Oasis Nursing & Rehab Of Green Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Henderson, Nevada.
- Location
- 100 Delmar Gardens Drive, Henderson, Nevada 89074
- CMS Provider Number
- 295041
- Inspections on file
- 20
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Oasis Nursing & Rehab Of Green Valley during CMS and state inspections, most recent first.
The facility did not enforce or document its Legionella Water Management Program as required, with no evidence of regular monitoring or review prior to being notified of possible Legionella contamination. Two residents with complex respiratory and cardiac conditions tested positive for Legionella after being transferred to acute care, and the facility could not provide documentation of required water system inspections or control measures before the incident. The water management plan was found to be adequate but had not been periodically reviewed or tailored to the facility, and documentation of compliance only began after external notification.
A resident with intact cognition reported being inappropriately touched on the chest by another resident, who later admitted to the act. The incident was not immediately reported to staff, and the facility's investigation substantiated the abuse. Both residents had behavioral care plans addressing prior concerns, but the event was not prevented or promptly identified, resulting in a deficiency for failure to protect residents from abuse.
A resident with a kidney transplant was given Cialis tablets instead of the prescribed Tacrolimus capsules for several days due to a pharmacy mislabeling error. LPNs administered the medication based on the mislabeled bubble pack without recognizing the form discrepancy, and the error was only discovered after multiple doses when a nurse questioned the medication's appearance. The DON and Consultant Pharmacist confirmed the mislabeling and the failure to identify the error during medication administration.
A facility failed to monitor and document behaviors and side effects for residents on psychoactive medications, affecting six residents with conditions like dementia and psychosis. The issue arose during a transition to a new EHR system, where necessary orders did not migrate, leading to inconsistent documentation. Nurses were instructed to use progress notes instead of the MAR, but this resulted in inadequate monitoring, as acknowledged by the Clinical Care Coordinator.
The facility restricted residents from accessing the front porch area without a chaperone, despite no elopement risk and intact cognition for some. Residents were redirected to a courtyard gazebo, which is also a smoking area, causing dissatisfaction. The facility lacked a policy for this restriction, conflicting with residents' rights to self-determination.
A resident with chronic vision and hearing loss was inaccurately assessed, leading to inadequate care in a LTC facility. Despite being clinically blind and hard of hearing, the resident's MDS assessments documented adequate vision and hearing, resulting in insufficient meal assistance. The LPN and DON confirmed the inaccuracies, and the family reported a lack of accommodations for the resident's health status changes, contributing to weight loss and hospitalization.
The facility failed to conduct PASRR Level 2 evaluations for three residents with psychiatric diagnoses and behavioral issues. One resident exhibited combative behavior and delusions, another showed exit-seeking and inappropriate interactions, and a third displayed delusional behavior. The facility lacked a PASRR policy, and the Social Services Director was unaware of the requirement for PASRR Level 2 evaluations for residents with psychiatric diagnoses.
Two residents using CPAP and BiPAP machines lacked comprehensive care plans in a facility. One resident had no documented care plan for their CPAP machine, while the other had a care plan without interventions for their BiPAP machine. The DON confirmed the absence of necessary care plans and interventions, which are required for individualized care.
A high-risk resident developed a deep tissue injury (DTI) on the left heel due to the facility's failure to implement necessary interventions and conduct regular skin assessments. Despite a care plan outlining preventive measures, the DTI went untreated for weeks, with staff unaware of the condition until the resident complained of pain. The facility's policies for skin monitoring and pressure ulcer care were not followed, leading to a lack of documentation and communication among staff.
A facility failed to provide necessary meal assistance to a blind resident, resulting in significant weight loss and hospitalization. Despite the resident's need for one-on-one feeding assistance due to blindness, this requirement was not communicated or documented, leading to inadequate care. The interdisciplinary team did not address the need for feeding assistance, and the resident's family was not involved in care planning, contributing to the resident's decline and eventual hospitalization for dehydration.
A facility failed to obtain physician orders for a resident's PEG tube care, including bolus feeding and water flushes. The resident, with a history of dementia and dysphagia, was observed with an outdated Glucerna bottle and lacked documented orders for tube care. The LPN and CCC confirmed the absence of necessary orders, despite the resident consuming more than 75% of meals. The facility had transitioned to a new EHR system, but the required orders were not ensured.
