Caremeridian Llc, Dba Neurorestorative
Inspection history, citations, penalties and survey trends for this long-term care facility in Reno, Nevada.
- Location
- 3980 Lake Placid Drive Ste 2, Reno, Nevada 89511
- CMS Provider Number
- 295103
- Inspections on file
- 19
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Caremeridian Llc, Dba Neurorestorative during CMS and state inspections, most recent first.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects.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.
A resident with quadriplegia, ventilator dependence, complex wound care needs, and significant pain management requirements was transferred to a hospital for surgical and ID evaluation of a stage 4 pressure injury. After the hospital determined the wounds were stable, discontinued IV pain meds, and cleared the resident for return, facility emails showed that leadership expressed concerns about worsened wounds, the pain regimen, and the likelihood of rapid re-hospitalization, and ultimately declined readmission. However, the facility’s records lacked documentation of the specific needs it could not meet, any attempts to meet those needs, or communication of those needs to the hospital at the time of the readmission referral, and there was no policy governing return after hospitalization despite admission agreement language on transfer, discharge, and bed-hold rights.
A resident with acute respiratory failure, quadriplegia, and ventilator dependence was transferred to an acute care hospital for surgical evaluation and an ID consult for a hip wound infection, after the SW coordinated acceptance, secured a hospital bed, and arranged transportation. Although the facility's admission agreement contained a bed-hold policy and readmission rights, the clinical record showed no written notice of this policy was provided to the resident or representative at the time of transfer. The Administrator confirmed the transfer was non-emergent, acknowledged relying on calls or emails rather than written notice, and admitted that written bed-hold information was not given upon this hospital transfer.
A resident with acute respiratory failure and cystic fibrosis had multiple gaps in documentation on the Respiratory Administration Record (RAR), including missing entries for emergency equipment checks, continuous pulse oximetry, oxygen via NC with titration parameters, and rotation of the pulse ox probe on several shifts. Additional omissions involved undocumented q8h Albuterol nebulizer treatments, chest percussion, and HyperSal nebulizer treatments for secretions. The DON confirmed that respiratory care is to be documented on the RAR, that the blanks could not be explained as either care not given or not charted, and that refusals or held treatments should have been recorded per facility policy requiring documentation of all assessments, interventions, treatments, outcomes, and refusals.
The Administrator failed to ensure the Facility Assessment (FA) included all resident types and any ethnic, cultural, or religious factors affecting care. The FA documented care for children but omitted the adult resident population and relevant cultural factors. The Administrator acknowledged the oversight and confirmed the absence of a policy for FA completion, despite following state and federal regulations.
The QAPI committee failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. The Administrator acknowledged the issue was not identified until mid-January 2025, and no EBP was in place, potentially exposing all residents, staff, and visitors to harmful infectious agents.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, as required by policy and CDC guidance. Observations showed a lack of EBP signage and PPE use during high-contact care activities. Additionally, an increase in respiratory infections in the pediatric unit was not investigated, and quarterly legionella testing was not completed as per the Water Management Program.
The facility did not document, investigate, or resolve resident grievances as required by their policy. During a Resident Council Meeting, residents expressed concerns about unaddressed grievances, with one resident noting a grievance from December 2024 remained unresolved. The Administrator acknowledged the grievance binder was missing after the Licensed Social Worker left, and no efforts were made to recover the information. The policy requires grievances to be investigated and resolved within thirty days, with forms retained for one year.
Expired medications were found in two medication storage rooms and two medication carts, posing a risk of administration to residents. Inspections revealed expired Diphenhydramine, Iron supplements, Geri-Tussin, Ondansetron, and Bisacodyl suppositories. Staff confirmed these should have been removed from active storage according to facility policy.
The facility failed to ensure timely completion of initial and annual elder abuse prevention training for six employees, including the DON, a Registered Dietician, two CNAs, an RN, and an LPN. This deficiency was confirmed by the Office Manager and was contrary to the facility's policy, potentially placing all residents at risk for abuse and neglect.
A facility failed to provide a resident with the required CMS Form 10055 and Form 10123 during a Medicare Part A stay. The resident, admitted with hypertension and muscle weakness, did not receive these forms due to the absence of a social worker or case worker. The Regional Support DON confirmed the oversight and the lack of a policy on beneficiary notifications.
