Saint Vincent Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1810 N. Fair Oaks Ave, Pasadena, California 91103
- CMS Provider Number
- 555119
- Inspections on file
- 18
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Saint Vincent Healthcare during CMS and state inspections, most recent first.
The facility failed to follow proper food handling practices, including improper storage of frozen meats, unlabeled and improperly sealed dry pasta, and expired food items in the kitchen. These deficiencies were observed during a kitchen inspection, with the Dietary Service Supervisor acknowledging the importance of adhering to storage protocols to prevent contamination and potential illness among the 67 residents consuming food by mouth.
The facility failed to keep two dumpsters in the parking lot closed and free from overflowing trash, contrary to its policy. During an inspection, the Maintenance Supervisor and Assistant observed that the dumpsters were overflowing, preventing the lids from closing. The facility's policy requires lids to remain closed to deter pests. A review of the policy confirmed that trash should be packed down, boxes folded, and lids closed when not in use.
The facility failed to implement enhanced barrier precautions (EBP) for 11 residents, as required by their policy, to prevent the spread of multidrug-resistant organisms (MDROs). Staff did not consistently wear gowns during high-contact care activities, and there was a lack of signage and PPE availability outside residents' rooms. This deficiency placed residents at a higher risk for cross-contamination and increased the spread of infection.
A resident with Parkinson's disease and other conditions was observed with an uncovered urinary catheter bag, contrary to the facility's policy requiring dignity bags. Staff interviews confirmed the policy's importance for maintaining dignity and self-esteem, highlighting a deficiency in adhering to these standards.
A resident with hand contractures and limited mobility was not provided with an appropriate call light device, relying instead on verbal calls for assistance. Despite facility policies emphasizing the need for adaptive devices, the resident was given a standard call cord, which she could not use. Staff confirmed the resident's inability to use the call cord, highlighting a failure to accommodate her needs.
A resident with chronic kidney disease, urinary retention, dementia, and gross hematuria had a care plan that included inappropriate interventions, such as providing fluids via a PEG tube, despite the resident not having one. Additionally, the care plan included cranberry use for UTI prophylaxis without an order. These discrepancies were identified by an RN, highlighting a failure to ensure the care plan was resident-centered and based on accurate data.
A resident was diagnosed with schizophrenia without proper evaluation by a Medical Doctor, leading to a potential provision of unnecessary care. The resident, initially admitted with dementia and other conditions, was prescribed Seroquel for aggressive behavior. The CNP added the schizophrenia diagnosis based on staff reports, without documenting delusions or consulting the resident's family. Observations showed no symptoms of schizophrenia, and the DON noted the diagnosis was inconsistent with the resident's history.
A resident with reduced mobility and Parkinson's disease was not provided necessary assistance during meals, as required by their care plan. Observations showed the resident struggling to eat, resulting in food spillage, and interviews confirmed the resident's preference for assistance over using a plate guard. The facility's policies on daily living activities and accommodation of needs were not followed, leading to this deficiency.
A resident with a stage 3 pressure injury on the right heel did not receive the prescribed wound care treatment from October 1 to October 7. The resident, with severe cognitive impairment and multiple health conditions, required specific wound care that was not followed due to discrepancies between the physician's order and the wound care physician's progress note. Nursing staff acknowledged the failure to implement the correct treatment plan, which was essential for proper wound care and healing.
A resident receiving gastrostomy tube feeding was observed with the head of bed (HOB) less than 30 degrees, contrary to the facility's policy requiring 30 to 45 degrees elevation to prevent aspiration. The resident, with dysphagia and severe cognitive impairment, was dependent on assistance for daily activities. Both the LVN and DON confirmed the necessity of HOB elevation during feeding.
A facility failed to provide trauma-informed care for a resident with PTSD, as staff were unaware of the resident's diagnosis and triggers. The resident had informed staff about his PTSD triggers, but there was no care plan in place. The Social Services Director confirmed the lack of reassessment and care planning upon the resident's readmission, contrary to the facility's policy.
A facility failed to verify the competency of a Registry Certified Nursing Assistant (RCNA) before they provided care to residents. The Director of Staff Development did not check or request documentation of the RCNA's skills or certification, relying only on verbal confirmation from the registry. The Director of Nursing acknowledged the importance of knowing staff competencies for resident safety, but the facility lacked documentation. This oversight had the potential to compromise resident care and safety.
A resident was administered Risperdal without a clinical justification, as there was no diagnosis of schizophrenia, which the medication is intended to treat. The facility's DON and RN acknowledged the lack of evidence for the diagnosis, and the facility's policy requiring evaluation of antipsychotic medication use was not followed. This resulted in the unnecessary use of Risperdal, contrary to the facility's guidelines.
