Seacrest Post-acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Pedro, California.
- Location
- 1416 West 6th Street, San Pedro, California 90732
- CMS Provider Number
- 055070
- Inspections on file
- 39
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 35 (1 serious)
Citation history
Health deficiencies cited at Seacrest Post-acute Care Center during CMS and state inspections, most recent first.
The facility failed to provide private telephone access for several residents, including individuals with DM, CKD, heart failure, and atrial fibrillation who required varying levels of assistance with mobility and transfers. After a change in ownership, resident and work phones were confiscated, leaving only nursing station phones and RN supervisor work cell phones available. Ambulatory residents had to make calls at the nursing station in front of staff, while bedbound residents used a staff work cell phone that contained sensitive information, requiring staff to remain present during calls. One resident reported no longer being able to speak with a family member because she could not get out of bed to reach the nursing station phone and was not allowed independent access to a phone. Staff and administration acknowledged that residents’ calls were monitored due to concerns about access to confidential information on the work phones, resulting in a lack of privacy despite facility policies guaranteeing confidential and private telephone communication.
A resident with DM, HTN, and CAD was observed being quickly fed by a CNA during lunch, and the resident later stated feeling very sad and frustrated because they were rushed. The resident was cognitively intact and preferred to take time eating; an LVN and the DON stated that rushing a resident during feeding would make the resident feel they were not receiving compassionate care and would feel frustrated, irritated, and dissatisfied.
A resident with DM, HTN, and CAD had a light cord placed behind the bed and later on the floor behind the bed, leaving it out of reach while the resident was lying in bed. The resident said this was frustrating, and an LVN and the DON acknowledged that an out-of-reach light cord could frustrate the resident and create a fall risk if the resident tried to get out of bed. The facility policy stated residents should have comfortable yet adequate lighting.
Late Transmission of Quarterly MDS Assessment: A resident with depression, atrial fibrillation, difficulty walking, and cognitive impairment had a quarterly MDS assessment that was not transmitted to CMS on time. The MDS Nurse stated she forgot to send the assessment, and the DON acknowledged it was late and had not been submitted to CMS.
Inaccurate MDS coding affected two residents. One resident with dementia and ADL dependence was coded as not wearing a hearing aid, although she stated she wore a left hearing aid that staff kept in another room. Another resident with breast cancer and muscle weakness was coded as having cavities or broken natural teeth, but observation showed missing bottom teeth with one broken and one loose tooth; the resident requested dentures. The MDS nurse and DON stated the assessments were inaccurate and used to develop individualized care plans.
Failure to revise a communication care plan for a resident with hearing impairment. A resident with dementia, HF, and DM was documented as having minimal hearing difficulty and no hearing aid use, yet was observed not wearing hearing aids and stated she could not hear. The FM reported the resident wore a hearing aid in the left ear and staff kept it, and the LVN and DON both stated the communication care plan needed to be updated to reflect the resident's current needs.
Delayed Incontinent Care and ADL Assistance: A resident with moderate cognitive impairment and dependence for ADLs was left in a soiled incontinent pad for an extended period after the prior shift. CNA observed the resident needed changing but delayed care while busy with another resident and an orientee, and the pad was later found heavily soiled with bowel movement and redness around the buttocks. The DON stated CNAs were expected to provide timely care and request help when behind.
A CNA failed to report a resident’s buttocks redness and did not complete the required daily skin check after providing personal care and finding a soiled incontinent pad with heavy BM. The resident had generalized weakness, difficulty walking, muscle wasting, and moderate cognitive impairment, and was dependent for ADLs. The CNA later acknowledged the omission, and two LVs confirmed the change was not reported; the DON stated daily skin assessments and prompt reporting of skin changes were required.
A resident admitted with an indwelling urinary catheter was not assessed on admission to determine the indication for the catheter or whether it should be removed. The physician order listed straight drainage but did not document a reason for use, and the DON confirmed the indication was not noted. An RN stated catheter assessment on admission should identify why the catheter is in place and when it can be discontinued.
A resident with dementia, DM2, and severely impaired cognition was ordered one-on-one feeding assistance, aspiration precautions, and Boost TID, but staff repeatedly left meal trays untouched, did not consistently provide the ordered supplement, and failed to communicate the resident’s declining oral intake as a change in condition. The RD noted the resident’s intake was poor and not meeting nutritional standards, while the DON acknowledged a breakdown in communication and that the resident’s needs were not fully met.
Open medications were left unattended at a resident’s bedside, within reach and without staff present. The resident was not approved for self-administration, yet the resident said this was a usual practice and that he sometimes took the meds and sometimes did not. The MAR showed the morning meds were documented as administered, and the LVN who left them could not explain why they were left there; the DON stated meds should not be left at the bedside.
Failure to Complete Monthly Pharmacist Medication Regimen Review: The facility did not maintain evidence that a licensed pharmacist completed the required monthly MRR for a resident with dementia and DM2 who was prescribed Remeron for depression with poor appetite. CNA staff observed the resident as extremely sleepy and not wanting to eat, and the DON could not provide completed MRRs for several months. The RD reported the resident continued to have consistently low caloric intake despite the medication.
Failure to obtain a dental assessment for a resident with broken, loose, and missing teeth. The resident had breast cancer, atrial fibrillation, muscle weakness, and moderate cognitive impairment, and was observed with two lower teeth, one broken and one loose. She said she had not seen a dentist in a long time and wanted dentures because it would be easier to eat. The RNS said she forgot to place the order for a dental visit, and the DON stated residents with missing teeth need an oral assessment and interventions.
Inaccurate Medication Administration Documentation: A resident with CKD and a TIA history had open medications left unattended at the bedside while the MAR showed they had already been administered. An LVN stated he documented the meds before giving them, and the DON confirmed that documenting medication administration before the meds are actually given was not in line with facility policy or professional standards.
Infection control practices were not consistently followed for residents on EBP and for facility monitoring tasks. A resident on EBP lacked isolation signage, laundry staff did not document dryer lint trap cleaning every two hours, and kitchen staff did not keep the snack refrigerator temperature log current. In addition, an DSD was observed repositioning a resident on EBP without PPE, and a caregiver left another resident’s room and walked in the hallway while still wearing PPE. Staff and leadership acknowledged the expected practices and the missed steps.
The facility failed to follow its antibiotic stewardship protocol for two residents receiving antibiotics for UTI. One resident with intact cognition and another with severely impaired cognition both had antibiotic orders, but the Infection Surveillance Form and staff interviews showed they did not meet McGeer's criteria, and the IPN stated their doctors were not informed. The DON stated that when McGeer's criteria are not met, the doctor should be notified to possibly discontinue the antibiotic.
A resident with hemiplegia, DM, difficulty walking, intact cognition, and wheelchair use was observed in a room so small that a TV stand blocked access to the left side of the bed and had to be moved for care. Facility staff and leadership acknowledged that several 4-bed rooms did not meet the 80 sq ft per resident requirement and described safety concerns, including tripping hazards and residents bumping into objects.
A resident with severe cognitive impairment and a history of mental illness exhibited new wandering behavior, including being found outside the facility. Staff did not notify the physician of this change in condition, as required by policy. This failure resulted in the resident's wandering and aggressive behaviors not being addressed, leading to a physical altercation with another resident.
Two residents with cognitive impairments were involved in a physical altercation after one, who had a history of wandering and taking items, was not properly care planned for these behaviors, and the other did not receive prescribed Trazodone for several days. The lack of medication administration and failure to update care plans or communicate behavioral risks led to an incident where one resident struck another, resulting in injury.
A resident with major depressive disorder and moderate cognitive impairment received Trazodone without proper monitoring of sleep behaviors or adverse effects, and without an active informed consent for over three weeks. Facility staff failed to document required observations and did not renew the psychotropic medication consent as per policy.
A resident with severe cognitive impairment and a history of mental illness developed new wandering behaviors, including leaving the facility and taking items from others. Staff and other residents observed these behaviors, but the care plan was not updated to address the changes. This omission led to an incident where the resident entered another's room and a physical altercation occurred.
A nurse was not assessed for medication administration competency upon hire, as required by facility policy. As a result, a resident with multiple health conditions did not receive prescribed Trazodone for three days, with no documentation to confirm administration. Staff interviews and record reviews confirmed the lapse in both competency assessment and medication documentation.
A resident's responsible party requested access to medical records, but the facility failed to provide the records or any update for at least 10 months after the written request was received. The Medical Records Director admitted to forgetting about the request, which violated the facility's policy requiring records to be provided within a set timeframe. The resident had multiple chronic conditions and moderately impaired cognition but was able to make decisions.
A resident with significant medical needs and severe cognitive impairment did not receive required physician visits within the mandated timeframe. Facility records and staff interviews confirmed that the last physician visit occurred several months prior, in violation of policy requiring regular physician assessments.
