Highland Manor Of Elko Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Elko, Nevada.
- Location
- 2850 Ruby Vista Drive, Elko, Nevada 89801
- CMS Provider Number
- 295078
- Inspections on file
- 21
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Highland Manor Of Elko Rehabilitation Llc during CMS and state inspections, most recent first.
A facility failed to ensure proper hand hygiene during meal service, as observed with two CNAs who did not wash hands between tasks involving resident contact. One CNA in the 600 hall dining room engaged in multiple tasks, including assisting residents and serving beverages, without hand hygiene. Another CNA in the 400 hall dining room did not wash hands between assisting two residents with eating. Both CNAs acknowledged the requirement for hand hygiene, which was confirmed by the DON and facility policies.
The facility failed to implement Enhanced Barrier Precautions for two residents, did not conduct active infection surveillance for July, and an LPN did not perform hand hygiene between residents during medication administration. Additionally, a resident on contact precautions due to MRSA was not isolated in a private room and was allowed to dine in a shared dining room, contrary to CDC guidelines.
The facility failed to track and trend infections and antibiotic use for July 2024, affecting two residents on antibiotics for infections. The Infection Preventionist/ADON did not perform necessary tracking due to a vacation, and the covering staff lacked access to logs. Resident precautions for MRSA were not adequately managed, and the facility's antibiotic stewardship policy was not followed.
The facility's DON lacked the necessary knowledge to implement contact precautions for a resident with MRSA, failing to follow CDC guidelines and facility policy. Additionally, the DON was unable to navigate the new EMR system effectively, impacting the management of clinical records and protocols. These deficiencies had the potential to affect the entire resident census.
The facility failed to ensure the Infection Preventionist (IP) had the necessary education and competency to track and trend infections, affecting the entire resident census. The IP, also the ADON, did not maintain an infection log for July 2024 and lacked understanding of medication differentiation. Additionally, the facility did not properly implement contact precautions for a resident with MRSA, as the IP misunderstood CDC guidelines, leading to inconsistent use of PPE by staff.
A resident with a history of falls sustained a major injury after falling from a bed positioned at its highest level. Despite the serious injury, the facility did not report the incident to the State Agency, as required by their policy. The Administrator assumed the resident had adjusted the bed height themselves and did not suspect abuse or neglect. However, the facility's policy mandates reporting any serious injury to the State Agency within two hours.
The facility failed to update care plans for two residents, one with a Stage III pressure ulcer and another with a history of falls. A resident's pressure ulcer was reassessed as Stage III, but the care plan was not updated to reflect this change. Another resident had multiple falls, and although new interventions were implemented, such as using floor mats and lowering the bed, these were not documented in the care plan. The DON confirmed the care plans did not accurately reflect the current assessments and interventions.
A resident with neuromuscular dysfunction of the bladder had their catheter drainage bag improperly placed above bladder level, risking urine backflow and potential UTI. The DON confirmed the incorrect placement, which violated the facility's catheter care policy requiring the bag to be below bladder level.
A resident with a colostomy did not receive care consistent with professional standards when a CNA, lacking proper training and outside their scope of practice, changed the resident's colostomy wafer. The facility's policy and standard practice required that only nurses perform this task, as it involves assessing skin integrity, which CNAs are not authorized to do.
A resident with respiratory failure and pneumonia was not administered oxygen as ordered, with the concentrator set incorrectly and turned off at times. An LPN and RN confirmed the discrepancy, and the DON emphasized the need to follow physician orders.
A facility failed to complete Dialysis Communication Forms for a resident requiring dialysis, missing critical post-dialysis information. Additionally, a resident with a hemodialysis catheter was placed in a shared room with another resident on contact precautions for MRSA, contrary to facility policy. The DON and IP confirmed these actions increased the risk of MDRO transmission.