A resident with sleep disorders reported being disturbed by a loud exit door near their room, which disrupted their sleep. Despite submitting a grievance, the facility had not addressed the issue. The Administrator confirmed the door's noise and acknowledged the lack of policy on noise levels in maintaining a homelike environment.
A resident's funds were misappropriated by facility staff when $100 was taken from the resident's property to pay vendors without consent. The Administrator admitted to the action, which violated the facility's policy on resident funds and valuables. The incident was documented in a Facility Reported Incident and a complaint was filed.
A facility failed to ensure the accuracy of an MDS assessment for a resident with hemiplegia, leading to potential impacts on their care plan. The MDS assessment inaccurately documented significant weight loss, which was not supported by the resident's weight records. The MDS RN confirmed that different staff completed various sections of the MDS, and the Dietician was responsible for the incorrect entry in Section K.
The facility failed to ensure that direct care staff maintained current CPR certification for two employees, an LPN and a CNA, whose certifications had expired. The Office Manager confirmed the requirement for all direct care staff to have current CPR certification, as documented in the Facility Assessment.
A facility failed to ensure a PRN psychotherapeutic medication was prescribed with a diagnosed indication, limited to 14 days, and monitored for side effects and behavior for a resident. The resident received Hydroxyzine HCl for anxiety without a documented diagnosis, and the medication was administered beyond the 14-day limit without required monitoring, contrary to facility policy.
A resident with spastic quadriplegic cerebral palsy and muscle weakness did not receive the prescribed physical therapy (PT) sessions for two weeks due to staffing shortages. The physician's order required one hour of PT per week, but the facility failed to provide this, as confirmed by the RSDON and the Director of Rehabilitation.
The facility failed to document pre-restraining assessments for residents prescribed psychotherapeutic medications and did not obtain consent for one resident's medication. Residents with various diagnoses, including anxiety and depression, were affected. The facility's policy required these assessments and consents, but they were not conducted or documented, as confirmed by the Regional Support Director of Nursing.
The facility failed to provide staff education on the Antimicrobial Stewardship Program (ASP) and did not document evaluations to determine if residents met McGeer criteria before starting antibiotics. A RN reported not receiving ASP training, and the RSDON/IP could not confirm staff training. The facility's ASP policy required education and documentation, but the Monthly Line Listing of Resident Infections lacked assessment protocols, and the RSDON/IP confirmed missing documentation of criteria in residents' records.
The facility failed to provide the required twelve hours of in-service training for two CNAs who had been employed for over a year. One CNA did not have an annual performance review by their anniversary date and lacked necessary training. Another CNA had a delayed performance review and also lacked required training. The Office Manager confirmed these deficiencies, noting that all CNAs were required to have annual evaluations by their hire date.
A resident dependent on a ventilator did not receive physician-ordered weaning care, despite documentation by an RT indicating the care was provided. Review of the ventilator's event log revealed no evidence of required setting changes, confirming that the ordered care was not performed and that the RT had engaged in fraudulent charting and neglect.
The facility did not promptly report two separate incidents to the State Agency as required: one involving a resident with chronic respiratory failure who did not receive physician-ordered care from a Respiratory Therapist, and another where a resident's cash was taken from a lock box by the Administrator to pay vendors without consent. In both cases, staff failed to follow mandatory reporting timelines for suspected neglect and misappropriation.
A resident with multiple complex medical conditions experienced a fall with injury while receiving care. The facility submitted an incomplete FRI report that lacked details about the injury and subsequent treatment, and was unable to provide a full investigation report for State Agency review, contrary to facility policy.
A CNA did not receive a timely annual performance evaluation as required by facility policy. The evaluation was not completed by the employee's anniversary date, and the Office Manager confirmed the delay and lack of documentation.
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.
