Alta Skilled Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reno, Nevada.
- Location
- 555 Hammill Lane, Reno, Nevada 89511
- CMS Provider Number
- 295077
- Inspections on file
- 27
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Alta Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident receiving hospice services for a large, tunneling breast mass did not have a care plan in the facility's records addressing wound care, despite hospice providing this care. Facility staff confirmed the absence of a wound care order and care plan, which was not in accordance with facility policy requiring comprehensive, integrated care planning.
The facility did not update care plans for two residents: one with Parkinson's disease who required a neurology appointment for increased tremors, and another with ongoing nicotine use who stored smoking paraphernalia in their room. Staff were unaware of the status of the neurology appointment and the location of smoking materials, and care plans lacked necessary revisions to address these issues.
A resident with Parkinson's disease and multiple sclerosis experienced increased tremors, prompting repeated requests and physician orders for a neurology referral. Despite these, staff only sent referrals to the resident's previous neurologist, who could not accept the patient due to insurance issues, and did not attempt referrals to other neurologists. The care plan was not updated to reflect the resident's symptoms or referral needs, and clinical leadership did not monitor the referral process, resulting in a delay in care.
Two residents did not receive care in accordance with physician orders and facility policy: one experienced increased tremors without timely neurology referral due to repeated attempts only with a non-contracted provider, and another had a non-healing wound managed by hospice without a facility order or care plan documenting wound care responsibilities.
A resident at risk for pressure injuries developed a Stage III coccyx ulcer, and wound care was not consistently provided as ordered by the physician. Documentation showed multiple missed wound care treatments over several weeks, and both the DON and Wound Care Nurse confirmed that care was not completed as required. Facility policies for skin inspection and wound management were not followed, resulting in a deficiency.
A resident with a G-tube and orders to check gastric residuals before administering medications did not have their residual volume checked by an LPN prior to receiving medication. The LPN and DON confirmed that this step was missed, which was not in accordance with physician orders and facility policy.
A resident had a prescribed bottle of lorazepam present in the medication storage room, but there was no corresponding order in the electronic health record or entry on the MAR. Additionally, an ordered C-PDR cream for nausea or vomiting was not available for the resident. The DON confirmed that all ordered medications should be available, and facility policy required accurate medication order documentation.
A medication cart was found unattended, unlocked, and with the keys left on top in a hallway, making medications accessible to unauthorized individuals. An RN confirmed the cart was left unsecured and out of sight, which was not in accordance with facility policy requiring medication carts to be locked and keys kept with nursing staff.
A resident receiving hospice care did not have coordinated care between the facility and the hospice agency, resulting in discrepancies in medication orders, missing wound care plans, and unavailable prescribed medications. Facility staff and hospice personnel confirmed that medication reconciliation and care plan updates were not completed as required, and the facility lacked a designated hospice coordinator.
A CNA entered a room under Enhanced Barrier Precautions (EBP) to assist a resident with an ESBL urinary tract infection without performing required hand hygiene, despite clear signage and available alcohol-based hand rub. This action was observed by an RN and confirmed by facility leadership as a violation of policy.
A wound cart and a medication cart containing resident medications were left unlocked and unattended in two separate hall entrances, with residents present nearby. An LPN and an RN confirmed the carts were unsecured, and the DON stated that floor nurses are responsible for ensuring carts are locked according to facility policy.
The facility failed to provide necessary care for a resident with DVT, leading to severe gangrene and hospitalization, and did not protect residents from physical abuse by another resident. Despite worsening symptoms, the resident with DVT did not receive timely medical intervention, and the facility's documentation lacked consistent assessment of pedal pulses. Additionally, the facility did not implement new interventions for a resident with disruptive behaviors, resulting in an incident of physical abuse.
The facility failed to properly screen and offer pneumococcal vaccinations to 28 residents based on medical conditions, only considering age in their screening process. This oversight led to eligible residents not receiving the vaccine as per CDC guidelines.
A resident with multiple diagnoses exhibited significant decline, including bluish discoloration and severe pain in the lower extremity. Despite a physician's order for an ultrasound, the facility's contracted diagnostics company lacked an ultrasound technician, and the family and physician were not informed of the ongoing decline. The resident was eventually sent to the hospital after a week of worsening symptoms.
A facility failed to provide a comfortable, homelike environment for a resident when the AC unit in their room was broken and not promptly repaired. Despite the resident's spouse informing staff, the issue persisted for three days without alternative accommodations. The facility's policy on maintaining a homelike environment was not followed, leading to the deficiency.
A resident reported $20 missing from their wallet shortly after admission, but the facility failed to follow its policy for investigating the report. The CNA who received the report did not document it, and the DON was unaware of the issue until the survey team brought it to attention. No follow-up was conducted by Social Services, and the facility's policy on investigating misappropriation was not followed.
A resident with a urinary catheter repeatedly pulled out the catheter, resulting in hospital visits for reinsertion and treatment for hematuria. Despite these incidents, the care plan did not include interventions to prevent this behavior. Both the LPN and DON acknowledged the need for documented interventions, which were not in place at the time of the incidents.
The facility failed to implement interventions for a resident with a urinary catheter who repeatedly pulled it out, did not provide timely care for a resident with a suspected DVT, and did not communicate a hospice physician's order, resulting in the resident not receiving the ordered medication.
The facility failed to ensure that two residents were weighed according to the facility's policy, leading to significant gaps in weight monitoring and documentation. One resident was not weighed for over six months despite significant weight fluctuations, and another resident experienced a drastic weight loss without proper follow-up.
