Horizon Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 660 Martin Luther King Blvd, Las Vegas, Nevada 89106
- CMS Provider Number
- 295017
- Inspections on file
- 21
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Horizon Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified failures in food storage and temperature control, including refrigerators holding food at temperatures above policy requirements and expired food items present in dry storage. The Kitchen Manager confirmed that staff had not consistently monitored temperatures or removed expired products, contrary to the facility's Food Services Plan.
Residents were denied access to the secured outdoor patio after evening hours due to facility-imposed restrictions following incidents of smoking by a few individuals. Despite requests from residents, including those without cognitive impairment, to use the patio during cooler evening times, staff confirmed the area was closed by 8 PM because of supervision and safety concerns, with no alternatives attempted. The facility lacked a written policy for these restrictions, and the practice conflicted with stated resident rights to self-determination and choice.
A resident with severe cognitive impairment and multiple diagnoses was not provided with information or documentation regarding advance directives. The facility did not identify a primary decision maker or develop a care plan for advance directives, and relied solely on a physician's order for full code status, which is not a valid substitute for an advance directive.
A resident with psychiatric diagnoses exhibited persistent yelling and disruptive behaviors, disturbing the sleep and comfort of nearby residents. Despite staff and leadership being aware of the ongoing issue and attempting interventions such as room changes and relocation, there was no documented communication with the psychiatric provider or effective resolution, resulting in a failure to maintain a peaceful, homelike environment as required by facility policy.
The facility did not coordinate assessments with the PASRR program and failed to refer a resident for necessary services, resulting in noncompliance with assessment and referral requirements.
A resident with a recent psychiatric hospitalization and new diagnosis of PTSD did not have a comprehensive care plan developed or implemented to address their updated mental health needs. The facility failed to conduct or document a PASRR Level 2 evaluation after the resident's acute change in condition, and the resulting recommendations for specialized services were not incorporated into the medical record or care planning process.
A resident with a history of respiratory failure and an ingrown toenail developed a blackened area on the right great toe after a podiatry procedure. Despite reporting the issue and associated pain to multiple staff, the concern was not promptly communicated to the wound care team as required by facility protocol. A CNA observed the impairment and informed an LPN, but the wound care team was not notified until later, and required documentation was not completed, resulting in delayed intervention.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the affected area.
A resident with an indwelling Foley catheter did not receive timely assessment or care as ordered, including weekly drainage bag changes and notification of a physician when foul-smelling, cloudy urine with sediment was observed. Staff failed to document the change in condition or follow facility policy for catheter care and communication.
A resident dependent on gastrostomy tube feeding did not consistently receive the full prescribed volume of enteral nutrition, and staff failed to monitor and document total intake as required. Despite physician orders and facility policy, the actual volume delivered was significantly less than ordered, and the MAR lacked consistent documentation. Interviews with the ADON, RD, and physician confirmed the deficiency in following and recording tube feeding orders.
A resident with insomnia, anxiety disorder, and major depressive disorder exhibited constant yelling and disruptive behaviors that were well-documented and known to staff, yet these behaviors were not communicated to the psychiatric provider, nor was a psychiatric consult or referral for bedside psychotherapy services initiated. Non-pharmacological interventions were attempted without success, and the lack of appropriate referrals resulted in ongoing disruption to other residents.
A resident with PTSD was prescribed Prazosin for night terrors, but staff did not monitor or document the target behaviors as required by facility policy. Both the ADON and DON confirmed that, despite the medication being used for a psychiatric diagnosis, there was no evidence of monitoring for effectiveness or adverse effects.
A medication pass resulted in a 9.68% error rate when an LPN administered Aspirin without a physician order, failed to give a prescribed Multivitamin, and gave Vistaril (hydroxyzine pamoate) at the wrong time to a resident with multiple diagnoses. These errors were confirmed by facility leadership and clinical consultants, and occurred despite clear facility policy on medication administration.
The facility did not have a comprehensive, facility-specific QAPI plan in place, instead relying on a general policy that lacked required elements such as processes for performance improvement and individualized guiding principles. The Administrator confirmed the absence of a tailored QAPI plan and acknowledged that the current policy did not meet regulatory requirements.
