Meadowood A Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 3110 Wagner Heights Road, Stockton, California 95209
- CMS Provider Number
- 555713
- Inspections on file
- 29
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Meadowood A Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with impaired mobility was unable to summon assistance due to a malfunctioning call light that did not illuminate outside the room, resulting in an episode of incontinence when staff did not respond. Staff were unaware of alternative communication methods, and the resident was not provided with a hand bell, despite facility policy requiring such measures during call light outages.
The facility failed to record the temperature of soup served to eight residents during lunch, risking foodborne illness. Dietary staff heated soup without documenting its temperature, contrary to facility policies requiring temperature checks to ensure food safety.
The facility failed to implement proper infection control measures for residents on Enhanced Barrier Precautions (EBP). Signage indicating the need for PPE was missing from a resident's room, and PPE supplies were not readily available outside the rooms of several residents on EBP, increasing the risk of infection spread. Staff confirmed the absence of necessary precautions, and the facility's policy for isolation precautions was not followed.
A resident with Alzheimer's disease was left with a meal in front of her for over 20 minutes without being fed, compromising her dignity. The resident required assistance with feeding, but staff fed another resident instead. When finally fed, the meal was at an inappropriate temperature. Staff interviews and facility policies confirmed the failure to promptly assist and serve food at the correct temperature.
A facility failed to maintain a resident's Advance Directive in their medical record, despite the POLST form indicating its existence. The resident, admitted with hip surgery aftercare and a femur fracture, did not have their Advance Directive in either their physical chart or EHR. Interviews with the SSD and DON confirmed this oversight, which contradicted facility policy requiring the document's inclusion and review during admission and quarterly.
A resident's privacy was compromised when their incontinence care instructions were publicly displayed in their room. The instructions, related to the use of a condom catheter, were posted on the bathroom door facing into the room, visible to anyone entering. Staff acknowledged the breach and noted that the information could have been placed inside the bathroom door to maintain privacy.
A resident with Parkinsonism and dementia was unable to independently unbuckle a self-release belt in their wheelchair, classifying it as a restraint. Despite initial approval and demonstration of the belt's use, the resident was observed struggling to release it, requiring assistance from a nurse. The facility failed to reassess the resident's ability to use the belt independently during the quarterly MDS assessment, leading to a deficiency.
A resident in the facility was found to be receiving an incorrect oxygen rate due to the absence of a care plan for their oxygen needs. The resident was supposed to receive oxygen at 4 LPM continuously, but was instead receiving 2.5 LPM. Both the LN and DON confirmed the lack of a care plan, which is crucial for guiding nursing staff in administering the correct oxygen rate.
A resident with multiple diagnoses, including sepsis and bilateral hydronephrosis, experienced inadequate urinary catheter care when their catheter bag was found on the floor without a dignity cover. This was confirmed by two LNs and the DON, who acknowledged the risk of contamination and the importance of maintaining resident dignity. Facility policy and CDC guidelines were not followed, potentially affecting the resident's self-worth and increasing the risk of infection.
A resident receiving oxygen therapy was administered 2.5 LPM instead of the prescribed 4 LPM, as confirmed by a licensed nurse and the DON. This failure to follow the physician's order placed the resident at risk for hypoxia, contrary to the facility's policy on oxygen administration.
A facility failed to maintain safe medication administration practices, resulting in a medication error rate of 5.55%. Errors included not administering prescribed eye drops to a resident, yet documenting them as given. The DON confirmed that medications should not be charted if not administered, and the facility's policy requires timely administration with documentation of any deviations.
The facility failed to ensure safe medication storage, with staff personal items found in medication rooms and expired medication on a cart. Personal belongings were improperly stored in the Sequoia and Redwood/Harmony unit medication rooms, confirmed by LNs and the Administrator. An expired Ipratropium bromide/albuterol was found on a medication cart, posing risks of reduced effectiveness and adverse reactions, as confirmed by LN 7 and the DON.
A resident admitted with bronchiectasis and migraines did not receive necessary medications due to facility failures. Cefiderocol, required for infection, was delayed due to pharmacy order issues, and Sumatriptan for migraines was unavailable, leading to unrelieved pain. The facility did not adhere to its policies on admissions and medication shortages.
A facility failed to inform a resident's responsible party of the discharge appeal process. The resident, unable to make health care decisions due to severe dementia, signed her own discharge notice. The case manager did not verify the resident's decision-making capacity before obtaining her signature, contrary to facility policy. The responsible party was not informed of the appeal rights, potentially affecting the resident's access to necessary services.
