Highland Manor Of Fallon Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fallon, Nevada.
- Location
- 550 North Sherman Street, Fallon, Nevada 89406
- CMS Provider Number
- 295085
- Inspections on file
- 29
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 50
Citation history
Health deficiencies cited at Highland Manor Of Fallon Rehabilitation Llc during CMS and state inspections, most recent first.
A facility failed to prevent the employment of a CNA with a disciplinary action for abuse, placing residents at risk. The CNA was hired despite a restriction on their license due to a previous incident of abuse. The facility's hiring process included background checks and license verification, but the CNA was retained based on positive feedback and observations, contrary to the facility's policy against employing individuals with a history of abuse. The CNA was suspended after the issue was identified.
A resident with a documented penicillin allergy was administered Augmentin, a penicillin-class antibiotic, due to a failure to record the allergy in the facility's electronic health record. This resulted in the resident developing a severe allergic reaction, requiring hospitalization. The facility's policy to verify medication allergies prior to administration was not followed.
A resident with severe protein-calorie malnutrition and significant weight loss was not monitored for weight changes upon readmission to the facility. Despite the facility's policy requiring weekly weight checks, no weights were documented, as confirmed by the RD and DON.
The facility did not hold the required quarterly QAPI meetings from January to June 2024, as evidenced by the lack of documented meeting records. The last meeting was held in the 4th quarter of 2023. The Administrator confirmed the absence of documentation for the specified period, despite the facility's policy stating that the QAPI Committee should meet monthly.
The facility failed to implement a comprehensive infection prevention and control program, as evidenced by the lack of a surveillance plan for all infections. Staff did not wear appropriate PPE during wound care for a resident on Enhanced Barrier Precautions, and proper infection control practices were not followed during the care of another resident's ileostomy and oxygen humidifier. These deficiencies were contrary to the facility's policies and posed potential infection risks.
The facility did not provide eight consecutive hours of RN coverage on six occasions, as confirmed by the DON. This deficiency was identified through a review of staffing records and could have affected the care of 87 residents.
The facility failed to ensure accurate medication management for residents, leading to discrepancies in controlled drug records and unavailability of ordered medications. A resident's oxycodone administration was improperly documented, raising concerns about diversion. Another resident experienced discrepancies in lorazepam and oxycodone counts, impacting anxiety management. Additionally, two residents did not receive necessary medications due to supply issues, with the DON acknowledging the risks of missed doses.
A LTC facility failed to ensure proper medication management, including mismatched pharmacy labels and physician orders, unlabeled pre-poured medications, expired medications, and improper storage of insulin pens and refrigerated medications. These deficiencies were confirmed by the DON and were not in line with the facility's policies, posing risks to resident safety.
The facility failed to obtain consent from representatives before administering psychotropic medications to two residents. One resident was given Depakote for dementia-related behaviors without prior consent, and another was administered Trazodone for insomnia without documented consent. The DON confirmed that consent should have been obtained before medication administration, as per facility policy.
A facility failed to accurately complete the MDS assessment for a resident who was incorrectly documented as receiving dialysis, despite having no history or evidence of dialysis treatment. The MDS Coordinator/RN confirmed the error, highlighting the importance of MDS accuracy for reimbursement and care planning.
A resident with schizoaffective disorder was admitted to a facility with multiple diagnoses, including hallucinations and dementia. Despite a significant change in the resident's condition, which led to an inpatient behavioral health admission, the facility failed to submit a PASARR Level II determination. The resident's care plan noted verbal and physical behaviors, and an LPN confirmed hallucinations and combative behavior. The facility administrator acknowledged the lack of PASARR Level II submission.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. A resident on psychotropic medications lacked a documented care plan, confirmed by both an LPN and the DON. Another resident on continuous oxygen therapy had no care plan for its administration and monitoring. Additionally, a resident experienced verbal abuse from another resident, but the incident was not documented in the clinical record. These deficiencies indicate a failure to provide individualized care plans, potentially impacting resident care outcomes.
A facility failed to implement a care plan intervention for a resident with schizophrenia and dementia, who preferred sleeping in a recliner due to resistive care behaviors and fear of falling. Despite a care plan indicating the need for a recliner, the resident's room only had a mattress on the floor, and the Director of Nursing was unaware of the need for a recliner. The facility's policy required a comprehensive care plan, which was not followed in this instance.
A resident with hereditary motor and sensory neuropathy and muscle weakness did not receive scheduled showers on two consecutive Saturdays. Both the resident and their spouse confirmed the missed showers, and the clinical record lacked documentation of showers being given or refused. A CNA and an LPN acknowledged the issue, with the LPN citing time constraints on the evening shift as a reason for the missed showers.
The facility failed to employ a qualified Activities Director, with an Activities Assistant filling the role without necessary training or certification for several months. The Business Office Manager and Administrator were unaware of the deficiency, and the consultant responsible for training did not fulfill contracted hours. Personnel records lacked evidence of required qualifications, leading to the facility being without a qualified Activities Director.
A resident with hereditary neuropathy and a history of falls did not receive a required Physical Therapy (PT) evaluation after admission to the facility. Despite being identified as a fall risk and having a care plan that included a PT referral, the resident's clinical record showed no evidence of a PT evaluation. Facility staff confirmed the oversight, acknowledging the resident should have been evaluated within 10 days of admission.
