El Jen Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 5538 W Duncan Dr, Las Vegas, Nevada 89130
- CMS Provider Number
- 295008
- Inspections on file
- 32
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at El Jen Skilled Care during CMS and state inspections, most recent first.
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 resident with a history of smoking and cognitive decline was not re-assessed for smoking safety or had their care plan updated after a significant change in condition. After being found smoking in their room while on oxygen, staff did not complete a new smoking safety assessment or revise the care plan. The facility also failed to secure the resident's lighter and cigarettes, resulting in a fire that caused burns and smoke inhalation, requiring hospitalization.
Surveyors identified that the facility did not maintain its fire alarm system, as the main panel displayed a trouble alarm for a missing duct detector and showed an incorrect date and time after a power outage. The facility also lacked documentation of annual portable fire extinguisher inspections and had a fire safety plan that omitted protocols for extinguisher use and procedures for reviewing the fire alarm panel during alarms. These deficiencies affected 36 residents in one smoke compartment.
Staff removed the battery from a resident's motorized wheelchair without first obtaining the resident's permission or providing an explanation, following an incident where the resident accidentally ran over another individual's foot. The action was taken while the resident was out of the room, and both the Administrator and Maintenance Director later acknowledged that consent should have been obtained in accordance with resident rights.
A resident with multiple psychiatric and medical diagnoses was administered Seroquel, a psychotropic medication, without documented informed consent prior to the first dose. Facility staff, including an RN and the DON, confirmed that policy requires consent before administration, but the required documentation was missing from the resident's medical record.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not upheld, reflecting a failure to ensure resident autonomy in medical decision-making.
Two residents with complex medical conditions were not provided with education on the risks and benefits of pneumococcal, influenza, and COVID-19 vaccines, nor was there documentation of vaccine administration or declination. Staff interviews confirmed that required procedures for reviewing and documenting immunization status were not followed for these residents.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with cognitive impairment and a history of wandering was able to exit the facility undetected while wearing a wander guard bracelet that failed to activate an alert. The resident was not discovered missing until several hours later and was found outside the facility. Investigation revealed that the wander guard device's functionality had not been properly tested for this resident, leading to the deficiency.
A resident with multiple health conditions was physically abused by a CNA during a verbal altercation, resulting in the CNA's arrest. The incident was witnessed by another CNA, and the resident reported no physical or emotional harm. The facility documented the incident and implemented safety interventions.
A facility failed to report an alleged verbal abuse incident involving a resident with parkinsonism and other conditions to the State Agency within the required timeframe. The resident was documented as threatening another resident with a butter knife. The incident was reported five days late, contrary to the facility's policy requiring a two-hour reporting window for abuse allegations.
A facility failed to follow physician's orders for a resident requiring bilateral heel protectors at all times in bed. Observations showed the protectors were not applied, and staff interviews revealed inconsistencies in their application. The resident had a history of a healed wound and was at risk for skin breakdown, necessitating the use of heel protectors as ordered.
The facility failed to maintain an effective pest control program, as live cockroaches were found in the kitchen. During an inspection, two live and several dead baby cockroaches were observed behind the stove near the sink, with the area soiled by food debris and grease. The Maintenance Director confirmed the findings and provided a pest control report from two weeks prior, which did not document any live insect detection.
A facility failed to refer a resident for a PASRR Level 2 evaluation after a new diagnosis of bipolar disorder. The resident, admitted with various medical conditions, had no documented referral for evaluation following the new diagnosis. The ADON was unaware of the process, and the MDS Coordinator confirmed the oversight, citing new management and staff as contributing factors. The facility's policy required PASRR completion for all admissions, which was not followed.
The facility failed to develop and implement person-centered care plans for two residents, leading to potential health risks. One resident with end-stage renal disease exceeded fluid restrictions without a care plan addressing non-compliance, while another resident with dementia and high sodium levels lacked a hydration care plan despite refusal to drink fluids. Staff confirmed the absence of necessary care plans, highlighting a failure to adhere to facility policies.
A resident with Alzheimer's and other conditions, who was dependent on staff for oral care, did not receive consistent oral hygiene. The resident was observed with a dry mouth and white stringy material, indicating neglect in oral care. Despite the care plan requiring daily mouth care, records showed inconsistent provision of oral hygiene. The DON confirmed that oral care should have been provided at least twice daily.