A resident with a urinary tract infection had a PICC line inserted for antibiotic therapy, but the facility failed to document care orders for site monitoring, flushes, and dressing changes. The last antibiotic dose was given without follow-up on the stop date or PICC line maintenance. Observations showed improper management, with a gauze pad covering the insertion site, preventing monitoring. The DON confirmed the absence of care orders, and the NP was unaware of the situation, highlighting a risk of infection due to inadequate PICC line care.
The facility failed to obtain physician orders for oxygen administration and monitoring for a resident with respiratory conditions, and for the use of a CPAP machine for another resident. The first resident received oxygen without documented orders or saturation monitoring, while the second resident used a CPAP machine without a physician's order or care plan. Staff confirmed the necessity of these orders to ensure proper respiratory care.
The facility failed to complete annual performance appraisals for four CNAs, risking substandard care. Employees hired between 2021 and 2022 lacked evaluations for multiple years. The HR Coordinator confirmed the absence, and the DON cited miscommunication with a former SDC as a reason. The Administrator was unaware of the issue, despite the appraisal form's importance for feedback and quality care.
The facility failed to ensure proper food storage and handling, with unlabeled and expired items found in storage, and improper meal service practices observed. A refrigerator was also operating above the recommended temperature, posing potential risks to resident safety.
Failure to Enforce Legionella Water Management Program and Document Required Activities
Penalty
Summary
The facility failed to enforce its Legionella Water Management Program (LWMP) as required by its own policy. The LWMP included a checklist of inspection items, frequencies, and documentation requirements, but there was little to no evidence that these activities were performed or recorded prior to notification from the local health department. The Maintenance Director confirmed that while some activities may have been conducted, there was no documentation to support ongoing compliance with the LWMP until after the facility was alerted to possible Legionella contamination. The LWMP itself was found to be adequate for the facility type, but it had not been periodically reviewed, and some of its documentation was not specific to the facility. The deficiency came to light during a complaint investigation after two residents who had been admitted with complex respiratory and cardiac conditions tested positive for Legionella following their transfer to acute care facilities. One resident experienced a significant drop in oxygen saturation and required emergency transfer, while the other was treated for a persistent cough and tested positive for Legionella antigen. The source of the Legionella could not be conclusively determined, but the facility's lack of documented implementation of its water management plan was evident. Interviews with facility leadership, including the Administrator, Maintenance Director, and DON, revealed that the LWMP had not been reviewed or updated except in response to the notification of possible Legionella cases. Water testing and mitigation activities were only documented after the facility was informed of the potential contamination. Prior to this, there was no evidence of regular monitoring, system flushing, or other control measures as outlined in the LWMP.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident reported that another resident had touched their chest under their shirt without permission. The incident was reported to the Director of Social Services and the Administrator, and the accused resident admitted to the inappropriate contact. The facility's investigation substantiated the allegation of abuse. Prior to the incident, the resident who committed the abuse had a behavioral care plan addressing inappropriate sexual comments, while the resident who reported the abuse had a care plan for making false accusations and having physical altercations. The incident was not immediately reported to staff, as the affected resident only disclosed it to a relative, who also did not inform the facility. Skin assessments conducted during the relevant period noted a rash on the upper left chest of the affected resident, but no complaints of pain or discomfort were documented. The facility's policy requires maintaining an environment free from abuse, neglect, and exploitation. The failure to promptly identify and address the abuse, as well as the delay in reporting, contributed to the deficiency cited in the report.
Medication Administration Error Due to Pharmacy Mislabeling
Penalty
Summary
A resident with end stage renal disease and a history of kidney transplant was admitted and had a physician's order for Tacrolimus 0.5 mg capsule, an anti-rejection medication. However, due to a pharmacy error, a medication bubble pack containing Cialis 5 mg tablets was mislabeled as Tacrolimus and dispensed with the resident's name. Over a period of six days, the resident was administered Cialis instead of the prescribed Tacrolimus. The medical record did not show any order for Cialis for this resident. Licensed Practical Nurses confirmed administering the mislabeled medication, relying on the label and the five rights of medication administration, but failed to notice the discrepancy between the ordered capsule form and the tablet form present in the bubble pack. The error was only identified after several doses when another nurse questioned the form of the medication. The Director of Nursing and Consultant Pharmacist acknowledged the pharmacy's mislabeling and the failure of nursing staff to detect the error before administration, despite facility policies requiring verification of medication form and label against physician orders.