A resident with chronic respiratory failure was not administered oxygen as ordered on two occasions. The resident was observed without the nasal cannula in place, despite a physician's order for continuous oxygen at five LPM. Both a CNA and an LPN confirmed the resident's need for continuous oxygen, and the facility's policies on oxygen administration and following physician orders were not followed.
The facility failed to provide timely and available pain management for two residents. A resident with back pain received Lidocaine patches late on multiple occasions, while another resident with knee pain went without patches for weeks due to unavailability. The facility's policies on medication administration and ordering were not followed, leading to deficiencies in pain management.
A facility failed to reassess a resident for entrapment risk after cognitive decline, lacked safety assessments and informed consent for side rail use for two residents, and did not document necessary evaluations for another resident. The DON confirmed the absence of required assessments and documentation, posing potential safety hazards.
The facility did not complete an annual performance evaluation for a CNA in a timely manner. The CNA, hired in early 2023, had their evaluation completed several months late in 2024, contrary to the facility's policy requiring annual evaluations. This was confirmed through personnel record review and interviews with HR staff.
A resident with moderate protein-calorie malnutrition had their bottom dentures broken, and the facility failed to provide timely dental services. Despite being aware of the issue, the facility did not attempt to repair the dentures for nearly a month. The resident expressed dissatisfaction, stating the dentures were broken by a staff member and they were unable to chew food properly. The facility's policy required referrals for dental services within three days, but there was no evidence of such action or documentation of delays.
A resident with a preference for a vegetarian diet was repeatedly served meat due to the facility's failure to document and honor their dietary preferences. Despite the resident's requests and the dietary manager's awareness, the facility lacked a vegetarian menu and did not update the resident's care plan or meal tickets to reflect their preferences.
A facility failed to document the administration of physician-ordered nutritional shakes for a resident with moderate protein-calorie malnutrition. The MAR showed blank spaces for Ensure administration on three dates, indicating a lack of documentation. Interviews with an LPN and the DON confirmed the absence of documentation, and the facility's policy required initialing the MAR after administering medications.
The QAPI committee did not identify issues with medication labeling, storage, and controlled substances documentation. The Regional President confirmed the lack of awareness, suggesting audits and reconciliations could have highlighted these concerns. The facility's QAPI plan, revised in 2014, aimed to monitor care quality but did not address these specific deficiencies.
A facility failed to protect residents from verbal abuse. A CNA wrote disparaging remarks on a resident's communication board during a transfer, causing distress. Another incident involved a resident with a history of aggressive behavior using racial slurs against another resident. The facility lacked documentation and follow-up for the latter incident, violating their abuse prevention policy.
A facility failed to timely report a verbal abuse incident involving a resident with communication challenges. A CNA, frustrated during a transfer, wrote derogatory comments on the resident's communication board, causing distress. The incident was substantiated, and the CNA was terminated, but the final report was submitted late to the State Agency.
A facility failed to investigate and report an incident of resident-to-resident verbal abuse involving racial slurs and profanity. Despite an initial report, the facility did not document the investigation or submit a final report to the State Agency. The Administrator confirmed the lack of documentation and investigation, contrary to the facility's policy requiring thorough investigation and reporting within five days.
A CNA failed to maintain the dignity of three residents by standing over them while providing feeding assistance and not using hand sanitizer between residents. The CNA was unaware of the maximum number of residents they could assist at one time, and the facility's policies lacked specific guidance on these practices.
A resident was injured during transport due to improper securing in a wheelchair, resulting in a fall and multiple injuries. Additionally, two residents were subjected to verbal and physical abuse by another resident with known violent behavior. The facility failed to implement its abuse prevention policy effectively, leading to these incidents.
The facility failed to report suspected abuse incidents to the Ombudsman's office for 9 out of 19 investigated cases and submitted final reports late to the State Agency for 5 cases. Incidents included verbal and physical altercations and inappropriate touching among residents. The facility did not adhere to its policy requiring immediate reporting to the Ombudsman and timely submission of final reports.
A facility failed to thoroughly investigate abuse allegations involving a resident and the Director of Rehab (DOR). The DOR was suspended but not interviewed, and the investigation concluded without comprehensive documentation or interviews with all involved parties, contrary to the facility's policy. The current Administrator confirmed the lack of documentation, highlighting a failure to adhere to the established procedures.
The facility failed to update care plans for several residents following incidents of resident-to-resident altercations and an allegation of employee-to-resident abuse. Despite having various diagnoses, the care plans did not reflect necessary updates to address these incidents. Staff confirmed the expectation for care plans to be updated, but this was not done, leading to deficiencies in care documentation.
The facility did not meet the requirement for eight consecutive hours of RN coverage on a specific day, as the two RNs on duty worked less than the required hours. Additionally, the facility lacked a full-time DON after the previous DON resigned, and the position remained unfilled.
The facility failed to ensure staff followed proper hand hygiene practices in the kitchen and during meal service. A CNA entered the kitchen without performing hand hygiene and used gloves improperly while serving drinks and meals. Another CNA did not use hand sanitizer between assisting residents. The Dietary Manager and ADON confirmed the requirements for hand hygiene, which were not followed according to facility policy.