A resident with severe dementia and a high fall risk suffered a hip dislocation after falling in a facility. The care plan lacked specific interventions like fall mats and a low bed position, contributing to the incident. Staff interviews revealed inconsistent adherence to fall prevention measures, despite awareness of the resident's risk.
A resident with Parkinson's disease fell from his wheelchair, resulting in the loss of his front teeth. Despite visible injuries and the resident's report of pain, the nursing staff failed to conduct an oral assessment or inform the physician about the potential dental damage. This oversight led to the resident experiencing pain, difficulty eating, and weight loss.
A resident missed 6 doses of dronabinol and 3 doses of vitamin B6 due to the facility's failure to acquire the medications from the pharmacy in a timely manner. The resident had severe protein calorie malnutrition and moderate cognitive impairment. The facility did not follow its policy for promptly ordering and delivering new medications.
A resident with diabetes experienced a low blood sugar episode, and the facility failed to follow the physician's orders for treatment. The nurse administered orange juice instead of glucagon gel, did not notify the physician, and did not recheck the blood sugar every 15 minutes as required.
Failure to Provide Functioning Call Light and Alternative Communication
Penalty
Summary
The facility failed to ensure that a resident's call light was functioning properly, resulting in the resident being unable to summon assistance when needed. The call light in the resident's room did not illuminate outside the doorway when pressed, although it did activate the panel at the nurse's station. This malfunction persisted from a Saturday through the following Tuesday, during which time the resident experienced an episode of urinary incontinence because staff did not respond to his call for assistance to the bathroom. The resident, who had a history of pneumonia and lack of coordination, was unable to get up independently to use the bathroom. Interviews with staff revealed that when a call light was broken, the issue was logged for maintenance, but repairs were delayed over weekends. Staff were unaware of alternative methods for residents to call for help when the call light was not working, and the resident was not provided with a hand bell or other means of communication during the outage. Facility policy required that an alternative method, such as individual bells, be provided if the call light system malfunctioned, but this was not implemented. Maintenance records confirmed the call light was reported broken, and an incorrect bulb replacement further delayed the repair.
Failure to Record Soup Temperatures
Penalty
Summary
The facility failed to adhere to professional standards of food service safety by not recording the temperature of soup served to eight residents during lunch. On the specified date, during a tray line observation, it was noted that tomato soup was not initially available, prompting dietary staff to heat a pan of soup on the stove. Subsequently, servings of chicken noodle soup were placed on meal trays for the residents. However, there was no recorded temperature check for the soups before they were served, which is a critical step to ensure food safety. The Certified Dietary Manager confirmed that the temperature log for the lunch did not include a temperature check for the soups, acknowledging that this should have been done to ensure the food was in the safe temperature zone. A staff member stated that she typically checks and documents food temperatures before serving, as incorrect temperatures could lead to illness. The facility's policies on time and temperature control, as well as meal temperature, emphasize the importance of recording accurate temperatures to prevent foodborne illness. The failure to record the soup temperatures put the residents at risk for foodborne illness, as it was unknown if the soup was served at a safe temperature.
Inadequate Infection Control Measures for Residents on EBP
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for residents on Enhanced Barrier Precautions (EBP). Specifically, signage indicating the need for personal protective equipment (PPE) was not posted on or near the doorway of Resident 335's room, who was on EBP due to staph aureus bacteremia. The Unit Manager/Case Manager and the Infection Preventionist confirmed the absence of the EBP sign, which is crucial for informing staff about the necessary precautions to prevent the spread of infection. Additionally, PPE supplies were not readily available outside the rooms of several residents on EBP, including Residents 14, 35, 42, and 64. These residents had various conditions such as dialysis ports, pressure ulcers, and gastrostomy tubes, which increased their risk of infection. Staff members, including Licensed Nurses and Certified Nurse Assistants, confirmed that PPE supplies were either located inside the residents' rooms or in utility rooms, rather than being immediately accessible outside the rooms as required. The Director of Nursing and the Infection Preventionist acknowledged that the facility's policy and procedure for isolation precautions were not followed, which posed a potential risk for the spread of infection. The lack of proper signage and readily available PPE supplies compromised the facility's ability to effectively implement EBP and protect both residents and staff from infection and cross-contamination.