The facility failed to ensure a CNA had an annual performance evaluation completed timely. A CNA hired over a year ago had their last evaluation documented late, missing the required annual review date. The Human Resources Manager confirmed the delay, violating the facility's policy for annual reviews.
A resident with chronic pancreatitis and muscle spasms missed several doses of prescribed medications due to the facility's failure to reorder them in a timely manner. The facility's policy required medications to be reordered at least three days before running out, but this was not followed, leading to missed doses and increased pain for the resident.
The facility failed to ensure timely ultrasounds for residents due to the contracted diagnostics company not having an ultrasound technician available for onsite visits. The Administrator was unsure when first notified about the issue and could not provide documented evidence that the lack of an ultrasound technician was addressed or that any direction was given to the nursing staff. The DON was aware of the issue and had instructed to send residents to the hospital for ultrasounds but was not aware if the nursing staff had been informed of this need prior to their tenure as DON.
The facility failed to ensure complete medical records for two residents. One resident missed several required weekly weight measurements, and another resident's G-Tube flushes were not documented as per physician orders. The DON confirmed these deficiencies.
The QAPI committee failed to identify that the contracted diagnostics company lacked an ultrasound technician, leading to a delay for a resident with a physician's order for an ultrasound. The Administrator was unsure when notified and could not provide documented evidence of addressing the issue. The DON knew about the lack of a technician and instructed to send residents to the hospital but was unaware if nursing staff had been informed.
A facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for a resident with a jejunostomy tube (J-tube). An LPN did not wear a gown or gloves while disconnecting the tube feeding, despite the requirement indicated by a sign outside the resident's room and the resident's care plan. The Director of Nursing confirmed the necessity of gown and gloves to prevent infections, as outlined in the facility's Infection Prevention and Control Program (IPCP) policy.
A resident with a history of wandering and wearing a Wanderguard device followed a CNA out of an alarmed exit door, but the alarm failed to activate, allowing the resident to wander into the parking lot. The facility's policy required staff to prevent such incidents, but the alarm system malfunctioned, and maintenance did not detect the issue during weekly checks.
A resident with hydrocephalus and difficulty walking experienced a loss of dignity when a PT verbally confronted them for walking in the facility. The resident felt disrespected and embarrassed, leading to emotional distress. An RN witnessed the incident and reported it to the Administrator and DON. The resident expressed a desire to leave against medical advice rather than work with the PT again.
A resident was verbally abused by an RN at the nurse's station, witnessed by a CNA and a family member. The RN was suspended and later terminated, but the investigation was incomplete as not all witnesses were interviewed, and documentation was lacking. The resident did not report psychosocial harm, but the facility's investigation did not meet its own standards.
A resident with chronic health conditions reported being roughly handled and slapped by a CNA. Despite the facility's policy requiring prompt investigation and reporting of abuse allegations, the Administrator and DON did not investigate or report the incident, citing the resident's history of unfounded allegations. The CNA continued to work with the resident, contrary to policy requirements.
A resident with chronic health conditions reported being roughly handled and slapped by a CNA. The facility's Administrator and DON failed to report or investigate the allegation, citing the resident's history of unfounded claims, despite policy requirements for prompt reporting and investigation.
A facility failed to investigate and report abuse allegations involving a CNA and an RN. A resident alleged a CNA slapped and handled them roughly, but the facility did not suspend the CNA or report the incident. Another incident involved an RN verbally abusing a resident, witnessed by a CNA and a family member. The facility's investigation was incomplete, lacking interviews with all involved parties and proper documentation.
An LPN at the facility was observed leaving premixed doses of MiraLAX unattended on a medication cart, posing a risk of ingestion by others. The DON confirmed that medications should not be left unattended and should be prepared individually. The facility lacked competency checklists for new nurses, contributing to the deficiency.
A resident's medications were left unsupervised at the bedside, resulting in a 100% medication error rate. The medications, documented as administered, were not taken by the resident. An LPN confirmed the error, and the physician highlighted the risk of drug interactions. The facility's policy on medication administration was not adhered to.
The facility failed to properly store and supervise medications, with an LPN leaving premixed MiraLAX unattended on a medication cart, posing a risk of ingestion by others. Additionally, medication carts were left unlocked and unattended, allowing access by staff, residents, and visitors, contrary to facility policy.
Failure to Integrate Hospice Wound Care into Resident Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's care plan was integrated with the hospice plan of care and did not include a care plan addressing the resident's wound care needs. The resident, who was admitted with diagnoses including palliative care and abnormal diagnostic findings, developed a large, tunneling breast mass that required wound care. The resident's representative stated that hospice was providing wound care, and hospice documentation confirmed ongoing wound management. However, there was no corresponding order for wound care or a care plan in the facility's electronic health record. Interviews with facility staff, including an RN, the Unit Manager, and the DON, confirmed that the resident did not have a care plan for wound care provided by hospice, and that such care should have been documented and integrated into the facility's care planning process. The facility's policy required comprehensive, person-centered care plans that incorporate all identified problem areas and professional services, but this was not followed in the resident's case.
Failure to Update Care Plans for Neurology Needs and Smoking Safety
Penalty
Summary
The facility failed to update and revise care plans for two residents, resulting in deficiencies related to the management of a resident's neurological needs and another resident's smoking habits. For one resident with Parkinson's disease and multiple sclerosis, the care plan did not reflect the resident's increased tremors or the need for a neurology appointment, despite repeated requests from the resident's representative and a physician's order indicating the necessity for such an appointment. Staff communicated verbally about the appointment status, but no appointment had been scheduled, and the care plan was not updated to address the resident's changing condition. For another resident with a history of tobacco use and hemiplegia, the care plan failed to address the resident's ongoing nicotine use and did not include interventions for the safe storage and use of smoking paraphernalia. The resident was observed smoking outside the facility and storing cigarettes and a lighter in the bedside table, but staff were unaware of the location of these items. The care plan only referenced a reminder of the facility's no smoking policy and had not been revised to address the resident's current smoking behaviors or associated safety concerns.
