Sunnyview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2000 W Washington Bl, Los Angeles, California 90018
- CMS Provider Number
- 555071
- Inspections on file
- 36
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Sunnyview Care Center during CMS and state inspections, most recent first.
A resident with a history of traumatic subdural hemorrhage and repeated falls experienced an unwitnessed fall when attempting to get out of bed to go to the bathroom without using the call light, resulting in contact with the floor and minor injury to the nose. Despite a Change of Condition note documenting this event, two MDS assessments indicated that the resident had not had any falls since admission, entry, reentry, or the prior assessment, and no significant error assessment was completed to correct the record. The MDS Coordinator acknowledged that the event met the facility’s definition of a fall and should have been coded as such, and the DON confirmed that facility policies requiring accurate, complete documentation of incidents and accidents were not followed.
A resident with a traumatic subdural hemorrhage, repeated falls, severe cognitive impairment, and documented need for extensive assistance with transfers had a physician’s order and care plan for continuous 1:1 sitter supervision due to frequent unassisted attempts to get out of bed. The facility’s own fall risk assessment and policy on Safety and Supervision of Residents identified the need for targeted interventions and adequate supervision. Despite this, the night-shift assignment sheet did not include a 1:1 sitter, progress notes showed no evidence of 1:1 monitoring, and no staff were present at shift change. The resident subsequently got out of bed without using the call light, fell, and sustained a bump and superficial cut to the nose, with the fall unwitnessed and no sitter documented as present.
A resident with ESRD on hemodialysis, hypertension, and a history of falls experienced prolonged waits after dialysis treatments because the facility did not ensure transportation was properly notified of post-dialysis pick-up times. On at least one occasion, dialysis records showed treatment ended mid-afternoon while the resident was not picked up until several hours later, requiring the dialysis center to arrange an Uber ride back. The resident reported that transportation frequently arrived too early, too late, or not at all, and that he had waited for hours feeling tired, weak, hungry, and ignored. Review of the resident’s dialysis/transportation flyer showed it only listed the outbound pick-up time from the facility and omitted a return pick-up time, and the SSD acknowledged this omission despite a policy stating social services must help arrange needed transportation and address transportation concerns.
Licensed nurses did not perform required weekly skin progress reports for a resident with moisture-associated skin damage (MASD), despite the resident's high risk for skin breakdown due to diabetes, immobility, incontinence, and other factors. Facility policy and the care plan called for weekly assessments, but these were not completed, as confirmed by both the treatment nurse and DON.
A resident with cognitive impairment and high fall risk experienced a fall from a wheelchair, but staff did not conduct an IDT review or update the care plan as required. After a subsequent fall from bed, staff returned the resident to bed without notifying the charge nurse or assessing for injuries, resulting in a fractured femur and hospital transfer.
A resident with cognitive impairment and multiple medical conditions was not assessed for pain after a fall when a CNA failed to notify the Charge Nurse, instead returning the resident to bed and monitoring for discomfort. The facility's policy requiring immediate reporting and documentation of incidents was not followed, resulting in a delay in pain assessment and intervention.
Three residents did not have accurate MDS assessments completed, including failure to document the use of an anti-psychotic medication, significant weight loss, and the use of an anti-coagulant. These omissions were confirmed by the MDS nurse and were inconsistent with the residents' medical records and physician orders.
A resident with multiple medical conditions, who was cognitively intact and required substantial assistance with ADLs, was limited to smoking only one cigarette per day at a set time by the DON, rather than being allowed to smoke at her own preference. This restriction, imposed due to the resident's wounds and weakness, was found to violate the resident's rights as outlined in the facility's policy.
A resident with dementia, bipolar disorder, and schizophrenia, who lacked decision-making capacity, was started on Depakote and risperidone without written informed consent or an IDT meeting as required by facility policy. The DON confirmed that the necessary consent forms were not signed and no IDT meeting occurred prior to medication initiation.
A resident with severe cognitive impairment and significant ADL needs was found to have curtains hanging from a bent curtain rod, resulting in a lack of privacy and a potential safety hazard. The resident expressed feeling violated due to visibility from outside, and the Maintenance Supervisor confirmed the poor condition of the curtain and rod, which did not support a homelike environment.
Two residents with limited range of motion did not receive required services: one did not receive timely quarterly joint mobility assessments to monitor changes in ROM, and another did not receive daily passive range of motion exercises as ordered by the physician. These failures were confirmed by staff and documented in facility records, in violation of facility policies and procedures.
A resident with severe cognitive impairment and multiple medical conditions continued to have a peripheral IV catheter in place two days after the completion of IV antibiotic therapy. Facility policy required immediate removal of the catheter after therapy, but this was not done, as confirmed by staff during observation and interview.
A resident with multiple medical conditions was prescribed Lyrica, a controlled medication. The facility failed to maintain accurate documentation and accounting of the drug, with discrepancies found between the destruction log, medication bubble pack, and drug record form. The DON noted that doses were given without proper documentation, and required procedures for shift handoff and medication reconciliation were not followed, resulting in uncertainty about the drug's disposition.
A resident with multiple medical conditions was prescribed Depakote for a mood disorder, and the consultant pharmacist recommended ordering valproic acid and ammonia levels to monitor medication safety. The facility did not inform the physician or act on this recommendation, and no orders for the tests were placed, contrary to facility policy requiring timely follow-up on pharmacy consultant recommendations.
A resident with severe cognitive impairment and multiple diagnoses did not receive monthly ammonia level lab tests as ordered by the physician. Review of records showed that the required tests were not completed for several months, and there was no documentation of results, despite facility policy requiring staff to arrange for such tests.
A resident with a feeding tube, identified as being at moderate risk for infection, did not receive care in accordance with enhanced barrier precautions. An LVN was observed checking the feeding tube while wearing gloves but not a gown, despite facility policy and posted signage requiring both. The LVN later acknowledged the omission and its importance in preventing infection.
