Barton Hospital D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in South Lake Tahoe, California.
- Location
- 2170 South Avenue, South Lake Tahoe, California 96150
- CMS Provider Number
- 555698
- Inspections on file
- 23
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Barton Hospital D/p Snf during CMS and state inspections, most recent first.
Wheelchair Armrests Found Cracked and Exposed: Three residents who used wheelchairs were observed with cracked arm pads and exposed foam on their wheelchair armrests. The PT, CNA, IP nurse, and DON confirmed the arm pads were not in good repair, could be uncomfortable, and were expected to be reported or replaced; the facility policy stated equipment should be routinely monitored for damage that could hinder function or create uncleanable surfaces.
Morphine administration times did not match between the MAR and the CDR for a resident receiving scheduled morphine for chronic pain. The MAR showed the narcotic was given at 9 p.m., while the CDR documented it was administered 1 hour and 10 minutes early on two occasions. The DON and PSQN stated the MAR and CDR times are supposed to match for narcotic oversight and that giving a narcotic more than an hour early was not acceptable.
Medication Storage and Labeling Deficiencies: An expired eye drop medication was still being administered to a resident with dry eyes, an open hydrocortisone cream lacked an open date, and another resident’s vitamin C bottle had an illegible expiration date. In addition, a treatment cart was left unlocked and unattended in the hall with multiple prescription creams and ointments that were unlabeled, undated, or expired, making them accessible to residents and visitors.
Food Storage and Kitchen Sanitation Deficiencies: A resident's refrigerator contained expired butter, opened juice without proper dating or labeling, and an opened jar of mayonnaise without dates or labels. In the kitchen, food prep utensils were stored in a bin with crumbs and debris. The DM, IP, and DON all confirmed the items and areas were not maintained as expected, and facility policy required opened food to be dated or discarded and kitchen items to be kept clean.
Failure to maintain dryer lint compartment cleanliness: Surveyors observed a thick layer of lint in the dryer lint trap compartment during a laundry room tour. The IP Nurse and DES both confirmed the lint buildup and could not provide documentation of routine lint removal. The facility had no formal schedule for inspecting or cleaning the dryer lint compartment, and the linen room cleaning policy did not include specific guidance for dryer maintenance.
A resident with Alzheimer's disease and no decision-making capacity had a POLST indicating DNR status, but the form was not signed by the court-appointed Public Guardian and required sections were left blank. The DON and DPSQ confirmed the POLST was incomplete, and staff stated the guardian participated by phone in a care conference but did not want to sign the DNR POLST. Physician notes referenced the resident as full code on the POLST before later documenting review with the ethics committee and public guardian.
A resident’s private medical information was displayed on an unattended medication cart computer screen in a hallway, including MAR details such as code status and medications. The LPN stated she had only partially closed the screen flap and acknowledged it was a breach of privacy, while the DON stated staff are expected to lock the screen when leaving the cart so the information is not visible to visitors or other residents.
Failure to obtain ordered monthly weights for a resident with Alzheimer’s disease and Crohn’s disease. The resident was at risk for weight loss and had an order for monthly weights, but the WVS showed missed weights in two months and documented weight declines. During observation, the resident had a partially eaten pureed meal at the bedside, and staff confirmed the expectation was to weigh the resident monthly using a Hoyer lift.
A resident with a urinary catheter returned from the hospital after treatment for a UTI, but the catheter was not included in the care plan, there were no provider orders for catheter care, no TAR documentation for catheter cleaning, and no urine output amounts were charted. An LN and the DON both confirmed the missing documentation, and the DON stated staff would not be aware the resident had a catheter and needed catheter care.
Unnecessary Psychotropic Medication Use Without Documented Diagnosis: A resident received Citalopram for depression even though the clinical record, MDS assessments, and psychotropic medication reviews did not document depression or related symptoms. The resident was cognitively intact, denied feeling depressed or hopeless, and staff described her as calm and pleasant. The DON and pharmacy consultant confirmed the diagnosis was not reflected in the resident’s profile.
