Highland Park Skilled Nursing And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 5125 Monte Vista St., Los Angeles, California 90042
- CMS Provider Number
- 555165
- Inspections on file
- 32
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Highland Park Skilled Nursing And Wellness Center during CMS and state inspections, most recent first.
A resident with toxic encephalopathy, depression, impaired safety awareness, and severe mobility limitations, who had a documented history of elopement and multiple recent elopement attempts, was not adequately supervised or protected despite care plan identification of elopement risk. On the day of the incident, staff noted increased confusion and observed the resident trying to open an exit door, but no 1:1 observation, wander guard, or enhanced monitoring was implemented, and staff instead attempted to block the exit with a medication cart. The resident was last seen in her room at lunchtime and was later found missing, having exited through a door opened for visitors, in contrast to facility policies requiring individualized elopement risk interventions and person-centered monitoring systems.
A resident with multiple chronic conditions was administered Ativan without a specific behavioral indication in the physician's order, and staff failed to monitor or document the resident's behaviors and side effects as required by facility policy. Interviews and record reviews confirmed that the MAR and MPDM forms lacked necessary documentation, and staff did not follow protocols for psychotropic medication management.
A resident with end-stage renal disease missed a scheduled hemodialysis treatment due to transportation issues, and the facility failed to arrange alternate transportation. Additionally, the resident was not monitored for fluid overload, and blood pressure medications were not administered as ordered. These failures led to the resident experiencing severe symptoms, requiring transfer to a hospital for emergency treatment.
A resident with multiple health conditions had medications left unattended on their bedside table by an LVN, contrary to facility policy. The resident was not approved for self-administration, and the medications were left unlabeled and uncovered, posing a risk of accidental ingestion by others. Staff confirmed this practice was against policy, which requires medications to be stored in the medication cart if refused.
The facility did not update the Daily Posted Nurse Staffing information from 2/14/2025 to 2/25/2025, as required by its policy. An observation on 2/25/2025 revealed that the posted staffing information was outdated by eight days. RN 1, covering for the DON, confirmed the lapse and acknowledged the importance of daily updates to ensure adequate staffing for resident care.
The facility failed to maintain the dignity and privacy of two residents. A resident with Alzheimer's was fed by a CNA who stood instead of sitting at eye level, violating the facility's policy. Another resident with an indwelling catheter had their urinary collection bag uncovered, contrary to the facility's requirement for dignity bags to ensure privacy. These actions did not align with the facility's policies aimed at promoting resident dignity and respect.
The facility failed to accurately assess the MDS for two residents, omitting diagnoses of anxiety and depression despite evidence of these conditions and prescribed medications. This oversight could hinder the development of individualized care plans, as confirmed by staff interviews and record reviews.
The facility failed to provide necessary respiratory services for three residents, leading to potential health risks. A resident with COPD was not given the prescribed continuous oxygen therapy, and their equipment was not properly labeled. Another resident's nebulizer equipment was improperly stored, and a third resident received excessive oxygen, contrary to physician orders.
The facility failed to follow proper food storage and dish sanitization practices. Several food items were improperly labeled or stored, with some past their use-by dates, and the dishwasher was operated below the required temperature. These deficiencies could lead to foodborne illness among residents.
The facility failed to maintain proper waste management as two dumpsters were observed with overflowing trash, causing the lids to remain open. The Maintenance Supervisor confirmed that the facility policy required trash to be compressed to keep lids closed, preventing the attraction of pests. The Waste Management policy indicated that waste containers must be closable and food waste should be placed in covered garbage cans.
The facility failed to update care plans for two residents. One resident's fall care plan was not revised after a fall with injury, despite being at high risk for falls. Another resident's care plan was not updated to reflect a new fluid restriction order. Both failures were acknowledged by facility staff, highlighting a lack of adherence to policies requiring care plan updates following changes in condition or physician orders.
A resident with dementia and mobility issues experienced a fall with a head injury, but the facility failed to conduct a Post Fall Evaluation, neuro checks, or an IDT meeting as required by their policy. The ADON confirmed these actions were not taken, despite the facility's Fall Management Program outlining these necessary steps.
A resident with an indwelling urinary catheter did not receive appropriate care as per physician's orders, leading to delayed identification of a potential UTI. Despite observations of sediment and concentrated urine, there was no documentation or physician notification, contrary to facility policy. The resident's medical history included conditions that increased UTI risk.
A facility failed to monitor the fluid intake of a resident on dialysis with a fluid restriction, leading to a deficiency. The resident's fluid intake exceeded the prescribed limits, and there was no record of fluid intake with medication administration. Staff were unaware of the fluid restriction, and facility policies were not followed, posing a risk of fluid overload or dehydration.
A resident with multiple diagnoses, including dementia and psychosis, was left with eight medications unattended on their nightstand by an IPN, contrary to facility policy. The resident was not approved for self-administration, and the IPN admitted to leaving the medications due to a disruption. This failure to supervise medication administration posed a risk of medication errors and potential harm.
A facility failed to act on a pharmacy consultant's recommendations during a Medication Regimen Review for a resident with type 2 diabetes, depression, and dementia. The review identified issues with medication administration, including the concurrent use of Saxagliptin and Sitagliptin, missing 'Do not crush' instructions for Ferrous Sulfate, and incorrect timing for Repaglinide. The facility lacked a designated staff member to review and follow up on these recommendations, resulting in no action being taken.
The facility did not ensure daily temperature checks of the Activity Room Refrigerator, which stored food brought by family for a resident, as required by policy. The temperature log lacked entries for several days, and the Dietary Services Supervisor confirmed the oversight.
The facility failed to meet the required 80 square feet per resident in 12 out of 22 rooms, with measurements ranging from 64.6 to 76.6 square feet per resident. Despite the deficiency, residents reported comfort, and observations showed adequate space for mobility aids and care provision. The Department recommended a waiver for the affected rooms.
