Pershing General Hospital Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Lovelock, Nevada.
- Location
- 855 6th Street, Lovelock, Nevada 89419
- CMS Provider Number
- 295000
- Inspections on file
- 24
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pershing General Hospital Snf during CMS and state inspections, most recent first.
Two residents had inaccurate MDS 3.0 assessments: one was incorrectly documented as receiving an antidepressant, despite no current order or administration, and another was recorded as using a floor mat alarm, though no such device was ordered or present. The DON confirmed both MDS entries were incorrect.
A resident with dementia and foot drop was observed multiple times with heel boots applied without a physician's order and not correctly positioned, as the boots were unfastened and the heels were not aligned with the pressure redistribution opening. Nursing staff and the DON confirmed the lack of an order and improper application, despite facility policy requiring both an order and correct use of such equipment.
A newly hired RN did not complete required behavioral health care training within the facility's specified timeframe. Personnel records lacked documentation of the training, and both HR and administration confirmed the oversight, despite facility policy mandating completion within 40 hours of hire.
A facility failed to create a care plan for a resident with bilateral lower extremity edema, despite a physician's order for compression stockings to manage swelling associated with bilateral primary osteoarthritis of the knee. The resident's clinical record lacked documentation of a care plan, and the DON confirmed this oversight, which was contrary to the facility's policy requiring individualized care plans.
The facility failed to revise care plans for a resident receiving psychotropic medication and two residents at risk of falls. One resident's care plan did not include physician-identified behaviors necessary for medication administration. Another resident's care plan lacked new interventions after a fall, despite suggestions from the IDT. A third resident experienced multiple falls, and the care plan was not updated with effective interventions. These deficiencies highlight the facility's failure to ensure comprehensive care plans and appropriate interventions.
Two residents with a history of falls and cognitive impairments did not receive appropriate fall prevention interventions. One resident's care plan was not updated with recommended grip strips, and a Morse scale evaluation was not completed. Another resident experienced multiple falls without effective interventions being added to the care plan, despite therapy staff deeming a proposed intervention inappropriate. The facility did not adhere to its fall prevention policy, which requires care plan updates and post-fall evaluations.
The facility failed to complete timely annual performance evaluations for three CNAs. An Activity Director/CNA and two CNAs did not have their evaluations documented for 2024, despite the facility's policy requiring annual evaluations by the anniversary date of hire. The Human Resources Director confirmed the oversight.
A resident did not receive prescribed Restasis Ophthalmic Emulsion due to unavailability in the facility, despite multiple requests to the pharmacy. The facility lacked a documented procedure for the safe procurement of medications, as confirmed by the DON and Administrator.
A facility failed to ensure behaviors monitored were associated with specific conditions indicated by physicians for psychotropic medication use. A resident with major depressive disorder and vascular dementia was prescribed Seroquel and Cymbalta, but behavior monitoring was not personalized to the medication. Additionally, five other residents had psychotropic medications without specific conditions documented for use. The facility's policy required daily monitoring of resident-specific behaviors, but this was not followed, leading to the deficiency.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate. An RN omitted Metoprolol during a medication pass for a resident with heart failure, due to nervousness while being observed. The error was corrected after verification of the medication cup contents.
A resident with heart failure did not receive their prescribed Metoprolol Tartrate during a medication pass due to an RN's omission. The RN, who was nervous about being observed, failed to include the medication in the cup before administration. The facility's policy requires medications to be administered as per physician's orders, and omissions are considered errors.
The facility failed to document psychotropic behavior monitoring for six residents and inaccurately recorded medication administration for another resident. Behavioral Health Records had blank spaces for required monitoring, and a resident's MAR incorrectly showed administration of unavailable eye drops. The DON confirmed these documentation errors.
The facility failed to provide the Restorative Nursing Program (RNP) to 13 residents in need of restorative nursing services due to staffing changes and lack of documentation. The program was inactive from January to April 2024, affecting residents' baseline physical abilities.
The Administrator failed to maintain a Restorative Nursing Program (RNP) due to staffing changes, and the Abuse Committee did not properly investigate abuse allegations by misapplying the definition of abuse. The RNP was inactive from January to April 2024, and an abuse incident was unsubstantiated despite the employee admitting responsibility.
The facility failed to ensure that 10 out of 20 sampled staff members received mandatory QAPI training. The personnel records of various employees, including the DON, Registered Dietitian, CNAs, RN, LPN, Dietary Aides/Cooks, and Housekeeper, lacked documented evidence of completed QAPI training. The Administrator and Risk Manager acknowledged the issue and confirmed that the training had not been part of the onboarding process but would be included moving forward.
The facility failed to recognize and address verbal and physical abuse towards a non-verbal, quadriplegic resident by a CNA. Additionally, the Director of Nursing lacked the knowledge and skills to manage the Restorative Nursing Program, resulting in a lack of restorative care for residents over several months.
The facility failed to protect a resident's right to dignity and respect by updating a care plan to include sexual behaviors without evidence or assessment. This occurred after staff observed physical and verbal abuse by a CNA toward a cognitively impaired, non-verbal resident. The resident's guardian and other staff members questioned the validity of the claim, given the resident's limited mobility and non-verbal status.
A resident with limited mobility and non-verbal status was allegedly slapped by a CNA after the resident brushed the CNA's breast. The incident was witnessed and reported by the Food Services Supervisor, but the facility's investigation was unsubstantiated, citing a lack of negative psychosocial outcomes and no physical signs of injury. The facility did not take disciplinary action against the CNA.
The facility failed to implement its abuse policies regarding identification, investigation, protection, and reporting for an allegation of verbal and physical abuse toward a non-verbal, quadriplegic resident by a CNA. The incident was witnessed and reported, but the facility did not take appropriate disciplinary action, and the incident was unsubstantiated due to a lack of physical injury.
The facility failed to obtain informed consent from a resident's Guardian before placing an air mattress on a bariatric bed. The resident, who was quadriplegic, had no care plan addressing the air mattress, and there was no documented evidence of risk assessment or explanation of risks and benefits to the Guardian. The DON confirmed the air mattress was considered a restraint, and the facility's policy on restraints was not followed.