Resident's Dignity Compromised Due to Delayed Feeding
Penalty
Summary
The facility failed to honor a resident's right to be treated with dignity and respect when a resident with Alzheimer's disease was left with a meal in front of her for over 20 minutes without being fed. The resident, who required assistance with feeding due to her condition, was observed seated at a table with her meal while licensed staff fed another resident at the same table. The resident was alert and looking around the room, and later began crying out, yet her meal remained untouched until a licensed nurse began feeding her. At that point, the temperature of the food was recorded at 110 degrees Fahrenheit, which was below the appropriate serving temperature. Interviews with staff revealed that the licensed nurse had placed the meal in front of the resident expecting a CNA student to assist with feeding, but when no one came, the nurse proceeded to feed another resident. The Director of Nurses acknowledged that it was a dignity issue for residents not to eat their meals together and that a fresh meal should have been requested when the delay occurred. The Certified Dietary Manager confirmed that food should be served at temperatures between 145-150 degrees Fahrenheit and that the food served to the resident was inappropriate. Facility policies reviewed indicated that residents needing assistance should be promptly fed and that food should be served at safe and appetizing temperatures.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's rights related to treatment choices were known and protected, as a copy of the resident's Advance Directive was not maintained in their medical record. The resident, who was admitted with diagnoses including aftercare following right hip joint surgery and a fracture of the neck of the right femur, had a Physician Orders for Life-Sustaining Treatment (POLST) form indicating the existence of an Advance Directive. However, upon review, the Advance Directive was neither found in the resident's physical chart nor uploaded into their Electronic Health Record (EHR). Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed the absence of the Advance Directive in the resident's records. The SSD and DON both acknowledged that the Advance Directive should have been included in the resident's chart to ensure their treatment preferences were known and could be followed, especially during transfers to other facilities. The facility's policy required that the Advance Directive be obtained and reviewed during the admission process and at least quarterly thereafter, but this was not adhered to in this case.
Resident Privacy Breach Due to Public Posting of Care Instructions
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of Resident 12's personal and medical information. Resident 12, who was admitted with a diagnosis of urinary incontinence, had his incontinence care needs publicly displayed in his room. A handwritten sign and two photos detailing the care instructions for his condom catheter were posted on the bathroom door facing into the room, making the information visible to anyone entering the room. During interviews, a licensed nurse acknowledged that the information was posted to inform staff about the supplies needed for Resident 12's care but admitted that it could have been placed inside the bathroom door for privacy. The Director of Nurses also recognized that the posting of personal information without covering it with a blank page created a dignity issue for the resident. The facility's document on residents' rights emphasized the right to be treated with respect and dignity, which was not upheld in this instance.
Resident Unable to Independently Release Self-Release Belt
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 12, was free from physical restraints. Resident 12, who had been diagnosed with Parkinsonism and unspecified dementia, was observed to be unable to independently unbuckle a self-release belt while seated in his wheelchair. Despite the resident's request for the belt and initial demonstration of its use, during an observation, the resident was unable to release the belt independently, indicating it functioned as a restraint. Licensed Nurse 6 confirmed the resident's inability to release the belt without assistance. The MDS Coordinator acknowledged that Resident 12's condition, affected by Parkinson's disease, impacted his cognition and mobility, and confirmed that the resident's quarterly MDS assessment did not include a reassessment of the self-release belt, which should have been conducted. The facility's policy emphasizes a restraint-free environment unless medically necessary, and the resident's inability to remove the belt independently classified it as a restraint. The facility's failure to reassess the need for the belt and ensure the resident's ability to release it independently led to the deficiency.
Failure to Develop Oxygen Use Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident's oxygen needs, which led to the resident receiving an incorrect rate of oxygen. During an observation and record review, it was confirmed that the resident was receiving oxygen at 2.5 liters per minute (LPM) instead of the prescribed 4 LPM continuously. The Licensed Nurse (LN) confirmed the discrepancy and acknowledged that a care plan should have been in place to guide the nursing staff in administering the correct oxygen rate. Further interviews and record reviews with the Director of Nursing (DON) confirmed that no care plan was created for the resident's oxygen use. The DON emphasized the importance of a care plan in providing nurses with interventions and guidance to prevent such errors. The absence of a care plan potentially contributed to the resident receiving insufficient oxygen, which could lead to complications such as shortness of breath.
Inadequate Urinary Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident, identified as Resident 71, who was admitted with multiple diagnoses including sepsis and bilateral hydronephrosis. During an observation, it was noted that Resident 71's urinary catheter bag was placed on the floor and lacked a dignity cover. This was confirmed by Licensed Nurse 1, who acknowledged that the catheter bag should not be on the floor due to the risk of contamination and should be covered to maintain the resident's dignity. Licensed Nurse 2 also confirmed that the catheter bag should be placed below the bladder and attached to the bedrail when the resident is in bed, and should have a dignity cover. The Director of Nursing (DON) stated that the staff is expected to ensure urinary catheter bags are off the floor and covered at all times to prevent infection and protect resident dignity. The facility's policy on indwelling catheters also indicated that catheter bags should be covered to maintain resident dignity. The Centers for Disease Control and Prevention guidelines for preventing catheter-associated urinary tract infections also specify that catheter bags should not rest on the floor. These failures had the potential to affect Resident 71's sense of self-worth and self-esteem and placed the resident, and others in the facility, at risk for adverse medical outcomes.