A resident with a history of aggressive behavior and mental health issues repeatedly verbally abused a legally blind roommate, making him feel unsafe and uncomfortable. Despite care plans and staff awareness of the resident's history of aggression, the facility did not prevent ongoing verbal outbursts and bullying in shared spaces, as confirmed by interviews with other residents and staff.
The facility failed to ensure safe food storage and preparation practices. There was no trash can near the handwashing sink, and a dietary aide did not change gloves or wash hands when handling clean dishes. Food items were stored beyond safe periods, and recalled nutritional supplements were accessible. Unpasteurized eggs were used, and thawed turkey was refrozen. Sanitizer solution for cleaning was ineffective, risking unsanitized surfaces.
A facility failed to label a resident's insulin with an 'open date,' risking administration of expired medication. Additionally, medications in two refrigerators were stored at improper temperatures, potentially compromising their safety and effectiveness. LVNs and the DON acknowledged these issues, which could lead to adverse health outcomes.
A resident's blankets were lost after laundering, and the resident received blankets belonging to others. The resident, with multiple health conditions, was dependent on staff for personal care. Staff interviews revealed inadequate procedures for returning laundered items, leading to the misplacement of the resident's belongings. The facility's policy requires respect for residents' belongings and prompt investigation of misappropriation complaints.
A resident with multiple health issues, including severe cognitive impairment, was found to have an inaccessible call light, wrapped around the bed's siderail. The DSD and DON confirmed the importance of the call light for communication and emergency assistance, and the facility's policy requires it to be within reach at all times.
A resident with ovarian cancer, type 2 diabetes, and hypertension did not receive an individualized care plan with measurable objectives and interventions. Despite being prescribed treatment for cellulitis, the resident refused RNA treatments due to leg pain. The care plan was deemed inappropriate by the DON, as it did not address the resident's specific concerns.
A resident was administered Seroquel without a documented medical diagnosis to support its use, contrary to professional standards. The resident's records did not indicate a diagnosis of schizophrenia or other psychiatric disorders, which is necessary for such medication. The facility's policy requires psychotropic medications to be prescribed only when clinically indicated, which was not followed. The Medical Records Supervisor entered a diagnosis based on instructions from the DON, not a physician's evaluation, leading to potential risks for the resident.
A resident with multiple health conditions did not receive proper denture care as required by their care plan. Observations and interviews revealed that the resident's dentures were not cleaned or stored properly, and necessary supplies like denture cups and cleaning tablets were unavailable. Staff acknowledged the oversight, which was contrary to the facility's policy on denture care.
The facility failed to maintain IV catheters for two residents according to professional standards. One resident's IV catheter was not removed after therapy completion, and another's IV site was not rotated every 72 hours as required. Both residents had care plans indicating the need for regular monitoring to prevent complications, and the facility's policy emphasized site rotation to avoid infection risks.
A facility failed to ensure an LVN was properly trained in BP monitoring, leading to incorrect BP checks for a resident with hypertension and renal disease. The LVN placed the BP cuff incorrectly and was unaware of the correct procedure, risking inaccurate readings and potential harm. The DSD intervened to correct the procedure, but the resident refused medication due to a misunderstanding of physician orders. Interviews revealed gaps in training and competency assessments for BP monitoring.
Two residents in an LTC facility experienced medication administration deficiencies. A resident was given a chewable aspirin tablet without being instructed to chew it, contrary to physician orders. Another resident received Vitamin D3 two hours late due to a lack of capsule formulation, which was not clarified with the physician in a timely manner. The DON confirmed the need for proper administration and timely clarification of medication orders.
A facility and consultant pharmacist failed to identify irregularities in a resident's medication regimen review, leading to the unnecessary administration of Seroquel without a proper diagnosis. The resident, admitted with conditions like sepsis and dementia, was prescribed Seroquel for schizophrenia despite the absence of a documented psychiatric disorder. The oversight in the medication review process resulted in the resident receiving the medication unnecessarily, potentially causing adverse side effects.
A resident was administered Seroquel without a corresponding psychiatric diagnosis, contrary to the facility's policy on psychotropic medication use. The resident's MDS did not indicate any psychiatric disorders, yet the medication was prescribed for schizophrenia. The QA LVN acknowledged the oversight, noting the risk of adverse effects due to the unnecessary drug use.
A facility failed to maintain a medication error rate below 5%, resulting in an 11.54% error rate. Errors included not labeling insulin with an open date for a resident, failing to instruct another resident to chew aspirin, and delaying Vitamin D3 administration for a third resident due to formulation issues. These actions led to potential risks in medication effectiveness and timely administration.
The facility failed to ensure kitchen staff were trained and competent in using sanitizer test strips for the dish machine. A Dietary Aide (DA1) was unable to identify the correct test strip and was unaware of the chlorine sanitizer concentration, leading to potential risks for foodborne illness among residents.
A facility failed to ensure proper infection control when a treatment nurse did not perform hand hygiene between glove changes while providing wound care to a resident with osteomyelitis and diabetes. The nurse acknowledged the oversight, and the DON confirmed the importance of hand hygiene to prevent cross-contamination, as outlined in the facility's policy.
A resident with a history of UTIs was prescribed Keflex, but the facility failed to complete the necessary Surveillance Data Collection form. The Infection Preventionist Nurse did not document the antibiotic use or check for signs of infection, missing the resident's antibiotic order. This oversight risked inappropriate antibiotic use and resistance.
The facility failed to provide necessary dementia care training to staff, as confirmed by interviews with CNAs and the DSD. Despite the requirement for initial and ongoing training, the scheduled session was not conducted, leaving staff unprepared to handle residents with dementia, potentially jeopardizing their safety.
The facility failed to post accurate daily nurse staffing information, leading to discrepancies between the posted data and actual staffing levels on several occasions. The Director of Staff Development acknowledged that the posted information was not updated to reflect staff call-offs, which could impact the quality of care.
The facility was found to have exceeded the regulatory limit of four residents per room in rooms [ROOM NUMBER] and 34, each housing five residents. Despite a waiver letter indicating sufficient space for mobility and care, the occupancy exceeded the allowed number. Observations confirmed that the rooms provided ample space per bed, and no adverse effects on residents' privacy, health, or safety were noted.
The facility did not meet the required 80 square feet per resident in 8 out of 17 rooms, specifically Rooms 20, 21, 22, 23, 25, 26, 27, and 32. Despite a waiver letter indicating sufficient space for mobility and care, these rooms did not comply with the size requirement. Other rooms were observed to have adequate space for movement and care without compromising residents' privacy, health, or safety.
A resident with severe cognitive impairment and multiple diagnoses, including bipolar disorder, repeatedly refused Risperidone, a medication prescribed for their condition. Despite the refusals documented in the MAR, the facility failed to notify the physician, contrary to their policy. Interviews with staff confirmed the lack of notification, which could delay alternative treatment measures.
A resident with severe cognitive impairment and multiple diagnoses, including schizophrenia and cancer, did not have a care plan addressing their noncompliance with care, such as refusing medications and meals. Despite the facility's policy requiring comprehensive care plans, staff interviews confirmed the absence of such a plan, highlighting a deficiency in meeting the resident's needs.
A resident with a history of diabetes and hypertension was found to have severe pitting edema in both legs, but the LTC facility failed to document any assessment of the condition from July to August. An LVN confirmed that the edema should have been assessed and documented weekly, including details such as location, type, grade, and pedal pulses. The DON and DSD acknowledged the lack of documentation, which was required by the facility's policy for ongoing assessments.
A resident's echocardiogram was not completed as ordered due to a nurse's error, leading to a delay in care. The resident, with conditions like diabetes and hypertension, required the test to assess heart function related to edema. Facility policies for prompt diagnostic services were not followed.
A facility failed to inspect a hand sink in a resident's bathroom, resulting in the sink detaching from the wall and causing a resident to fall and sustain multiple injuries, including a left hip fracture. The resident, who had a history of cerebral infarction, dementia, and glaucoma, required moderate to maximal assistance for daily activities. The maintenance staff and administration were unaware of any issues with the sink prior to the incident.