Expired medications, including Fish Oil capsules and Tramadol tablets, were found in a medication cart during a review. The RN noted monthly checks for expired medications, and the DON highlighted the risk of medication errors. Facility policy required expired medications to be returned to the pharmacy, except for controlled drugs, which should be disposed of on-site by two licensed staff.
A resident with dementia and other conditions experienced a lack of documentation in their care records, including treatment, side effect, pain, COVID-19 symptom, and behavior monitoring. Nurses confirmed that blank spaces in the Treatment Administration Record indicated missed documentation, which was attributed to forgetfulness. The facility's policy on psychoactive medication monitoring was not followed, leading to a deficiency in maintaining medical records according to professional standards.
A resident with chronic health conditions was not screened for eligibility before receiving influenza and pneumococcal vaccines, contrary to facility policy. The Infection Preventionist/ADON confirmed the oversight, and the Administrator noted the absence of a specific job description for the Infection Preventionist role.
A resident with dementia and muscle weakness was unable to reach their call light, which was draped over an oxygen concentrator. A CNA found the call light out of reach and confirmed the resident would have to yell for help. The facility's policy requires call lights to be within easy reach.
The facility did not make the most recent survey results available in the secured memory care unit, limiting access for residents and visitors. A RN was unsure of the survey results' location, and the Administrator confirmed they were not posted, potentially affecting 27 residents.
The facility did not post nursing hours in the secured memory care unit, making them inaccessible to visitors and 27 residents. A Registered Nurse confirmed the absence of posted hours, and the Administrator acknowledged the issue, confirming that the nursing hours were not accessible within the unit.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff during meal service, as observed on two separate occasions. On the first occasion, a CNA in the 600 hall dining room engaged in multiple tasks involving direct contact with residents and their personal items without performing hand hygiene between tasks. These tasks included assisting residents to their seats, handling their oxygen tubing, serving beverages, and providing physical contact such as hugs. The CNA admitted to not using hand sanitizer between touching residents and expressed a preference for washing hands only when handling cups, contrary to the facility's infection control policy. On the second occasion, another CNA in the 400 hall dining room did not perform hand hygiene between assisting two residents with eating. The CNA provided feeding assistance to one resident, then assisted another resident with cleaning up food spills before continuing to feed both residents without washing hands in between. The CNA acknowledged the requirement for hand hygiene prior to and between feeding assistance, which was confirmed by the Director of Nursing. The facility's policies on infection control and handwashing procedures emphasized the importance of hand hygiene between resident interactions and after potential contamination.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with a Foley catheter and another receiving wound care. Despite the facility's policy and CDC guidelines requiring EBP signage and PPE carts outside the rooms of residents with indwelling catheters or wounds, these were absent for the two residents. The Infection Preventionist/Assistant Director of Nursing (IP/ADON) confirmed the oversight and acknowledged the facility's non-compliance with CDC standards. The facility also failed to conduct active infection surveillance for July 2024. The IP/ADON was unable to produce a Monthly Antibiotic/Infection Control Log for the month, as the IP/ADON had been on vacation and had not started tracking infections. This lack of documentation and tracking meant the facility could not determine if infections were contained or spreading. Additionally, a Licensed Practical Nurse (LPN) did not perform hand hygiene between residents during medication administration, contrary to the facility's infection control policy. Furthermore, a resident on contact precautions due to MRSA was not isolated in a private room and was allowed to dine in a shared dining room, increasing the risk of infection spread. The facility's policy did not align with CDC guidelines regarding PPE usage for contact precautions, contributing to the deficiency.
