Gardnerville Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gardnerville, Nevada.
- Location
- 1573 South Muller Pkwy, Gardnerville, Nevada 89410
- CMS Provider Number
- 295082
- Inspections on file
- 25
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Gardnerville Health & Rehabilitation Center during CMS and state inspections, most recent first.
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.
Two residents with ESBL E. coli UTIs were placed in a shared room under contact precautions, contrary to facility policy and CDC guidelines requiring private room placement for MDRO infections. Despite available private rooms, both residents remained together, and one developed an ESBL UTI after rooming with the other. Staff and documentation confirmed the lapse in infection control practices.
The facility did not follow its own policy and CDC guidelines for infection control, as two residents with ESBL-producing E. coli were placed together in a shared room instead of private rooms, and three residents with wounds or Foley catheters did not have Enhanced Barrier Precautions in place. Staff confirmed the lack of required signage and PPE carts, and acknowledged that the necessary precautions were not implemented.
The facility did not consistently report allegations of abuse, neglect, and serious injury to the State Agency within required time frames. Incidents included verbal and physical abuse by staff, resident-to-resident physical and sexual abuse, and a fall resulting in a hip fracture. Delays in reporting ranged from several days to over a week, contrary to facility policy requiring immediate notification.
A resident with significant neurological diagnoses had their mattress placed on the floor by an LPN without prior device evaluation, physician notification, or obtaining consent from the resident or their representative. This action, which restricted the resident's ability to get up independently, was not communicated to staff or family and was later substantiated as neglect following facility investigation.
A resident with dementia and behavioral disturbances was removed from their room during an episode of agitation and aggression, and left alone in the dining room wearing only a soiled brief and t-shirt. Staff drew back the curtains, exposing the resident to view, and observed from outside the room while the resident continued to display aggressive behaviors. The DON confirmed the resident's dignity was not respected during this incident.
A resident with diabetes and chronic kidney disease was prescribed and administered Eliquis for DVT prophylaxis, but the MDS assessment failed to document the use of this anticoagulant in the appropriate section. The MDS Coordinator confirmed the assessment was inaccurate after reviewing the records.
A resident with newly documented mental health diagnoses was admitted without an updated PASARR Level I or referral for Level II evaluation. Staff interviews revealed a lack of knowledge and training regarding PASARR requirements, and no staff member was overseeing the process, resulting in the facility's failure to follow its own policy for screening and referral.
A resident with chronic obstructive pulmonary disease and congestive heart failure was receiving oxygen therapy, but the care plan did not document the use of oxygen or related diagnoses. Staff observed the resident with varying oxygen delivery and noted the resident often removed the nasal cannula, yet the care plan lacked problems, goals, or interventions for oxygen use and monitoring. The DON confirmed these omissions after reviewing the clinical record.
A resident who required substantial staff assistance for bathing and showering did not receive scheduled showers or baths on multiple occasions, with no documentation of refusals or alternative care provided. The resident reported not receiving regular showers and performed their own bed bath, while staff and the DON confirmed the lack of documentation and missed care.
A resident with COPD and heart failure received oxygen at a higher flow rate than ordered, as staff increased the oxygen from 2 LPM to 2.5–3 LPM without a physician's order or titration instructions. The clinical record did not contain authorization for this change, and facility policy required strict adherence to prescriber orders.
A CNA employed for over one year did not have a documented annual performance review as required by facility policy. The DON confirmed that the evaluation was not completed at the one-year anniversary, resulting in a missed opportunity to identify areas for improvement and training needs.
Two residents did not receive their prescribed medications because the medications were out of stock and not available in the facility, resulting in a medication error rate above 5%. In both cases, RNs identified the missing medications, marked them as 'On Order' from the pharmacy, but did not document physician notification or alternative orders, and the facility lacked a specific policy on medication administration errors.
A multi-dose vial of Tuberculin PPD was found in the medication storage refrigerator without a cap and with a puncture site, but neither the vial nor its box was labeled with the date it was opened, contrary to facility policy and manufacturer instructions. The Infection Preventionist confirmed the vial was open and not dated.
The facility's Facility Assessment was created and implemented solely by the Interim Executive Director without documented review or approval from the QAA Committee or other required leadership. The assessment lacked an attendance sheet and did not follow established procedures for review and input from necessary facility management.
Surveyors found that a nurse administered PRN Acetaminophen to a resident for pain but did not document the administration in the MAR as required by facility policy. In a separate incident, a resident received wound care for a cranial abrasion without a documented physician order, despite the IP stating verbal approval had been obtained. Both deficiencies involved failures in timely and complete documentation of care provided.
The facility did not develop or implement a required Performance Improvement Project (PIP) within the past year. Leadership, including the IED, DON, and LAN, could not provide documentation or details of any PIP, citing loss of access to electronic records after a former administrator's departure. The QAPI committee was not made aware of failures related to reporting abuse, neglect, or other incidents, and there was no evidence of ongoing evaluation of PIPs as outlined in the facility's QAPI Plan.
A resident with chronic health conditions was not offered a timely pneumococcal vaccination to complete the recommended schedule, despite being eligible and having pending immunizations noted in the record. The required vaccine was not administered, and documentation of consent or refusal was missing, contrary to facility policy and CDC guidelines.
A resident with diabetes and hypertension was identified as eligible for the COVID-19 vaccine, but the facility failed to document administration or declination of the vaccine after screening. The clinical record showed only a pending immunization status, and required consent or declination forms were incomplete, resulting in a lack of evidence that the vaccine was offered or given as per facility policy and CDC guidelines.