Failure to Provide Private Telephone Access for Residents
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of telephones, affecting three sampled residents. Resident 1, admitted with diagnoses including diabetes mellitus and chronic kidney disease, had intact cognition and required substantial assistance with transfers and walking. Resident 3, with diabetes mellitus and atrial fibrillation, had mildly impaired cognition and required supervision or moderate assistance with mobility. Resident 2, with heart failure and chronic kidney disease, had moderately impaired cognition and was dependent on staff for transfers. These residents relied on staff and facility resources to access telephones for personal communication. Staff interviews and observations showed that, following a change in facility ownership, the previous owner confiscated all work phones and residents’ phones for private use, and the facility no longer had a dedicated resident cell phone. RN 1 reported that residents who were able to ambulate used the phone at the nursing station, while bedbound residents used the nursing staff’s work cell phone, which contained sensitive information about many residents. Because of this, staff remained with residents during calls to prevent access to confidential information on the device, acknowledging that this could be a violation of privacy since staff could hear the conversations, even though they tried not to listen. Resident interviews and direct observations confirmed the lack of private telephone access. Resident 2, who was bedbound, stated she previously spoke with her daughter weekly but had been unable to do so for a couple of months because the facility no longer allowed her to use the phone and she could not get out of bed to reach the nursing station phone. Resident 3 stated that when he needed to use the phone, he did so at the nursing station and had conversations in front of staff. Resident 1 was observed using the phone at the nursing station while RN 1 sat nearby. The Social Services Director and the Administrator both confirmed that, as an interim measure, residents were using the RN supervisor’s work cell phone under staff monitoring, which prevented residents from having private telephone conversations. Facility policies on confidentiality and resident rights stated that residents would have their written and telephone communications protected and would have access to a telephone with privacy, which was not being met in these instances. These failures resulted in Resident's 1, 2, and 3 being unable to make personal phone calls without staff's presence and monitoring, violating their rights to private communication. These deficient practices had the potential to cause psychosocial harm, including fear of being overheard when discussing personal information, and feelings of distress and isolation due to lack of communication with family.
Rushed Feeding During Meal Service
Penalty
Summary
The facility failed to provide enough time for one of one sampled resident, Resident 30, to enjoy their meal. Resident 30 was admitted on 3/12/2026 with diagnoses including diabetes mellitus, hypertension, and coronary artery disease. The MDS dated 3/19/2026 indicated the resident was cognitively intact. During an observation on 3/24/2026 at 12:51 p.m., CNA 5 was seen quickly feeding Resident 30 their lunch meal. During an interview on 3/25/2026, Resident 30 stated they felt very sad and frustrated when the CNA rushed to feed them. LVN 4 stated Resident 30 prefers to take their time eating and that a resident who feels rushed while being fed would feel they were not receiving compassionate care. The DON stated that if a resident was not given enough time to finish their meal, the resident would feel frustrated, irritated, and dissatisfied. The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated the facility will maintain a culture of compassion and caring for all residents.
Light Cord Out of Reach
Penalty
Summary
The facility failed to ensure that Resident 30’s light cord was within reach. Resident 30 was admitted with diagnoses including diabetes mellitus, hypertension, and coronary artery disease, and the MDS dated 3/19/2026 indicated the resident was cognitively intact. During an observation on 3/24/2026, Resident 30 was lying in bed and the light switch cord was behind the bed. During a later concurrent observation and interview on 3/25/2026, the light switch cord was on the floor behind the resident’s bed, and Resident 30 stated it was frustrating that the light switch cord was out of reach. An LVN stated that a resident would feel frustrated if the light switch cord was out of reach, and the DON stated that if a light switch cord was not within reach, the resident would be at risk for falling if trying to get out of bed. The facility policy titled Homelike Environment stated the facility shall provide the resident comfortable yet adequate lighting.
Late Transmission of Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident 11’s quarterly MDS assessment was transmitted to CMS within the required time frame. Resident 11’s record showed admission and readmission with diagnoses including depression, atrial fibrillation, and difficulty walking. The resident’s H&P dated 1/30/2026 indicated the resident was alert and oriented to name, and the MDS dated [DATE] indicated moderate cognitive impairment and dependence with ADLs. A review of the MDS batch status dated 3/26/2026 showed the last assessment had been transmitted to CMS on 11/17/2025 and accepted on 11/25/2025. During interview and record review, the MDS Nurse stated she forgot to send Resident 11’s quarterly MDS assessment and said it was late and would be sent right away. The DON stated she was aware the quarterly assessment had not been sent to CMS and was late, and stated there was a potential for a delay in care and services for Resident 11.
Inaccurate MDS Coding for Hearing and Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurate for two residents. For one resident with diagnoses including heart failure, diabetes mellitus, and dementia, the admission record and H&P showed the resident lacked capacity to understand and make decisions, and the MDS also reflected no capacity and dependence with ADLs. However, the MDS coded the resident as having minimal hearing difficulty and not wearing a hearing aid, while the resident stated she was hard of hearing and wore a hearing aid on the left side that staff stored in another room. For another resident with diagnoses including breast cancer, atrial fibrillation, and muscle weakness, the H&P described the resident as alert and oriented, while the MDS indicated moderate cognitive impairment and substantial/maximal assistance with ADLs. The MDS also coded the resident as having obvious or likely cavities or broken natural teeth, but during observation the resident’s bottom teeth were seen to include two teeth, one broken and one loose. The resident stated she wanted to see a dentist for dentures so she would not have to eat baby food anymore. The MDS nurse and DON both stated the hearing and dental assessments were inaccurate and that MDS assessments are used to help develop an individualized plan of care.
Failure to Revise Communication Care Plan for Hard-of-Hearing Resident
Penalty
Summary
The facility failed to revise the communication care plan for one sampled resident who was hard of hearing. Resident 12 was admitted and later readmitted with diagnoses including heart failure, diabetes mellitus, and dementia. The resident's H&P and MDS indicated the resident did not have the capacity to understand and make decisions, and the MDS also noted minimal difficulty with hearing and no hearing aid use. During observation, Resident 12 was not wearing hearing aids and stated, "Can you repeat yourself, I can't hear you," and said she only needed her hearing aid on the left side when talking to people. Family Member 1 stated the resident wore a hearing aid in the left ear and that staff kept it and only put it in when the resident had visitors. The LVN reviewing the care plan stated the resident was hard of hearing and only wore a hearing aid in the left ear, and that the communication care plan needed to be updated to reflect the resident's current plan of care. The DON stated the care plan is a guide for staff to provide appropriate care and that Resident 12's communication care plan needed to be revised to reflect the current plan of care. The facility policy stated care plans are revised as resident information and conditions change.
Delayed Incontinent Care and ADL Assistance
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received timely incontinent care and assistance with grooming. Resident 60 was admitted with diagnoses including generalized muscle weakness, difficulty walking, and muscle wasting and atrophy. The MDS dated 03/01/2026 indicated the resident had moderate cognitive impairment and was dependent for ADLs. During a concurrent observation and interview on 03/24/2026 at 10:25 a.m., Resident 60 was observed in bed and stated he needed his incontinent pad changed and had not been changed since the previous shift. During an observation at 10:30 a.m., CNA 4 provided personal care and the resident's incontinent pad was observed soiled with heavy bowel movement, with redness around the buttocks area. During interview, CNA 4 stated she normally changed Resident 60 after breakfast, but that day she was behind because she had an orientee slowing her down. She stated she saw the pad was full, told the resident she would come back in 15 minutes, and later said she felt bad because the resident was left in a soiled pad filled with heavy feces. The DON stated CNAs were expected to clean and change residents in a timely manner and request assistance if they fell behind. The facility's ADL policy stated residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
Failure to Report Skin Redness and Complete Daily Skin Check
Penalty
Summary
The facility failed to ensure CNA 4 reported changes in Resident 60’s skin condition and completed the required daily shift body check and skin assessment. Resident 60 was admitted with diagnoses including generalized muscle weakness, difficulty walking, and muscle wasting and atrophy. The MDS dated 03/01/2026 indicated the resident had moderate cognitive impairment and was dependent for ADLs. During an observation on 03/24/2026 at 10:30, CNA 4 provided personal care to Resident 60 and observed the resident’s incontinent pad soiled with heavy bowel movement and redness around the buttocks area. CNA 4 stated she would report the skin redness to the charge nurse and complete the daily shift body check per protocol. During a later concurrent interview, CNA 4 stated she thought she had reported the redness but had not, and that she failed to do the daily shift body check skin assessment. LVN 5 and LVN 6 stated CNA 4 did not report the redness on 03/24/2026. The DON stated skin assessments must be completed daily and any significant change in condition must be reported to the charge nurse and treatment nurse. The facility policy stated staff are to maintain daily skin checks and nurses are to be notified if skin changes are identified.
Failure to Assess Indwelling Urinary Catheter on Admission
Penalty
Summary
The facility failed to assess Resident 56, who was admitted with an indwelling urinary catheter, to determine the indication for the catheter and whether it should be removed. Resident 56’s admission record showed diagnoses including generalized muscle weakness, difficulty walking, and urinary retention. The Minimum Data Set dated 03/10/2026 indicated severe cognitive impairment and dependence with activities of daily living. The Physician Order Summary dated 03/10/2026 included an order for an indwelling urinary catheter to straight drainage, but no indication was documented. During interview and record review, the DON stated there was no indication noted in the physician order and that the order should specify the reason for the catheter. An RN stated residents admitted with an indwelling urinary catheter should be assessed on admission to determine the reason for use and when it should be discontinued, and that failing to assess the catheter places residents at risk for infections and discomfort.
