive their prescribed medications on specific days when they were out of the facility for dialysis. The resident, who was admitted on 04/06/2024, had a medical history including acute pulmonary embolism, dependence on renal dialysis, major depressive disorder, hypotension, chronic embolism and thrombosis of the left lower extremity, and chronic kidney disease. The resident's care plan indicated dialysis on Mondays, Wednesdays, and Fridays. However, the Medication Administration Record (MAR) showed that medications such as fluoxetine, Lasix, Eliquis, and metoprolol were not administered on several dialysis days in March 2025. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) acknowledged the resident missed medications due to being at dialysis and stated that the physician should have been notified. Another LVN claimed to have notified the physician but could not provide documentation to support this. The Medical Doctor expressed a desire to be informed when medications were missed, and both the Assistant Director of Nursing and the Director of Nursing confirmed that staff were expected to notify the physician in such cases. However, the Director of Nursing was unable to find a policy related to physician notification, and the Administrator deferred questions to nursing staff.
Failure to Complete PASARR for Residents Staying Over 30 Days
Penalty
Summary
The facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR) for two residents who remained in the facility beyond 30 days. Resident #53, admitted with a history of borderline personality disorder and bipolar disorder, was identified as a 30-day hospital exempt resident. However, the MDS Coordinator acknowledged that a new Level I PASARR should have been completed prior to the resident's 31st day in the facility, which was not done due to an oversight. The Director of Nursing confirmed the requirement for a new PASARR if a resident stays longer than 30 days, but it was not completed for Resident #53. Similarly, Resident #75, admitted with diagnoses including post-traumatic stress disorder, bipolar disorder, and anxiety disorder, also did not have a new Level I PASARR completed after 30 days. The MDS Coordinator admitted that another Level I screening should have been conducted on the 31st day of admission, but it was overlooked. The Director of Nursing reiterated the necessity of a new PASARR for residents staying beyond 30 days, which was not fulfilled for Resident #75. The Administrator was not involved in the PASARR process and deferred to nursing staff.
Failure to Update Care Plan for Resident's Smoking Policy Refusal
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected the resident's refusal to sign the smoking policy and did not include interventions for staff to obtain a cigarette lighter from the resident. The resident, who was admitted with a medical history of dementia, delirium, and nicotine dependence, was identified as having a heightened safety risk related to confusion and a personal desire to smoke. Despite the resident's severe cognitive impairment, as indicated by a BIMS score of 0, the care plan did not adequately address the resident's refusal to relinquish their cigarette lighter, nor did it provide clear guidance for staff on how to manage this situation. The deficiency was identified through interviews, record reviews, and facility policy reviews. The facility's policy required that any smoking-related privileges, restrictions, and concerns be noted on the care plan, and that all personnel be alerted to these issues. However, the care plan lacked specific interventions for obtaining the lighter from the resident, despite the resident's refusal to sign the smoking policy. Interviews with the Director of Nursing, the Administrator, and the MDS Coordinator revealed a lack of communication and coordination among the interdisciplinary team to address the resident's refusal and ensure the care plan was updated accordingly.
Failure to Account for Resident's Albuterol Inhaler
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident when the resident's Albuterol Sulfate inhaler was not accounted for as active medication and was kept by the resident on her overbed table for an extended period. The resident, who was admitted from an acute care hospital with multiple diagnoses including hypertension, congestive heart failure, and anxiety disorder, was cognitively intact as per her BIMS assessment. Despite this, the inhaler was not prescribed by the facility's attending physician, and there was no record of monitoring for potential side effects, which is a requirement for self-administration of medications. The Registered Nurse Supervisor confirmed that the inhaler was not prescribed and that self-administration requires a physician order and a nursing care plan, which were not in place. The Director of Nursing stated that licensed nurses are expected to query residents about their medications during admission and check for any home medications brought to the facility. The facility's policy requires medications to be administered only upon a written order from a licensed prescriber, which was not adhered to in this case. This oversight had the potential to result in the resident using the inhaler without proper staff supervision, increasing the risk of adverse side effects and potential drug interactions.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a rate of 7.69% during the observation period. This deficiency was identified during a medication administration observation where 2 errors were noted out of 26 opportunities. Specifically, a resident with a medical history of muscle weakness and age-related osteoporosis was administered incorrect dosages of medications. The resident was supposed to receive calcium 600 +D plus minerals oral tablet 600-400 mg twice a day and cranberry oral capsule 425 mg once a day. However, the resident was given a cranberry 450 mg tablet and an Oyster Shell Calcium 500 mg tablet instead. The errors occurred because the facility only had the incorrect medications available as stock, and the LVN administering the medications did not follow the prescriber orders. The LVN stated that if the correct medication was not available, the physician should be notified to decide on an alternative. The Director of Nursing and the Administrator both confirmed that staff were trained to administer medications correctly and were expected to notify the physician if a medication was unavailable. Despite this expectation, the correct procedures were not followed, leading to the medication errors.