A resident with severe dementia and behavioral disturbances was removed from their room during an episode of agitation and placed alone in the dining room, wearing only a soiled brief and t-shirt. Staff closed the door, isolating the resident from others and observing through windows, while the resident continued to display aggressive behaviors. Facility documentation and staff interviews confirmed the resident was involuntarily secluded, contrary to policy and resident rights.
A facility failed to ensure an agency CNA completed required elder abuse prevention training upon hire. The CNA was involved in an incident where a resident, exhibiting signs of psychosis, was left in a public area wearing only a t-shirt and soiled brief, visible to others. The CNA's personnel record lacked documentation of abuse training, in violation of facility policy.
A long-term care facility failed to remove expired COVID-19 test kits from a medication room and cart, despite weekly audits by the DON. Additionally, a resident's Oxycodone tablets went missing after an LPN left the medication cart keys unattended, allowing unauthorized access. The facility's policies on medication storage and access were not followed, leading to these deficiencies.
The facility failed to maintain cleanliness of an ice machine, did not discard expired heavy cream, and a staff member neglected hand hygiene protocols during food preparation. The ice machine had a white, flaky substance despite recent maintenance, and expired heavy cream was found in the refrigerator. A staff member entered the trayline without washing hands or changing gloves, contrary to facility policy.
The facility failed to ensure proper infection control practices, including hand hygiene by an Activities Director, who did not sanitize hands between resident contacts. A glucometer was improperly sanitized by an LPN using an incorrect cleaning method. Additionally, unsanitary laundry practices were observed, with a fan blowing air from the dirty to the clean side of the laundry room, and a blanket placed on a floor cleaner to dry. The IP and DON did not oversee these practices, as they were managed by a contracted agency.
A resident was administered Amitriptyline and Buspirone for anxiety without obtaining informed consent as required by facility policy. The medications were given for several days before the necessary consents were signed, contrary to the policy that mandates consents be completed within 48 hours of admission.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately documented bed rails as restraints, despite confirmation from the resident and staff that they were used for mobility. Another resident's MDS did not reflect a DVT diagnosis, although the resident was receiving anticoagulant treatment for it. The MDS Coordinator acknowledged these discrepancies.
The facility failed to develop care plans for two residents with specific conditions. A resident with DVT did not have a care plan despite receiving anticoagulant therapy, and another resident receiving Trazodone for insomnia lacked a care plan for this condition. The DON confirmed that care plans should be created upon admission and updated within 48-72 hours, highlighting a lapse in protocol adherence.
A resident with Parkinsonism and dementia was confirmed to have a DVT and prescribed Eliquis, but the care plan for DVT was not added until 11 months later. The MDS Coordinator backdated the care plan, which was deemed unprofessional conduct by the DON, as per the Nevada Nurse Practice Act.
The facility failed to ensure that two LPNs were trained and certified in CPR, as required by the facility's policy. The personnel records for these LPNs lacked evidence of current CPR certifications. The BOM, responsible for personnel record review, was unsure about the CPR training policy, including certification requirements and frequency.
A resident received acetaminophen outside of physician-prescribed parameters, with pain levels recorded higher than the ordered range. The LPN confirmed the discrepancy, and the DON acknowledged the failure to follow physician orders, as per the facility's medication administration policy.
A resident was administered Trazodone for insomnia without having a corresponding diagnosis. Despite receiving the medication daily, both an LPN and the DON confirmed the absence of an insomnia diagnosis. The facility's policy required a physician's justification for the use of psychotropic drugs, which was not provided in this instance.
The facility failed to offer timely pneumonia and flu vaccinations to residents, as identified through interviews and record reviews. Several residents with conditions like respiratory failure, diabetes, and hypertension were not screened or offered vaccines upon admission or during their stay. The Infection Preventionist confirmed that vaccines were only offered during quarterly clinics, potentially missing residents admitted and discharged between these times.
The facility failed to offer COVID-19 vaccinations to several residents upon admission and did not provide an updated vaccine to one resident. The Infection Preventionist confirmed that vaccines were only offered during quarterly clinics, leading to missed opportunities for vaccination. The facility's policy required offering vaccinations per CDC and FDA guidelines, but documentation was lacking in the residents' medical records.
The facility failed to maintain a safe temperature in the laundry room, which lacked air conditioning for a year. A fan was used to cool staff by blowing air from the dirty to the clean side. The ambient temperature was recorded at 86°F, exceeding the recommended 71-81°F range.
The facility did not ensure annual elder abuse training for a housekeeper, as required by policy. The housekeeper's record showed training in 2023 but lacked evidence for 2024. The BOM confirmed the oversight and expressed uncertainty about training timeframes, despite policy requirements for annual training.
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.