Deficient Monitoring of Psychoactive Medications
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of residents' behaviors and side effects for those receiving psychoactive medications. This deficiency was identified for six residents, each with various diagnoses such as dementia, depression, anxiety, and psychosis. The facility's policy required monitoring for significant negative changes from baseline and ruling out medications as the cause of these changes. However, the medical records for these residents lacked documented evidence of orders to monitor target behaviors and side effects related to the use of psychoactive medications. The deficiency was partly attributed to the facility's transition from one electronic health record (EHR) system to another. During this transition, the necessary orders for monitoring behaviors and side effects did not migrate successfully to the new system. As a result, licensed nurses were instructed to document observations in the progress notes rather than the medication administration record (MAR), leading to inconsistent monitoring and documentation practices. The Clinical Care Coordinator acknowledged the issue and took responsibility for auditing and ensuring the necessary orders were in place. The lack of consistent documentation and monitoring of psychoactive medication side effects was further complicated by the facility's reliance on paper MARs and progress notes during the EHR transition. Nurses were not keen on charting into paper MARs, and the facility was still pending training for entering order sets into the new EHR. This situation resulted in a lack of monitoring documentation essential for the physician and pharmacist during resident drug reviews, as highlighted by the facility's policies on medication monitoring and management.
Facility Restricts Resident Access to Front Porch
Penalty
Summary
The facility failed to honor the residents' right to self-determination by not allowing them to make choices about significant aspects of their lives, specifically regarding their ability to sit outside on the front porch area. This deficiency was observed in one sampled resident and three unsampled residents. Despite having no elopement risk, these residents were restricted from accessing the front porch area without a chaperone, which was not a documented policy of the facility. The residents expressed dissatisfaction with this restriction, comparing the facility to a prison due to the lack of freedom to sit outside without supervision. The report highlights that the facility is located near a minor street with a large, covered portico and a wrap-around porch area with park benches for residents to enjoy. However, residents were instructed to use the gazebo area in the courtyard, which is also the designated smoking area, instead of the front porch. This restriction was enforced by the receptionist, who would redirect residents to the courtyard unless a staff or family member was available to accompany them. The facility's administrator and social services director justified this practice by citing protective oversight and safety concerns, despite the residents' cognitive abilities and low elopement risk. The facility lacked a formal policy requiring residents to have a chaperone to access the front porch area, and the residents' rights document in the admissions packet emphasized their right to self-determination and a dignified existence. The residents' inability to make independent choices about their outdoor activities, despite their cognitive status and elopement assessments, was a significant oversight in respecting their rights and preferences, leading to potential psychosocial distress.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for a resident, specifically regarding vision, hearing, and functional status impacting activities of daily living. The resident, who was admitted with chronic vision and hearing loss, Parkinson's disease, and weakness, was observed struggling with meal assistance due to these impairments. Despite being clinically blind and hard of hearing, the resident's meal ticket did not indicate the need for assistance, and the staff was not informed of the resident's requirements for one-on-one feeding assistance. The resident's Minimum Data Set (MDS) assessments inaccurately documented adequate vision and hearing, and only required setup or cleanup assistance with eating. However, the resident was clinically blind and required full assistance with meals. The Licensed Practical Nurse (LPN) assigned to the resident confirmed these inaccuracies, noting that the resident had been blind and hard of hearing for some time and was dependent on staff for activities of daily living since the death of their spouse. The MDS Coordinator, responsible for the assessments, admitted to not being aware of the resident's true condition and acknowledged the oversight in the assessments. The Director of Nursing (DON) and a family member corroborated the resident's condition, confirming the resident's blindness and hearing difficulties. The family member expressed concerns about the facility's failure to accommodate the resident's health status changes, which contributed to a significant weight loss and hospitalization. The report highlights the importance of accurate assessments to ensure appropriate care plans and assistance levels for residents.
Failure to Complete PASRR Level 2 Evaluations for Residents with Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation for three residents who displayed behavioral activity or had a psychiatric diagnosis. Resident 99 was admitted with diagnoses including psychosis and bipolar disorder, but the PASRR Level 1 used for admission did not reflect these diagnoses. Observations and nursing progress notes documented Resident 99's combative and aggressive behavior, refusal of medications, and episodes of delusions and confusion, indicating a need for a PASRR Level 2 evaluation. Resident 135 was admitted with diagnoses including bipolar disorder and schizophrenia, but the PASRR Level 1 used for admission only documented dementia and Alzheimer's. The resident exhibited behaviors such as exit-seeking and inappropriate interactions with other residents. The Director of Social Services was unaware that a PASRR Level 2 was required for residents with psychiatric diagnoses and behavioral issues, and the facility lacked a PASRR policy. Resident 72 was readmitted with multiple psychiatric diagnoses, including schizophrenia and dementia with psychotic disturbance. Despite displaying delusional behavior and expressing concerns about an impersonator, there was no documented evidence of a PASRR Level 2 screening. The Social Services Director acknowledged that the PASRR Level 2 process should have been initiated. The facility's policy stated that new or changed behaviors indicating a serious mental disorder should be referred for a PASRR Level 2 evaluation, but this was not done for Resident 72.