Failure to Document Unmet Needs When Declining Hospital Readmission
Penalty
Summary
The deficiency involves the facility’s failure to document specific unmet needs and attempts to meet those needs when declining to readmit a resident following an acute care hospitalization. The resident had diagnoses including acute respiratory failure with hypoxia, C1–C4 complete quadriplegia, and ventilator dependence, and required tracheostomy care, ventilator services, G-tube feeding, pain management, and wound care for a stage 4 pressure injury with a wound vac. The resident was transferred from the facility to an acute care hospital for surgical evaluation and infectious disease consultation related to a right hip/buttock wound. The clinical record at the facility did not contain documentation that the resident returned, nor did it identify any specific needs that the facility could not meet that would prevent readmission. Hospital discharge documentation later showed that the resident’s decubitus ulcers had been evaluated by plastic surgery, no surgical intervention was recommended, the wounds were considered stable with no change to pre-admission management, and IV pain medication had been discontinued in preparation for discharge, with pain status returned to pre-admission levels. Email communications among the Administrator, facility staff, and the Ombudsman showed that the facility initially indicated it would hold the resident’s bed and that the resident would need to be clinically stable prior to return. Subsequent emails documented that the facility expressed concerns that the resident’s condition, including pain medication regimen and wound status, appeared different from when the resident was transferred out, and that there was concern the resident might quickly require a return to acute care. The Administrator and DON later confirmed that decisions about readmission were made by a team and typically documented via email, and that the facility regularly provided wound care and pain management, including a process requiring residents to be off IV pain medication for at least 24 hours prior to admission or readmission. The DON recalled that the facility declined readmission due to perceived worsening wounds and a belief that the resident needed LTACH-level wound care and IV pain management, while acknowledging that hospital records indicated the resident’s wounds were stable and IV pain medication had been stopped. Both the Administrator and DON were unsure whether any documentation existed specifying the resident’s needs that could not be met, attempts to meet those needs, or communication of those needs to the hospital at the time of referral for readmission, and no such documentation was produced during the survey. The facility also lacked a policy regarding permitting a resident to return following hospitalization, despite an admission agreement that addressed transfer, discharge, and bed-hold rights.
Failure to Provide Written Bed-Hold Policy Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to a resident and the resident's representative upon transfer to an acute care hospital. The resident involved had diagnoses including acute respiratory failure with hypoxia, quadriplegia at C1-C4, and dependence on a ventilator. The clinical record showed the resident was discharged to an acute care hospital for surgical evaluation and an infectious disease consult related to a right hip wound infection. A Social Services Progress Note documented that the social worker notified the resident's guardian of the physician's recommendation for hospital transfer, contacted the hospital, secured a bed, and arranged transportation. However, the clinical record lacked any documented evidence that written notice of the facility's bed-hold policy was provided at the time of transfer. During interview, the Administrator stated they usually called or emailed residents and representatives to provide notification of the bed-hold policy when a resident was transferred, and that in emergent 911 transfers the priority was resident care with notification possibly occurring after the resident left. The Administrator confirmed this resident's transfer was coordinated and not emergent, recalled leaving a message for the resident's representative about paying a bed-hold fee after the transfer, and acknowledged that written notice of the bed-hold policy was not provided to the resident or representative upon transfer. The Administrator also stated the facility did not have separate policies on transfers, discharges, and bed-holds, and that related information was contained in the admission packet. The facility's Resident Admission Agreement included sections on transfers, discharges, and a bed-hold policy, including provisions for bed-hold charges and readmission rights, but there was no documentation that this required written notice was given at the time of the hospital transfer.
Incomplete Respiratory Treatment Documentation in Clinical Record
Penalty
Summary
The facility failed to ensure complete and accurate clinical records for a resident with acute respiratory failure with hypoxia and cystic fibrosis with pulmonary manifestations. Review of the resident’s February 2026 Respiratory Administration Record (RAR) showed multiple scheduled respiratory tasks and treatments with no documentation of completion or reason for omission. These included checking emergency equipment at the bedside every shift, continuous pulse oximetry every shift, oxygen via nasal cannula with titration parameters every shift, and rotation of the pulse oximeter probe every shift, all of which had blank entries on several specified dates. The DON confirmed that respiratory care and treatments were to be documented on the RAR and acknowledged the blank spaces on the record. Further review of the same resident’s RAR revealed missing documentation for ordered respiratory treatments scheduled every eight hours, including Albuterol Sulfate nebulizer treatments for shortness of breath, chest percussion for respiratory insufficiency, and HyperSal (7% Sodium Chloride) nebulizer treatments for secretions, with multiple dates left blank. The DON stated uncertainty as to whether the care or treatments were not provided or were provided but not documented, and confirmed that if care or treatment was held or refused, the RAR should indicate this rather than be left blank. The facility’s documentation policy, revised 11/07/2024, required staff to document assessments, interventions, procedures, treatments, outcomes, services provided, and any refusals of medications and/or treatments in the resident’s record.