Failure to Isolate Residents with MDRO UTI According to Infection Control Policy
Penalty
Summary
The facility failed to ensure appropriate care and infection control practices for residents with multidrug-resistant organism (MDRO) urinary tract infections (UTIs), specifically Extended-Spectrum Beta-Lactamase (ESBL) producing E. coli. Two residents, both diagnosed with ESBL E. coli UTIs, were placed in a shared room despite facility policy and CDC guidelines recommending private room placement for residents with MDROs. Clinical records and staff interviews confirmed that both residents were on contact precautions, yet continued to share a room for an extended period, even though the facility had available private rooms. One resident, with a history of chronic respiratory failure and chronic kidney disease, tested positive for ESBL E. coli in the urine and was treated with IV antibiotics. This resident was not placed in a private room upon return from the hospital, as required by infection control policy, but instead continued to share a room with another resident. The second resident, with multiple psychiatric and neurological diagnoses, subsequently developed an ESBL E. coli UTI after sharing the room with the first resident. This resident reported being in isolation for approximately one month, which exacerbated existing anxiety. Facility documentation, including infection line listings and staff schedules, confirmed that the two residents shared a room during the period of infection and that staffing levels were sometimes below the facility's stated minimum. The Infection Preventionist and DON acknowledged that the resident with the initial ESBL infection should have been placed in a private room, and that the failure to do so was not in accordance with facility policy or CDC recommendations. The deficiency was further supported by the presence of empty beds in the facility at the time, indicating that private room placement was feasible.
Failure to Implement Transmission-Based and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) according to its own policy and CDC recommendations for several residents. Specifically, two residents with confirmed ESBL-producing E. coli infections in their urine were placed in the same shared room, despite facility policy and CDC guidelines indicating that such residents should be placed in private rooms to prevent the spread of multidrug-resistant organisms (MDROs). Documentation showed that one resident tested positive for ESBL E. coli after sharing a room with another resident who had the same organism, and both were kept on contact precautions in a shared room. Staff interviews confirmed that the residents were not separated, and the Infection Preventionist and DON acknowledged that a private room should have been used. Additionally, the facility did not implement EBP for three residents who met the criteria for these precautions. These residents had conditions such as open wounds and indwelling Foley catheters, which, according to facility policy and CDC guidance, require EBP regardless of confirmed MDRO status. Observations during facility tours revealed that there was no EBP signage or PPE carts outside the rooms of these residents, and staff confirmed that EBP was not in place for them. The DON and IP verified that these residents should have been under EBP but were not. The facility's own infection control policies, as well as CDC guidelines, were not followed in these cases. The policies specified the need for private rooms for residents with certain infections and the use of EBP for residents with specific medical devices or wounds. Despite having available private rooms, the facility did not adhere to these protocols, and staff schedules indicated periods of minimal staffing, which may have contributed to the lapses in infection control practices.
Failure to Timely Report Allegations of Abuse, Neglect, and Serious Injury
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse, neglect, and serious bodily injury to the State Agency (SA) as required by both facility policy and federal regulations. In seven out of ten Facility Reported Incidents (FRIs) reviewed, initial reports were submitted to the SA outside the mandated time frames. Specific incidents included allegations of verbal abuse by a Certified Nursing Assistant, resident-to-resident physical and sexual abuse, neglect resulting in a fall with a hip fracture, and employee-to-resident physical and verbal abuse. Documentation showed delays ranging from several days to over a week between the occurrence of the incidents and the submission of initial reports to the SA. Facility policy required immediate reporting, but interviews with facility leadership confirmed that the process was not consistently followed. The incidents involved various forms of abuse and neglect, including physical altercations between residents, inappropriate sexual contact, and a fall resulting in serious injury. Progress notes and interviews indicated that staff did not always report incidents to facility leadership immediately, and leadership did not always report to the SA within the required two-hour or 24-hour windows, depending on the severity of the allegation.
Mattress Used as Restraint Without Evaluation or Consent
Penalty
Summary
A deficiency occurred when a resident with metabolic encephalopathy and idiopathic normal pressure hydrocephalus had their mattress placed directly on the floor by an LPN without prior evaluation or consent. The LPN removed the resident's bed frame and placed the mattress on the floor without notifying other staff, the physician, or the resident's family. This action was witnessed by a CNA and later reported after the resident had been discharged. The facility's investigation substantiated the allegation of neglect, noting that the mattress on the floor acted as a restraint, as the resident was unable to get up unassisted, whereas previously the resident had been able to get out of bed independently. Facility policy required a device evaluation and consent from the resident or their representative before implementing any device that could act as a restraint. The policy also mandated physician notification and an order specifying the type, reason, and duration of use for any restraint. In this case, none of these steps were followed prior to the intervention, and the resident and their family were not informed of the risks and benefits associated with the change. The lack of a barrier between the mattress and the floor and the absence of required notifications and evaluations led to the substantiated finding of neglect.
Resident Left in Soiled Brief and T-Shirt in Dining Room During Behavioral Episode
Penalty
Summary
A resident with diagnoses including severe unspecified dementia with behavioral disturbances, anxiety disorder, cognitive communication deficit, seizures, and difficulty walking experienced a behavioral episode while being assisted with a brief change. The resident became verbally agitated, exhibited signs of psychosis, and began yelling and making accusations against staff. During the episode, the resident grabbed and injured a CNA, attempted to strike staff with a call light, and threw items in the room. In response, staff, including an LPN and CNA, removed the resident from the room and transferred the resident to the dining room as a behavioral intervention. The resident was left in the dining room wearing only a soiled brief and a t-shirt, with the curtains drawn back, exposing the resident to view. Staff left the resident alone in the dining room, closed the door, and observed the resident through the windows. While in the dining room, the resident continued to display aggressive behaviors, including attempting to remove the television from the wall, swinging the television cord at staff, and throwing the remote control. The LPN attempted to calm the resident by offering food, drink, and medication, with the resident eventually accepting medication and calming down. Throughout the incident, the resident remained in a soiled brief and t-shirt in a common area, with the curtains open, which was confirmed by the DON as disrespectful to the resident's dignity. Facility documentation and staff interviews confirmed that the resident was secluded in the dining room and not treated with respect and dignity during the behavioral episode.