Failure to Provide Ordered Feeding Assistance, Supplements, and Communication for Declining Intake
Penalty
Summary
Resident 27, who was admitted with dementia and type 2 diabetes and had severely impaired cognition and dependence for eating, was ordered to receive feeding assistance for all meals, aspiration precautions with head of bed elevation, and Boost three times daily. The resident also had a fortified mechanical soft diet with regular liquids and a care plan directing staff to monitor oral intake, evaluate for problems, and notify the physician as needed. The record showed the resident’s nutritional intake had been declining, with multiple documented meal intakes in the 0-25% range and a BMI of 18.1, which the RD described as underweight and not meeting nutritional standards. During observation, the resident was found asleep in bed while meal trays were left within reach, including one tray that appeared untouched and unopened with no staff present to provide the ordered one-on-one feeding assistance. On another occasion, the resident’s breakfast tray was found untouched on the meal cart outside the room, and staff confirmed it had not been eaten. CNA 1 stated the resident required one-on-one feeding and could not eat independently, but also stated she left the tray at the bedside and intended to return later. CNA 1 further stated the resident had not eaten breakfast or lunch and had not drunk liquids at breakfast, but she did not report this decline to the charge nurse. The record and interviews also showed Boost was not consistently administered as ordered. CNA 2 stated she informed LVN 2 that the resident did not eat breakfast and that LVN 2 said she would notify CNA 1 to provide Boost, but CNA 1 stated she was not informed and did not give it. LVN 2 acknowledged she had not been administering Boost during medication passes and could not explain why. The RD stated nursing staff were not implementing the ordered interventions consistently or on time, that staff did not provide follow-up to her, and that she did not notify the physician despite the resident’s declining intake. The DON stated there was a breakdown in communication, that the resident’s decline in nutritional intake was a change in condition, and that it did not appear the resident’s condition was communicated to the physician in a timely manner. The resident was later transferred to a GACH due to abnormal lab test, abdominal distention, and poor oral intake.
Open Medications Left Unattended at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were not left open and unattended at the bedside of one sampled resident. Resident 63 was admitted with diagnoses including chronic kidney disease and a transient ischemic attack, and the MDS indicated the resident required dependent assistance with toileting, oral hygiene, bathing, and showering. During observation on 3/24/2026 at 10:53 a.m., nine open pills were found at the resident’s bedside within reach, with no licensed nurse or staff member present. The resident stated the medications had been sitting there for a while and that leaving medications at the bedside was a usual practice, with the resident sometimes taking them and sometimes not depending on how he felt. The MAR showed that the 9:00 a.m. medications for that day had been documented as administered, including cholecalciferol, clopidogrel, cyanocobalamin, ferrous sulfate, folic acid, magnesium oxide, and Rena-Vite. During a concurrent interview, LVN 3 stated the medications had been left by him and could not explain why they were left at the bedside. LVN 3 stated the resident was not approved for self-administration and acknowledged that medications should not be left at the bedside because there was no assurance residents would take them as prescribed. The DON also stated medications should not be stored or left at the resident’s bedside and that only residents assessed and approved may self-administer medications.
Failure to Complete Monthly Pharmacist Medication Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed and documented a monthly Medication Regimen Review (MRR) for one of three residents, Resident 27. Resident 27 was admitted with diagnoses including dementia and type 2 diabetes mellitus, and the MDS dated 2/1/2026 indicated severely impaired cognition and dependence with eating, toileting, and showering. The resident’s order summary dated 7/24/2024 included Remeron 30 mg at bedtime for depression manifested by poor appetite. During observation on 3/26/2026, CNA 2 reported that Resident 27 was extremely sleepy at breakfast and did not want to eat, and the resident was later observed lying in bed with eyes closed, sleepy, and responding only to tactile stimuli. During review with the DON, the facility could not provide evidence of completed pharmacist MRRs for Resident 27 for September 2025 through February 2026, and the DON stated the reviews were required to identify medication irregularities and evaluate whether medications were clinically appropriate. The RD stated the resident continued to have consistently low caloric intake despite being prescribed Remeron for poor appetite. The facility policy stated that each resident’s medication regimen is to be reviewed at least monthly and documented in the consultation report.
Failure to Obtain Dental Assessment for Resident With Broken and Loose Teeth
Penalty
Summary
The facility failed to ensure that Resident 75 was seen by a dentist for broken, loose, and missing teeth. Resident 75 was admitted with diagnoses including breast cancer, atrial fibrillation, and muscle weakness. The admission record and H&P indicated she was alert and oriented, while the MDS dated 3/6/2026 indicated moderate cognitive impairment, substantial/maximal assistance with ADLs, and obvious or likely cavities or broken natural teeth. During a concurrent observation and interview on 3/24/2026, Resident 75 was observed at bedside with two bottom teeth, one broken and one loose. She stated she had not seen a dentist in a long time and wanted to get dentures because it would be easier to eat and she did not want to have to eat baby food anymore. On 3/27/2026, the RNS stated she admitted Resident 75 to the facility, knew she was missing teeth, and forgot to put in the order for a dental visit. The DON stated residents with missing teeth need to be seen by a dentist for an oral assessment and interventions. The facility policy stated a consultant dentist is responsible for providing a dental assessment within 90 days of admission.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one resident when medication administration was documented before the medications were actually given. Resident 63 was admitted with diagnoses including chronic kidney disease and transient ischemic attack, and the MDS dated 3/11/2026 indicated the resident required dependent assistance with toileting, oral hygiene, bathing, and showering. During a concurrent observation and interview on 3/24/2026 at 10:53 a.m., nine open medications were observed left unattended at Resident 63’s bedside with no licensed nurse or staff member present. Resident 63 was lying in bed with the medications within reach and stated the medications had been sitting at the bedside for a while, that leaving medications at the bedside was usual practice, and that he sometimes takes the medications and sometimes does not depending on how he feels. The MAR showed staff initials documenting administration of cholecalciferol, clopidogrel bisulfate, cyanocobalamin, ferrous sulfate, folic acid, magnesium oxide, and Rena-Vite at the 9:00 a.m. administration time, and the Medication Administration Audit Report also indicated these medications were administered. LVN 3 stated he documented the medications at 8:08 a.m. before they were administered and that they had been left at the bedside. The DON reviewed the record and stated documenting medication administration before the medications are actually given was not in accordance with facility policy or professional standards.
Infection Control Lapses With EBP, Laundry, Kitchen, and PPE Use
Penalty
Summary
Infection prevention and control practices were not consistently followed for residents on Enhanced Barrier Precautions (EBP) and for facility environmental monitoring tasks. Resident 6 had an order for EBP for a left heel wound, and the resident’s assessment showed severely impaired cognition and dependence with activities of daily living. During observation, CNA 3 stated there was no isolation signage outside Resident 6’s room, and the Infection Prevention Nurse stated signage should be posted for all residents on isolation to indicate the precautions to take. Laundry staff did not document cleaning of dryer lint trap screens every two hours as required. In the laundry room, Laundry Aide 1 was observed cleaning a dryer lint trap screen that was full of lint and stated he had cleaned it earlier but had not documented it. The Laundry Supervisor stated the lint trap screens are supposed to be cleaned every two hours and documented on the log sheet. Kitchen staff also failed to keep the snack refrigerator temperature log current. An observation showed the log was not up to date, with missing entries for two dates. Staff stated it was their responsibility to check and document refrigerator temperatures, and the Dietary Supervisor stated temperatures are to be checked and documented per shift. The DON stated the refrigerator temperatures should be checked and documented to ensure food does not spoil. Direct care staff did not consistently use PPE for residents on EBP. Resident 12 had diagnoses including heart failure, diabetes mellitus, and dementia, and records showed the resident lacked capacity to understand and make decisions and was dependent with ADLs. Resident 12 was on EBP for stasis ulcers, yet the DSD was observed repositioning the resident without PPE. Resident 79, who had diagnoses including a left tibia fracture, anemia, and muscle weakness, was also dependent with ADLs. Resident 79’s caregiver was observed leaving the room and walking down the hallway to the dirty linen cart without removing PPE. The caregiver stated she had not been educated about PPE use, and the IP stated PPE is not to be worn in the hallway and should be removed in the room.
Failure to Follow Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol for two sampled residents, Resident 54 and Resident 66. Resident 54 was admitted and later readmitted with diagnoses including cerebral infarction and HTN. His MDS dated 2/28/2026 indicated intact cognition for daily decision making and dependence with toileting, bathing, and dressing. An order dated 2/25/2026 showed Levaquin 250 mg by mouth daily for a UTI, and the Infection Surveillance Form dated 3/1/2026 documented that Resident 54 was asymptomatic and did not meet McGeer's criteria for antibiotic usage. Resident 66 was admitted with diagnoses including HTN and Alzheimer's Disease. His MDS indicated severely impaired cognition and need for supervision with ADLs. An order dated 2/6/2026 showed Macrobid 100 mg twice a day for a UTI. During a concurrent interview and record review on 3/25/2026, the IPN stated that Resident 54 and Resident 66 did not meet McGeer's criteria and that neither resident's doctor was informed, although they should have been. The DON stated on 3/27/2026 that when a resident does not meet McGeer's criteria, the doctor should be notified to possibly discontinue the antibiotic. The facility's policies stated that antibiotics are to be prescribed and administered under the antibiotic stewardship program and that McGeer's criteria are used to determine infection.