A resident with dementia fell in the dining area, struck their head, lost consciousness, and was transferred to the ER. Despite facility policies requiring such incidents to be reported to the State Agency (SA), the Administrator and Director of Nursing (DON) failed to report the fall, believing it did not meet the criteria for serious bodily injury.
The facility failed to notify the State LTC Ombudsman of a resident's discharge. The resident, with type II diabetes and COPD, was transferred to the hospital due to slurred speech and altered mental status and was discharged the next day. The MDS RN confirmed the notification was not submitted as required by facility policy.
The facility failed to ensure the accuracy of MDS assessments for three residents. One resident's MDS inaccurately documented an indwelling catheter, another's MDS incorrectly noted the use of an antipsychotic and bed rails as restraints, and a third's MDS misclassified an antiplatelet medication as an anticoagulant. These errors were confirmed by the MDS Coordinator.
The facility failed to follow physician's orders for insulin therapy for two residents with type II diabetes mellitus. Despite administering the correct insulin dosages, there was no documented evidence that the physician was notified when blood sugar levels exceeded 400, as required by the orders.
The facility failed to assess an air mattress for entrapment and restraint for a resident with multiple conditions, including quadriplegia and dementia. The necessary assessments, consents, and care plan were not completed, and the risks and benefits were not reviewed with the resident's guardian.
The facility failed to ensure proper care and documentation for a resident with an indwelling catheter. The resident did not have physician orders for ongoing catheter care, nor was there a care plan developed and implemented. Staff interviews revealed that catheter care tasks were not communicated effectively, leading to a lack of documented catheter care.
The facility failed to properly handle and store medications, including not discarding a multidose vial past its use-by date, not disposing of a resident's medication after discharge, and not consistently logging refrigerator temperatures.
The facility failed to assist a resident with cerebellar stroke syndrome in obtaining dental services after experiencing bleeding gums. Despite a care plan and physician's order, no dental appointment was made following the resident's reported oral pain and bleeding gums. The facility did not follow up adequately after the Guardian did not respond to the initial contact attempt.
A resident with lactose intolerance received meals containing cheese due to inaccurate diet documentation. The facility's diet type report did not include the resident's milk allergy, leading to inappropriate meal service.
The facility failed to complete a discharge MDS assessment for a resident and did not document catheter care for another resident, resulting in incomplete clinical records and documentation.
The facility failed to ensure timely infection control training for an MDS Coordinator, who had not completed the required annual training for 2024. The HR Generalist confirmed the lapse, despite the facility's policy mandating yearly infection control education for all permanent nursing staff.
The facility failed to develop and implement care plans for three residents with specific medical needs, including an indwelling catheter, end-of-life care, and an air mattress, despite physician's orders and facility policies requiring individualized care plans.
The facility failed to ensure a timely MDS assessment transmission for a discharged resident with metabolic encephalopathy and major depressive disorder. The required final validation report was over 120 days late, and the facility lacked a policy for MDS final validation reporting.
The facility failed to ensure residents were treated with dignity when residents felt bothered, annoyed, or harassed by other residents' comments and behaviors. Despite staff attempts to redirect inappropriate behavior, the administration was not fully aware of the extent of the issues, leading to continued distress for the affected residents.
A non-verbal resident with severe cognitive impairment was verbally abused by a CNA, who told the resident to 'shut the (expletive) up.' Despite a Dietary Aide witnessing and reporting the incident, the facility's investigation deemed the allegation unsubstantiated due to lack of corroboration and the resident's inability to communicate effectively. The CNA was suspended and later terminated.
The facility failed to ensure a Facility Reported Incident (FRI) was completed and submitted timely to the State Agency (SA) for allegations of abuse. An FRI involving resident-to-resident abuse was submitted late, outside the required timeframes. The facility's policy mandates immediate reporting, but not later than two hours if the alleged violation involves abuse or results in serious bodily injury, and within 24 hours for all other allegations.
The facility failed to thoroughly investigate and document an allegation of verbal abuse by a CNA towards a resident, and did not update the resident's care plan with preventive measures. Additionally, the facility did not report investigation results within the required five working days for two separate incidents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) 3.0 assessments for two residents. For one resident with a diagnosis of major depressive disorder, the quarterly MDS assessment indicated the use of an antidepressant within the seven-day look-back period. However, a review of physician orders revealed that no antidepressant medication was currently ordered or administered for this resident. The Director of Nursing confirmed that the resident had not been receiving an antidepressant at the time of the assessment, indicating an incorrect MDS entry. For another resident with multiple diagnoses including aphasia, intellectual disabilities, and a history of falls, the quarterly MDS assessment documented daily use of a floor mat alarm during the look-back period. Physician orders did not include any documentation for a floor mat alarm, and direct observation confirmed the absence of such equipment in the resident's room. The Director of Nursing further confirmed that the facility did not possess or use floor mat alarms, and acknowledged that the MDS assessment had been coded incorrectly for this resident as well.
Failure to Obtain Order and Correctly Apply Heel Boots
Penalty
Summary
The facility failed to obtain a physician's order prior to the application of pressure redistribution/heel protector boots for a resident with multiple diagnoses, including dementia, foot drop, and lower leg pain. Observations on multiple occasions revealed that the resident was resting in bed with heel boots placed under their feet, but the boots were not fastened and the resident's heels were not positioned over the pressure redistribution opening as required. The clinical record lacked an order for the use and monitoring of heel boots, and there was no documentation of heel assessments or monitoring for pressure injuries or deep tissue injuries related to the use of the boots. Interviews with nursing staff and the DON confirmed that both nurses and CNAs applied the heel boots without a physician's order and that the boots were not correctly applied, as the resident's heels were not aligned with the opening. Staff explained that the boots were left unfastened due to the resident's sensitivity and preference, but acknowledged that an order was required and that the boots should have been properly positioned to prevent pressure injuries. Facility policy required orders for all equipment used in resident care and specified correct application of pressure redistribution devices, which was not followed in this case.