Inaccurate MDS Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) 3.0 assessment for one resident. The resident, who had a diagnosis of type one diabetes mellitus with diabetic chronic kidney disease, was prescribed and administered Eliquis, an anticoagulant, for deep vein thrombosis (DVT) prophylaxis. Review of the resident's Medication Administration Record (MAR) confirmed that the medication was given consistently throughout the month. However, the MDS assessment completed for the resident did not indicate that the resident was receiving an anticoagulant in Section N, which is designated for documenting high-risk medications. The MDS Coordinator acknowledged that the assessment was inaccurate after reviewing the documentation and confirmed that the omission occurred despite the resident's ongoing anticoagulant therapy.
Failure to Implement PASARR Screening and Referral Process
Penalty
Summary
The facility failed to ensure that there was a process in place to identify and refer residents for Preadmission Screening and Resident Review (PASARR) Level II, and did not initiate a PASARR Level I submission for one of thirteen sampled residents. Specifically, a resident was admitted with diagnoses including unspecified psychosis and depression, but the PASARR Level I on file was completed years prior and did not reflect the current mental health diagnoses. The resident's active diagnoses, including psychosis and cognitive symptoms, were documented after admission, but there was no evidence that a new or updated PASARR Level I or a referral for Level II evaluation was initiated. Interviews with facility staff revealed a lack of understanding and training regarding PASARR processes. The Licensed Social Worker stated they had no responsibilities related to PASARR, and the Admissions Director admitted to not knowing what PASARR was or the required timeframes for completion. The Administrator confirmed that no staff member was overseeing PASARR procedures and acknowledged that the process was not being followed. The facility's policy required validation and tracking of PASARR Level I and referral for Level II when indicated, but this was not implemented for the resident in question.
Failure to Include Oxygen Therapy and Related Diagnoses in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a complete care plan was developed and implemented for a resident with chronic obstructive pulmonary disease, chronic systolic (congestive) heart failure, and asthma. The resident was observed receiving oxygen via nasal cannula, with the oxygen concentrator set at varying rates, and staff reported the resident often removed the cannula at night, requiring adjustments to oxygen delivery. Despite a physician's order for continuous oxygen at 2 liters per minute, the resident's care plan did not include documentation related to oxygen use or the associated diagnoses. Interviews and record reviews confirmed that the care plan lacked problems, goals, or interventions addressing the resident's need for oxygen therapy and monitoring for respiratory symptoms. The DON acknowledged that the care plan should have included these elements and confirmed their absence prior to a later update. This omission meant that staff may not have been fully aware of the resident's needs regarding oxygen administration and monitoring.
Failure to Provide Scheduled Showers or Baths for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required substantial to maximal assistance with activities of daily living, specifically bathing and showering, did not receive scheduled showers or baths as required. The resident, who had diagnoses including intervertebral disc degeneration, muscle weakness, and atrial fibrillation, reported not receiving regular showers and resorted to giving themselves a bed bath. The resident expressed feeling itchy and bad about themselves due to the lack of regular scheduled showers. The resident's care plan and Minimum Data Set (MDS) indicated a need for staff assistance with bathing and showering. A review of the resident's medical records for a three-month period revealed multiple dates where there was no documented evidence that a shower, bath, or bed bath was provided as scheduled. There was also no documentation indicating the resident refused care or that alternative arrangements were made to compensate for missed showers or baths. Staff interviews confirmed that showers were scheduled twice weekly and that refusals or completed showers were to be documented in both paper and electronic records. The Director of Nursing confirmed the absence of documentation for the missed dates and acknowledged that there was no evidence the resident had refused or was unavailable for care on those occasions.
Oxygen Administration Not in Accordance with Physician Order
Penalty
Summary
The facility failed to ensure that oxygen was administered according to a physician's order for one resident with chronic obstructive pulmonary disease and chronic systolic heart failure. The resident was observed receiving oxygen via nasal cannula at a rate of 2.5 to 3 liters per minute, despite a physician's order specifying continuous oxygen at 2 liters per minute. Staff reported that the resident often removed the nasal cannula at night, and in response, staff increased the oxygen flow rate without obtaining a new physician's order or titration instructions. Review of the clinical record confirmed there was no order to increase or titrate the oxygen flow rate based on oxygen saturation readings. The facility's policy required medications, including oxygen, to be administered strictly according to prescriber orders, and any changes or clarifications were to be documented. The Director of Nursing confirmed that staff increased the oxygen flow rate without proper authorization or documentation, and the clinical record lacked any order supporting this change.
Annual CNA Performance Review Not Completed
Penalty
Summary
The facility failed to complete an annual performance review for a Certified Nursing Assistant (CNA) who had been employed for more than one year. Review of personnel records showed that the CNA, hired on 08/31/2023, did not have documentation of a performance review for 2024. During an interview, the Director of Nursing confirmed responsibility for conducting CNA performance evaluations and acknowledged that the required review had not been completed at the one-year mark. Facility policy requires employee reviews every 12 months to identify areas for improvement and necessary competencies.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with a calculated error rate of 7.69% based on 26 observed opportunities and two errors. The errors involved two residents who did not receive their prescribed medications due to the medications being out of stock. In both cases, the registered nurses identified that the medications were not available in the medication cart and attempted to locate them in the medication storage room and automated dispensing system. When the medications were not found, the nurses indicated they would contact the pharmacy, but the medications were not administered as ordered. One resident, with a history of cerebral infarction, intracardiac thrombosis, and ventricular tachycardia, did not receive a scheduled dose of Pradaxa because it was not available in the facility. The nurse documented the medication as 'On Order' from the pharmacy but did not provide documentation of physician notification or alternative orders. Another resident, with diagnoses including obstructive and reflux uropathy and post-surgical aftercare, did not receive a scheduled dose of Finasteride for similar reasons, with the medication also marked as 'On Order' and no documentation of physician notification or alternative instructions. The Director of Nursing confirmed that there was no facility policy specifically addressing medication administration errors and that staff were expected to follow the rights of medication administration. The DON also acknowledged that there was no documentation of physician notification or pharmacy contact for the missed doses. Facility policy required medications to be administered as prescribed and for any withheld or missed doses to be documented with an explanatory note, which was not done in these cases.
