Alpine Skilled Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reno, Nevada.
- Location
- 3101 Plumas St, Reno, Nevada 89509
- CMS Provider Number
- 295043
- Inspections on file
- 25
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Alpine Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of verbally aggressive behavior used a racial slur during a verbal altercation with another resident who has a history of racial trauma. The incident was confirmed by staff and both residents, but the affected resident's care plan was not updated and documentation of the event was minimal, despite facility policies prohibiting discrimination and requiring prompt reporting.
A verbal altercation involving racial slurs occurred between two residents, one with a history of trauma, and was witnessed by an LPN. The DON did not initiate an official investigation, submit a Facility Reported Incident, or notify required parties, despite facility policy mandating prompt investigation and reporting of all abuse allegations.
A resident with nicotine dependence and on oxygen therapy repeatedly expressed intent to continue smoking and was observed attempting to smoke, but staff did not develop a care plan to address these behaviors. This omission led to an incident where the resident's wheelchair caught fire, resulting in burns, as no interventions or monitoring were in place to manage the risk.
Two residents were involved in a verbal altercation that included racial slurs, but their care plans were not updated to reflect the incident or address new behavioral concerns. Staff, including a CNA and an LPN, were unaware of any changes or new interventions, and the care plans did not document the altercation or provide guidance for managing future interactions.
A resident with nicotine dependence and COPD was not adequately supervised or care planned for continued smoking while using oxygen, despite staff awareness and facility policies prohibiting smoking. The resident was injured when their wheelchair caught fire while smoking with oxygen in place, and other residents had to intervene.
The facility failed to maintain comfortable temperatures in communal shower rooms, with temperatures recorded at 62.1°F, 62.4°F, and 67.6°F. Residents expressed discomfort and reluctance to use the shower rooms, opting for personal hygiene in their rooms instead. Staff acknowledged the issue, and the Maintenance Director and Engineering Manager confirmed the low temperatures. Facility policies require temperatures between 71°F and 81°F, which were not met, leading to widespread resident discomfort.
The facility failed to remove expired medications from two medication storage rooms and left a wound care cart unlocked near the 400 Hall nurses' station. Expired Iron Liquid Supplement and Tubersol vials were found, and the wound care cart contained potentially hazardous opened items. An LPN confirmed the cart was unlocked and acknowledged the potential hazard. Facility policy required outdated drugs to be returned or destroyed and carts to be locked when not in use.
A resident's personal and medical records were left visible on an unattended computer attached to a medication cart, violating confidentiality protocols. The RN responsible admitted to leaving the information accessible while attending to another resident. The DON confirmed the breach of privacy and emphasized the importance of protecting electronic health records.
A resident with a Foley catheter did not have a comprehensive care plan developed in a timely manner, despite having an indwelling catheter documented in their MDS assessments. Facility staff acknowledged that the care plan should have included specific interventions to prevent complications, but these were not implemented as required by facility policy.
A resident at high risk for falls experienced two falls, but the care plan was not updated with new interventions after the second incident. Despite the facility's policy requiring care plan updates following falls, the DON confirmed that the care plan lacked necessary revisions, such as ensuring the resident's belongings were within reach.
A resident with a right elbow wound did not receive physician-ordered daily wound care, as documented in the facility's records. An LPN assigned to the resident was unaware of the wound and did not provide care on a specific date. The DON confirmed the lack of documentation and acknowledged the oversight, which contradicted the facility's policy on wound management.
A resident with a history of type II diabetes and sepsis repeatedly requested a dental appointment for broken teeth and pain, but the facility failed to schedule it. Despite documentation of oral pain in the resident's care plan and MDS notes, the process involving social services and transportation services did not result in an appointment. The Director of Nursing acknowledged the importance of addressing the resident's dental needs.
The facility failed to address low ambient temperatures in three communal shower rooms, with temperatures recorded at 62.1°F, 62.4°F, and 67.6°F. The Administrator was unaware of the issue, while the Director of Engineering had been aware of a thermostat problem since December 19, 2024, but believed it was resolved. Maintenance staff did not communicate the ongoing issue, highlighting a lapse in communication and oversight.
