Royal Springs Healthcare And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 8501 Del Webb Blvd, Las Vegas, Nevada 89134
- CMS Provider Number
- 295073
- Inspections on file
- 20
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Royal Springs Healthcare And Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility failed to update comprehensive care plans after significant changes in two residents’ conditions and treatments. One resident with hydronephrosis returned from the hospital with only one nephrostomy tube after the other was replaced with a stent, but the care plan continued to reference bilateral nephrostomy tubes and was not revised to reflect the new status. Another resident with lung cancer returned from a hospitalization under hospice care with a change in code status from full code to DNR, supported by a hospice DNR election form, yet the comprehensive care plan was not updated to include the hospice status or new code status. These omissions were confirmed by facility nursing leadership and were inconsistent with the facility’s policy requiring ongoing assessment and revision of care plans when residents’ conditions change.
A hospice resident with metastatic lung cancer, previously documented as full code, returned from a hospital stay under hospice care, but the facility did not obtain or maintain required hospice documents, including a DNR POLST, hospice election form, and physician certification of terminal illness, as required by policy and the hospice agreement. When the resident was later found unresponsive but with vital signs, an RN contacted hospice and the family, but only a DNR election form without a physician signature could be produced, and it took time to arrive. The family began compressions and called 911, and EMS requested hospice documents and a DNR POLST that the facility could not provide, leading to the resident’s transfer to the hospital. Surveyors found that the absence of a DNR POLST and complete hospice paperwork caused confusion among staff and emergency personnel and placed hospice residents at risk for their advance directives not being honored.
The facility experienced significant staffing shortages on weekends from December 2024 to February 2025, resulting in delayed and inadequate care for residents. The facility's staffing levels were below the national average, with numerous instances of missing licensed nurses and CNAs. Staff and residents reported increased complaints, burnout, and dissatisfaction due to the low staffing levels, which affected the quality of care provided. The facility's failure to maintain sufficient nursing staff contributed to its one-star rating.
The facility failed to manage discontinued and expired medications in two medication rooms, risking medication errors. In 200 Hall, discontinued and expired medications like Cefepime and Teflaro were found mixed in the active supply. In 300 Hall, Lovenox injections, discontinued for a resident, were not removed. The facility's policy requires such medications to be destroyed or returned, but this was not followed.
The facility failed to complete PASARR level two referrals for five residents with newly identified psychiatric diagnoses, such as bipolar disorder and schizophrenia. Despite initial PASARR level one screenings indicating no mental illness, these residents were later diagnosed with psychiatric conditions during their stay. The Behavioral Coordinator and Director of Nursing acknowledged a knowledge deficit in the PASARR referral process, and the facility's policy identified the social worker as responsible for referrals, yet they were not trained or involved in the process.
The facility failed to update care plans for four residents, resulting in unaddressed weight loss and lack of restorative nursing services. Two residents with significant weight loss did not receive 1:1 feeding assistance as ordered, and two others with mobility issues were not provided RNA services despite therapy recommendations. The care plans were not revised to reflect these necessary interventions.
Two residents did not receive restorative nursing services due to staffing shortages and communication failures. One resident, with hemiplegia, expressed concerns about not receiving services after therapy coverage ended, while another resident with a traumatic brain injury was never placed on the restorative nursing case load. The facility's understaffing and lack of communication with attending physicians contributed to the deficiency.
Two residents with significant weight loss did not receive timely one-on-one feeding assistance as ordered, leading to improper food temperatures and inconsistent meal consumption. CNAs were overburdened with 15 residents each, including those needing feeding assistance, contributing to the delay. The facility's previous restorative dining program, which could have mitigated this issue, was discontinued during COVID and not reinstated.
A facility failed to deliver prescribed enteral feeding volumes for a resident with a gastrostomy, resulting in a significant deficit over three days. Additionally, another resident receiving tube feeding for dysphagia was observed with their head of the bed flat, contrary to orders requiring elevation to prevent aspiration. These deficiencies were confirmed by facility staff and were not in compliance with the facility's enteral feeding policy.