Resident Misses Critical Medications on Dialysis Days
Penalty
Summary
The facility failed to ensure that a resident did not experience significant medication errors. Specifically, the resident, who had a medical history including acute pulmonary embolism, dependence on renal dialysis, major depressive disorder, hypotension, chronic embolism and thrombosis of the left lower extremity, and chronic kidney disease, did not receive their prescribed medications on dialysis days. These medications included fluoxetine hydrochloride, Lasix, Eliquis, and metoprolol tartrate, which were not administered on multiple occasions when the resident was out of the facility for dialysis. Interviews with facility staff revealed that the medications were not given because the resident was at dialysis, and there was a lack of communication with the physician regarding these missed doses. The Licensed Vocational Nurse (LVN) acknowledged the oversight, and the Medical Doctor (MD) expressed a preference to be notified of such occurrences to adjust medication orders accordingly. The Director of Nursing (DON) stated that medications should be administered before the resident leaves for dialysis, and the Pharmacist highlighted the potential health impacts of missing these medications. However, there was no documentation to show that the physician had been notified of the missed doses.
Inadequate Maintenance of Oxygen Concentrator Filter
Penalty
Summary
The facility failed to maintain an effective infection control program when a resident's oxygen concentrator filter was found covered with dust and lint. This deficiency was identified during an observation and interview with the Registered Nurse Supervisor, who acknowledged that the condition of the oxygen concentrator was unacceptable. The resident, who was admitted with multiple diagnoses including End Stage Renal Disease, Congestive Heart Failure, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease, was using the oxygen concentrator to manage wheezing and shortness of breath. The Registered Nurse Supervisor noted that the resident was not receiving the full benefit of supplemental oxygen due to the dirty filter, which could exacerbate the resident's respiratory issues. The Director of Nursing and the Director of Staff Development confirmed that the use of a dirty oxygen concentrator was not acceptable and could potentially lead to respiratory infections. The facility's policy and procedure documents, as well as the oxygen concentrator's user manual, indicated that filters should be cleaned weekly to prevent infection. However, the facility failed to adhere to these guidelines, resulting in a lapse in infection control practices. The job descriptions for Licensed Vocational Nurses and Registered Nurses also emphasized the importance of maintaining a safe and clean environment, which was not upheld in this instance.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by his roommate, who repeatedly used racial epithets against him. The resident reported the abuse to the facility's Social Services Department, which promised to move the offending roommate to a different room. However, the move did not occur as promised, and the resident continued to experience verbal abuse without any intervention or explanation from the facility. Interviews with staff and other residents confirmed the ongoing verbal abuse. A Certified Nursing Assistant (CNA) and another resident corroborated the victim's account, noting that the abusive roommate frequently used racial slurs and spat in the direction of the victim. Despite these reports, the facility's Social Services Director and Administrator claimed to be unaware of the specific allegations of racial abuse, and no documentation of the complaints was found in the resident's records. The facility's failure to act promptly and effectively on the reports of abuse violated its own policies on resident protection and abuse prevention. The staff's inaction and lack of communication allowed the abusive behavior to continue unchecked, causing distress to the resident. The facility did not report the abuse to the appropriate authorities or conduct an investigation, further neglecting its responsibility to ensure a safe and respectful environment for all residents.
Failure to Investigate Verbal Abuse Allegations
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving two residents, where one resident repeatedly used racial epithets towards another. Resident 1, who was cognitively intact, reported to the facility's Social Services Department that his roommate, Resident 2, was continuously using racial slurs against him. Despite Resident 1's complaints and corroborating statements from Resident 3 and a Certified Nursing Assistant (CNA), the facility did not document or investigate these allegations. Interviews with various staff members, including the Social Services Director (SSD), the Administrator, and the Director of Nursing (DON), revealed a lack of awareness and action regarding the verbal abuse allegations. The SSD claimed no knowledge of the racial slurs, despite the SSA stating that the issue was reported and discussed in a team meeting. The Administrator and DON were also unaware of the specific nature of the complaints, indicating a communication breakdown within the facility. The facility's policies and procedures require the investigation and reporting of all abuse allegations, but these were not followed in this case. The Administrator did not initiate an investigation or report the incident to the Department, as required by the facility's policies. This oversight resulted in Resident 1 being subjected to further verbal abuse without any protective measures being implemented.