A trash dumpster lid was observed open and filled with trash during a walkthrough with the Dietary Supervisor, who confirmed that dumpsters should remain closed according to facility policy. This failure to keep the dumpster lid closed was not in accordance with the facility's waste control procedures.
A resident with a history of cognitive impairment and psychiatric diagnoses, who had been refusing prescribed antipsychotic medication, physically assaulted another resident, causing serious injuries including head trauma and a suspected facial fracture. Staff were aware of the resident's medication non-compliance and escalating paranoia but did not take effective action to prevent the assault, resulting in a violation of the facility's abuse prevention policy.
A resident with schizophrenia and a history of medication non-compliance was not provided with an IDT meeting as required by their care plan. The resident refused Lithium Carbonate on multiple occasions, and the facility failed to notify the physician or document the refusals properly. The DON acknowledged the need for an IDT meeting, which was not conducted, leading to unaddressed medication refusals.
A facility failed to adhere to its infection control policy when an LVN was observed drinking cranberry juice and placing a personal cell phone on a medication cart, both actions contrary to the facility's 'Work Practices' policy. The LVN acknowledged the risk of germ spread and illness from these actions, which violated the policy prohibiting food and drink in areas of possible contamination.
A resident with schizoaffective disorder and mobility issues fell during a shower due to the absence of a specific ADL care plan for showering supervision. Despite requiring supervision, the resident was left unsupervised by a CNA, resulting in a fall. The DON acknowledged the need for a care plan, as per facility policies, to ensure proper supervision during such activities.
A facility failed to protect and account for personal belongings of two residents, leading to a deficiency. One resident's ID, Medi-Cal card, and passport were not documented or accounted for, while another resident's Bible CDs were lost. The facility did not follow its policy on inventorying and documenting personal property, nor did it investigate the complaints of missing items.
A resident with complex medical conditions received oxygen without a physician's order, leading to low oxygen saturation levels. The LVN failed to notify the physician as required by the care plan, resulting in a delay in appropriate interventions and the resident's transfer to a hospital. The facility did not adhere to its policies on changes in condition and oxygen administration.
A resident with multiple diagnoses had discrepancies in their cognitive assessment records and experienced a change in condition that was not thoroughly documented. The facility failed to maintain complete clinical records, as vital signs and a detailed account of the resident's condition change were missing from the progress notes, contrary to the facility's policy.
The facility failed to ensure call lights were within reach for three residents, potentially delaying necessary care. A resident was found unable to reach his call light, tied to a nightstand, while two others had their call lights clipped to an overhead light cord. Staff acknowledged the oversight, and the DON confirmed the importance of accessible call lights, as per facility policy.
The facility did not perform yearly competency assessments for three CNAs, as required by policy. The DSD acknowledged the oversight, which could jeopardize resident safety by not ensuring staff have the necessary skills. The DON confirmed the importance of these assessments for maintaining care standards.
The facility failed to label three tubs of ice cream with received-by and delivery dates in Freezer #5, risking the use of expired food. Additionally, a dirty apron bin was improperly placed in the dry storage area, potentially contaminating food items. These actions were against the facility's policies, as confirmed by dietary staff and the supervisor.
The facility failed to implement proper infection control measures for two residents on Enhanced Standard Precautions due to their use of gastrostomy tubes. Staff did not wear the required PPE, specifically gowns, when administering medication via g-tube, which could lead to cross-contamination and infection spread. Both residents had significant medical conditions and were dependent on staff for daily activities, necessitating strict adherence to infection control protocols.
A resident with Alzheimer's and a seizure disorder was observed using a lap buddy restraint in a wheelchair without regular evaluations or attempts to use less restrictive measures. Staff acknowledged the lack of ongoing assessments, contrary to facility policy, which required frequent reassessment and reduction of restraints.
A facility failed to resubmit a PASRR Level I screening for a resident with epilepsy, anxiety disorder, and schizophrenia after a hospital exemption, despite the resident staying over 30 days. The MDS coordinator admitted the oversight, which was against the facility's policy requiring a new PASRR submission if a resident remains longer than 30 days. This failure potentially impacted the resident's psychiatric treatment and evaluation.
A facility failed to accurately complete the PASRR Level 1 screening for a resident with schizophrenia, resulting in the omission of a necessary Level 2 evaluation. The resident's records indicated a diagnosis of schizophrenia and dementia, but the screening did not reflect this, leading to the case being closed without further evaluation. The MDS coordinator acknowledged the error, which potentially prevented the resident from receiving appropriate treatment recommendations.
A facility failed to implement a bed alarm for a resident at high risk for falls, despite it being part of the care plan. The resident, with Alzheimer's and a seizure disorder, was found trying to get out of bed without the alarm. Interviews revealed staff were unaware of the care plan requirement, contrary to facility policy.
A resident's nasal cannula for oxygen therapy was found undated and improperly stored, risking contamination. The resident also lacked a physician's order for oxygen, which is required for safe administration. The facility's policy did not specify the need for covering oxygen tubing when not in use, contributing to the oversight.
A resident with cerebral infarction and contracture of the left hand was observed without prescribed splints, and the facility failed to document the resident's refusal to wear them. The RNA admitted to not documenting the refusal, and the LVN was unaware of the situation. The DON confirmed that documentation and reporting were required per facility policy.