Incomplete Facility Assessment Lacks Comprehensive Resident Data
Penalty
Summary
The Administrator failed to ensure the Facility Assessment (FA) included all portions of the facility's resident population and any ethnic, cultural, or religious factors that could affect the care provided. The FA, approved on January 16, 2025, documented that the facility provided post-acute care and rehabilitation to children, from infants to young adults, in a safe, home-like environment. However, the FA lacked documentation related to the facility's adult resident population and did not address any ethnic, cultural, or religious factors that could influence the care provided. On February 19, 2025, the Administrator acknowledged the responsibility to complete the FA annually, which includes reviewing the needs and complexity of the residents, as well as staffing and training needs. The Administrator confirmed that the FA should have included all resident types and addressed any ethnic, cultural, or religious factors. Additionally, the Administrator admitted that the facility did not have a policy related to the completion or required components of the FA, although they followed state and federal regulations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to implement corrective actions to address the lack of Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. This deficiency was identified during a QAPI review with the Administrator, who acknowledged that the facility had not recognized the issue until mid-January 2025. Despite being aware of the problem, the facility did not implement EBP, and no current residents were receiving these precautions. The Administrator's job description, dated 11/29/2011, indicated responsibility for the Performance Improvement Program, yet the deficiency persisted, potentially exposing all residents, staff, and visitors to harmful infectious agents.
Failure to Implement Enhanced Barrier Precautions and Investigate Infections
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for 20 residents with indwelling medical devices, as per the facility's policy and CDC guidance. Observations revealed that there were no EBP signage or personal protective equipment (PPE) carts near residents' rooms, and staff were not wearing gowns during high-contact care activities. Interviews with the Director of Nursing (DON) and the Regional Support DON/Infection Preventionist (RSDON/IP) confirmed that EBP had not been implemented for any residents, despite the presence of indwelling medical devices. The RSDON/IP acknowledged the need for EBP to prevent the transmission of multidrug-resistant organisms (MDROs) but stated that the facility was still working on its implementation. The facility also failed to investigate an increase in respiratory infections in the pediatric unit, affecting four residents in December 2024. The Monthly Line Listing of Resident Infections showed an increase from one respiratory infection in November to four in December, but no investigation was conducted to determine the cause. The RSDON/IP admitted that no enhanced or transmission-based precautions were implemented for the affected residents, and there was no evidence of staff training or in-service provided during the increase in infections. Additionally, the facility did not complete quarterly legionella testing as required by its Water Management Program. The Maintenance Manager revealed that water testing was only performed twice a year instead of quarterly. The facility's Water Management Program outlined the need for quarterly testing to prevent the growth and spread of legionella and other waterborne pathogens, but the results for the remaining quarters of 2024 were not documented or kept with the program.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were documented, investigated, and resolved, as required by their grievance policy. During a Resident Council Meeting, it was noted that residents had expressed concerns about the facility not responding to written grievances. One resident specifically mentioned that a grievance submitted in December 2024 had not been addressed. The facility's Administrator admitted that the binder containing grievance forms was missing after the Licensed Social Worker left employment, and no attempts had been made to recover or recreate the missing information. The facility's grievance policy mandates that grievances be investigated and a written decision provided to the resident within thirty days, with grievance forms retained for one year.
Expired Medications Found in Active Supply
Penalty
Summary
The facility failed to remove expired medications from the active supply in two medication storage rooms and two medication carts, which had the potential for expired medications to be administered to residents. During an inspection of the medication cart in the 400 unit, a bottle of Diphenhydramine Hydrochloride oral solution was found with an expiration date of January 2025. The Licensed Practical Nurse (LPN) confirmed the medication had expired. Additionally, in the medication storage room on the 400 unit, three bottles of Iron supplement liquid and one bottle of Geri-Tussin were found with expiration dates of December 2024 and October 2024, respectively. The LPN acknowledged these medications were expired and should have been removed from active storage. Further inspections revealed additional expired medications. On the 300 unit, a bubble pack containing Ondansetron tablets with an expiration date of January 2025 was found in the medication cart. The Registered Nurse (RN1) confirmed the tablets were expired and explained the process for handling expired medications, which includes removing them from the cart and placing them in a designated bin for destruction. In the medication storage room on the 200 unit, two boxes of Bisacodyl suppositories with expiration dates of January 2025 were found. RN2 confirmed these were expired and should have been removed. The Director of Nursing (DON) stated that expired medications should be destroyed and removed from active storage to prevent accidental administration to residents. The facility's policy requires expired medications to be stored separately until destroyed or returned to the pharmacy.