The facility failed to maintain a clean kitchen environment and proper refrigeration, risking foodborne illnesses. Observations revealed greasy and dusty equipment, improper fan use, and unsafe refrigerator temperatures. The kitchen manager acknowledged inadequate cleaning and reliance on incorrect temperature readings, leading to unsafe food storage.
A malfunctioning walk-in refrigerator in the facility was not maintained at a safe temperature, with internal readings between 54 to 58 degrees Fahrenheit. The kitchen manager failed to report the issue promptly, and food products remained at unsafe temperatures, risking foodborne illnesses. The Maintenance Director was unaware of the problem due to a lack of communication from the kitchen staff.
A resident on anticoagulants was not monitored for signs of bleeding as required. Despite receiving Heparin as prescribed, there was no documented evidence of monitoring for bleeding symptoms until a month later. The resident was later observed with minimal bleeding and bruising, which was confirmed by an LPN. Both the ADON and DON acknowledged the need for monitoring orders, which were not timely obtained, leading to this deficiency.
A resident at risk for pressure ulcers developed a stage 4 ulcer due to the facility's failure to perform and document regular skin assessments and repositioning. Despite a care plan requiring daily skin inspections and hourly repositioning, these actions were not documented for a significant period. Staff interviews confirmed lapses in expected care practices, contributing to the ulcer's development.
The facility failed to obtain and implement physician orders for splinting for two residents with contractures, despite recommendations from the rehabilitation department. One resident was observed with fingers digging into palms, and family members applied rolled towels, while another resident had a contracture with no splint in place. Delays in order transcription and lack of updated care plans contributed to the deficiency.
A facility failed to complete a nutritional assessment and obtain care orders for a resident with a PEG tube upon readmission. The resident, with anoxic brain injury and dysphagia, was observed with a non-infusing tube feeding and bloating. The necessary care orders for managing the PEG tube were not documented, and the staff did not follow the policy for obtaining physician orders for enteral feedings.
The facility did not post daily staffing information in an accessible location for residents and visitors. Staffing details were placed on small paper near nursing stations, difficult to read due to small font size, and lacked total Patient Per Day (PPD) hours. The Administrator acknowledged the requirement for more prominent and readable postings, including PPD information.
A facility failed to maintain a medication error rate below five percent, with two errors identified out of 30 opportunities. An LPN did not administer vitamin B12 and Refresh eye drops to a resident as ordered, incorrectly documenting a refusal without consulting the resident. The resident later confirmed they had not refused the medications and wished to receive them. The LPN also failed to notify the physician of the supposed refusal, contrary to facility policy.
Deficient Food Storage and Temperature Control in Kitchen and Dry Storage
Penalty
Summary
During a kitchen inspection, surveyors observed that the facility failed to maintain proper food storage and temperature control practices. One refrigerator used for storing tray line salads, ham, salami, and cheeses displayed a temperature of 42°F, but internal checks showed food items ranging from 45-50°F. A bag of shredded cheese was measured at 50°F and a packet of salami at 45°F. The temperature log for the month did not document any readings above 40°F, and the refrigerator lacked an internal thermometer for verification. The Kitchen Manager confirmed these findings. A second refrigerator used for beverages and dairy products also displayed a temperature of 42°F, but an internal thermometer measured 50°F, with a container of whole milk at 42°F. Ice was observed covering the condenser, and the Kitchen Manager acknowledged the need for defrosting. In the dry storage area, several expired food items were found, including sugar, oatmeal, white rice, and flour, with expiration dates ranging from July 2024 to February 2025. One container of brown rice did not have an expiration date documented. The Kitchen Manager stated that staff should have been regularly inspecting and labeling food items to ensure expired products were identified and removed in a timely manner. The facility's Food Services Plan required refrigerator temperatures to be maintained at 40°F, functional and calibrated thermometers, regular temperature monitoring, and removal of food items past their use-by date.