Multi-Dose Vial of Tuberculin PPD Not Dated Upon Opening
Penalty
Summary
Surveyors observed that a multi-dose vial of Tuberculin Purified Protein Derivative (PPD) was stored in the medication storage refrigerator without a cap and with a visible puncture site in the rubber stopper. Neither the vial nor its manufacturer box was labeled with the date the vial was opened, despite manufacturer instructions to discard the vial within 30 days of opening. The Infection Preventionist confirmed that the vial was open and lacked an open date, acknowledging that it would need to be destroyed. Facility policy required that the date opened and the initials of the first person to use the vial be recorded on all multi-dose vials, but this was not followed in this instance.
Facility Assessment Lacked Required Review and Approval
Penalty
Summary
The facility failed to ensure that the Facility Assessment (FA) was properly reviewed, updated, and approved by the required facility leadership and management, including the Quality Assessment and Assurance (QAA) Committee. The FA dated 03/25/2025, which was presented by the Interim Executive Director (IED), did not include documented evidence of review or approval by the QAA Committee, nor did it have an attendance sheet indicating participation from the necessary leadership members. The IED confirmed that the FA was created and implemented solely by themselves without input or review from other required members of facility leadership or management. Additionally, the facility did not have a policy or procedure in place regarding the review, updating, or implementation of the FA, nor did it specify the required attendees for such processes. The previous FA, dated 08/29/2024, did include an attendance sheet with various facility leaders, but the IED stated that this version was considered null and void. The lack of proper review and approval processes for the FA was acknowledged by the IED, who admitted that the 03/25/2025 FA did not meet federal regulations and requirements.
Failure to Timely Document PRN Medication and Wound Care Orders
Penalty
Summary
A deficiency was identified when a registered nurse administered two tablets of Acetaminophen 325 mg to a resident who complained of back pain, but failed to document the administration in the resident's Medication Administration Record (MAR) at the time of administration. The nurse confirmed the omission during a review of the MAR, acknowledging that the medication had been given but not recorded. Facility policy required immediate documentation of medication administration, including PRN medications, specifying the need to record the date, time, dose, symptoms, results, and the signature or initials of the administering staff. Another deficiency occurred when a resident returned from the emergency room with a cranial abrasion and had a dressing applied to the head. The Infection Preventionist (IP) and an LPN evaluated and treated the abrasion, with the IP applying Xeroform and wrapping the resident's head. However, the clinical record for this resident lacked a physician's order for the wound care that was provided. The IP later confirmed that, although verbal approval from the physician had been obtained, the order was not documented in the resident's record as required by facility policy. Both deficiencies were confirmed through observation, interview, and record review. The facility's policies on medication administration and skin integrity required timely and complete documentation of all care provided, including obtaining and recording physician orders for treatments and documenting all medication administrations in the MAR.
Failure to Develop and Implement Required Performance Improvement Project
Penalty
Summary
The facility failed to develop and implement at least one Performance Improvement Project (PIP) within the past year, as required. During interviews, the Interim Executive Director (IED), Director of Nursing (DON), and Lead Administrator of Nevada (LAN) confirmed that while monthly Quality Assurance Performance Improvement (QAPI) committee meetings were held, they were unable to provide documentation or describe any PIP completed in the last year. The LAN explained that the facility's electronic system for documenting PIPs became inaccessible after the former Administrator left, leaving the QAA committee without access to necessary records. The IED, who had only recently assumed the role, was unable to confirm the existence of any current PIPs or locate related documentation. Additionally, the QAPI committee had not been informed of the facility's failure to follow policies and regulations regarding the reporting of abuse, neglect, mistreatment, misappropriation of property, and exploitation. The facility's QAPI Plan indicated that PIPs should be evaluated on an ongoing basis by the QAA committee, but there was no evidence that this process had occurred in the past year.
Failure to Offer and Document Timely Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was offered a timely pneumococcal vaccination to complete the recommended vaccine schedule. The resident, who had a history of type two diabetes mellitus with circulatory complications and chronic diastolic (congestive) heart failure, had previously received the PPSV23 vaccine on three occasions. However, there was no documentation in the clinical record or immunization audit report indicating that the resident had received any of the other recommended pneumococcal vaccines, such as PCV13, PCV15, or PCV20. The resident's record listed these vaccines as pending, and a multi-vaccine consent form indicated eligibility but lacked a signature for consent or declination. Interviews with the Infection Preventionist (IP) revealed that the facility determined vaccine eligibility based on consent, vaccination history, and CDC recommendations. The IP confirmed that the resident had not received the PCV vaccines and that pending immunization status indicated the resident was due and had given consent. The facility's policy required vaccination upon admission and as per CDC guidelines, with documentation of administration, refusal, or non-vaccination in the electronic health record. Despite these procedures, the required pneumococcal vaccine was not administered, and proper documentation of consent or refusal was not present.