Failure to Report and Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the California Department of Public Health involving a resident who was subjected to racial epithets by his roommate. The abuse was reported by the affected resident to the facility's Social Services Department, but no action was taken to report the incident to the appropriate authorities. Interviews with the resident and other staff members confirmed that the verbal abuse was ongoing and had been witnessed by others, yet it remained unreported and uninvestigated. The facility's staff, including a Certified Nursing Assistant and a Licensed Vocational Nurse, were aware of the abusive behavior and had communicated their concerns to the Social Services Assistant and the charge nurse. Despite these reports, the Social Services Director and the Administrator claimed to be unaware of the situation until it was brought to their attention by the surveyor. The facility's policy required immediate reporting of such incidents, but this protocol was not followed, resulting in a failure to protect the resident from further abuse. The facility's policies on abuse prevention and reporting were not adhered to, as the incident was not reported within the required timeframes, and no investigation was conducted. The Administrator and Director of Nursing were informed of the allegations but did not take the necessary steps to report or investigate the abuse. This lack of action allowed the verbal abuse to continue, violating the resident's right to be free from abuse and neglect.
Failure to Develop Safe Discharge Plan for Resident
Penalty
Summary
The facility failed to develop a safe and effective discharge plan for a resident who was discharged to an assisted living facility (ALF) without an interdisciplinary team (IDT) meeting to establish discharge goals and post-discharge care needs. The resident, who had a Public Guardian Conservator (PGC) responsible for managing their financial and medical decisions, was discharged without the PGC being involved in the discharge planning process. This oversight was contrary to the facility's policy and procedure, which required the involvement of the resident's representative in discharge planning. The resident had multiple medical conditions, including difficulty in walking, hypertensive heart disease, diabetes mellitus with diabetic neuropathy, dementia with agitation, Alzheimer's Disease, and hyperglycemia. The resident's cognitive status was moderately impaired, as indicated by a Brief Interview of Mental Status (BIMS) score of 12 out of 15. Despite these conditions, the resident was discharged to an ALF that could not provide skilled nursing care, including the administration of insulin and fingerstick blood sugar checks, which the resident required. Interviews with facility staff revealed that the discharge process was initiated by social services, who failed to document discussions with the IDT or the PGC regarding the resident's discharge. The resident's physician discontinued insulin without consulting the PGC, and the facility did not provide documentation of a discharge plan or evidence that the PGC was informed of the final discharge plan. The PGC was assured that the resident would receive the same level of care at the ALF, which was not the case, as the ALF could not administer insulin or perform blood sugar checks.
Failure to Maintain Safe Environment for Residents at Risk of Elopement
Penalty
Summary
The facility failed to maintain a safe environment for two residents who were at high risk for elopement due to severe cognitive impairments. Both residents were supposed to have Wander guard bracelets, which are designed to alert staff when a resident is near an exit door. However, neither resident had a functioning Wander guard at the time of the incidents. Resident 1 was able to leave the facility in his wheelchair and cross a busy highway without staff knowledge, while Resident 2 was found without a Wander guard during an inspection. The deficiency was further compounded by the failure of the staff to check the placement and functionality of the Wander guards every shift, as required by the physician's orders. Despite the medication administration records indicating that checks were performed, interviews with staff revealed that the checks were not actually conducted. Additionally, the facility's exit door alarms were not functioning properly, as demonstrated during an inspection when the alarm failed to sound upon opening the door. The facility lacked a policy and procedure for the use and testing of Wander guards and door alarms, which contributed to the oversight. The Director of Nursing and other staff members were unable to determine how Resident 1 managed to elope, and there was no documentation of the Wander guard being found after the incident. The facility's existing policy on elopements did not adequately address the use of Wander guards or the testing of door alarms, leading to a significant lapse in resident safety protocols.
