Rosewood Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reno, Nevada.
- Location
- 2045 Silverada Blvd, Reno, Nevada 89512
- CMS Provider Number
- 295020
- Inspections on file
- 29
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Rosewood Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of vertebral fractures was found deceased after a CNA reported taking vital signs earlier that morning. The facility's investigation into the alleged neglect was incomplete, lacking interviews with key staff, the resident's roommate, and other residents, contrary to facility policy.
A resident with dysphagia received tube feeding based on an incomplete physician order that did not specify the formula type, and staff continued administration without this detail until the order was updated. Additionally, an LPN documented tube feeding as completed before actually administering it, then failed to return and provide the feeding after the resident requested a delay, without documenting the missed administration or a refusal.
A resident with multiple fractures and malnutrition did not have complete documentation in the clinical record regarding showers, bed baths, or refusals of care during a period when they were Covid-19 positive. Staff interviews confirmed that care and refusals should have been documented electronically, but records were missing for several days.
The facility failed to inform residents about the rules for leaving on pass both orally and in writing prior to or upon admission. A resident with type two diabetes felt confined and uninformed about the ability to leave. Staff confirmed that a physician's order was needed for leaving on pass, but this was not communicated at admission. The Director of Nursing acknowledged the omission, and the facility's admission packet lacked documentation of these rules, contrary to their policy.
The facility was found deficient in maintaining cleanliness of the ice machine and proper food storage practices. The ice machine had black buildup, and refrigerated foods, such as fruit cocktail, were uncovered and not labeled with dates. The Dietary Manager confirmed these practices did not meet the facility's expectations.
A resident with limited mobility was not informed of menu options or alternatives, leading to frustration and delays in receiving meals. The menu in the resident's room was outdated and not visible from their bed, and staff did not notify the resident of daily menu items, violating the resident's right to self-determination.
A facility failed to report an incident of resident-to-resident abuse within the required timeframe. A resident with severe vascular dementia was involved in an incident where another resident with dementia and agitation slammed their wheelchair into the first resident's legs. The incident was not reported to the State Agency until two days later, violating the facility's policy that mandates reporting within 24 hours for abuse without serious bodily harm.
The facility failed to create comprehensive care plans for two residents, one on anticoagulants with gastrointestinal bleeding symptoms and another with hypoxemia receiving oxygen therapy. The absence of care plans for these conditions was confirmed by the DON, contradicting facility policies and potentially compromising resident care.
A facility failed to monitor lab results and communicate bleeding symptoms for a resident on anticoagulant therapy. The resident, on apixaban, showed signs of gastrointestinal bleeding, but the care plan lacked documentation of the medication and symptoms. An LPN was unaware of the bleeding, and a stool sample was mishandled, leading to a lack of follow-up on test results.
A resident with hypoxemia was receiving oxygen therapy without a physician's order, contrary to the facility's policy. The resident, who had not used oxygen before admission, was unsure of its necessity. The DON confirmed the absence of a physician's order, despite the resident receiving oxygen since admission.
A medication cart was found unlocked and unattended outside the nurse's station while a resident and visitors were present. The DON confirmed the cart should have been locked when unattended, as per facility policy, which allows only authorized personnel access to medication carts.
A resident with kidney disease was served meals inconsistent with their prescribed diet order, receiving pureed and mechanically altered foods instead of a regular diet. The Dietary Supervisor misunderstood the diet requirements and failed to communicate with nursing staff for clarification. The facility lacked a policy for following diet orders, leading to this deficiency.
The facility did not follow its water management policy by failing to conduct Legionella testing every five years. The Director of Environmental Services confirmed that the maintenance department, responsible for the program, lacked testing results and had no plan for future testing. This non-compliance with the policy could lead to undetected bacteria in the water lines.
A facility failed to ensure annual elder abuse training for a Registered Nurse, as required by their policy. The nurse's personnel record showed training was last completed in August 2023, with no evidence of completion in 2024. The HR representative confirmed the lapse, despite the facility's policy mandating annual training.
A resident developed Moisture Associated Skin Damage (MASD) and a pressure injury while in the facility, despite having no active skin conditions upon admission. The facility failed to adhere to physician's orders for skin breakdown prevention, including the application of barrier cream and regular repositioning. The deficiency was confirmed by the Wound Nurse and DON, highlighting a lapse in the facility's skin and wound management practices.
A resident tripped over a sprinkler head in the courtyard, resulting in fractures, due to the facility's failure to address a known tripping hazard. Observations confirmed that sprinkler heads were raised above ground level, posing a risk. Staff interviews revealed a lack of communication and awareness about the hazard, and the facility's report did not include corrective measures.
A resident with chronic kidney disease and benign prostatic hyperplasia had a physician's order for indwelling catheter care, but the facility failed to update the care plan to include this. The DON confirmed the care plan lacked necessary updates, despite facility policy requiring comprehensive care plans.
The facility failed to ensure a high-temp dishwasher was operating correctly and expired food items were discarded. The dishwasher's final rinse cycle was below the required temperature, and expired macaroni salad and grits were found in the kitchen. The Dietary Supervisor confirmed the issues and acknowledged that the items should have been discarded according to facility policies.