Failure to Document and Administer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to ensure that one of five sampled residents received or declined an updated or booster dose of the COVID-19 vaccine after being screened for eligibility. The resident, who had diagnoses including type two diabetes mellitus without complications and hypertension, was admitted to the facility and identified as eligible for the COVID-19 vaccine. However, the Immunization Audit Report only documented a status of pending immunization, and the Resident Multi-Vaccine Consent Form lacked a signature indicating consent or declination. There was no documented evidence in the clinical record that the vaccine was administered or declined. Interviews with the Infection Preventionist (IP) confirmed that the resident's record did not contain documentation of previous COVID-19 vaccination and that the vaccine had not been administered. The facility's policy required that residents be offered recommended COVID-19 vaccinations upon admission and as eligible, with documentation of acceptance or declination. Despite these requirements and CDC recommendations, the necessary documentation and administration or declination of the vaccine for this resident were not completed.
Resident Subjected to Involuntary Seclusion During Behavioral Episode
Penalty
Summary
A deficiency occurred when a resident with severe dementia, anxiety disorder, cognitive communication deficit, and other medical conditions was subjected to involuntary seclusion. During an episode of behavioral disturbance, the resident became verbally agitated, exhibited signs of psychosis, and physically aggressive behaviors, including grabbing and scratching a CNA and attempting to strike staff with a call light. In response, staff removed the resident from their room and transferred them to the community dining room while the resident was only wearing a soiled brief and a t-shirt. Once in the dining room, staff closed the door, isolating the resident from others, and observed the resident through the windows with the curtains drawn back. The resident continued to display agitated behaviors, such as attempting to rip the television from the wall, swinging the television cord at staff, and throwing objects. Staff offered food, drink, and medication, with the resident eventually accepting medication and calming down. The resident was then returned to their room. Facility documentation and interviews confirmed that the resident was left alone in the dining room with the door closed, separated from other residents, and exposed to view while in a state of distress and undress. The facility's own policies and resident rights documents define involuntary seclusion as the separation or isolation of a resident against their will, which occurred in this incident. The DON acknowledged that the situation was handled poorly and that the resident was isolated from the community during the episode.
Failure to Provide Timely Elder Abuse Training to Agency CNA Involved in Resident Incident
Penalty
Summary
The facility failed to ensure that an agency contracted Certified Nursing Assistant (CNA), identified as Employee #24, completed initial elder abuse prevention training upon hire. Employee #24 was hired on 11/08/2024 and terminated on 03/05/2025, but their personnel record lacked documented evidence of elder abuse training completion at any point during employment. Facility policy required all staff, including agency staff, to complete abuse training upon hire and annually thereafter. An incident occurred in which Employee #24 was involved with a resident who became verbally agitated and exhibited signs of psychosis during assistance with a brief change. The CNA removed the resident from their room and transferred them to the community dining room while the resident was wearing only a t-shirt and a soiled brief. The resident was left in the dining room with the curtains drawn back, visible to others, while staff observed from outside the room. As a result of this incident, three employees were terminated for policy violations. The lack of required abuse prevention training for Employee #24 was confirmed by both the Director of Nursing and the Administrator.
Expired Supplies and Missing Narcotics in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, leading to expired COVID-19 testing supplies being present in the medication room and on a medication cart. During an inspection, it was observed that the medication storage room contained a box of COVID-19 test kits that had expired, and the same was found in the medication cart for the 200 hall. The Resident Care Manager and the LPN confirmed the expiration of these supplies. Although the Director of Nursing (DON) claimed to conduct weekly audits to remove expired items, the expired test kits were not removed because the expiration date had been extended, as per the Administrator's documentation. However, the Administrator later confirmed that the test kits were indeed expired. Additionally, the facility failed to store narcotic medications appropriately, resulting in the loss of a resident's narcotic pain medication. Resident #188, who was admitted with diagnoses requiring pain management, had a physician order for Oxycodone. However, 38 tablets of the medication went missing from the medication cart. The LPN responsible for the cart reported the missing medication to the DON and admitted to leaving the keys on top of the cart, which could have allowed unauthorized access. The facility was unable to determine who accessed the medication, and the missing Oxycodone was not recovered. The facility's policy stated that only authorized personnel should have access to controlled medications, and the medication nurse should maintain possession of the keys, which was not adhered to in this case.
Deficiencies in Ice Machine Cleanliness, Food Storage, and Hand Hygiene
Penalty
Summary
The facility failed to maintain cleanliness standards for an ice machine, as observed on June 24, 2024. The ice machine in the kitchen had a hard, white, flaky substance around the outside and inside of the door. Despite a task sheet indicating routine maintenance was completed on June 4, 2024, including door gasket cleaning, the Nutrition Services Supervisor could not locate the contractor's cleaning log or the schedule for the next deep cleaning. The facility's policy required monthly cleanings of the ice machine, which were to be documented, but this was not adhered to. Additionally, the facility did not follow its policy for discarding expired food. On June 24, 2024, a cardboard case containing seven unopened and one opened one-quart cartons of heavy cream with expiration dates of June 16, 2024, was found in the walk-in refrigerator. The Nutrition Services Supervisor confirmed these should have been discarded. Furthermore, during a lunch trayline observation on June 25, 2024, a staff member failed to perform hand hygiene as required. The staff member entered the trayline from the kitchen prep area without washing hands or changing gloves, despite knowing the policy required handwashing and new gloves before handling food. The Nutrition Services Supervisor confirmed the breach in protocol.