The facility failed to document wound care treatments for four residents, resulting in incomplete clinical records. An LPN admitted to providing care but forgetting to document it, which was confirmed by the DON. The facility's policies require all treatments to be recorded, but the lack of documentation indicates a failure to adhere to these policies.
A Social Services employee entered a resident's room on contact-based isolation precautions without donning the required PPE, despite the room being clearly marked with a sign indicating the need for such precautions. The employee acknowledged awareness of the precautions but believed PPE was unnecessary as no direct care was provided. The incident was observed by an LPN, who reiterated the PPE requirement, and the DON confirmed the need for PPE to prevent infection spread.
The facility did not update the nursing staff posting daily as required, with the last update being two days old. The DON confirmed the posting was only in one location, not on each unit, and the Administrator acknowledged the oversight, confirming the posting was outdated and not compliant with the facility's policy.
A resident with chronic hepatic failure was subjected to verbal and physical abuse by a CNA, who yelled at them and threw a pillow. The resident's roommate witnessed the incident. The facility's DON confirmed the abuse and reported it to the Nevada State Board of Nursing, substantiating the allegations.
A resident with severe protein-calorie malnutrition and a stage four pressure ulcer did not receive a timely dietary evaluation or the prescribed Pro-Stat supplement. Despite a physician's order and confirmation by an RN, the January MAR lacked documentation of Pro-Stat administration. The facility's policies required a comprehensive nutrition assessment for such cases, which was not completed.
A resident with chronic conditions was asked by a Housekeeper to borrow money, which was against facility policy. Although the money was repaid, this action violated the resident's right to be free from misappropriation of property. An investigation confirmed the incident, and other residents reported no similar requests.
The facility failed to administer medications per physician's orders for two residents. An LPN administered the wrong dosage of Calcium Citrate-Vitamin D to one resident and applied a Lidocaine patch to the wrong shoulder for another. Both errors were confirmed by the LPN and acknowledged by the DON and Administrator.
Failure to Protect Resident from Racial Discrimination During Verbal Altercation
Penalty
Summary
The facility failed to protect a resident's right to a dignified existence and freedom from discrimination when a verbal altercation between two residents involved the use of racial slurs. One resident, with a diagnosis of bipolar disorder and a history of verbally aggressive behaviors, walked past another resident's room and, after being yelled at to leave, responded with a racial slur. The incident was confirmed by both residents and staff, with documentation indicating that the resident who used the slur had a care plan addressing verbally aggressive behaviors, but not specifically racial discrimination. The other resident, who has a history of post-traumatic stress disorder related to racial trauma, did not have their care plan updated following the incident. Staff interviews revealed that the incident was known to some, but not all, staff members, and that the facility's policies prohibit discrimination and require prompt reporting of such incidents. The Director of Nursing acknowledged the incident as racially abusive language and bullying, and noted that racism was a pervasive issue in the facility. Despite this, the clinical record for the resident who experienced the slur lacked documentation of the incident beyond a single communication note, and there was no evidence of additional interventions or care plan updates related to the racial discrimination event.
Failure to Investigate and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of verbal abuse involving two residents, one of whom had a history of post-traumatic stress disorder related to prior abuse and racial trauma. On the date of the incident, one resident walked past another resident's room, resulting in a verbal altercation where racial slurs were exchanged. The incident was witnessed by an LPN, who intervened after hearing the commotion from another hallway. Documentation shows that the social worker met with both residents the following day to discuss the incident, but the care plan for the resident with a history of trauma was not updated, and there was no further documentation or investigation into the event. The Director of Nursing (DON), who also served as the Abuse Coordinator, determined after a verbal conversation with the LPN that the incident did not constitute abuse and did not initiate an official investigation, submit a Facility Reported Incident (FRI) report, or notify the State Agency, Ombudsman, residents' families, or Medical Director. The facility's policy required that all allegations of abuse be investigated and reported within two hours, including interviews with all involved parties and appropriate notifications. However, the DON did not interview the residents involved or any potential witnesses, and the incident was not documented as an abuse allegation, resulting in a failure to follow established procedures.