Failure to Follow Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who was receiving oxygen therapy. During an observation, it was noted that the resident was receiving oxygen at a rate of 2.5 liters per minute (LPM) via nasal cannula, contrary to the physician's order of 4 LPM. This discrepancy was confirmed by a licensed nurse who acknowledged that the oxygen order was not being followed as prescribed. The Director of Nursing also confirmed that the ordered amount of oxygen for the resident was 4 LPM continuously. The failure to administer the correct oxygen dosage placed the resident at risk for hypoxia, which is a condition where there is insufficient oxygen supply to the body's tissues. The facility's policy on oxygen administration, which requires licensed nurses to carry out oxygen therapy orders, was not adhered to in this instance.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 5.55%, which is above the acceptable threshold of 5%. This was observed during medication administration to a resident, where two errors occurred out of 36 opportunities. Specifically, the errors involved the failure to administer dorzolamide-timolol and Restasis eye drops to a resident as prescribed. Despite not administering these medications, the licensed nurse documented them as given at the scheduled time. During an interview, the Director of Nursing acknowledged that medications should not be charted as given if they were not administered. The facility's policy requires medications to be administered within 60 minutes of the scheduled time, and any deviations should be documented with an explanatory note. The failure to adhere to these practices had the potential to result in unsafe medication use and affect the resident's health and well-being.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed during inspections of the medication storage rooms and medication carts. In the Sequoia unit medication room, personal items belonging to staff, such as an opened partial bottle of water, coffee cups, tote bags, and a staffing schedule, were found stored under the sink. Similarly, in the Redwood/Harmony unit medication room, personal items including a water bottle, backpack, lunch box, and another personal bag were found on the countertop and under the sink. Both Licensed Nurses (LN 4 and LN 5) confirmed the presence of these items and acknowledged that staff personal belongings should not be stored in medication rooms or under sinks. The Administrator also confirmed that staff personal belongings were not allowed in these areas. Additionally, an inspection of medication cart #2 on the Sequoia unit revealed an expired medication, Ipratropium bromide/albuterol, which was found with an opened date exceeding the recommended two-week usage period after opening. LN 7 confirmed the medication was expired and should have been removed from the cart, acknowledging the risk of reduced effectiveness and potential adverse reactions if administered to residents. The Director of Nursing (DON) stated that the expectation was to remove the medication 14 days after opening, as per the facility's medication storage policy, which emphasizes proper storage and organization of medications.
Failure to Provide Necessary Medications for Resident
Penalty
Summary
The facility failed to provide necessary medications for a resident, leading to potential prolonged illness and unrelieved pain. The resident was admitted with conditions including bronchiectasis with pseudomonas/klebsiella infections and migraines. The resident required intravenous Cefiderocol every 8 hours, but the medication was unavailable at the scheduled times due to a delay in the pharmacy receiving the infusion order request. The Director of Nursing (DON) had to approve medications above certain price points, and the approval for Cefiderocol was not given until the day after the resident's admission. Additionally, the resident required Sumatriptan for migraine headaches, which was also unavailable. The pharmacy informed the facility that the medication was temporarily out of stock and suggested an oral alternative if a doctor's order was obtained. However, there was no documentation that the medical doctor was informed of this request on the day it was made. Consequently, the resident experienced unrelieved pain, as the alternative narcotic pain reliever administered was ineffective. The facility's policies on admissions and medication shortages were not adhered to, as the facility admitted a resident whose needs could not be met and failed to ensure the availability of ordered medications. The DON confirmed that the nurse should have informed the medical doctor of the medication request, and the lack of available Sumatriptan led to the resident experiencing unrelieved pain.