Deficiency in Timely Elder Abuse Prevention Training
Penalty
Summary
The facility failed to ensure that initial and annual elder abuse prevention training was completed in a timely manner for six out of eighteen sampled employees. This deficiency was identified through personnel record reviews, interviews, and document reviews. Specifically, the Director of Nursing, hired on December 20, 2024, lacked documented evidence of elder abuse prevention training upon hire. The Registered Dietician, hired on October 18, 2018, had completed training in 2022 but lacked evidence of training in 2024. Two Certified Nursing Assistants, hired in 2023, had completed training in 2023 but not in 2024. Additionally, a Registered Nurse and a Licensed Practical Nurse, both hired in 2022, lacked evidence of annual training, with the LPN also missing initial training documentation. The Office Manager confirmed that abuse training was required to be completed during the first orientation and annually thereafter, and that staff were not permitted to work on the floor prior to completing this training. The facility's policy, revised on October 2, 2024, stipulated that initial abuse training must be completed before starting floor training, and that all healthcare workers receive education and training on abuse during orientation, annually, and as needed. The lack of timely elder abuse training for these employees had the potential to place all residents at risk for abuse and neglect.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required CMS Form 10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) and Form 10123, Notice of Medicare Non-Coverage (NOMNC) to a resident discharged from a Medicare-covered Part A stay with benefit days remaining. The resident, who was admitted with diagnoses including essential primary hypertension and generalized muscle weakness, had a Medicare Part A Skilled Services Episode from 12/20/2024 to 02/02/2025. The resident's clinical record lacked documented evidence of receiving these forms. The Regional Support Director of Nursing confirmed the absence of these forms and acknowledged that they may not have been completed due to the lack of a social worker or case worker. Additionally, the facility was unable to locate a policy on beneficiary notifications.
Facility Fails to Address Noise Complaint Affecting Resident's Sleep
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for a resident who reported being disturbed by the loud closing of an exit door used by staff in the 200 Hall. The resident, who was admitted with diagnoses including circadian rhythm sleep disorder and unspecified sleep disorder, submitted a grievance in December 2024 about the noise from the door, which disrupted their sleep multiple times each night. Despite the grievance, the facility had not addressed the issue by the time of the survey. During the survey, the Director of Nursing confirmed that staff used the door next to the resident's room as an exit. The Administrator, upon testing the door, acknowledged that it closed loudly enough to wake residents in the hall. The facility's policy on resident rooms did not include considerations for noise levels, and the Administrator stated that this was the only policy related to maintaining a homelike environment.
Misappropriation of Resident's Funds by Facility Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal property, specifically involving the wrongful use of the resident's money. The incident involved the facility Administrator and a previous Recreational Therapist, who commingled the resident's property with the facility's petty cash. The resident, who had been admitted with a primary diagnosis of atherosclerotic heart disease, discovered $100 missing from their wallet after signing it out. This was confirmed by the previous Assistant Director of Nursing. A Registered Nurse's statement indicated that the resident's valuables were moved from the medication cart to the Administrator's office at the Administrator's insistence. The Administrator admitted to removing $100 from the resident's property to pay vendors, as there was insufficient time to cash a petty cash check. The Administrator acknowledged this action as misappropriation, as the money was taken without the resident's consent. The facility's policy on resident funds and valuables clearly states that misuse of funds or property, including theft and commingling of funds, is considered misappropriation and must be reported. This incident was documented in a Facility Reported Incident and a complaint was filed, highlighting the failure to adhere to the facility's policy and protect the resident's financial resources.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for one resident, which had the potential to impact the resident's person-centered care plan. The resident was admitted with a primary diagnosis of hemiplegia affecting the left nondominant side. An Admission MDS assessment indicated that the resident had experienced significant weight loss, which was not accurate according to the weights and vitals summary. The MDS RN confirmed that different sections of the MDS were completed by different staff members, and the Dietician was responsible for completing Section K, which documented the incorrect weight loss. Upon review, the MDS RN acknowledged that the resident did not actually experience the reported weight loss by the time the MDS assessment was completed.
Expired CPR Certifications Among Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff maintained current Cardio-Pulmonary Resuscitation (CPR) certification for two of twelve sampled direct care employees. Employee #14, a Licensed Practical Nurse (LPN), and Employee #16, a Certified Nursing Assistant (CNA), both had expired CPR certifications. The LPN's certification expired on a specific date, and the CNA's certification also expired on a different date. The Office Manager confirmed that CPR certification was required for all direct care staff and acknowledged that these two employees did not have current certifications. The Facility Assessment indicated that all staff were expected to be Basic Life Support certified.
