Mountain View Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carson City, Nevada.
- Location
- 201 Koontz Lane, Carson City, Nevada 89701
- CMS Provider Number
- 295079
- Inspections on file
- 27
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Mountain View Health & Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to provide adequate supervision and follow elopement procedures when an unsecured window was discovered on a secured memory care unit. A resident with schizophrenia and documented elopement risk, whose care plan included safety on a secured unit and monitoring for exit-seeking, was last seen near the nurses’ station early in the morning. When a restorative aide reported that plywood covering a previously broken window was missing, an LPN assumed another exit-seeking resident had removed it and did not conduct a head count, despite facility guidance requiring an immediate count when an open door or window was found. The resident was later found to be missing during breakfast, leading to a delayed recognition of the elopement and delayed activation of the facility’s elopement response.
A resident on anticoagulation therapy experienced a fall with head injury and was not promptly reported to the on-call provider by the night shift RN. The resident was later found to have significant bruising and cognitive changes, prompting the day shift LPN to contact the NP, who arranged for hospital evaluation. Facility documentation and interviews confirmed delayed provider notification and lack of a clear policy for such events.
A newly hired CNA began work without documented completion of required elder abuse prevention training, contrary to facility policy mandating such training during initial orientation and before floor assignment. The Administrator confirmed the lapse in timely training for this staff member.
A resident with dementia and a known history of wandering, who was care planned for a secured unit, was able to leave the facility unsupervised and was later found re-entering through the main entrance. Facility policy required staff accompaniment for such residents outside the secured area, but the resident was unaccounted for by staff for over 30 minutes, indicating a lapse in supervision and safety measures.
The facility failed to protect residents from physical abuse, resulting in harm to two residents. One resident with severe cognitive impairment was repeatedly involved in altercations, sustaining lacerations requiring staples. Another resident sustained a facial fracture after being attacked by a resident with a history of aggressive behavior and medication refusal. The facility's inadequate management of these behaviors and delayed interventions contributed to these incidents.
The facility failed to secure a medication cart, properly label a multi-dose vial, and remove outdated medications. An unlocked medication cart was found unattended with a resident nearby, and a multi-dose vial lacked the required date and initials. Outdated medications were discovered on several carts and in a storage room, contrary to facility policies.
A LTC facility reported a medication error rate of 53.85%, with errors including late administration and incorrect dosages. An LPN administered medications beyond the allowed time window, and a resident self-administered medication without proper authorization. The facility lacked a clear policy on medication errors.
A resident's right to self-determination was violated when a CNA, unaware of the resident's preference not to be disturbed at night, attempted to turn the resident, resulting in bruising. The resident, with conditions like arthritis and COPD, had a care plan indicating they should not be awakened for rounds. The facility's policy on resident rights was not upheld, leading to an investigation.
A resident with anxiety and insomnia was disturbed by loud staff during the night shift, despite being moved away from the nurses' station. Multiple grievances about noise were documented, but the facility had not conducted a root cause analysis to address the issue effectively.
A facility failed to ensure the accuracy of an MDS assessment for a resident with low back pain, leading to potential issues in their care plan. The MDS assessment inaccurately documented multiple falls, while progress notes only recorded one fall. The MDS Coordinator confirmed the assessment's inaccuracy.
A resident with spinal stenosis and chronic pain syndrome did not receive showers as per their preference and care plan in an LTC facility. Despite the care plan documenting showers twice a week, the resident only received them once a week due to time constraints and prioritization of other residents. The DNS acknowledged the lack of adherence to the facility's standard practice for showering.
The facility failed to conduct weekly evaluations of a resident's surgical wounds, report significant cognitive decline and infection signs to a physician, and adhere to blood sugar monitoring orders for residents with diabetes. These deficiencies involved a resident with chronic surgical wounds, another with a significant drop in mental status, and a third with diabetes whose blood sugar levels were not consistently checked as ordered.
A resident with chronic respiratory conditions was receiving oxygen at an incorrect flow rate of three LPM instead of the physician-ordered two LPM. This discrepancy was observed during a survey, and both an LPN and the DNS confirmed the error, which did not align with the facility's policy requiring adherence to physician orders for oxygen administration.
A facility failed to identify triggers for a resident with PTSD, risking re-traumatization. The resident's care plan lacked specific triggers and tailored interventions, and the LPN could not specify where baseline behaviors were documented. The DNS admitted to not knowing the resident's PTSD triggers, despite the facility's policy on trauma-informed care.