A resident with severe cognitive impairments and multiple diagnoses, including malnutrition, refused more than 50% of meals for three consecutive times. The facility failed to notify the physician as required by policy, which considered this a Change of Condition (COC). The Director of Nursing confirmed the oversight, which could delay necessary care for the resident.
The facility failed to promote dignity for two residents by not covering a urinary catheter bag and standing above a resident while feeding. Staff acknowledged the importance of these actions for resident dignity, but they were not followed.
The facility failed to provide necessary ADL care and communication devices for two residents. One resident with severe cognitive impairment was not given a communication device in their primary language and was improperly positioned in bed. Another resident faced communication barriers due to the lack of a communication device in their preferred language. Staff interviews and observations confirmed the absence of required communication tools and proper positioning, leading to deficiencies in care.
The facility failed to ensure a safe environment for two residents, leading to potential risks for falls, injuries, and delayed care. One resident's room was cluttered, impeding emergency access, while another resident's overhead trapeze setup posed entanglement and injury risks. Staff acknowledged these hazards, but the facility's safety policies were not adequately followed.
The facility failed to ensure sanitary conditions in food storage and preparation, with issues including an oven with an unreadable temperature knob and improperly labeled or expired food items in the kitchen and dry storage.
The facility failed to follow its Antibiotic Stewardship protocol, leading to the inappropriate administration of antibiotics to two residents who did not meet the McGeer's Criteria. The physician was not notified of the residents' screening scores, resulting in unnecessary antibiotic use.
The facility failed to provide education, offer, and document the updated COVID-19 vaccinations for the year 2023-2024 for 96 out of 105 employees. Interviews and record reviews revealed incomplete documentation and lack of a clear process for notifying all employees about the vaccination clinic, placing residents and staff at risk for possible COVID-19 infection.
The facility failed to ensure that the call light was within reach of three residents, leading to a potential delay in the provision of services and assistance with ADLs. The call lights for these residents were found in inaccessible locations, contrary to their care plans and facility policy.
The facility failed to accurately document a resident's eating ability on the MDS. Despite being assessed as needing substantial/maximal assistance, the resident was observed eating independently with minimal assistance. Staff interviews confirmed the resident's ability to feed herself, highlighting a discrepancy in the MDS documentation.
The facility failed to accurately complete the PASRR form for a resident with schizophrenia, leading to the resident not receiving necessary psychiatric treatment. Despite medical records indicating a diagnosis of schizophrenia and the use of psychotropic medications, the PASRR forms were incorrectly marked as negative. Interviews with staff revealed lapses in the submission and verification process of the PASRR forms.
The facility failed to update the care plan for a resident with a history of seizures, despite changes in prescribed seizure medications. The care plan did not reflect all current medications, which was acknowledged by both the Registered Nurse Supervisor and the Director of Nursing.
A resident was found hiding Colace capsules to avoid taking too much medication, leading to a failure in proper medication administration as per the facility's policy. The DON confirmed that nurses must observe residents taking their medications to prevent double dosing or missed doses.
The facility failed to ensure a shower chair used by residents was in good condition and free from stains. A CNA was observed using a stained and worn-out shower chair, which was confirmed by the RNS, MS, and DON to be unsuitable for use. The facility's policy emphasized providing a safe, clean, and comfortable environment, which was not upheld in this instance.
The facility failed to post accurate nurse staffing information at the start of each shift, as required by its policy. The Director of Staff Development admitted that the information had not been updated since 3/24/2024 and was unsure of the required format.
The facility failed to ensure that 12 out of 22 resident rooms met the required 80 square feet per resident in multiple resident bedrooms. Despite the deficiency, residents reported feeling comfortable and having enough space for their belongings and mobility aids. The Department recommended approval of a room waiver request for the 12 rooms in question.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise, monitor, and implement safety measures for a resident with known elopement risk and cognitive impairment, resulting in an elopement. The resident was admitted with diagnoses including toxic encephalopathy, depression, difficulty walking, and lack of coordination, and had intermittent ability to understand and make decisions. Therapy notes documented that the resident was unsteady when walking and standing, required substantial/maximal assistance to walk ten feet, had a mobility function score of 0, and had impaired safety awareness. The care plan identified the resident as being at risk for decline in functional status and safety concerns during daily care tasks, and also documented a history of elopement at home and prior elopement or attempted leaving the facility without informing staff. On the day of the incident, the resident’s Change of Condition note indicated an increase in confusion that was a persistent change from usual cognitive function and documented that the resident had attempted to elope multiple times prior to the successful elopement. The resident was last seen in her room at 12:30 PM when lunch was delivered, and at 1:05 PM a CNA noted the resident was not in the room when picking up the lunch tray. By approximately 1:20 PM, staff determined the resident was missing and activated a code yellow. Interviews revealed that earlier that day the RN observed the resident attempting to open the exit door and redirected her back to her room after 12:30 PM, and the RN reported that the resident had tried to elope at least four times prior to successfully leaving. The RN stated a huddle was called to inform staff, including the primary CNA, to be more vigilant in watching the resident, although the primary CNA later reported not recalling this huddle, while another CNA confirmed it occurred. Staff interviews and policy review showed that the facility did not implement enhanced monitoring or safety devices consistent with the resident’s identified elopement risk and change in condition. The DON acknowledged that if staff knew the resident was attempting to exit through the door, the resident would be at risk for elopement and that the physician should have been notified to obtain an order for a wander guard. The DON also stated the resident should have been closely monitored with staff visually seeing the resident at all times or placing the resident on 1:1 observation, and that these interventions were not implemented. The RN reported that despite multiple elopement attempts, the resident did not have a 1:1 sitter, and staff instead tried to block the exit door with a medication cart. The facility’s wandering and elopement and resident safety policies required assessment of elopement risk, development of a person-centered care plan, and establishment of observation or monitoring systems, including more frequent safety checks when indicated, but the resident was able to leave through the exit door when visitors exited and was not observed by staff as she left.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drug use, specifically Ativan, by not providing a specific indication for its use and not monitoring for manifested behaviors or side effects as required by facility policy and care plan. The resident in question had multiple diagnoses, including congestive heart failure, dementia, and diabetes mellitus, and was assessed as having severely impaired cognitive skills and being dependent on staff for all activities of daily living. The care plan indicated the resident had episodes of agitation and anxiety, with interventions to administer medications as ordered and monitor for side effects and effectiveness, as well as to document behaviors and potential causes. Record reviews revealed that the physician's order for Ativan lacked a specific manifested behavior for restlessness, which was necessary for accurate monitoring and administration. Interviews with the DON, LVN, MDS Nurse, and ADON confirmed that the order did not specify the required behavioral manifestations, and that staff did not document or monitor the resident's specific behaviors or side effects associated with Ativan use. The Medication Administration Record (MAR) and Monthly Psychoactive Drug Management (MPDM) forms did not reflect any monitoring for the resident's behavior or side effects during the period when Ativan was administered. Facility policies required that any order for psychoactive medications include a specific behavior manifestation and that residents be monitored for side effects and adverse consequences, with all occurrences documented monthly. Staff interviews and record reviews confirmed that these policies were not followed, resulting in incomplete and inaccurate documentation regarding the resident's behavior and medication use. This failure to follow established protocols led to the deficiency cited in the report.