A facility failed to obtain and implement a physician's order for a resident's oxygen (O2) use, despite the resident's continuous O2 administration for shortness of breath and pulmonary disease. The resident's medical records lacked documentation of a physician's order or care plan, and the humidifier bottle was undated and empty. Staff confirmed the absence of necessary orders and care plans, contrary to the facility's oxygen therapy policy.
A facility failed to provide proper dialysis care for a resident with end-stage renal disease. The resident's medical records lacked documentation of a physician's order for dialysis, monitoring of the dialysis access, and pre- and post-dialysis vital signs. Staff confirmed that vital signs should have been taken before and after dialysis, but this was not done. The facility's policy required documentation of dialysis observations, but the necessary forms were incomplete.
The facility's FA was not updated to reflect current staffing needs and services, missing documentation on resident care requirements, services provided, and risk assessments. The AIT and DON confirmed the absence of leadership involvement and a staffing plan, despite a QAPI meeting to finalize the FA.
The facility's QAPI committee failed to effectively manage staffing issues, including a PIP for staffing shortages, high staff turnover, and low weekend staffing. The PIP was outdated, and no root cause analysis was conducted for the high turnover rate. Additionally, the facility did not maintain oversight over weekend staffing, leading to increased staff and resident complaints.
The facility failed to adhere to infection control practices in the nourishment room, where a staff member was observed drinking, ice was improperly placed in a handwashing sink, and the trash can was overflowing. Loose ice was also found in the freezer around food products. Interviews revealed a lack of awareness about proper procedures, and the Infection Preventionist confirmed these practices were against facility policies.
A resident with chronic heart failure experienced a decline in condition due to the facility's failure to adequately assess and monitor their symptoms. Despite reporting chest pain and shortness of breath, the resident did not receive timely or thorough assessments, leading to a lack of communication with the medical provider. The resident was eventually hospitalized and passed away from cardiogenic shock, highlighting deficiencies in the facility's care protocols and documentation practices.
A facility failed to assist a resident with hygiene needs, specifically facial shaving, despite the resident's scheduled shower days. The resident, with multiple medical conditions, was observed with a thick beard and expressed that shaving had not occurred as expected. Staff confirmed the resident's lack of personal clothing and the use of donated clothing, as well as the expectation for shaving on shower days. Facility logs lacked evidence of shaving, contrary to policy requirements for grooming assistance.
Failure to Revise Care Plans After Changes in Nephrostomy Status and Code Status
Penalty
Summary
The deficiency involves the facility’s failure to revise comprehensive care plans within 7 days of comprehensive assessments and when residents’ conditions or treatments changed. For one resident with hydronephrosis and bilateral nephrostomy tubes, the care plan initiated in mid-February 2025 identified bilateral nephrostomy tubes and included goals and interventions such as monitoring for infection, checking tubing for kinks, monitoring and recording output, and monitoring discomfort. A subsequent hospital discharge summary documented that the left nephrostomy tube was removed and replaced with a stent, and the resident returned with only a right-sided nephrostomy tube. The medical record contained no evidence that the care plan was updated to reflect the removal of the left nephrostomy tube, and the Unit Manager acknowledged that the care plan had not been revised and that this would have been an appropriate time to add interventions such as site cleansing and dressing changes per facility policy. The deficiency also includes a failure to update the comprehensive care plan for another resident who returned from the hospital under hospice care with a change in code status. This resident, admitted with malignant neoplasm of the bronchus or lung, initially had a POLST indicating no decisional capacity and a family election of full code/attempt resuscitation. After hospitalization for acute on chronic hypoxic respiratory failure, the resident returned under hospice care, and a hospice DNR election form documented the family’s agreement to allow natural death and not perform procedures to restart the heart. Despite these changes, the comprehensive care plan was not revised to reflect the resident’s hospice status or the change in code status from full code to DNR. The DON confirmed that the care plan did not reflect these changes, contrary to the facility’s policy stating that assessments are ongoing and care plans are revised as residents’ conditions change.