Failure to Prevent Employment of CNA with Abuse History
Penalty
Summary
The Administrator of the facility failed to ensure that a Certified Nursing Assistant (CNA) with a disciplinary action against their license for abuse was not employed, which placed residents at risk for abuse. The CNA was hired on 09/18/2024, and the facility received a letter from the Nevada State Board of Nursing (NV SBON) on 10/08/2024, indicating a restriction on the CNA's license due to a previous incident of abuse at another facility. Despite this, the CNA continued to be scheduled to work in the facility as of January 2025. The facility's hiring process, as explained by the Office Manager and Administrator, included background checks and license verification to prevent hiring individuals with a history of abuse. However, the Administrator and Director of Nursing (DON) acknowledged that the CNA had admitted to being verbally abusive and rough with a resident in the past. The decision to retain the CNA was based on positive feedback from residents and staff, as well as the DON's observations. The facility's policy explicitly stated that they would not knowingly employ individuals convicted of abuse, neglect, or mistreatment, yet the CNA was only suspended after the issue was identified.
Resident with Known Allergy Administered Penicillin Antibiotic
Penalty
Summary
The facility failed to prevent a significant medication error when a resident with a known penicillin allergy was administered a penicillin-class antibiotic, Augmentin. The resident, who had been admitted with multiple diagnoses including dementia and Alzheimer's disease, had a documented allergy to penicillin in a hospital discharge summary prior to their admission to the facility. However, this allergy was not recorded in the facility's electronic health record. As a result, the resident received Augmentin for a colostomy wound infection over several days. The administration of Augmentin led to the resident developing a maculopapular, pruritic rash, generalized weakness, nausea, and vomiting, which required hospitalization. The Director of Nursing confirmed that the allergy was documented in the hospital discharge summary but was not included in the facility's records, leading to the administration of the contraindicated medication. The facility's policy required verification of medication allergies before administration, which was not adhered to in this case.
Failure to Monitor Resident's Weight Post-Readmission
Penalty
Summary
The facility failed to monitor a resident with a known history of significant weight loss upon their readmission. The resident, who had been diagnosed with severe protein-calorie malnutrition, dysphagia, and nausea with vomiting, experienced a severe weight loss of 32.1 pounds over a five-month period prior to their hospitalization. Upon readmission, the facility did not document any weights for the resident, despite the facility's policy requiring weights to be taken upon admission and weekly for four weeks thereafter. Interviews with the Registered Dietitian (RD) and the Director of Nursing (DON) confirmed the lack of adherence to the facility's weight monitoring policy. The RD acknowledged the importance of monitoring the resident's weight to identify the cause of the weight loss and implement necessary interventions. The DON confirmed that the facility policy was not followed, as no weights were documented after the resident's readmission, which was a critical oversight given the resident's medical history and recent weight loss.
Failure to Hold Quarterly QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee held meetings at least quarterly, as required. The QAPI sign-in sheets showed that all required committee members attended the meeting in the 4th quarter of 2023, with the last documented meeting occurring on September 20, 2023. However, there was no documented evidence of any QAPI meetings being held from January 2024 through June 2024. During an interview on August 22, 2024, the Administrator stated that the committee would meet as often as needed and at a minimum quarterly. The Administrator confirmed that the facility could not provide documented evidence of a QAPI meeting during the specified period. The facility's policy, revised in April 2014, indicated that the QAPI Committee was supposed to meet monthly to review reports, evaluate data significance, and monitor quality-related activities across all departments, services, or committees.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, as evidenced by the lack of a surveillance plan for identifying and tracking all infections. The Infection Preventionist (IP) was only tracking infections requiring antibiotic treatment and did not include viral infections such as COVID-19 in the surveillance documentation. This oversight was contrary to the facility's policy, which required the use of surveillance tools to recognize infections, record their frequency, and detect outbreaks. In the case of Resident #52, who was on Enhanced Barrier Precautions (EBP) due to a history of MRSA, staff failed to wear the appropriate Personal Protective Equipment (PPE) during wound care. Both the Certified Nursing Assistant (CNA) and the Licensed Practical Nurse (LPN) did not wear gowns while providing wound care, despite the requirement to do so for high-contact care activities. The LPN acknowledged the oversight after reviewing the signage on the resident's door, which indicated that gowns should be worn. Additionally, the facility did not ensure proper infection control practices during the care of Resident #134's ileostomy and Resident #32's oxygen humidifier. A CNA changed Resident #134's ileostomy bag without donning gloves or washing hands, contrary to the facility's policy. For Resident #32, the oxygen humidifier was found lying on the ground, which was identified as an infection control concern by the Director of Nursing (DON) and other staff members. The facility's policy required the humidifier to be securely fastened to the oxygen concentrator to prevent contamination.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to ensure eight consecutive hours of Registered Nurse (RN) coverage for six out of ninety days reviewed for staffing. This deficiency was identified through interviews and document reviews, specifically the facility's Daily Nursing Staff Posting and Census sheets. On the dates of 06/02/2024, 06/14/2024, 06/18/2024, 06/19/2024, 06/24/2024, and 08/17/2024, there was no RN coverage, which could have impacted the care and assessments required for all 87 residents residing in the facility on those dates. The Director of Nursing (DON) confirmed the absence of RN coverage on the specified dates, acknowledging the facility's failure to meet the regulatory requirement for RN presence. This lack of coverage could have potentially left residents without proper assessments or care that only RNs are qualified to perform.