Failure to Ensure Timely Hemodialysis and Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received necessary hemodialysis treatment as scheduled, which was critical due to the resident's end-stage renal disease. On the day of the scheduled treatment, the transportation company contracted by the resident's insurance was unable to provide a driver, resulting in the resident missing the dialysis appointment. Despite multiple calls to the transportation company, no alternate transportation was arranged, even though a list of backup transportation options was available at the nurses' station. Additionally, the facility did not transcribe the physician's order to monitor the resident for signs and symptoms of fluid overload after the missed dialysis treatment. This oversight meant that the resident was not adequately monitored for potential complications arising from the missed treatment. Furthermore, the resident's blood pressure medications were not administered as ordered, which could have helped manage the resident's hypertension after the dialysis was canceled. As a result of these failures, the resident experienced shortness of breath, chest pain, and elevated blood pressure later that day, necessitating transfer to a general acute care hospital. The hospital records indicated that the resident suffered from acute fluid overload, bilateral pleural effusions, and pulmonary edema, requiring immediate medical intervention, including hemodialysis and other treatments to stabilize the resident's condition.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing a Licensed Vocational Nurse (LVN) to leave medications unattended on a resident's bedside table. This incident involved a resident with multiple diagnoses, including end-stage renal disease, hypertension, atrial fibrillation, and diabetes mellitus. The resident, who had intact cognition but required supervision for certain activities, was not approved for self-administration of medications. Despite this, medications were left at the bedside, posing a risk of accidental ingestion by other residents. During an observation, it was noted that the medications were left unlabeled and uncovered on the bedside table. Both a Certified Nurse Aide and an LVN confirmed the presence of the medications and acknowledged that leaving them unattended was against facility policy. The Registered Nurse Supervisor also confirmed that medications should not be left at the bedside and should be stored in the medication cart if refused by the resident. The facility's policies emphasized the importance of maintaining a safe environment and outlined procedures for handling medication refusals, which were not followed in this instance.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Posted Nurse Staffing information was updated and posted in accordance with its policy from 2/14/2025 to 2/25/2025. During an observation on 2/25/2025, it was noted that the Census and Direct Care Service Hours Per Patient Day (DHPPD) form displayed was dated 2/12/2025, indicating that the information had not been updated for eight days. This lapse was confirmed during an interview and record review with RN 1, who was covering for the Director of Nursing (DON) in her absence. RN 1 acknowledged that the DHPPD should be updated and posted daily at the beginning of each shift, and the failure to do so meant that the staffing information for the current day was not available. The facility's policy, titled Nursing Department - Staffing, Scheduling & Postings, revised on 1/22/2025, mandates that the facility post specific staffing information daily. This includes the facility name, current date, total number, and actual hours worked by registered nurses, licensed vocational nurses, and certified nurse aides, as well as the resident census. The policy emphasizes the importance of calculating projected and actual staffing hours to ensure adequate staffing levels for resident care. The failure to adhere to this policy had the potential to leave residents and visitors uninformed about the facility's staffing and census, as well as hinder the facility's ability to address staffing shortages effectively.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents by not adhering to its own policies. For Resident 35, who has Alzheimer's disease and severely impaired cognitive skills, the facility's policy requires staff to sit at eye level while assisting with feeding to avoid intimidating the resident. However, during an observation, CNA 2 was seen standing while feeding Resident 35, contrary to the facility's Restorative Dining Program policy. This policy aims to improve mealtime behavior, self-image, and socialization skills for residents who are unable to feed themselves. For Resident 43, who has an indwelling catheter due to obstructive uropathy, the facility's policy mandates that urinary collection bags be covered with a dignity bag to maintain the resident's privacy and dignity. During an observation, Resident 43's catheter bag was found uncovered, and CNA 1 confirmed the absence of a dignity bag. The Director of Nursing acknowledged that the facility's policy requires catheter bags to be covered to ensure residents' dignity and respect, as outlined in the facility's Resident Rights - Quality of Life policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments of the Minimum Data Set (MDS) for two residents, leading to potential issues in developing and implementing individualized care plans. Resident 42 was admitted with diagnoses including dementia with agitation, mood disturbance, psychotic disturbance, and anxiety disorder. However, the MDS did not reflect the anxiety disorder diagnosis, despite the resident being prescribed Buspirone for anxiety. Interviews with staff confirmed the resident exhibited anxiety symptoms, such as screaming and repetitive movements, which were not documented in the MDS. Similarly, Resident 49 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), anxiety, and depression. The MDS for this resident also failed to include the active diagnoses of anxiety and depression, even though the resident was prescribed medications like Buspirone, Sertraline, and Trazadone for these conditions. The psychological evaluation indicated moderately severe depressive symptoms and severe anxiety symptoms, yet these were not reflected in the MDS assessments. The MDS Nurse acknowledged the omissions in both cases, stating that the MDS should accurately reflect the residents' diagnoses to ensure proper care and monitoring. The facility's policy on the Resident Assessment Instrument (RAI) process emphasizes the importance of accurate assessments, which was not adhered to in these instances, potentially affecting the residents' overall well-being.