Inaccurate MDS Coding of Resident Fall Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment related to a resident’s health conditions, specifically falls. The resident was admitted with diagnoses including traumatic subdural hemorrhage, repeated falls, restlessness, and agitation. An H&P dated 1/10/2026 documented that the resident had the mental capacity to understand but could not make medical decisions. An MDS dated 1/14/2026 indicated severe cognitive impairment, no acute change in mental status, no hallucinations or delusions, and that the resident required maximal assistance for bed mobility, transfers, and walking ten feet in the room. This MDS also indicated the resident had not experienced any falls since admission, reentry, or the prior assessment. On 1/16/2026, a Change of Condition (COC) documented that at 8:30 a.m. the resident got out of bed without using the call light to go to the bathroom, their knees buckled, and they made contact with the floor, sustaining a small bump and superficial cut to the nose with minimal bleeding. A subsequent MDS again documented that the resident had not had any falls since admission, entry, reentry, or the prior assessment, despite the documented fall on 1/16/2026. During interviews, the MDS Coordinator acknowledged that the 1/16/2026 event met the facility’s definition of a fall (any unintentional contact with the ground), that it was unwitnessed, and that it should have been coded as a fall on the MDS and as a fall since the prior assessment, but was not. The MDS Coordinator also confirmed that no significant error assessment was completed to correct the inaccuracy. The DON stated that facility policy requires assessments and documentation to be accurate, complete, and to include events, incidents, and accidents, and that this policy was not followed when the MDS failed to reflect the resident’s fall.
Failure to Provide Ordered 1:1 Sitter Supervision Resulting in Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Safety and Supervision of Residents policy, as well as the physician’s order and care plan, to provide continuous 1:1 sitter supervision for a resident at high risk for falls. The resident was admitted with diagnoses including traumatic subdural hemorrhage, repeated falls, restlessness, and agitation. A Rehab Fall Risk Assessment dated 1/9/2026 documented that the resident required extensive assistance for bed mobility and transfers, used a wheelchair without proper safety, did not use the call bell properly, did not demonstrate safety techniques during transfers, and lacked sufficient strength and posture in sitting or standing. The H&P dated 1/10/2026 indicated the resident had the mental capacity to understand but could not make medical decisions. A physician’s order dated 1/13/2026 required 1:1 monitoring every shift because the resident constantly attempted to get out of bed unassisted. The MDS dated 1/14/2026 showed severe cognitive impairment and a need for maximal assistance for transfers and ambulation in the room. The resident’s care plan, also dated 1/14/2026, identified non-compliance with unassisted transfers and risk of falls/injuries, and directed CNAs to provide a 1:1 sitter. Despite this, the nursing assignment sheet for the 11:00 p.m.–7:00 a.m. shift on 1/15/2026 did not list a 1:1 sitter for the resident’s room, and progress notes from 1/15/2026 at 11:00 p.m. through 1/16/2026 at 7:00 a.m. contained no indication that 1:1 supervision was provided. On the 7:00 a.m.–3:00 p.m. shift on 1/16/2026, the nursing assignment indicated that a CNA was assigned as a 1:1 sitter for the resident’s room. However, a Change of Condition note dated 1/16/2026 documented that at 8:30 a.m. the resident got out of bed to go to the bathroom without using the call light, his knees buckled, and he made contact with the floor, sustaining a small bump and superficial cut to the nose with minimal bleeding. The COC did not indicate that a 1:1 sitter was present or that the fall was witnessed. Interviews with CNAs, the MDS Coordinator, and the DON confirmed that the resident had an order for continuous 1:1 monitoring, that no sitter was present at the end of the night shift, that the fall was unwitnessed, and that the physician’s orders and care plan for 1:1 supervision were not followed. The facility’s policy required targeted interventions, including adequate supervision, to be implemented correctly and consistently, which did not occur in this case.
Failure to Coordinate Dialysis Transportation Leading to Prolonged Post-Treatment Waits
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate coordination of transportation for a resident who required thrice-weekly hemodialysis. The resident, who had end stage renal disease requiring dialysis, hypertension, and a history of repeated falls, was admitted and re-admitted to the facility and was cognitively able to express needs and understand information. The resident used a walker or wheelchair and required substantial/maximal assistance with several ADLs. Documentation from the hemodialysis flowsheet showed that on 1/7/2026, the resident’s dialysis treatment ran from 10:48 a.m. to 2:56 p.m., but an Uber receipt from the hemodialysis center indicated the resident was not picked up until 5:29 p.m. and did not arrive back at the facility until 6 p.m. A hemodialysis social worker note stated that on that date the resident experienced long wait times after treatment, was not picked up by the arranged transportation, and the hemodialysis administrator had to assist with arranging Uber transportation back to the facility. Interviews and record review showed that the facility’s social services did not ensure that transportation pick-up times from the hemodialysis center were properly arranged or communicated. The Social Services Director (SSD) reported that the resident had ongoing problems with dialysis transportation related to insurance, including transportation arriving too early while the resident was still receiving treatment, but the SSD could not provide documentation of follow-up with the transportation agency. The resident reported that transportation during dialysis days often arrived too early, too late, or not at all, and stated he had waited three hours after dialysis for pick-up, feeling tired, weak, hungry, and ignored. The hemodialysis social worker indicated the problem could be that the facility did not inform transportation to arrange a pick-up time aligned with the end of treatment. Review of a document containing the resident’s insurance, dialysis schedule, and transportation information showed it listed only the pick-up time from the facility to the dialysis center and did not include a return pick-up time from the dialysis center. The SSD acknowledged that the flyer lacked a return pick-up time and that waiting for late or unarranged transportation would not make the resident feel good. The facility’s transportation policy stated that social services should help residents arrange needed transportation and that transportation concerns should be referred to social services.
Failure to Complete Weekly Skin Assessments for Resident with MASD
Penalty
Summary
The facility failed to follow its policy and procedure regarding skin breakdown by not performing weekly skin progress reports for a resident with moisture-associated skin damage (MASD). The resident had multiple risk factors, including diabetes mellitus, generalized muscle weakness, immobility, incontinence, and a history of candidiasis, all of which increased the likelihood of skin breakdown and infection. Documentation showed that the resident was dependent for personal hygiene and had documented skin impairment, with a care plan in place to resolve skin damage and reduce infection risk through regular skin assessments and weekly body checks. Despite these interventions being outlined in the care plan and facility policies, licensed nurses did not complete the required weekly skin assessments or progress reports for the resident during the specified month. Interviews with the treatment nurse and DON confirmed that weekly assessments were not performed, and the facility's policies required such monitoring and documentation. The lack of weekly assessments meant that the resident's MASD was not regularly evaluated for changes or response to treatment, as required by facility policy.