The facility failed to administer pneumococcal vaccines to two residents who had requested them and did not screen or offer the influenza vaccine to 25 residents. Additionally, 12 residents who requested the influenza vaccine did not receive it. The facility's policies for immunizations were not followed, leading to a significant portion of the resident population not being vaccinated.
The facility failed to maintain the privacy of resident health information when an unattended computer screen displayed the names of three residents. An LPN admitted to forgetting to lock the screen, and the DON confirmed that staff are expected to secure screens when unattended.
The facility failed to prevent resident-to-resident abuse and neglect. One resident attempted to hit another, and in a separate incident, a resident was found soaked in urine with the call light unplugged. The facility's abuse and neglect prevention policies were not effectively implemented.
The facility failed to submit a final report for a Facility Reported Incident (FRI) involving an allegation of force-feeding by a CNA within the required five-day timeframe. The delay was due to a miscalculation of dates by the DON.
The facility failed to ensure timely transmission of MDS 3.0 assessments for five residents, with delays ranging from 14 to 15 days past the required seven-day transmission period. The MDS Coordinator confirmed the delays, acknowledging non-compliance with the RAI Manual timelines.
The facility failed to ensure care plans were person-centered and complete for residents with cognitive impairments, communication barriers, psychotropic medication needs, bedrail use, and incidents of abuse and neglect. Staff did not use designated communication tools, and care plans lacked specific details and necessary interventions.
The facility failed to follow professional standards during medication administration for two residents and did not properly assess a resident before diagnosing schizoaffective disorder and administering psychotropic medication. An LPN administered pain medication without assessing pain severity and location, and insulin without sterilizing the stopper or timing it before meals. Additionally, a resident's need for psychotropic medication was not properly assessed or documented.
The facility failed to offer a non-English speaking resident a communication device and/or provide translation services. Despite the resident's care plan documenting the need for a language line, staff members did not use it and instead relied on hand gestures, short sentences, and infrequent family visits for communication. The Director of Nursing confirmed that translation services were supposed to be used, especially during assessments.
The facility failed to ensure coordinated care with a hospice agency for a resident receiving hospice services. Despite a care plan indicating regular visits from hospice staff, there was a lack of documentation in the hospice binder and EHR regarding the care provided. Interviews revealed that hospice aides did not consistently report their visits or document the care provided, leading to a significant gap in record-keeping and communication.
The facility failed to assess a resident's pain level and location before administering an as-needed narcotic pain medication. An LPN gave 10 mg of oxycodone to a resident and only asked for the pain level and location afterward, contrary to the facility's policy. The DON confirmed that pain assessment should occur prior to medication administration.
The facility failed to ensure that appropriate alternatives were attempted and implemented before using bed rails for a resident with difficulty in walking and unsteadiness of feet. The clinical record lacked documented evidence of alternatives tried and failed, and the Director of Nursing confirmed that therapy should complete an evaluation and obtain consent prior to bed rail use, which was not documented.
The facility failed to ensure that a resident on a psychotropic medication had an assessment addressing why the medication was prescribed. The resident had a new diagnosis of schizoaffective disorder, and a physician's order for Seroquel was renewed without an assessment. The care plan also lacked necessary documentation related to the medication.
The facility failed to maintain a medication error rate below 5%, with 11 errors out of 33 opportunities. An LPN administered oxycodone without assessing a resident's pain level and gave Geri-Kot instead of Senna Plus. Another LPN did not sterilize an insulin pen before use and administered insulin after a resident had eaten. Several 7:00 AM medications were also administered late.
The QAPI committee failed to identify that 45.11% of the residents had not been screened for influenza vaccination or had been screened and desired to receive the influenza vaccine, but the vaccine was not administered. This deficiency was confirmed by the Administrator, and the facility's QAPI plan, dated 2022-2023, aimed to correct such deficiencies but did not identify this issue.
A resident with type two diabetes mellitus was observed receiving insulin from an insulin pen without the rubber stopper being scrubbed with alcohol by an LPN. The LPN believed the stopper was already sterile, contrary to the facility's policy.
The facility failed to administer a COVID-19 vaccine to a resident who had a signed consent form indicating they wished to receive the vaccine. Despite the consent being documented, there was no evidence that the vaccine was administered, as confirmed by the Infection Preventionist.
The facility failed to ensure timely completion of elder abuse training for 7 out of 20 sampled employees, with delays ranging from a few days to over a month after the hire date. The HR Representative confirmed that the training was supposed to be completed during orientation and annually thereafter, as per the facility's policy.
Failure to Thoroughly Investigate Allegation of Neglect Following Resident Death
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident who was found deceased in their room. The resident, admitted with a history of vertebral fractures and orthopedic aftercare, was last reported to have had vital signs taken by a CNA at approximately 6:00 AM. The resident was later found unresponsive, cold to touch, and exhibiting signs of rigor mortis around 7:10 AM, with EMS pronouncing the resident deceased after arrival. There was a discrepancy between the reported time of the last vital signs and the timeline of the resident's death. The facility's investigation into the incident was incomplete. Documentation provided included initial and final incident reports, vital sign flowsheets, nursing progress notes, and statements from some staff. However, the investigation lacked interviews with the resident's roommate, other residents cared for by the accused CNA, and staff from other shifts who had contact with the resident or the accused CNA. The Administrator and ADON confirmed that not all relevant staff or residents were interviewed, and the facility's own policy requiring comprehensive interviews and documentation during investigations was not followed.
