Rock Creek Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, California.
- Location
- 260 Racetrack Street, Auburn, California 95603
- CMS Provider Number
- 055446
- Inspections on file
- 32
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Rock Creek Care Center during CMS and state inspections, most recent first.
A resident with a history of stroke sequelae and anxiety, and mild memory impairment, was transferred by non-emergent transport to a hospital ED for reported behavioral symptoms without accompanying paperwork, prior physician or family notification, or a documented assessment supporting the need for transfer. Hospital case management documented that the resident was calm, cooperative, and agreeable to return, yet the facility’s Admission Coordinator repeatedly refused readmission, citing rooming concerns, despite multiple open beds. The facility completed a discharge notice indicating the resident was not expected to return, but the notice and required information on appeal rights and bed-hold policy were not provided at the time of transfer, and the LTC Ombudsman was notified only later. The DON and ADON confirmed there was no documentation of a bed-hold offer, no transfer packet, no required transfer/discharge notices, and no assessment of the resident’s status and needs at the time of proposed return, contrary to the facility’s own transfer/discharge policy.
Surveyors found that kitchen and storage areas contained multiple expired and unlabeled food items, including cooked tomato sauce, raw meats, vegetables, and bread. The Dietary Services Supervisor and other staff confirmed these items were not properly labeled or discarded according to facility policy, and that some foods had been stored beyond recommended timeframes.
The facility failed to follow prescribed dietary menus, affecting residents on modified texture, NCS/CCHO, and 60g Protein Renal diets. Errors included incorrect bread and dessert items, and a lack of menu-specified vegetables and garnishes. The Dietary Supervisor and Registered Dietitian acknowledged these issues, citing kitchen errors and lack of communication with residents.
The facility failed to meet food safety standards, with issues including wet and dirty sheet pans, improperly stored and labeled food, an unclean ice machine, incorrect hot food cooling practices, and dietary aides lacking knowledge of dishwashing and sanitizer procedures. Additionally, the microwave for residents' food was found dirty.
The facility failed to ensure that two dietary aides were adequately trained in food safety procedures. The aides were unable to correctly verbalize the process of manual dishwashing and the correct concentration range for sanitizer solutions, as required by facility policy. This lack of knowledge was confirmed by the Dietary Supervisor and acknowledged by the Registered Dietitian, highlighting a deficiency in staff training and competency verification.
The facility failed to ensure call lights were within reach for two residents, both with severely impaired cognition and requiring assistance with daily activities. Observations showed that call lights were not accessible, despite care plans and facility policy indicating they should be. Staff confirmed the deficiency during interviews.
A resident admitted with diagnoses of adult failure to thrive and malnutrition was inaccurately assessed in their MDS, which failed to mark them as edentulous despite having no teeth. Observations and interviews confirmed the resident's edentulous status, and the MDS LVN admitted the error. The facility could not provide policies on assessment accuracy.
A CNA transferred a resident alone using a Hoyer lift, contrary to the facility's policy requiring two staff members for such transfers. The resident, who was non-weight bearing and required assistance from two or more staff for transfers, was at risk due to this action. The Director of Staff Development confirmed that two-person transfers are standard for safety.
A CNA failed to wear the required N95 mask when entering a COVID-19 positive resident's room, despite signage indicating droplet precautions. The resident was under isolation due to COVID-19, and the facility's policy required an N95 mask, which was not followed, leading to a deficiency in infection control.
The facility failed to provide the required 80 square feet per resident in 28 multiple-resident rooms, with space ranging from 70.47 to 78.93 square feet. While some residents reported no issues, one resident experienced difficulties with space when using a Hoyer lift, affecting care provision.
The facility failed to serve food at a palatable and safe temperature, affecting three residents who reported receiving cold meals. Incomplete temperature recordings and lack of a test tray temperature log were noted. The Dietary Manager was unaware of the need for temperature checks at the point of service, and the facility's policies for meal service and food transport were not effectively implemented.