Failure to Implement Post-Fall Care Plan and IDT Review
Penalty
Summary
The facility failed to implement its policy and procedure for comprehensive, person-centered care planning following a resident's fall. After a non-verbal, bedbound resident with multiple diagnoses, including right knee osteoarthritis, hypertension, and ataxia, slid out of a wheelchair and onto the floor, the facility did not conduct an Interdisciplinary Team (IDT) meeting or document a post-fall care plan. The resident was identified as high risk for falls, and the facility's policy required measurable objectives and timetables to be developed and implemented after such incidents. However, there was no evidence of an IDT meeting or updated care plan in the resident's records after the initial fall. Subsequently, the same resident experienced another fall, sliding out of bed and onto the floor. Staff returned the resident to bed without notifying the charge nurse or supervisor and without a qualified staff member assessing for injuries. This resulted in the resident sustaining a fractured femur, enduring hours of pain, and requiring transfer to a general acute care hospital. Interviews with facility staff confirmed that required documentation and care planning were not completed after the initial fall, and the lack of these actions may have jeopardized the resident's safety.
Failure to Assess Pain After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with right knee osteoarthritis, hypertension, and ataxia was not assessed for pain following a fall. The resident, who had cognitive impairment and required substantial assistance with daily activities, was found on the floor by a CNA after a loud noise was heard. The CNA, noting the resident was nonverbal but nodded to indicate she was okay, did not notify the Charge Nurse of the fall due to nervousness and the presence of a recertification survey. Instead, the CNA returned the resident to bed and monitored for pain or discomfort without further assessment. A review of the resident's records indicated that, during a change of condition assessment, the resident exhibited facial grimacing and right leg pain when moved, but was unable to verbalize pain. The facility's policy required that all incidents or accidents be reported to the Charge Nurse and documented immediately, with the Charge Nurse responsible for the completeness and accuracy of the report. However, this protocol was not followed, resulting in a delay in pain assessment and intervention for the resident.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in incorrect data being transmitted to CMS. For one resident with diagnoses including paranoid schizophrenia and psychosis, the MDS did not reflect the administration of risperidone, an anti-psychotic medication, despite physician orders and documentation indicating its use. The MDS nurse confirmed that the anti-psychotic drug section was not properly marked, which was inconsistent with the resident's medication records. Another resident, diagnosed with congestive heart failure, anemia, and psychosis, experienced significant weight loss over a one-month period, as documented in the weights and vitals summary. However, the MDS assessment failed to code this weight loss under the appropriate section, despite clear evidence from the resident's records. The MDS nurse acknowledged the error, noting that the assessment should have indicated the resident was on a physician-prescribed weight-loss regimen due to the documented weight loss. A third resident, with diagnoses including hypertension, schizoaffective disorder, and atrial fibrillation, was prescribed Dabigatran Etexilate Mesylate, an anti-coagulant, as indicated in the order summary and care plan. The MDS assessment, however, did not document the use of this anti-coagulant. The MDS nurse confirmed that the medication should have been coded accordingly. Facility policies reviewed indicated that staff completing any portion of the MDS are required to certify the accuracy of the information provided.
Resident's Right to Smoke Restricted Against Policy
Penalty
Summary
A deficiency was identified when the facility failed to honor a resident's right to self-determination regarding smoking preferences. The resident, who was admitted with cellulitis of the right lower limb, sepsis, bacteremia, and an open wound to the right thigh, was found to be cognitively intact and required substantial assistance with activities of daily living. Despite this, the resident reported being limited to smoking only one cigarette per day at a designated time, as directed by the DON, rather than being allowed to smoke at her own preference. The resident expressed frustration and anger over this restriction. The DON confirmed that the limitation was imposed due to the resident's medical condition upon admission, specifically her weakness and wounds, and stated that the restriction would remain until her wounds began to heal. The facility's policy on resident rights, however, guarantees the right to exercise personal preferences, including smoking. The survey found that this practice resulted in a violation of the resident's rights as outlined in the facility's policy and federal and state regulations.
Failure to Obtain Informed Consent and IDT Review Before Initiating Psychotropic Medication
Penalty
Summary
The facility failed to obtain written informed consent and conduct an interdisciplinary team (IDT) meeting prior to initiating psychotropic medications for a resident diagnosed with dementia, bipolar disorder, and schizophrenia. The resident was determined to lack capacity to make decisions, as documented in the history and physical and the Minimum Data Assessment, which indicated severely impaired cognitive skills and total dependence on staff for daily care. Despite this, the resident was started on Depakote and risperidone based on physician telephone orders, and these medications were administered as documented in the medication administration records. During review, the Director of Nursing confirmed that informed consent forms for the psychotropic medications were not signed by the IDT and that no IDT meeting minutes were completed before the medications were initiated. The facility's policy required an IDT review and a bioethics meeting involving the resident's physician, another physician, and the IDT prior to administering psychoactive medications to residents lacking capacity, except in emergencies. These steps were not followed in this case.
Broken Curtain Rod Compromises Resident Privacy and Safety
Penalty
Summary
A deficiency was identified when a resident's room was found to have curtains hanging from a bent curtain rod, which had been in disrepair for some time. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, reported feeling violated due to the lack of privacy, as people outside could see into the room. The observation was made during a concurrent interview and inspection, confirming the ongoing issue with the room's curtains and curtain rod. The Maintenance Supervisor acknowledged responsibility for repairing equipment and furnishings and confirmed that the curtain and curtain rod in the resident's room were not in good condition and did not promote a homelike environment. The facility's policy on maintaining a homelike environment was reviewed, which emphasized the importance of staff and management maximizing characteristics that reflect a personalized, homelike setting. The deficiency resulted in a violation of the resident's right to privacy and a potential safety hazard.