A resident with severe cognitive impairments and specific food preferences, including Mexican food, was not provided with their requested meals on multiple occasions, despite these preferences being documented in their care plan. The facility's failure to honor these preferences led to the resident refusing meals, as observed in the Daily Meal Eating Log. Interviews with staff revealed a lack of awareness and documentation regarding the resident's preferences, and the facility's policy on accommodating resident needs was not followed.
A facility failed to offer the pneumococcal vaccine to a resident upon readmission, as required by its policy. The resident, with a history of ventricular tachycardia, Parkinson's Disease, and major depressive disorder, had previously refused the vaccine but was not offered it again during the current admission. Interviews with the DON and IPN confirmed the lapse in protocol, and the resident expressed interest in receiving the vaccine, citing a history of pneumonia.
The facility failed to meet the minimum square footage requirements for resident rooms, affecting 25 out of 27 rooms. Despite this, residents and staff reported no issues with space for care and movement. A waiver was recommended for the affected rooms.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as outlined in their policies and procedures, which could potentially lead to foodborne illnesses among the 67 residents consuming food by mouth. During an observation in the kitchen, it was noted that frozen food items, such as sliced bacon and frozen meat, were not stored in airtight, moisture-resistant wrappers as required by the facility's policy. Instead, the kitchen staff only folded the flaps of the original boxes, which the Dietary Service Supervisor incorrectly stated was sufficient. Additionally, dry pasta was improperly stored; a bag of twisted pasta was ripped and not sealed, and a bag of egg noodles was neither labeled nor dated, contrary to the facility's procedures for dry storage. Further inspection revealed expired food items in the kitchen, including Worcestershire sauce, peanut butter, baking soda, and a package of seasoning with an unreadable expiration date. The Dietary Service Supervisor confirmed that opened food items should be labeled with the date they were opened and a use-by date, and expired items should be discarded. The facility's policy mandates that all food items in storage must be labeled and dated, and opened items should be used by the date following storage guidelines. The failure to follow these protocols was acknowledged by the Dietary Service Supervisor, who emphasized the importance of proper storage to prevent contamination and potential illness among residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two garbage containers (dumpsters) in the parking lot had their lids closed and were not overflowing with trash, as per the facility's policy. During an observation and interview with the Maintenance Supervisor and Maintenance Assistant, it was noted that the dumpsters were overflowing with trash, causing the lids to remain open. The Maintenance Assistant acknowledged the issue, stating that the trash was overflowing and the lids could not be closed. The Maintenance Supervisor confirmed that the facility's policy required dumpster lids to remain closed to prevent pests such as rodents, flies, and insects from being attracted to the dumpsters and potentially entering the facility. A review of the facility's Policy and Procedure on Exterior Maintenance indicated that garbage and trash containers should be maintained in a clean and pest-free condition, with trash packed down, boxes folded, and lids closed when not in use.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for 11 residents, as required by their policy, to prevent the spread of multidrug-resistant organisms (MDROs). This deficiency was observed through various instances where staff did not wear the appropriate personal protective equipment (PPE) such as gowns during high-contact care activities. For example, a Licensed Vocational Nurse (LVN) did not wear a gown while administering medications through a gastrostomy tube (GT) for a resident, and a Certified Nurse Assistant (CNA) did not wear a gown while changing a resident's diaper. Additionally, there was a lack of signage and PPE availability outside the rooms of residents on EBP. The facility's policy indicated that EBP should be implemented for residents with wounds, indwelling catheters, and feeding tubes, regardless of their MDRO status. However, observations revealed that the facility did not adhere to this policy. For instance, there were no EBP signs or PPE carts outside the rooms of residents who required them, and staff members were not consistently using gowns during high-contact activities. Interviews with staff, including the Infection Prevention Nurse (IPN), revealed a misunderstanding of when EBP should be applied, with some staff believing it was only necessary for residents with current infections. The failure to implement EBP as per the facility's policy placed residents at a higher risk for cross-contamination and increased the spread of infection. The facility's policy clearly outlined the need for gowns and gloves during specific high-contact activities, yet these measures were not consistently followed. This lack of adherence to infection control protocols was evident in multiple instances across the facility, highlighting a systemic issue in the implementation of EBP and the availability of necessary PPE.