Failure to Maintain and Provide DNR POLST and Hospice Documentation
Penalty
Summary
The facility failed to ensure that a physician’s order for life-sustaining treatment (POLST) and required hospice documentation were obtained, maintained on-site, and made available to emergency personnel for a hospice resident with metastatic lung cancer. The resident was initially admitted as full code with a POLST indicating full resuscitation, later hospitalized for acute on chronic hypoxic respiratory failure, and then returned under hospice care. A hospice policy and hospice agreement required the facility to maintain the most recent care plan including advance directives, the hospice election form, physician certification of terminal illness, and other hospice orders. However, review of the hospice binder and medical record showed that the hospice election form, physician certification of terminal illness, and advanced directives including a DNR POLST reflecting the resident’s DNR status were missing. The DON confirmed that the hospice DNR election form alone was not an acceptable substitute in the state because it lacked a physician’s order. On the day of the incident, the RN found the hospice resident unresponsive but with vital signs during morning rounds and contacted hospice and the family. The RN reported that there was no DNR POLST in the hospice binder and hospice could only provide a DNR election form, which took time to be received and did not have a physician’s signature. During this period, the family panicked over the resident’s unresponsive state, began chest compressions, and another family member called 911. When emergency medical services arrived, they requested hospice documents and the DNR POLST, but the facility was unable to provide them, and the resident was transported to the hospital. Surveyors determined that the lack of a DNR POLST and other required hospice paperwork in the facility, contrary to facility policy and the hospice agreement, resulted in confusion among staff and emergency personnel and placed hospice residents at risk for advance directives not being honored at end of life.
Inadequate Weekend Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate nursing staff coverage during weekends from December 2024 through February 2025, leading to inappropriate and delayed care for residents. The Payroll-Based Journal (PBJ) Staffing Data Report indicated excessively low weekend staffing, with the facility utilizing 2.1 total nursing hours per resident per day, significantly below the national average of 3.355 hours. The facility's staffing schedules and timesheets confirmed numerous instances of missing licensed nurses and CNAs on both day and night shifts across multiple weekends, resulting in increased staff complaints, burnout, and resident dissatisfaction. Interviews with staff and residents highlighted the impact of staffing shortages on care quality. A CNA reported being assigned up to 20 residents when working short-staffed, which compromised the quality of care provided. During a resident council meeting, a resident reported waiting over six hours for a call light response due to low weekend staffing. Another resident noted consistent understaffing on night shifts, with only two nurses present instead of the scheduled five, leading to overworked CNAs who eventually quit. The Director of Nursing (DON) and the Scheduler acknowledged the staffing deficiencies and verified the accuracy of the schedules. They noted increased staff complaints and burnout, with staff transferring to weekday positions when available. The facility's failure to maintain sufficient nursing staff with the necessary competencies and skills resulted in unmet resident needs, as evidenced by the challenges reported by CNAs in providing essential care such as showering, turning, repositioning, and feeding. The facility's staffing issues contributed to its one-star rating as of January 2025, down from a two-star rating previously.
Failure to Remove Discontinued and Expired Medications
Penalty
Summary
The facility failed to properly manage discontinued and expired medications in two of its three medication rooms, which could lead to medication errors. During an inspection of the medication room in 200 Hall, accompanied by an LPN, it was found that several medications, including Cefepime, Teflaro, Meropenem, and Sodium Chloride solutions, had been discontinued for discharged residents and some had expired. The LPN and the Unit Manager confirmed these medications should have been removed from the active supply for destruction or return but were instead mixed back in. Additionally, expired supplies such as BD SurePath collection containers and BinaxNOW boxes were also found in the active supply. In the medication room in 300 Hall, another LPN confirmed that Lovenox injections, discontinued for a resident upon discharge, had not been removed from the active supply. The Unit Manager acknowledged the oversight in checking the medication room and missing the separation of these medications. The facility's policy on the storage of medications, revised in September 2019, clearly states that discontinued or expired drugs and biologicals should not be used and must be returned to the dispensing pharmacy or destroyed, highlighting a failure to adhere to this policy.