Failure to Provide Timely ROM Assessments and Daily PROM Services
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for two residents with limited ROM. For one resident with diagnoses including bipolar disorder, dementia, and mobility abnormalities, the facility did not complete timely quarterly Joint Mobility Screenings/Assessments as required. The last assessment was completed at admission, and subsequent quarterly screenings were missed, which are necessary to monitor changes in ROM and determine if therapy services are needed. This omission was confirmed by both the Minimum Data Set Nurse and the Director of Rehab, who acknowledged that the screenings were not performed according to schedule. For another resident with diagnoses including dysphagia, seizures, and hemiplegia, the facility failed to ensure that passive range of motion (PROM) exercises were provided daily as ordered by the physician. Review of the RNA task forms showed that PROM was not performed every day, despite a physician's order for daily exercises. Both the Licensed Vocational Nurse and the Restorative Nurse Assistant confirmed that PROM was not completed as required, and acknowledged the importance of these exercises in preventing contractures and maintaining function. Facility policies and procedures reviewed indicated that residents with limited ROM should receive regular assessments and services to prevent further decline. The job description for the Restorative Nurse Assistant also specified the responsibility to assist residents with ROM exercises as ordered. The failure to follow these protocols resulted in missed opportunities to monitor and maintain the residents' joint mobility.
Failure to Remove Peripheral IV Catheter After Completion of Therapy
Penalty
Summary
A peripheral intravenous (IV) catheter was not removed from a resident after the completion of IV antibiotic therapy. The resident, who had diagnoses including urinary tract infection, dementia, and type 2 diabetes mellitus, was severely cognitively impaired and totally dependent on staff for daily care. According to the resident's medication administration records, the last dose of IV ceftriaxone was administered on 6/1/2025 at 4:30 p.m. On 6/3/2025, during an observation and interview, it was noted that the resident still had an IV line in place on the left hand, despite the antibiotic therapy having ended two days prior. The Minimum Data Set Nurse confirmed that the IV should have been removed immediately after the last dose, as per facility policy, which states that peripheral catheters are to be removed at the completion of therapy.
Failure to Accurately Account for and Document Controlled Drug
Penalty
Summary
The facility failed to ensure accurate accounting and documentation of a controlled drug, Lyrica, for one resident. The resident, who had diagnoses including hypertension, seizure disorder, and hemiplegia, was admitted with the capacity to make decisions and required moderate assistance with daily activities. Upon review, discrepancies were found in the documentation and physical count of Lyrica pills. The Controlled Medication Destruction Log indicated that 28 pills were turned in for destruction, but there was no signature to confirm receipt. The Director of Nursing (DON) did not sign the form due to an incorrect drug count, and the medication bubble pack showed 28 pills remaining, while the controlled drug record form indicated 30 pills. The DON stated that the nurse administered doses without documenting them and that proper handoff and drug count procedures during shift changes were not followed. Further review and interviews confirmed that the documentation did not accurately reflect the location or disposition of the controlled drug, and the process for destruction and reconciliation was incomplete. Facility policies required that controlled substances be reconciled at various points, including administration and shift changes, and that both the administering nurse and a witness sign off on the destruction of medications. The Licensed Vocational Nurse job description also required timely and accurate documentation of medication administration, which was not adhered to in this instance.
Failure to Act on Pharmacist's Recommendation for Medication Monitoring
Penalty
Summary
The facility failed to ensure that a consultant pharmacist's recommendation to consider ordering valproic acid and ammonia levels for a resident was acknowledged and acted upon. The resident in question had diagnoses including congestive heart failure, anemia, and psychosis, and was prescribed Depakote Delayed Release for mood disorder. The consultant pharmacist documented a recommendation in the Medication Regimen Review for the physician to consider ordering these laboratory tests to monitor the therapeutic blood level of the medication. However, the facility did not inform the resident's physician of this recommendation, and no orders for the tests were placed. The Director of Nursing confirmed that the facility's policy requires pharmacy consultant recommendations to be addressed within 14 days and that the purpose of the recommended tests was to ensure the medication was safe to administer. The facility's policy also states that recommendations should be acted upon and documented by staff or the prescriber, with the physician either accepting and acting on the suggestion or providing an explanation for disagreement. In this case, there was no documentation of action or physician response regarding the pharmacist's recommendation.
Failure to Complete Ordered Monthly Ammonia Level Lab Tests
Penalty
Summary
The facility failed to ensure that a laboratory test to check ammonia levels was completed monthly as ordered by the physician for one resident. The resident, who was admitted with diagnoses including bipolar disorder, dementia, and gait abnormalities, was determined to lack the mental capacity to make decisions and had severely impaired cognitive skills, requiring substantial assistance with daily activities. A physician's telephone order was placed for monthly ammonia level checks, but a review of the clinical records revealed that these tests were not completed for the months of March, April, and May. There was no documentation of the laboratory results for these months, and the Minimum Data Set Nurse confirmed that the tests had not been performed and results were unavailable. The facility's policy required staff to process test requisitions and arrange for laboratory tests as ordered by the physician. However, the required monthly ammonia level tests were not conducted, and there was no evidence in the records to indicate that the orders were followed. The Minimum Data Set Nurse acknowledged the omission and stated the importance of monitoring ammonia levels for the resident's medical management.
Failure to Follow Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
A deficiency occurred when staff failed to implement enhanced barrier precautions (EBP) during the care of a resident with a feeding tube. The resident, who had diagnoses including hypertension, dysphagia, and malnutrition, was dependent on staff for activities of daily living and was identified as being at moderate risk for infection related to his feeding tube. The resident's care plan and facility policy both required the use of gloves and a gown when providing care involving the feeding tube. During an observation, a Licensed Vocational Nurse (LVN) was seen applying gloves but not a gown while checking the resident's feeding tube residual. The EBP signage at the resident's room and bed clearly indicated the need for both gloves and a gown. In an interview, the LVN acknowledged that EBP should have been followed and admitted to forgetting to wear a gown, which she recognized put the resident at risk for infection. The facility's policy confirmed that gown and gloves are required for such care activities.