A resident with osteoarthritis and muscle weakness was unable to reach her call light, as it was wrapped around the bed's side rail. Her roommate reported having to assist with the call light, and a CNA confirmed the inaccessibility. The facility's policy requires call lights to be within easy reach, which was not followed, potentially compromising the resident's safety.
A resident's surgical staples were not removed within the physician-ordered timeframe, leading to a deficiency in maintaining professional standards of quality. The staples, located on the resident's forehead, were ordered to be removed within 10-14 days but were removed late, increasing the risk of infection. Interviews with staff confirmed the oversight and the importance of adhering to physician orders.
A resident admitted with alcohol abuse did not receive chlordiazepoxide as ordered for three days, leading to uncomfortable symptoms during detoxification. The facility's Infection Preventionist confirmed the delay was unacceptable, and records showed the medication was awaiting pharmacy delivery.
The facility failed to maintain food service safety standards when dirty and uncleanable dishware was found in use and storage. Observations revealed mugs with residue in the dining room and unclean dishware in the kitchen. Staff acknowledged the need for cleanliness checks and disposal of unsanitary items, as per facility policy, to prevent potential food-borne illnesses.
Two residents in a facility did not receive the RNA program services as ordered, which were intended to maintain or improve their range of motion and strength. Despite being referred to the RNA program after completing physical therapy, documentation showed inconsistencies in the provision of services. The Director of Rehabilitation confirmed the referrals, and the Director of Nursing and Director of Staff Development were responsible for oversight. However, the RNA program was not implemented per physician's orders, with significant gaps in documented sessions, leading to potential declines in residents' range of motion and strength.
Failure to Provide Required Notices and Readmit a Hospitalized Resident After Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure an appropriate transfer and discharge for a resident and to provide required discharge notices and bed-hold information. The resident was admitted with sequelae of cerebral infarction and an anxiety disorder, had mild memory impairment, and no documented physical behavioral symptoms directed toward others on the MDS. The baseline care plan documented psychosocial goals related to recognition and management of depression, anxiety, fear, disability, pain, and limitations in daily living. On the morning following admission, the Social Services Director documented that the resident would be sent out for further evaluation. Shortly thereafter, a SNF-to-hospital transfer form indicated the resident was being transferred to the hospital for behavioral symptoms such as agitation and psychosis, with noted restlessness, irritability, verbal/combative behavior, and refusal of care. Nurse’s notes documented that the resident was transferred to the hospital ED for further evaluation and treatment. Case management documentation from the hospital later that evening indicated the resident arrived at the ED by non-emergent transportation without paperwork or notification of the direct transfer, and the facility’s Admission Coordinator reported the transfer was due to the resident being aggressive and combative. The case manager documented that the resident was agreeable to return to the facility, but the Admission Coordinator stated the facility was at capacity and could not place the resident in a single room, despite facility census records showing multiple empty beds on that date and subsequent days. Over the next several days, hospital case management notes documented repeated notifications to the facility that the resident was ready to return, while the facility refused readmission. The Admission Coordinator refused readmission, and a Notice of Proposed Transfer/Discharge was completed indicating the resident was discharged and not expected to return. The notice to the Long Term Care Ombudsman was faxed the day after the notice was dated, and the Ombudsman later stated the notice should have been provided at the time of transfer or discharge and that the facility should have accepted the resident back. The DON and ADON confirmed there was no documentation that the resident’s family, emergency contacts, or physician were contacted prior to the ER transfer, no documentation that a bed hold was offered, no transfer packet or required transfer/discharge notices were provided, and no assessment of the resident’s status and needs was completed at the time the resident was ready to return. The DON also acknowledged that the documentation in the record did not support the transfer to the ER and that the facility did not readmit the resident due to concerns over behaviors, contrary to the facility’s own transfer/discharge policy requirements for documentation, notice, and appeal rights. Additional interviews corroborated the lack of appropriate transfer documentation and notice. The hospital case manager stated the resident sat in the ED waiting room without paperwork or information from the facility regarding the reason for the direct transfer, and that the facility refused readmission because they were not comfortable with the resident returning to a three-person room. The transportation company manager reported that, unlike typical practice where facilities provide a transfer packet or paperwork for ER transfers or medical appointments, this facility did not provide any transfer documents or instructions for this resident. Review of the facility’s transfer/discharge policy showed that residents have the right to remain in the facility, that transfers and discharges must meet specific criteria, and that the facility must document the basis for transfer/discharge, provide appropriate notice, communicate necessary information to the receiving provider, and inform the resident of appeal rights and the bed-hold policy. These policy requirements were not met in this case, as confirmed by the DON, ADON, and documentary evidence.