Failure to Support Resident Choice in Patio Access
Penalty
Summary
The facility failed to honor residents' rights to make choices about significant aspects of their lives, specifically regarding access to the outdoor patio area. Multiple residents, including one with no cognitive impairment and a history of paraplegia, cellulitis, and a puncture wound, reported that they were not allowed to use the secured patio after 7:00 or 7:30 PM during the summer, despite this being the most comfortable time to be outside. Residents expressed frustration that the restriction was due to a few individuals violating the no-smoking policy, resulting in all residents being denied access to the outdoor space after a certain hour. Interviews with the Administrator, Activity Director, and DON confirmed that the patio was closed by 8:00 PM due to lack of staff to supervise and concerns about residents smoking. None of the staff interviewed were aware of any alternatives being tried to allow non-smoking residents access to the patio after hours, and there was no written policy regarding the patio restrictions. The facility's own Resident Rights document states that residents have the right to make choices about their activities and schedules, but this was not upheld in practice.
Failure to Provide Advance Directive Information to Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide a resident with information regarding the right to formulate an advance directive. Upon admission, the resident, who had diagnoses including diffuse traumatic brain injury, bipolar disorder, anxiety disorder, and unspecified dementia, was identified as having severe cognitive impairment with a BIMS score of three. The facility did not have any documentation of advance directives, such as Power of Attorney paperwork, Guardian paperwork, or a POLST form, for this resident. The only documentation present was a physician's order indicating full code status, which the Director of Social Services acknowledged is not a valid advance directive. Interviews revealed that no discussion regarding advance directives took place with the resident due to their low cognitive status and lack of decisional capacity. The facility's policy requires that upon admission, the resident's decision-making capacity be determined, the primary decision maker identified, and existing choices reviewed with the resident or legal representative. However, this process was not followed, and no care plan was developed regarding advance directives for the resident, resulting in a failure to honor the resident's rights as outlined in facility policy.
Failure to Address Disruptive Resident Behaviors Affecting Homelike Environment
Penalty
Summary
The facility failed to address a resident's persistent yelling and disruptive behaviors, which deprived other residents of their right to a peaceful and homelike environment with comfortable noise levels. The resident in question had a history of insomnia, anxiety disorder, and major depressive disorder, and was documented by nursing staff to yell almost daily. Multiple residents and staff reported that the yelling occurred both day and night, disturbing sleep and causing distress to those nearby. Staff attempted interventions such as room changes and temporarily relocating the resident to other areas, but these measures did not resolve the issue. Despite the ongoing nature of the disruptive behaviors and their impact on other residents, there was no documented evidence that the behaviors were communicated to the psychiatric provider for further evaluation or intervention. Facility leadership, including the ADON, DON, and Administrator, were aware of the situation and acknowledged the negative effects on other residents, but no effective plan was documented or implemented to address the root cause of the behaviors. The facility's own policy stated that each resident had the right to a homelike atmosphere with comfortable noise levels, which was not maintained in this case.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements.
Failure to Develop and Implement Comprehensive Care Plan for PTSD Following PASRR Level 2 Determination
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with newly diagnosed post-traumatic stress disorder (PTSD) following a recent psychiatric hospitalization. The resident, who had a history of neurological and psychiatric conditions including hemiplegia, seizure disorder, anxiety, and bipolar disorder, experienced an acute exacerbation of mental health symptoms, including severe depression and suicidal ideation. After expressing suicidal thoughts and being placed on a legal hold, the resident was hospitalized and subsequently diagnosed with PTSD. Upon the resident's return to the facility, documentation showed that the baseline care plan referenced the need to implement PASRR recommendations for mental health needs. However, there was no evidence in the medical record that a comprehensive care plan specifically addressing PTSD was developed or implemented. Additionally, the facility did not conduct or document a PASRR Level 2 evaluation after the resident's acute change in condition, despite the previous PASRR Level 1 screening being outdated and no longer reflective of the resident's current mental health status. Further review revealed that a PASRR Level 2 determination had been completed by the hospital and indicated the need for specialized services, but this information was not incorporated into the resident's medical record or the most recent MDS assessment. The MDS Coordinator was unaware of the PASRR Level 2 process and confirmed that the new diagnoses and recommendations were not included in the care planning process, resulting in the absence of a comprehensive plan to address the resident's updated mental health needs.