A resident with dementia and anxiety disorder experienced two falls, but the facility failed to complete post-fall neurological checks as required by their protocol. The Director of Staff Development and the DON confirmed the absence of these checks in the medical records, which could delay necessary medical intervention.
A resident with dementia and cognitive impairment was found shaving with multiple razors in their room, resulting in a small facial cut. The RN confirmed the resident should not have had access to razors due to confusion and accident risk. Facility policy required interventions to reduce environmental hazards, but this was not followed.
The facility failed to implement a fluid restriction for a dialysis-dependent resident and did not provide a one-on-one feeding assistant for another resident at risk for weight changes. Despite physician orders, the fluid restriction was not monitored, and the feeding assistance was not provided, leading to potential adverse health outcomes.
A resident with a midline IV line had the access left in place without therapeutic need, despite the initial treatment for hypotension being completed. The facility's policy required removal of unused IV lines, but there was no documentation or action taken to address the unnecessary IV access, posing a potential infection risk.
The facility failed to provide prescribed medications for two residents due to a lack of timely reordering. One resident did not receive Duloxetine for depression, and another did not receive Sertraline for major depressive disorder. The nursing staff did not follow the facility's policy to ensure medication availability, leading to a deficiency in pharmaceutical services.
The facility failed to discard expired medications, including compounded IV Vancomycin and Sodium Chloride tablets. An LPN confirmed that the medications, which were past their 'do not use' dates, should have been discarded or returned to the pharmacy as per facility policy.
The facility failed to follow guidelines for food storage, as eight packets of hamburger buns were found in the dry storage area beyond the recommended time. The cook confirmed the buns had been stored for more than two weeks, contrary to the facility's policy and storage chart, which indicated a storage time of four to five days.
A facility failed to ensure wound care contractors followed enhanced barrier precautions (EBP) during the treatment of a resident with a stage 4 decubitus ulcer. Despite a sign indicating the need for EBP, including PPE such as gloves and gowns, the wound care staff did not wear PPE during the procedure. This was confirmed by the charge nurse and the Director of Nursing, who noted the lack of training for the wound care team on EBP, as required by the facility's policy.
A facility failed to ensure abuse policies were implemented when a CNA reported hearing a noise suggestive of abuse but did not intervene to stop it. Despite being up to date on abuse training, the CNA did not follow protocol to ensure resident safety first.
The facility failed to ensure an incident where a resident with dementia and Alzheimer's disease was forced to take medications was promptly reported to the abuse coordinator and the agency. The incident, witnessed by multiple staff members, was not reported immediately, leading to a delay in investigation and reporting to the state agency. The deficiency highlights a failure in timely reporting and addressing suspected abuse, neglect, or theft.
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.
Failure to Reassess Smoking Safety and Secure Smoking Materials Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff re-assessed a resident's smoking status and updated the care plan following a significant change in the resident's cognitive condition. The resident, who had a history of cigarette smoking and was at risk for injury and inappropriate behaviors, experienced a decline in cognition as documented by a lower BIMS score. Despite this significant change, the resident's smoking safety was not re-evaluated, and the Minimum Data Set (MDS) inaccurately reflected no tobacco use. The medical record lacked a corresponding Smoking Safety evaluation and care plan update after the change in condition. Additionally, after an incident where the resident was found smoking inside their room while using oxygen, staff did not complete a new smoking safety assessment or update the care plan as required by facility protocol. The Activity Director and DON confirmed that the event should have triggered a reassessment and care plan revision, but these actions were not taken. The resident's medical record did not reflect any follow-up or documentation of the incident in the smoking safety evaluation. Furthermore, the facility failed to secure the resident's lighter and cigarettes, contrary to the facility's protocol that prohibited residents from retaining smoking paraphernalia. Despite the implementation of a new smoking program protocol, the resident was able to access smoking materials and subsequently caused a fire in their room while using oxygen. This resulted in the resident sustaining burns and smoke inhalation, requiring hospitalization.