Failure to Timely Act on Neurology Referral for Resident with Parkinson's Disease
Penalty
Summary
The facility failed to ensure that a physician's order for a neurology referral was acted upon in a timely manner and monitored for completion for a resident with Parkinson's disease and multiple sclerosis. Despite repeated requests from the resident's representative at care conferences over several months, and documentation in care conference notes and progress notes indicating the need for a neurology appointment due to increased tremors, the facility did not schedule an appointment. The care plan was not revised to address the resident's increased symptoms or the need for a neurology referral. Referrals were sent twice to the resident's previous neurologist, but both times the neurologist's office responded that they could not see the patient due to insurance issues and lack of recent visits. No referrals were sent to other neurologists in the area. The Transportation Coordinator, responsible for coordinating referrals, only sent referrals to the previous neurologist as directed by information from nursing staff, and this process was not monitored by clinical leadership. The Director of Nursing and Unit Manager confirmed that the resident did not have an appointment scheduled and that the referral process was not adequately overseen or documented.
Failure to Coordinate Timely Specialist Referral and Wound Care Documentation
Penalty
Summary
The facility failed to ensure timely management of a resident's increased tremors as ordered by the physician. Despite repeated requests from the resident's representative and documentation in care conference notes and physician orders, the facility did not secure a neurology appointment for the resident experiencing worsening tremors related to Parkinson's disease. Referrals were only sent to the resident's previous neurologist, who no longer accepted the resident's insurance, and no attempts were made to contact other neurologists in the area. Communication between nursing staff and the transportation coordinator was limited to a spreadsheet, and there was no oversight to ensure the referral process was completed as ordered. The resident's care plan was not updated to reflect the need for neurology follow-up or the increased symptoms. Additionally, the facility did not monitor or document wound care for another resident who was on hospice and had a non-healing breast wound. The resident's representative reported that hospice was providing wound care, but there was no physician order or care plan in the facility's records addressing the wound or the facility's role in the care process. The facility's own policy required care planning and documentation for wound management, but this was not followed. The care plan was not integrated with the hospice plan of care, and facility staff did not have clear documentation of their responsibilities regarding the resident's wound care. These deficiencies were identified through observation, interviews with staff and resident representatives, and review of clinical records and facility policies. The lack of timely specialist referral and absence of wound care documentation and planning demonstrated a failure to provide care and services in accordance with physician orders, resident needs, and facility protocols.
Failure to Provide Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with multiple diagnoses, including adult failure to thrive, chronic kidney disease, and sequelae of cerebral infarction, was admitted to the facility and assessed as being at risk for pressure-related skin impairment due to factors such as shear friction and bed confinement. The care plan included interventions like keeping the resident clean and dry, providing peri care after incontinence, and weekly skin checks by a licensed nurse. Despite these measures, a Stage III pressure injury was identified on the resident's coccyx during a post-shower skin check, which had not been previously observed. Following the identification of the pressure injury, physician orders were written for specific wound care treatments, including cleansing with normal saline, applying skin prep or medi-honey and zinc oxide, and covering or leaving the wound open to air as directed. These orders specified the frequency of care, including every shift and as needed for soiling or dressing dislodgement. However, review of the Wound Care Treatment Administration Records (TAR) for April and May revealed multiple dates and shifts where there was no documented evidence that wound care was provided as ordered. The DON and Wound Care Nurse confirmed that the blanks in the TAR indicated the wound care was not completed on those dates and that the care was not provided according to the physician's orders. Facility policies required daily skin inspections during personal care, prompt identification and documentation of skin changes, and adherence to prescribed wound care treatments. The failure to provide wound care as ordered and to follow the facility's own policies for prevention and monitoring of pressure injuries resulted in a deficiency, as the resident did not receive the necessary care to prevent the development and progression of a pressure injury.
Failure to Check Gastric Residual Prior to G-Tube Medication Administration
Penalty
Summary
A deficiency was identified when a resident with a history of dysphagia, gastroparesis, and gastrostomy status did not have their gastric residual volume checked prior to the administration of medication via a gastrostomy tube (G-tube). The resident had a physician's order specifying that residuals should be checked before administering water, medications, or formula through the G-tube. Despite this order, an LPN administered levetiracetam solution through the G-tube without performing the required residual check. The LPN confirmed that the residual was not checked prior to medication administration, and the Director of Nursing also acknowledged that residuals should be checked before administering anything through a G-tube, in accordance with facility policy. The facility's policy on enteral feedings and safety precautions also documented the requirement to check tube placement and gastric residual volume prior to medication administration. This lapse was observed and confirmed through interviews and record reviews.
Medication Documentation and Availability Discrepancies
Penalty
Summary
The facility failed to ensure that there were no discrepancies between a resident's available medications, the resident's medication orders, and the medication administration record (MAR). During a review of a resident's medications, a bottle of lorazepam was found in the medication storage room with a label indicating it was prescribed for the resident, with specific administration instructions. However, the facility's electronic health record did not include an order for lorazepam, and the medication was not listed on the resident's MAR. The RN confirmed that the medication had been delivered by the hospice agency's pharmacy, but it was not properly documented in the facility's records. Additionally, the resident had an order for C-PDR cream to be applied as needed for nausea or vomiting, which was part of the hospice comfort package. The RN stated that the facility did not have the C-PDR cream available for the resident. The Director of Nursing confirmed that all medications ordered for a resident should be available in the facility. Facility policy required that a current list of orders be maintained in the clinical record for each resident, and the pharmacy services contract required regular medication regimen reviews by a consultant pharmacist.