Failure to Track and Trend Infections and Antibiotic Use
Penalty
Summary
The facility failed to ensure proper tracking and trending of infections and antibiotic use for July 2024, affecting two residents who were on antibiotics for infections. Resident #13 was prescribed Ciprofloxacin for an arm infection related to a fracture, while Resident #8 was given Doxycycline and Amoxicillin for elevated white blood cells. The facility's Antibiotic Stewardship binder lacked documentation of infections, antibiotic use, tracking, room mapping, and trending for the month, and there was no Monthly Antibiotic/Infection Control Log available. The Infection Preventionist (IP)/Assistant Director of Nursing (ADON) was unable to produce the necessary documentation and confirmed that infection tracking and trending had not been performed for the first 16 days of July 2024. The IP/ADON had been on vacation, and the person covering did not have access to the necessary logs. The facility used Point Click Care (PCC) for electronic documentation, but the IP/ADON had not started an infection notebook for July 2024. Additionally, the IP/ADON did not understand the difference between tracking infections and tracking antibiotics to treat infections. Resident #40, who was on contact precautions due to a MRSA-positive wound, was also affected by the lack of infection tracking. The Director of Nursing (DON) confirmed the oversight of the IP/ADON and acknowledged the risks associated with MRSA for immunocompromised residents. The facility's policy on Antibiotic Stewardship, revised in January 2024, required daily tracking of antibiotic use and monitoring for adverse reactions, but these practices were not followed. The CDC's core elements of antibiotic stewardship were not fully implemented, as evidenced by the lack of accountability and tracking in the facility's program.
Deficiencies in Infection Control and EMR Navigation
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) possessed the necessary knowledge to correctly implement contact precautions for a resident with a known infection of a Multi-Drug Resistant Organism (MDRO). Specifically, the DON did not adhere to the facility's policy or CDC guidelines regarding the use of personal protective equipment (PPE) for residents on contact precautions. The report highlights that Resident #40, who was diagnosed with MRSA, was placed in a shared room with Resident #26, contrary to the facility's policy of placing such residents in private rooms or with others having the same infection. Observations and interviews revealed that staff did not consistently wear gowns or gloves when entering the room, which was required to prevent the spread of infections. Additionally, the DON demonstrated a lack of proficiency in navigating the facility's new Electronic Medical Record (EMR) system following a change of ownership. During an interview, the DON was unable to access or interpret a resident's Medication Administration Record (MAR) and was unfamiliar with the facility's fall protocol. The DON's training on the new EMR system was described as informal and minimal, which contributed to the inability to effectively manage clinical records and protocols. The deficiencies identified in the report had the potential to affect the entire resident census of 79, as the DON's lack of knowledge and skills in infection control and EMR navigation could compromise the quality of care provided. The facility's policies and CDC guidelines were not followed, particularly in the management of residents with MDROs, which could lead to increased risk of infection transmission among residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) had the necessary education and competency to effectively track and trend infections, which could potentially affect the entire resident census of 79. The IP, who also served as the Assistant Director of Nursing (ADON), was unable to produce a Monthly Antibiotic/Infection Control Log for July 2024, as the IP had been on vacation for three days that month. The IP admitted to not having started an infection notebook for July 2024 and confirmed that infection tracking and mapping were typically done at the end of the month, which resulted in the omission of residents with infections not treated with antibiotics. The IP also demonstrated a lack of competency in the implementation of the Antibiotic Stewardship Program (ASP) and infection surveillance. The Antibiotic Stewardship binder lacked necessary documentation for July 2024, and the IP was unable to accurately differentiate between antibiotic, antifungal, and antiviral medications. This was evident when the IP provided a list of residents on antibiotics, which incorrectly included residents on antifungal and antiviral medications. The IP confirmed the lack of surveillance of infections and antibiotics for July 2024, and the facility's Administrator acknowledged the absence of a job description for the IP role, which was considered a nursing role of the ADON. Additionally, the facility failed to demonstrate an understanding of contact precautions as per CDC guidance. A resident with a positive MRSA culture was not placed in a private room as required by the facility's policy. The IP/ADON confirmed that the facility used CDC signage for contact precautions but misunderstood the requirements, believing that PPE was not necessary if the infected area was covered. This misunderstanding led to improper implementation of contact precautions, as staff were not consistently wearing gowns and gloves when entering the room of the resident with MRSA.