Failure to Communicate New Skin Impairment to Wound Care Team
Penalty
Summary
A deficiency occurred when a new skin impairment on a resident's right great toe was not promptly communicated to the wound care team according to facility protocol. The resident, who had a history of acute and chronic respiratory failure and an ingrown nail, developed a blackened area on the toe after a podiatrist attempted but was unable to fully remove the ingrown nail due to pain. The resident reported the toe discoloration and pain to multiple staff members, but did not receive a response. A CNA noticed the blackened area and reported it to an LPN, but there was no evidence that the LPN communicated this to the wound care team. The CNA also did not complete the required 'Stop and Watch' form to document the change in condition. The wound care nurse and the assistant director of nursing confirmed that the facility's protocol required immediate reporting of new skin impairments to the wound care team for timely intervention. The delay in communication resulted in a delay in the wound care team being notified and in the initiation of appropriate interventions. Facility policy required daily skin checks by CNAs and weekly evaluations by licensed nurses, but these protocols were not followed, leading to a delay in addressing the resident's skin impairment.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Timely Catheter Care and Physician Notification
Penalty
Summary
The facility failed to provide appropriate care and timely assessment for a resident with an indwelling Foley catheter. The resident, who had diagnoses including neoplasm of the kidney, obstructive and reflux uropathy, and benign prostatic hyperplasia, had physician orders for weekly changes of the urinary drainage bag and as-needed catheter changes for obstruction or dislodgement. Observations revealed the resident had a Foley catheter and drainage bag in place with dark yellow, cloudy urine containing visible sediment and a foul odor. The resident reported the catheter and drainage bag had not been changed in over a month, and staff attributed moisture in the resident's diaper to leakage from the catheter insertion site. The LPN confirmed the presence of sediment, an old and discolored drainage bag, and cloudy, foul-smelling urine, but there was no evidence in the medical record that the catheter was assessed in a timely manner, the physician was notified of the foul-smelling urine, or that the change in condition was documented. Further review showed that although the treatment administration record indicated weekly catheter changes, these were not performed as ordered. The Assistant Director of Nursing and Director of Nursing both confirmed that staff were expected to follow physician orders, assess for changes in condition, and document findings, including using the SBAR process for communication. However, there was no documentation of leakage, symptoms of urinary tract infection, or physician notification. Facility policy required monitoring and documentation of urine characteristics and prompt notification of abnormal findings, but these procedures were not followed for this resident.
Failure to Follow and Document Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that enteral feeding orders for a resident with a gastrostomy tube were followed as prescribed, and that the total volume delivered was consistently monitored and documented. The resident, who was entirely dependent on tube feeding due to dysphagia and had diagnoses including risk for malnutrition, diabetes mellitus, and dementia, had a physician order for Nepro 1.8 at 35 mL/hour for 15 hours daily, totaling 525 mL per day. Observations revealed that the tube feeding was not always flowing as ordered, and the total volume delivered over a 30-day period was 1,927 mL less than prescribed. The Medication Administration Record (MAR) lacked consistent documentation of the total tube feeding volume administered. Interviews with nursing staff, the Assistant Director of Nursing, the Registered Dietitian, and the physician confirmed that the ordered volume was not fully administered and that monitoring and documentation were insufficient. The Registered Dietitian noted that the resident's tube feeding met only 88.9% of daily caloric needs and 72.8% of protein needs, and that requests to nursing staff to document total volume delivered had not been implemented. Facility policy required daily monitoring and documentation of enteral nutrition intake, but this was not consistently followed for the resident in question.