Failure to Keep Dumpster Lids Closed
Penalty
Summary
During an observation with the Dietary Supervisor, one of two trash dumpster lids was found open and filled with trash. The Dietary Supervisor confirmed that all dumpsters were supposed to remain closed and acknowledged that leaving the lid open could lead to pest and vermin infestation. A review of the facility's waste control and disposal policy indicated that trash bins should be covered at all times.
Failure to Prevent Resident-on-Resident Physical Abuse Due to Inadequate Implementation of Abuse Policy
Penalty
Summary
The facility failed to implement its policy and procedure regarding the identification and prevention of abuse, resulting in a serious incident involving two residents. One resident, with a history of hypertension, bilateral hearing loss, type 2 diabetes, and hypercalcemia, and who was cognitively intact but required assistance with activities of daily living, was physically assaulted by another resident. The assault occurred after staff heard a loud noise and discovered the resident on the floor, being kicked and stomped on the head by another resident. The injured resident sustained significant injuries, including swelling to the forehead, a suspected zygomatic arch fracture, traumatic injury to the right ear and temple, temporary unconsciousness, and bleeding, necessitating transfer to an acute care hospital for treatment and subsequent readmission to the facility. The resident who committed the assault had diagnoses including paranoid schizophrenia, mood affective disorder, hypertension, and type 2 diabetes, and was noted to have severely impaired cognitive skills but was independent with activities of daily living. This resident had a care plan addressing non-compliance with treatment, specifically refusal of prescribed antipsychotic medication (Haldol), which was documented as refused daily for over two weeks prior to the incident. Staff interviews confirmed that the resident's refusal of medication was known and that the risk of aggression due to non-compliance was recognized, yet the facility did not take effective action to mitigate this risk or prevent the assault. The facility's policy, which strictly prohibits any form of resident abuse, was not effectively implemented in this case. Staff were aware of the resident's escalating paranoia, delusions, and refusal of antipsychotic medication, but failed to prevent the resulting physical abuse. The incident was directly observed by multiple staff members, who confirmed the sequence of events and the severity of the injuries sustained by the assaulted resident.
Failure to Implement Care Plan for Non-Compliant Resident
Penalty
Summary
The facility failed to implement a care plan for a resident who was non-compliant with medication, specifically Lithium Carbonate prescribed for paranoid schizophrenia. The resident had a history of refusing medications for two months, and the care plan required an Interdisciplinary Team (IDT) meeting to address this non-compliance. Despite the care plan's directive, the facility did not conduct an IDT meeting, nor did they document the resident's response to non-compliance or notify the physician of the medication refusals on specific dates. The resident, diagnosed with schizophrenia, suicidal ideations, and restlessness, was admitted to the facility with a history of non-compliance. The resident refused medication on multiple occasions, and progress notes indicated episodes of distress and refusal to take psychiatric medications. The Director of Nursing acknowledged that an IDT meeting should have been conducted due to the resident's non-compliance. The facility's policy required IDT involvement to address refusals, but this was not followed, resulting in the resident's continued refusal of medication not being addressed.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement its policy and procedure titled 'Work Practices,' which indicated that drinks should not be stored in areas of possible contamination. During an observation, a Licensed Vocational Nurse (LVN) was seen reviewing the computer screen on the medication cart while drinking cranberry juice. In a subsequent observation and interview, the same LVN was observed with a cup of cranberry juice and her personal cell phone ringing on top of the medication cart. The LVN acknowledged that both the juice and cell phone belonged to her and admitted awareness that she should not be drinking cranberry juice or placing her personal cell phone on the medication cart due to the risk of germ spread and potential illness. The facility's policy, dated April 2023, clearly stated that food and drink should not be stored in areas with possible contamination.
Lack of ADL Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident had a care plan for Activities of Daily Living (ADL) specific to showering, which included necessary interventions. This deficiency was identified during a review of the resident's records and interviews with staff. The resident, who was admitted with diagnoses including schizoaffective disorder, restlessness, lack of coordination, and abnormalities of gait/mobility, required supervision for showers, dressing, and personal hygiene as indicated in the Minimum Data Set (MDS). However, on a shower day, a Certified Nursing Assistant (CNA) allowed the resident to shower without direct supervision, resulting in the resident falling and sustaining an injury. The Director of Nursing (DON) confirmed that the resident should have had a care plan detailing the required supervision during showering. The facility's policies and procedures mandate the development of a comprehensive person-centered care plan with measurable objectives and timetables to meet the resident's needs. The lack of a specific care plan for showering supervision led to the resident not receiving the necessary care, contributing to the fall incident.