Failure to Administer Prescribed Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory services for three residents, leading to potential health risks. Resident 49, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), anxiety, and depression, was not administered the prescribed 2 to 3 liters per minute (LPM) of continuous oxygen therapy as indicated in the physician's order. During an observation, it was noted that Resident 49's oxygen concentrator was off, and the resident was not receiving any oxygen therapy, contrary to the physician's order for continuous administration. Additionally, the plastic respiratory equipment bag containing the nasal cannula tubing was not labeled or dated, which is against the facility's infection control policy. Resident 21, who also had COPD and other pulmonary conditions, had their nebulizer equipment improperly stored. The nebulizer, nebulizer cup, and aerosol mask were observed unbagged on the bedside table, which is a violation of the facility's policy requiring respiratory equipment to be stored in a labeled and dated bag to prevent contamination and infection. Resident 54, diagnosed with COPD and respiratory failure, was administered oxygen at a rate of 5 to 6 LPM, exceeding the physician's order of 2 to 3 LPM. This discrepancy was confirmed by a licensed vocational nurse who acknowledged the error and the potential harm of administering excessive oxygen, especially for a resident with COPD. The facility's policy mandates that oxygen be administered as prescribed, and deviations from this can lead to serious complications, including respiratory acidosis.
Improper Food Storage and Dish Sanitization Practices
Penalty
Summary
The facility failed to adhere to its food storage and handling policies, as observed during a survey. Several food items in the facility's kitchen were found to be improperly labeled or stored. Specifically, numerous refrigerated and frozen items were either past their use-by dates or lacked proper labeling, including items such as sausage, cheese frosting, turkey meat, tomato paste, spaghetti, milk, sour cream, apple juice, almond milk, gelatin cocktail, bread rolls, corn, carrots, juice, paprika, cayenne pepper, sugar cookies, baking soda, cereal, biscuit mix, and rice. The Dietary Services Supervisor (DSS) confirmed that per facility policy, all food items should be labeled with a receive date and a use-by date once opened, and items must be discarded after the use-by date to ensure food safety for residents. Additionally, the facility failed to ensure proper sanitization of dishes. During an observation, a staff member ran the dishwasher with the hottest temperature reaching only 100 degrees Fahrenheit, below the required 120 degrees Fahrenheit. The staff member admitted to not checking the temperature gauge during the cycle. The DSS stated that facility policy requires staff to check the temperature during each dishwashing cycle and to rerun the cycle if the temperature does not reach at least 120 degrees Fahrenheit. The facility's policy also mandates routine monitoring of the dish machine to ensure appropriate wash and rinse temperatures are maintained, and any deviations must be reported to the Dietary Manager. These deficiencies have the potential to result in foodborne illness among the residents consuming food at the facility.
Improper Waste Management in Facility Dumpsters
Penalty
Summary
The facility failed to ensure that two of three garbage dumpsters had their lids closed and were not overflowing with trash, as required by the facility's policy. During an observation, two dumpsters were seen with trash overflowing, causing the lids to remain open. This was confirmed during an interview with the Maintenance Supervisor, who stated that the facility policy required trash to be compressed to keep the lids closed and prevent the attraction of flies and rodents. A review of the facility's Waste Management policy indicated that waste containers must be closable and food waste should be placed in covered garbage cans.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to update and revise the care plan for two residents, Resident 42 and Resident 33, as per the facility's policy. Resident 42's fall care plan was not updated after a fall with injury occurred on January 3, 2025. Despite being at high risk for falls, as indicated in the Fall Risk Evaluation dated November 15, 2024, and having a history of falls, the care plan was not revised to include new interventions after the second fall. The Assistant Director of Nursing and the MDS Nurse both acknowledged that the care plan should have been updated to address the underlying causes of the fall and to implement new interventions. Resident 33's care plan was not revised to reflect an updated fluid restriction order from the physician dated January 15, 2025. The care plan still contained outdated fluid restriction measurements, which did not align with the physician's order. Licensed Vocational Nurse 1 confirmed that the care plan was not updated, and the Assistant Director of Nurses emphasized the importance of updating the care plan to prevent potential health issues such as fluid overload, edema, or dehydration. The facility's policies and procedures require that care plans be reviewed and revised following changes in a resident's condition or new physician orders. However, in these cases, the care plans for Residents 42 and 33 were not updated as required, potentially affecting the quality of care and services provided to these residents.
Failure to Conduct Post-Fall Evaluations and Meetings
Penalty
Summary
The facility failed to meet professional standards of quality for one resident, identified as Resident 42, by not conducting necessary evaluations and meetings following a fall with an injury. Resident 42, who was admitted with diagnoses including dementia with psychotic disturbance, lack of coordination, and reduced mobility, experienced a fall resulting in a laceration to the left upper eyebrow. Despite the fall and the resident's altered mental status and behavioral symptoms, the facility did not conduct an Interdisciplinary Team (IDT) meeting, a Post Fall Evaluation, or a neurological exam as required by their policy. The Assistant Director of Nursing (ADON) confirmed that the facility's policy mandates a post-fall evaluation, neuro checks for unwitnessed falls or head injuries, and an IDT meeting within 24 hours to revise the care plan. However, these actions were not taken for Resident 42 after the fall on January 3, 2025. The facility's Fall Management Program policy, reviewed in January 2025, outlines these requirements, but the licensed nurses failed to document the fall details, perform the necessary evaluations, or revise the care plan, as confirmed by the ADON during the review.