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled medications and availability of ordered medications for several residents. For Resident #4, the Controlled Drug Records (CDR) were not correctly completed, leading to discrepancies in the documentation of oxycodone hydrochloride administration. The medication card label did not match the physician's order, and there were inconsistencies in the documentation of medication wastage, raising concerns about potential diversion. A half tablet of oxycodone was found in the medication cart, indicating improper handling and documentation. Resident #74 also experienced discrepancies in the CDR for lorazepam and oxycodone hydrochloride, with the actual medication count not matching the documented count. This inconsistency raised concerns about medication diversion and the potential impact on the resident's anxiety management. The Director of Nursing (DON) confirmed the discrepancies and the risk they posed to the resident's well-being. Additionally, the facility failed to provide ordered medications for Residents #79 and #40. Resident #79 did not receive Lidocaine patches for knee pain due to a lack of supply, despite the patches being available over the counter. Resident #40 experienced multiple missed doses of critical medications, including Apixaban, Cinacalcet, Polyethylene Glycol, and Potassium Chloride, due to the facility's failure to maintain an adequate supply. The DON acknowledged the issues with medication availability and the risks associated with missed doses, but the facility's pharmacy fax call reports were missing, indicating a lack of proper medication management.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that the pharmacy label's instructions for administration on a medication dispensing card matched the physician's order for a resident with chronic pain syndrome and opioid dependence. The physician's order required administering one and a half tablets of oxycodone hydrochloride, but the medication card label instructed to give only one tablet. This discrepancy led to inconsistent practices regarding the wasting of the remaining half tablet, raising concerns about potential medication diversion. The Director of Nursing (DON) confirmed that the label on medication containers should always match the physician's order, and the remaining half tablet was not consistently wasted, creating a risk for the medication to become loose in the medication cart. Another deficiency was observed when a resident's pre-poured medications were stored unlabeled in a medication cart. The resident had refused the medications, and the RN placed the medication cup, labeled only with the resident's first name, in a drawer of the medication cart to be administered later. This practice was confirmed by the DON to be against the facility's policy, which required medications to be stored in their original packaging to maintain a clean, safe, and sanitary environment. Additional issues included expired medications found in the medication cart, insulin pens stored without separation or labels, and medications requiring refrigeration not being stored at the correct temperature. The DON confirmed these practices were not in line with the facility's policy, which required proper labeling, storage, and separation of medications to prevent mixing and ensure resident safety. Loose and unlabeled medications were also found in the medication cart, with the DON acknowledging that such practices could lead to medication errors and compromise resident safety.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that consent was obtained from a resident's representative before administering psychotropic medication to two residents. Resident #51, who had diagnoses including Alzheimer's disease and atherosclerosis, was prescribed Depakote as a mood stabilizer for dementia-related behaviors. The medication was administered starting on July 10, 2024, but consent from the resident's power of attorney was only documented on August 7, 2024, after the medication had already been given. The Licensed Practical Nurse and the Director of Nursing confirmed that consent should have been obtained prior to the first administration of the medication. Similarly, Resident #32, with diagnoses including depression and insomnia, was prescribed Trazodone for insomnia. The clinical record for this resident lacked evidence of informed consent for the psychotropic drug before its administration. The Director of Nursing acknowledged that consent was required before administering Trazodone, but no consent was completed. The facility's policy on psychoactive medication use, revised in 2016, states that residents and their representatives should be informed of the potential risks and benefits of such medications and have the right to refuse treatment.
Inaccurate MDS Assessment for Dialysis
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) assessment for one resident. The resident, who was admitted with a diagnosis of essential hypertension, did not receive dialysis and had no documented evidence in their clinical record indicating dialysis treatment, including progress notes, care plans, or physician's orders. Despite this, a quarterly MDS assessment inaccurately documented that the resident was on dialysis. The MDS Coordinator/Registered Nurse confirmed that the assessment was incorrect, as the resident had never received dialysis treatments. This inaccuracy was significant for both reimbursement and the accuracy of diagnoses and resident care plans.
Failure to Submit PASARR Level II for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to initiate a submission for a Preadmission Screening and Resident Review (PASARR) Level II determination for a resident diagnosed with schizoaffective disorder. The resident was admitted and readmitted to the facility with multiple diagnoses, including schizoaffective disorder, hallucinations, anxiety disorder, and dementia. The resident's PASARR Level I was completed in 2018, indicating no mental illness or related conditions, and was deemed appropriate for nursing facility placement. However, a significant change in the resident's condition occurred, as documented in a physician progress note, which indicated the resident was admitted to inpatient behavioral health for psychosis, aggressive behavior, and resistance to care. Despite these changes, the clinical record lacked evidence of a PASARR Level II submission. The resident's care plan, initiated in 2024, noted verbal and physical behaviors related to schizoaffective disorder and dementia. An LPN confirmed the resident experienced hallucinations and combative behavior, and the facility administrator acknowledged the resident's transfer to an inpatient behavioral health facility due to these behaviors. The administrator also confirmed that a PASARR Level II was not submitted, highlighting the facility's failure to comply with regulatory requirements for residents with significant changes in mental health status.
Deficiencies in Care Planning for Psychotropic Medications, Oxygen Administration, and Resident Abuse
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and implemented for three residents, leading to deficiencies in their care. Resident #51, who was diagnosed with atherosclerosis of the aorta, lack of coordination, and Alzheimer's disease, was prescribed psychotropic medications Clonazepam and Effexor. However, the care plan for this resident lacked documentation of these medications, which was confirmed by both the LPN and the DON. The facility's policy required the interdisciplinary team to develop a care plan for psychotropic medications, but this was not done for Resident #51. Resident #32, diagnosed with chronic respiratory failure with hypoxia and other conditions, was on continuous oxygen therapy at five liters per minute. Despite this, there was no documented care plan for the administration and monitoring of oxygen, as confirmed by the LPN and the DON. Additionally, Resident #79, who had end-stage renal disease, experienced a resident-to-resident verbal abuse incident, but the clinical record lacked documentation of the incident, including a care plan. The DON confirmed the absence of documentation for this incident. These deficiencies indicate a failure to provide individualized care plans for residents, potentially impacting their care outcomes.