Failure to Communicate Behavioral Health Needs and Refer for Psychotherapy Services
Penalty
Summary
The facility failed to ensure that a resident with a history of insomnia, anxiety disorder, and major depressive disorder received necessary behavioral health care and services. The resident was observed and reported by staff and other residents to be yelling constantly, both day and night, which disrupted the sleep and well-being of nearby residents. Nursing staff documented these behaviors almost daily, and multiple staff members, including LPNs and the ADON, were aware of the ongoing disruptive behaviors. Despite this, there was no documented evidence that these behaviors were communicated to the psychiatric provider, nor was a psychiatric consult requested to address the resident's behavioral health needs. Interviews with staff revealed that non-pharmacological interventions, such as room changes and separating the resident from others, were attempted but proved ineffective. The psychiatric nurse practitioner confirmed only seeing the resident once for an unrelated issue and was not informed of the ongoing disruptive behaviors. The DON acknowledged awareness of the behaviors and their negative impact on other residents but admitted that no one had thought to refer the resident for a psychiatric consult, which could have allowed for further evaluation and intervention. Additionally, the facility failed to refer the resident for bedside psychotherapy services through their contracted Behavioral Health Services provider. The process required identification by the interdisciplinary team (IDT) and a referral for Medicaid approval, but the resident was neither identified nor referred, despite being classified as a Tier one resident due to disruptive behaviors. The facility's own policy required documentation of provided or attempted behavioral health services, but the medical record lacked evidence of such referrals or services for this resident.
Failure to Monitor Target Behaviors for Medication Used to Treat PTSD
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not monitoring target behaviors for a medication prescribed to treat Post Traumatic Stress Disorder (PTSD). The resident, who had a history of chronic respiratory failure with hypercapnia and PTSD, was prescribed Prazosin to address night terrors associated with PTSD. Although the physician’s order specified that the medication was for night terrors, there was no documented evidence in the resident’s medical record that these target behaviors were being monitored as required. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that Prazosin, while not classified as a psychotropic medication, was being used off-label for a psychiatric diagnosis and should have been monitored for effectiveness and adverse effects. Both the ADON and DON acknowledged that the resident’s night terrors, the target behavior for the medication, were not being tracked. The facility’s policy required monitoring and documentation of residents’ responses to psychotropic medications, including symptoms, behaviors, and side effects, but this was not followed in this case.
Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication pass, resulting in a calculated error rate of 9.68% based on 31 observed opportunities and three identified errors. During the medication administration, an LPN gave a resident Aspirin 81 mg without a physician order, did not administer the prescribed Multivitamin 18 mg with iron and folic acid, and administered Vistaril (hydroxyzine pamoate) 25 mg at the incorrect time, contrary to the physician's specific instructions. The LPN acknowledged mistaking the Aspirin bottle for the Multivitamin and confirmed the errors in medication administration and timing. The resident involved had diagnoses including hemiplegia, major depressive disorder, and generalized anxiety disorder, and was under a care plan that included monitoring for complications related to blood thinning medications. The errors were confirmed by the LPN, the Assistant Director of Nursing, the Pharmacist Consultant, and the Nurse Practitioner, all of whom verified that the medications were not administered as ordered. Facility policy required staff to follow the eight medication rights, including administering the right drug at the right time, which was not adhered to in this instance.
Failure to Develop and Implement a Facility-Specific QAPI Plan
Penalty
Summary
The facility failed to ensure that a Quality Assurance Performance Improvement (QAPI) plan was in place, as required by regulations. During an interview, the Administrator acknowledged that there was no specific QAPI plan, and that the facility was relying on its QAPI policy as a substitute. Document review revealed that the existing policy, titled 'Quality Assurance and Performance Improvement Program Committee Guidelines' and last revised in 2019, did not include the necessary elements for a QAPI plan, such as processes for guiding performance improvement efforts, tracking and measuring performance, or identifying and correcting quality deficiencies. Further, the Administrator confirmed that the QAPI plan should be individualized to the facility, including vision, mission, and purpose statements, as well as guiding principles tailored to the specific units, programs, departments, and population served. The lack of a comprehensive and facility-specific QAPI plan was acknowledged by the Administrator, and it was noted that the current policy did not meet the requirements outlined in the state operations manual.