Insufficient Room Size and Space in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure adequate room size and space to support the comfort and well-being of one sampled resident, Resident 59, and failed to ensure 6 of 26 residents' rooms met the required square footage for multiple-occupancy rooms. During a concurrent observation and interview, Resident 59 was seen at bedside with a TV stand blocking access to the left side of the bed and preventing the resident from maneuvering a wheelchair to that side. Resident 59 stated the room was too small and that the TV stand had to be moved to allow access to the bed. Resident 59 was admitted with diagnoses including hemiplegia, diabetes mellitus, and difficulty walking, and records showed intact cognition and substantial/maximal assistance needed with ADLs, with wheelchair use for mobility. The facility's room measurement analysis dated 3/25/2026 showed six 4-bed rooms measuring 292.87, 306.40, 308.81, 307.20, 310.22, and 310.22 square feet. During interviews, a CNA stated the room was small and that the TV stand had to be moved every time care was provided on the left side of the bed, with safety concerns related to the limited space. The plant supervisor stated the room did not meet the 80 square feet per resident requirement and described safety hazards and tripping concerns with smaller rooms. The Administrator stated she was aware some rooms were smaller and that there were safety concerns because residents could bump into things when there was not enough space.
Failure to Notify Physician of Resident's New Wandering Behavior
Penalty
Summary
The facility failed to notify the physician when a resident exhibited new wandering behavior, which was a change in condition. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and depression, and was assessed as having severe cognitive impairment and lacking decision-making capacity, was found outside the facility by a nurse. This incident was not communicated to the physician as required by the facility's policy, which states that the physician must be notified of any accident or incident involving a resident. Multiple staff interviews confirmed that the resident had a history of wandering and aggressive behavior when denied certain items, such as hot chocolate. The lack of physician notification resulted in the resident's wandering behaviors not being addressed, which subsequently led to a physical altercation between this resident and another. The staff and another resident reported that the wandering resident would take food and drinks from others and from carts, and that this behavior was known among staff. The Assistant Director of Nursing acknowledged that the physician should have been notified of the new behavior, specifically when the resident was found outside the facility, and that failure to do so could delay care.
Failure to Prevent Resident-to-Resident Abuse and Address Behavioral Risks
Penalty
Summary
The facility failed to protect two residents from abuse when they became involved in a physical altercation. One resident, who had moderate cognitive impairment and diagnoses including major depressive disorder and heart failure, did not receive their prescribed Trazodone for three consecutive days. This medication was intended to address depression and insomnia, and the lack of administration was not documented or explained in the Medication Administration Record. Staff interviews confirmed that missing this medication could result in restlessness, agitation, or other safety concerns, and there was no evidence that adverse effects or side effects were being monitored during this period. Another resident, with severe cognitive impairment and a history of schizoaffective disorder and depression, exhibited wandering behaviors and frequently took items from snack carts and other residents. These behaviors were known to staff but were not communicated to the provider or addressed in the resident's care plan. Multiple staff members confirmed the resident's pattern of wandering and taking food, and the resident had previously attempted to leave the facility. Despite this, there was no evidence that the care plan was updated to address these behaviors or that interventions were implemented to mitigate the risks associated with them. On the evening of the incident, the resident with wandering behaviors took milk and belongings from the other resident, leading to a physical confrontation. Video footage confirmed that one resident made a fist and struck the other, who then retaliated by punching the first resident in the face, resulting in a visible bruise. The facility's policies required that care plans be updated as residents' conditions changed and that safety risks, including unsafe wandering, be addressed. However, these policies were not followed, contributing to the altercation and resulting injury.
Failure to Monitor Psychotropic Medication Use and Maintain Informed Consent
Penalty
Summary
The facility failed to ensure that a psychotropic medication, Trazodone, was not used unnecessarily for a resident by not monitoring the behaviors for which the medication was prescribed, not monitoring for adverse effects, and not maintaining an active informed consent for its administration. Specifically, for three consecutive days, there was no documentation of the resident's hours of sleep during the evening shift, which was required to assess the effectiveness of Trazodone prescribed for depression manifested by insomnia. Additionally, the Medication Administration Record did not show that adverse effects or side effects were being monitored as required. The resident involved had a history of major depressive disorder, moderate cognitive impairment, and required varying levels of assistance with daily activities. The responsible party for the resident was the resident's brother. The facility's own policies required written informed consent for psychotropic medications to be renewed every six months, but the resident received Trazodone for over three weeks without an active informed consent. Staff interviews confirmed the lapses in documentation and monitoring, and the Assistant Director of Nursing acknowledged the importance of these procedures for resident safety and rights.
Failure to Update Care Plan for New Wandering Behavior
Penalty
Summary
The facility failed to update the care plan for a resident who developed new wandering behaviors. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and depression, and was assessed as having severe cognitive impairment and lacking decision-making capacity, was observed wandering within and outside the facility. Despite being found outside the facility and displaying behaviors such as taking items from snack carts and other residents' belongings, the care plan was not revised to address these new behaviors. Multiple staff interviews confirmed that the resident was known to wander and could become aggressive if not given desired items. On one occasion, the resident entered another resident's room and took personal belongings, which led to a physical altercation. The facility's own policies require care plans to be updated when there is a change in a resident's condition or behavior, and to address safety risks such as unsafe wandering. However, after the incident of the resident being found outside, there was no documented update to the care plan to address the wandering behavior, as confirmed by the Assistant Director of Nursing and review of the medical record.
Failure to Ensure Nurse Competency in Medication Administration
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) was competent in medication administration upon hire, as required by facility policy. Review of the employee file showed that the LVN was hired on 5/14/2025, but the only competency checklist present was dated 9/2/2025, indicating that a medication administration competency was not completed at the time of hire. The facility's policy requires competency evaluations upon hire, annually, and as needed, specifically including medication management. Interviews with the Director of Staff Development and Assistant Director of Nursing confirmed that the medication competency should have been completed upon hire to assess the nurse's skills and address any deficiencies immediately. As a result of this lapse, a resident with diagnoses including urinary tract infection, heart failure, and major depressive disorder did not receive scheduled doses of Trazodone for three consecutive days. Review of the Medication Administration Record (MAR) for August 2025 showed no documentation of Trazodone administration on 8/23, 8/24, and 8/25, and interviews with nursing staff confirmed that the documentation was blank for those dates. The absence of documentation meant there was no proof the medication was administered, and staff acknowledged that missing doses could affect the resident's condition.
Failure to Provide Medical Records Upon Request
Penalty
Summary
A deficiency occurred when the facility failed to provide medical records upon request to a resident's responsible party (RP). The responsible party submitted a written request for access to the resident's protected health information, which was received by the Medical Records Director (MRD). Despite this, the MRD did not follow through with the request, resulting in a delay of at least 10 months without the records being provided or any update correspondence sent to the responsible party. The MRD acknowledged forgetting about the request and recognized that this was a violation of the resident's rights, as records are required to be provided within 30 days of the request. The resident involved had a history of chronic obstructive pulmonary disease (COPD), chronic diastolic heart failure, and ischemic heart disease, and was assessed as having moderately impaired cognition but retained the ability to understand and make decisions. The facility's policy and procedure for release of information required that records be transmitted within 15 calendar days after receiving a written request. The failure to provide the requested records in a timely manner was confirmed through interviews and record review, with the responsible party expressing feelings of distrust and concern due to the lack of response from the facility.
Failure to Ensure Timely Physician Visits
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including Type 2 diabetes, dementia, anemia, and peripheral vascular disease, did not receive required physician visits. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was last seen by a physician on 9/6/2024, as confirmed by a review of the admission record and physician visit documentation. Interviews with facility staff, including the QA nurse and the DON, confirmed that the resident had not been seen by a physician within the required timeframe, with the DON stating that the last visit occurred in September 2024. The facility's policy requires physician visits at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, in accordance with state and federal regulations. This lapse in physician visits was directly observed through record review and staff interviews.