The facility failed to protect resident-identifiable information and maintain accurate medical records. Unattended computer screens on medication carts displayed resident information, confirmed by an LPN and RN. Additionally, a resident's medical record inaccurately documented no signs of infection for an elbow abrasion, despite evidence of cellulitis and antibiotic treatment. The DNS confirmed the presence of a wound, and facility policy required accurate documentation.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage three pressure ulcer, as required by a physician's order. Observations showed missing EBP signage, and staff interviews revealed confusion about EBP protocols. The CNA and LPN did not follow EBP guidelines, and the Director of Nursing Services and Infection Preventionist confirmed the oversight.
A resident with chronic conditions did not receive an influenza vaccine despite guardian consent, due to an oversight by the facility. The resident's clinical record lacked documentation of vaccine administration, which was confirmed by the Infection Preventionist.
The facility failed to prevent resident-to-resident abuse for seven residents and employee-to-resident neglect for one resident. Incidents included physical altercations between residents and a delayed medical response to a resident's fall, highlighting lapses in care and reporting procedures.
A resident with a history of traumatic brain injury and epilepsy was found on the floor with the mattress from the bed. Despite a care plan requiring fall mats, these were not in place, leading to the resident being sent to the hospital where leg fractures were discovered. Staff mistakenly placed the fall mats by the resident's roommate's bed.
A resident with multiple diagnoses, including dementia and repeated falls, experienced a delay in medical attention after a fall because a Hospitality Aide and CNA did not report the incident to a Licensed Nurse. The resident was later found to have a fractured left hip and required hospitalization.
Failure to Verify Resident Presence After Discovery of Unsecured Window on Secured Unit
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention on a secured memory care unit when staff did not verify that all residents were present after discovering an unsecured window. A resident with paranoid schizophrenia and unspecified psychosis, identified through multiple elopement risk evaluations as an elopement risk due to schizophrenia and wandering behaviors, had care plan interventions that included ensuring safety on a secured unit and monitoring exit-seeking behaviors such as pushing on exit doors. On the morning of the incident, a restorative nurse aide notified an LPN that the plywood covering a previously broken window on the secured unit was missing. The LPN, who had last seen the resident near the nurses’ station at approximately 6:00 AM, assumed the plywood had been removed by another resident known for breaking windows and exit-seeking, and did not initiate a head count or otherwise confirm that all residents on the unit were present. Later that morning during breakfast, staff noticed the resident was not present in the dining room and began searching for the resident on the unit and then in the surrounding area after the resident could not be located. The administrator confirmed that when staff discovered the missing plywood and unsecured window between 7:00 AM and 8:00 AM, they notified the administrator and confirmed only that the resident assigned to that room was present, but did not complete a full resident count on the secured unit. The facility’s elopement policy defined elopement as a resident exiting the facility or entering an unsafe area without staff knowledge and required care plan interventions based on elopement risk evaluations. An additional facility document on elopement risk directed staff to ensure all doors and windows in the memory care unit were locked and secured and to complete an immediate head count for the entire facility if any potential elopement risk, such as an open door or window, was identified. Staff’s failure to follow these procedures resulted in delayed identification of the resident’s elopement and delayed implementation of the facility’s elopement response procedures.
Failure to Notify Provider After Resident Fall with Injury
Penalty
Summary
The facility failed to notify the on-call medical provider after a resident experienced a fall with injury, resulting in bruising to the forehead. The resident, who had a history of traumatic subdural hemorrhage, atrial fibrillation, congestive heart failure, and was on anticoagulation therapy, was found on the floor with purple lumps on the forehead and a small skin tear on the left wrist. The RN on duty performed an assessment, provided basic wound care, and notified the Executive Director, Resident Care Manager, Nurse Practitioner (NP), and Guardian, but did not contact the on-call medical provider at the time of the incident. The resident was monitored, and pain medication was administered. Later, during the day shift, an LPN noticed additional bruising and changes in the resident's cognition and reached out to the NP, who then assessed the resident and decided to send the resident to the emergency department for further evaluation due to the high risk associated with anticoagulation. Review of facility documentation and interviews confirmed that the NP was not notified of the fall and injury until the day shift, several hours after the incident. The facility lacked a clear policy for physician notification related to change of condition, and the relevant fall management policy did not specify provider notification requirements.