Deficiency in Comprehensive Care Plans for Sleep Apnea Devices
Penalty
Summary
The facility failed to ensure comprehensive care plans were created for the management of sleep apnea devices for two residents. Resident 64, who was admitted with diagnoses including an open wound on the lower back and hemiplegia after a cerebral infarction, used a CPAP machine at night to aid breathing. However, there was no documented evidence in the physician and nursing progress notes that the resident was using the CPAP machine, nor was there a comprehensive care plan for its use, care, and maintenance. Similarly, Resident 390, admitted with obstructive sleep apnea and amyotrophic lateral sclerosis, used a BiPAP machine at night. Although the care plan documented the medical diagnosis and the use of the BiPAP machine, it lacked any care interventions, leaving the space allotted for them blank. The Director of Nursing confirmed the absence of care interventions in Resident 390's care plan and the lack of a care plan for Resident 64's CPAP machine, acknowledging that care plans are required to ensure individualized care provisions.
Failure to Provide Adequate Pressure Ulcer Care for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care for a high-risk resident, identified as R52, who developed a deep tissue injury (DTI) on the left heel. R52 was admitted with multiple diagnoses, including diabetes mellitus and dysphagia, and was assessed as high risk for pressure sores with a Braden Scale score of 10. Despite the care plan outlining necessary interventions such as turning, repositioning, and using pressure-reducing devices, these measures were not consistently implemented. The resident's medical records lacked evidence of regular skin assessments and appropriate treatment for the DTI. On a specific date, R52 complained of heel pain, and an LPN confirmed the presence of a DTI, which appeared to be several weeks old. The wound care treatment nurse noted that the injury had not been previously addressed, and the necessary offloading techniques were not applied. The CNA responsible for R52's care reported observing skin discoloration weeks earlier but did not ensure the information was properly documented or acted upon. The facility's policy required skin assessments twice a week, but records showed only one assessment was completed in September. The facility's failure to adhere to its policies and procedures for skin monitoring and pressure ulcer care resulted in the DTI going untreated for an extended period. The lack of documentation and communication among staff members contributed to the oversight, as the LPN and clinical care coordinator were unaware of the resident's condition until it was too late. This deficiency highlights a breakdown in the facility's processes for identifying and managing pressure injuries in high-risk residents.
Failure to Assist Blind Resident with Meals Leads to Weight Loss and Hospitalization
Penalty
Summary
The facility failed to provide adequate assistance with food and fluids to a resident who was clinically blind, leading to significant weight loss and hospitalization. The resident, who had chronic vision and hearing loss, was observed with an untouched breakfast tray and expressed the need for help with meals due to blindness. Despite the resident's condition, the meal ticket did not reflect the need for full assistance, and the CNA assigned was not informed of the requirement for one-on-one feeding assistance. The interdisciplinary team had discussed the resident's weight loss and added supplements to the diet, but the need for feeding assistance was not addressed. The resident's medical records inaccurately documented adequate vision and hearing, which contributed to the lack of appropriate care. The speech therapy evaluation recommended feeding assistance due to the risk of aspiration and malnutrition, but this was not communicated to the team or reflected in the resident's care plan. The Director of Nursing acknowledged the oversight and confirmed that the resident's significant weight loss was not adequately addressed. The dietary team failed to communicate the resident's needs during weekly meetings, and the resident's family was not involved in care plan discussions. The resident was eventually sent to the hospital for dehydration and weakness, highlighting the facility's failure to provide necessary assistance and hydration.
Failure to Obtain Physician Orders for PEG Tube Care
Penalty
Summary
The facility failed to ensure that physician orders for bolus tube feeding, water flushes, and gastrostomy tube care were obtained for a resident with a PEG tube. The resident, who was admitted with diagnoses including dementia, diabetes mellitus, urinary tract infection, dysphagia, and gastrostomy, was observed with an unopened Glucerna tube feeding bottle labeled with an outdated date. The resident's medical records lacked documented evidence of physician orders for bolus feeding, water flushing, placement verification, and PEG tube site care or monitoring. The LPN and Clinical Care Coordinator confirmed that the bolus feeding was intended only if the resident's meal intake was less than 75%, and the resident was on a soft mechanical diet, consuming more than 75% of meals. However, the necessary physician orders for administering the bolus feeding and managing the PEG tube were not obtained. The facility had transitioned to a new electronic health record system, and the Clinical Care Coordinator was responsible for ensuring the necessary orders were in place, but this was not done. The facility's policy required checking the tube's position before each feeding and medication administration, which was not adhered to in this case.