Failure to Protect Resident from Repeated Verbal Abuse by Roommate
Penalty
Summary
The facility failed to protect a legally blind resident from repeated verbal abuse by another resident. The abusive resident, who had a history of cerebral infarction and paranoid personality disorder, was documented as having intact cognition but exhibited aggressive and disruptive behaviors, including yelling, cursing, and using profanity towards roommates. Multiple care plans were in place for this resident, focusing on physical abuse and risk for violence, with interventions such as behavioral analysis and calm approaches, but these measures did not prevent ongoing verbal aggression. Incident records and staff interviews confirmed that the abusive resident frequently yelled at and cursed at roommates, particularly targeting the legally blind resident, making him feel unsafe and uncomfortable. Other residents and staff corroborated the pattern of verbal aggression, with reports of bullying, random outbursts, and altercations in shared spaces, especially the bathroom. Staff expressed concerns for the safety of residents sharing a room or bathroom with the aggressive resident, suggesting that he should be housed alone. The facility's policy on abuse prevention clearly states residents' rights to be free from all forms of abuse, including verbal and mental abuse, but the policy was not effectively implemented in this case, resulting in a failure to protect vulnerable residents from repeated verbal abuse.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, as observed during a survey. In the kitchen, there was no trash receptacle next to the handwashing sink, which is necessary for disposing of used paper towels without contaminating clean hands. The trash can was reportedly left outside for cleaning, and its foot pedal was broken, requiring staff to use their hands to open the lid, thus risking contamination. A dietary aide in the dishwashing area did not follow proper hand hygiene protocols. The aide was observed rinsing soiled dishes, then rinsing her gloved hands, and proceeding to handle clean dishes without washing her hands or changing gloves. This practice was repeated multiple times, and the aide acknowledged the mistake, understanding that it could lead to contamination of clean dishes. Several food items in the facility's refrigerator were stored improperly. Puddings and sour cream were kept beyond their recommended storage periods, and nutritional supplements that were recalled due to potential listeria contamination were stored with a 'do not use' sign but remained accessible. Additionally, unpasteurized shell eggs were used for residents' meals, and thawed turkey deli meat was refrozen, which could affect food quality. Furthermore, the sanitizer solution used for cleaning food contact surfaces was found to be ineffective, as it was not tested properly before use, leading to unsanitized surfaces.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to potential risks for residents. Specifically, Resident 54's Humalog KwikPen, used for managing diabetes, was not labeled with an 'open date,' making it impossible to determine its expiration. This oversight was discovered during an observation and interview with an LVN, who acknowledged the absence of the open date and the associated risk of administering expired insulin, which could lead to hyperglycemia. Additionally, the facility did not maintain the required storage temperatures for medications in two medication room refrigerators. Observations revealed that medications requiring refrigeration were stored at 50°F, exceeding the manufacturer's recommended range of 36°F to 46°F. This included various medications such as insulin, antibiotics, and other critical drugs, which were found in both Station 1 and Station 2 medication room refrigerators. LVNs acknowledged the improper storage temperatures and the potential for medications to become unsafe or ineffective. The Director of Nursing confirmed the importance of maintaining proper storage temperatures to ensure medication safety and effectiveness. The facility's policies and procedures also emphasized the need for proper labeling and storage of medications according to manufacturer recommendations. However, the failure to adhere to these guidelines resulted in the potential for adverse health consequences for residents due to the administration of expired or improperly stored medications.
Failure to Return Resident's Personal Items After Laundering
Penalty
Summary
The facility failed to ensure that a resident's personal items were returned after laundering, resulting in the loss of the resident's blankets and the receipt of blankets that did not belong to him. The resident, who was admitted with multiple diagnoses including hypertension, bladder cancer, Alzheimer's dementia, diabetes mellitus, and dysphagia, was dependent on nursing staff for various personal care tasks. The resident's family member reported that a blanket brought for the resident, which was labeled with his name, was lost after being washed, and the resident received two blankets with other residents' names instead. Interviews with facility staff revealed that there was a lack of proper procedures in place to ensure the correct return of laundered items. A CNA mentioned that she was instructed to return the resident's blankets if found in other residents' rooms, but was unsure if the blankets were found. An LVN confirmed the family's complaint about the missing blankets and stated that items should be returned to the correct resident. A housekeeper noted that sometimes laundry staff mixed up residents' blankets, and these were mistakenly placed in donation closets. The Registered Nurse Supervisor acknowledged that the missing blanket should have been reported to Social Services for replacement or reimbursement. The facility's policy indicated that residents' belongings should be treated with respect and any complaints of misappropriation should be promptly investigated.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 319, which had the potential to compromise the resident's safety and personal needs. Resident 319 was admitted with multiple diagnoses, including multiple myeloma, difficulty walking, muscle weakness, and dementia, which severely impaired his cognitive abilities. The Minimum Data Set (MDS) indicated that Resident 319 required substantial assistance with activities of daily living. During an observation, it was noted that the call light was wrapped around the siderail of the bed, which was in a down position, making it inaccessible to the resident. The Director of Staff Development (DSD) confirmed during an observation and interview that the call light was not within reach and emphasized its importance for communication and emergency assistance. The Director of Nursing (DON) also stated that the call light should be accessible to prevent falls and injuries. The facility's policy on answering call lights requires staff to ensure that the call light is plugged in, functioning, and accessible to residents at all times, which was not adhered to in this case.
Failure to Implement Individualized Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan with measurable objectives, timeframe, and interventions for a resident, identified as Resident 38. This resident was admitted with diagnoses including ovarian cancer, type 2 diabetes mellitus, and hypertension. The Minimum Data Set indicated that the resident's cognition was intact, and she required substantial assistance with Activities of Daily Living. A Change of Condition report noted that the resident had right leg swelling and redness, and was prescribed medication for cellulitis. However, the resident's RNA Treatment Administration Record showed non-participation in restorative nursing treatments for 16 days in February, with refusals and unavailability noted on specific dates. The care plan for Resident 38, dated late February, indicated non-compliance with the RNA program, citing multiple reasons for non-participation. The care plan goals and interventions included educating the resident on the risks and benefits of refusing services and offering RNA services at various times. During interviews, it was revealed that the resident refused to walk due to leg pain, and the Director of Nursing acknowledged that the care plan was not appropriate for the resident's identified concerns. The facility's policy requires comprehensive, person-centered care plans with measurable objectives, which was not met in this case.
Improper Administration of Psychotropic Medication Without Diagnosis
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident by administering the psychotropic drug Seroquel without a documented medical diagnosis to support its use. The resident, who was admitted with various medical conditions including unspecified schizophrenia and vascular dementia with agitation, was given Seroquel for delirium and later for schizophrenia manifested by hallucinations. However, the Minimum Data Set (MDS) and other records did not indicate a diagnosis of schizophrenia or other psychiatric disorders, which is necessary to justify the use of such medication. The Medication Regimen Review conducted by the consultant pharmacist did not identify the lack of a corresponding medical diagnosis for the administration of quetiapine. Instead, the review noted the potential adverse effects of the medication, such as the risk of type II diabetes and hyperlipidemia. The facility's policy requires that psychotropic medications be prescribed only when clinically indicated to treat a specific, documented condition, which was not adhered to in this case. Interviews with the Quality Assurance Licensed Vocational Nurse (QA LVN) revealed that the Medical Records Supervisor entered the diagnosis of schizophrenia into the resident's records based on instructions from the Director of Nursing, rather than a physician's evaluation. The QA LVN acknowledged that this practice was incorrect and that the resident should not have been on quetiapine without a proper diagnosis, as it posed risks of adverse effects and could negatively impact the resident's function, especially given the resident's existing dementia.
Failure to Ensure Proper Denture Care for a Resident
Penalty
Summary
The facility failed to ensure proper denture care for Resident 29, who was admitted with multiple diagnoses including hypertension, bladder cancer, Alzheimer's dementia, diabetes mellitus, and dysphagia. The resident's care plan, dated 3/8/2023, indicated a goal of maintaining adequate oral/dental hygiene, with nursing staff responsible for providing good mouth care. However, observations and interviews revealed that Resident 29's dentures were not being cleaned or stored properly in a denture container, as required by the facility's policy. During interviews, Resident 29's family member expressed concerns about the lack of oral care and improper storage of dentures. Certified Nursing Assistant (CNA) 4 confirmed that Resident 29's dentures were not stored in a denture cup and that cleaning tablets were not available at the bedside. Licensed Vocational Nurse (LVN) 6 also noted the absence of a denture container and cleaning tablets, stating that the facility had run out of the necessary supplies. The Registered Nurse Supervisor (RNS) acknowledged the oversight and confirmed that all nursing staff were responsible for ensuring dentures were cleaned and stored correctly. The facility's policy on denture care, revised in 3/2028, outlined the procedures for cleaning and storing dentures to prevent infections and protect them from damage. Despite this policy, the facility failed to provide the necessary equipment and supplies, such as denture cups and cleaning tablets, to ensure Resident 29's dentures were properly maintained. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Maintain IV Catheters According to Standards
Penalty
Summary
The facility failed to maintain intravenous (IV) catheters for two residents, Resident 20 and Resident 318, in accordance with professional standards of practice. For Resident 20, the IV catheter was not removed in a timely manner after the completion of IV therapy. The IV therapy was completed on February 5, 2025, but the catheter remained in place as observed on February 25, 2025. The Registered Nurse Supervisor (RNS) confirmed that the catheter should have been removed after the therapy was completed, acknowledging that IV sites are potential sources of infection. For Resident 318, the facility failed to rotate the IV site every 72 hours as required. The IV site, placed on February 14, 2025, was observed on February 25, 2025, without having been changed. The RNS stated that while an IV site can remain longer than 72 hours, it requires daily monitoring and documentation to ensure there are no signs of infection or complications. The Director of Nursing (DON) reiterated the importance of rotating IV sites every 72 hours to prevent infection and complications due to the fragility of veins. Both residents had specific care plans indicating the need for regular monitoring and rotation of IV sites to prevent complications such as infection, phlebitis, and embolism. The facility's policy and procedure for Peripheral IV Catheter (PIVC) and Site Selection also emphasized the need for site rotation based on prescribed therapies and potential complications. The failure to adhere to these standards posed a risk of infection at the IV insertion sites for both residents.