Failure to Maintain Fire Alarm System, Fire Extinguishers, and Fire Safety Plan
Penalty
Summary
The facility failed to maintain its fire alarm system, portable fire extinguishers, and fire safety plan in accordance with National Fire Protection Association (NFPA) standards. During a facility tour, the main fire alarm panel was observed to display a system trouble alarm, specifically indicating a missing duct detector in the water heater room. The fire alarm panel also showed an incorrect date and time, which the Maintenance Director attributed to a recent power outage and subsequent hard reset of the system. The facility was aware of the trouble alarm but had only scheduled future repairs with the vendor. Additionally, document review revealed that the facility could not provide evidence of annual inspections for portable fire extinguishers. Review of the facility's evacuation and fire safety plan showed that it lacked protocols for the use of portable fire extinguishers, such as the P.A.S.S. method, and did not include procedures for reviewing the fire alarm annunciator panel during an alarm condition. These deficiencies affected 36 residents in one of six smoke compartments, with the facility having a census of 137 residents at the time of the survey.
Failure to Obtain Resident Permission Before Removing Wheelchair Battery
Penalty
Summary
Staff failed to obtain permission from a resident prior to removing the battery from the resident's motorized wheelchair. The resident, who had diagnoses including multiple sclerosis, generalized anxiety disorder, and pain, was involved in an incident where the motorized wheelchair accidentally ran over another resident's foot. Following this incident, the resident was informed that they would be using a manual wheelchair for safety reasons. However, the battery of the motorized wheelchair was removed from the resident's room by the Maintenance Director, under the Administrator's instruction, without the resident's knowledge or consent while the resident was away at a doctor's appointment. The resident reported being upset that the battery was removed without their permission and confirmed that no one from the facility had asked for consent or explained the reason for the removal prior to the action. Both the Administrator and Maintenance Director acknowledged that the resident's permission should have been obtained and that the reason for the removal should have been communicated. The facility's own policy, as outlined in the Notice of Resident Rights, affirms the resident's right to a dignified existence, self-determination, and to be treated with respect and dignity.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering a psychotropic medication to a resident. The resident, who had diagnoses including type 2 diabetes mellitus, schizoaffective disorder bipolar type, major depressive disorder, and anxiety disorder, was prescribed Seroquel for paranoia, agitation, and irritability. Documentation showed that Seroquel was first administered on 07/17/2025, but there was no evidence in the medical record that informed consent had been obtained from the resident or their representative before the initial dose. Both a Registered Nurse and the Director of Nursing confirmed that facility policy requires informed consent prior to administering psychotropic medications, and that this was not documented for the resident in question.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulation. Specific actions or inactions leading to this deficiency are not detailed in the provided excerpt, but the deficiency centers on the lack of adherence to resident autonomy in medical decision-making.
Failure to Document and Educate on Vaccination Status
Penalty
Summary
The facility failed to ensure that education regarding the risks and benefits of pneumococcal, influenza, and COVID-19 vaccines was provided to residents, and did not ensure administration or obtain documented declinations for two of five residents reviewed for infection control. Specifically, two residents with significant medical histories, including infection of an amputation stump, cellulitis, depression, and chronic systolic heart failure, could not recall being offered immunizations or receiving explanations about the risks and benefits. There was no documented evidence that these residents had been educated about or offered the relevant immunizations. Interviews with facility staff revealed that the process for new admissions included reviewing immunization status, offering vaccines, and obtaining signed consent or declination, but this process was not documented for the two residents in question. The Infection Preventionist and Director of Nursing both acknowledged the absence of documentation regarding vaccination status for these residents, despite facility policy requiring immunization status to be determined and recorded upon admission or soon after.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Resident Elopement Due to Failure of Wander Guard System and Inadequate Supervision
Penalty
Summary
A resident with a history of Parkinsonism, major depressive disorder, and dementia with mood disturbance, who had demonstrated moderate to severe cognitive impairment, was able to elope from the facility without detection. The resident was last seen by staff in the evening and received medications and vital sign checks, but was later observed on security footage independently exiting the facility through a designated door in the early morning hours. The resident was not discovered missing until several hours later during a routine check, prompting a facility-wide search and eventual recovery of the resident outside the facility by a staff member. At the time of the elopement, the resident was wearing a wander guard bracelet, which failed to trigger an alert when the resident exited the building. The facility's investigation revealed that the functionality of the wander guard device had not been adequately tested for this resident, and the system did not activate as intended. Documentation showed that the maintenance department routinely checked the wander guard system at facility doors, but there was an oversight in ensuring the resident's individual device was operational, which contributed to the resident's ability to leave the facility undetected.