A resident with dementia, a history of frequent falls, and recent hip arthroplasty aftercare was assessed as high fall risk and had orders for a bed pad alarm and chair clip alarm, along with a care plan for staff-assisted ambulation and transfers. The care plan did not address the resident’s poor safety awareness or specify hourly checks, even though the resident could not reliably use a call light. On the day of the incident, the resident, who required one-person assistance for all walking and transfers, was found by an LPN ambulating unassisted in the hallway without a walker, became unsteady, and fell, striking his head and right side. Staff reported that the bed pad alarm, which had been activated earlier by a CNA, did not sound when the resident got up. The resident sustained a displaced right femur fracture with intramuscular hemorrhage and was transferred to the ED and then airlifted for further care, later being placed on comfort care and dying a few days after the fall. The DON stated that pad alarms were assumed to function for 30 days without routine checks and could not explain why this alarm failed, and surveyors also observed another high-risk resident’s bed alarm sounding without staff present in the hall or at the nurses’ station.
Two residents with dementia were involved in a witnessed altercation, resulting in one being hit on the head and the other sustaining bleeding skin tears. Although staff provided first aid, required assessments and documentation of the injuries were not completed in the clinical record, contrary to facility policy. Interviews and record reviews confirmed the lack of proper documentation and assessment following the incident.
A resident with Alzheimer's disease and dementia, identified as high risk for falls and requiring supervision, was left unattended by a CNA who did not inform other staff. The resident subsequently experienced an unwitnessed fall, resulting in a hip fracture that required surgery and skilled nursing care. Staff interviews and documentation confirmed the need for continuous supervision, which was not provided.
A resident with moderate memory impairment was struck in the face by her roommate, who had a documented history of behavioral disturbances and was under one-on-one supervision by a Patient Safety Technician. Despite this supervision, the aggressive resident was able to approach and hit the other resident, who was sitting at the foot of her bed. The incident was witnessed by staff and met the facility's definition of abuse.
Wheelchair Armrests Found Cracked and Exposed
Penalty
Summary
The facility failed to ensure that wheelchairs were maintained in safe condition when three sampled residents were found with cracked and exposed wheelchair armrests. Resident 13 was admitted with diagnoses including a right artificial hip joint, polymyalgia rheumatica, and chronic pain, and was dependent on a wheelchair and walker; her care guide stated she frequently used her wheelchair for short distances. During observation, her wheelchair arm handles were found cracked with exposed foam inside the cushion, and she confirmed the wheelchair was uncomfortable and wanted it changed. Resident 30 was admitted with diagnoses including a history of falling and failure to thrive and was dependent on a wheelchair and walker; his care guide stated he was often found propelling his wheelchair around the facility. During observation and interview, his wheelchair arm handles were found cracked with exposed foam, and he stated he preferred the arm handles not be cracked to avoid his arm being pinched. Resident 43 was admitted with diagnoses including pain in the right knee, a right artificial knee joint, and chronic pain, and was dependent on a wheelchair and walker; her care guide stated she used a wheelchair for mobility and should be encouraged to use it instead of a walker due to severe knee pain. Her wheelchair arm handles were also observed cracked with exposed foam, and she and a family member agreed the condition could cause discomfort or skin issues and should be replaced. The PT, CNA, IP nurse, and DON all confirmed the cracked and exposed arm pads were not in good repair and were expected to be reported or replaced, and the facility policy stated equipment should be routinely monitored for damage that could hinder function or result in uncleanable surfaces.