Failure to Complete Timely Behavioral Health Training for New Staff
Penalty
Summary
The facility failed to ensure that initial behavioral health care training was completed in a timely manner according to its own policy for one employee. Specifically, a Registered Nurse hired as the Minimum Data Set 3.0 nurse did not have documented evidence of completing behavioral health care training within 40 hours of their start date, as required by the facility's policy. This was confirmed through personnel record review and interviews with the Human Resources Director, who acknowledged the training had not been completed, and the Administrator, who was unaware of the requirement. The facility's policy, revised on 06/28/2023, clearly states that new employees must complete behavioral health training within 40 hours of starting employment.
Failure to Develop Care Plan for Resident's Edema
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with bilateral lower extremity edema, which was necessary to address the side effects and required monitoring for the condition. The resident, who was admitted and readmitted with a diagnosis of bilateral primary osteoarthritis of the knee, reported swelling in both legs and was not wearing compression stockings. Despite a physician's order for compression stockings as needed for occasional swelling, the resident's clinical record lacked a documented care plan for managing the edema associated with their osteoarthritis. The Director of Nursing confirmed the absence of a care plan for the resident's condition and acknowledged that the compression stockings should have been included as an intervention in the care plan. The facility's policy mandates an individualized, interdisciplinary plan of care for all residents, tailored to their needs and goals, which was not adhered to in this case. This oversight had the potential to result in adverse health outcomes due to staff being unaware of the necessary monitoring for the resident's leg swelling.
Failure to Revise Care Plans for Psychotropic Medication and Fall Prevention
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to include physician-identified behaviors for the administration of psychotropic medication for one resident and new interventions for the prevention of falls for two other residents. For the first resident, the care plans did not reflect the paranoid ideation behavior indicated in the physician's orders for psychotropic medications. The Director of Nursing (DON) confirmed that the care plans lacked documentation of this behavior, which was necessary for the administration of the prescribed medications. For the second resident, the facility did not update the care plan with new interventions after the resident experienced a fall. The resident had a history of impulsive behavior, poor safety awareness, and confusion, which contributed to the fall. Despite the interdisciplinary team's (IDT) suggestion to use grip strips as a preventive measure, the facility failed to implement this intervention, and the care plan was not revised to include it. The third resident also experienced multiple falls, and the facility did not adequately update the care plan with effective interventions. The resident had impulse control issues and often attempted to self-transfer, leading to falls. Although a trapeze was considered as an intervention, it was deemed inappropriate by the therapy team, and no alternative interventions were documented in the care plan. The facility's failure to revise care plans and implement appropriate interventions contributed to the ongoing risk of falls for these residents.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents following incidents of falls. Resident #23, who has a history of dementia and major depressive disorder, experienced a fall from the bed on 10/08/2024 due to impulsivity and poor safety awareness. Despite the interdisciplinary team's recommendation to apply grip strips to the floor to prevent further falls, this intervention was not implemented, and the resident's care plan was not updated with new interventions. Additionally, a required Morse scale evaluation was not completed post-fall to assess the resident's risk and potential decline. Resident #25, diagnosed with major depressive disorder, experienced multiple unwitnessed falls in September and October 2024. The resident's falls were attributed to impulsivity and poor safety awareness, with the resident often attempting to self-transfer without assistance. Although a bed alarm was placed after one fall, the care plan was not updated with effective interventions following the falls on 09/14/2024 and 09/25/2024. A proposed intervention involving a trapeze was deemed inappropriate by therapy staff, and no alternative interventions were suggested or implemented. The facility's policy on falls and fall prevention, revised in 05/2024, requires that extra measures be added to the care plan for fall prevention and that a Morse scale evaluation be completed post-fall. However, these requirements were not met for the residents involved, indicating a failure to adhere to established protocols for fall prevention and risk assessment.
Failure to Complete Timely Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) received their annual performance evaluations in a timely manner. Employee #3, hired as an Activity Director/CNA, had their last evaluation completed in May 2023, but lacked documentation for May 2024. Employee #8, hired as a CNA, had their last evaluation in April 2023, with no documentation for April 2024. Employee #9, also a CNA, had their last evaluation in June 2023, with no documentation for June 2024. The Human Resources Director confirmed that the annual performance evaluations for these employees were not completed as required by the facility's policy, which mandates annual evaluations by the anniversary date of hire.
Medication Unavailability and Lack of Procurement Procedure
Penalty
Summary
The facility failed to ensure that ordered medications were available for a resident, specifically Restasis Ophthalmic Emulsion, which was prescribed for cataract inflammation. The medication was not administered on multiple occasions as it was unavailable in the facility and on order from the pharmacy. The Medication Administration Record (MAR) for the resident documented the absence of the medication over several days, with notes indicating that the medication was on order and awaiting delivery. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the medication had been unavailable since a specific date, and the DON had contacted the pharmacy multiple times to request a refill. Additionally, the facility lacked a documented policy or procedure for the safe procurement of drugs and biologicals, as confirmed by the Administrator and the DON. The Consultant Pharmacist Agreement indicated that the consultant pharmacist was responsible for assisting with the implementation of such policies and procedures.
Failure to Document Specific Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that behaviors monitored were associated with the specific condition indicated by the physician for the use of psychotropic medications for one of the sampled residents. Resident #2, who was diagnosed with major depressive disorder and vascular dementia, was prescribed Seroquel and Cymbalta for low mood, anxiety, and paranoid ideation. However, the behavior monitoring in the electronic Medication Administration Record (eMAR) was not personalized to the specific psychotropic medication, and there was no documented evidence of the behaviors exhibited by the resident on a specific date. The Director of Nursing (DON) confirmed that the behavior monitoring was not related to the behaviors identified for the administration of the psychotropic medications. Additionally, the facility did not ensure that physician-ordered psychotropic medications had a specific condition documented for indication of use associated with the diagnoses for five other sampled residents. These residents were prescribed various psychotropic medications for conditions such as major depressive disorder and unspecified psychosis. The DON explained that physician orders for psychotropic medications were required to include the specific behaviors and/or symptoms the medication was ordered for, but the physician had not been identifying specific behaviors related to the administration of the psychotropic medications. The facility's policy on psychotropic medications required daily monitoring to include the presence and frequency of resident-specific targeted behaviors. However, the interdisciplinary team did not ensure that the lowest possible effective dose was used in managing identified behaviors, and the provider's order did not include the reason for the psychotropic being ordered. This lack of specific documentation and monitoring led to the deficiency identified by the surveyors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 6.9% error rate. This was identified through observation, interview, clinical record review, and document review. Specifically, there were 29 medication administration opportunities, and two errors were noted. One of the errors involved a registered nurse (RN) who did not administer Metoprolol to a resident during the morning medication pass. The RN initially prepared the medications but forgot to include Metoprolol in the medication cup due to nervousness about being observed. The resident involved had a medical history that included heart failure and dry eye syndrome. The physician's orders for the resident included Restasis Ophthalmic Emulsion for eye inflammation and Metoprolol for heart failure and tachycardia. The RN realized the omission after being asked to verify the contents of the medication cup and subsequently administered the Metoprolol. The facility's Director of Nursing (DON) confirmed that the expectation was for nursing staff to verify and administer medications according to physician orders, and that omissions constituted medication errors.