Inadequate Training Leads to Improper BP Monitoring
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) was adequately trained and knowledgeable in conducting blood pressure (BP) checks for a resident before administering hydralazine, a medication used to treat hypertension. The LVN attempted to check the resident's BP using a monitor but placed the cuff incorrectly on the resident's right forearm instead of the upper arm. The LVN was unable to find the BP reading and sought assistance from the Director of Staff Development (DSD), who corrected the placement of the cuff. However, the LVN was initially unaware of the correct procedure and the importance of checking BP on the appropriate arm, especially considering the resident's medical conditions. The resident, who had essential hypertension, end-stage renal disease, and was dependent on renal dialysis, had specific physician orders for hydralazine administration based on BP parameters. The LVN initially checked the BP on the wrong arm, which had a dialysis port, increasing the risk of inaccurate readings and potential harm. The DSD later intervened and instructed the LVN to check the BP on the left arm, which was free of the dialysis port, resulting in a different BP reading. Despite the corrected reading, the resident refused the medication, citing a misunderstanding of the physician's orders. Interviews with the LVN, DSD, and Director of Nursing (DON) revealed gaps in training and competency assessments for BP monitoring. The LVN's training was provided by a registry, and the facility had not conducted recent educational in-services on BP monitoring. The facility's policy and procedure for measuring BP emphasized the correct placement of the cuff and the importance of notifying supervisors if a resident refused treatment. The deficiency highlighted the potential for medication errors and adverse health outcomes due to improper BP monitoring and lack of staff training.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and manufacturer specifications for two residents. Resident 37, who was admitted with diagnoses including hypertension and hyperlipidemia, was prescribed an 81 mg chewable aspirin tablet for stroke prevention. During medication administration, the Licensed Vocational Nurse (LVN) did not instruct Resident 37 to chew the aspirin tablet, resulting in the resident swallowing it whole. This action was contrary to the physician's order and the manufacturer's instructions, potentially affecting the medication's absorption and efficacy. Resident 367, who had diagnoses including disorders of bone density and difficulty walking, was prescribed a 125 mcg Vitamin D3 capsule. The LVN did not have the capsule formulation in stock and needed to clarify with the physician if a tablet formulation could be used. The Vitamin D3 was administered two hours later than the scheduled time, which was not in accordance with the facility's policy that requires medications to be administered within 60 minutes of the prescribed time. This delay in administration was acknowledged by the LVN during an interview. The Director of Nursing (DON) confirmed that the facility staff should have ensured the chewable aspirin was administered correctly and that the Vitamin D3 order was clarified with the physician to prevent delays. The facility's policy on medication administration emphasizes that medications should be administered as prescribed and within the specified time frame to ensure their intended effect.
Failure to Identify Medication Irregularities in Resident's Drug Regimen Review
Penalty
Summary
The facility and consultant pharmacist failed to identify irregularities during the medication regimen review (MRR) for a resident, leading to the administration of Seroquel (quetiapine) without a proper medical diagnosis or indication. The resident, who was admitted with various diagnoses including sepsis, acute cystitis, encephalopathy, and vascular dementia, was prescribed Seroquel for delirium and later for schizophrenia manifested by hallucinations. However, the Minimum Data Set (MDS) did not indicate any psychiatric or mood disorders such as schizophrenia, which should have been a prerequisite for such medication. The consultant pharmacist's review on February 11, 2025, failed to identify that the resident was receiving quetiapine without a corresponding medical diagnosis of a psychiatric disorder. Instead, the pharmacist noted the potential side effects of the medication, such as type II diabetes and hyperlipidemia, and recommended periodic lab tests. This oversight resulted in the resident receiving the medication unnecessarily, which could have led to adverse side effects and impacted the resident's well-being. During an interview, the Quality Assurance Licensed Vocational Nurse (QA LVN) confirmed that the resident was receiving quetiapine for schizophrenia due to hallucinations, despite the lack of a documented diagnosis. The facility's policy and procedures for medication regimen reviews emphasize the importance of identifying and resolving medication-related problems, including the use of medications without clinical indication. The failure to adhere to these guidelines resulted in the resident being at risk for various side effects and complications due to the unnecessary administration of quetiapine.
Unnecessary Psychotropic Drug Use Without Diagnosis
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 22, was free from the use of unnecessary psychotropic drugs. The resident was administered Seroquel (quetiapine fumarate), a medication used to treat schizophrenia, without a corresponding medical diagnosis to support its use. The resident's Minimum Data Set (MDS) did not indicate any psychiatric or mood disorders such as schizophrenia, anxiety, depression, or bipolar disorder, which are typically required to justify the use of such medication. The resident was admitted with various diagnoses, including sepsis, acute cystitis, encephalopathy, and vascular dementia with agitation, but not schizophrenia. Despite this, the facility's Physician Order Summary Report indicated that Seroquel was prescribed for schizophrenia manifested by hallucinations. The Medication Regimen Review (MRR) failed to identify the lack of a psychiatric diagnosis, and the medication was administered multiple times without proper justification. During an interview, the Quality Assurance Licensed Vocational Nurse (QA LVN) acknowledged that the resident should not have been on quetiapine without a corresponding diagnosis, as it placed the resident at risk for adverse effects. The facility's policy on psychotropic medication use clearly stated that such medications should only be prescribed when clinically indicated to treat a specific condition diagnosed and documented in the medical record. This oversight in medication management led to the deficiency identified in the report.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration, resulting in an error rate of 11.54%. This deficiency was observed in the cases of three residents. For Resident 54, the facility did not label the Humalog insulin pen with an 'open date,' which is necessary to ensure the medication is not expired before administration. The Licensed Vocational Nurse (LVN) was unable to determine the expiration date of the insulin, leading to a delay in administration as a new pen had to be retrieved. Resident 37 was prescribed chewable aspirin to prevent stroke, but the LVN failed to instruct the resident to chew the tablet, resulting in the resident swallowing it whole. This oversight could affect the absorption and effectiveness of the medication. The LVN acknowledged the error and stated that the aspirin should have been separated from other medications and administered as chewable. For Resident 367, there was a delay in administering Vitamin D3 due to the unavailability of the prescribed capsule formulation. The LVN needed to clarify with the physician whether a tablet formulation could be used, resulting in the medication being administered two hours later than scheduled. This delay was contrary to the facility's policy, which requires medications to be administered within 60 minutes of the prescribed time.
Inadequate Training of Kitchen Staff on Sanitizer Use
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in their duties, specifically regarding the use of sanitizer test strips for the dish machine. During an observation, a Dietary Aide (DA1) was unable to identify the correct sanitizer test strip to use for the dish machine and was unaware of the concentration strength of the chlorine sanitizer. DA1 attempted to use QUAT sanitizer test strips instead of the correct chlorine test strips, indicating a lack of knowledge and training. DA1 also admitted to not knowing where the test strip container was located and had used the last test strip without reporting it to the Dietary Supervisor (DS). Further observations revealed that DA1 did not know how to check the dish machine sanitizer concentration or the normal range for the sanitizer concentration. The facility's policy and procedure for dishwashing required that a chlorine log be maintained to ensure the dish machine was functioning correctly, with a specified chlorine level of 50-100 PPM. The job description for dishwashers included the ability to operate the dish machine and knowledge of sanitary requirements. The lack of training and competency in these areas had the potential to result in unsafe and unsanitary food production, putting 60 out of 62 residents at risk for foodborne illness.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to observe proper infection control measures during the care of a resident with a history of osteomyelitis, type 2 diabetes mellitus, and a partial traumatic amputation of the left foot. During an observation of wound care for this resident, the treatment nurse did not perform hand hygiene between glove changes on four occasions. This lapse in protocol occurred despite the resident's condition requiring careful management to prevent infection. Interviews with the treatment nurse and the Director of Nursing confirmed the oversight in hand hygiene practices. The treatment nurse acknowledged the failure to perform hand hygiene, attributing it to a mistaken belief that she had not touched her gloves. The Director of Nursing reiterated the importance of hand hygiene between glove changes to prevent cross-contamination. The facility's policy on hand hygiene, which emphasizes its role in preventing healthcare-associated infections, was not adhered to during this incident.