Failure to Properly Store and Label Food Items in Kitchen and Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to properly store food in accordance with professional standards and its own policies. During an inspection of the kitchen's walk-in refrigerator and freezer, multiple food items were found to be either expired, unlabeled, or both. These included cooked tomato sauce, fresh parsley, raw chicken pieces, meat packages of raw hamburger, shredded red cabbage, and fresh spinach in the refrigerator, as well as an opened, unsealed, unlabeled, and undated package of veggie burgers in the freezer. The Dietary Services Supervisor (DSS) confirmed uncertainty regarding how long some of the meat products had been thawing and acknowledged that expired and unlabeled food should not be served. In the dry goods storage area, additional items such as hamburger buns and cinnamon bread were found to be unlabeled or past their recommended storage time, with both the DSS and another staff member confirming these items should have been labeled and were inedible. Interviews with the DSS and the Administrator confirmed that kitchen staff were not following facility procedures, which require all food items to be labeled, dated, and used or discarded within specified timeframes. Facility policies reviewed by surveyors outlined clear guidelines for the storage and labeling of refrigerated, frozen, and dry goods, including maximum storage times and the requirement to discard food past expiration dates. The failure to adhere to these procedures resulted in the storage of expired and unlabeled food items, creating the potential for foodborne illness among the facility's residents.
Failure to Follow Prescribed Dietary Menus
Penalty
Summary
The facility failed to adhere to the prescribed dietary menus for residents during a lunch meal service. Specifically, three residents on modified texture diets did not receive the appropriate wheat roll preparations as indicated on the menu. Additionally, two residents on a No Concentrated Sweets/Consistent Carbohydrate diet received wheat rolls contrary to their dietary restrictions. Furthermore, two residents on a 60-gram Protein Renal diet were served vanilla wafers instead of the specified cookies, and three residents received mashed potatoes and green beans instead of the planned rice and carrots. The dietary supervisor acknowledged these discrepancies, noting that some items were not prepared due to kitchen errors, such as not preparing enough rice and carrots and substituting vanilla wafers for cookies. The Registered Dietitian confirmed these issues, stating that the kitchen staff did not follow the standardized recipes, leading to insufficient preparation of certain menu items. The RD also mentioned that any substitutions should have been approved and communicated to the residents, which did not occur. Additionally, all meals were served without the parsley garnish as indicated on the menu. The facility's policy and procedure documents emphasize the importance of following prepared menus and portion control guides, as well as the necessity of adhering to standardized recipes. The failure to follow these guidelines resulted in the potential compromise of the medical and nutritional status of the residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Several metal sheet pans in the clean and ready-to-use storage areas were found stacked while still wet and contained food debris. This was confirmed by the Dietary Supervisor (DS) and Registered Dietician (RD), who acknowledged that dishes, pans, and pots should be completely air-dried and clean before being stored to prevent mold and bacteria growth. The facility's policy and procedure (P&P) on dishwashing indicated that dishes are to be air-dried before stacking and storing. Additionally, the facility did not properly manage opened food items in storage. Opened bags of elbow noodles and croutons were not tightly closed or labeled with open or use-by dates, and a package of hamburger meat patties was similarly unlabeled. The DS confirmed these findings and stated that opened packages should be wrapped tightly and labeled with dates. The facility's P&P on food storage and labeling required that opened food items be tightly closed, labeled, and dated. The facility also failed to maintain cleanliness and proper procedures in other areas. The ice machine had an orange slimy substance on the ice chute, which was dripping onto the ice, and the DS confirmed that the machine had not been cleaned as frequently as required. The hot food cool down process was not practiced correctly, with logs showing improper cooling times and temperatures. Dietary aides were unable to correctly verbalize the manual dishwashing process and the concentration of the sanitizer solution. Furthermore, the microwave used for residents' food was found to be dirty, with black dry food splashes inside.