Medication Administration Error for Heart Failure Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Metoprolol Tartrate. The resident, who was admitted with a diagnosis of unspecified heart failure, had a physician's order for Metoprolol Tartrate 12.5 mg to be administered twice daily, with specific parameters to hold the medication if the blood pressure was below 90/50 or the heart rate was below 50. During a medication pass observation, a registered nurse (RN) prepared the medications for the resident but failed to include the Metoprolol in the medication cup before attempting to administer it. The RN realized the omission after being prompted to verify the contents of the medication cup. The RN attributed the error to nervousness due to being observed. The Director of Nursing (DON) confirmed that the facility's policy required medications to be administered according to physician's orders and that omissions constituted medication errors. The facility's policy and the drug information for Metoprolol Tartrate emphasized the importance of administering the medication as prescribed to manage hypertension and heart failure effectively.
Documentation and Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation of psychotropic behavior monitoring for six residents, as required by physician orders. These residents, diagnosed with various mental health conditions such as major depressive disorder and dementia, had blank spaces in their Behavioral Health (BH) Records for specific dates, indicating that behavior monitoring was not documented during certain day shifts. The Director of Nursing (DON) confirmed the omissions, attributing them to possible forgetfulness by the nursing staff. Additionally, the facility did not maintain accurate medication administration records for one resident. This resident was supposed to receive Restasis Ophthalmic Emulsion eye drops, but the medication was unavailable in the facility from a certain date. Despite this, the Medication Administration Record (MAR) inaccurately documented that the medication was administered during the morning medication pass on several days. The DON acknowledged the error, explaining that the medication was not available and had been documented as administered in error. The facility's policy on medication administration emphasizes the importance of the seven rights, including right documentation, which was not adhered to in this case. The DON and a Registered Nurse (RN) confirmed the unavailability of the medication and the incorrect documentation, highlighting a lapse in following the facility's medication administration procedures.
Failure to Provide Restorative Nursing Program
Penalty
Summary
The facility failed to ensure the Restorative Nursing Program (RNP) was provided to 13 residents in need of restorative nursing services. The deficiency was identified through observation, interview, clinical record review, and document review. The Restorative Nursing Aide (RNA) confirmed that the RNP had not been active since January 2024 due to staffing changes, and the program only resumed when the RNA was hired in April 2024. The Director of Nursing (DON) also confirmed that no restorative care was provided to residents from January to April 2024, which led to a lapse in maintaining residents' baseline physical abilities. The report detailed specific cases of residents who were affected by the lack of restorative nursing services. For instance, Resident #1, who had diagnoses including generalized anxiety disorder and muscle contracture, lacked documented evidence of participation in the RNP. Similarly, Resident #2, with chronic respiratory failure, and Resident #3, with intracranial injury and muscle contracture, also lacked documentation of RNP participation. The RNA admitted that there was no official list of residents in the RNP, and the RNA had to create a handwritten list of residents to work with. The DON and RNA both acknowledged the failure to document and provide necessary restorative care. The DON admitted to misunderstanding what constituted restorative nursing, believing that activities like showering and brace assistance were sufficient. However, the clinical records of the residents requiring RNP services lacked documented evidence of these activities being part of the RNP. The Administrator also admitted that the facility failed to execute the plan to have more than one person oversee the RNP when the LPN left the position in January 2024, leading to the oversight.
Failure to Maintain Restorative Nursing Program and Properly Investigate Abuse
Penalty
Summary
The Administrator failed to ensure a Restorative Nursing Program (RNP) was maintained for residents with the potential to participate. The Restorative Nursing Aide (RNA) confirmed that the RNP had not been active since January 2024 due to the Licensed Practical Nurse (LPN) responsible for restorative care changing job duties because of short staffing. The Director of Nursing (DON) corroborated that from January 8, 2024, to April 8, 2024, no restorative care was provided. The Administrator admitted that the plan to have more than one person oversee the RNP was not executed, leading to the program being neglected. The Abuse Committee failed to properly investigate allegations of employee-to-resident abuse by not applying the correct definition of abuse as per federal regulations. A Facility Reported Incident (FRI) involving an employee allegedly verbally and physically abusing a resident was unsubstantiated by the facility, despite the employee admitting responsibility. The Administrator and the Abuse Committee incorrectly believed that abuse was only substantiated if the resident experienced injury, harm, pain, or mental anguish. This misunderstanding led to inappropriate investigations of abuse allegations.
Failure to Ensure QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that 10 out of 20 sampled staff members received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. The personnel records of employees, including the Director of Nursing, Registered Dietitian, Certified Nursing Assistants, Registered Nurse, Licensed Practical Nurse, Dietary Aides/Cooks, and Housekeeper, lacked documented evidence of completed QAPI training. This deficiency was identified during a review of personnel records, interviews, and document reviews conducted by surveyors. The Administrator acknowledged that the issue with QAPI training had been identified in previous surveys and that some staff had not yet completed the training. The Administrator also mentioned that QAPI training had not been part of the onboarding employee orientation but would be included moving forward. The Risk Manager confirmed that it was their responsibility to ensure QAPI training was completed and acknowledged that 10 of the 20 sampled employees had not yet completed the required training. The facility's policy on QAPI, reviewed on 10/11/2023, stated that facility-wide training would be conducted to inform all employees about the QAPI plan.