Morphine administration times did not match between MAR and controlled drug record
Penalty
Summary
The facility failed to ensure the administration time for morphine on the MAR matched the Controlled Drug Record for one sampled resident. Resident 5 was admitted in 2022 with diagnoses including chronic pain and osteomyelitis. Her order summary dated 3/27/25 showed morphine sulfate extended release 15 mg, two tablets by mouth at bedtime for chronic pain, and her March 2026 MAR showed the morphine was scheduled for 9 p.m. The MAR documented that two tablets of morphine were given at 9 p.m. on 3/29/26 and 3/31/26, but the CDR for those same dates showed the morphine was administered at 7:50 p.m., 1 hour and 10 minutes before the scheduled time. During interview, the DON and PSQN stated the administration window was one hour before or after the MAR time, that the MAR and CDR times are supposed to match for oversight of narcotic medications, and that it was not acceptable to administer a narcotic more than an hour early.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medications and biologicals were not stored and labeled in accordance with accepted professional principles. During observation and interview, Resident 17’s artificial tears eye drops were found with an expiration date of 4/5/26 written on the box, and the LN confirmed the drops were expired because the facility considered eye drops expired 30 days after opening. The MAR showed the resident continued to receive the eye drops through the morning of 4/8/26. Resident 17 had been admitted in 2024 and had an order for artificial tears, 2 drops twice daily for dry eyes. Resident 20, also admitted in 2024, had an order for vitamin C 500 mg daily, and the bottle of ascorbic acid had a smudged, illegible expiration date. An open tube of hydrocortisone cream 1% for general resident use was found without an open date, and the LN confirmed it had been opened but not dated. The LN stated the medication was available for resident use if ordered by the physician, and the facility’s posted guide on the cart stated that all items were to be dated and initialed when opened. During interview, the DON stated that hydrocortisone creams were to be labeled upon opening and that if they were not labeled, they should be discarded because no one would know whether the medication was expired. A treatment cart containing prescription ointments and creams was left unlocked and unattended in the hall, accessible to residents and visitors. Treatment Cart 1 contained multiple items in an unlocked drawer, including a tube of mupirocin 2% ointment without a resident name, an unlabeled and undated tube of Premarin 0.625 mg cream, an unlabeled and undated tube of permethrin 5% cream with an expiration date of 5/2025, a tube of betamethasone dipropionate ointment with an expiration date of 5/31/25, and three tubes of lubricating jelly with an open date of 10/8/2024. The LN acknowledged the cart was unlocked and accessible, and the DON stated treatment carts containing medicated ointments and creams should never be left unlocked.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored and prepared in accordance with professional standards for food service safety in a facility with a census of 45. During an observation of a resident's refrigerator, surveyors found a one-gallon plastic bag of expired individual butters with an expiration date of 3/20/26, a bottle of cranberry cocktail juice with an open date of 12/10/25, an opened bottle of cranberry juice that was undated and unlabeled, and an opened jar of mayonnaise that was also undated. During a concurrent interview, LN 4 confirmed the unlabeled and outdated items and stated resident food from home was expected to be labeled so residents would be safe. LN 3, CNA 1, the DM, DA 1, and the DON each stated food should be labeled, dated, and not expired, and that expired items should be removed from the refrigerator. The facility policy titled Food handling and storage from outside SNF stated opened food would remain in the refrigerator for no more than 7 days and anything without a name and/or date would be immediately discarded. During a kitchen inspection tour, food preparation utensils were found stored in a metal bin with crumbs and debris. The DM confirmed the utensils were lying in debris and stated the bin was expected to be clean and free of debris. The IP stated crumbs and debris in clean and sanitized areas were not safe and could harbor bacteria that could make a resident sick. The DON stated crumbs and debris should not be inside a clean area to avoid illness to residents. The facility policy titled Departmental Safety: Food Service stated dishes should be kept clean and serviceable and stored properly in the kitchen service area.
Failure to Maintain Dryer Lint Compartment
Penalty
Summary
The facility failed to maintain electrical equipment in a safe condition when it did not routinely remove lint buildup from the dryer in the laundry room. During a tour of the laundry room on 4/9/26 at 2:45 p.m., accompanied by the Infection Prevention Nurse, surveyors observed a thick layer of lint accumulation in the lint trap compartment of the dryer. The Infection Prevention Nurse stated the lint trap was to be cleaned on a regular basis to remove lint accumulation, but she was unable to provide documentation or a log confirming routine lint removal. She also stated she did not inspect the laundry room for cleanliness and that the laundry room was managed by the Director of Environmental Services. During a concurrent observation and interview with the Director of Environmental Services on 4/9/26 at 3:02 p.m., the Director acknowledged the lint compartment had lint accumulation and stated it looked like it had not been cleaned that day. The Director stated the dryer needed to be inspected and cleaned of lint accumulation every day, but was unable to provide documentation or a log confirming routine lint removal. The Director confirmed the facility did not have a formalized schedule requiring routine inspection and cleaning of the dryer lint compartment, and stated there were no documents available showing when the last inspection of the dryer lint compartment was done. Review of the facility policy titled, Clean Linen Room Cleaning Procedure, dated 11/5/21, showed the purpose was to maintain the linen room in a clean, safe, sanitary and outstanding condition, but it did not include specific procedures or guidance for routine cleaning and maintenance of laundry equipment, including dryers, to prevent lint accumulation.