Failure to Complete PASARR Level Two Referrals for Residents with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete Preadmission Screening and Resident Review (PASARR) level two referrals for five residents with newly identified psychiatric diagnoses. These residents were initially admitted with PASARR level one screenings that did not indicate mental illness, intellectual disability, or related conditions, and were deemed appropriate for nursing facility placement. However, during their stay, these residents were diagnosed with various psychiatric conditions such as bipolar disorder, depression, anxiety disorder, and schizophrenia, which were not followed by the necessary PASARR level two referrals. The Behavioral Coordinator, responsible for PASARR for the past two years, admitted to a lack of knowledge regarding the criteria for referring residents for a new level of care or PASARR level two. This knowledge deficit resulted in the failure to refer residents with newly identified psychiatric conditions for further evaluation and determination. The Director of Nursing also acknowledged the facility's knowledge deficit in the PASARR referral process, noting that the interdisciplinary team was not well-versed in identifying residents who met the criteria for a new level of care or PASARR level two referral. The facility's PASARR policy, revised in December 2006, stated that residents with level one screenings who meet criteria for mental illness, intellectual disability, or related disorders should be referred to the state PASARR representative for level two screening. However, the policy identified the social worker as responsible for the referral process, yet the social worker was neither trained nor involved in the PASARR process. This lack of training and involvement contributed to the facility's failure to ensure appropriate referrals for residents with newly identified psychiatric diagnoses.
Failure to Revise Care Plans for Nutrition and Mobility
Penalty
Summary
The facility failed to revise comprehensive care plans to reflect new interventions for nutrition and mobility for four residents. Two residents, one with hemiplegia and hemiparesis and another with mild neurocognitive disorder and protein calorie malnutrition, experienced significant weight loss over a three-month period. Despite physician orders for 1:1 feeding assistance, both residents were observed without staff assistance during meals, and their care plans were not updated to include these new interventions. Additionally, two other residents with mobility issues were not provided with restorative nursing services as recommended by therapy discharge summaries. One resident, with hemiplegia and hemiparesis, expressed concerns about not receiving RNA services due to staff shortages, which were supposed to be provided three times a week. The other resident, with a traumatic brain injury and epilepsy, was also not receiving RNA services despite recommendations to maintain their current level of performance and prevent decline. The Director of Nursing and Unit Manager confirmed that the care plans for these residents were not revised to include the necessary interventions, which should have been done according to the facility's Comprehensive Care Plan policy. This policy requires care plans to be updated when a resident's condition changes or when new interventions are added.
Failure to Provide Restorative Nursing Services Due to Staffing and Communication Issues
Penalty
Summary
The facility failed to provide restorative nursing services to two residents, leading to potential declines in their functional abilities. Resident 156, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, expressed concerns about not receiving restorative nursing services due to staffing shortages. The resident had previously received physical and occupational therapy, but after insurance coverage ended, was placed on restorative nursing services, which were not consistently provided due to the departure of two restorative nurse aides. The Director of Rehabilitation and the 100-Hall Unit Manager confirmed that the therapy recommendations for restorative nursing services were not communicated to the resident's attending physician, which contributed to the lack of service provision. Resident 67, admitted with diagnoses including traumatic brain injury and epilepsy, also did not receive restorative nursing services after being discharged from physical and occupational therapy. The Director of Rehabilitation was unaware if the therapy recommendations were communicated to the appropriate staff, and the medical record lacked evidence of such communication. The Unit Manager and the restorative nurse aide confirmed that Resident 67 was never placed on the restorative nursing case load due to a breakdown in communication, resulting in the resident not receiving the necessary services. The Director of Nursing acknowledged that the facility was understaffed, with only one restorative nurse aide responsible for multiple tasks, making it impossible to provide adequate restorative nursing services to all residents in need. The facility's policy stated that residents should receive nursing care to promote safety and independence, but the lack of communication and staffing issues led to a failure in providing these services, potentially impacting the residents' quality of life.