Failure to Use Dignity Bag for Resident's Catheter
Penalty
Summary
The facility failed to ensure that a foley catheter was covered with a dignity bag for one resident, which is a violation of the resident's right to a dignified existence. The resident, who was admitted with diagnoses including Parkinson's disease, muscle wasting, atrophy, and polyneuropathy, was observed with an uncovered urinary catheter bag. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for substantial assistance with daily activities, including toileting. Despite the resident's capacity to understand and make decisions, as noted in their Initial History & Physical, the facility did not adhere to its policy requiring dignity bags for catheter bags. Interviews with facility staff, including a Treatment Nurse and the Director of Nursing, confirmed that the facility's policy mandates the use of dignity bags to maintain residents' dignity and self-esteem. The facility's Policy and Procedure on Dignity, revised in February 2021, emphasizes the importance of treating residents with dignity and respect, prohibiting practices that compromise dignity. The failure to cover the catheter bag as per policy was identified as a deficiency that could potentially impact the resident's self-worth and self-esteem.
Failure to Provide Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 63, by not providing an appropriate call light device. Resident 63 was admitted with several diagnoses, including left hand contracture, pain in the right shoulder, weakness, and major depressive disorder. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and functional limitations in both upper extremities, requiring substantial assistance with daily activities. Despite these limitations, the resident was provided with a standard call cord, which she was unable to use due to her hand contractures. Observations and interviews revealed that Resident 63 was unaware of the call cord's presence and unable to reach or use it effectively. Staff members, including Certified Nursing Assistants (CNAs) and a Registered Nurse (RN), confirmed that the resident had restricted movement in her arms and hands, making it difficult for her to use the call cord. Instead, the resident relied on verbally calling for assistance or waiting for staff to check on her during regular rounds. The RN acknowledged that Resident 63 had not been evaluated for a more suitable call light device, such as a pad call light, which could accommodate her physical limitations. The facility's policies and procedures emphasized the importance of accommodating residents' individual needs and preferences, including the use of adaptive devices. However, the failure to provide an accessible call light device for Resident 63 demonstrated a lack of adherence to these policies. This oversight had the potential to impact the resident's quality of care and life, as she was unable to independently call for help when needed.
Inappropriate Care Plan Interventions for a Resident
Penalty
Summary
The facility failed to ensure that the care plan for one of its residents, identified as Resident 3, was applicable and resident-centered. Resident 3 was readmitted to the facility with several diagnoses, including chronic kidney disease, urinary retention, dementia, and gross hematuria. The Minimum Data Set (MDS) assessment indicated that Resident 3 had severely impaired cognitive skills and required significant assistance with daily activities. However, the care plan included an intervention to provide fluids via a PEG tube, which was inappropriate as Resident 3 did not have a PEG tube and consumed food and liquids orally. This inappropriate intervention was acknowledged by Registered Nurse 1 (RN1) during a review. Additionally, the care plan for Resident 3 included an intervention for cranberry use as a prophylaxis for urinary tract infections, but there was no order for cranberry in the resident's records. RN1 confirmed that Resident 3 never had an order for cranberry, indicating that the care plan was not aligned with the resident's current needs. The facility's policy on comprehensive, person-centered care plans emphasizes the importance of developing care plans based on accurate data gathering and relevant clinical decision-making, which was not adhered to in this case.
Improper Schizophrenia Diagnosis Without MD Evaluation
Penalty
Summary
The licensed nursing staff at the facility failed to meet professional standards of quality by not ensuring that a resident was properly assessed and evaluated by a Medical Doctor before adding a new diagnosis of schizophrenia. The resident, who was admitted with diagnoses including dementia, major depressive disorder, and Alzheimer's Disease, was given a physician order for Seroquel to manage aggressive behavior associated with dementia. However, the diagnosis was later changed to schizophrenia without proper documentation or evaluation by a psychiatrist. The Certified Nurse Practitioner (CNP) added the schizophrenia diagnosis based on his evaluation and reports from facility staff, despite the resident's psychiatric follow-up note indicating no new symptoms or need for medication adjustment. The CNP admitted to not documenting the resident's delusions in the psychiatric follow-up note and planned to write a late entry note. The Director of Nursing confirmed that there was no documentation of communication with the resident's family to confirm the mental history or schizophrenia diagnosis, and noted that schizophrenia typically develops at a younger age. Observations of the resident showed no aggressive behavior or symptoms consistent with schizophrenia, and the resident's psychiatric condition was noted as generally unchanged. The American Psychiatric Association's guidelines indicate that schizophrenia symptoms usually appear in early adulthood and require a thorough medical examination to rule out other conditions. The facility's failure to adhere to these standards resulted in a potential provision of unnecessary care for the resident.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to provide necessary assistance to a resident with limitations in mobility, specifically during meal times, as outlined in the care plan and facility policy. The resident, who was diagnosed with reduced mobility and Parkinson's disease, had a care plan indicating the need for assistance with activities of daily living due to a right hand contracture. Despite this, observations revealed that the resident was not provided with the required assistance while eating, which was necessary to meet their nutritional needs and prevent further decline in their ability to perform daily activities. During dining observations, the resident was seen struggling to eat using only their right hand, resulting in food spillage onto their clothes and the floor. The occupational therapy notes had recommended the use of a plate guard to aid in self-feeding, but this was not utilized during the observations. Interviews with the resident and staff confirmed that the resident preferred assistance over using the plate guard and expressed dissatisfaction with the lack of help, which led to food spillage and frustration. The facility's policies on activities of daily living and accommodation of needs emphasize providing appropriate care and assistance to maintain or improve residents' abilities to perform daily tasks. However, the staff failed to adhere to these policies, as evidenced by the lack of assistance provided to the resident during meals, despite the resident's clear need for support due to their physical limitations and cognitive impairments.