Unattended and Unlocked Medication Cart with Keys Left Accessible
Penalty
Summary
A medication cart was observed unattended and unlocked in the 300 hall, with the keys left on top of the cart and no staff members in sight. The drawers of the cart, which contained drugs and biologicals, were facing the hallway, making the medications accessible to unauthorized individuals. This was directly observed by surveyors at 7:22 AM, and shortly after, a Registered Nurse confirmed that the cart had been left in this unsecured state while unattended and out of sight. The Director of Nursing later confirmed that the facility's policy requires medication carts to be locked when not in use and that the keys should always remain with the nurse. The facility's written policy, adopted in 2019, also specifies that only authorized personnel should have access to medication storage and that carts should not be left unattended if open or accessible. The observed incident was not in compliance with these established procedures.
Failure to Coordinate Hospice Care and Medication Orders
Penalty
Summary
The facility failed to coordinate care and services with a hospice agency for a resident who was receiving hospice care, resulting in discrepancies between the facility's records and the hospice agency's plan of care. The resident, admitted with diagnoses including palliative care and anxiety disorder, had a significant wound on the right breast that was being managed by hospice staff. However, the facility's electronic health record (EHR) did not include an order for wound care, nor did it have a care plan addressing the resident's wound or the use of certain medications prescribed by hospice. There were notable inconsistencies between the facility's medication orders and those from the hospice agency. The facility's EHR listed a different dosage of metronidazole than the hospice agency, included pravastatin which was not on the hospice list, and omitted lorazepam, which was prescribed by hospice for symptom management. Additionally, the facility did not have PDR cream available, despite it being ordered by both the facility and hospice. Interviews with facility staff and hospice personnel confirmed these discrepancies and revealed a lack of medication reconciliation and care plan updates. The facility's policy required coordination with hospice, including reconciling medication orders and care plans, but this was not followed. The Director of Nursing acknowledged that staff should have reconciled medications and care plans with hospice, and the facility did not have a designated hospice coordinator. The process for receiving and communicating new hospice orders was not effectively implemented, resulting in the resident not having appropriate care plans or access to all prescribed medications and therapies.
Failure to Perform Hand Hygiene Before Entering EBP Room
Penalty
Summary
A Certified Nursing Assistant (CNA) entered a room designated for Enhanced Barrier Precautions (EBP) without performing required hand hygiene, either by using alcohol-based hand rub (ABHR) or washing hands. The room was clearly marked as being on EBP, and an ABHR dispenser was available outside the room. The CNA entered to assist a resident with their meal tray and later acknowledged forgetting to use ABHR before entering, despite the resident being on EBP due to an extended-spectrum beta-lactamase (ESBL) urinary tract infection. A Registered Nurse (RN) observed the CNA's failure to perform hand hygiene and confirmed the resident's EBP status due to ESBL in the urine. The facility's policy, updated in March 2024, requires all individuals to clean their hands with ABHR before entering any room on EBP. The Administrator also confirmed that the CNA should have performed hand hygiene prior to entry. The incident was identified through observation, interview, and document review, and the deficiency was noted as having the potential to affect the resident population.
Unsecured Medication and Wound Carts Left Unattended
Penalty
Summary
A wound cart containing resident medications was observed left unlocked in the 200 hall entrance, with four residents sitting nearby. An LPN later confirmed the cart was unsecured and acknowledged that residents could have accessed the medications. Additionally, a medication cart was found unlocked and unattended in the 100 hall entrance, which was confirmed by an RN. The Director of Nursing stated that floor nurses are responsible for ensuring carts are locked and not left unattended. Facility policy requires all compartments containing drugs and biologicals to be locked when not in use and not left unattended if open or accessible.
Failure to Provide Necessary Care and Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure a resident with a deep vein thrombosis (DVT) received the necessary care to prevent the resident from developing gangrene in a lower extremity and requiring hospitalization. Resident #305 was admitted with multiple diagnoses, including other pulmonary embolism and peripheral vascular diseases. On 04/30/2024, a nurse noticed bluish discoloration and cold, clammy skin on the resident's right lower extremity and informed the physician, who ordered a bilateral leg arterial ultrasound. However, the facility's contracted diagnostics company did not have an ultrasound technician available, leading to a delay in the ultrasound. Despite the resident's worsening condition, including increased pain and further discoloration, the resident was not sent to the hospital until 05/07/2024, resulting in severe gangrene and the need for an above-the-knee amputation or end-of-life care. The facility's documentation lacked consistent assessment of pedal pulses, and the physician was not informed of the resident's clinical decline in a timely manner, contributing to the delay in appropriate care and treatment for the resident's condition. The facility also failed to protect residents from physical abuse by another resident. Resident #83, who had a history of schizophrenia and anxiety disorder, was involved in an incident on 04/09/2024, where the resident spit on and threw a cup of water at their roommate, Resident #122, while the roommate was asleep. Despite Resident #83's documented potential for disruptive behaviors and the need for monitoring and intervention, the facility did not implement new interventions to address the resident's increased behaviors. Resident #83 was eventually transferred to a behavioral health center for additional services, and Resident #122 was moved to another room. The facility's policy on abuse prevention was not effectively implemented to protect residents from abuse by other residents. The Director of Nursing (DON) and the Unit Manager (UM) acknowledged the deficiencies in care and communication. The DON confirmed that the resident should have been sent to the hospital earlier and that the facility failed to notify the physician about the lack of an ultrasound technician and the resident's declining condition. The UM admitted that the facility should have monitored pedal pulses daily for a suspected DVT and that the resident's increasing pain and discoloration were indicative of loss of blood flow. The facility's failure to provide timely and appropriate care resulted in significant harm to Resident #305 and inadequate protection for Resident #122 from abuse by another resident.