Resident Safety Compromised by CNA Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Certified Nurse Assistant (CNA) and a resident. The resident, who was admitted with acute respiratory failure, chronic obstructive pulmonary disease, and diabetes mellitus type 2, was involved in a verbal altercation with a CNA while being cared for in bed. This altercation escalated when the CNA struck the resident in the rib area with a closed fist. The incident was witnessed by another CNA, and the police were contacted, leading to the arrest of the offending CNA. The resident underwent a head-to-toe assessment following the incident, which revealed no bruising or discoloration, and the resident reported no pain or discomfort. Social Services and the facility's Administrator provided emotional support to the resident, who reported no psychosocial harm or emotional distress from the incident. The facility documented the incident in the resident's care plan, noting the altercation and implementing interventions to ensure the resident's safety and encourage communication of concerns.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident to the State Agency (SA) within the required timeframes. The incident involved a resident who was admitted with diagnoses including parkinsonism, dysphagia, cognitive communication deficit, and depression. On a specific date, the resident was documented in a behavior note as standing in the hallway with a butter knife in their sleeve, threatening to harm another resident. The Facility Reported Incident (FRI) was submitted to the SA five days after the incident, which was not within the required 24-hour timeframe for reporting abuse without serious bodily harm. The facility's policy, revised in 2022, mandates that allegations of verbal abuse, including threats, be reported to the appropriate agencies within two hours if the allegation involves abuse. The Administrator/Abuse Coordinator confirmed the delay in reporting.
Failure to Apply Heel Protectors as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders for the application of heel protectors for one resident, identified as Resident 5. The physician's orders, dated September 2, 2023, specified that bilateral heel protectors should be worn at all times when the resident is in bed to provide pressure relief and prevent skin breakdown. However, observations on December 18, 2024, revealed that the heel protectors were not applied while the resident was in bed at multiple times throughout the day. Instead, the heel protectors were found on top of a three-drawer organizer at the foot of the resident's bed. Interviews with facility staff, including a CNA, an LPN, and the Wound Treatment Nurse, indicated a lack of consistent application of the heel protectors. The CNA mentioned that the heel protectors were applied and removed at different times during the day, while the LPN incorrectly stated that the protectors were only needed at night if the resident had wounds. The Wound Treatment Nurse confirmed that the resident had a history of a healed wound and was at risk for skin breakdown, thus necessitating the use of heel protectors as ordered. The Director of Nursing also verified the need for heel protectors to be in place as per the physician's orders, highlighting a failure in following the prescribed care plan for the resident's condition and needs.
Deficient Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of live cockroaches in the kitchen. During a kitchen inspection, two live baby cockroaches and several dead ones were found in a corner behind the stove area near the triple compartment sink. The floor surface in this area was soiled with food debris and grease. The Maintenance Director confirmed the observation and provided proof of pest control performed two weeks prior, but the report did not document if live insects were detected during that visit. The facility's policy, last revised in May 2024, stated that an ongoing pest control program would be maintained to keep the facility free of insects.
Failure to Refer Resident for PASRR Level 2 Evaluation
Penalty
Summary
The facility failed to establish a process to identify residents with newly found changes or diagnoses that require a referral for a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation. This deficiency was identified for one of the 27 sampled residents, specifically Resident 98, who was admitted with diagnoses including orthopedic aftercare following surgical amputation, type 2 diabetes, and peripheral vascular disease. Despite a new diagnosis of bipolar disorder being documented on 08/13/2024, there was no evidence in the medical record that a referral for a PASRR Level 2 evaluation was made. The Assistant Director of Nursing (ADON) was unaware of the facility's process for requesting a PASRR Level 2 evaluation following a new mental illness diagnosis. The Minimum Data Set (MDS) Coordinator acknowledged that the medical record should have been reviewed after the new diagnosis, and a referral for evaluation should have been completed. The lack of a system to evaluate for PASRR Level 2 after a new diagnosis was attributed to new management and staff. The facility's policy, titled PASRR Completion Policy, indicated that all admissions should have the appropriate PASRR completed, but this was not adhered to in this case.