Failure to Complete Timely Elder Abuse Prevention Training for New CNA
Penalty
Summary
The facility failed to ensure that initial elder abuse prevention training was completed in a timely manner for one newly hired Certified Nursing Assistant. Personnel records showed that this staff member, hired on 11/01/2025, did not have documented evidence of completing elder abuse prevention training upon hire. According to the facility's policy, all staff, including contract staff and volunteers, are required to receive training on abuse prevention, reporting, and intervention upon hire, annually, and as needed. The Administrator confirmed that abuse training should be completed during the first orientation and that staff are not permitted to work on the floor prior to completing this training. However, the record review and Administrator interview confirmed that this requirement was not met for the identified employee.
Failure to Prevent Elopement of Resident with Dementia
Penalty
Summary
A resident with a history of dementia, memory deficit, and wandering behaviors was identified as being at significant risk for elopement, as documented in their Elopement Risk Evaluation and care plan. The care plan specified that the resident required a secured unit due to impaired safety awareness and a tendency to wander. Despite these documented risks and interventions, the resident was able to leave the secured unit and exit the facility without staff knowledge. The incident was discovered when the resident was observed re-entering the facility through the main entrance from outside, after being unaccounted for by staff for approximately 35 minutes. The facility's policy required that residents at risk for elopement residing in a locked unit be accompanied by staff when outside the facility. The Executive Director confirmed the elopement and was unable to determine how the resident exited the secured area, indicating a failure to provide adequate supervision and maintain a hazard-free environment as required by facility policy.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in harm to two residents. Resident #72, who had severe cognitive impairment and was at risk for altercations due to dementia, was involved in multiple incidents of resident-to-resident abuse. On one occasion, Resident #72 was hit by another resident, resulting in lacerations requiring staples. The facility's care plan for Resident #72 included interventions to redirect the resident away from others, but these measures were insufficient to prevent the incidents. Resident #240, who had a history of aggressive behavior and refused medications, was involved in several altercations with other residents, including hitting Resident #72. Despite being identified as having potential for physical aggression, the facility did not effectively manage Resident #240's behavior, leading to repeated incidents of abuse. The facility's system for reviewing behavioral documentation was inadequate, delaying necessary interventions such as 1:1 supervision. Another incident involved Resident #104, who sustained a facial fracture after being attacked by Resident #140. Both residents had cognitive impairments and behavioral disturbances. Resident #140 had a history of refusing medications and exhibiting aggressive behavior. The altercation was initially unwitnessed, but staff intervened upon hearing the commotion. The facility's failure to manage Resident #140's behavior and ensure the safety of Resident #104 resulted in significant physical harm and subsequent regressive behaviors in Resident #104.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications, as evidenced by several observations and interviews. An unattended medication cart was found unlocked in the 100 hall, with a resident standing next to it, posing a risk of unauthorized access to medications. The Director of Nursing Services (DNS) confirmed that medication carts should be secure when not in use, and the facility policy mandates that only licensed nurses and authorized personnel should have access to medication carts, which should remain locked when unattended. Additionally, a multi-dose vial of Tubersol was found in a medication storage room without the date opened or the initials of the first person to use it, contrary to the facility's policy requiring such documentation. Furthermore, outdated medications were discovered on multiple medication carts and in a medication storage room, including Albuterol inhalers, Tramadol tablets, Diclofenac Gel, and other medications with expired discard dates. The DNS confirmed that medications should be removed from stock on or before their expiration or discard after dates, as per the facility's policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, with a reported error rate of 53.85%. This was determined through observations, interviews, clinical record reviews, and document reviews. The errors involved multiple residents and included administering medications at incorrect times and incorrect dosages. Specifically, medications scheduled for 7:00 AM were administered late, beyond the one-hour window allowed by the facility's policy. One resident was administered medications at 8:15 AM, including Vitamin D, Loratadine, Fish Oil, Multivitamin, Fluticasone, Thiamine, and Lisinopril, all of which were scheduled for 7:00 AM. Another resident self-administered Fluticasone nasal spray without a physician's order or safety evaluation, resulting in an incorrect dosage. A third resident received Baclofen, Sertraline, Docusate Sodium, Gabapentin, and Quetiapine at 8:34 AM, all scheduled for 7:00 AM. Lastly, a fourth resident was given two tablets of Cyanocobalamin instead of one, as per the physician's order. The Director of Nursing Services (DNS) confirmed the expectation that medications should be administered within one hour of the scheduled time and that residents could self-administer medications only with a physician's order and safety evaluation. The facility lacked a policy defining medication errors, and the Executive Director acknowledged that errors included wrong time and dose administration. The LPN involved admitted to running behind schedule during the morning medication pass, contributing to the late administration of medications.