Failure to Monitor and Document Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter, as indicated in the physician's orders. The resident, who had a history of malignant neoplasm of the prostate, benign prostatic hyperplasia, obstructive uropathy, and reflux uropathy, was at risk for urinary tract infections (UTIs). The physician's orders required the staff to assess urinary drainage for signs and symptoms of infection every shift, including cloudiness, color, sediment, blood, odor, and amount of urine output. Observations revealed that the resident's Foley catheter tubing had small to moderate amounts of white sediment and concentrated yellow urine, indicating potential signs of infection. However, there was no documentation of these observations in the resident's Treatment Administration Record (TAR), Progress Notes, or Change of Condition/Situation, Background, Assessment, Request/Recommendation (COC/SBAR) forms. The Treatment Nurse confirmed that the presence of sediment or cloudiness should have been documented and reported to the physician for further evaluation and potential laboratory testing. Interviews with the Director of Nursing (DON) and the Treatment Nurse highlighted that the facility's policy required staff to monitor and report any signs of infection to the physician. The DON stated that minimal sediment or cloudiness should be monitored for eight hours, while moderate to severe sediment or cloudiness required immediate physician notification. The lack of documentation and communication with the physician regarding the resident's catheter condition resulted in a delayed identification of a potential UTI, which could lead to worsening infection and delayed treatment.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to accurately monitor the fluid intake for a resident with fluid restrictions and on dialysis, leading to a deficiency in care. The resident, who was admitted with end-stage renal disease and dependent on dialysis, had a physician's order for a fluid restriction of 1000 ml per day. However, the facility did not adhere to this order. Certified Nurse Assistant 4 confirmed that the resident's fluid intake exceeded the prescribed limits during meals, and there was no awareness of the fluid restriction. Additionally, the Licensed Vocational Nurse 1 admitted that there was no record of the fluid intake associated with medication administration, which was supposed to be documented in the Medication Administration Record. The Assistant Director of Nurses acknowledged that the CNAs were not supposed to provide extra fluids to the resident and that the fluid intake from meals and medications should have been recorded. The facility's policies and procedures for dialysis care and fluid restriction were not followed, as there was no documentation of fluid intake, and the staff failed to monitor and ensure compliance with the fluid restriction. This lack of monitoring and documentation had the potential to cause fluid overload or dehydration, posing a risk to the resident's health.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not supervising the medication administration for one of the residents, identified as Resident 39. During a record review, it was found that Resident 39 was not approved for self-administration of medications and was not allowed to keep medications at the bedside. Despite this, eight medications were left on the nightstand by the Infection Prevention Nurse (IPN) without supervision. The IPN admitted to leaving the medications unattended due to being disrupted, acknowledging that this was against the facility's policy, which requires medications to be administered directly by the licensed nurse preparing them. Resident 39, who was admitted with diagnoses including atherosclerosis, chronic pulmonary edema, psychosis, and dementia, was found to have intact cognitive skills for daily decision-making according to the Minimum Data Set. However, the resident required assistance with daily activities and was at risk for self-care performance deficits due to mood disorder and forgetfulness. The care plan for Resident 39 included maintaining a safe environment and providing assistance as needed. The failure to supervise medication administration posed a risk of medication errors and potential harm to Resident 39 and other residents who might access the medications.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to act upon the Pharmacy Consultant's recommendations during the Medication Regimen Review (MRR) for December 2024 for one of the sampled residents, Resident 41. The MRR, conducted by the consulting pharmacist, identified several irregularities in Resident 41's medication regimen, including the concurrent use of Saxagliptin and Sitagliptin, the absence of a 'Do not crush' instruction for Ferrous Sulfate, and the timing of Repaglinide administration. These recommendations were not reviewed or acted upon by the facility, as indicated by the Medication Administration Record (MAR) for December 2024, which showed that the medications were administered without addressing the pharmacist's recommendations. Resident 41, who was initially admitted and later readmitted to the facility, had a medical history that included type 2 diabetes mellitus, depression, and unspecified dementia. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a need for substantial assistance with daily activities. Despite these needs, the facility did not ensure that the pharmacist's recommendations were reviewed and communicated to the attending physician, as required by the facility's policy and procedure for medication regimen reviews. Interviews with the Director of Nurses (DON), a licensed vocational nurse (LVN 1), and the Assistant Director of Nurses (ADON) revealed that there was no designated staff member responsible for reviewing and following up on the MRR. The responsibility was informally assigned to all licensed nurses, leading to a lack of accountability and oversight. As a result, the irregularities identified in the MRR were not addressed, and the attending physician was not notified, which could have led to potential adverse medication outcomes for Resident 41.
Failure to Monitor Refrigerator Temperatures for Resident Food
Penalty
Summary
The facility failed to ensure that the temperature of the Activity Room Refrigerator, which contained food brought by family members for a resident, was checked daily as per the facility's policy. During an observation and interview with the Dietary Services Supervisor (DSS), it was noted that the refrigerator contained a food container labeled with a resident's room number and bed, indicating it was brought by the resident's family. The facility's Policy & Procedure required that refrigerator temperatures be checked routinely throughout the day and maintained at 41 degrees or below. However, the temperature log for the refrigerator did not have documented temperatures from February 3 to February 9, both in the morning and evening. The DSS confirmed that staff should have checked and documented the refrigerator temperatures according to the policy.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 12 out of 22 resident rooms met the regulatory requirement of providing at least 80 square feet per resident in multiple resident bedrooms. This deficiency was identified through observations, interviews, and record reviews conducted from February 10 to February 13, 2025. The rooms in question, specifically Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17, and 18, were found to have less than the required space per resident, with measurements ranging from 64.6 to 76.6 square feet per resident. Despite this, some residents expressed comfort with their space during interviews, and observations indicated that there was adequate room for mobility aids and the provision of care. The facility's Client Accommodation Analysis Form confirmed the deficiency, listing specific room measurements that fell short of the required square footage. For instance, one room with three beds measured 194 square feet, equating to only 64.6 square feet per resident. Despite the spatial limitations, observations noted that residents had enough space to move freely and that the care provided was not compromised. The Department recommended approval of a room waiver request for the affected rooms, acknowledging the facility's efforts to maintain adequate care and mobility within the limited space.