Failure to Implement Person-Centered Care Plans for Fluid Management
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to potential health risks. Resident 112, who was admitted with end-stage renal disease and a history of sudden cardiac arrest, was on a physician-ordered fluid restriction of 1000 ml per day. However, observations revealed that the resident had access to fluids exceeding this limit, including a yellow pitcher with ice water and additional drinks. Despite the resident's non-compliance with the fluid restriction, there was no documented care plan addressing this issue, and the staff failed to notify the physician or formulate a care plan to manage the resident's fluid intake. Resident 93, diagnosed with dementia, had consistently high sodium levels and was at risk of dehydration. The resident refused to consume fluids, and despite a physician's order to encourage fluid intake, the nursing staff did not actively promote hydration during meals. The resident's medical record lacked a care plan for hydration, even though the dietitian noted the resident's refusal to drink and the potential need for a feeding tube if hydration could not be maintained. The facility's policy on nutrition and hydration, which was outdated, indicated that a care plan should be documented for residents at risk of dehydration, but this was not done for Resident 93. The deficiencies in care planning for both residents were confirmed by various staff members, including an LPN, an RN Supervisor, and the Director of MDS. They acknowledged the absence of care plans for fluid restriction and hydration, which should have been developed upon receiving physician orders or identifying non-compliance. The lack of proper documentation and care planning for these residents' specific needs highlighted a failure to adhere to the facility's policies and procedures, potentially compromising the residents' health and safety.
Inadequate Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate oral care for a resident who was totally dependent on staff for assistance. The resident, who had diagnoses including Alzheimer's, hypothyroidism, hypertension, dysphagia, and schizoaffective disorder, was receiving hospice care and required assistance from two or more helpers for oral care. On a specific date, the resident was observed with a dry mouth and white stringy material, indicating a lack of proper oral hygiene. A Licensed Practical Nurse confirmed that oral care should have been provided by a Certified Nursing Assistant. The resident's care plan highlighted the need for daily mouth care due to the potential for oral health problems. However, a review of the Oral Care Record showed that oral care was provided inconsistently over a period of time. The Director of Nursing acknowledged that oral care should have been administered at least twice daily, regardless of the resident's hospice status.
Failure to Complete Post-Fall Neurological Checks
Penalty
Summary
The facility failed to complete post-fall neurological checks for a resident after two separate falls, which is a deficiency in following the established post-fall protocol. Resident 106, who has diagnoses including unspecified dementia, adult failure to thrive, and anxiety disorder, experienced falls on two occasions. On 06/09/2024, the resident was found on the floor with skin tears and bleeding, but the post-fall evaluation lacked documentation of fall details, vitals, contributing factors, and interventions. Similarly, on 08/16/2024, the resident reported a fall, but the medical record did not contain evidence of completed neurological checks. The Director of Staff Development and the Director of Nursing both confirmed the absence of documented neurological checks in the medical records for the falls on 06/09/2024 and 08/16/2024. The facility's protocol, as outlined in an undated document titled 'Fall Documentation Requirements,' mandates neurological checks and continued monitoring after a fall, which were not adhered to in these instances. This failure to follow protocol could potentially delay necessary medical intervention and care for residents.
Resident Access to Razors Despite Cognitive Impairment
Penalty
Summary
The facility failed to ensure a resident with dementia did not have access to razors in their room, leading to a deficiency in maintaining a safe environment free from accident hazards. Resident 8, who was admitted with diagnoses including dementia with behavioral disturbance, psychotic disorder, depressive disorder, and anxiety, was observed on August 20, 2024, at 10:00 AM shaving himself in the bathroom with a small cut on the left side of his face and five additional razors on the sink. A Registered Nurse confirmed the observation and noted that the resident had cognitive impairment, and it was unknown how the resident obtained the razors. The RN stated that Certified Nursing Assistants were responsible for assisting the resident with activities of daily living, including shaving, and indicated that the resident should not have had access to razors due to confusion and the risk of accidents. The facility's policy titled Safety and Supervision of Residents, dated July 2017, required the care team to implement interventions to reduce individual risks related to environmental hazards, including providing adequate supervision. However, the facility did not adhere to this policy, resulting in the resident's access to razors and the subsequent accident.