Deficient Food Safety Practices in Kitchen and Refrigeration
Penalty
Summary
The facility failed to maintain a clean food preparation environment and ensure proper refrigeration of food products, potentially exposing residents to foodborne illnesses. During an inspection, it was observed that the kitchen's exhaust hood and oven were greasy and dusty, with food debris on the floor behind cooking equipment. The preparation area floor was soiled, and a fan was improperly used, blowing air onto food. Additionally, the air conditioning vents were dusty and corroded. The kitchen manager admitted that the cleaning schedule was inadequate and acknowledged the improper use of fans. The walk-in refrigerator's temperature was not maintained within the safe range, with internal thermometers reading significantly higher than the required 34 to 40 degrees Fahrenheit. Despite the external thermometer showing a lower temperature, the internal readings indicated unsafe conditions for food storage. The kitchen manager confirmed the discrepancy and noted that staff relied on the external thermometer for documentation. Food items, including dairy products and frozen goods, were found at unsafe temperatures, leading to their disposal. The facility's policy required maintaining the refrigerator's ambient temperature between 34 and 40 degrees Fahrenheit, which was not adhered to.
Refrigerator Malfunction Leads to Unsafe Food Storage
Penalty
Summary
The facility failed to maintain a walk-in refrigerator in proper working condition, resulting in unsafe temperature levels for stored food products. On multiple occasions, the internal thermometers of the refrigerator indicated temperatures significantly above the safe range, with readings of 54 to 58 degrees Fahrenheit. Despite the external thermometer showing a lower temperature, the internal readings were consistently high, indicating a malfunction. The kitchen manager acknowledged the issue but did not immediately relocate the food products to a safer environment, which could have prevented the exposure of residents to foodborne illnesses. The kitchen manager failed to report the malfunctioning refrigerator to the maintenance department promptly. The Maintenance Director confirmed that no report was received regarding the refrigerator issue on the dates in question. Additionally, the facility's Engineering Repair Request form lacked documentation of any concerns reported by the kitchen staff about the refrigerator. The last preventive maintenance check, conducted a day before the issue was observed, did not identify any problems, suggesting a lack of immediate follow-up or communication regarding the malfunction.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to monitor the signs and symptoms of bleeding for a resident on anticoagulants, which was identified as a deficiency. Resident 2, who was admitted with diagnoses including anoxic brain damage and iron deficiency anemia, was prescribed Heparin Solution to be administered subcutaneously every 12 hours for deep vein prophylaxis. Although the medication was administered as ordered, the medical records lacked documented evidence of monitoring for signs and symptoms of bleeding until a month after the prescription was given. On observation, the resident was found to have minimal bleeding and bruising in the lower abdomen, which was confirmed by an LPN. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both acknowledged that residents on anticoagulant medications should be monitored for signs of bleeding, and an order for such monitoring should have been in place. The facility's policy on anticoagulation monitoring emphasized individualized management to reduce harm, but the necessary monitoring orders were not obtained and transcribed in a timely manner, leading to this oversight.
Failure to Prevent Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate care to prevent a stage 4 pressure ulcer in one resident, who was at risk due to conditions such as paraplegia and muscle wasting. The resident was admitted with a Braden Scale score indicating a risk for pressure ulcers, and the care plan included daily skin inspections and repositioning every hour. However, the facility did not document any skin evaluations from late January until the end of February, when the ulcer was identified. Additionally, the record showed that repositioning was not documented for two weeks prior to the ulcer's discovery. Interviews with staff revealed that CNAs were expected to check skin daily and report changes, while nurses were to perform weekly skin checks. The Wound Care Nurse confirmed that the ulcer was unstageable when first identified and later classified as stage 4. The DON acknowledged that the Point of Care system failed to display repositioning options after mid-February, but staff should have continued the practice regardless. The lack of documented skin assessments and repositioning contributed to the development of the pressure ulcer, which was deemed avoidable if the processes had been followed.