Failure to Protect and Account for Residents' Personal Belongings
Penalty
Summary
The facility failed to ensure the protection and accountability of personal belongings for two residents, leading to a deficiency in maintaining a safe and homelike environment. Resident 1's identification card, Medi-Cal card, and passport were not documented on the resident's Inventory List, despite being submitted to the Social Services Director (SSD) by the resident's brother. The Business Office Manager (BOM) claimed not to have received these items, and the SSD admitted to not updating the Inventory List. This oversight resulted in the resident's personal documents being unaccounted for when the resident's representative received an envelope missing these items. Additionally, the facility did not prevent the loss or theft of Resident 3's personal belongings, specifically 20 Compact Discs (CDs) and a CD player. Resident 3, who is blind, reported the loss of her Bible CDs to the SSD and an unnamed supervisor, but the issue was not addressed. The Director of Nursing (DON) was unaware of the missing CDs and acknowledged the importance of these items for Resident 3's well-being due to her visual impairment. The facility's Policy and Procedure on Personal Property, which mandates the inventory and documentation of residents' belongings upon admission and as necessary, was not followed. The policy also requires prompt investigation of any complaints regarding misappropriation or mistreatment of resident property, which was not conducted in these cases. This failure to adhere to established procedures contributed to the deficiency in safeguarding residents' personal belongings.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for oxygen administration, which led to the resident receiving oxygen without proper authorization. The resident, who had a history of complex medical conditions including metabolic encephalopathy, sepsis, pneumonitis, diabetes mellitus, anemia, hypertension, chronic systolic heart failure, bacteremia, kidney failure, and adult failure to thrive, was admitted without an order for oxygen. On a specific date, the resident experienced low oxygen saturation levels of 79%-81% while on 2 liters of oxygen per minute, yet the physician was not notified to obtain the necessary orders for oxygen administration. The Licensed Vocational Nurse (LVN) on duty did not follow the facility's policy to notify the physician of the resident's change in condition, as indicated in the care plan. The Director of Nursing (DON) confirmed that the care plan required prompt notification of the medical doctor for respiratory distress symptoms, which was not done. The facility's policy and procedure for changes in a resident's condition and oxygen administration were not adhered to, resulting in a delay in receiving appropriate interventions from the physician, ultimately leading to the resident's transfer to a general acute care hospital.
Incomplete Clinical Records for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, which is necessary for providing appropriate care. The resident was admitted with multiple diagnoses, including metabolic encephalopathy, sepsis, pneumonitis, diabetes mellitus, anemia, hypertension, chronic systolic heart failure, bacteremia, kidney failure, and adult failure to thrive. A discrepancy was noted between the resident's History and Physical (H&P) and the Minimum Data Set (MDS) regarding the resident's cognitive ability and decision-making capacity. The H&P did not indicate the resident's capacity to understand and make decisions, while the MDS showed impaired cognitive ability and dependence on staff for activities of daily living and mobility. On a specific date, the resident experienced shortness of breath, and vital signs were taken but not documented in the progress notes by the Licensed Vocational Nurse (LVN). The Director of Nursing (DON) confirmed that the progress notes were incomplete, lacking a thorough account of the assessment, interventions, and physician notification of the change in the resident's condition. The facility's policy and procedure for changes in a resident's condition or status required detailed observations and documentation, which were not followed in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for three residents, leading to a potential delay in obtaining necessary care. Resident 65 was observed in his room, unable to reach his call light, which was tied to the nightstand. Despite being awake and alert, Resident 65 had to resort to pressing the TV remote control and shouting for help. The resident's medical history included cerebral infarction, contracture of the left hand, and major depression, and he was dependent on staff for activities of daily living. A CNA admitted to forgetting to check the call light during rounds, acknowledging the risk of falls if the call light was not accessible. In another instance, the call lights for two residents, Resident 43 and Resident 72, were found clipped to a string on the overhead light above their beds, out of reach. Resident 43 had a history of type 2 diabetes, anxiety disorder, and schizophrenia, and required supervision for daily activities. Resident 72 had dementia, anxiety disorder, and chronic kidney disease, and also required assistance for daily living activities. A CNA confirmed that the call lights should not have been placed on the overhead light cord and emphasized the importance of having them within reach for emergencies. The Director of Nursing confirmed that call lights should always be within reach to prevent potential harm to residents. The facility's policy on call lights stated that staff should ensure call lights are accessible to residents in their rooms or when on the toilet. The failure to adhere to this policy resulted in a deficiency that could have delayed necessary care and services for the affected residents.
Failure to Conduct Yearly Competency Assessments for CNAs
Penalty
Summary
The facility failed to ensure that competency assessment skills were performed yearly for three out of five randomly selected Certified Nursing Assistants (CNAs). During an interview and record review with the Director of Staff Development (DSD), it was found that CNAs 2, 3, and 5 did not have their competency assessments completed on an annual basis. The DSD acknowledged that these assessments should be conducted upon hire and then yearly, and she was responsible for completing them. The lack of these assessments could potentially jeopardize resident health and safety, as it would prevent the facility from assessing the necessary skills to provide nursing services. The Director of Nursing (DON) confirmed that all nursing staff should have current competency assessments to ensure they can provide the standard of care and practice within regulations. The facility's policy and procedure, titled 'Sufficient and Competent Nursing Staffing,' revised in August 2022, indicated that the facility is required to provide sufficient numbers of nursing staff with the appropriate skills and competency necessary to care for all residents in accordance with their care plans and the facility assessment. The failure to perform these assessments as per policy could lead to a deficiency in providing adequate care to residents.
Deficiencies in Food Labeling and Storage Practices
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, as well as maintaining cleanliness in the kitchen area. During an observation, three tubs of ice cream in Freezer #5 were found without received-by and delivery dates. This oversight was confirmed by Dietary staff, who acknowledged that the tubs should have been dated to prevent the risk of serving expired food, which could potentially cause illness among residents. The Dietary Supervisor also confirmed that all food items should be labeled with appropriate dates to avoid possible contamination and foodborne illnesses. Additionally, a dirty apron bin was observed in the dry storage area of the kitchen, which is against the facility's policy. The presence of the dirty apron bin in the dry storage area was acknowledged by the Dietary staff and the Dietary Supervisor, who stated that it could lead to contamination of food items stored in that area. The facility's policy requires that storage areas be clean, dry, and well-ventilated, and that all items in refrigerators and freezers be properly covered, dated, and labeled.
Failure to Implement Infection Control Measures for Residents on Enhanced Standard Precautions
Penalty
Summary
The facility failed to implement proper infection control measures for two residents, identified as Residents 15 and 24, who were on Enhanced Standard Precautions (ESP) due to their use of gastrostomy tubes (g-tubes). Staff did not wear the required Personal Protective Equipment (PPE), specifically gowns, when administering medication via g-tube to these residents. This oversight was observed during a survey, and it was noted that the lack of PPE use could lead to cross-contamination and the spread of infections, putting other residents at risk. Resident 15 had a history of peripheral vascular disease, type 2 diabetes mellitus, and heart failure, and was assessed to rarely or never understand others, being dependent on staff for activities of daily living. Similarly, Resident 24 had diagnoses including cerebral infarction, acute kidney failure, and type 2 diabetes mellitus, and was also assessed to rarely or never understand others, requiring staff assistance for daily activities. Both residents were on ESP due to their g-tubes, and the facility's policy required the use of gowns and gloves during high-contact care activities, which was not adhered to by the staff.