Failure to Administer Tube Feeding per Complete Physician Order and Accurate Documentation
Penalty
Summary
The facility failed to ensure that tube feeding was administered to a resident according to physician orders and that a complete physician order was in place prior to administration. One resident with a diagnosis of dysphagia following cerebral infarction had a tube feeding order that, prior to being updated, did not specify the type of formula to be administered. Staff confirmed that the resident had been receiving tube feeding since admission, but the order was incomplete until it was updated. The interim Director of Nursing acknowledged that the previous order lacked essential details, such as the formula type, which is necessary for safe administration. Additionally, on one occasion, a Licensed Practical Nurse documented that the resident received tube feeding when, in fact, the feeding was not administered as ordered. The nurse prepared the feeding and documented its completion before actually providing it, then failed to return to administer the feeding after the resident requested a short delay. The nurse did not document the resident's refusal or the missed administration. The facility's policy and the nurse's job description both require accurate documentation and adherence to physician orders for tube feeding, which were not followed in this instance.
Incomplete Documentation of Resident Bathing and Care Refusals
Penalty
Summary
A deficiency was identified when a clinical record review revealed that documentation for a resident was incomplete. The resident, who had multiple rib fractures and mild protein-calorie malnutrition, was admitted to the facility and was scheduled to receive showers twice weekly. Documentation showed that the resident received showers and a full-body bath on specific dates, but there were blank entries for several PM shifts. Additionally, after the resident tested positive for Covid-19, the facility limited the use of communal showers and was expected to offer bed baths instead. However, there was no documentation in the clinical record indicating that a shower or bed bath was provided, nor any record of refusals or alternative care offered during a specific period. Interviews with facility staff, including a CNA, the ADON, and the Administrator, confirmed that the expectation was for all care provided, refusals, and alternative offers to be documented in the electronic medical record. The Administrator acknowledged that the clinical record lacked documentation of bathing care or refusals for the resident during the period in question. Facility policy required that ADL support and resident performance be documented electronically, but this was not done for the identified dates.
Failure to Inform Residents of Leave Policies
Penalty
Summary
The facility failed to inform residents both orally and in writing about the rules related to leaving the premises on pass prior to or upon admission. This deficiency was identified during interviews and document reviews, revealing that residents were not made aware of the process for going out on pass until they requested to do so. Specifically, Resident #3, who was admitted with a primary diagnosis of type two diabetes mellitus without complications, expressed feeling confined and uninformed about the ability to leave the facility. Interviews with staff, including a CNA and an LPN, confirmed that a physician's order was required for residents to leave on pass, but this information was not communicated to residents at the time of admission. The Director of Nursing acknowledged that residents were not informed of the rules and processes for going out on pass during admission, which is a resident right that should have been included in the admission packet. The facility's admission packet lacked documentation of these rules, and the facility's policy on Resident Rights and Responsibilities stated that residents should receive a written copy of their rights and the facility's rules upon admission. The policy on Out on Pass or Leave of Absence required a physician's order and interdisciplinary team decision for a resident to leave, but this was not communicated to residents as part of their admission process.
Deficiencies in Ice Machine Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage practices, as observed during a survey. The ice machine in the kitchen was found to have black buildup on the plastic visor above the ice, which was confirmed by the Dietary Manager (DM) who stated that the machine was cleaned every three months, but any visible buildup should have been addressed by the staff. Additionally, refrigerated foods were not properly covered, labeled, and dated. Specifically, three cups of fruit cocktail were found uncovered in the trayline refrigerator. The DM confirmed that the expectation was for all food stored in the refrigerator to be covered and labeled with the date.