Failure to Properly Screen and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility to receive a pneumococcal vaccination, provided with education regarding the vaccine, and offered the vaccine for administration or declination. Specifically, 28 residents were not screened for eligibility based on criteria other than age, despite having medical conditions that could make them eligible for the vaccine. The facility's policy and flowchart used for screening only considered age, leading to the exclusion of residents under 65 who had conditions such as diabetes or were immunocompromised, which should have made them eligible for the vaccine according to CDC guidelines. For instance, Resident #104, who had type two diabetes mellitus, was not offered the pneumococcal vaccine because the screening process only considered age. The Infection Control Preventionist (ICP) and the Vice President of Clinical Services (VPCS) confirmed that the resident should have been offered the vaccine based on their medical condition. This oversight was consistent across the other 27 residents, who were also not screened for additional eligibility criteria beyond age. The facility's policy, adopted in 2019, stated that all residents should be offered pneumococcal vaccines to prevent pneumonia/pneumococcal infections. However, the policy was not followed correctly, as the screening process did not align with CDC guidelines, which recommend the vaccine for individuals with certain medical conditions regardless of age. This failure to properly screen and offer the vaccine to eligible residents represents a significant deficiency in the facility's vaccination protocol.
Failure to Notify Physician and Family of Resident's Decline
Penalty
Summary
The facility failed to ensure that a resident's representative and physician were notified of a significant change in the resident's condition. Resident #305, who had multiple diagnoses including pulmonary embolism and peripheral vascular diseases, exhibited bluish discoloration and cold, clammy skin on the right lower extremity. Despite the physician ordering a bilateral leg arterial ultrasound, the facility's contracted diagnostics company did not have an ultrasound technician available. The resident's condition worsened over several days, with increased pain and continued discoloration, but the family and physician were not informed of the ongoing decline and the inability to perform the ultrasound in-house. The resident's condition continued to deteriorate, leading to severe pain and behavioral changes. It was only on 05/07/2024 that the physician was notified, and the resident was subsequently sent to the hospital. Interviews with the Unit Manager and Director of Nursing confirmed that there was no documentation of the physician being informed about the lack of an ultrasound technician or the resident's declining condition. The facility's policy required prompt notification of changes in a resident's condition to the healthcare provider and resident representative, which was not adhered to in this case.
Failure to Provide Comfortable Environment Due to Broken AC Unit
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for Resident #257 when the air conditioning (AC) unit in the resident's room was broken and not promptly repaired. Despite the resident's spouse informing the Administrator and staff about the issue, the AC unit remained unfixed for three days. During this period, the room was reported to be uncomfortably warm, and no alternative accommodations, such as moving the resident to another room or providing a fan, were offered. The Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) were unaware of any restrictions on using fans in the room, and the Head Operations Manager (HOM) confirmed that there were no such restrictions. The HOM acknowledged the broken AC unit and stated that a replacement unit had to be ordered from the home office, which arrived and was installed on the third day. The facility's policy on providing a homelike environment was not adhered to, as the staff failed to ensure a comfortable and safe temperature in the resident's room. The Administrator admitted that the resident was not experiencing a comfortable environment due to the broken AC unit and high temperatures. A work order for the AC repair was not created until the third day, and the HOM confirmed that no prior work order had been made. The facility's delay in addressing the broken AC unit and lack of immediate accommodations for the resident led to the deficiency in providing a homelike environment as required by their policy.
Failure to Investigate Missing Money Report
Penalty
Summary
The facility failed to investigate a resident's report of missing money according to its policy. Resident #149, who was admitted with diagnoses including anxiety disorder and homelessness, reported to a CNA that $20 was missing from their wallet shortly after admission. Despite this report, no follow-up was conducted by the facility staff. The resident's clinical record noted the missing money, but the Review and Inventory of Valuable Items was completed seven days after the report and did not include any money in the wallet. The CNA who received the report did not document it and only verbally informed the DON, who was unaware of the issue until the survey team brought it to attention. The DON stated that the correct process would involve documenting the concern as a grievance and having Social Services follow up, which did not occur in this case. The Director of Social Services confirmed that no follow-up had been conducted with the resident or the CNA who received the initial report. The facility's policy on Abuse Investigation and Reporting requires thorough investigation of all reports of misappropriation, including reviewing documentation and interviewing all relevant parties. This process was not followed, leading to the deficiency noted by the surveyors.
Failure to Update Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident with a urinary catheter and a behavior of pulling out the catheter had an updated care plan to include interventions to prevent this behavior. Resident #98, who was admitted with diagnoses including benign prostatic hyperplasia and urinary retention, had pulled out the catheter multiple times since admission, resulting in hospital visits for reinsertion and treatment for hematuria. Despite these incidents, the care plan initiated on 06/03/2024 did not document any interventions to address the resident's behavior of pulling out the catheter. On 06/12/2024, both the LPN and the DON confirmed that the resident had pulled out the catheter for the third time that day and acknowledged the need for documented interventions to prevent this behavior. The LPN noted that the resident previously had a leg strap to secure the catheter, but it was not in place during the incidents. The facility's policy on comprehensive person-centered care plans emphasized the need for ongoing assessments and revisions as the resident's condition changed, which was not adhered to in this case.