Infection Control Deficiencies in Hand Hygiene, Glucometer Use, and Laundry Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by a staff member, specifically the Activities Director (AD), who did not perform hand hygiene between contact with residents and environmental surfaces. The AD was observed touching a resident's hand and bedding, then placing hands on the nurse's station counter, and subsequently greeting another resident without performing hand hygiene. The Infection Preventionist (IP) confirmed that hand hygiene should be completed before and after contact with residents, but had not provided education to the AD on this matter, as the IP only provided infection control education to nursing staff. The Director of Nursing (DON) stated that all staff received training on hand hygiene at the time of hire, yet the AD did not adhere to these practices. The facility also failed to properly sanitize a glucometer between resident uses. A Licensed Practical Nurse (LPN) used the same glucometer for two residents and cleaned it with a 70 percent isopropyl alcohol prep pad instead of the required Sani-Cloth germicidal disposable wipe. The DON confirmed that the glucometer should be cleansed with a Sani-Cloth and remain wet for two minutes, following the manufacturer's instructions to prevent the spread of blood-borne pathogens. The facility's policy and the manufacturer's instructions specified the use of specific disinfectant wipes and procedures, which were not followed by the LPN. Additionally, the facility's laundry practices were found to be unsanitary. A fan was observed blowing air from the dirty side of the laundry room to the clean side, potentially contaminating clean laundry. Industrial floor cleaners were stored on the clean side, and a blanket was placed on a floor cleaner to dry, which was then stored on a wire rack without a solid bottom. The IP and DON did not oversee the infection control practices of the laundry room, as these services were provided by a contracted agency. The facility's policy required soiled laundry to be handled in a manner preventing microbial contamination, which was not adhered to in this instance.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consents were obtained prior to administering two psychotropic medications to a resident. The resident, who was admitted with diagnoses including unspecified dementia, obstructive sleep apnea, and anxiety disorder, was prescribed Amitriptyline and Buspirone for restlessness related to anxiety. These medications were administered from June 18, 2024, through June 24, 2024, without obtaining the necessary informed consents beforehand. The facility's policy required informed consents for psychotropic drugs to be completed within 48 hours of admission. However, the consents for Amitriptyline and Buspirone were only signed and dated on June 24, 2024, after the medications had already been administered. The Director of Nursing confirmed that the medications were given prior to obtaining the informed consent documentation, which was a violation of the facility's policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment inaccurately documented the use of bed rails as restraints. The resident, along with a CNA and an LPN, confirmed that the bed rails were used to assist with mobility and did not restrict movement. The MDS Coordinator also acknowledged that the bed rails were not used as restraints, despite being coded as such in the MDS assessment. The facility's policy stated that bed rails are not considered restraints unless they prevent the resident from getting out of bed. For another resident, the MDS assessment failed to reflect an active diagnosis of Deep Vein Thrombosis (DVT), despite the resident receiving anticoagulant medication for this condition. The resident's clinical record lacked documentation of a DVT diagnosis in the active diagnosis list, although a Nurse Practitioner Progress Note and a physician's order indicated the presence of a DVT. The MDS Coordinator confirmed that the MDS should have been updated to include the DVT diagnosis.
Failure to Develop Care Plans for DVT and Insomnia
Penalty
Summary
The facility failed to develop a care plan for two residents with specific medical conditions. Resident #13, who was admitted with diagnoses including Parkinsonism and unspecified dementia, was confirmed to have a deep vein thrombosis (DVT) on 07/24/2023. Despite receiving anticoagulant therapy with Eliquis as per a physician's order, a care plan addressing the DVT was not initiated until 06/25/2024. The care plan should have included interventions such as leg elevation, monitoring for color changes, and assessing anticoagulant therapy to prevent clot dislodgment. Similarly, Resident #20, admitted with anxiety and cellulitis, was receiving Trazodone for insomnia as per a physician's order dated 03/12/2024. However, the resident's comprehensive care plan did not include a plan for managing insomnia. The Director of Nursing confirmed that care plans should be created upon admission and updated within 48-72 hours as new problems or interventions arise, indicating a lapse in the facility's adherence to this protocol.
Backdating of Care Plan for DVT
Penalty
Summary
The facility failed to meet professional standards for accurate recording as per the Nevada Nurse Practice Act when the Minimum Data Set Coordinator, a Registered Nurse, backdated a resident's care plan for deep vein thrombosis (DVT) by 11 months. The resident, who was admitted with diagnoses including Parkinsonism and unspecified dementia, was confirmed to have a DVT on July 24, 2023, and was prescribed Eliquis, an anticoagulant, on July 26, 2023. However, the resident's Comprehensive Care Plan did not include a care plan for DVT or the anticoagulant until June 25, 2024, despite the medication being administered from June 1, 2024, to June 25, 2024. The MDS Coordinator admitted to adding the care plan for DVT on June 25, 2024, and backdating it to July 24, 2023, based on a progress note. The Director of Nursing confirmed that backdating the care plan was unacceptable and that care plans should be created upon admission and updated within 48-72 hours as new problems or interventions arise. The Director of Nursing provided an audited copy of the Comprehensive Care Plan, which documented that the DVT care plan was indeed created on June 25, 2024. This action was considered unprofessional conduct under the Nevada Nurse Practice Act, which prohibits inaccurate recording or falsifying records.