Failure to Regularly Evaluate and Reduce Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 69, was free from the use of physical restraints unless necessary for medical treatment. Resident 69, who was admitted with Alzheimer's disease and a seizure disorder, was observed using a lap buddy restraint in a wheelchair. The resident's cognitive skills were severely impaired, and the restraint was reportedly used for safety due to involuntary movements. However, the facility did not conduct regular evaluations or attempt less restrictive measures as required. The last physical restraint assessment for Resident 69 was conducted several months prior, and no ongoing quarterly assessments were performed. During interviews, staff members, including an LVN and the MDS coordinator, acknowledged the lack of regular assessments and attempts to use less restrictive devices. The facility's policy required the interdisciplinary team to evaluate restraint measures and make recommendations, but this process was not followed. The Director of Nursing confirmed that physical restraints should not be permanent and should be reassessed frequently. The failure to conduct regular evaluations and explore less restrictive options placed Resident 69 at risk for unnecessary prolonged use of restraints.
Failure to Resubmit PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I screening was re-submitted for a resident after a hospital exemption, despite the resident staying in the facility for more than 30 days. This oversight was identified during an interview and record review, where it was noted that the resident, who had diagnoses including epilepsy, anxiety disorder, and schizophrenia, did not have the necessary PASRR Level II evaluation and determination completed. The resident was dependent on staff for activities of daily living, and the lack of a timely PASRR submission had the potential to impact the psychiatric level of treatment and evaluation the resident received. The Minimum Data Set (MDS) coordinator acknowledged that the PASRR should have been resubmitted on the 31st day of the resident's stay, as per the Department of Health Care Services Letter. The facility's policy indicated that a new Level I PASRR should be submitted if the pre-admission screening was exempted for fewer than 30 days and the resident remained at the facility longer than 30 days. The Director of Nursing confirmed that the PASRR is essential for assessing the services a resident may need. The failure to resubmit the PASRR was a deviation from the facility's policy and procedure, potentially affecting the resident's access to necessary services.
Failure to Accurately Complete PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident diagnosed with schizophrenia. The resident, who was originally admitted and later readmitted to the facility, had a documented diagnosis of schizophrenia and dementia. Despite this, the PASRR Level 1 screening did not reflect the resident's schizophrenia diagnosis, leading to the case being closed without a Level 2 evaluation. This oversight was identified during a review of the resident's records and an interview with the Minimum Data Set (MDS) coordinator, who acknowledged the error in the screening process. The resident's medical records, including the History and Physical (H&P) and Minimum Data Set (MDS), indicated significant cognitive and functional impairments, such as total dependence in personal care activities. The facility's policy required a new Level 1 PASRR to be submitted in case of any discrepancies, but this was not done. The failure to correctly identify the resident's mental disorder in the PASRR Level 1 screening potentially prevented the resident from receiving appropriate treatment recommendations for schizophrenia.
Failure to Implement Bed Alarm for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as high risk for falls. The resident, who was admitted with Alzheimer's disease and a seizure disorder, had severely impaired cognitive skills and required maximum assistance for daily activities. The care plan for this resident included the use of a bed alarm to alert staff when the resident attempted to get up unassisted. However, during an observation, the resident was found trying to get out of bed without a bed alarm in place, despite being on a low bed with side rails and a floor mat. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the bed alarm intervention was not implemented. The DON was unaware of the care plan requirement for a bed alarm, and the LVN confirmed that the resident was found on the floor mat without the alarm. The facility's policy on personal alarms and managing falls indicated that sensor pads should be used to alert staff to potential falls, but this was not followed for the resident in question.
Improper Storage and Use of Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident by not dating and properly storing a nasal cannula used for oxygen therapy. During an observation, an oxygen concentrator and nasal cannula were found at the resident's bedside, with the concentrator turned off and the nasal cannula undated and uncovered, exposing it to potential contamination. The Licensed Vocational Nurse (LVN) confirmed that the nasal cannula was not dated and lacked a protective covering, which is necessary to prevent contamination from room air. Additionally, the resident did not have a physician's order for oxygen therapy, which is required to administer oxygen safely. The Director of Nursing (DON) confirmed that a physician's order is necessary and that oxygen tubing should be dated and stored in a plastic bag with a label when not in use. The facility's policy on oxygen administration did not specify the need for covering oxygen tubing when not in use, contributing to the oversight.
Failure to Document Resident's Refusal of Splints
Penalty
Summary
The facility failed to document a resident's refusal to wear prescribed splints, which are external devices used to support and immobilize injuries or joints. This deficiency was identified through observation, interview, and record review. The resident, who was admitted with diagnoses including cerebral infarction and contracture of the left hand, was observed without the splints on multiple occasions. The resident's Minimum Data Set indicated dependency on staff for various activities and noted the provision of passive range of motion and splint assistance. However, the Restorative Nurse Assistant (RNA) admitted to not documenting the resident's refusal to wear the splints, which was a requirement per the facility's policy. The RNA stated that the splints were stored in the resident's drawer and acknowledged forgetting to document the refusal weekly. The Licensed Vocational Nurse (LVN) was unaware of the resident's refusal, and the Director of Nursing (DON) confirmed that the RNA should have documented the refusal and reported it to the charge nurse. A review of the facility's policy on charting and documentation emphasized the need for complete and accurate records, including details of procedures and treatments. The lack of documentation regarding the resident's refusal to wear the splints was a clear deviation from these standards.
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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