Failure to Care Plan for Smoking Risk with Oxygen Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's ongoing nicotine dependence and stated intent to continue smoking, despite the resident's use of oxygen therapy and multiple documented behaviors indicating a desire to smoke. The resident, who had diagnoses including nicotine dependence and chronic obstructive pulmonary disease, repeatedly expressed intentions to smoke while on oxygen and was observed attempting to obtain cigarettes and expressing frustration over smoking restrictions. Staff were aware of the resident's behaviors and risk factors, as evidenced by nursing and behavioral notes, but did not include these issues in the resident's care plan. This lack of care planning resulted in staff being unaware of or unprepared for the resident's actions, culminating in a serious incident where the resident's wheelchair caught fire while the resident was outside, leading to burns on the resident's upper legs, abdomen, nostrils, and hands. Documentation shows that the resident had been counseled about the dangers of smoking with oxygen and had been prescribed nicotine replacement therapy, but no formal interventions or monitoring were established in the care plan to address the risk of smoking while using oxygen.
Failure to Update Care Plans After Resident Altercation Involving Racial Slurs
Penalty
Summary
The facility failed to update the care plans for two residents following a resident-to-resident altercation involving the use of racial slurs. One resident, with a diagnosis of bipolar disorder, was documented to have yelled a racial slur at another resident after being yelled at to leave the area. Both residents had a history of negative interactions, including police involvement. Despite documentation of the incident in nursing and social work notes, neither resident's care plan was revised to reflect the altercation or to address the new behavioral concerns that arose from the incident. Staff interviews revealed that direct care staff were unaware of any new interventions or changes to the care plans following the altercation. The care plans for both residents had not been updated to include the incident or to address the specific needs related to racial trauma and behavioral issues, as required by facility policy. The lack of care plan updates was confirmed by the Assistant Director of Nursing, who acknowledged that care plans should have been revised to document the incident and guide staff in preventing further occurrences.
Failure to Supervise Resident Smoking with Oxygen Resulting in Fire and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident with a history of nicotine dependence and chronic obstructive pulmonary disease who continued to smoke while using oxygen. Despite multiple documented instances where the resident expressed intent to smoke and was observed smoking on facility property, the care plan did not address the resident's risk factors related to smoking while on oxygen. Staff were aware of the resident's behavior, and there were several notes indicating the resident's frustration with smoking restrictions and attempts to smoke, including while on oxygen. The facility's policies required comprehensive care planning and strict adherence to oxygen and smoking safety, but these were not effectively implemented for this resident. On the date of the incident, the resident's wheelchair caught fire in the facility parking lot while the resident was smoking with oxygen in place, resulting in burns to the resident's upper legs, abdomen, nostrils, and hands. Other residents witnessed the event and intervened to help the resident. Staff interviews confirmed prior knowledge of the resident's unsafe smoking practices and lack of care plan interventions addressing these risks. The facility's smokefree policy and procedures for handling residents who refuse to follow safe smoking practices were not enforced in this case.
Inadequate Shower Room Temperatures
Penalty
Summary
The facility failed to ensure a comfortable ambient air temperature in the communal shower rooms, affecting multiple residents. Observations and interviews revealed that the temperatures in three shower rooms were recorded at 62.1°F, 62.4°F, and 67.6°F, which were considered too cold for comfortable use. Residents expressed discomfort and reluctance to use the shower rooms due to the chilly conditions, with some opting to perform personal hygiene in their rooms instead. Staff, including CNAs, RNs, and LPNs, acknowledged the residents' complaints and agreed that the shower rooms were too cold. The Maintenance Director and Engineering Manager confirmed the low temperatures and expressed that they would not want to shower in such conditions. The Administrator and Owner were aware of the issue, with the Owner noting that the facility had been waiting for a vendor to address the problem. The Director of Engineering became aware of a thermostat issue in December 2024 and believed it had been resolved, but maintenance staff did not communicate the ongoing problem. Facility policies guarantee residents the right to a safe, clean, comfortable, and homelike environment, with specified temperature ranges between 71°F and 81°F. The failure to maintain these temperatures in the shower rooms violated these policies, leading to widespread discomfort among residents. The report highlights the lack of effective communication and timely resolution of maintenance issues, contributing to the deficiency.