Failure to Inform Resident's Representative of Discharge Appeal Rights
Penalty
Summary
The facility failed to ensure a resident's right to be fully informed of her discharge and the possibility for appeal was protected. Resident 1, who was deemed unable to make health care decisions due to severe unspecified dementia, signed her own discharge notice. The resident's responsible party was not informed of the discharge appeal process, which is a requirement when a resident is unable to make their own health care decisions. The resident's advance health care directive designated her husband as her agent for health care decisions, with her daughter and son as alternates, effective when her primary physician determined she was unable to make her own decisions. A physician order dated shortly before the discharge confirmed that Resident 1 was not capable of making her own health care decisions. The case manager admitted to not verifying Resident 1's decision-making capacity before having her sign the discharge paperwork, despite usually reviewing physician orders for such information. The facility's policy requires that residents and/or their representatives be provided with written notice of an impending transfer or discharge, including a statement of the resident's appeal rights. However, the documentation did not indicate that the responsible party was informed of the right to appeal the discharge decision. This oversight resulted in the responsible party being uninformed of the appeal rights, potentially affecting the resident's access to necessary services if an appeal was sought and upheld.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement adequate measures to prevent injury from falls for a resident who was at high risk for falling. The resident, who had severe dementia and was recovering from a hip hemiarthroplasty, was assessed with a high fall risk score. Despite this, the care plan did not include specific interventions such as the use of fall mats or ensuring the bed was kept in a low position. This oversight contributed to the resident sustaining a complete dislocation of the right hip after a fall. On the day of the incident, the resident was found on the floor with a dislocated hip, which required hospital readmission and surgical intervention. Interviews with staff revealed that the resident's bed was often left in a high position, contrary to the care plan's directives. The staff, including CNAs and licensed nurses, were aware of the resident's fall risk but failed to consistently implement the necessary precautions, such as keeping the bed low and using fall mats. The facility's policies on fall prevention and care planning were not adequately followed, as evidenced by the lack of specific interventions in the resident's care plan. The interdisciplinary team did not incorporate all identified risk factors into the care plan, which should have included measures to prevent falls and potential injuries. This failure to adhere to established protocols resulted in the resident's fall and subsequent injury.
Failure to Provide Dental Care After Resident's Fall
Penalty
Summary
The facility failed to provide necessary dental care for a resident who experienced an unwitnessed fall, resulting in the loss of his front teeth. The resident, who was admitted with Parkinson's disease and required assistance with personal care, fell from his wheelchair and was found bleeding from the mouth. Despite the visible injuries and the resident's report of pain and missing teeth, no oral assessment or follow-up dental care was provided. The nursing staff, including a Certified Nurse Assistant and a Licensed Nurse, observed the resident's injuries but did not take appropriate action to assess the dental damage or inform the physician about the potential loss of teeth. The Licensed Nurse admitted to not being sure about the resident's dental status prior to the fall and failed to communicate the possibility of lost teeth to the doctor. This lack of communication and assessment led to the resident experiencing pain and difficulty eating, which potentially contributed to weight loss. Interviews with family members and a speech therapist confirmed that the resident had a full set of teeth before the fall. The Director of Nursing acknowledged the expectation for nurses to notify the physician and representative party about such incidents and the importance of conducting a thorough oral assessment. The failure to assess and address the resident's dental needs after the fall had a negative impact on his well-being and quality of life.
Failure to Administer Medications in a Timely Manner
Penalty
Summary
The facility failed to ensure that medications ordered by the physician were administered to a resident when dronabinol and vitamin B6 were not acquired from the pharmacy in a timely manner. This resulted in the resident missing 6 doses of dronabinol and 3 doses of vitamin B6. The resident, who was admitted with severe protein calorie malnutrition and had undergone gastric bypass surgery, had a BIMS score indicating moderate cognitive impairment. The missed doses were documented in the Medication Administration Record (MAR) as being unavailable and pending delivery from the pharmacy. During an interview and record review, a Licensed Nurse confirmed that there was no follow-up phone call to the pharmacy or the physician documented in the resident's record. The nurse stated that nursing staff should have contacted the physician to get an order to hold the medications until they were delivered. The facility's policy indicated that new medications should be promptly ordered and delivered to avoid delays in administration, but this procedure was not followed in this case.
Failure to Follow Physician's Orders for Diabetic Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. On 5/16/23, a Licensed Nurse (LN) administered orange juice to a resident with a low blood sugar reading of 59 mg/dL instead of the physician-ordered glucagon gel. Additionally, the LN did not notify the resident's physician of the low blood sugar reading as required by the physician's order and did not recheck the resident's blood sugar level every 15 minutes until it reached at least 110 mg/dL. These actions were not in compliance with the physician's orders and the facility's policy on administering drugs and treatments only upon the order of a licensed and authorized prescriber. The resident, who was admitted to the facility with a diagnosis of diabetes and had a moderate cognitive impairment, experienced a low blood sugar episode. The nurse's progress notes indicated that the resident's blood sugar levels were rechecked only twice from 8:51 a.m. to 2 p.m., instead of every 15 minutes as required. The blood sugar levels did not reach the target of 110 mg/dL. During an interview, another LN confirmed that the physician's orders were not followed, and the facility's policy was not adhered to in this instance.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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