Failure to Inform Resident of Menu Options
Penalty
Summary
The facility failed to ensure that a resident was informed in advance of menu options and alternative meal choices, which is a violation of the resident's right to self-determination. Resident #44, who is bedbound and has limited mobility, was not made aware of the daily menu or alternative meal options. The resident frequently had to send meal trays back to the kitchen and request a bowl of soup, as they were not informed of the menu in advance and could not see the menu posted on the wall due to their condition. The menu in the resident's room was outdated, and staff did not notify the resident of the menu items each day. The Dietary Manager confirmed that there was no process in place to ensure that residents with limited mobility could see the menu, and the Director of Nursing acknowledged that menus should be up to date and accessible to bedbound residents. A Certified Nursing Assistant also confirmed that the menu in the resident's room was from the previous week and not visible from the resident's bed. The facility's policy on Resident Rights states that residents have the right to make choices about aspects of their life in the facility, which was not upheld in this case.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the State Agency (SA) within the required timeframes. Resident #23, who was admitted with severe vascular dementia and unspecified mood disorder, was involved in an incident with Resident #57, who has unspecified dementia with agitation. On 10/05/2024, Resident #57 was observed slamming their wheelchair into Resident #23's legs. However, the Facility Reported Incident (FRI) was not submitted to the SA until 10/07/2024, exceeding the 24-hour reporting requirement for abuse without serious bodily harm. The facility's policy, revised in 10/2022, mandates that allegations of abuse be reported within the applicable timeframes, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to potential adverse health outcomes. Resident #71, who was on anticoagulant medication, exhibited symptoms of gastrointestinal bleeding and had low hemoglobin and hematocrit levels. Despite these significant clinical changes, the resident's care plan did not include documentation of the anticoagulant use or the symptoms of gastrointestinal bleeding. Additionally, a stool sample collected for testing was mishandled, and the results were not tracked, leaving staff unaware of the resident's condition. The Director of Nursing confirmed the absence of a care plan addressing these issues, which was contrary to the facility's policy requiring updates to care plans following a change in medical condition. Resident #134, diagnosed with hypoxemia, was receiving oxygen therapy via a nasal cannula. However, the resident's clinical record lacked a care plan for the diagnosis of hypoxemia and the administration of oxygen. The Director of Nursing acknowledged this oversight, which was inconsistent with the facility's policy mandating the development of person-centered care plans with measurable objectives to meet residents' medical needs. These deficiencies highlight a failure in the facility's care planning process, potentially compromising the residents' health and safety.
Failure to Monitor Lab Results and Communicate Bleeding Symptoms
Penalty
Summary
The facility failed to ensure timely monitoring and communication of laboratory results for a resident on anticoagulant therapy, which could have led to severe adverse health outcomes. Resident #71, who was on apixaban for atrial fibrillation, exhibited signs of gastrointestinal bleeding, such as blood-streaked stool, which was reported by a CNA and observed by a licensed nurse. However, the resident's care plan did not document the use of apixaban or the symptoms of gastrointestinal bleeding, and the fecal occult blood test results were not included in the clinical record. Additionally, the LPN caring for Resident #71 was unaware of the resident's bleeding symptoms or any concerns with lab values. The DON confirmed that the resident's care plan lacked documentation for the blood thinner and the bleeding concern. The stool sample collected was sent to the lab in the wrong container, and a new sample was not sent, resulting in a lack of follow-up on the test results. The facility's policy required updates to the care plan after a change in medical condition, but this was not adhered to in this case.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen for a resident diagnosed with hypoxemia. The resident was admitted to the facility and was observed receiving oxygen via a nasal cannula from an oxygen concentrator set at two liters-per-minute. However, the clinical record for the resident lacked documented evidence of a physician's order for this oxygen therapy. The resident expressed uncertainty about the need for oxygen, having not used it prior to admission. The Director of Nursing confirmed that the resident had been receiving oxygen since admission without a physician's order, which was against the facility's policy that required oxygen therapy to be administered as ordered by a physician or as an emergency measure until an order could be obtained. The deficiency was identified through clinical record review, observation, interview, and document review, highlighting a lapse in following the facility's policy on oxygen administration.
Unsecured Medication Cart Found Unattended
Penalty
Summary
The facility failed to ensure that medications were secured in a medication cart, which could have facilitated unauthorized access. During an observation, a medication cart located outside the nurse's station was found to be unlocked and unattended while a resident and visitors were present in the hallway. The Director of Nursing (DON) confirmed the cart was unlocked and acknowledged that the expectation was for medication carts to remain locked when unattended. The facility's policy on the storage of medication, dated 2007, specifies that only licensed nurses and those lawfully authorized to administer medications are allowed access to medication carts. It also states that medication rooms, cabinets, and supplies should remain locked when not in use or attended by authorized personnel.
Failure to Follow Resident's Diet Order
Penalty
Summary
The facility failed to adhere to a resident's prescribed diet order, resulting in a deficiency. Resident #134, who was admitted with acute kidney failure and chronic kidney disease, was observed receiving meals that did not align with the physician's order. The resident's diet was ordered as a regular diet with regular texture and thin liquid consistency, but the resident was served pureed and mechanically altered foods. The resident expressed confusion and dissatisfaction with the texture of the meals, as they had no swallowing issues and possessed their own teeth. The Dietary Supervisor admitted to a lack of understanding regarding the GI soft diet and incorrectly assumed it to be a mechanically altered diet after searching online. This misunderstanding was not communicated with the nursing staff for clarification. The Director of Nursing confirmed that a GI diet is not mechanically altered and acknowledged that the diet order should have been clarified. Additionally, it was revealed that the facility lacked a policy related to following diet orders, contributing to the oversight.
Failure to Conduct Legionella Testing as per Policy
Penalty
Summary
The facility failed to adhere to its water management policy by not conducting Legionella testing on a five-year basis. During an interview, the Director of Environmental Services acknowledged that the maintenance department was responsible for the water management program but admitted that the facility did not have results of Legionella testing and was unaware of when the last testing occurred. Furthermore, there was no plan in place to conduct future testing. This practice was not in compliance with the facility's policy, which required random water samples to be collected and submitted for Legionella testing every five years to a certified testing facility, with additional testing as needed based on results.