Failure to Implement Physician Orders for Splinting
Penalty
Summary
The facility failed to ensure that a physician order for splint application was obtained and implemented for two residents with contractures. Resident 2 was admitted with contractures of the hands and atrophy, and despite a care plan indicating the need for palm protector splints or hand rolls, there was no documented evidence of a physician order for these interventions. Observations revealed that Resident 2 was in bed with fingers digging into the palms, and family members were applying rolled towels to the hands. The Director of Rehabilitation Services and the lead Restorative Nursing Assistant acknowledged the delay in obtaining and transcribing the necessary orders, which was attributed to challenges in processing paperwork in a timely manner. Resident 77, who was admitted with hemiplegia, hemiparesis, and a right-hand contracture, also did not have a splint in place despite recommendations for rehabilitation services and a right-hand splint. The Director of Rehabilitation Services confirmed that the implementation of the splinting was delayed, and the Assistant Director of Nursing acknowledged the lack of an updated care plan and the delay in order transcription. Observations showed that Resident 77 was in bed with a contracture on the right arm and a closed fist, and the resident reported not having received rehabilitation services. The facility's policies on joint mobility and restorative nursing emphasized the importance of implementing a restorative program through the care plan to maintain or improve joint mobility. However, the failure to obtain and implement physician orders for splinting as recommended by the rehabilitation department led to deficiencies in the care provided to the residents. The Director of Nursing highlighted the need for better communication among staff to ensure the prompt implementation of splinting to prevent further contracture or injury.
Failure to Complete Nutritional Assessment and Obtain Care Orders for PEG Tube
Penalty
Summary
The facility failed to complete a nutritional assessment for a resident with a percutaneous endoscopic gastrostomy (PEG) tube upon readmission, as required by policy. The resident, who had anoxic brain injury and dysphagia, was readmitted with a PEG tube for feeding. Observations revealed that the tube feeding was not infusing, and the nutritional assessment was outdated from the resident's previous stay. The Licensed Practical Nurse and Assistant Director of Nursing confirmed that the assessment should have been completed by the Registered Dietitian upon readmission, but it was not done until several days later. Additionally, the facility did not obtain and transcribe care orders to manage the resident's PEG tube upon readmission. The resident's medical records lacked documentation of care orders such as verification of PEG tube placement, elevating the head of the bed, and monitoring for complications. The Wound Care Certified Nurse and Director of Nursing indicated that these orders should have been obtained and implemented by the assigned licensed nurses. The resident was observed to be bloated, and the family expressed concerns about the resident's condition. The facility's policy required physician orders for all enteral feedings and monitoring for complications. However, the necessary care orders were not in place, and the staff did not follow the policy to ensure proper management of the resident's PEG tube. This oversight could potentially compromise the resident's safety and well-being, as the care orders were essential for managing the resident's nutritional needs and preventing complications.
Failure to Post Accessible Daily Staffing Information
Penalty
Summary
The facility failed to post daily staffing information in a location accessible to residents and visitors, as required. During a tour of the facility, it was observed that the staffing information, including licensed nurses and Certified Nurse Assistant assignments, was posted on small-sized paper near the nursing stations. The postings were affixed to the corridor wall at a height of four to five feet above the floor, with text in approximately size-14 font, making it difficult to read unless viewed up close. Additionally, the staffing documents did not include the total Patient Per Day (PPD) hours information. The Director of Nursing confirmed that this was the customary practice for daily staffing postings. The Administrator acknowledged the requirement for the staffing information to be posted in a prominent place, such as the front lobby, and in a larger font for ease of review, including the PPD information.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two errors identified out of 30 opportunities, resulting in an error rate of 6.67%. The deficiency involved a resident who was admitted with diagnoses including muscle weakness and spasms. On a specific date, an LPN prepared the resident's medications but failed to administer vitamin B12 tablets and Refresh eye drops as ordered by the physician. The Medication Administration Record inaccurately documented that the resident refused these medications. Upon further investigation, the resident confirmed that they had not refused the medications and expressed a desire to receive them, particularly the eye drops for eye dryness. The LPN admitted to missing the administration of the medications and incorrectly documenting the refusal without consulting the resident. Additionally, the LPN did not notify the physician of the supposed refusal, as required by the facility's policy. The Director of Nursing confirmed that staff are expected to accurately document medication administration, missed doses, or actual refusals.
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Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
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