Failure to Implement Interventions and Provide Timely Care
Penalty
Summary
The facility failed to implement interventions for a resident with a urinary catheter who had a history of pulling out the catheter, resulting in repeated physical trauma. Despite the resident pulling out the catheter multiple times, the care plan lacked documentation of measures to prevent this behavior. Observations and interviews revealed that the resident did not have a leg strap or a StatLock in place, which were previously used to secure the catheter. The Director of Nursing confirmed the need for documented interventions to prevent the resident from pulling out the catheter again. The facility also failed to provide timely care for a resident with a suspected deep vein thrombosis (DVT). The resident exhibited symptoms such as bluish discoloration and cold, clammy skin on the right lower extremity. Although an ultrasound was ordered, it was not performed due to the unavailability of an ultrasound technician. The resident's condition worsened, but the facility did not send the resident to the hospital promptly. The Director of Nursing and the Unit Manager acknowledged that the resident should have been sent to the hospital earlier and that pedal pulses should have been monitored daily. Additionally, the facility did not communicate a hospice physician's order for a resident to the facility's physician, resulting in the resident not receiving the ordered medication. The hospice order for Potassium Chloride ER was scanned into the resident's clinical record but was not entered into the electronic medical record (EMR) or the Medication Administration Record (MAR). The Director of Nursing confirmed that the order was not communicated to the facility's physician and was not administered as required. The facility lacked a designated hospice coordinator, leading to communication gaps between hospice and facility staff.
Failure to Adhere to Weight Monitoring Policy
Penalty
Summary
The facility failed to ensure that two residents were weighed according to the facility's policy. Resident #37, who had diagnoses including type II diabetes mellitus, unspecified dementia, and adult failure to thrive, was not weighed monthly as required. The resident's weight records showed significant fluctuations, and there was no documented weight for August 2023. The clinical record lacked evidence of any weight measurements between November 2023 and June 2024. Despite a significant weight gain noted in October 2023, no follow-up weights were documented, and the resident was not weighed for over six months. The facility's staff, including an LPN, RN, RD, and the DON, confirmed the failure to adhere to the monthly weighing policy and the absence of documented reasons for not weighing the resident, such as resident refusal. Resident #143, who had diagnoses including acute duodenal ulcer with hemorrhage and age-related cognitive decline, also experienced a failure in weight monitoring. The resident was supposed to have weekly weights for four weeks and then monthly if stable, as per physician's orders. However, the resident's weight records showed only one weight measurement since admission, which indicated a drastic and questionable weight loss of 71 lbs. The RD used a hospital weight as a baseline instead of obtaining a new admission weight, and despite the significant weight loss, weekly weights were not performed as ordered. The DON and RD confirmed the failure to follow the weight monitoring orders and the lack of follow-up on the weight monitoring. The facility's policy on Weight Assessment and Intervention required residents to be weighed upon admission, the following day, and weekly for two weeks, with monthly weights thereafter if no concerns were identified. Any weight change of 5% or more required re-weighing the following day for confirmation. The policy also mandated immediate notification of the RD for significant weight changes. The facility staff failed to adhere to these policies for both residents, leading to deficiencies in weight monitoring and documentation.
Late Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for one of the two CNAs employed for more than one year. Employee #8, who was hired on 05/18/2022, had their last performance evaluation documented on 07/11/2023. However, the annual performance evaluation was due by 05/18/2023. During an interview on 06/11/2024, the Human Resources Manager and Regional Human Resources confirmed that the annual performance evaluation for Employee #8 was completed late, failing to adhere to the facility's policy that mandates annual reviews from the date of employment.
Failure to Ensure Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that ordered medications were available and administered for a resident with chronic pancreatitis, chronic pain, and muscle spasms. The resident reported running out of medication for muscle spasms and pancreatitis, which exacerbated their chronic pain. The physician had ordered Cyclobenzaprine for muscle spasms and Creon for chronic pancreatitis, but the resident missed several doses of both medications in May 2024 due to the facility's failure to reorder them in a timely manner. A Registered Nurse confirmed that the resident missed multiple administrations of both medications and that the medications had to be reordered from the pharmacy. The facility's policy required medications to be reordered at least three days before running out, but there was no evidence that this was done. The Director of Nursing confirmed the missed doses and acknowledged that the medications were not reordered within the required timeframe, as per the facility's policy.
Failure to Ensure Timely Ultrasounds Due to Lack of Technician
Penalty
Summary
The facility failed to ensure timely ultrasounds for residents due to the contracted diagnostics company not having an ultrasound technician available for onsite visits. The Administrator was unsure when first notified about the issue, possibly at the end of April 2024, and could not provide documented evidence that the lack of an ultrasound technician was addressed or that any direction was given to the nursing staff. The Director of Nursing (DON) was aware of the issue and had instructed to send residents to the hospital for ultrasounds when working in the Rehabilitation Department before becoming the DON. However, the DON was not aware if the nursing staff had been informed of this need prior to their tenure as DON. The facility's Quality Assurance and Performance Improvement (QAPI) Program policy indicated that the committee would oversee the implementation of the QAPI Plan and identify and correct quality deficiencies, but this was not effectively demonstrated in this instance.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure that the medical records for two residents were complete and in accordance with physician orders. Resident #143, who was admitted with diagnoses including acute duodenal ulcer with hemorrhage and age-related cognitive decline, had physician orders for weekly weight measurements. However, the clinical record showed only one weight measurement for April and May 2024, missing several required weekly weights. The Director of Nursing (DON) confirmed that the resident should have been weighed weekly for four weeks and then monthly if stable, but this was not done. The Registered Dietician (RD) also confirmed that the weekly weights had not occurred as ordered. Resident #205, admitted with diagnoses including unspecified protein-calorie malnutrition and dysphagia following cerebral infarction, had physician orders for gastrostomy tube (G-Tube) flushes. The Treatment Administration Record (TAR) and Medication Administration Record (MAR) lacked documented evidence that the G-Tube was flushed per the physician orders on multiple occasions. The DON confirmed the absence of documentation for the G-Tube flushes as required by the physician orders. The facility's policy on Charting and Documentation required that medications administered and treatments performed be documented in the resident's clinical record, which was not adhered to in these cases.