Failure to Follow Wound Care Treatment Plan for Resident with Stage 3 Pressure Injury
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a stage 3 pressure injury on the right heel. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, unspecified protein-calorie malnutrition, and hyperlipidemia, was assessed as having severely impaired cognitive skills and required substantial assistance with daily activities. Despite having an order for specific wound care treatment starting on October 1, 2024, the treatment plan was not followed from October 1 to October 7, 2024. The treatment plan required cleansing with normal saline, applying collagen powder, and covering with a dry dressing, but this was not implemented as per the physician's order. Interviews with nursing staff revealed discrepancies between the treatment plan documented in the physician's order and the wound care physician's progress note. The registered nurse and treatment nurse acknowledged the inconsistency and failure to follow the wound care physician's treatment plan, which included using a wound cleanser, applying collagen, and covering with calcium alginate and bordered gauze dressing every three days. The Director of Nursing confirmed that the treatment plan should have been verified and followed to ensure proper wound care and healing, as per the facility's policy and procedure on pressure ulcers and skin breakdown.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
The facility failed to ensure the head of bed (HOB) was elevated at a 30-degree angle for a resident receiving gastrostomy tube (GT) feeding, as per the facility's policy. The resident, identified as Resident 28, was observed receiving GT feeding with the HOB less than 30 degrees elevation. This observation was made during a concurrent room visit and interview with LVN 1, who acknowledged that the HOB should be at least 30 to 45 degrees to prevent aspiration, which can lead to pneumonia if the resident vomits and the feeding enters the lungs. Resident 28 was initially admitted to the facility with diagnoses including dysphagia and was dependent on assistance for daily activities. The resident's care plan, initiated on 4/9/2024, indicated the need to elevate the HOB during GT feeding. The facility's policy, revised in November 2018, also required the HOB to be elevated at least 30 degrees during tube feeding to prevent aspiration. Despite these directives, the deficiency was noted during the survey, with both the LVN and the Director of Nursing confirming the requirement for HOB elevation during feeding.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as required by their policy. The resident, who had an intact cognitive ability for daily decision-making, had previously informed staff about his PTSD triggers, which included seeing guns and violence on television. However, during interviews, both a CNA and an LVN were unaware of the resident's PTSD diagnosis and triggers, indicating a lack of communication and awareness among the staff. The Social Services Director confirmed that the resident did not have a care plan for trauma-informed care and acknowledged that the resident should have been reassessed for trauma-informed care upon readmission. The facility's policy on trauma-informed care emphasized the importance of minimizing triggers and re-traumatization through proper assessment and care planning, which was not followed in this case.
Failure to Verify Competency of Temporary Nursing Staff
Penalty
Summary
The facility failed to ensure that a Registry Certified Nursing Assistant (RCNA 1) had the necessary competencies before providing care to residents. RCNA 1 worked in the facility on a specific date without the Director of Staff Development (DSD) verifying their competency skills and certification. The DSD admitted to not having checked or requested documentation of RCNA 1's competency skills or certificate verification, relying solely on verbal confirmation from the registry. This oversight meant that the facility did not have any documentation or information regarding RCNA 1's competency skill sets before they began working. The Director of Nursing (DON) also acknowledged the importance of knowing the competency skill sets of staff to ensure proper care and resident safety. However, the facility lacked documentation of RCNA 1's competencies. The facility's policy and procedure on competency and training emphasized the need for an effective training program for all staff, including those under contractual arrangements, to ensure they possess the necessary skills to meet resident needs and ensure safety. This deficiency had the potential to result in residents not receiving appropriate nursing services and placed them at risk for injury or harm.