Failure to Notify Physician of Resident's Meal Refusal
Penalty
Summary
The facility failed to notify the resident's physician when a resident, who was diagnosed with protein-calorie malnutrition, dementia, Alzheimer's disease, and dysphagia, refused more than 50% of meals for three consecutive times. The resident was admitted with severe cognitive impairments and was dependent on assistance for daily activities, including eating. Despite the resident's refusal to eat, which was documented in the Nutrition Meal Intake records, the physician was not informed as required by the facility's policy. The facility's policy stated that if a resident ate less than 50% for three consecutive meals, it should be considered a Change of Condition (COC), and the physician should be notified. However, the Director of Nursing confirmed that the physician was not informed of the resident's poor meal intake. Additionally, the resident's care plan required monitoring and reporting changes in behavior or appetite loss, which was not adhered to. This oversight had the potential to delay necessary care and services for the resident, who was already at risk of severe malnutrition.
Failure to Promote Resident Dignity
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not ensuring proper handling of a urinary catheter bag and inappropriate feeding assistance. Resident 16, who had diagnoses including COPD, UTI, and difficulty walking, was observed with an uncovered urinary catheter bag, which should have been covered with a dignity bag to protect the resident's dignity. Multiple staff members, including CNAs and the Director of Nursing, acknowledged that the dignity bag should have been used to cover the catheter bag, but it was not in place when the resident returned from the hospital. Resident 11, who had diagnoses including nontraumatic subarachnoid hemorrhage, atrial fibrillation, and epilepsy, was observed being fed by a CNA who stood above the resident's eye level. The CNA admitted that she should have been sitting at eye level with the resident but did not do so because there was no available chair. Another staff member, an LVN, confirmed that feeding residents at eye level is important for their dignity and to encourage proper eating. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Provide Necessary ADL Care and Communication Devices
Penalty
Summary
The facility failed to provide necessary care and services to ensure the residents' abilities in activities of daily living (ADLs) for two sampled residents. Resident 15, who has severe cognitive impairment and multiple diagnoses including bilateral primary osteoarthritis of the knee and Alzheimer's disease, was not provided with a communication device in their primary language and was observed in an uncomfortable and improper bed position. Despite the care plan indicating the need for alternative communication tools and proper positioning, these interventions were not implemented. The Director of Nursing acknowledged the lack of frequent visual checks to ensure proper positioning and the absence of a communication board at the bedside. Resident 29, diagnosed with end-stage renal disease and other conditions, also faced a communication barrier due to the lack of a communication device in their primary language. The resident, who is capable of understanding and making decisions, reported difficulty in communicating with staff who did not speak their preferred language. The care plan for Resident 29 included the use of communication boards and translation assistance, but these measures were not in place. Interviews with staff confirmed the reliance on other staff members for translation and the absence of communication boards at the bedside. The facility's policies on positioning and body alignment, as well as accommodation of residents' communication needs, were not followed. The failure to provide appropriate communication devices and ensure proper positioning in bed for these residents led to deficiencies in their care. Observations and interviews with staff and residents highlighted the lack of adherence to the care plans and facility policies, resulting in inadequate support for the residents' ADLs and communication needs.
Failure to Ensure Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment for Resident 16 and Resident 36, leading to potential risks for falls, injuries, and delayed care. Resident 16's room was cluttered with multiple items such as nightstands, an oxygen concentrator, and a trash can, which were placed parallel to the bed. This clutter was observed to impede quick access to the resident in case of an emergency. Despite the resident's high fall risk and the use of medications that increase fall risk, the room arrangement was not adjusted to mitigate these hazards. The Director of Nursing (DON) acknowledged that the room was not free of accident hazards and that the clutter could delay staff response in an emergency situation. Additionally, the room was smaller than the required 80 square feet per resident, necessitating a room waiver, which further complicated the safety concerns for Resident 16, who was already at high risk for falls and anxiety attacks that could lead to injury. Resident 36's environment also posed safety risks. The resident had an overhead trapeze with multiple cords hanging from it, including the call light and bed remote. This setup was observed to be unsafe as the cords could potentially entangle the resident, who had periods of confusion. During an observation, the trapeze was seen making contact with the resident's face, which the resident confirmed was uncomfortable and unavoidable due to the need to reach the call light and bed remote. Staff, including a Registered Nurse (RN) and a Certified Nurse Assistant (CNA), acknowledged that the trapeze setup was not safe and could cause injury. The DON also confirmed that the trapeze could injure the resident if it made contact with her face or head. The facility's policies on resident safety and accommodation of needs were not adequately followed, as evidenced by the unsafe conditions in the rooms of Resident 16 and Resident 36. The clutter in Resident 16's room and the unsafe trapeze setup in Resident 36's room were not addressed, despite the known risks and the facility's own procedures requiring regular evaluation of resident safety. These deficiencies highlight a failure to provide a safe environment, putting residents at risk for accidents and delayed care.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure the storage, preparation, and distribution of food were conducted under sanitary conditions for fifty-two residents. The first deficiency was observed in the kitchen where the conventional oven's temperature knob had no visible settings, making it difficult for the dietary staff to determine the correct cooking temperature. Both the Dietary Staff Supervisor (DSS) and the Cook confirmed that they had to guess the temperature, which could result in improperly cooked food. The Maintenance Supervisor also acknowledged the issue, stating that the faded numbers on the temperature knob could be dangerous as it is crucial to know the exact temperature when cooking food for residents. The second deficiency involved improper labeling and storage of food items in the kitchen produce refrigerator and dry storage. Several food items, including Parmesan cheese, mayonnaise, pickle relish, liquid whole eggs, cream cheese, frozen sausage, pizza dough, and doughnuts, were either past their expiration dates or not labeled with a received or expiration date. Additionally, items in the dry storage such as black eye peas, ground black pepper, oregano leaves, domestic paprika, and dark chili powder were not labeled with open or expiration dates. The DSS admitted to missing the expired food items during inventory checks and acknowledged that all staff should ensure proper labeling and checking of food items. The facility's policies and procedures on food storage, which require all items to be correctly labeled and dated, were not followed.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship, leading to the inappropriate use of antibiotics for two residents. Resident 16, who had diagnoses including COPD, pneumonia, sepsis, and UTI, was prescribed Cefepime despite not meeting the McGeer's Criteria for antibiotic use. The Infection Prevention Nurse (IPN) confirmed that the resident's screening score was zero, indicating a suspected infection that did not meet the criteria for antibiotic administration. The physician was not notified of this score, and the antibiotic was administered regardless, contrary to the facility's protocol and the purpose of the Infection Screening Evaluation. Similarly, Resident 35, with diagnoses including ESBL resistance, an open wound, and diabetes with neuropathy, was prescribed Ertapenem Sodium without meeting the McGeer's Criteria. The IPN confirmed that Resident 35's screening score was also zero, and the physician was not informed. The antibiotic was administered despite the resident not meeting the criteria, and the physician was not consulted to confirm the necessity of the antibiotic. The Director of Nursing (DON) acknowledged that the physician should have been notified when the McGeer's Criteria score was zero, to determine whether to continue with the antibiotic. The facility's policy on Antibiotic Stewardship, which aims to optimize antibiotic use and reduce inappropriate prescriptions, was not followed, leading to the potential for antibiotic resistance and adverse side effects in the residents.