Failure to Report Resident Fall with Major Injury
Penalty
Summary
The facility failed to report a fall with major injury involving a resident to the State Agency as required by their policy. The incident involved a resident who was admitted with a history of repeated falls and other medical conditions, including a nondisplaced oblique fracture of the left femur. On the day of the incident, a Certified Nursing Assistant heard a loud noise from the resident's room and found the resident on the floor with the bed in the highest position. The resident sustained a skin tear and complained of left hip and leg pain, with the left leg appearing rotated outward. The resident was subsequently transferred to the emergency room and later flown to a larger hospital for treatment of a distal femur fracture. The facility's Administrator explained that the resident had a remote to control the bed height and it was assumed the resident had raised the bed themselves. Despite the serious injury, the Administrator did not report the incident to the State Agency, believing there was no indication of abuse or neglect by the facility. However, the facility's policy required that any event resulting in serious bodily injury be reported to the State Agency, the Ombudsman's office, and law enforcement within two hours. This oversight in reporting the incident constituted a deficiency in adhering to the facility's abuse prohibition and reporting policy.
Failure to Update Care Plans for Pressure Ulcer and Fall Interventions
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident with a Stage III pressure ulcer. Resident #69 was admitted with a diagnosis that included a pressure ulcer of the sacral region, initially staged as a Stage II. However, on 07/08/2024, the wound was reassessed by the Wound Care Nurse and determined to be a Stage III ulcer. Despite this reassessment, the care plan was not updated to reflect the current wound stage, leading to a discrepancy between the care plan and the actual wound care needs of the resident. Additionally, the facility did not update the care plan for a resident with a history of falls when new interventions were implemented. Resident #31, who had diagnoses including severe dementia and muscle weakness, experienced multiple falls. The facility implemented several interventions, such as placing the bed in a low position and using floor mats, to prevent fall-related injuries. However, these interventions were not documented in the resident's care plan, which was last revised on 07/02/2024. The Director of Nursing confirmed that the care plans for both residents were not accurately updated to reflect the current assessments and interventions. The facility's policy requires that comprehensive care plans be developed and implemented to meet the residents' needs as identified in their assessments, but this was not adhered to in these cases.
Improper Catheter Drainage Bag Placement
Penalty
Summary
The facility failed to ensure proper placement of a catheter drainage bag for a resident with a Foley catheter, which could potentially lead to a urinary tract infection. Resident #58, who was admitted with a diagnosis of neuromuscular dysfunction of the bladder, was observed with the catheter drainage bag hanging from the top rung of a walker, positioned higher than the resident's bladder while seated in a wheelchair. This improper placement was confirmed by the Director of Nursing (DON) during an observation, who acknowledged that the bag should have been placed below the level of the bladder to ensure proper drainage. The facility's policy on catheter care, revised in 2014, mandates that a urinary drainage bag must be positioned lower than the bladder at all times to prevent urine from flowing back into the bladder. Despite this policy, the improper placement of the drainage bag was observed, and the DON confirmed the risk of urine backup and potential urinary tract infection. The resident had a previous positive culture for Klebsiella aerogenes, indicating a history of urinary tract infection, although the DON was unsure if this occurred after admission to the facility.