Unjustified Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from the unnecessary use of a psychotropic drug, specifically Risperdal, as there was no clinical justification for its use. The resident, who was initially admitted and later readmitted to the facility, had diagnoses including major depressive disorder and dementia but did not have a diagnosis of schizophrenia, which is one of the conditions Risperdal is used to treat. Despite this, the resident was prescribed Risperdal 0.5 mg twice a day upon discharge from a general acute care hospital, and this prescription was continued at the facility without proper justification. The Director of Nursing (DON) and Registered Nurse 3 (RN 3) both acknowledged that there was no evidence to support a diagnosis of schizophrenia for the resident. The DON confirmed that the resident received Risperdal without a diagnosis of schizophrenia, and RN 3 admitted to transcribing the medication order from the hospital discharge without verifying the diagnosis. The facility's policy requires that residents transferred from a hospital and receiving antipsychotic medications be evaluated for the appropriateness and indications for use, which was not adhered to in this case. The facility's policy and procedure on antipsychotic medications, revised in July 2022, clearly state that residents should not receive medications that are not clinically indicated to treat a specific condition. Despite this policy, the resident's psychiatric evaluations did not list Risperdal as a current medication, and there was no documentation of a schizophrenia diagnosis in the resident's health records. This oversight led to the unnecessary administration of Risperdal, which was not clinically justified according to the facility's own guidelines.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident 68, which is a violation of the care plan and facility policy. The resident had expressed a preference for Mexican food, including tacos and beef soup, on multiple occasions. However, these preferences were not honored on specific dates, despite being documented in the resident's care plan and food preference records. This failure to provide the requested meals was observed through various records, including the resident's Speech/Language Pathology Daily Note and Dietary Progress Notes. Resident 68, who has severe cognitive impairments and requires assistance with daily activities, was admitted with diagnoses including major depressive disorder, metabolic encephalopathy, and dementia. The resident's nutritional care plan specified a mechanical soft, no added salt diet, and emphasized the importance of honoring reasonable food preferences. Despite this, the facility did not provide the requested Mexican food, leading to multiple meal refusals by the resident throughout September 2024, as documented in the Daily Meal Eating Log. Interviews with facility staff, including the Dietary Service Supervisor (DSS) and the Director of Nursing (DON), revealed a lack of awareness and documentation regarding the resident's food preferences. The DSS admitted that Mexican food was not regularly included in the menu, except on specific occasions like Cinco de Mayo. The DON acknowledged the absence of documentation showing that the resident's meal preferences were offered, which could lead to meal refusals and potential weight loss. The facility's policy on accommodating resident needs and food preferences was not adhered to, as evidenced by the lack of Mexican food options provided to Resident 68.
Failure to Offer Pneumococcal Vaccine Upon Readmission
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to Resident 2 upon readmission on 9/26/2024, as required by the facility's policy. Resident 2, who was admitted with conditions including ventricular tachycardia, Parkinson's Disease, and major depressive disorder, had previously refused the vaccine on 4/14/2022. However, there was no documentation of the vaccine being offered or declined during the current admission, nor was there any record of education provided to the resident about the vaccine. Interviews with the Director of Nursing and the Infection Preventionist Nurse confirmed that the facility's protocol requires staff to offer the pneumococcal vaccine during all admissions and readmissions, and to document the administration or declination in the resident's medical record. The Infection Preventionist Nurse acknowledged that the vaccine was not offered to Resident 2 during the current admission, which was a deviation from the facility's policy. Resident 2 expressed interest in receiving the vaccine, citing a history of pneumonia, but could not recall being offered the vaccine during the current admission.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required square footage per resident bed in 25 out of 27 resident rooms. The deficiency was identified during a re-certification survey conducted from October 15 to October 18, 2024. Observations revealed that rooms 1 to 9 and 11 to 26 did not meet the minimum requirement of 80 square feet per resident. Despite the deficiency, residents did not express complaints about the room size, and staff reported that there was sufficient space to provide care and store residents' belongings. Wheelchair-bound residents were able to move in and out of their rooms without difficulty. Interviews with residents and staff further supported that the room sizes did not hinder the provision of care. For instance, Resident 45, who uses a wheelchair, stated that she had no issues with the room size and that staff assistance was adequate. Similarly, a Certified Nursing Assistant (CNA) reported that the room was spacious enough to care for residents, as demonstrated by the successful transfer of Resident 52 from bed to wheelchair. Despite these observations, the facility's room waiver request indicated that the rooms did not meet the required square footage, prompting the Department to recommend a waiver for the affected rooms.
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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