Failure to Complete Annual Elder Abuse Training
Penalty
Summary
The facility failed to ensure that annual elder abuse training was completed for one of its employees, a Registered Nurse hired in December 2015. The personnel record for this employee showed that elder abuse training was last completed in August 2023, but there was no documented evidence of the required annual training being completed in 2024. During an interview, the Human Resources Representative confirmed that all staff were required to complete elder abuse training upon hire and annually thereafter, and acknowledged the absence of the 2024 training documentation for this employee. The facility's policy on abuse prevention and prohibition, revised in May 2023, mandates training for new and existing nursing staff on preventing, identifying, recognizing, and reporting abuse.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide adequate care to prevent Moisture Associated Skin Damage (MASD) and a pressure injury for a resident who was admitted with a displaced intertrochanteric fracture of the left femur and type two diabetes mellitus with a foot ulcer. Initially, the resident's daily skilled note documented no active skin conditions. However, a few days later, a CNA noticed redness and an open area on the resident's coccyx, which was confirmed by a licensed nurse skin evaluation. Despite having a physician's order to apply barrier cream and assist in turning and repositioning every shift, the resident developed MASD and a pressure injury while in the facility. The facility's policy stated that residents who entered without a pressure injury should not develop one unless it was unavoidable due to their clinical condition. The Wound Nurse and the Director of Nursing confirmed that the resident did not have a pressure injury upon admission and that the MASD and pressure injury were acquired at the facility. The deficiency was identified through clinical record review, interviews, and document review, indicating a failure in the facility's skin and wound monitoring and management practices.
Failure to Address Tripping Hazard in Courtyard
Penalty
Summary
The facility failed to address a known tripping hazard in the courtyard, which resulted in a resident tripping over an irrigation sprinkler head and sustaining a fracture to the right elbow and patella. The incident was documented in the Facility Reported Incident (FRI) #NV00071929, but the final report did not include corrective measures to prevent future occurrences of tripping caused by the sprinkler heads. Observations confirmed that five sprinkler heads were raised above ground level, posing a potential tripping hazard. Interviews with facility staff, including the Director of Environmental Services, Director of Nursing (DON), and Operations Manager, revealed a lack of communication and awareness regarding the tripping hazard. The Director of Environmental Services was unaware of the incident, and the DON could not confirm if the information had been conveyed to Maintenance. The Operations Manager also confirmed that the FRI Final Report lacked corrective action to address the hazard. The facility's Fall Management System policy, revised in December 2023, stated that resident environments should be free from hazards, but this was not adhered to in this case.
Failure to Update Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with an indwelling catheter. The resident, who was admitted with chronic kidney disease and benign prostatic hyperplasia, had a physician's order for indwelling catheter care every shift and to change the catheter every 30 days. Despite these orders, the resident's care plan did not include any documentation related to the indwelling catheter or the necessary catheter care. The Director of Nursing (DON) confirmed that the care plan lacked updates to reflect the catheter placement and care requirements. The facility's policy required the interdisciplinary team to develop a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's needs. However, the care plan for this resident was not updated to include the catheter care, which was a responsibility of the DON and the Social Worker.
Dishwasher Malfunction and Expired Food Items
Penalty
Summary
The facility failed to ensure that a high-temperature dishwasher was operating correctly and that expired food items were discarded. During an initial kitchen tour, the dishwasher was observed making a noise, and its final rinse cycle was recorded at 178 degrees Fahrenheit, below the required 180 degrees Fahrenheit. A Cook mentioned that the lower dishwasher sprayers were not working correctly and would get stuck together, but was unsure if a work order had been submitted. The Dietary Supervisor confirmed that no work order had been submitted and acknowledged that the dishwasher was not sanitizing dishes properly due to the malfunctioning sprayers and insufficient rinse temperature. Additionally, expired food items were found in the kitchen. A container of homemade macaroni salad in the reach-in refrigerator was labeled with a prepared date that exceeded the facility's policy of using refrigerated leftovers within 48 hours. In the dry storage room, 12 containers of grits were found with a use-by date that had passed. The Dietary Supervisor confirmed that kitchen staff were responsible for discarding expired foods and acknowledged that the macaroni salad and grits should have been discarded according to the facility's policies.
Failure to Administer Pneumococcal and Influenza Vaccines
Penalty
Summary
The facility failed to ensure that two residents who requested a pneumococcal vaccine were administered the vaccine. Resident #308, who had diagnoses including orthopedic aftercare following surgical amputation, pulmonary hypertension, and heart failure, had a signed consent form for the pneumococcal vaccine, but the vaccine was not administered. Similarly, Resident #55, with a diagnosis of nontraumatic ischemic infarction of the right lower leg, also had a signed consent form for the pneumococcal vaccine, but the vaccine was not administered. The Infection Preventionist confirmed that both residents had signed consents and requested the vaccine, but it was not given to them. The facility's policy stated that pneumococcal immunizations should be offered and administered to eligible residents after obtaining consent, but this was not followed in these cases. Additionally, the facility failed to screen and offer the influenza vaccine to 25 out of 82 residents and did not administer the vaccine to 12 residents who had requested it. The facility received the influenza vaccine from the pharmacy, but the Infection Preventionist confirmed that not all residents were screened or offered the vaccine, and some who requested it did not receive it. The Administrator was unaware of the number of residents who had not been screened or who had requested but not received the influenza vaccine. The facility's policy required that all residents be screened and offered the influenza vaccine annually during flu season, but this was not adhered to, resulting in a significant portion of the resident population not being vaccinated as required.