Inadequate Training of Dietary Aides in Food Safety Procedures
Penalty
Summary
The facility failed to ensure that two dietary aides were adequately trained to safely and effectively carry out the functions of the food and nutrition services. Dietary Aides 1 and 2 were unable to correctly verbalize the process of manual dishwashing using three-compartment sinks. Specifically, DA 1 could not state the correct immersion time for the sanitizing step, while DA 2 incorrectly stated the immersion time as 20 seconds instead of the required 60 seconds. This discrepancy was confirmed by the Dietary Supervisor and was contrary to the facility's policy, which mandates a 60-second immersion time. Additionally, DA 1's competency audit indicated she was competent in the procedure, despite her inability to verbalize it correctly during the interview. Furthermore, DA 2 was unable to verbalize the correct concentration range for the sanitizer solution used in the sanitation bucket, which should be between 200-400 ppm. This lack of knowledge was confirmed by the Dietary Supervisor and acknowledged by the Registered Dietitian, who emphasized the importance of staff knowing the correct procedures to prevent food-borne illness. DA 2's employee file showed no completed competency audit or evidence of attending any in-service training for sanitation, which is a requirement according to the facility's job description for dietary aides.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident 17, who was admitted with Parkinson's disease and muscle weakness, had severely impaired cognition and required assistance with activities of daily living. During an observation, it was noted that the call light was not within reach, and a licensed nurse confirmed that the resident would use the call light if it were available. The resident's care plan specifically indicated that the call light should be within reach and answered timely. Similarly, Resident 25, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, also had severely impaired cognition and required substantial assistance with daily activities. Observations revealed that the call light was not within reach on two separate occasions, once when the resident was in bed and once when sitting in a reclining seat. Both the Director of Staff Development and a licensed nurse confirmed the call light was not accessible. The resident's fall risk care plan also indicated that the call light should be kept within reach. The facility's policy on answering call lights emphasized the importance of ensuring the call light is within easy reach of residents.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, identified as Resident 22, who was admitted with multiple diagnoses including adult failure to thrive and malnutrition. The Minimum Data Set (MDS) for Resident 22, dated shortly after admission, inaccurately indicated that the resident had no memory problems and did not mark the resident as edentulous, despite the resident having all teeth missing. Observations and interviews confirmed that Resident 22 had no teeth and required dentures, information that was also communicated by the resident's responsible party during admission. The MDS Licensed Vocational Nurse acknowledged the inaccuracy in the MDS, attributing it to a mistake. The facility was unable to provide policies on the accuracy of assessments.
Inadequate Staffing for Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skill sets to meet the care and services for a resident when a Certified Nursing Assistant (CNA) transferred the resident by herself using a Hoyer lift. The resident, who was admitted with diagnoses including a fracture of the upper end of the right leg, muscle weakness, abnormalities in gait and mobility, and hemiplegia and hemiparesis following a cerebral infarction, required the assistance of two or more staff for chair/bed-to-chair transfers. The resident was also non-weight bearing on the right lower extremity, as indicated in the Minimum Data Set and Physical Therapy Evaluation. During an observation, the CNA was seen transferring the resident alone using the Hoyer lift, despite the facility's policy and procedure requiring at least two nursing assistants for such transfers. The CNA confirmed that she performed the transfer without additional staff assistance, acknowledging that Hoyer lift transfers should be done by two persons. The Director of Staff Development also stated that Hoyer lift transfers were always done by two persons for the safety of the residents, as part of training and education.