Failure to Recognize and Address Abuse; Inadequate Restorative Nursing Program
Penalty
Summary
The facility's Abuse Committee, including the Director of Nursing (DON), failed to recognize and identify actual employee-to-resident verbal and physical abuse towards a resident. This incident involved a Certified Nursing Assistant (CNA) who was observed slapping a non-verbal, quadriplegic resident on the hand and verbally threatening the resident. Despite multiple staff members witnessing and reporting the abuse, the facility's investigation concluded that the incident did not meet the criteria for abuse because there were no physical signs of injury on the resident. The Administrator and DON both failed to acknowledge the psychological impact of the abuse, focusing solely on the absence of physical harm. The report also highlights a deficiency in the facility's Restorative Nursing Program (RNP). The DON admitted to a lack of knowledge and skills needed to manage the program effectively. From early January to early April, the facility did not provide restorative care to residents due to staffing changes. The newly hired Restorative Nursing Aide (RNA) began working without a clear list of residents requiring restorative care, and there was no proper documentation of the care provided. The DON was unaware of the residents' participation in the RNP and did not know where to access relevant physical therapy notes. The facility's policies on abuse prevention and restorative nursing were not followed. The abuse policy required immediate suspension of the caregiver, notification of family or guardians, and reporting to law enforcement and state authorities, none of which were adequately executed. Similarly, the RNP policy required daily documentation and specific care plans for each resident, which were not maintained. These failures indicate a significant lapse in the facility's adherence to its own policies and procedures, leading to deficiencies in resident care and safety.
Failure to Protect Resident's Right to Dignity and Respect
Penalty
Summary
The facility failed to ensure a resident's right to be treated with respect and dignity was protected when a care plan was updated to include sexual behaviors of the resident without evidence or assessment of a change in the resident's baseline. This occurred after facility staff observed physical and verbal abuse by a Certified Nursing Assistant (CNA) toward a cognitively impaired, non-verbal resident. The resident, who had limited fine motor skills and was non-verbal, had a care plan initiated as part of their clinical record without any prior history of such behaviors or a proper assessment to substantiate the change. The incident began when a Dietary Aide overheard a CNA telling the resident, 'I told you I would slap you if you did that again,' and alleged that the resident was touching the CNA's breasts. The facility's investigation into the incident was unsubstantiated, but the care plan was still updated to reflect inappropriate sexual behaviors. The resident's guardian and other staff members questioned the validity of the claim, given the resident's limited mobility and non-verbal status. The resident's guardian expressed disbelief and concern over the staff's abusive language and actions toward the resident. Multiple witness statements and assessments indicated that the resident had not exhibited any sexual behaviors prior to this incident. The facility's policies on abuse prevention and care planning were not followed, as the care plan was updated without proper assessment or evidence. The Administrator and MDS Coordinator acknowledged that the care plan was inaccurate and that the resident's mental and physical abilities had remained unchanged. Despite this, the care plan was still updated to include inappropriate sexual behaviors, violating the resident's right to dignity and respect.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse by a Certified Nursing Assistant (CNA). Resident #3, who was non-verbal and had limited mobility due to quadriplegia, was allegedly slapped on the hand by CNA1 after the resident brushed the CNA's breast. The incident was witnessed by the Food Services Supervisor, who reported that CNA1 told the resident, 'I told you I would slap you if you did that again,' and then slapped the resident's hand. The facility's investigation into the incident was unsubstantiated, citing a lack of negative psychosocial outcomes for the resident and no physical signs of injury. The resident's Guardian expressed disbelief that Resident #3 could have touched the CNA inappropriately, given the resident's limited mobility and non-verbal status. The Guardian also noted that the resident had no history of such behavior. The facility's Care Plan for Resident #3 indicated a risk for victimization due to cognitive impairment, communication barriers, and physical limitations. Despite this, the facility did not take disciplinary action against CNA1, and the Administrator did not refer the CNA to the Board of Nursing or conduct a further investigation. Multiple staff members, including the Food Services Supervisor and other CNAs, provided statements corroborating the incident. The Licensed Social Worker and Director of Nursing both acknowledged that abuse does not require physical injury to be substantiated. However, the Administrator and DON concluded that the incident did not meet the facility's definition of abuse, as there were no physical signs of injury. The facility's policies on abuse prevention, resident rights, and psychosocial needs emphasize the importance of protecting residents from all forms of abuse, yet these policies were not effectively enforced in this case.
Failure to Implement Abuse Policies
Penalty
Summary
The facility failed to implement its abuse policies regarding identification, investigation, protection, and reporting for an allegation of verbal and physical abuse toward a resident by a Certified Nursing Assistant (CNA). The incident involved a resident who was non-verbal, quadriplegic, and had cognitive impairments. The resident was allegedly slapped on the hand by a CNA after the resident brushed their hand against the CNA's breast. The incident was witnessed by a Food Services Supervisor who reported it to the Charge Nurse immediately. Despite the report, the facility did not take appropriate disciplinary action against the CNA, and the incident was unsubstantiated due to a lack of physical injury on the resident. The facility's investigation included statements from various staff members, including the Food Services Supervisor, other CNAs, and the Administrator. The Food Services Supervisor described the CNA's attitude as frustrated and observed the CNA slap the resident's hand and verbally threaten the resident. Other staff members also overheard the CNA telling the resident to stop touching the CNA's breasts. The Administrator and Director of Nursing (DON) were informed of the incident, but the Administrator concluded that the incident did not meet the criteria for abuse as defined in the State Operations Manual (SOM) because there were no physical signs of injury on the resident. The facility's policy on abuse prevention and prohibition was not followed. The policy required the formation of an Abuse Investigation Team to interview witnesses, gather statements, and make a recommendation based on the information collected. However, the Administrator did not refer the CNA to the Board of Nursing or investigate the allegation further. The Licensed Social Worker (LSW) monitored the resident for three days for any negative psychosocial outcomes but determined no further monitoring was necessary. The facility's failure to follow its own policies and procedures resulted in the deficiency noted in the report.