Failure to Respect Resident's Self-Determination
Penalty
Summary
The facility failed to respect a resident's right to self-determination by not informing a new Certified Nursing Assistant (CNA) of the resident's preference not to be disturbed for care during the night. This oversight led to an incident where the CNA attempted to turn the resident despite the resident's request to stop, resulting in bruising on the resident's thigh. The resident, who had been admitted with conditions including arthritis, hypertension, and chronic obstructive pulmonary disease, had a care plan specifying that they should not be awakened for rounds and would use the call light if assistance was needed. The incident was reported to the State Agency as a Facility Reported Incident, and the resident alleged rough care by the CNA, who was identified by the resident. The Executive Director confirmed that the CNA was not informed of the resident's wishes, which contributed to the incident. The facility's policy on resident rights emphasizes the right to a dignified existence and self-determination, which was not upheld in this case. The incident was under investigation, and the Executive Director acknowledged the failure to communicate the resident's preferences to the CNA.
Facility Fails to Maintain Quiet Environment During Night Shift
Penalty
Summary
The facility failed to ensure a comfortable, homelike environment for a resident who reported being disturbed by loud and disruptive staff during the night shift. The resident, who had a history of generalized anxiety disorder and insomnia, expressed concerns about being woken up by staff talking loudly in the hallways about personal matters and other residents' care. Despite being moved to a different room away from the nurses' station, the noise level did not improve, leading to frustration and sleep disturbances for the resident. The facility's grievance log documented multiple complaints from the resident council about night shift staff being loud in the hallways, with grievances confirmed and marked as resolved on several occasions. The Executive Director acknowledged the issue of excessive noise at night as a known and consistent problem in the facility. Although grievances were reviewed during clinical meetings and staff were re-educated on appropriate noise levels, the facility had not conducted a root cause analysis to address the issue effectively.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for one resident, which had the potential to affect the resident's person-centered care plan. The resident was admitted with a primary diagnosis of low back pain and had a quarterly MDS assessment that inaccurately documented multiple falls. The assessment indicated two falls with no injury, one fall with injury, and two falls with major injury since the last assessment. However, the resident's progress notes only documented one fall with no injury. The MDS Coordinator, who used the Resident Assessment Instrument (RAI) Manual to guide MDS activities, confirmed the inaccuracy of the assessment, acknowledging that the resident had only one fall with no injury, contrary to what was recorded in the MDS assessment.
Failure to Provide Showers as Per Resident Preference
Penalty
Summary
The facility failed to provide showers for a resident, identified as Resident #108, as per their preference and the facility's standard practice. Resident #108, who was admitted with conditions such as spinal stenosis, chronic pain syndrome, and difficulty in walking, expressed that they did not receive showers or bed baths as expected. The resident's care plan documented a requirement for showers twice a week, but the resident preferred showers three times a week. Despite this preference, the resident only received showers once a week and did not refuse showers when offered. Interviews with facility staff, including a CNA/Shower Aid and the Director of Nursing Services (DNS), revealed that the resident was not showered as per the documented schedule due to time constraints and prioritization of residents with skin issues. The DNS acknowledged that all residents should receive showers twice a week and according to their preferences, but there was no facility policy followed related to showering. The facility's standard of practice was not provided by the DNS, indicating a lack of adherence to established procedures for activities of daily living, including showering.
Deficiencies in Wound Care, Condition Reporting, and Blood Sugar Monitoring
Penalty
Summary
The facility failed to conduct weekly evaluations of a resident's significant surgical wounds, as required by their policy. Resident #67, who was admitted with a diagnosis of an unspecified open wound of the abdominal wall, had a care plan that included weekly wound evaluations. However, the clinical record lacked evidence of these evaluations. The Director of Nursing Services (DNS) confirmed that the facility's practice did not align with their policy, as weekly evaluations were not conducted for surgical wounds, including those of Resident #67. The facility also failed to report a significant change in a resident's condition to a physician in a timely manner. Resident #36 experienced a decline in their Brief Interview for Mental Status (BIMS) score from 12 to 4, indicating a significant cognitive decline. Despite this change, the Social Worker did not perform a repeat BIMS evaluation or notify the physician, as required by the facility's protocol. Additionally, Resident #62 exhibited signs of infection, such as a low-grade fever and a red, swollen elbow, which were not reported to the physician until several days later, contrary to the facility's policy on reporting changes in condition. Furthermore, the facility did not adhere to a physician's order for blood sugar monitoring for Resident #52. The resident, who had type two diabetes mellitus, had an order for blood sugar checks four times daily. However, the Medication Administration Record (MAR) showed that blood sugar readings were marked as 'Not Applicable' for several scheduled times, indicating that the checks were not performed. The DNS confirmed that this was not in compliance with the physician's order, as the blood sugar levels were not monitored as required.