Failure to Provide Timely Feeding Assistance
Penalty
Summary
The facility failed to provide timely feeding assistance to two residents, Resident 110 and Resident 84, who had physician's orders for one-on-one feeding assistance. Resident 110, diagnosed with hemiplegia and hemiparesis following a cerebral infarction, experienced significant weight loss over a three-month period. Despite having a physician's order for one-on-one assistance with meals, staff often left Resident 110's meal tray unattended, resulting in food being served at improper temperatures, which affected the resident's appetite and meal consumption. Resident 84, diagnosed with mild neurocognitive disorder and protein-calorie malnutrition, also experienced significant weight loss. The resident had orders for one-on-one feeding assistance due to fluctuating meal consumptions related to cognitive issues. However, staff served Resident 84's meal tray without immediate assistance, leading to inconsistent meal consumption. Both residents were part of a larger issue where CNAs were assigned to care for 15 residents each, including multiple residents requiring feeding assistance, which contributed to the delay in providing necessary one-on-one feeding support. The Unit Manager and Registered Dietitian confirmed the significant weight loss and the need for one-on-one feeding assistance for both residents. They acknowledged that the facility's previous restorative dining program, which allowed staff to assist multiple residents simultaneously, had been discontinued during COVID and had not been reinstated. The Director of Nursing emphasized the importance of following physician's orders for one-on-one feeding assistance and acknowledged that the facility had not discussed reinstating the restorative dining program in their Quality Assurance Performance Improvement meetings.
Deficiencies in Enteral Feeding Administration and Positioning
Penalty
Summary
The facility failed to ensure that enteral feeding was completely delivered as ordered for one resident, identified as Resident 105. The resident was admitted with diagnoses including bed confinement and gastrostomy, requiring tube feeding due to Pelizaeus-Merzbacher disease. The physician's order specified a continuous infusion of Jevity 1.2 at a rate of 70 ml per hour for 20 hours daily. However, observations revealed that the feeding was frequently paused or not infusing, and the total volume delivered over three days was significantly less than ordered, resulting in a deficit of 1,221 ml. The Registered Nurse and Unit Manager confirmed the feeding was not completed as prescribed, and the Registered Dietitian noted the deficit could contribute to malnutrition. Another deficiency was identified for Resident 136, who required tube feeding due to dysphagia and had a physician's order to keep the head of the bed elevated during and after feeding to prevent aspiration. Observations showed that the resident's head of the bed was flat while the tube feeding was running, contrary to the care plan and physician's order. The RN Unit Manager confirmed the head of the bed was not elevated as required, acknowledging that staff might have failed to reposition the resident after providing care. The facility's policy on enteral tube feeding required verification of physician orders and adherence to procedures, including labeling the formula and maintaining the head of the bed at a semi-Fowler's position during feeding. These deficiencies in following prescribed orders and facility policies could lead to inadequate nutrition and increased risk of complications for the residents involved.
Failure to Obtain and Implement Physician's Orders for Oxygen Use
Penalty
Summary
The facility failed to ensure a physician's order for oxygen (O2) use and care orders were obtained and implemented for a resident with diagnoses including shortness of breath and pulmonary disease. The resident was observed receiving O2 at 2 liters per minute (LPM) via nasal cannula, with an undated and empty humidifier bottle, indicating a lack of proper documentation and care planning. Despite the resident's continuous O2 use, there was no documented evidence of a physician's order or care plan until several days after the resident's admission. Interviews with facility staff, including a registered nurse and the unit manager, confirmed the absence of necessary O2 orders and care plans. The staff acknowledged that O2 use required a physician's order, transcription into the medication administration record, and inclusion in the care plan, none of which were completed in a timely manner. The facility's policy on oxygen therapy, which mandates administration based on physician's orders and proper labeling and dating of equipment, was not adhered to, resulting in a deficiency in the resident's care.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to ensure proper dialysis care for a resident with end-stage renal disease, who was dependent on renal dialysis. The resident's medical records lacked documentation of a physician's order for dialysis, monitoring of the dialysis access, and pre- and post-dialysis vital signs. Observations and interviews revealed that the resident's dialysis port was not assessed at the facility, and vital signs were not taken immediately before leaving for dialysis or upon return, as required. Licensed staff confirmed that vital signs should have been taken shortly before the resident left for dialysis and upon return to monitor for potential hypotension. The facility's policy required shunt sites to be checked every shift and evaluated after each dialysis treatment for complications, with documentation of pre- and post-dialysis observations, including vital signs and the condition of the shunt site. However, the Unit Manager and Director of Nursing confirmed that the dialysis orders were not fully transcribed into the Medication Administration Record, and the dialysis communication forms were incomplete. This lack of documentation and monitoring could compromise the resident's health and safety.