Failure to Address Lack of Ultrasound Technician
Penalty
Summary
The facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify that the contracted diagnostics company lacked an ultrasound technician, resulting in a delay for a resident with a physician's order for an ultrasound. The Administrator was unsure when they were first notified about the lack of an ultrasound technician but believed it was possibly at the end of April 2024. The Administrator could not provide documented evidence that the issue was addressed or that any direction or instruction was given to the nursing staff. The Director of Nursing (DON) was aware of the lack of an ultrasound technician and had instructed to send residents to the hospital for ultrasounds if needed. However, the DON was not aware if the nursing staff had been informed of this need prior to becoming the DON. The facility's policy stated that the QAPI committee would oversee the implementation of the QAPI Plan and identify and correct quality deficiencies, which was not done in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented when providing care to a resident's jejunostomy tube (J-tube). Specifically, a Licensed Practical Nurse (LPN) did not wear a gown or gloves while disconnecting the tube feeding from the resident's J-tube, despite a sign outside the resident's room indicating the need for EBP. The LPN confirmed the requirement for gown and gloves and acknowledged the failure to adhere to the precautions. The resident's care plan also documented the need for EBP due to the presence of the J-tube, with interventions including EBP per facility policy. The Director of Nursing (DON) explained that gown and gloves were required for residents with feeding tubes to prevent the introduction of bacteria and potential infections. The facility's Infection Prevention and Control Program (IPCP) policy stated that EBP served to reduce the transmission of multidrug-resistant organisms (MDRO) and applied to residents with indwelling medical devices. The policy required staff to wear a gown and gloves when performing high-contact resident care activities, including indwelling medical device care.
Failure to Prevent Resident Elopement Due to Alarm Malfunction
Penalty
Summary
The facility failed to provide protective supervision for a resident who was at risk of elopement. The resident, who had a history of wandering and was wearing a Wanderguard device, followed a Certified Nursing Assistant out of an alarmed exit door. The alarm system failed to activate, allowing the resident to wander into the parking lot. This incident was discovered when the resident's significant other found them outside and brought them back into the facility. The resident's care plan had identified them as an elopement risk and included interventions such as one-on-one supervision and the use of a Wanderguard device to alert staff of any attempts to exit the building. The Director of Nursing (DON) confirmed that the elopement was preventable and explained that all staff were trained annually on elopement prevention. The facility's policy required staff to prevent residents from leaving the premises and to report any such attempts to a nurse. However, the investigation revealed that the alarm system had malfunctioned at all exits, and the maintenance team had not detected this issue during their weekly checks. The Administrator confirmed that the alarm system was replaced following the incident.
Resident Dignity Compromised by PT's Verbal Confrontation
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #9, who was admitted with diagnoses including hydrocephalus and difficulty walking. An incident occurred where a Physical Therapist (PT) was reported to have verbally berated the resident at the nurse's station. The resident expressed that the interaction was a misunderstanding but noted that the PT's demeanor needed to be gentler. The resident's comprehensive care plan highlighted the risk for loss of dignity due to stern instructions from staff and included measures to maintain dignity, such as notifying the physician and next of kin if instructions were perceived as harsh. During a subsequent interview, the resident recounted being confronted and yelled at by the PT for walking around the facility, which led to the resident breaking down into tears and feeling disrespected and embarrassed in front of others. A Registered Nurse (RN) corroborated the resident's account, stating that the PT forcefully escorted the resident back to their room, preventing them from picking out a book. The RN reported the incident to the Administrator and Director of Nursing (DON), and the resident expressed a desire to leave against medical advice rather than work with the PT again.
Verbal Abuse Incident Involving RN and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Registered Nurse (RN), who was witnessed verbally berating a resident at the nurse's station. The incident involved Resident #7, who was admitted with diagnoses including unspecified chronic bronchitis, severe protein-calorie malnutrition, and depression. The verbal abuse was reported by a Certified Nursing Assistant (CNA) and a family member of another resident, who observed the RN cursing and throwing medication bottles around the nurse's station, with comments directed at Resident #7. The Director of Nursing (DON) was notified of the incident and initiated an investigation. The RN was immediately suspended and later terminated due to misconduct. Despite the trauma screening conducted on Resident #7, which did not indicate psychosocial harm, the investigation was deemed incomplete. The Administrator acknowledged that the investigation lacked interviews with all involved parties, including Resident #19 and another resident mentioned by the CNA, and the statement from Resident #19's family member was not included in the Facility Reported Incident (FRI) documentation. The facility's policy on abuse investigation and reporting requires thorough investigation and documentation of all reports of resident abuse, including interviews with witnesses. However, the investigation into this incident did not meet these standards, as not all witnesses were interviewed, and the documentation was incomplete. The RN had a history of disciplinary action for verbal misconduct, which was not adequately addressed prior to this incident.