Inadequate PPE Usage for COVID-19 Positive Resident
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for a resident diagnosed with COVID-19. The resident, who was admitted with diagnoses including COVID-19, moderate protein-calorie malnutrition, and muscle weakness, was placed under droplet precautions. Despite the presence of signage indicating the need for droplet precautions, a Certified Nursing Assistant (CNA) entered the resident's room wearing only a yellow surgical mask, instead of the required N95 mask, along with a gown and gloves. During an observation, the CNA acknowledged the mistake upon being reminded of the proper protocol. The facility's policy on transmission-based precautions required masks to be worn when entering rooms under droplet precautions. The Infection Preventionist confirmed that the signage indicated the need for an N95 mask, which was not adhered to by the CNA, leading to a deficiency in infection control practices.
Inadequate Room Size in Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure that 28 multiple-resident rooms met the required 80 square feet per resident. Measurements of these rooms revealed that the space per resident ranged from 70.47 to 78.93 square feet, which is below the regulatory requirement. This deficiency was identified through observations, interviews, and record reviews conducted during the survey. Despite the inadequate space, some residents reported having enough room for their belongings and did not express concerns about the room size. However, one resident reported difficulties due to the limited space, particularly when using a Hoyer lift for transfers. The resident mentioned that CNAs had to maneuver furniture, such as the bedside table, to accommodate the lift, which sometimes encroached on the roommate's space. This situation indicates that the limited room size could potentially hinder the provision of care, especially for residents requiring assistive devices. The Department recommended the continuation of a waiver for the affected rooms.
Deficiency in Serving Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide palatable food at a safe and appetizing temperature for three of seven sampled residents, leading to dissatisfaction with meals. Residents reported that their meals were served cold, and this was confirmed through interviews and record reviews. Resident 3, who was admitted with multiple diagnoses including hemiparesis and moderate protein calorie malnutrition, reported that her breakfast was cold and could not be reheated. Resident 4, admitted with osteoarthritis and moderate protein calorie malnutrition, stated that her food was always cold, particularly the vegetables, and she was not eating well. Resident 7, with hemiparesis and diabetes, expressed that her meals were consistently cold, leading to weight loss. The facility's dietary management practices were inadequate, as evidenced by incomplete temperature recordings on the menus and the absence of a test tray temperature log. The Dietary Manager, who recently started working at the facility, acknowledged that she was not aware of the need to maintain a test tray temperature log and was only managing temperatures in the kitchen, not at the point of service to residents. The Director of Nursing and the Administrator confirmed that temperature monitoring was incomplete and that the previous cook had not documented food temperatures. The facility's policy and procedure for meal service required that food temperatures be taken prior to service and recorded on the daily therapeutic menu. However, this was not consistently done, as shown by missing temperature entries on multiple dates. Additionally, the policy for covering food during transport to maintain proper temperature was not effectively implemented, contributing to the issue of cold food being served to residents.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 3, by not ensuring that her call light was within reach. Resident 3, who was admitted with multiple diagnoses including osteoarthritis and muscle weakness, had moderately impaired cognition as per the Minimum Data Set assessment. During an interview, Resident 2, who shared a room with Resident 3, reported that Resident 3 was unable to push the call light and often had to call out for help. Resident 2 also mentioned that she had to assist by pushing the call light for Resident 3 on multiple occasions. An observation confirmed that Resident 3 was lying in bed on her right side, facing the wall, with the call light wrapped around the left side rail, making it inaccessible. Certified Nursing Assistant 1 acknowledged that Resident 3 could not reach her call light, which could lead to potential risks such as falls if the resident attempted to move without assistance. The facility's policy on answering call lights and accommodating resident needs emphasized the importance of ensuring call lights are within easy reach and adapting the environment to meet individual needs, which was not adhered to in this case.