Failure to Obtain Informed Consent for Air Mattress Use
Penalty
Summary
The facility failed to ensure that a resident's Guardian gave informed consent prior to placing an air mattress on top of a bariatric bed for a resident. The resident, who was quadriplegic and required assistance with all Activities of Daily Living (ADL), was observed in a geri-chair next to a bariatric bed with an air mattress. The clinical record for the resident lacked a care plan addressing the air mattress and did not contain documented evidence that the risks and benefits were explained to the resident's Guardian. Additionally, there was no assessment for the risk of entrapment and restraint. The Director of Nursing (DON) confirmed that the air mattress was considered a restraint and that the facility needed to document interventions attempted prior to its use, assess the resident for risk of entrapment, and review the risks and benefits with the Guardian. The DON and the Minimum Data Set (MDS) Coordinator both confirmed that informed consent was not obtained from the resident's Guardian before placing the air mattress on the bed. The facility's policy on Mobility Devices and Physical Restraints required an assessment, monitoring, a physician's order, consents, and a care plan before using any physical restraint, which was not followed in this case.
Failure to Report Fall with Serious Injury
Penalty
Summary
The facility failed to report a fall resulting in serious bodily injury to the State Agency (SA) for one resident. Resident #7, who had diagnoses including unspecified dementia with behavioral disturbances and wandering, fell in the dining area and struck the back of their head on a door frame. The resident lost consciousness for five seconds and was transferred to the emergency room (ER) for further assessment. Despite the severity of the incident, the Administrator did not report the fall to the SA, believing it did not meet the definition of serious bodily injury. The Director of Nursing (DON) confirmed that the incident should have been reported as it involved a head injury, loss of consciousness, and transfer to the ER, but the DON also failed to report it to the SA. The facility's policies on Falls and Fall Prevention and Abuse Prevention and Prohibition both required that falls with significant injury be reported to the SA. The policies defined significant injury as one requiring the resident to be sent to the ER, clinic, or x-ray department for medical attention. Despite these policies, the incident involving Resident #7 was not reported, indicating a failure in adhering to the facility's own reporting requirements. The Administrator and DON both acknowledged the oversight, confirming that the incident met the criteria for reporting but was not reported as required.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide a discharge notification to the State Long Term Care Ombudsman for Resident #26. Resident #26, who had diagnoses including type II diabetes mellitus with other specified complications and chronic obstructive pulmonary disease, was admitted to the facility on an unspecified date. On 03/03/2024, the resident exhibited slurred speech and altered mental status and was subsequently transferred to the hospital. The resident was discharged from the facility on 03/04/2024. However, the clinical record lacked documented evidence that a notification of discharge was provided to the State Long Term Care Ombudsman's office. The Minimum Data Set (MDS) Registered Nurse confirmed that it was their responsibility to notify the Ombudsman's office of discharges and acknowledged that the notification for Resident #26 had not been submitted, despite the facility's policy requiring such notification.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. Resident #2's MDS assessment inaccurately documented the presence of an indwelling catheter, which was confirmed to be an error by the MDS Coordinator. Resident #2's clinical record lacked any evidence of an indwelling catheter, and the resident denied having one during an interview. This discrepancy was acknowledged by the MDS Coordinator, who admitted the mistake in the documentation. Resident #15's MDS assessment incorrectly documented the use of an antipsychotic medication and the use of bed rails as physical restraints. The resident was actually receiving Depakote, an anticonvulsant, for behavioral disturbances related to vascular dementia, not an antipsychotic. Additionally, the bed rails were used for mobility and safety, not as restraints, as confirmed by the MDS Coordinator. Resident #17's MDS assessment inaccurately documented the use of an anticoagulant medication. The resident was taking Clopidogrel, an antiplatelet agent, not an anticoagulant. The MDS Coordinator admitted the error, stating that Clopidogrel should have been documented as an antiplatelet according to the Resident Assessment Instrument (RAI) Manual.
Failure to Follow Physician's Orders for Insulin Therapy
Penalty
Summary
The facility failed to follow physician's orders for insulin therapy for two residents diagnosed with type II diabetes mellitus. Resident #9 had a physician's order to administer NovoLOG Insulin FlexPen based on a sliding scale and to notify the physician if blood sugar levels exceeded 400. On two occasions, the resident's blood sugar levels were over 400, and although the correct insulin dosage was administered, there was no documented evidence that the physician was notified as required by the order. Resident #13 had a similar issue with HumaLOG Insulin KwikPen. The resident's blood sugar levels exceeded 400 multiple times over several months, and while the correct insulin dosages were administered, there was no documented evidence that the physician was notified on any of these occasions. The physician's orders explicitly required notification for blood sugar levels over 400, but this was not followed. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged that it was the facility's expectation for nurses to notify the physician and document the notification in the resident's record. The facility's policy also required such notifications, emphasizing the importance of physician awareness to manage potential complications like diabetic ketoacidosis or to adjust treatment plans as necessary.
Failure to Assess Air Mattress for Entrapment and Restraint
Penalty
Summary
The facility failed to assess an air mattress for entrapment and restraint for a resident diagnosed with multiple conditions including quadriplegia, dementia, and anxiety. The resident's clinical record lacked a care plan addressing the air mattress, and there was no documented evidence that the risks and benefits were explained to the resident's guardian. Additionally, the resident had not been assessed for the risk of entrapment and restraint. A physician's order was in place for the air mattress to prevent skin breakdown, but the necessary assessments and consents were not completed. The Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator confirmed that the air mattress was considered a restraint and that the facility's policy required an assessment, consents, and a care plan before its use. The DON acknowledged that the air mattress could pose a suffocation risk if the resident rolled into the air barriers. The MDS Coordinator also confirmed that the required assessments and consents were not completed, and the risks and benefits were not reviewed with the resident's guardian. The facility's policy on mobility devices and physical restraints mandated these steps, but they were not followed in this case.