Failure to Maintain Resident Health Information Privacy
Penalty
Summary
The facility failed to ensure the privacy of resident health information for three residents whose names were visible on an unattended computer screen. The computer, located on top of a treatment cart outside of room five, was logged into the electronic health record (EHR) and displayed the names of three residents under the wounds tab. This occurred while the computer was facing the hallway and unattended, allowing two visitors to walk by and potentially view the resident information. The residents involved had various medical conditions, including acute kidney failure, type two diabetes mellitus, metabolic encephalopathy, and respiratory failure. An LPN returned to the cart and acknowledged forgetting to lock the screen when walking away, which is against the facility's policy. The Director of Nursing (DON) confirmed that staff are expected to log out or lock the screen when leaving a computer unattended to maintain resident privacy. The facility's policy on the use and disclosure of protected health information, revised in March 2016, mandates that such information be used and disclosed in a secure and confidential manner.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to prevent resident-to-resident abuse and neglect. In one incident, a resident with schizoaffective disorder and anxiety disorder attempted to hit another resident with cognitive communication deficit and dementia. The altercation was witnessed by staff, and the residents were separated, with one being moved to a different room. The facility's policy on abuse prevention was not effectively implemented to protect the residents from such incidents. In another incident, a resident with a history of traumatic subdural hemorrhage and memory deficit was found soaked in urine with the call light unplugged. The resident reported that staff had initially responded to the call light but eventually stopped coming into the room. A CNA discovered the resident in the same position as the previous day, indicating neglect. The facility's policy on abuse and neglect prevention was not followed, leading to the resident's needs being unmet and the staff member responsible being terminated.
Late Submission of FRI Final Report
Penalty
Summary
The facility failed to submit a Facility Reported Incident (FRI) final report to the State Survey Agency within the required five-day timeframe for one of seven FRIs investigated. Specifically, FRI# NV00069177, which involved an allegation that a Certified Nursing Assistant had force-fed a resident, was initially reported to the State on 08/09/23. However, the final investigation report was not submitted until 08/17/23, three days past the required deadline. The Director of Nursing (DON) confirmed responsibility for submitting the reports and attributed the delay to a miscalculation of the dates. The facility's policy, reviewed in 10/2022, mandates adherence to State and Federal reporting timeframes for all reports of resident abuse.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were transmitted timely for five sampled residents. Resident #8, diagnosed with cerebral palsy, had a quarterly MDS assessment with a completion date of 10/16/23, which should have been transmitted by 10/23/23 but had not been transmitted by 11/02/23. Resident #9, diagnosed with dementia, had a quarterly MDS assessment completed on 10/10/23, which should have been transmitted by 10/17/23 but was transmitted 15 days late on 11/01/23. Resident #11, diagnosed with type II diabetes mellitus with hyperglycemia, had a quarterly MDS assessment completed on 10/21/23, which should have been transmitted by 10/28/23 but had not been transmitted by 11/02/23. Resident #41, diagnosed with type II diabetes mellitus with diabetic neuropathy, had a quarterly MDS assessment completed on 10/11/23, which should have been transmitted by 10/18/23 but had not been transmitted by 11/02/23. Resident #46, diagnosed with type II diabetes mellitus with hyperglycemia, had a quarterly MDS assessment completed on 10/11/23, which should have been transmitted by 10/18/23 but was transmitted 14 days late on 11/01/23. The MDS Coordinator confirmed the delays in transmission for all five residents and acknowledged that the facility's policy, which follows the Resident Assessment Instrument (RAI) Manual timelines, was not adhered to. The RAI Manual specifies that quarterly assessments must be transmitted within seven days after the completion of the assessment. Despite the facility's policy being in place, the assessments for the sampled residents were not transmitted within the required timeframe, leading to the identified deficiency.
Deficiencies in Care Planning and Communication
Penalty
Summary
The facility failed to ensure that care planned interventions related to cognitive functioning and communication were completed and person-centered for a resident with type II diabetes mellitus. The care plan lacked specific details and interventions for the resident's impaired cognitive function and limited English proficiency. Staff members, including a Hospitality Aide, LPN, and CNA, did not use the designated language line for communication, relying instead on family members and non-clinical staff, which could lead to inaccurate assessments. The Director of Nursing confirmed the care plan was incomplete and not person-centered. Another resident with major depressive disorder and schizoaffective disorder was prescribed Seroquel, but the care plan did not include specific details about the medication, behaviors to monitor, or the diagnosis associated with its use. The clinical record also lacked documented evidence of an assessment to determine the resident's change of condition and new diagnosis requiring psychotropic medication. The Director of Nursing confirmed the care plan was not medication-specific and missing necessary details to make it person-centered. Additionally, the facility failed to develop care plans related to the use of bedrails for a resident with cirrhosis of the liver and mobility issues, and for two residents following incidents of abuse and neglect. One resident's care plan did not include documentation of employee-to-resident neglect, while another resident's care plan lacked details of a resident-to-resident altercation and any changes in services or care to prevent further incidents. The Director of Nursing confirmed these deficiencies in the care plans, which should have included specific interventions and outcomes to ensure proper care and prevent further occurrences.