Failure to Monitor and Limit PRN Psychotherapeutic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotherapeutic medication was prescribed with a diagnosed indication for use, was limited to 14 days, and was monitored for side effects and behavior for a resident. Resident #19 was admitted with a primary diagnosis of hemiplegia, unspecified affecting the left nondominant side. An active physician's order dated 01/08/2025, prescribed Hydroxyzine Hydrochloride (HCl) 25 mg via gastrostomy tube every 24 hours PRN for episodes of feeling anxious or stressed over recent life changes. However, the resident's electronic health record (EHR) lacked documentation of an anxiety diagnosis, and the physician orders did not include evidence of side effect or behavior monitoring for the medication. The medication administration records indicated that Hydroxyzine HCl was administered from 01/09/2025 through 02/15/2025, exceeding the 14-day limit for PRN psychotherapeutic medications. Interviews with a Registered Nurse and the Regional Support Director of Nursing confirmed the absence of an anxiety diagnosis in the resident's EHR and the lack of required monitoring. The facility's policy on psychotherapeutic medications required that PRN orders be limited to 14 days and include behavior monitoring every shift, which was not adhered to in this case.
Failure to Provide Physical Therapy as Ordered
Penalty
Summary
The facility failed to provide physical therapy (PT) to a resident as per the physician's order, which required one hour of PT per week for 12 weeks. The resident, who was diagnosed with spastic quadriplegic cerebral palsy, muscle weakness, and abnormal posture, was admitted and readmitted to the facility with a care plan that included interventions for limited physical mobility and high fall risk. Despite the physician's order dated 01/08/2025, the resident did not receive PT from 02/02/2025 through 02/15/2025, as confirmed by the Regional Support Director of Nursing (RSDON) and the facility's Director of Rehabilitation. The RSDON acknowledged the lack of PT during this period and attributed it to staffing shortages in the rehabilitation department. Documentation provided by the RSDON and the resident's clinical record confirmed the absence of PT sessions during the specified two-week period. The facility's policy required nursing or designees to provide healthcare as regulated by the physician, which was not adhered to in this case, leading to the deficiency.
Failure to Document Pre-Restraining Assessments and Obtain Consent for Psychotherapeutic Medications
Penalty
Summary
The facility failed to ensure that residents prescribed psychotherapeutic medications had a documented pre-restraining assessment as required by the facility's policy. This deficiency was identified for five residents who were sampled for unnecessary medications. The residents involved had various diagnoses, including anxiety, depression, and cerebral palsy, and were prescribed medications such as Sertraline, Fluoxetine, Lorazepam, Cymbalta, Hydroxyzine, and Escitalopram. The electronic health records of these residents lacked documentation of a pre-restraining assessment related to their psychotherapeutic medications. The Regional Support Director of Nursing confirmed that the facility had not conducted pre-restraining assessments for any residents receiving psychotherapeutic medications, which was a requirement per the facility's policy. Additionally, the facility failed to obtain consent for the administration of a psychotherapeutic medication for one resident. This resident was prescribed Sertraline for anxiety, and the medication was administered without documented evidence of consent being obtained prior to its administration. The facility's policy required that consent be obtained and reviewed by a physician before ordering or administering psychotherapeutic medications. The Regional Support Director of Nursing confirmed that consent had not been obtained for this resident, which was a violation of the facility's policy.
Lack of Antimicrobial Stewardship Education and Documentation
Penalty
Summary
The facility failed to ensure that staff received education regarding the Antimicrobial Stewardship Program (ASP) and did not document evaluations to determine if residents met McGeer criteria before initiating antibiotic therapy. A Registered Nurse (RN) who had been working at the facility for about a year reported not receiving any training related to the facility's ASP. The RN also stated that the facility lacked an antibiotic stewardship program and did not perform antibiotic timeouts, with all antibiotic prescribing decisions being made by the physician. The Regional Support Director of Nursing/Infection Preventionist (RSDON/IP) could not confirm that staff had received formal training on the ASP or its importance. The facility's Antimicrobial Stewardship Program, last reviewed in January 2025, required continuing education for all staff on antimicrobial stewardship, including resistance and appropriate infection assessment. However, the facility did not have a specific form or criteria for documenting suspected infections before starting antibiotic therapy. The Monthly Line Listing of Resident Infections for November and December 2024 showed antibiotics were prescribed for most infections, but did not include an assessment protocol or indicate if residents met criteria for antibiotic therapy. The RSDON/IP confirmed that the facility tracked communicable diseases and antibiotic use but lacked documentation of assessments and criteria in residents' records, as required by the facility's policy.