Failure to Ensure Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper care and documentation for a resident with an indwelling catheter. Specifically, Resident #19, who was admitted with diagnoses including unspecified sequelae of cerebral infarction and schizoaffective disorder, did not have physician orders for ongoing catheter care, nor was there a care plan developed and implemented for the catheter. The clinical record lacked evidence of catheter care documentation, and the necessary tasks were not populated in the Treatment Administration Record (TAR) due to the absence of physician orders. Interviews with staff, including a CNA, RN, and the MDS Coordinator, revealed that catheter care tasks were typically communicated through the electronic medical record and during shift changes. However, it was discovered that Resident #19's catheter care was not documented because the tasks were not generated in the TAR until several days after the catheter was inserted. The facility's policies on indwelling urinary catheter maintenance and standards of care were not followed, as evidenced by the lack of documented catheter care and an updated care plan for the resident.
Medication Handling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper handling and storage of medications, leading to several deficiencies. During an inspection of the medication storage room, a multidose vial of tuberculin purified protein derivative was found in the refrigerator past its use-by date. The vial, which should have been discarded 28 days after opening, was still present, and the Director of Nursing (DON) confirmed that it should have been discarded earlier. Additionally, an unopened box containing a suprep bowel preparation kit belonging to a resident who no longer resided in the facility was found in a cabinet. The medication should have been destroyed upon the resident's discharge or expiration, but it was not. The DON confirmed that the medication should have been disposed of timely according to the facility's policy. Furthermore, the facility failed to consistently log the temperature of the refrigerator containing medications. The temperature log for two months showed missing entries for several days, indicating that the temperature was not monitored and recorded daily as required. The DON confirmed that the floor nurse was responsible for checking and logging the refrigerator temperature daily, and acknowledged the importance of this task to ensure the safety and efficacy of stored medications. The facility's policy required maintaining a daily log of refrigerator temperatures, but this was not adhered to, leading to potential risks of medication spoilage.
Failure to Assist Resident in Obtaining Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining dental services after the resident experienced bleeding gums. Resident #10, who was admitted with a diagnosis of cerebellar stroke syndrome, had a care plan that included coordinating dental care due to oral health problems. Despite a physician's order allowing the facility to arrange dental consultations and a care plan intervention to coordinate dental care, the facility did not ensure a dental appointment was made. On 01/10/2024, a CNA observed the resident experiencing oral pain, and an attempt was made to inform the Guardian to schedule a dentist appointment. However, no further documented attempts were made after the Guardian did not respond to the initial contact attempt until 04/10/2024, when the Guardian requested a follow-up dentist appointment. The resident's progress notes indicated that on 02/20/2024, the resident had a large amount of plaque and bleeding gums during oral care. Despite the resident's ongoing dental issues and the care plan's directive, the facility did not follow up adequately to ensure the resident received the necessary dental care. Interviews with the CNA and Social Worker confirmed that the last known attempt to notify the Guardian was on 01/10/2024, and no further actions were taken until the Guardian's response on 04/10/2024. The facility's policy on dental services, which mandates assisting residents in obtaining routine and emergency dental care, was not adhered to in this case.
Failure to Accommodate Lactose Intolerance
Penalty
Summary
The facility failed to accommodate a resident's lactose intolerance, leading to the resident receiving meals containing cheese. Resident #17, diagnosed with lactose intolerance, reported receiving cheese on multiple occasions, including on an egg and sausage bake for breakfast. The resident's physician's orders and comprehensive care plan documented the need for dairy-free products and noted episodes of diarrhea related to lactose intolerance. However, the diet type report used by the kitchen did not include the resident's allergy to milk products. The Dietary Manager confirmed that the diet type report lacked documentation of the resident's allergies, despite having a diet order and communication form indicating a milk allergy. The Minimum Data Set (MDS) Coordinator acknowledged that the diet order and communication form were inaccurate, as they only indicated no milk instead of no milk products. This discrepancy led to the resident receiving inappropriate meals that did not adhere to their dietary restrictions.
Incomplete Clinical Records and Documentation of Care
Penalty
Summary
The facility failed to ensure a resident's clinical record was complete when a Minimum Data Set (MDS) assessment was not completed for a resident upon discharge. Resident #22, who was admitted with diagnoses including metabolic encephalopathy and major depressive disorder, was discharged from the facility, but the clinical record lacked a discharge MDS assessment. The MDS Coordinator confirmed that the required MDS assessment was not submitted to the Centers for Medicare and Medicaid Services (CMS) within the mandated timeframe, resulting in an incomplete and inaccurate clinical record for Resident #22. Additionally, the facility lacked a policy related to MDS final validation reporting. The facility also failed to document care provided related to a resident's indwelling catheter. Resident #19, admitted with diagnoses including unspecified sequelae of cerebral infarction and schizoaffective disorder, had a physician's order for an indwelling catheter. However, the clinical record lacked documented evidence of catheter care being provided or ordered. Staff interviews revealed that catheter care tasks were not populated in the Treatment Administration Record (TAR) until after the care was provided, leading to undocumented catheter care. The facility's policies required daily documentation of catheter care and perineal care, but these were not followed for Resident #19, resulting in incomplete medical records.
Failure to Provide Timely Infection Control Training
Penalty
Summary
The facility failed to ensure timely infection control training for one of its employees, specifically the Minimum Data Set (MDS) Coordinator hired on 08/16/2021. The personnel record for this employee documented that the last infection control training was completed on 01/25/2023, and there was no documented evidence of training for 2024. On 04/15/2024, the Human Resources (HR) Generalist confirmed that infection control training is required upon hire and annually, and acknowledged that the employee had not completed the training timely. The facility's policy, reviewed on 04/13/2023, mandates yearly infection control educational programs for all permanent nursing department employees.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for three residents with specific medical needs. Resident #19, who had an indwelling catheter, did not have a care plan addressing catheter care, despite a physician's order and the MDS Coordinator's acknowledgment that such a care plan was necessary. Similarly, Resident #24, who was on end-of-life/comfort care, lacked a care plan for this critical aspect of their treatment, even though there were multiple physician's orders and progress notes indicating the need for comfort medications and end-of-life care discussions with the family. The MDS Coordinator admitted that the care plan was not updated to reflect these needs. Resident #3, who had a bariatric bed with an air mattress to prevent skin breakdown, also did not have a care plan addressing the use of the air mattress. This omission was despite a physician's order and the MDS Coordinator's explanation that the care plan should include interventions to ensure the resident's safety, such as monitoring for entrapment and assessing the resident's abilities. The facility's policies on mobility devices, comprehensive care plans, and standards of care all emphasize the need for individualized care plans, which were not followed in these cases.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure a Minimum Data Set 3.0 (MDS) assessment was transmitted timely for a discharged resident. Resident #22, who had diagnoses including metabolic encephalopathy and major depressive disorder, was admitted to the facility and later discharged. The clinical record for Resident #22 lacked a discharge MDS assessment, and the MDS Coordinator confirmed that the required final validation report was not submitted within the mandated timeframe. The report was due by 12/04/2023 but was over 120 days late as of 04/09/2024. Additionally, the facility did not have a policy related to MDS final validation reporting, despite having a policy that required MDS data to be transmitted within seven days of a discharge event.