Failure to Implement Fluid Restriction and Feeding Assistance
Penalty
Summary
The facility failed to adhere to a fluid restriction order for a dialysis-dependent resident, Resident 112, which was not properly implemented or monitored. Despite a physician's order for a 1000 ml fluid restriction, Resident 112 was observed with excess fluids at the bedside, including a large pitcher of ice water and additional drinks. The resident's medical records lacked documentation of the fluid restriction being followed, and there was no evidence of physician notification regarding the resident's non-compliance. Staff interviews revealed a lack of communication and documentation regarding the fluid restriction, contributing to the oversight. Additionally, the facility did not provide a one-on-one feeding assistant for Resident 22, who was at risk for weight changes. Despite a physician's order for one-on-one feeding assistance due to abnormal weight fluctuations, Resident 22 was observed eating meals without the required supervision. The resident's intake records showed inconsistent meal consumption, and staff interviews confirmed the absence of the mandated feeding assistance. The deficiencies in both cases highlight a failure in communication and adherence to physician orders, resulting in potential adverse health outcomes for the residents involved. The facility's policies and procedures for monitoring and implementing dietary restrictions and assistance were not effectively followed, as evidenced by the lack of documentation and staff awareness of the residents' specific needs.
Failure to Discontinue Unused IV Access
Penalty
Summary
The facility failed to ensure the discontinuation of an Intravenous (IV) access when it was no longer therapeutically needed for one resident. The resident, who was admitted with diagnoses including cerebral infarction and dysphagia, had a midline IV line in place with a dressing dated two days prior to the observation. Despite the IV access being present, there was no IV pump in the vicinity, and the resident, who was non-verbal, could not confirm its use. The physician's orders indicated that the IV was initially placed for a one-time hydration treatment due to hypotension, which was resolved after the administration of a saline bolus. However, there was no documented evidence in the physician or nursing progress notes justifying the continued presence of the midline IV. Interviews with nursing staff and the infection preventionist revealed that the unused IV line should have been addressed with the primary physician and discontinued if not needed. The facility's policy on IV catheter removal stated that the catheter should be removed if infusion therapy was discontinued, if not used within 24 hours, or if it was no longer part of the care plan. The failure to remove the IV line when it was no longer necessary posed a potential risk of infection due to the prolonged portal of entry for microorganisms.
Medication Unavailability for Two Residents
Penalty
Summary
The facility failed to ensure medications were acquired and available as prescribed for two residents, leading to a deficiency in pharmaceutical services. Resident 29, who was admitted with diagnoses including muscle wasting, atrophy, depression, and anxiety disorder, had a physician order for Duloxetine Hydrochloride 30 mg daily for depression. However, on August 22, 2024, the medication was not administered due to unavailability. The Licensed Practical Nurse (LPN) explained that the Duloxetine ran out of supply because the previous nurses did not reorder it when the supply was low. The Pharmacy Technician confirmed that the last order was placed on August 9, 2024, with 14 tablets delivered, and refills needed to be requested manually. Similarly, Resident 7, admitted with anxiety disorder and major depressive disorder, had a physician order for Sertraline Hydrochloride 50 mg daily. On the same day, the medication was unavailable for administration, and the LPN indicated it needed to be reordered. The Pharmacy Technician confirmed that a refill request was not placed until that day. The facility's policy required the nursing staff to ensure a sufficient supply of medications and contact the pharmacy if medications were unavailable, which was not adhered to in these cases.
Expired Medications Not Discarded
Penalty
Summary
The facility failed to ensure the proper disposal of expired medications, specifically compounded intravenous (IV) antibiotics and a bottle of tablet medications. During an observation on 08/22/2024, it was found that two bags of compounded IV Vancomycin, filled on 07/30/2024, and four bags filled on 08/01/2024, were still stored in the medication refrigerator of the 400 Hall medication room, despite having a 'do not use' date of 08/15/2024. A licensed practical nurse (LPN) confirmed that these IV medications should have been discarded as the resident had completed the antibiotic regimen, and the leftover bags should have been returned to the pharmacy. Additionally, an expired bottle of Sodium Chloride tablets, which expired in 07/2024, was found in the medication storage room. An LPN confirmed that the Sodium Chloride tablets were expired and should have been discarded to ensure resident safety. The facility's policy on Medication Labeling and Storage, revised in February 2023, states that discontinued, outdated, or deteriorated medications should be returned or destroyed as per the dispensing pharmacy's instructions.