Improper Ostomy Care by CNA
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with a colostomy, as a Certified Nursing Assistant (CNA) changed the resident's colostomy wafer, which was outside the CNA's scope of practice. Resident #21, who had a colostomy following necrotizing enterocolitis and colectomy surgery, expressed a preference for being in a different hall where CNAs were familiar with their colostomy care. The resident's care plan included interventions assigned to a licensed nurse, such as monitoring stool characteristics and skin integrity, and encouraging the resident not to tamper with the stoma paste. The CNA involved in the incident admitted to changing the ostomy wafer, despite lacking documented training or competency evaluation for this task. The Director of Nursing (DON) confirmed that only nurses were permitted to change ostomy wafers, as it required assessing the resident's skin integrity, which was not within a CNA's scope of practice. The facility's policy and the Lippincott Manual of Nursing Practice, which the facility used as a standard, both indicated that assessment of peristomal skin was necessary with each pouching system change, a task that CNAs were not trained or authorized to perform.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen as ordered for a resident diagnosed with acute and chronic respiratory failure with hypoxia and pneumonia. The resident was observed with an oxygen concentrator set at one liter per minute, despite a physician's order for four liters per minute continuous oxygen administration. The resident's care plan also indicated the need for oxygen as ordered due to altered respiratory status. On a subsequent observation, the oxygen concentrator was found turned off, and the resident was not receiving any oxygen. A Licensed Practical Nurse (LPN) confirmed the oxygen concentrator was off and later set it to one liter per minute, which was not in accordance with the physician's order. The LPN and a Registered Nurse (RN) acknowledged the discrepancy and confirmed there was no order to adjust the oxygen level. The RN explained that attempts to taper the oxygen had been unsuccessful and should have been discussed with the physician. The Director of Nursing (DON) emphasized the importance of following physician orders for oxygen administration, as per facility policies, which were not adhered to in this case.
Deficiencies in Dialysis Care and Infection Control
Penalty
Summary
The facility failed to ensure that Dialysis Communication Forms were completed and maintained for a resident requiring dialysis services. Resident #24, who was admitted with diagnoses including end-stage renal disease and diabetes mellitus type II, had incomplete Dialysis Communication Forms on multiple occasions. Specifically, the forms dated 05/14/2024, 06/18/2024, and 07/06/2024 were missing critical post-dialysis information such as physical assessments for shunt/location status, bruit/thrill presence, bleeding, and the general condition of the resident. The forms were also undated and unsigned by a licensed nurse, which was confirmed by the Director of Nursing (DON) as a gap in care documentation. Additionally, the facility did not adhere to infection control protocols by placing a resident with a hemodialysis catheter in a shared room with another resident who had a wound infected with a multi-drug resistant organism (MDRO). Resident #26, who had a dialysis port, was sharing a room with Resident #40, who was on contact precautions due to a wound positive for Methicillin-Resistant Staphylococcus Aureus (MRSA). The facility's policy required residents on contact precautions to be placed in a private room or with another resident with the same infection, which was not followed in this case. The Infection Preventionist (IP) and the DON confirmed that placing Resident #26 in a shared room with Resident #40 increased the risk of MDRO transmission. Despite the facility having vacant rooms, Resident #40 was not placed in a private room as recommended by the facility's policy and the State Health Program Specialist. The facility's failure to adhere to its own infection control policies and ensure proper documentation for dialysis care resulted in deficiencies in the care provided to these residents.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure expired medications were not kept in a medication cart, as observed during a review of a medication cart in the 600 hall. A bottle of Fish Oil capsules with an expiration date of January 2024 and a bubble pack containing 25 tablets of Tramadol with an expiration date of 05/14/2024 were found. The Registered Nurse (RN) present during the review explained that facility staff conducted monthly checks of the medication cart for expired medications, emphasizing the importance of removing expired medications to prevent residents from getting sick. The Director of Nursing (DON) further explained that failure to remove expired medications could result in a medication error and that expired medications might not have the same effect as prescribed. The facility's policy on Pharmaceutical Procedures, revised on 01/31/2024, stated that all expired medications should be returned to the pharmacy for proper disposition, except for controlled drugs, which should be disposed of on the premises by two licensed staff.