Medication Administration and Assessment Deficiencies
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during medication preparation and administration for two residents. One resident, who was on pain medication therapy, received oxycodone without the LPN assessing the location and severity of the pain prior to administration. The LPN confirmed this oversight and acknowledged that the pain level should have been assessed before administering the medication. The Director of Nursing (DON) also confirmed that the pain level was supposed to be assessed prior to administration, as per the facility's policy on pain management. Another resident, who had diabetes mellitus, received insulin without the LPN scrubbing the rubber stopper with alcohol before applying the needle. The LPN believed the stopper was already sterile and administered the insulin after the resident had eaten breakfast, despite the insulin being ordered to be administered before meals. The DON confirmed that the rubber stopper should have been wiped with alcohol and that insulin should be administered before meals to ensure its effectiveness. Additionally, the facility failed to adhere to professional standards for assessing and diagnosing a resident with schizoaffective disorder. The resident's clinical record lacked documentation of an assessment to determine the need for psychotropic medication. The DON confirmed that an assessment was required prior to the administration of such medication, and the physician admitted to knowing the resident prior to admission but had no documentation of an assessment. The facility's policy on psychotropic drug use required a documented clinical rationale for administering medication based on an assessment of the resident's condition.
Failure to Provide Translation Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to offer a non-English speaking resident a communication device and/or provide translation services. Resident #26, who had limited English proficiency and a diagnosis of type II diabetes mellitus, was admitted and readmitted to the facility. Despite the resident's Comprehensive Care Plan documenting the need for a language line, staff members, including a Hospitality Aide, a Certified Nursing Assistant, and a Licensed Practical Nurse, did not use the language line to communicate with the resident. Instead, they relied on hand gestures, short sentences, and assistance from family members who visited infrequently. The Director of Nursing confirmed that translation services were supposed to be used, especially during assessments, and acknowledged that using family and non-clinical staff for translation could lead to inaccurate assessments. The facility's Language Access Plan (LAP) outlined the requirement to provide equitable and meaningful access to services for individuals with Limited English Proficiency, in accordance with section 1557 of the Affordable Care Act. The LAP specified that staff should be trained to access written translations and oral language assistance services effectively. It also stated that individuals were not required to provide their own interpreters, and the facility should not rely on minors or adult friends and family for interpretation. Despite these guidelines, the facility did not adhere to the LAP, resulting in a failure to provide appropriate communication support for Resident #26.
Failure to Coordinate Care with Hospice Agency
Penalty
Summary
The facility failed to ensure coordinated care with a hospice agency for a resident receiving hospice services. Resident #34, who was admitted with diagnoses including tubulo-interstitial nephritis, quadriplegia, and a history of transient ischemic attack, expressed concerns that the facility did not follow hospice instructions. Despite a physician's order to admit the resident to hospice and a care plan indicating regular visits from hospice staff, there was a lack of documentation in the hospice binder and the electronic health record (EHR) regarding the care provided by hospice aides. The Licensed Social Worker (LSW) and Director of Nursing (DON) confirmed the absence of necessary documentation, which was supposed to be maintained as per the Hospice Services Agreement and facility policy. Interviews with the resident, Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), and LSW revealed that hospice aides did not consistently report their visits or document the care provided. The LSW and DON acknowledged that the hospice agency was required to check in with facility staff and document care in the hospice binder, but this was not done. The most recent documentation from hospice in the EHR was dated 10/16/23, indicating a significant gap in record-keeping and communication between the hospice agency and the facility staff.
Failure to Assess Pain Before Administering Medication
Penalty
Summary
The facility failed to ensure a resident's pain level and location were assessed prior to the administration of an as-needed (prn) narcotic pain medication. Resident #56, who had diagnoses including polyneuropathy, unspecified osteoarthritis, and opioid dependence, was observed receiving 10 mg of oxycodone from an LPN. The LPN asked the resident for their pain level and location only after administering the medication. The LPN confirmed this sequence of actions and acknowledged that the pain assessment should have been conducted before administering the medication. The Director of Nursing also confirmed that the facility's policy required pain assessment prior to the administration of prn pain medications to ensure appropriateness. The facility's policy on Pain Recognition and Management, revised in January 2022, documented the need for interviewing and evaluating residents for pain before administering pain management interventions.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to ensure that appropriate alternatives were attempted and implemented before using bed rails for Resident #31. The resident, who had diagnoses including unspecified cirrhosis of the liver, difficulty in walking, and unsteadiness of feet, was observed with half bedrails up on both sides of the bed. The resident's physician had ordered bilateral quarter-size bed side rails for improved safety and stability during mobility. However, the clinical record lacked documented evidence of alternatives tried and failed before the use of bed rails. The Director of Nursing confirmed that therapy should complete an evaluation and obtain consent prior to a resident using bed rails, which was not documented in Resident #31's case. The facility's policy required the use of appropriate alternatives before installing bed rails, which was not followed in this instance.