Failure to Follow Physician Orders for Staple Removal
Penalty
Summary
The facility failed to adhere to physician orders for a resident, resulting in a deficiency in maintaining professional standards of quality. The resident, who was admitted with multiple diagnoses including a fracture of the right lower leg and rhabdomyolysis, had surgical staples on the right side of the forehead. The physician's order specified that these staples should be removed within 10-14 days, between April 24 and April 28. However, the staples were not removed until May 3, which was beyond the ordered timeframe. Interviews with the Infection Preventionist and the Treatment Nurse confirmed the oversight. The Infection Preventionist stated that the treatment nurse is responsible for removing staples and emphasized the importance of following physician orders. The Treatment Nurse acknowledged the delay in removing the staples and recognized the associated risk of infection. The facility's policy mandates that licensed staff carry out physician orders as prescribed, which was not followed in this instance.
Delayed Medication Administration for Alcohol Withdrawal
Penalty
Summary
The facility failed to ensure timely pharmacy services for a resident who was admitted with multiple diagnoses, including alcohol abuse. Upon admission, the resident had a physician's order for chlordiazepoxide, a medication used to treat alcohol withdrawal symptoms. However, the resident did not receive the medication until three days after the order was placed. This delay was confirmed during an interview with the resident, who expressed concern about not receiving the medication needed for detoxification. The facility's Infection Preventionist acknowledged that a three-day delay in receiving medications is unacceptable and could lead to side effects. A review of the resident's records showed that the medication was not available in the emergency kit and was awaiting delivery from the pharmacy. The facility's policy requires licensed staff to carry out physician orders as prescribed, but this was not adhered to in this case, resulting in the resident experiencing uncomfortable symptoms during alcohol detoxification.
Failure to Maintain Food Service Safety Standards
Penalty
Summary
The facility failed to maintain professional standards for food service safety, as observed during a survey. During an observation in the main dining room, it was noted that three mugs available for resident use had brown and white residue stuck inside. The Activities Assistant confirmed the mugs were not clean and should not be used for residents, indicating a lapse in cleanliness standards. Additionally, in the kitchen, the Certified Dietary Manager identified a plastic cup with yellow residue and a bowl with white residue on the rack of ready-to-use dishware, confirming they were not clean and needed to be rewashed. Furthermore, a plastic cup with brown residue and two bowls with rough surfaces were deemed uncleanable and required disposal. The Dietary Aide, responsible for putting away dishware, acknowledged the expectation to check for cleanliness and stated that uncleanable dishware should be discarded, while dirty but cleanable items should be sent back for washing. The facility's policy on sanitation, dated 2023, mandates that unsightly, unsanitary, or hazardous dishware should be discarded. These observations and interviews highlight the facility's failure to adhere to its own sanitation policies, potentially exposing residents to food-borne illnesses due to the use of dirty dishware.
Failure to Implement RNA Program as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents as part of the Restorative Nursing Assistant (RNA) program, which was intended to help maintain or improve their range of motion and strength. Resident 1, who was admitted with muscular dystrophy and multiple sclerosis, reported inconsistencies in receiving RNA program assistance, which was supposed to occur three times a week. Similarly, Resident 2, admitted with generalized muscle weakness and gait abnormalities, expressed uncertainty about the frequency of RNA sessions and noted infrequent assistance. Interviews and record reviews revealed that both residents were referred to the RNA program after completing physical therapy, as indicated in their PT discharge summaries. The Director of Rehabilitation confirmed the referrals, and the Director of Nursing (DON) and Director of Staff Development (DSD) were responsible for overseeing the RNA program. However, documentation showed that neither resident received RNA assistance as ordered, with significant gaps between documented sessions. The DSD confirmed the lack of documentation for refusals and acknowledged that undocumented sessions were not conducted. The facility's policy required certified and trained RNA staff to provide treatments per physician's orders, but this was not adhered to. The RNA 1 confirmed that if RNA assistance was not documented, it was not performed. The failure to implement the RNA program as ordered had the potential to result in declines in range of motion and strength for the affected residents.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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