Failure to Monitor Antibiotic Use for a Resident
Penalty
Summary
The facility failed to complete a Surveillance Data Collection form for a resident who was prescribed Keflex, an antibiotic, to treat a urinary tract infection (UTI). The resident, who had a history of recurrent UTIs, diabetes mellitus, bronchitis, and dementia, was admitted and readmitted to the facility with these diagnoses. The resident was prescribed Keflex from January 23, 2025, to January 30, 2025, but the necessary documentation to monitor the antibiotic use was not completed. The Infection Preventionist Nurse (IP) admitted to not documenting the resident's antibiotic use in the Antibiotic Stewardship binder and failing to check the resident's Nursing Progress Notes for signs and symptoms of infection. The IP also did not verify the resident's antibiotic order for Keflex or check the urine culture and sensitivity results. The IP acknowledged that if the Surveillance Data Collection form had been completed, it would have been evident that the resident did not meet the criteria for starting the antibiotic for a UTI. The facility's policy on Antibiotic Stewardship and Surveillance for Infections outlines the procedures for monitoring antibiotic use and identifying infections. However, these procedures were not followed in this case, as the IP missed the resident's antibiotic order and failed to document the necessary information. This oversight had the potential to put the resident at risk for antibiotic resistance and inappropriate antibiotic use.
Failure to Provide Dementia Care Training
Penalty
Summary
The facility failed to ensure that staff received necessary training for dementia care, which is crucial for the safety and well-being of residents with dementia. During interviews, two Certified Nurse Assistants (CNAs) admitted they had not received dementia training, despite providing care to residents with dementia. They emphasized the importance of such training to appropriately approach and communicate with these residents, who may become agitated or combative if not handled properly. The Director of Staff Development (DSD) confirmed that dementia care training was scheduled for January but was not conducted, and new staff had not received the required training. The facility's assessment and policy documents indicated that dementia management training is mandatory for nurse aides, with initial training upon hire and ongoing in-services. However, the DSD acknowledged the failure to provide the scheduled training, which is essential for ensuring that CNAs have the skills to deliver proper care. The lack of training could potentially lead to physical and mental harm to residents, as staff may not know how to approach residents with dementia appropriately.
Inaccurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information posted was accurate, which resulted in residents and visitors being unable to verify safe staffing ratios. On 2/25/2025, the staffing information was observed to be posted near Nurses Station One. However, during a review on 2/28/2025, discrepancies were found between the posted staffing information and the Nursing Staffing Assignment and Sign-In-Sheet for several dates, including 2/5/2025, 2/8/2025, 2/19/2025, 2/20/2025, and 2/22/2025. The Director of Staff Development (DSD) acknowledged that the posted staffing was not updated to reflect actual staffing changes, such as staff call-offs, and agreed that the discrepancies should have been addressed. The DSD also noted that the quality of care suffers without accurate posted staffing information.
Facility Exceeds Resident Room Occupancy Limit
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to four, as observed in rooms [ROOM NUMBER] and 34, which housed five residents each. This was identified during an initial tour on February 26, 2025, at 10:00 a.m. The Client Accommodations Analysis form, provided by the facility's Maintenance Supervisor, confirmed the occupancy of five residents in these rooms. Despite the facility's Room Waiver letter dated February 28, 2025, which stated that the rooms provided ample space for mobility and care, the occupancy exceeded the regulatory limit. The rooms were noted to have sufficient space per bed, exceeding the required 80 square feet per bed, and no adverse effects on residents' privacy, health, or safety were observed during the survey period from February 25 to February 28, 2025.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 8 out of 17 resident rooms met the required 80 square feet per resident in multiple resident rooms. Specifically, Rooms 20, 21, 22, 23, 25, 26, 27, and 32 did not meet this requirement. This deficiency was identified during an initial tour and confirmed through a record review of the Client Accommodations Analysis form provided by the facility's Maintenance Supervisor. Despite a Room Waiver letter from the Administrator indicating that residents and caregivers had ample space for mobility and care, the rooms did not meet the specified size requirement. Observations during the survey period noted that other resident rooms had sufficient space for movement and care provision, with no adverse effects on residents' privacy, health, or safety observed due to room size.
Failure to Notify Physician of Medication Noncompliance
Penalty
Summary
The facility failed to notify the physician about a resident's noncompliance with taking Risperidone, a medication prescribed for bipolar disorder. The resident, who was admitted with diagnoses including malignant neoplasm of the right breast, schizophrenia, anxiety disorder, and bipolar disorder, was noted to have severely impaired cognitive skills for daily decision-making. The Medication Administration Record (MAR) indicated that the resident refused Risperidone twice in July and nine times in August, and spit out the medication three times during this period. Despite these refusals, there was no documented evidence that the physician was informed of the resident's noncompliance. Interviews with the Director of Staff Development and the Director of Nursing confirmed the lack of notification to the physician, which was against the facility's policy. The facility's policy required that repeated refusals of medication be reported to the Director of Nursing Services and the physician, with detailed documentation of the refusal, including the date and time, the medication, the resident's response, and the physician's notification and response. The failure to notify the physician of the resident's medication refusal could potentially delay necessary alternative treatment measures.
Failure to Develop Care Plan for Noncompliant Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who exhibited noncompliance with care, including refusing medications and meals. The resident, who was admitted with diagnoses of malignant neoplasm of the right breast, schizophrenia, anxiety disorder, and bipolar disorder, was noted to have severely impaired cognitive skills for daily decision-making. Despite these challenges, the facility did not have a care plan addressing the resident's noncompliance, which was identified during a review of the resident's records and interviews with facility staff. The deficiency was highlighted during an interdisciplinary team meeting where it was noted that the resident had episodes of refusing care, including wound care and general hygiene, even with family present. Interviews with the Director of Staff Development and the Director of Nursing confirmed the absence of a care plan to address the resident's behavior issues. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables, which was not implemented for this resident.
Failure to Document Edema Assessment
Penalty
Summary
The facility failed to provide quality care in accordance with professional standards of practice by not assessing a resident's lower extremities edema after it was identified. The resident, who had a medical history including type 2 diabetes, hypertension, and atherosclerosis, was noted to have 4+ pitting edema in both legs. Despite this significant finding, there was no documented assessment of the edema in the resident's medical records from July to August, as confirmed by a Licensed Vocational Nurse (LVN) during an interview. The LVN stated that the edema assessment should have included documentation of the location, whether it was pitting or nonpitting, the grade of the edema, and pedal pulses. The Director of Staff Development (DSD) and the Director of Nursing (DON) both acknowledged that if the assessment was not documented, it was not done, and emphasized the importance of documenting such assessments to monitor the resident's condition. The facility's policy and procedure required ongoing assessments and documentation of any abnormalities, including edema, in the resident's medical record.
Failure to Order Correct Diagnostic Test
Penalty
Summary
The facility failed to ensure that a resident's echocardiogram was completed as ordered, resulting in a delay of care. The resident, who was admitted with diagnoses including type 2 diabetes, hypertension, difficulty walking, and atherosclerosis of the aorta, had an order for an echocardiogram to assess heart function and its potential contribution to lower extremity edema. However, due to an error by a registered nurse, an electrocardiogram was ordered instead of the required echocardiogram. The facility's policy and procedure for diagnostic services, which mandates that orders for such services be promptly carried out, was not followed. The facility's policy also states that clinical radiology services should be available 24/7 to meet residents' needs. This oversight in ordering the correct diagnostic test led to a delay in diagnosing a potential heart problem for the resident.
Failure to Inspect Hand Sink Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the hand sink in a resident's bathroom was inspected during daily rounds by the maintenance staff and/or the facility's administrative staff. This resulted in the hand sink detaching from the wall and falling to the floor when the resident placed her hands on it while washing her face. The resident fell to the floor and sustained a left hip fracture, a bump with discoloration to her left eye, and a bump with discoloration to the left side of the back of her head. The resident, who had a history of cerebral infarction, dementia, glaucoma, and a history of falling, required moderate to maximal assistance for activities of daily living. On the day of the incident, the resident was being supervised by a Certified Nursing Assistant (CNA) when the sink fell off the wall. The CNA stated that the resident landed on her left hip and bumped the left side of her head. The Maintenance Supervisor and the Administrator both stated that they were not aware of any problems with the hand sink prior to the incident. The facility's policy and procedure indicated that the maintenance department is responsible for maintaining the building in good repair and free from hazards. However, the daily rounds conducted by the maintenance staff failed to identify the issue with the hand sink. The incident investigation summary and interviews with staff revealed that the sink falling off the wall was unexpected and that the maintenance staff had not reported any issues with the sink prior to the incident.
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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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