Expired Medications and Unsecured Wound Care Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from two of three medication storage rooms. During an observation, expired Geri Care Iron Liquid Supplement and Tubersol tuberculin purified protein derivative vials were found in the medication storage rooms. The Unit Manager confirmed the expiration of the Iron Liquid Supplement and the lack of opening dates on the Tubersol vials, which were considered expired. The Director of Nursing also confirmed the expiration of the Iron Liquid Supplement and acknowledged the potential adverse effects of administering expired medications. The facility's policy stated that outdated drugs should not be used and must be returned to the pharmacy or destroyed. Additionally, a wound care cart located near the 400 Hall nurses' station was found unlocked and unattended, containing potentially hazardous opened treatment items. These items included a bottle of sodium hypochlorite solution, a jar of Silver Sulfadiazine cream, and a tube of diclofenac sodium gel, all labeled for topical use only. An LPN confirmed the cart was unlocked and acknowledged the potential hazard if the items were consumed by residents. The LPN did not have a key to the cart, which was left open for scheduled wound care treatments. The facility policy required medication carts to be locked when not in use and not left unattended if opened.
Confidentiality Breach of Resident's Health Records
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records by leaving an electronic health record open and accessible on a computer attached to a medication cart. This incident involved a resident who was admitted with diagnoses including major depressive disorder and bipolar disorder. On the morning of January 6, 2025, the computer displayed the resident's name, picture, and current medications with associated diagnoses, while no staff member was present to monitor the cart. A Certified Nursing Assistant confirmed that the Registered Nurse responsible for the cart was attending to another resident on a different hall. The RN admitted to leaving the resident's information visible and unattended. The Director of Nursing acknowledged that the resident's personal information should not have been visible and emphasized the responsibility of staff to protect electronic health records from unauthorized access. The facility's policy on Protected Health Information mandates that such information should be managed and protected to prevent unauthorized disclosure.
Deficiency in Foley Catheter Care Planning
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a Foley catheter, which was identified as a deficiency. The resident, who had been admitted and readmitted with diagnoses including an unstable burst fracture and paraplegia, had an indwelling catheter documented in their Minimum Data Set (MDS) assessments. Despite this, the care plan lacked specific focus areas, goals, or interventions related to the catheter's care, such as monitoring for infection, cleaning the insertion site, and ensuring proper positioning of the drainage bag. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that a care plan for a resident with a Foley catheter should include specific interventions to prevent complications. The DON confirmed that a care plan should have been developed for the resident's catheter care, but it was not done in a timely manner. The facility's policy required the Interdisciplinary Team (IDT) to develop and update comprehensive, person-centered care plans, but this was not adhered to in the case of the resident with the Foley catheter.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update the care plan for a resident identified as high risk for falls, following two documented falls. The resident, who was admitted with diagnoses including metabolic encephalopathy and osteonecrosis of the right femur, experienced falls on two separate occasions. Despite being identified as high risk for falls in evaluations conducted on three different dates, the care plan was not updated with new interventions after the second fall. The care plan initially included reminders for the resident to ask for help with transfers and to follow the facility's fall protocol, but it lacked updates after the second fall to include additional preventive measures. The Director of Nursing (DON) confirmed that the care plan was not revised after the resident's fall on the second occasion, despite the facility's policy requiring such updates. The DON acknowledged that an intervention to place the resident's belongings within reach should have been added to the care plan. The facility's policy on fall prevention and management mandates that individualized precautions be noted for high-risk residents and that care plans be updated with appropriate interventions following a fall to prevent recurrence or minimize injury.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that physician-ordered wound care was performed for a resident, identified as Resident #448, which had the potential to worsen the resident's wound or delay healing. Resident #448 was admitted with diagnoses including metabolic encephalopathy and osteonecrosis of the right femur. On a specific date, it was observed that the dressing on the resident's right elbow was dated the previous day, indicating a lapse in daily wound care. The Treatment Administration Record (TAR) for January lacked documentation of wound care being provided on another specific date, despite an active physician's order for daily treatment. Interviews with facility staff revealed that the LPN assigned to the resident on the date in question was unaware of the wound and did not provide the necessary care. The Director of Nursing confirmed the absence of documentation for the required wound care and acknowledged that the resident should have received treatment according to the physician's order. The facility's policy on Skin and Wound Management emphasized the importance of providing services and treatment to prevent infection and promote healing, which was not adhered to in this instance.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to address a resident's repeated requests for a dental appointment to address broken teeth and pain with chewing food. The resident, who was admitted with diagnoses including type II diabetes mellitus and other specified sepsis, had been asking to see a dentist since May 2024. Despite verbalizing these concerns to nursing staff and social services, the resident did not receive confirmation of any efforts made to schedule a dental appointment or any barriers to receiving dental care. The resident's Minimum Data Set (MDS) notes and care plan documented oral pain and chipped teeth, yet no dental appointment was scheduled. The facility's process for scheduling dental appointments involved notifying social services, who would then send a referral to the Social Work Coordinator (SWC). However, the SWC's request to Transportation Services (TS) was not documented, and TS did not have a record of scheduling a dental appointment for the resident. The Transportation Log showed two entries requesting dental appointments, but one was crossed out as a duplicate, and there was no documentation indicating the resident still needed an appointment. The Director of Nursing acknowledged the importance of dental care for the resident's well-being and the need for documentation if there were delays in scheduling appointments.