Incomplete POLST for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure the POLST for a resident with Alzheimer's disease and hearing loss was properly completed with the signature of the resident's Public Conservator. The resident had been admitted in 2019 and was documented by physician order on 9/23/19 as lacking capacity to make decisions, with the [County] Public Guardian listed as the surrogate decision maker. A Letter of Conservatorship dated 1/2/2020 identified the Public Guardian as the court-appointed conservator with exclusive authority to consent for medical treatment. The resident's clinical record contained a POLST indicating DNR status, signed by two physicians on 12/20/22. However, Section D did not list the required name, did not indicate whether the DNR status was discussed with the legally recognized decisionmaker, and did not contain the signature of the resident's legally recognized decisionmaker. The POLST instructions stated that a legally recognized decisionmaker may include a court-appointed conservator or guardian and that the POLST must be signed by a physician and the patient or decisionmaker to be valid. During interviews, LN 3 stated the POLST must be signed by the physician and public guardian when the resident lacks capacity and has no identified family members. The DON and DPSQ reviewed the form and validated that it was not completed properly and was not signed by the appointed Public Guardian. The DON stated the code status was changed to DNR after a care conference in which the Public Guardian participated by phone, but the Public Guardian did not want to sign the POLST and did not want to take responsibility. Physician progress notes referenced the resident as currently full code on the POLST and later noted review with ethics committee and the public guardian, after which the resident was changed from full code to DNR.
Unattended Medication Cart Screen Exposed Resident Medical Information
Penalty
Summary
The facility failed to maintain confidentiality for one resident when an unattended medication cart computer screen was left open in the hallway and displayed private medical information. During a concurrent observation and interview, the screen showed a section of the resident’s MAR, including his code status and medications. The resident had been admitted with diagnoses including chronic kidney disease and gangrene of the left foot, and his MDS indicated a BIMS score of 14 out of 15, showing intact cognition. His admission packet, signed on 4/6/26, included resident rights related to the confidentiality of information, including medical records. During the observation, the LPN who had been administering medications returned to the cart and stated she had partially closed the computer screen flap to conceal the resident’s medical information. She stated she should not have left the unattended computer screen open and that it was a breach of privacy because visitors or other residents could view the resident’s medications. The DON stated nurses are expected to lock the computer screen each time they leave the cart to administer medications, which blanks out the screen, and stated the LPN violated HIPAA by exposing the resident’s private health information to anyone walking down the hallway. The facility policy stated staff are expected to secure patient records containing individually identifiable health information so they are not readily available to those who do not need them.
Failure to Obtain Ordered Monthly Weights
Penalty
Summary
The facility failed to ensure a physician’s order was followed for one sampled resident who was ordered to be weighed monthly. The resident was admitted in Fall 2024 with diagnoses including Alzheimer’s disease and Crohn’s disease, and the MDS dated 3/12/26 indicated the resident did not have the capacity to make decisions and was at risk for weight loss. The order summary dated 4/10/26 directed staff to weigh the resident monthly and have CNAs document the weights in the plan of care. The Weight and Vital Summary dated 4/10/26 showed the resident was not weighed in December 2025 or February 2026, and it also reflected a 13 lb. 4 oz. decline in December 2025 and a 3 lb. 4 oz. decline in February 2026. During observation, the resident was found with a partially eaten pureed diet at the bedside, and a CNA stated the resident was on a pureed diet and had not been eating that day. Staff interviews confirmed the expectation was to obtain monthly weights using a Hoyer lift, and the DON stated monthly weights were expected when ordered and were important for monitoring weight changes.