Failure to Provide and Document Updated COVID-19 Vaccinations for Staff
Penalty
Summary
The facility failed to provide education, offer, and document the updated COVID-19 vaccinations for the year 2023-2024 for 96 out of 105 employees. This deficiency was identified through interviews and record reviews, which revealed that the Employee List and Vaccines form was incomplete and did not indicate how many employees were offered, received, or declined the updated COVID-19 vaccine. Several staff members, including a Certified Nursing Assistant (CNA), the Infection Prevention Nurse (IPN), and the Director of Nursing (DON), confirmed that they were either not offered the updated vaccine or did not have the necessary consent or refusal forms on file. The IPN admitted that the updated vaccines were not ordered for the employees and that there was no clear process for notifying all employees about the vaccination clinic, given their different work schedules and shifts. The facility's policy, revised on 8/2/2023, stated that the facility would continue to offer vaccines and booster doses per the requirements of CMS, CDC, and ACIP and document such. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and incomplete Employee List and Vaccines form. The CDC recommends the 2023-2024 updated COVID-19 vaccines to protect against serious illness, but the facility failed to ensure that all employees were offered and documented for the updated vaccine, placing residents and staff at risk for possible COVID-19 infection due to missed vaccination dosages.
Failure to Ensure Call Lights Were Within Reach
Penalty
Summary
The facility failed to ensure that the call light was within reach of three residents, leading to a potential delay in the provision of services and assistance with activities of daily living (ADLs). Resident 5, who had diagnoses including difficulty walking, lack of coordination, and schizophrenia, was found with their call light placed inside a closed drawer of the nightstand. This was observed during a room check, and the Certified Nursing Assistant (CNA) confirmed that the call light should have been clipped to the bed. The Director of Nursing (DON) acknowledged that the call light being out of reach was inappropriate and not in line with the resident's care plan, which required the call light to be within reach due to the resident's risk for falls and fluctuating cognitive capacity. Resident 27, who had severe cognitive impairments and a history of falls, was found with their call light cord wrapped and hanging on the wall above the bed frame. This was observed during a room check, and the CNA confirmed that the call light should have been placed on the bed. The DON reiterated that the call light should be within reach unless otherwise specified in the resident's care plan, which was not the case for Resident 27. The care plan indicated the need for the call light to be within reach due to the resident's risk for falls and impaired mobility. Resident 15, who had severe cognitive impairments and required total assistance for ADLs, was found with their call light inside the nightstand drawer, out of reach. This was observed during a room check, and both the CNA and a Registered Nurse (RN) confirmed that the call light should be clipped to the bedside. The DON stated that it was not appropriate for the call light to be inside a drawer, as the resident would not be able to call for help or assistance. The facility's policy and procedure on call systems also indicated that call cords should be placed within the resident's reach.
Inaccurate MDS Documentation for Eating Ability
Penalty
Summary
The facility failed to ensure the assessment entries on the Minimum Data Set (MDS) related to eating were accurately documented for Resident 6. Resident 6, who was admitted with diagnoses including anorexia, legal blindness, and unspecified hearing loss, was assessed on the MDS as requiring substantial/maximal assistance with eating. However, observations and interviews revealed that Resident 6 was able to eat by herself with minimal assistance, such as being informed about the location of food on her plate and occasional encouragement to eat. This discrepancy between the MDS documentation and the actual ability of Resident 6 to eat independently was noted during an observation and confirmed through interviews with the Certified Nursing Assistant (CNA 6) and the Infection Control Nurse (IPN 2). Both staff members indicated that Resident 6 could feed herself despite her impairments. During a review of Resident 6's MDS with the Minimum Data Set Coordinator (MDSC), it was revealed that the MDS entry for eating was based on the weekly notes of licensed nurses, interviews, and documents from CNAs, as well as the MDSC's assessment. The MDSC acknowledged that the MDS should reflect the correct level of acuity and that Resident 6's eating ability should have been documented as requiring set-up or clean-up assistance rather than substantial/maximal assistance. The MDSC also admitted that they did not remember if they had assessed Resident 6's eating ability during the look-back period. The facility's policy on the Resident Assessment Instrument (RAI) process, which aims to provide accurate resident assessments, was not adhered to in this case, leading to the inaccurate documentation on the MDS for Resident 6.