Deficiency in CPR Certification for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest. This deficiency was identified for two of the five sampled licensed nurses, specifically two Licensed Practical Nurses (LPNs). The personnel records for these LPNs lacked documented evidence of current CPR certifications. During the survey process, the Business Office Manager (BOM) confirmed responsibility for personnel record review but was unsure about the policy for CPR training, including who was required to be certified and how often training was required. The facility's policy on CPR, updated on a specified date, required licensed nurses to have current CPR certification.
Failure to Administer Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the administration of acetaminophen outside of physician-prescribed parameters. Resident #288, who was admitted with diagnoses including encephalopathy, hypothyroidism, and hypertension, had a physician's order for acetaminophen to be administered for pain levels between one and four. However, the medication administration record (MAR) documented that acetaminophen was given on multiple occasions when the resident's pain levels exceeded these parameters, with pain levels recorded as high as ten. The Licensed Practical Nurse (LPN) confirmed that the administration of acetaminophen did not adhere to the physician's order, and the Director of Nursing (DON) acknowledged that the medication was not administered as prescribed. The facility's policy on medication administration, dated January 2021, required that medications be administered as prescribed, and the DON emphasized the importance of following physician orders to ensure medications are given based on resident needs. Despite this, the facility could not confirm whether the medication was necessary, highlighting a failure to adhere to prescribed medication protocols.
Psychotropic Medication Prescribed Without Diagnosis
Penalty
Summary
The facility failed to ensure that a psychotropic medication was prescribed with a diagnosed indication for use for one of the residents. Resident #20 was admitted with diagnoses including anxiety and cellulitis of the left lower limb. However, the resident was receiving Trazodone for insomnia without having a diagnosis of insomnia. A Licensed Practical Nurse confirmed that the resident did not have a diagnosis for insomnia, despite receiving Trazodone daily for this condition. The Director of Nursing also confirmed the absence of an insomnia diagnosis for Resident #20, acknowledging that the resident should have had one. The facility's policy required a physician to provide justification for the continued use of psychotropic drugs, including a diagnosis and description of symptoms, which was not adhered to in this case.
Failure to Offer Timely Vaccinations
Penalty
Summary
The facility failed to ensure that certain residents were offered necessary vaccinations, specifically the pneumonia and influenza vaccines, upon admission or during their stay. This deficiency was identified through interviews, clinical record reviews, and document reviews. Four residents were not offered a pneumonia vaccine upon admission, and one resident was not offered a flu vaccine during the 2023 to 2024 influenza season. The residents involved had various medical conditions, including respiratory failure, diabetes, obesity, atrial fibrillation, chronic kidney disease, encephalopathy, and a history of COVID-19, which could increase their susceptibility to illnesses. The Infection Preventionist (IP) confirmed that the facility's practice was to offer vaccinations only during quarterly vaccine clinics provided by a contracted pharmacy. This practice resulted in some residents not being offered vaccines if they were admitted and discharged between these clinics. The facility's policies on pneumococcal and influenza vaccinations required determining each resident's vaccination status upon admission and obtaining informed consent, with documentation of refusals. However, these policies were not effectively implemented, leading to the identified deficiency.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to ensure that four out of fifteen residents reviewed for vaccinations were offered a COVID-19 vaccine upon admission, and one resident was not offered an updated 2023 to 2024 COVID vaccine. The residents involved had various medical conditions, including acute and chronic respiratory failure, type two diabetes mellitus, heart failure, atrial fibrillation, chronic kidney disease, encephalopathy, and end-stage renal disease. The clinical records for these residents lacked documentation indicating they were screened for or offered a COVID vaccination. The Infection Preventionist (IP) confirmed that residents had not been offered COVID vaccinations because the facility only provided them during vaccine clinics conducted quarterly by a contracted pharmacy. This scheduling meant that a resident could be admitted and discharged without being offered a vaccine. Additionally, one resident missed the opportunity to receive an updated vaccine because the clinic coincided with their dialysis appointment. The facility's policy stated that COVID-19 vaccinations and recommended boosters should be offered to all residents per CDC and FDA guidelines, with documentation maintained in the residents' medical records.
Unsafe Temperature in Laundry Room
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature in the laundry room, which had been without air conditioning for the past year. During a tour, it was observed that a fan was used to blow air from the dirty side to the clean side of the room to prevent staff from overheating. The Housekeeper confirmed the fan's use due to the lack of air conditioning. The Administrator also confirmed the absence of air conditioning, and the Maintenance Director noted that the temperature should be maintained between 71- and 81-degrees Fahrenheit. However, when the washing machine and dryers were not operating, the ambient temperature in the laundry room was recorded at 86-degrees Fahrenheit.
Failure to Complete Annual Elder Abuse Training
Penalty
Summary
The facility failed to ensure that annual elder abuse training was completed for one of the sampled employees, specifically a housekeeper. The housekeeper was hired on September 17, 2019, and their personnel record showed that elder abuse training was completed on May 4, 2023. However, there was no documented evidence of elder abuse training being completed in 2024. During the survey process, the Business Office Manager (BOM) confirmed their responsibility for personnel record review and acknowledged that all staff were required to complete elder abuse training upon hire and annually thereafter. The BOM expressed uncertainty about the expected timeframes for elder abuse training and confirmed that the housekeeper's personnel record lacked evidence of training in 2024. The facility's policy, updated in October 2022, stated that staff were to be trained on abuse prevention, reporting, and intervention upon hire, annually, and periodically thereafter.
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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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