Failure to Address Low Temperatures in Shower Rooms
Penalty
Summary
The facility failed to effectively manage its resources by not addressing low ambient temperatures in three communal shower rooms. On January 7, 2025, temperatures were recorded at 62.1°F, 62.4°F, and 67.6°F in the Boundary Peak, [NAME], and [NAME] Peak communal shower rooms, respectively. The Administrator was unaware of these low temperatures and admitted discomfort with the idea of showering in such conditions. The Director of Engineering had been aware of a thermostat issue since December 19, 2024, and had contacted a repair company, believing the problem was resolved. However, the maintenance staff did not communicate the ongoing issue to the Director of Engineering. The job descriptions for both the Administrator and the Director of Engineering outline their responsibilities in maintaining facility operations and ensuring quality care. The Director of Engineering is tasked with managing contracts, overseeing facility maintenance, and ensuring timely completion of work orders. The Administrator's role includes consulting with department managers to address and correct problem areas. Despite these outlined responsibilities, the failure to address the low temperatures in the shower rooms indicates a lapse in communication and oversight between the facility's administration and maintenance departments.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure proper documentation of wound care treatments for four residents, leading to deficiencies in maintaining accurate clinical records. Resident #3, diagnosed with spastic quadriplegic cerebral palsy and a stage 3 pressure ulcer, had multiple instances of undocumented wound care treatments in November and December 2024, and January 2025. The LPN Wound Care Nurse admitted to providing care but forgetting to document it, which was confirmed by the Director of Nursing (DON). Resident #198, with a history of spinal fusion and other lumbar conditions, also had missing documentation for wound care treatments in December 2024 and January 2025. The LPN Wound Care Nurse was responsible for documenting these treatments but failed to do so, leaving no proof that the care was provided on specific dates. Similarly, Resident #448, who had a skin tear on the right elbow, and Resident #133, with a right hip wound, both had missing documentation for wound care treatments in January 2025. The LPN Wound Care Nurse acknowledged providing the care but did not document it. The facility's policies on charting and documentation, as well as wound care, require that all services and treatments be recorded in the resident's medical record. The DON emphasized the expectation for nursing staff to document care as soon as possible and before the end of their shift. However, the lack of documentation for these residents indicates a failure to adhere to these policies, resulting in incomplete clinical records.
Failure to Follow Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed when a Social Services employee entered the room of a resident on contact-based isolation precautions without donning the required personal protective equipment (PPE). The resident, who was admitted with diagnoses including methicillin-resistant staphylococcus aureus (MRSA) and a recurrent urinary tract infection, was in a room clearly marked with a sign indicating the need for contact-based precautions. Despite this, the employee entered the room without wearing PPE, only using alcohol-based hand rub, and later confirmed awareness of the isolation precautions but believed PPE was unnecessary as no direct care was provided. The incident was observed by a Licensed Practical Nurse (LPN) who reiterated the requirement for PPE to the Social Services employee. The Director of Nursing (DON) also confirmed that the employee should have donned PPE to prevent infection spread. The facility's policy on isolation and transmission-based precautions, adopted in 2019, mandates that staff and visitors adhere to proper hand hygiene and wear gloves and disposable gowns when entering rooms under contact precautions. The resident expressed uncertainty about whether all individuals entering the room complied with the PPE requirements.