Failure to Ensure Resident Dignity and Address Behavioral Issues
Penalty
Summary
The facility failed to ensure residents were treated with dignity when residents felt bothered, annoyed, or harassed by other residents' comments and behaviors. Resident #1, who was admitted with diagnoses including type two diabetes mellitus and acquired absence of the right leg above the knee, was involved in an incident where Resident #2, diagnosed with unspecified dementia and anxiety, made a derogatory comment about Resident #1's appearance. Resident #1 retaliated with an expletive-laden comment about another resident. Staff had previously attempted to redirect Resident #1's behavior of staring at female residents, which had made several residents uncomfortable, including Resident #2. Despite these efforts, the administration was not fully aware of the extent of the issue, and Resident #2 was not assessed for psychosocial harm related to the incident, although they were sent to an inpatient behavioral health facility due to their behaviors. Resident #3, admitted with diagnoses including personal history of traumatic brain injury and mood disorder, experienced ongoing issues with their roommate, Resident #4, who was diagnosed with vascular dementia. Resident #4's behaviors, such as turning off lights while Resident #3 was reading, leaving the bathroom door open while using it, and throwing clothes on Resident #3's side of the room, caused significant distress to Resident #3. Despite multiple complaints and documented incidents dating back to September, the facility did not substantiate the Facility Reported Incident (FRI) as there was no outcome of psychosocial harm for Resident #3. However, Resident #3 was eventually provided with a room change after continued complaints and visible distress. The facility's policy on residents' rights, which includes the right to be treated with consideration, respect, dignity, and individuality, was not upheld in these cases. The administration and staff were aware of the ongoing issues but failed to take adequate measures to address the residents' concerns and ensure their dignity and comfort. The lack of timely and effective intervention led to continued distress for the affected residents, highlighting a deficiency in the facility's handling of resident interactions and behavioral issues.
Failure to Protect Non-Verbal Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure a non-verbal resident was not verbally abused by a staff member. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including traumatic brain injury and quadriplegia. On the morning of 12/28/23, a Dietary Aide (DA) overheard a Certified Nursing Assistant (CNA1) telling the resident to 'shut the (expletive) up' while the resident was receiving a beverage. The DA reported the incident to the Dietary Manager on 01/03/24, leading to an investigation. However, the resident's clinical record lacked documentation of the incident, and the resident's severe cognitive impairment made it difficult to ascertain their understanding of the event. The investigation included interviews with the resident, CNA1, the DA, and two other staff members. The Social Worker (SW) and Chief Nursing Officer (CNO) both noted the resident's severe cognitive impairment and inability to communicate effectively. Despite the DA's report and confirmation of the incident, the facility's Abuse Team and Administrator deemed the allegation unsubstantiated due to the lack of corroboration from other staff and CNA1's denial. CNA1 was suspended during the investigation and subsequently terminated on 01/03/24. The facility's policies on abuse prevention and resident rights emphasize the importance of protecting residents from all forms of abuse, including verbal and mental abuse. Despite these policies, the facility failed to document the incident properly and relied heavily on the judgment of staff members who did not witness the event. The Dietary Manager and Risk Management Director both acknowledged the inappropriateness of CNA1's behavior, but the facility ultimately did not substantiate the abuse allegation based on the available evidence and interviews.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure a Facility Reported Incident (FRI) was completed and submitted timely to the State Agency (SA) for allegations of abuse. Specifically, FRI #NV00069839, which involved an allegation of resident-to-resident abuse, was submitted to the SA on 11/14/23, despite the allegation being made on 11/12/23. The Chief Nursing Officer confirmed that the FRI was submitted late and outside of the required timeframes. The facility's policy on Abuse Prevention and Prohibition, last revised on 08/25/23, mandates that all alleged violations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property be reported immediately, but not later than two hours if the alleged violation involves abuse or results in serious bodily injury, and within 24 hours for all other allegations. The Administrator also verbalized these reporting requirements during the interview on 02/28/24.
Failure to Investigate and Document Alleged Abuse and Timely Report Investigation Results
Penalty
Summary
The facility failed to ensure an allegation of employee to resident verbal abuse was thoroughly investigated and documented for a resident. The incident involved a Certified Nursing Assistant (CNA) allegedly using abusive language towards the resident, which was overheard by a Dietary Aide (DA). The investigation was initiated seven days after the incident, and the resident's clinical record lacked documentation of the incident or investigation. Additionally, the resident's care plan was not updated to include methods and interventions to prevent further abuse or monitor for signs and symptoms of abuse or psychosocial effects. Interviews with the Administrator, Chief Nursing Officer (CNO), and Risk Management Director (RMD) revealed that the investigation was deemed unsubstantiated based on staff interviews and the resident's inability to communicate effectively. However, there was no documentation to support the investigation, including statements from the CNA or DA witness, and the resident's interview was not properly documented in the clinical record. The facility also failed to report investigation results within the required five working days for two Facility Reported Incidents (FRIs). One FRI involved an injury of unknown source for a resident, and the final report was submitted one day late. Another FRI involved resident-to-resident abuse, and the final report was submitted outside the required timeframes. The Administrator and CNO confirmed the late submissions and acknowledged that the final reports were not submitted within the required five-day timeframe as per the facility's policy on Abuse Prevention and Prohibition.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