Improper Food Storage Practices
Penalty
Summary
The facility failed to adhere to guidelines for food storage and use, which could potentially expose residents to foodborne illnesses. During an inspection of the kitchen, eight packets of hamburger buns dated 07/27/2024 were found in the dry storage area on 08/20/2024. The cook confirmed that each packet had a sticker indicating the date they were received and acknowledged that the buns had been stored for more than two weeks, exceeding the recommended storage time. According to the facility's policy titled 'Food Receiving and Storage,' food should be stored in compliance with safe handling practices. Additionally, the facility's 'Dry Storage Chart' indicated that unopened packets of bread, including hamburger buns, should be stored for four to five days in the dry storage area.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure that wound care contractors adhered to enhanced barrier precautions (EBP) during the treatment of a resident with a stage 4 decubitus ulcer. The resident, who was admitted with chronic obstructive pulmonary disease, schizoaffective disorder, and anemia, required wound care for a severe pressure ulcer in the sacral area. Despite a sign posted at the entrance of the resident's room indicating the need for EBP, including the use of personal protective equipment (PPE) such as gloves and gowns, the wound care staff did not wear PPE during the procedure. This observation was confirmed by the charge nurse, who acknowledged that the wound care team should have followed the EBP guidance to prevent cross-contamination. The deficiency was further supported by a physician order and a care plan, both of which documented the necessity of EBP for the resident's pressure injury. The Director of Nursing (DON) confirmed that the contractor wound care team lacked training related to EBP, which was a requirement according to the facility's policy. The policy, last revised in March 2024, stipulated that EBP, including the use of gloves and gowns, should be implemented during high-contact activities like wound care to reduce the transmission of multidrug-resistant organism (MDRO) infections. The policy also indicated that staff should be trained on EBP before caring for residents.
Failure to Implement Abuse Policies and Procedures
Penalty
Summary
The facility failed to ensure abuse policies and procedures were implemented for one of the sampled residents. A Certified Nursing Assistant (CNA1) reported hearing a noise that sounded like a hand slapping against skin while another CNA (CNA2) was providing care to a resident. Despite having concerns about potential physical abuse, CNA1 did not intervene to stop the alleged abuse and instead walked directly to the charge nurse to report the incident. The facility's investigation confirmed that CNA1 did not see any physical abuse but heard sounds that raised concern. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) both indicated that the facility protocol required staff to first ensure resident safety by intervening and then contact the abuse coordinator, which CNA1 failed to do. The Licensed Social Worker (LSW) familiar with the incident explained that a reenactment showed it would be nearly impossible to see the interaction between the staff member and the resident without entering the room. The LSW and DON both confirmed that CNA1's actions did not meet the facility's expectations. Despite being up to date on abuse training, CNA1 did not follow the protocol of intervening to stop suspected abuse. The facility's policy on Resident Rights documented that all residents would be free from abuse, neglect, misappropriation of property, and exploitation.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to ensure an incident involving an elderly resident with dementia and Alzheimer's disease, who was forced to take medications, was promptly reported to the abuse coordinator and the agency within the mandated timeframes. The incident occurred when a Certified Nursing Assistant (CNA) witnessed another CNA holding the resident's head while a Licensed Practical Nurse (LPN) forced the resident to take medication. The incident was not reported immediately, and the investigation and reporting to the state agency were delayed, compromising the resident's health and well-being. The resident's care plan documented episodes of resistance to care during medication administration, with interventions including re-approaching calmly and re-offering medication. Despite this, the incident where the resident was forced to take medication was witnessed by multiple staff members and reported to the family, but not to the supervisor or abuse coordinator. The family had previously witnessed similar incidents and had advised the LPN to stop forcing the medication. The facility's investigation confirmed the incident, but there was a significant delay in reporting it to the state agency. Interviews with staff and the Director of Nursing (DON) confirmed the delay in reporting and investigating the incident. The involved staff members received abuse training, and the facility reported the incident to the nursing board. The facility's policies on resident rights and abuse investigation and reporting were not followed, as the incident should have been reported immediately and within 24 hours to the state agency. The deficiency highlights a failure in timely reporting and addressing suspected abuse, neglect, or theft, which could lead to unaddressed abuse and compromise the resident's health and well-being.
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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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