Deficient PICC Line Management in Resident Care
Penalty
Summary
The facility failed to ensure proper care and management of a peripherally inserted central catheter (PICC) line for a resident, leading to a risk of infection. The resident was admitted with a urinary tract infection and had a PICC line inserted for antibiotic therapy. However, the medical record lacked documented evidence of care orders for the PICC line, such as site monitoring, flushes, and dressing changes, since its insertion. The last dose of the prescribed antibiotic was administered, but there was no follow-up with the physician regarding the stop date for the antibiotic therapy or instructions on whether to maintain or discontinue the PICC line. Observations revealed that the PICC line was not properly managed, with a gauze pad covering the insertion site, which should not have been there, as it prevented nurses from monitoring the site every shift. The Director of Nursing confirmed the absence of care orders and acknowledged that the lack of routine PICC line care placed the resident at risk for another infection. The Nurse Practitioner was unaware of the absence of care orders and indicated that they had not been contacted by the facility regarding the resident's antibiotic therapy, which could have led to further testing and appropriate management of the PICC line.
Failure to Obtain Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to obtain physician orders for the administration and monitoring of oxygen (O2) for Resident 155, who was admitted with diagnoses including pneumonia, respiratory tuberculosis, and dependence on supplemental O2. Observations revealed that Resident 155 was receiving O2 at 5 liters per minute via nasal cannula without documented physician orders or O2 saturation monitoring. A Licensed Practical Nurse confirmed the absence of necessary orders and monitoring, and the Clinical Care Coordinator acknowledged the requirement for such orders to prevent potential risks associated with improper O2 administration. Additionally, the facility did not secure a physician's order for the use of a CPAP machine for Resident 64, who was admitted with conditions including an open wound and hemiplegia after cerebral infarction. Resident 64 self-managed the CPAP machine brought from home, but there was no documented evidence of a physician's order or care plan for its use. The Director of Nursing confirmed that a physician's order was necessary for CPAP use, which would generate a care and maintenance order set in the electronic healthcare records.
Failure to Complete Annual Performance Appraisals for CNAs
Penalty
Summary
The facility failed to complete annual performance appraisals for four certified nursing assistants (CNAs), identified as Employees 6, 7, 9, and 10, which placed residents at risk for receiving substandard quality of care. Employee 6, hired in June 2022, and Employee 7, hired in July 2022, did not have performance evaluations for 2023 and 2024. Employee 9, hired in August 2021, lacked evaluations for 2022, 2023, and 2024, while Employee 10, hired in November 2021, was missing evaluations for 2022 and 2023. The Human Resources (HR) Coordinator confirmed the absence of these evaluations and explained the process involved the Director of Nursing (DON) completing the forms, which were then to be returned to HR. The DON acknowledged responsibility for completing the appraisals, a task previously shared with a former Staff Development Coordinator (SDC). The DON indicated that the forms might not have been completed due to an assumption that the other party had done so. The Administrator was unaware of the missing appraisals and emphasized their importance for discussing areas of improvement and ensuring quality care. The facility's appraisal form, dated 2007, highlighted the significance of these evaluations as feedback tools, with a process in place for managers to gather information and discuss performance with staff prior to filing the completed forms.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, which posed a potential risk to resident safety and health standards. Observations revealed that scrambled egg patties in the walk-in cooler were not labeled or dated, and corn muffin mixes in the dry storage area had expired. Additionally, previously baked pies and scooped ice cream in the freezer were unlabeled and undated. These lapses in labeling and dating could lead to contamination and inadequate storage of food items. During meal service, an uncovered plate of food was mistakenly served to a resident with the incorrect food texture. The plate was returned to the steam table and later served to another resident, contrary to safe food handling practices. The unit one refrigerator was also found to be operating at temperatures above the recommended range, potentially compromising the safety of stored items such as milk, juice, yogurt, and salads. These deficiencies highlight the facility's failure to adhere to professional standards for food storage and handling.
Latest citations in Nevada
Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
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