Oxygen Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen to a resident according to the physician's order, which was a deficiency observed during a survey. The resident, who was admitted with diagnoses including unspecified bacterial pneumonia, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease with acute exacerbation, was receiving oxygen via nasal cannula. The physician's order specified that the resident should receive oxygen at two liters per minute (LPM) to maintain oxygen saturation levels above 90%. However, during observations on two separate occasions, the resident's oxygen concentrator was set at three LPM, contrary to the physician's order. The Licensed Practical Nurse (LPN) confirmed that the oxygen concentrator was set incorrectly and adjusted it to the correct flow rate of two LPM. The Director of Nursing Services (DNS) also confirmed that the nursing staff is expected to follow the physician's orders when administering oxygen, which includes adhering to the specified liter flow. The facility's policy on oxygen administration, published in December 2017, also mandates that oxygen be administered per physician order. This failure to follow the physician's order for oxygen administration was identified as a deficiency during the survey.
Failure to Identify PTSD Triggers for Resident
Penalty
Summary
The facility failed to identify triggers for a resident diagnosed with post-traumatic stress disorder (PTSD), which placed the resident at risk for re-traumatization. The resident, who was admitted with diagnoses including PTSD and chronic paranoid schizophrenia, had a care plan that documented the risk of trauma or re-traumatization. However, the care plan did not specify the resident's triggers or provide interventions tailored to the resident's experiences or preferences. The Licensed Practical Nurse (LPN) was unable to articulate where the resident's baseline behaviors were documented, indicating a lack of clear documentation and communication regarding the resident's specific needs. The Director of Nursing Services (DNS) acknowledged that the interdisciplinary team was responsible for identifying triggers for residents with PTSD and incorporating them into the care plan. However, the DNS admitted to not knowing what might trigger the resident's PTSD or what the PTSD was related to. The facility's policy on Trauma-Informed Care emphasized the importance of accounting for residents' experiences and preferences to prevent re-traumatization, yet this was not reflected in the care plan for the resident in question.
Privacy Breach and Inaccurate Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain accurate medical records, as observed during a survey. On multiple occasions, computer screens on unattended medication carts in the 100 hall displayed resident information. This was confirmed by both a Licensed Practical Nurse (LPN) and a Registered Nurse (RN), who acknowledged that the screens should have been locked when not attended. The Director of Nursing Services (DNS) also confirmed that medication carts and computer screens should be secure when not in use. Additionally, a resident was observed standing next to an unattended medication cart with the computer displaying resident information, indicating a breach of privacy. The facility also failed to maintain accurate medical records for a resident with Alzheimer's disease and type two diabetes mellitus. The resident's Treatment Administration Record (TAR) inaccurately documented no signs of infection for an abrasion on the left elbow, despite the LPN recalling that the resident had completed antibiotics for cellulitis at the site. The LPN confirmed that the TAR was inaccurate as it did not reflect the swelling and redness noted on 10/30/2024, which led to the prescription of antibiotics. The DNS confirmed the presence of a wound on the resident's left elbow, and the facility's policy required significant abrasions to be evaluated weekly and documented, which was not accurately done in this case.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic pressure ulcers, leading to a deficiency in infection prevention and control. Resident #60, who was admitted with diagnoses including type two diabetes mellitus with hyperglycemia and a stage three pressure ulcer on the right heel, had a physician's order for EBP every shift for wounds. However, observations on multiple occasions revealed that EBP signage was not posted at the entrance of the resident's room, indicating a lack of adherence to the prescribed precautions. Interviews with staff members, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), highlighted a lack of understanding and implementation of EBP. The CNA was unsure of the specific personal protective equipment required under EBP and did not perform any special precautions when caring for Resident #60. The LPN, although aware of the EBP order, did not wear the necessary personal protective equipment during wound care, mistakenly believing the resident was not on EBP. The Director of Nursing Services and the Infection Preventionist confirmed the expectation for staff to follow EBP orders and acknowledged the oversight in posting the required signage.