Missing Catheter Orders, Care Plan, and Output Documentation
Penalty
Summary
Appropriate care for a resident with an indwelling urinary catheter was not provided when catheter placement and catheter care were not included in the resident’s care plan, orders, treatment record, or urine output log. The resident was admitted with diagnoses including removal of the left cancerous kidney and acute right kidney failure, and had been hospitalized for a UTI before returning to the facility with a urinary catheter inserted by the hospital to monitor exact urine output. The interim care plan noted only that the resident had an indwelling urinary catheter, with no further information, and the care plan report later showed no goal for catheter care. Record review also showed no medical orders for catheter care, no catheter care documentation in the TAR, and no urine output amounts entered in the urinary output log from the resident’s return through the date of review. During interview, an LN stated the catheter order was not in the record and that there was nowhere to document catheter care in the TAR, and the DON confirmed the order, care, and urine output amounts were missing. The DON stated the orders should have been entered soon after the resident’s readmission and that staff would not be aware the resident had a catheter and needed catheter care because it was not in the care plan.
Unnecessary Psychotropic Medication Use Without Documented Diagnosis
Penalty
Summary
The facility failed to ensure that psychotropic medication use was supported by a documented, clinically appropriate indication for one resident who was receiving Citalopram. Resident 6 was admitted in 2024 with diagnoses including high blood pressure, diabetes mellitus, and a right upper arm fracture. The resident’s record showed an order for Citalopram 10 mg daily for depression as manifested by hopelessness and lack of interest, and the medication had previously been started at 40 mg daily and then gradually reduced to 30 mg, 20 mg, and 10 mg. A review of the resident’s clinical record, physician admission history, and multiple physician progress notes did not show depression listed as a diagnosis. The resident’s MDS assessments also did not identify depression, and the mood assessments indicated a depression score of 00 with no reported symptoms such as little interest in doing things or feeling down, depressed, or hopeless. Psychotropic Medication Evaluations from June 2025 through December 2025 likewise documented 0 episodes of hopelessness and lack of interest and did not include depression as the diagnosis or required indication for Citalopram. During observation and interview, Resident 6 was pleasant, cognitively intact, and stated she did not think she had depression. She explained that she preferred staying in her room, doing puzzles and crosswords, listening to the news, and sometimes attending activities, and she denied feeling hopeless or lacking interest in life. Nursing staff described her as calm, pleasant, quiet, and not observed crying or expressing depression. The DON confirmed that the resident’s records did not include a diagnosis of depression, that depression was not listed on the MDS assessments, and that residents receiving antidepressants were required to have a documented diagnosis of depression reflected in the clinical profile; the pharmacy consultant also stated that any resident receiving antidepressant therapy was required to have a documented diagnosis of depression listed in the profile.
Failure to Adequately Supervise High-Risk Resident and Reliance on Non-Functioning Bed Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent an avoidable fall for a resident identified as high risk for falls. The resident was admitted with multiple diagnoses including aftercare following right hip arthroplasty, dementia, and a history of frequent falls. The resident’s fall risk evaluation showed a high fall risk score, and the admission MDS documented severely impaired cognitive status. Physician orders included use of a bed pad alarm every shift and a clip alarm while in a wheelchair. The fall risk care plan identified the resident as at risk for falls, with goals to reduce falls and injuries and interventions such as staff assistance with ambulation and transfers, use of bed pad and clip alarms, and environmental evaluation for fall risks. However, the care plan did not address the resident’s poor safety awareness and did not include hourly checking and monitoring, despite the resident’s inability to use a call light and impaired cognition. On the day of the incident, the resident was observed by staff ambulating in the hallway directly outside his room without an assistive device or staff assistance, despite having poor balance and requiring one-person assistance for all walking and transfers. According to the post-fall evaluation, the resident was unsteady, not using his walker, lost his balance, and fell to the right, landing on his right side and hitting the back of his head. Staff reported that the bed pad alarm, which was intended to alert them when the resident attempted to get out of bed, did not sound when the resident got up unassisted. The DON and LN stated that the resident’s bed pad alarm did not go off, and the DON acknowledged that staff were supposed to round on residents every hour, especially those at high risk for falls, but these visual checks were not documented. A CNA reported that earlier that day the resident had been up in a wheelchair for a long time, appeared very tired, and was transferred to bed with the bed pad alarm activated, as indicated by two short beeps. Following the fall, the resident was noted to be in significant pain, unable to move his lower extremities, and was transferred to the ED. ED documentation and CT imaging revealed a displaced fracture of the right femur with associated intramuscular hemorrhage and severe deformity of the right femur. The resident was subsequently airlifted to another hospital for further evaluation and treatment and was later placed on comfort care and died three days after the fall. Interviews with the PT indicated that, although the resident had become stronger with therapy, he still required staff assistance with transfers and had poor balance, with difficulty standing and a tendency to fall backward earlier the same day. The DON stated that pad alarms did not require routine functionality checks and were assumed to work for 30 days, and the facility was unable to determine why the alarm did not activate when the resident got up. During a tour of another hall, surveyors also observed another high fall risk resident with a bed pad alarm sounding and a call light blinking without staff present in the hallway or at the nursing station, demonstrating reliance on alarms without immediate staff response. A requested policy addressing resident safety, supervision, and accident prevention was not provided.