Failure to Post Current Nursing Staff Information
Penalty
Summary
The facility failed to ensure that current nursing hours were posted daily, as required by their policy. On January 5, 2025, it was observed that the nursing staff posting, located in the hallway near the entrance, was dated January 3, 2025, indicating it was not updated daily. The Director of Nursing (DON) acknowledged that the staffing information was only posted in one location and not on each unit. The Administrator confirmed that the posting was supposed to be updated daily and admitted that the current posting was outdated and not in compliance with the facility's policy, which mandates daily updates of nursing personnel responsible for direct care to residents.
Failure to Protect Resident from Verbal and Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Aide (CNA). The incident involved a resident who was admitted with a primary diagnosis of chronic hepatic failure without coma. The resident reported that the CNA was rude, yelled at them, threw a pillow at them, and shoved a pillow under their back. The resident expressed fear of asking for help due to the treatment received from the CNA. A witness statement from the resident's roommate corroborated the resident's account, observing the CNA yelling and throwing a pillow at the resident. The facility's Director of Nursing/Abuse Coordinator confirmed that the incident was reported to the Nevada State Board of Nursing and substantiated the allegations of abuse. The CNA's job description required treating residents with courtesy, respect, and dignity, which was not adhered to in this case. The facility's policies on recognizing signs of abuse and the abuse prevention program emphasized protecting residents from abuse by staff, which was not effectively implemented in this instance.
Failure to Administer Nutritional Supplement and Conduct Timely Dietary Evaluation
Penalty
Summary
The facility failed to ensure timely evaluation and administration of nutritional supplements for a resident with a stage four pressure ulcer. The resident, who was admitted with severe protein-calorie malnutrition and a stage four pressure ulcer of the sacral region, had a physician's plan that included a dietary evaluation and the administration of Pro-Stat, a concentrated liquid protein drink. However, the resident's clinical record lacked evidence of a dietary evaluation being completed in January or February, and the January Medication Administration Record (MAR) showed no documentation of Pro-Stat being administered. The Director of Nursing (DON) and the Administrator confirmed the absence of a timely dietary evaluation and the lack of Pro-Stat administration, despite a physician's order and confirmation by a registered nurse. The facility's policies required a comprehensive nutrition and hydration assessment for residents with stage two or greater pressure ulcers, which was not completed in this case. The DON explained that Pro-Stat was intended to help residents who might not be getting enough protein or to aid in wound healing, but it was not delivered or administered as required.
Misappropriation of Resident Property by Housekeeper
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a Housekeeper asked the resident for money. The incident involved a resident with chronic obstructive pulmonary disease, major depressive disorder, and anxiety, who was approached by a Housekeeper requesting to borrow money. The resident provided the money, and although the Housekeeper repaid the amount in full, this action was against the facility's policy. The facility's investigation revealed that the Housekeeper had indeed asked the resident for money, which was confirmed by both the resident and the Director of Nursing. The facility's policy clearly states that residents have the right to be free from misappropriation of property, and the Housekeeper's actions violated this policy. The incident was reported as a Facility Reported Incident (FRI), and the facility conducted interviews with 16 other residents, who confirmed they had not been asked for money by staff.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications per a physician's order for two residents. For Resident #2, the LPN administered a Calcium Citrate-Vitamin D tablet with a dosage of 400 mg-12.5 mcg instead of the prescribed 500 mg-10 mcg. This discrepancy was confirmed by the LPN upon reviewing the medication orders. Resident #2 had diagnoses including vitamin D deficiency and mild protein-calorie malnutrition at the time of the incident. For Resident #3, the LPN applied a Lidocaine patch to the resident's right shoulder instead of the prescribed left shoulder. The LPN acknowledged the error and confirmed that the order should have been verified prior to administration. Resident #3 had a diagnosis of unspecified pain. Both the Director of Nursing and the Administrator confirmed that these actions did not follow the physician's orders, as per the facility's policies and the Nevada Nurse Practice Act.
Latest citations in Nevada
Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
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