Failure to Administer Influenza Vaccine After Consent
Penalty
Summary
The facility failed to administer an influenza vaccine to a resident, despite having received consent from the resident's guardian. The resident, who was admitted with chronic obstructive pulmonary disease, type II diabetes mellitus, and adult failure to thrive, had a signed consent form dated 10/29/2024, indicating the guardian's approval for the influenza vaccine. The facility's policy required annual influenza vaccination for residents, and the guardian was provided with the necessary vaccine information and education. However, the clinical record for the resident did not show any evidence of the vaccine being administered. The Infection Preventionist confirmed that the vaccine was not given, acknowledging that it should have been administered on the day consent was obtained. This oversight left the resident without the intended protection against influenza, as documented in the facility's updated policy.
Failure to Prevent Resident Abuse and Neglect
Penalty
Summary
The facility failed to prevent resident-to-resident abuse for seven residents and employee-to-resident neglect for one resident. Resident #13 experienced an unwitnessed fall resulting in a fractured left hip, which was not reported or assessed by nursing staff until two days later. The Hospitality Aide and CNA who found Resident #13 on the floor did not report the incident, believing the resident had placed themselves on the floor to pray, as was their behavior. This lack of reporting and assessment led to a delay in medical attention for Resident #13, who was eventually hospitalized for the injury. Resident #14 pushed Resident #15, causing them to fall to the floor, and later hit Resident #22 on the arm twice. Resident #16 hit Resident #17 after Resident #17 grabbed the back of Resident #16's wheelchair, and Resident #17 retaliated by hitting Resident #16 in the back. Resident #18 hit Resident #19 on the cheek and mouth with a closed fist during an activity. Resident #20 swatted Resident #21's hand away and threw a coffee cup at Resident #21's chest. Resident #28 attempted to take Resident #16's food tray, leading Resident #16 to push Resident #28, causing a fall and a small abrasion. The facility's policies on resident fall response and abuse prevention were not followed in these incidents. The policies required that residents who have fallen should not be moved and should be assessed by a licensed nurse, and that residents have the right to be free from abuse. The failure to adhere to these policies resulted in multiple instances of resident-to-resident abuse and neglect, highlighting significant lapses in the facility's care and reporting procedures.
Failure to Implement Post-Fall Interventions
Penalty
Summary
The facility failed to ensure post-fall interventions were implemented and followed for a resident identified as a high fall risk. The resident, who had a history of traumatic brain injury, epilepsy, and other significant medical conditions, was found on the floor with the mattress from the bed. Despite being assessed and showing no apparent injury initially, the resident was later sent to the hospital where leg fractures were discovered. The care plan for the resident included fall mats on each side of the bed, but these were not in place during a subsequent observation, indicating a failure to follow the prescribed fall precautions. The Licensed Practical Nurse (LPN) and the Administrator both confirmed that the resident was supposed to have fall mats as a precautionary measure. However, the mats were mistakenly placed by the resident's roommate's bed instead. This oversight was acknowledged by the Nurse Supervisor, who explained that staff had read the care plan for the wrong resident. The facility's policy on Resident Fall Response, which mandates proper interventions and regular checks to ensure these interventions are in place, was not adhered to in this case.
Failure to Report and Assess Resident Fall
Penalty
Summary
The facility failed to ensure a Licensed Nurse provided care for a resident after a fall. A Hospitality Aide and a Certified Nursing Assistant (CNA) did not notify a Licensed Nurse of the resident's fall, which resulted in the resident not being assessed or given medical attention until two days later. The resident, who had multiple diagnoses including unspecified dementia and repeated falls, was found on the floor by the Hospitality Aide and was assisted back into bed by the CNA without reporting the incident to a nurse. This led to a delay in the resident receiving an x-ray and subsequent hospitalization for a fractured left hip. The facility's policy required that residents who have fallen should not be moved and must be assessed by a Licensed Nurse, regardless of visible injuries. The Administrator confirmed that the Hospitality Aide and CNA did not follow this policy and acted outside their scope of practice. The incident was documented in a Facility Reported Incident (FRI) final report, and the staff involved were later educated on the proper procedures for handling falls.
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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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