Failure to Implement Care Plan Intervention for Resident's Sleep Needs
Penalty
Summary
The facility failed to honor an intervention involving a recliner for a resident with resistive care behaviors and sleep issues. The resident, diagnosed with paranoid schizophrenia, major depressive disorder, and severe unspecified dementia with anxiety, was observed with a mattress on the floor and a fall mat next to it, but no recliner was present in the room. The comprehensive care plan, revised on 08/19/2024, indicated that the resident preferred sleeping on the floor mat and had previously slept in a recliner at home. Despite a physician's order for head elevation due to shortness of breath, the facility did not provide a recliner, which was part of the care plan intervention. The Director of Nursing (DON) confirmed the absence of a recliner and was unaware of any discussions with the resident's daughter about placing one in the room. The resident's daughter corroborated that the resident avoided sleeping in a bed due to fear of falling and had not seen a recliner in the room. The facility's policy on care plans, last revised in December 2016, required the development and implementation of a comprehensive person-centered care plan, which was not adhered to in this case, as the intervention of placing a recliner was neither honored nor revised.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident dependent on staff for Activities of Daily Living (ADLs) received the scheduled showers. Resident #46, who was admitted with diagnoses including hereditary motor and sensory neuropathy and generalized muscle weakness, did not receive showers on two consecutive Saturdays as scheduled. Both the resident and their spouse confirmed the missed showers, which were supposed to occur on Wednesdays and Saturdays. The clinical record for Resident #46 lacked documentation of showers being given or refused, as confirmed by a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN). The LPN noted that the resident's showers were scheduled for the evening shift, but time constraints often prevented them from occurring. The Regional Clinical Resource also confirmed the absence of documentation in the resident's clinical record, which was against the facility's policy of providing personalized care regarding shower frequency and timing.
Facility Lacks Qualified Activities Director
Penalty
Summary
The facility failed to employ a qualified Activities Director or a trained professional to oversee the activities department, as required by federal and state regulations. The deficiency was identified during a survey on 08/20/2024, when the State Agency attempted to set up a Resident Council Meeting with the Activities Director, only to find that the facility did not have one. An Activities Assistant had been filling in for the role for the past three to four months without the necessary qualifications or training. The Business Office Manager confirmed that the facility had been without a qualified Activities Director for six months, and the Administrator mistakenly identified the Activities Assistant as the Activities Director, despite the lack of completed training or certification. The Activities Assistant, who was initially a Certified Nursing Assistant, was promoted to the Director of Memory Care and then to Activities Director without obtaining the required certification or training. The facility's consultant, responsible for training and certifying employees for the Activities Director position, confirmed that the Activities Assistant did not complete the necessary training. The consultant was also not fulfilling the contracted hours of consultation. The personnel records lacked evidence of certification or training for the Activities Assistant, and the position description for the Activities Director did not include the responsibilities of a certified activities professional. This oversight resulted in the facility being without a qualified Activities Director for an extended period.
Failure to Conduct PT Evaluation for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a Physical Therapy (PT) evaluation was completed for a resident identified as a fall risk. The resident, who was admitted with hereditary motor and sensory neuropathy, muscle weakness, and a history of falling, required leg braces due to weakness and had experienced a fall prior to admission. Despite being care planned for fall risk and requiring a PT evaluation as an intervention, the resident's clinical record lacked evidence of such an evaluation. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Rehabilitation, confirmed that the resident had not received a PT evaluation or services. The Director of Nursing (DON) acknowledged that the resident was at risk for falling and should have received a PT evaluation within 10 days of admission, as per the facility's policy. The facility's policy on falls required nursing staff to identify individuals with a history of falls and document risk factors, which was not adequately followed in this case.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered for a resident with chronic respiratory failure and other related diagnoses. The resident was observed on two separate occasions not receiving oxygen as prescribed. On the first occasion, the resident was seated in a wheelchair with a portable oxygen concentrator, but the concentrator was not connected to the resident. A CNA confirmed that the concentrator was on, but the resident was not receiving oxygen. A physician's order required the resident to receive oxygen at five liters per minute via nasal cannula continuously for shortness of breath. On the second occasion, the resident was found sleeping in bed with the oxygen concentrator administering oxygen at the prescribed rate, but the nasal cannula was not affixed to the resident's face. A CNA confirmed that the nasal cannula was not in place, and the resident was supposed to be on continuous oxygen. An LPN and the DON both acknowledged that the resident required continuous oxygen to prevent exacerbation of their condition. The facility's policies on oxygen administration and following physician orders were not adhered to, resulting in the deficiency.