Inaccurate PASRR Completion for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the preadmission screening assessment (PASRR) form was accurately completed for a resident with a mental illness. Resident 24, who had diagnoses including schizophrenia, was admitted and readmitted to the facility with a negative PASRR Level I screening. The PASRR forms dated 8/31/2023 and 1/29/2024 incorrectly indicated that Resident 24 did not have a serious diagnosed mental disorder or was prescribed psychotropic medications, despite medical records showing otherwise. This led to the resident not receiving the necessary psychiatric level of treatment and evaluation in the facility. Interviews with the Admission Coordinator (AC) and Minimum Data Set Coordinator (MDSC) revealed that the facility staff were responsible for submitting and verifying the PASRR forms. The AC admitted to incorrectly filling out the PASRR forms, failing to include Resident 24's diagnosis of schizophrenia and the use of psychotropic medications. The MDSC confirmed that Resident 24 had been diagnosed with schizophrenia and was on psychotropic medication at the time of readmission, and acknowledged that the PASRR should have been corrected within seven days. The Director of Nursing (DON) emphasized the importance of accurate PASRR completion to determine appropriate care and placement for residents. The facility's policy required a new PASRR upon readmission if there was a significant change in the resident's condition. However, the PASRR for Resident 24 was not updated accurately, leading to a deficiency in providing the necessary psychiatric care and evaluation for the resident.
Failure to Update Care Plan for Resident with Seizures
Penalty
Summary
The facility failed to review and revise the care plan for one of the residents who has a history of seizures. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, paroxysmal atrial fibrillation, and epilepsy. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition and required substantial assistance with daily activities. Despite having a physician's order for multiple seizure medications, the resident's care plan did not reflect all current seizure medications, including Depakote, Levetiracetam, and Vimpat, after the discontinuation of Dilantin. During an interview, the Registered Nurse Supervisor (RNS) acknowledged that the care plan should have been updated to include all current seizure medications. The Director of Nursing (DON) also confirmed that all licensed staff are responsible for revising and updating care plans and that the resident's medication should have been revised when Dilantin was discontinued. The facility's policy indicated that care plans should be reviewed and revised based on assessed needs, new problems, changes in condition, and other appropriate times, which was not followed in this case.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that Resident 40 received all medications in accordance with the physician's order and the facility's policy and procedure. During a medication pass observation, Resident 40 was found in possession of three clear red capsules of Colace, a stool softener, which he had hidden in a zip lock bag. Resident 40 admitted to hiding the pills because he did not want to take too much and risk having diarrhea. This was confirmed by the Infection Prevention Nurse, who verified that the capsules in Resident 40's possession were indeed Colace capsules that he was supposed to take. The Medication Administration Record indicated that Resident 40 had been administered all 56 doses of Colace from 3/1/2024 to 3/27/2024, suggesting that the resident had been hiding the medication for some time. During an interview, the Director of Nursing stated that Licensed Vocational Nurses are required to observe residents taking their medications to ensure compliance. The failure to do so could lead to double dosing, missed medications, and potential adverse reactions. The facility's policy on medication administration mandates that medications must be given to the resident by the Licensed Nurse preparing the medication, and the nurse must chart the drug, time administered, and initial their name with each medication administration. The incident with Resident 40 highlights a lapse in this procedure, as the resident was able to hide the medication without the nurse's knowledge, potentially leading to an overdose or other harm.
Deficient Shower Chair Condition
Penalty
Summary
The facility failed to ensure that a shower chair used by residents was in good condition and free from stains. During an observation, a CNA was seen pushing a white shower chair with brown and yellowish stains and a ripped plastic woven backrest. The Registered Nurse Supervisor confirmed that the stains were old and the chair needed to be replaced, stating she would not want to sit on it if she were a resident. The Maintenance Supervisor was unaware of the chair's condition and agreed it should not be used. The Director of Nursing also acknowledged the poor condition of the chair and emphasized that CNAs should report old equipment to the charge nurse for replacement. The facility's policy, revised on 1/1/2012, indicated that residents should be provided with a safe, clean, comfortable, and homelike environment. The policy emphasized the importance of providing residents with a pleasant environment and person-centered care that focuses on their comfort, independence, and personal needs and preferences. The failure to maintain the shower chair in good condition was a deviation from this policy, potentially affecting the residents' dignity and self-worth.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to follow its policy to post nurse staffing information at the start of each shift. On 3/26/2024, the facility did not post the nurse staffing information for the current date and did not indicate the total number of projected hours and the actual hours of licensed and unlicensed nursing staff directly responsible for resident care per shift. This was confirmed during a general observation at the nurse's station and an interview with the Director of Staff Development (DSD), who admitted that the Nurse Staffing Information had not been updated since 3/24/2024. During a follow-up interview, the DSD revealed uncertainty about the required format for the Nurse Staffing Information sheets. The DSD stated that the staffing sheet was created by the previous DSD and had been copied and updated daily without verifying its accuracy or compliance with the facility's policy. A review of the facility's policy and procedure titled 'Nursing Department-Staffing, Scheduling & Postings' indicated that the facility should post the current date and the total number and actual hours worked by nursing staff per shift at the beginning of each shift, which was not adhered to in this instance.
Facility Failed to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that 12 out of 22 resident rooms met the required 80 square feet per resident in multiple resident bedrooms. During an observation of the facility and resident rooms, it was found that Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17, and 18 did not meet this requirement. Measurements of these rooms revealed that they ranged from 64.6 to 76.6 square feet per resident, which is below the mandated minimum. This deficiency was identified through a combination of observation, interviews, and record reviews conducted from March 26, 2024, to March 29, 2024. Despite the deficiency, residents in the affected rooms reported feeling comfortable and having enough space for their belongings and mobility aids such as wheelchairs and walkers. The facility's Client Accommodation Analysis Form confirmed the inadequate room sizes. However, observations indicated that the lack of space did not appear to affect the care and services provided to the residents. The Department recommended approval of a room waiver request for the 12 rooms in question.
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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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