Failure of Exit Door Alarm Leads to Resident Elopement
Penalty
Summary
The facility failed to provide a safe and functional environment when one of the four exit door alarms tested did not function properly. This deficiency was identified during an observation and interview with the Director of Maintenance (DOM), who discovered that the exit door alarm next to a specific room did not sound when the door was opened. The DOM attempted to fix the alarm, but it was initially non-functional, which was confirmed by multiple staff members who had not heard the alarm sound for some time. The deficiency was further highlighted by an incident involving a resident with severe cognitive impairment and a history of exit-seeking behavior. This resident had eloped from the facility without staff knowledge or supervision, as the Wander guard or exit door alarms failed to alert the staff. The resident was later found by a nurse in a church parking lot across the highway, indicating that the exit door alarm's failure contributed to the resident's undetected departure. Interviews with staff, including the Director of Nursing (DON) and the Administrator (ADM), revealed uncertainty about which exit door the resident used to elope and whether the door alarm had been checked for functionality after the incident. Additionally, the facility lacked a policy and procedure regarding the use and testing of exit door alarms and Wander guard door alarms, further contributing to the deficiency.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program for two residents during wound care. The Treatment Nurse (TN) did not follow proper infection control precautions, such as sanitizing hands between glove changes and using barriers for wound care supplies. For Resident 4, the TN placed wound care supplies directly on the bedside table without a barrier, did not sanitize hands between glove changes, and was unaware of the need for hand hygiene between glove changes. This resident had a stage 4 pressure ulcer and was cognitively intact, as indicated by a BIMS score of 15 out of 15. For Resident 6, the TN placed wound care supplies directly on the resident's bed without a barrier and did not sanitize the items before returning them to the treatment cart. The TN acknowledged that the cardboard box of gloves could not be properly sanitized and should not have been placed on the bed. This resident had a non-pressure chronic ulcer, an infection of an amputation stump, and type 2 diabetes mellitus, and was also cognitively intact with a BIMS score of 15 out of 15. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the facility's expectations for infection control during wound care were not met. The IP and DON both emphasized the importance of hand hygiene, using barriers, and not returning used supplies to the treatment cart. The facility's policy and procedure for wound care also outlined these steps, which were not followed by the TN, leading to potential risks of wound infections for the residents involved.
Failure to Develop and Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident who tested positive for COVID-19 and required oxygen therapy. The resident, who had a history of type 2 diabetes mellitus, atrial fibrillation, pulmonary embolism, weakness, and difficulty in walking, did not have a care plan with measurable goals and interventions after testing positive for COVID-19. Additionally, the licensed nurses did not develop a care plan for oxygen therapy since the resident's admission to the facility. During a review of the resident's records, it was found that the COVID-19 care plan was initiated three days after the positive test result, and the interventions were not personalized to meet the resident's needs. The care plan goal of maintaining normal oxygen saturation was deemed inappropriate as it did not consider the resident's medical history and baseline status. Furthermore, the facility's Director of Nursing confirmed that the care plan was generic and did not include specific care needs such as supplemental oxygen, vital signs, or symptom management. The facility's policies and procedures for care plans, oxygen administration, and changes in a resident's condition were reviewed and found to be inadequate in this case. The policies indicated that a comprehensive, person-centered care plan should be developed and implemented for each resident, including measurable objectives and timetables. However, the facility failed to adhere to these policies, resulting in the resident's COVID-19 and oxygen therapy care needs potentially going unmet.
Improper Oxygen Administration Without Physician's Order
Penalty
Summary
The facility failed to meet professional standards of practice when an LVN administered oxygen to a resident using a non-rebreather mask without a physician's order. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, atrial fibrillation, and a history of pulmonary embolism, tested positive for COVID-19. The resident's physician orders specified the use of a nasal cannula for oxygen administration, but the LVN used a non-rebreather mask instead, without obtaining the necessary physician's order. This action was not documented as an emergency, and there was no indication that the resident was in respiratory distress at the time. The resident's nurse's notes indicated that the non-rebreather mask was used because the resident was removing the nasal cannula. However, the facility's Director of Nursing (DON) confirmed that the use of a non-rebreather mask typically requires a physician's order and is generally reserved for emergencies. The DON also noted that the LVN's documentation did not justify the necessity of the non-rebreather mask, and there was no record of the LVN contacting the physician to request an order for its use. Professional references and the facility's policies were reviewed, confirming that oxygen therapy requires a prescription and continuous monitoring to ensure safe and effective use. The facility's policies also emphasized the need for physician orders for oxygen administration and the importance of documenting any changes in a resident's condition. The failure to follow these protocols placed the resident at risk for suffocation due to improper usage of the non-rebreather mask.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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