Deficiency in Pain Management Due to Late and Unavailable Medications
Penalty
Summary
The facility failed to ensure timely administration of pain medications for Resident #80, who was diagnosed with intervertebral disc degeneration and unspecified pain. The physician's order required Lidocaine patches to be applied to the lower back once daily and removed after twelve hours. However, the patches were administered late on multiple occasions, specifically on 08/05/2024, 08/11/2024, and 08/15/2024. The Licensed Practical Nurse (LPN) confirmed these late administrations and acknowledged that such delays could result in increased pain for the resident. The facility's policy required medications to be administered within one hour of their prescribed time, which was not adhered to in these instances. Additionally, the facility did not have Lidocaine patches available for Resident #80 on several days in July 2024, as documented in the Medication Administration Record (MAR). The Director of Nursing (DON) confirmed that the patches were out of stock and on order, but the facility did not receive them in time due to the pharmacy being out of state. This lack of availability was also noted for Resident #79, who experienced severe knee pain and was without Lidocaine patches for a couple of weeks. The facility's policy required nurses to reorder medications with a seven-day supply remaining, but this was not effectively managed, leading to missed administrations. The facility's failure to maintain an adequate supply of Lidocaine patches and ensure their timely administration resulted in deficiencies in pain management for the residents. The DON acknowledged the responsibility of the facility to ensure medications were on site and available, but the pharmacy fax call reports for July and August 2024 could not be found. The facility's policy on medication ordering and administration was not followed, contributing to the residents' increased pain and discomfort.
Failure to Assess and Document Side Rail Safety
Penalty
Summary
The facility failed to reassess a resident, identified as Resident #52, for the risk of entrapment after a significant cognitive decline was noted. Despite having a physician's order for the use of side rails as an enabler for bed mobility, the resident's clinical record lacked evidence of a completed Assistive Device/Potential Restraint Evaluation form upon readmission and after the cognitive decline. The facility's documentation did not include a quantitative assessment of potential entrapment risks, such as the fit of the mattress to the bed frame or gaps between the bed frame, mattress, and side rails. The Director of Nursing (DON) confirmed that the resident, who was not cognitively intact, should have been reassessed for entrapment risk, which was not done. Another resident, identified as Resident #134, had side rails installed on their bed without a physician's order or a completed safety assessment. The resident's clinical record also lacked informed consent documentation outlining the risks and benefits of side rail use. The DON acknowledged that a safety assessment and informed consent were necessary to ensure the resident's safety and to identify any potential hazards associated with side rail use. The absence of these assessments could pose a safety hazard and risk of entrapment for the resident. Additionally, Resident #37's clinical record did not contain a safety assessment or informed consent for the use of side rails, despite having a physician's order for their use as an enabler for bed mobility. The facility's policy on the proper use of side rails required an assessment of the resident's cognitive and physical status, as well as a review of potential entrapment risks. However, these assessments were not documented in the resident's record. The DON confirmed the lack of necessary documentation and assessments prior to the installation of side rails for this resident.
Delayed Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) received an annual performance evaluation in a timely manner. Employee #8, who was hired as a CNA on February 7, 2023, had their performance evaluation completed on August 19, 2024, which was past the due date of February 7, 2024. This deficiency was confirmed during an interview with the Human Resources Manager and Regional Human Resources, as well as through a review of the personnel records. The Business Office Manager was unable to provide evidence that the evaluation was completed by the required date, confirming the delay. The facility's policy mandates that performance evaluations for CNAs be conducted annually, but this was not adhered to in this instance.
Failure to Provide Timely Dental Care for Resident with Broken Dentures
Penalty
Summary
The facility failed to provide timely dental services for a resident with broken dentures. The resident, who was admitted with a diagnosis of moderate protein-calorie malnutrition, had their bottom dentures broken on two separate occasions, as documented in nursing progress notes. Despite being aware of the issue on 07/18/2024, the facility did not attempt to repair the dentures until 08/16/2024, when the hospice social worker intervened. The resident expressed dissatisfaction with the facility's handling of the situation, stating that the dentures were broken by a staff member and that they were unable to chew food properly, impacting their ability to eat solid food. The facility's policy required referrals for dental services within three days of lost or damaged dentures, with documentation of any delays. However, there was no evidence of such documentation or attempts to address the issue between 07/18/2024 and 08/16/2024. The resident advocate and administrator acknowledged the lack of follow-through and documentation by the previous resident advocate, which contributed to the delay in addressing the resident's dental needs. The resident was placed on a mechanical soft diet due to the broken dentures, but the facility failed to ensure timely dental care as per their policy.
Failure to Honor Vegetarian Meal Preferences
Penalty
Summary
The facility failed to honor a resident's meal preferences for a vegetarian diet, which led to the resident being served meat on multiple occasions. Resident #40, who was admitted with a primary diagnosis of metabolic encephalopathy, expressed a preference for a vegetarian diet as documented in a progress note. Despite this, the resident was served meals containing meat on at least two occasions, as confirmed by both the resident and staff members. The facility's dietary manager acknowledged that the resident's vegetarian preference was known but not properly documented in the care plan or meal tickets, resulting in the resident receiving meals with meat. The deficiency was further highlighted by the lack of a vegetarian menu and the facility's policy, which did not adequately accommodate vegetarian preferences. The dietary manager admitted that the facility did not have a specific vegetarian menu and that vegetarian residents would receive the day's menu without meat. However, this practice was not followed for Resident #40, as their meal tickets did not reflect their dietary preferences. The facility's policy on food service, which was supposed to offer choices based on a regular diet, failed to ensure that the resident's vegetarian preferences were met.