Failure to Investigate and Report Abuse Allegation
Penalty
Summary
The facility failed to implement its policy on abuse investigations and reporting, as evidenced by an uninvestigated and unreported allegation of abuse involving a resident. The resident, who had been admitted with chronic congestive heart failure, type 2 diabetes mellitus with diabetic neuropathy, and anxiety disorder, reported to an Adult Protective Services (APS) Social Worker that a Certified Nursing Assistant (CNA) had handled them roughly and slapped them on the cheek. Despite being informed of this allegation by the APS Social Worker, the facility's Administrator and Director of Nursing (DON) did not investigate the claim or report it to the State agency or law enforcement, citing the resident's history of unfounded allegations as the reason for inaction. The facility's policy, adopted in 2019, mandates that all reports of resident abuse be promptly reported and thoroughly investigated, with any accused employee being suspended pending the investigation's outcome. However, the Administrator and DON admitted that the abuse allegation was not investigated, and the CNA continued to work directly with the resident after the allegation was made. This failure to act according to the established policy placed the resident at continued risk of physical abuse by the staff member.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse against a resident by a staff member within the required two-hour time frame. The incident involved a resident who had been admitted with chronic congestive heart failure, type 2 diabetes mellitus with diabetic neuropathy, and anxiety disorder. The resident reported to an Adult Protective Services (APS) Social Worker that a Certified Nursing Assistant (CNA) had handled them roughly and slapped them on the cheek. This information was communicated to the facility's Administrator by the APS Social Worker. Despite being informed of the allegation, the Administrator and the Director of Nursing (DON) did not report the incident to the State agency or law enforcement, nor did they conduct an investigation. The Administrator justified the inaction by citing the resident's history of unfounded allegations. However, the facility's policy required all new allegations of abuse to be investigated and reported promptly. The failure to adhere to this policy resulted in a deficiency, as the facility did not ensure the allegation was reported and investigated as mandated.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident who claimed a CNA slapped and handled them roughly. Despite being informed of the allegation by an APS Social Worker, the facility did not suspend the CNA or report the incident to the State Survey Agency or law enforcement. The CNA continued to work with the resident and others in the facility, which posed a risk of further abuse. The facility's policy required immediate suspension of any employee accused of abuse and a thorough investigation, which was not followed in this case. Another incident involved a Registered Nurse allegedly verbally abusing a resident at the nurse's station. The incident was witnessed by a CNA and a family member of another resident. The RN was reportedly cursing and throwing medication bottles, which was overheard by a family member who expressed concern. The facility's investigation into this incident was incomplete, as not all involved parties were interviewed, and the family member's statement was not included in the investigation documentation. The Administrator and DON shared responsibility for abuse investigations but failed to conduct thorough investigations in both cases. The lack of complete documentation and interviews with all involved parties led to an incomplete investigation, which was acknowledged by the Administrator. The facility's failure to adhere to its own policies and procedures for handling abuse allegations resulted in deficiencies in protecting residents from potential harm.
LPN Medication Administration Competency Deficiency
Penalty
Summary
The facility failed to ensure that an LPN had the necessary competencies to safely perform medication administration. During an observation, the LPN was found to have premixed doses of Polyethylene Glycol 3350 (MiraLAX) in clear plastic cups and left them on top of the medication cart. These cups, containing a clear liquid, were indistinguishable from plain water and were left unattended in the hallway, posing a risk of being ingested by other residents or visitors. The LPN continued to leave the cups on the cart while attending to residents in their rooms, indicating a lack of proper medication administration practices. The Director of Nursing (DON) confirmed that medications should not be left on top of the medication cart and should be prepared for one resident at a time, not premixed. Furthermore, the facility did not have competency checklists for new nurses, nor did it have a medication administration competency checklist for the LPN involved. This lack of oversight and training contributed to the deficiency observed during the survey.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered, resulting in a medication error rate of 100%. A resident was found with two medication cups at their bedside, containing a total of ten medications that were supposed to be administered at specific times. These medications were documented as administered in the Medication Administration Record (MAR), despite the resident not having taken them. The medications included Baclofen, Buspirone HCl, Melatonin, Senokot S, Simvastatin, Lisinopril, and Venlafaxine, which were left unsupervised at the resident's bedside. The Licensed Practical Nurse (LPN) confirmed that the medications should not have been documented as administered if the resident had not taken them and acknowledged that leaving medications at the bedside was against protocol. The physician emphasized that medications should be given at the ordered time to avoid high-risk practices and potential drug interactions. The facility's policy on medication administration, which aligns with the National Institute of Health's five rights of medication administration, was not followed, leading to this deficiency.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure proper storage and supervision of medications, specifically a laxative powder dissolved in water, which was left unattended on top of a medication cart. An LPN was observed administering medications on the 400 hall, where three cups containing a clear liquid, identified as MiraLAX, were left on the cart. The LPN admitted to premixing the doses and acknowledged that the cups could be mistaken for plain water, posing a risk of ingestion by other residents or visitors. The cups remained unattended on the cart while the LPN entered various rooms, contrary to the facility's policy that medications should be prepared for one resident at a time and not premixed. Additionally, the facility did not secure medication carts, leaving them unlocked and unattended in the 300/400 hall. This was observed when a medication cart was left unlocked, allowing staff, residents, and visitors to pass by it. An RN later noticed the unlocked cart and confirmed that it should have been secured, especially given the presence of residents with dementia who could access the medications. Another instance involved a different LPN who also left a medication cart unlocked, acknowledging their responsibility for securing it. These actions violated the facility's policy on medication storage and security.
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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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