Deficiency in CNA Training and Performance Evaluations
Penalty
Summary
The facility failed to provide the required twelve hours of in-service training for two Certified Nursing Assistants (CNAs) who had been employed for over a year. Employee #6, hired on September 20, 2023, did not have an annual performance review conducted by their anniversary date of September 20, 2024, and lacked the necessary in-service training. Employee #7, hired on February 17, 2023, had a delayed performance review conducted on July 11, 2024, which was 145 days past their anniversary date of February 17, 2024. Additionally, Employee #7 did not have a performance review completed by their anniversary date of February 17, 2025, and also lacked the required in-service training. The Office Manager confirmed these deficiencies, noting that all CNAs were required to have annual evaluations by their hire date, which were to be completed by the Director of Nursing.
Failure to Provide Physician-Ordered Ventilator Weaning and Fraudulent Charting by RT
Penalty
Summary
A resident with chronic respiratory failure, tracheostomy status, and ventilator dependence was admitted and had a physician's order for daily ventilator weaning using specific sprint settings. The resident's family reported concerns that a Respiratory Therapist (RT) was not providing the ordered care. Upon review, the Respiratory Manager (RM) found that although the RT documented completion of the ventilator weaning, the ventilator's event log did not show any evidence that the required changes to the ventilator settings were made as ordered by the physician. The RM confirmed that the ventilator machine automatically records all setting changes, and no such changes were documented during the relevant period. The RT had charted that the care was provided, but the lack of corresponding evidence in the ventilator log indicated that the care was not actually rendered. This failure to provide physician-ordered care was substantiated as neglect by the facility, as it involved fraudulent charting and professional negligence.
Failure to Timely Report Allegations of Neglect and Misappropriation
Penalty
Summary
The facility failed to ensure timely reporting of two separate allegations to the State Agency (SA) as required by regulation and facility policy. In the first instance, a resident with chronic respiratory failure and tracheostomy status was allegedly neglected when a Respiratory Therapist (RT) did not provide physician-ordered care. The concern was initially reported to a facility employee on 10/30/2024, but the Administrator was not notified until 11/05/2024, at which point the incident was reported to the SA. Facility policy required all staff, including those with contractual agreements, to immediately report suspected abuse or neglect to the Administrator and the SA, but this did not occur in a timely manner. In the second case, an allegation of misappropriation of resident property was not reported to the SA within the required timeframe. A resident discovered $100 missing from their wallet, which had been stored in a lock box in the Administrator's office. The Administrator admitted to removing the cash from the resident's property to pay facility vendors without the resident's consent. Although the incident was known to the Administrator, it was not reported to the SA until several days later, contrary to the policy that required reporting within two hours of discovery. Both incidents involved failures by facility staff, including the Administrator, to follow mandatory reporting requirements for suspected neglect and misappropriation. Documentation and interviews confirmed that the reporting delays were due to staff not immediately notifying the appropriate authorities, as required by both state regulations and facility policy.
Failure to Provide Complete Investigation Documentation for Resident Fall
Penalty
Summary
The facility failed to ensure that a complete investigation report was available for review regarding a fall incident involving a resident with spastic diplegic cerebral palsy, diabetes insipidus, and bilateral knee contractures. The resident experienced a fall with injury while receiving care, as documented in the care plan and the Facility Reported Incident (FRI) submitted to the State Agency. However, the FRI report lacked specific details about the location of the fracture and the additional treatment provided. Upon request, the facility was unable to produce the full investigation report, with only the documents submitted to the State Agency available for review. This was not in accordance with the facility's policy, which requires a written report of the investigation results and actions taken.
Annual CNA Performance Evaluation Not Completed Timely
Penalty
Summary
The facility failed to complete an annual performance evaluation for a Certified Nursing Assistant (CNA) who had been employed for over one year. The CNA was hired on 09/20/2023, but there was no documented evidence of an annual performance review being conducted by the anniversary date of 09/20/2024. The Office Manager confirmed that the evaluation for 2024 was completed late and that the evaluation for 2025 had not yet been completed. Facility policy required annual evaluations for all CNAs by their hire date, to be completed by the Director of Nursing.
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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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