Failure to Document Administration of Nutritional Shakes
Penalty
Summary
The facility failed to document the administration of physician-ordered nutritional shakes (Ensure) for a resident diagnosed with moderate protein-calorie malnutrition. The resident was admitted with a physician's order to receive chocolate Ensure, with the option to leave two at the bedside per patient request once a day. The Medication Administration Record (MAR) for August 2024 showed blank spaces for the administration of Ensure on three specific dates, indicating a lack of documentation for those days. Interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the absence of documentation on the MAR for the specified dates. The LPN explained that the blank spaces could mean the administering nurse either forgot to document the administration or did not give the prescribed Ensures. The DON stated that a blank space on the MAR meant the medication was not documented as given, and if not administered, it should have been noted on the MAR and in progress notes. The facility's policy required the individual administering medications to initial the MAR after giving each medication, which was not followed in this case.
QAPI Committee Fails to Identify Medication Management Issues
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify deficiencies in the labeling and storage of medications and the documentation and reconciliation of controlled substances. During an interview on August 22, 2024, the Regional President confirmed that the facility had not recognized these issues. The Regional President indicated that the facility could have identified the concerns by conducting audits of medication storage areas and performing reconciliation of controlled substances. The facility's QAPI plan, revised in April 2014, was intended to monitor and evaluate the quality and safety of resident care and to resolve identified problems, but it did not address these specific issues.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with hearing loss who communicated using a whiteboard. During a transfer using a Hoyer lift, the CNA became frustrated and wrote disparaging remarks on the resident's communication board, calling the resident over dramatic and childlike. The CNA also verbally commented on the resident's weight, which upset the resident and caused them to cry. The facility substantiated the verbal abuse allegation and terminated the CNA involved. Additionally, the facility did not adequately protect a resident from verbal abuse by another resident. A resident with a history of erratic and aggressive behavior, including racial slurs and profanity, verbally abused another resident. Despite the incident being reported to the Administrator, there was no documentation in the clinical records of either resident involved, and the Director of Nursing (DON) and Administrator were unaware of the incident due to not being employed at the facility at the time. The facility's policy required follow-up visits and documentation, which were not completed, indicating a failure to adhere to their abuse prevention policy.
Late Reporting of Verbal Abuse Incident
Penalty
Summary
The facility failed to submit a final Facility Reported Incident (FRI) report to the State Agency (SA) in a timely manner for an incident involving a resident. The incident occurred when a Certified Nursing Assistant (CNA) became frustrated while transferring a resident using a Hoyer lift. The CNA wrote on the resident's communication board, accusing the resident of being over dramatic and acting like a child, which upset the resident and caused them to cry. The CNA admitted to writing these phrases and acknowledged losing their temper during the incident. The resident involved had a medical history that included monoplegia of the lower limb following a cerebral infarction, muscle wasting and atrophy, contractures of the hands, and unspecified hearing loss. The resident used a white board to communicate due to their hearing loss. The facility substantiated the allegation of verbal abuse and terminated the CNA involved. However, the final report of the incident was submitted late to the SA, which constitutes a deficiency in the facility's reporting obligations.
Failure to Investigate and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident verbal abuse and did not submit a final Facility Reported Incident (FRI) report to the State Agency for one of the sampled residents. The incident involved a resident who reported being verbally abused with racial slurs and profanity by another resident. Despite the initial FRI being documented, the clinical record of the affected resident lacked documentation related to the incident, and no final report was submitted to the State Agency within the required timeframe. The Administrator confirmed the absence of documented evidence of an investigation into the allegations and acknowledged that an investigative report was not completed or maintained by the facility. The facility's policy required that such incidents be investigated thoroughly, with interviews conducted and findings reviewed by the Quality Assurance committee, and results reported to the State Agency within five working days. However, these steps were not followed, and the Administrator, who was not present at the time of the incident, could not confirm the occurrence due to the lack of documentation.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to maintain the dignity of three residents requiring assistance with eating in the 200 unit dining room. A Certified Nursing Assistant (CNA) was observed standing over the residents while providing feeding assistance, which is contrary to the facility's expectations for maintaining resident dignity. The CNA assisted the residents by cutting up their food and feeding them without sitting down, which is not aligned with the facility's policy that staff should sit with residents during feeding assistance. Additionally, the CNA did not use alcohol-based hand sanitizer (ABHS) between assisting different residents, which is a breach of hygiene protocols. The CNA was unaware of the maximum number of residents they could assist at one time and had been assisting multiple residents simultaneously since their employment at the facility. The Assistant Director of Nursing (ADON) confirmed that CNAs receive training on feeding assistance during their certification and onboarding, which includes sitting with residents and sanitizing hands between assisting different residents. However, the facility's Feeding Assistance policy, last revised in 2004, did not specify the requirement for staff to sit or the maximum number of residents a staff member can assist at one time. The Resident Rights policy emphasized treating each resident with respect and dignity, which was not upheld in this instance.
Transport Safety and Resident Abuse Deficiencies
Penalty
Summary
The facility failed to ensure the safety of a resident during transport, resulting in a fall and subsequent injuries. Resident #11, who had multiple medical conditions including chronic obstructive pulmonary disease and Parkinson's disease, was not properly secured with a lap belt while being transported in the facility's bus. The wheelchair was strapped to the floor, but the absence of a lap belt allowed the resident to fall when the bus hit a curb. This incident led to injuries including a right tibial fracture and closed head trauma, which were confirmed after medical evaluation. Additionally, the facility did not protect two residents from verbal and physical abuse by another resident. Resident #12, who has cerebral palsy and violent behavior, was involved in an altercation with Resident #1, who has severe dementia and violent behavior. Resident #1 threatened and physically struck Resident #12, resulting in scratches on the forehead. Similarly, Resident #13, with a history of cerebral infarction and vascular dementia, was verbally abused and physically attacked by Resident #1, who struck Resident #13 with a closed fist. The facility's policy on abuse prohibition and reporting was not effectively implemented, as evidenced by the repeated incidents involving Resident #1. Despite the known behavioral issues, Resident #1 was able to engage in aggressive interactions with other residents, leading to physical harm. The facility's failure to adequately supervise and manage Resident #1's behavior contributed to the abuse incidents involving Residents #12 and #13.