Failure to Assess Need for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident on a psychotropic medication had an assessment addressing why the medication was prescribed. Resident #40, who was admitted with diagnoses including major depressive disorder, type 2 diabetes mellitus without complications, and restless legs syndrome, had a new diagnosis of schizoaffective disorder documented on the Resident Information sheet. A physician's order for Seroquel, a psychotropic medication, was renewed without an assessment to determine the resident's change of condition and the necessity of the medication. The care plan for Resident #40 also lacked documentation of the Seroquel, behaviors to monitor, completed assessments, and the diagnosis associated with the medication. The Director of Nursing confirmed that an assessment was required prior to the administration of psychotropic medications and acknowledged that Resident #40's clinical record lacked such documentation. The facility's policy on psychotropic drug use, revised in 2017, stated that psychotropic medications should only be considered after non-pharmacological interventions had been attempted and failed, and that an identified documented clinical rationale based on an assessment of the resident's condition was necessary. This policy was not followed in the case of Resident #40.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medication was administered with an error rate of less than 5%. There were 33 opportunities and 11 medication errors, resulting in a medication error rate of 33.33%. For Resident #56, an LPN administered 10 mg of oxycodone without assessing the resident's pain level beforehand, which is required to determine the appropriateness of the medication. Additionally, the LPN administered Geri-Kot instead of the prescribed Senna Plus, incorrectly assuming they were the same medication. The LPN later confirmed the error upon reviewing the MAR and medication label. For Resident #7, the LPN did not scrub the rubber stopper of the insulin pen with alcohol before applying the needle and administered the insulin after the resident had eaten breakfast, contrary to the prescribed timing. The LPN also failed to administer several 7:00 AM medications on time, including calcium, loratadine, probiotic, docusate sodium, famotidine, potassium chloride, gabapentin, and nystatin powder. The facility's policy requires medications to be administered within one hour before or after the ordered time frame, which was not adhered to in these instances.
Failure to Administer Influenza Vaccines Timely
Penalty
Summary
The facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify that 45.11% of the facility's residents had not been screened for influenza vaccination or had been screened and desired to receive the influenza vaccine, but the vaccine was not administered. This deficiency was confirmed by the Administrator on 11/02/23. The facility's policy, titled QAPI Plan and dated 2022-2023, documented that the QAPI plan was ongoing and comprehensive, aiming to correct identified deficiencies in quality services and ensure consistent performance improvement. However, the QAPI committee did not identify the delay in administering influenza vaccines after receiving the supplies, potentially affecting the health and safety of the residents during the influenza season.
Infection Control Lapse in Insulin Administration
Penalty
Summary
The facility failed to ensure appropriate infection control practices were adhered to when preparing an insulin pen for insulin administration for Resident #7. Resident #7, who was admitted with diagnoses including type two diabetes mellitus with diabetic neuropathy and hyperglycemia, was observed on 11/01/23 at 7:36 AM when an LPN prepared insulin for administration. The LPN applied the needle to the insulin pen without scrubbing the rubber stopper with alcohol. The LPN confirmed this oversight, believing the stopper to already be sterile. The Director of Nursing later confirmed that the rubber stopper should have been wiped with alcohol prior to needle insertion, as per the facility's policy revised in 03/2023.
Failure to Administer COVID-19 Vaccine as Requested
Penalty
Summary
The facility failed to ensure a COVID-19 vaccine was administered as requested for one resident. Resident #308, who was admitted with diagnoses including orthopedic aftercare following surgical amputation, pulmonary hypertension, and heart failure, had a signed consent form from their representative dated 10/27/23, indicating the resident wished to receive the COVID vaccine. However, the facility's Immunization Report dated 10/31/23 showed that while consent was obtained, there was no documented evidence that the vaccine was administered. This was confirmed by the Infection Preventionist on 11/01/23. The facility's policy, last reviewed in July 2023, required that COVID immunizations be offered and administered to eligible residents after obtaining consent and that vaccination details be documented in the medical record, which was not done in this case.
Failure to Ensure Timely Elder Abuse Training
Penalty
Summary
The facility failed to ensure timely completion of elder abuse training for 7 out of 20 sampled employees. Employee #4, hired as the Infection Preventionist, completed the training two days after the hire date. Employee #12, a CNA, completed the training a week after the hire date. Employee #20, the Registered Dietician, had no documented evidence of completing the training. Employee #21, a Registered Nurse, completed the training 20 days after the hire date. Employee #22, an LPN, completed the training three weeks after the hire date. Employee #23, another LPN, completed the training over a month after the hire date. Employee #24, a CNA, completed the training 18 days after the hire date. The Human Resources Representative confirmed that elder abuse training was supposed to be completed during employee orientation and annually thereafter. The facility's policy on abuse prevention, reviewed in October 2022, stated that the facility would engage in training and orienting new and existing nursing staff on topics such as prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. The HR Representative acknowledged that the training for the mentioned employees was not completed in a timely manner, which is a violation of the facility's policy.
Latest citations in Nevada
Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
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