Documentation Deficiency in Resident Care
Penalty
Summary
The facility failed to ensure proper documentation for a resident, leading to a deficiency in maintaining medical records according to professional standards. The resident, who was admitted with diagnoses including unspecified dementia, Alzheimer's Disease, anxiety disorder, and major depressive disorder, had several instances of missing documentation in their Treatment Administration Record (TAR). Specifically, there were blank spaces for lotion administration, side effect monitoring for medications like Amitriptyline and Seroquel, pain monitoring, COVID-19 symptom monitoring, and behavior monitoring on various dates in June 2024. The deficiency was identified through interviews, document reviews, and clinical record reviews. The Registered Nurse (RN) and Licensed Practical Nurse (LPN) confirmed that blank spaces in the TAR indicated a lack of documentation by the administering nurse. The Director of Nursing (DON) also confirmed these omissions, attributing them to the nurses forgetting to document the required information. The facility's policy on psychoactive medication use and monitoring was not adhered to, as there was no documented evidence of monitoring for side effects or target behaviors related to the resident's medication use. The lack of documentation was evident on specific dates, such as 06/06/2024, 06/14/2024, and 06/22/2024, for side effect and behavior monitoring, and on 06/15/2024 for lotion administration, pain monitoring, and COVID-19 symptom monitoring. The facility's failure to document these critical aspects of care for the resident highlights a significant lapse in following established protocols and ensuring comprehensive care for the resident.
Failure to Screen Resident for Vaccine Eligibility
Penalty
Summary
The facility failed to ensure that a resident was screened for eligibility to receive influenza and pneumococcal vaccinations. Resident #26, who was admitted with chronic kidney disease, type II diabetes mellitus, and acute and chronic respiratory failure, was not assessed for contraindications before receiving the vaccines. The facility documents for both the influenza and pneumococcal vaccines had blank sections for risk assessment and contraindications, although the resident had signed consent and received the vaccinations. The Infection Preventionist/Assistant Director of Nursing confirmed that the resident was not screened for eligibility prior to vaccine administration, which was against the facility's policy. The Administrator acknowledged the lack of a job description for the Infection Preventionist role, which was considered part of the ADON's responsibilities. The facility's policies required annual assessment of immunization status and screening for contraindications, which were not followed in this case.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a critical component for residents to communicate their need for assistance. Resident #53, who was admitted with diagnoses including unspecified dementia with agitation, muscle weakness, and anxiety disorder, was found in a situation where their call light was draped over an oxygen concentrator, making it unreachable. This resident's care plan, which was revised to address risks related to falls due to muscle weakness and dementia, included interventions to encourage the resident to call for assistance before getting out of bed or transferring. On the day of the observation, a CNA entered the room and initially could not locate the call light. Upon finding it draped over the oxygen concentrator, the CNA confirmed that the resident could not reach it and would have to yell for help. The CNA then attached the call light to the resident's blanket. An LPN also confirmed that the resident was capable of using the call light but would be unable to do so if it was out of reach. The facility's policy on responding to resident needs emphasized the importance of ensuring the call light is within easy reach when a resident is in bed or confined to a chair.
Survey Results Not Accessible in Memory Care Unit
Penalty
Summary
The facility failed to ensure that the most recent survey results were made available in the secured memory care unit, which restricted access for residents and visitors. This deficiency was observed on July 17, 2024, at 9:19 AM, when there was no evidence of the survey results being accessible within the unit. A Registered Nurse in the memory care unit expressed uncertainty about the availability or location of the survey results. On July 18, 2024, at 8:50 AM, the Administrator confirmed that the survey results were not posted in the secured memory care unit, and acknowledged that residents in this unit did not have access to them. This oversight had the potential to affect 27 residents.
Failure to Post Nursing Hours in Memory Care Unit
Penalty
Summary
The facility failed to ensure that nursing hours were posted in the secured memory care unit, making them inaccessible to visitors and residents. On July 17, 2024, at 9:19 AM, it was observed that the secured memory care unit lacked posted nursing hours. A Registered Nurse in the memory care unit confirmed that the nursing hours were not posted. On July 18, 2024, the Administrator acknowledged that visitors could use the entrance to the secured memory care unit but confirmed that the nursing hours were not posted within the unit, restricting access for the 27 residents in the secured memory care unit.
Latest citations in Nevada
Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
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