Failure to Report Abuse Incidents to Ombudsman and State Agency
Penalty
Summary
The facility failed to ensure that reports of suspected abuse toward residents were submitted to the Ombudsman's office from January 2024 through April 2024 for 9 out of 19 Facility Reported Incidents (FRI) investigated. Additionally, the final FRI investigation was not submitted to the State Agency in a timely manner for 5 out of 19 FRIs. This deficiency could result in inquiries of abuse not being investigated properly, allowing potential abuse to occur without being reported to the necessary authorities. Specific incidents included verbal and physical altercations between residents, inappropriate touching, and aggressive behavior, none of which were reported to the Ombudsman's office as required. The facility's policy, titled Abuse Prohibition and Reporting, mandates that allegations of abuse be reported immediately to the State Agency and the Ombudsman, with a final report submitted within five working days. However, the facility did not adhere to this policy, as evidenced by the lack of documentation of reporting to the Ombudsman's office and late submissions to the State Agency. The Administrator confirmed that allegations of abuse had not been reported to the Ombudsman during the specified period, and final reports were submitted late, contrary to the facility's policy.
Failure to Investigate Abuse Allegations Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving a resident and the Director of Rehab (DOR). The incident was initially reported on 12/14/2023, when the resident expressed concerns about a staff member to the Director of Nursing (DON), who then informed the abuse coordinator. The DOR was informed of the allegations and was suspended pending an investigation. However, the DOR was not interviewed face-to-face or via phone, and the facility's investigation concluded that the allegations were unsubstantiated without comprehensive documentation or interviews with all involved parties. The facility's policy on Abuse Prohibition and Reporting, revised in July 2023, requires interviews with all involved parties or potential witnesses, including the suspect, the accuser, the resident, and any other staff or residents who may have witnessed the incident. Despite this policy, the facility lacked documentation of interviews or statements from the involved parties, including the DOR and the resident. The current Administrator, who was not employed at the time of the incident, confirmed the absence of additional documentation related to the investigation, indicating a failure to adhere to the facility's policy.
Failure to Update Care Plans After Incidents
Penalty
Summary
The facility failed to update care plans for multiple residents following incidents of resident-to-resident altercations and an allegation of employee-to-resident abuse. Specifically, the care plans for 11 residents were not updated after altercations, and one resident's care plan was not updated following an abuse allegation. These deficiencies were confirmed through interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Administrator, who acknowledged the lack of updates in the care plans. The residents involved had various diagnoses, including cerebral palsy, dementia, anxiety disorders, and other behavioral disturbances. Despite these conditions, the care plans did not reflect the necessary updates to address the incidents and ensure appropriate care and interventions. The facility's policy required care plans to be updated to reflect incidents and specific behaviors, but this was not adhered to in these cases. The Administrator and other staff members confirmed the expectation that care plans should be updated to include documentation of incidents and new approaches to prevent future occurrences. However, the facility's practice did not align with this expectation, as evidenced by the lack of documented updates in the care plans for the residents involved in the incidents.
Deficient RN Coverage and Absence of Full-Time DON
Penalty
Summary
The facility failed to ensure there was adequate Registered Nurse (RN) coverage and a full-time Director of Nursing (DON) as required. On one of the days reviewed, the facility did not provide eight consecutive hours of RN coverage. Specifically, RN1 worked for six hours and 19 minutes, and RN2 worked for six hours, leaving a gap in the required coverage. The facility's administrator confirmed that these were the only RNs on duty that day, thus failing to meet the staffing requirement. Additionally, the facility did not have a full-time DON. The position had been vacant since the previous DON resigned, and the facility had not filled the position. The administrator acknowledged the absence of a DON, which is a requirement for the facility.
Failure to Ensure Proper Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff in the kitchen and during meal service to residents. On April 30, 2024, a Certified Nursing Assistant (CNA1) entered the kitchen in Unit 200 without performing hand hygiene before retrieving food items from the refrigerator. CNA1 also donned gloves after dropping one on the floor without disposing of it, and proceeded to distribute drinks to residents. Additionally, CNA1 used gloves from their pocket to serve plated meals without performing hand hygiene. Another staff member, CNA2, provided feeding assistance to three residents without using alcohol-based hand sanitizer between assisting each resident, despite having received training on proper hand hygiene practices. The Dietary Manager confirmed that employees entering the kitchen were required to perform hand hygiene and wear gloves when handling non-prepackaged food items. The facility's policy on food service sanitation and safety required employees to wash their hands with soap and water before starting work in the kitchen and as often as necessary. The policy on meal service in dining rooms required staff to use hand sanitizer between serving each resident unless hands became soiled, in which case soap and water should be used. The Assistant Director of Nursing (ADON) also confirmed that CNAs should perform hand hygiene between residents during meal service.
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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