Failure to Protect Residents from Abuse and Inadequate Documentation of Injuries
Penalty
Summary
The facility failed to protect two residents from abuse during an altercation in which one resident hit another on the head, and the second resident responded by grabbing the first resident's forearm, causing skin tears. Both residents had a history of dementia and moderate cognitive impairment, as indicated by their BIMS scores and care plans, which included interventions for resident-to-resident altercations. Staff witnessed the incident in the dining room, and it was documented that first aid was administered to the resident who sustained skin injuries. Despite the incident and the facility's policy requiring a full head-to-toe assessment and documentation of any injuries following abuse, there was no evidence in the clinical record that the resident's skin injuries were assessed or documented. The nursing staff did not record the location, measurements, or description of the injuries, nor did they document the treatment provided, as required by facility protocol. The DON and a licensed nurse confirmed that the assessment and documentation were missing from the resident's clinical record, despite expectations and policy. Observations and interviews with both residents confirmed the occurrence of the altercation and the resulting injuries. The resident who sustained the skin tears described the incident and the resulting pain and bleeding, while the other resident was unable to recall the event due to memory impairment. Staff interviews corroborated the sequence of events and the lack of proper documentation following the incident.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
Staff failed to provide adequate supervision to a resident with Alzheimer's disease and dementia, who was identified as high risk for falls. The resident's care plan specifically instructed staff not to leave her unattended due to her tendency to attempt self-transfers. Despite these instructions, a CNA left the resident alone at the nurse's station while responding to another call light, without notifying other staff members. At the time, all other staff were occupied in other rooms, leaving the resident unsupervised. As a result of being left unattended, the resident experienced an unwitnessed fall, which led to a left hip fracture. The resident required surgical intervention and subsequent skilled nursing care for pain management and rehabilitation. Facility records, including the resident's MDS, fall risk assessment, and care guide, all indicated the need for supervision and highlighted the resident's history of multiple falls. Interviews with staff and the interim DON confirmed that the resident should have been supervised at all times, especially during meals, and acknowledged that the fall could have been prevented with proper supervision.
Resident Struck by Roommate Despite One-on-One Supervision
Penalty
Summary
A deficiency occurred when a resident with moderate memory impairment was struck in the face by her roommate, who had a history of behavioral disturbances, including physical aggression toward staff and other residents. At the time of the incident, the aggressor was under one-on-one supervision by a Patient Safety Technician (PST), yet was able to approach and hit the other resident, who was sitting at the foot of her bed near the doorway. The PST witnessed the event but was positioned behind and to the side of the aggressor, which did not prevent the physical contact. The aggressor's medical history included dementia with behavioral disturbances, psychosis, and Alzheimer's disease, and prior documentation noted multiple instances of striking staff. The facility's policy required an environment free from abuse, but the incident was confirmed by the Interim Director of Nursing to meet the facility's definition of abuse. The resident who was struck reported pain and frustration, noting that the one-on-one supervision in place did not prevent 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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