Facility Assessment Lacks Critical Updates and Documentation
Penalty
Summary
The facility failed to ensure that the Facility Assessment (FA) was updated to accurately reflect the current staffing needs and services provided, as well as to include all required components. The FA, last updated on January 2, 2025, was missing critical documentation such as the care required by the resident population, services provided, and a facility-based and community-based risk assessment using an all-hazards approach. Additionally, the FA lacked active involvement from nursing home leadership and management, and did not include information on staffing levels needed for specific shifts. The Administrator-in-Training (AIT) and the Director of Nurses (DON) confirmed these deficiencies during interviews. The AIT was unable to find documentation of the types of services provided by the facility, such as respiratory therapy and wound care, and acknowledged the absence of a qualitative tool for risk assessment. Furthermore, the FA did not evaluate the resident population's acuity or include a staffing plan. The DON indicated that the Quality Assurance and Performance Improvement (QAPI) committee had convened to finalize the FA, but the staffing plan was not reviewed or included at that time.
Inadequate QAPI Oversight on Staffing Issues
Penalty
Summary
The facility failed to ensure the effective implementation and oversight of its Quality Assurance Performance Improvement Plan (QAPI) concerning staffing issues. The QAPI committee did not adequately follow through on the Performance Improvement Project (PIP) for staffing shortages, which was initiated in December 2021. Although the PIP identified pay rate and benefits as root causes and outlined action plans such as offering competitive pay, bonuses, and utilizing agency staff, there was no documentation to confirm whether these measures were still effective or if new interventions were needed. The Director of Nursing (DON) acknowledged that the PIP was not current, as the facility had stopped using agency nurses since 2022, and staffing issues had not been discussed in recent QAPI meetings. The facility also failed to conduct a root cause analysis on its high staff turnover rate. The CMS Provider Rating Report indicated a significant turnover rate for registered nurses and all nursing staff, with 51 licensed nurses leaving the facility over a one-year period. The DON and staff scheduler confirmed the turnover but admitted that the facility lacked a formal process for identifying reasons for staff departures, such as conducting exit interviews. The Human Resources Director corroborated this, noting that exit interviews were not routinely conducted, and reasons for staff leaving were informally gathered and not systematically analyzed. Additionally, the facility did not maintain adequate oversight over low weekend staffing patterns. The CMS Payroll-Based Journal Staffing Data Report highlighted excessively low weekend staffing, which was confirmed by the DON and staff scheduler upon reviewing staffing schedules. The DON reported increased staff complaints about weekend staffing and burnout, as well as resident complaints regarding call light response times. Despite these issues, the QAPI process was not fully utilized to address the staffing shortage, high turnover, and weekend staffing problems, as acknowledged by the DON.
Infection Control Lapses in Nourishment Room
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in the nourishment room, as observed on February 11, 2025. A staff member was seen consuming a drink while seated next to a handwashing sink, which is against facility policy. Additionally, a clear bag filled with cubed ice was improperly placed inside the handwashing sink, and the trash can was overflowing onto the floor. Loose cubed ice was also found at the bottom of the freezer and around food products, which could lead to contamination. Interviews with the Food Service Director and a Registered Nurse revealed a lack of awareness regarding the improper use of the handwashing sink for melting ice and the necessity of maintaining cleanliness in the nourishment room. The Infection Preventionist confirmed that these practices were not in line with infection control standards, as outlined in the facility's policies on employee hygiene, sanitary practices, and housekeeping. These deficiencies in maintaining a clean and safe environment in the nourishment room had the potential to cause the spread of bacteria.
Failure to Monitor Resident with Change in Condition
Penalty
Summary
The facility failed to adequately assess, re-assess, and monitor a resident, identified as Resident 3 (R3), who experienced a change in condition. R3 was admitted with chronic heart failure and was capable of communicating needs. The resident reported chest pain and shortness of breath to a family member, which led to a chest x-ray revealing pleural effusions. Despite these symptoms, there was a significant lack of documentation and follow-up assessments by the nursing staff over several days, which contributed to the resident's acute physical decline. The clinical notes for R3 showed gaps in documentation and monitoring, with no focused or complete assessments conducted to establish a baseline or identify potential causes of the symptoms. The notes indicated that R3's condition was not adequately monitored, with long intervals between progress notes and insufficient reassessment of the resident's respiratory and cardiac status. The facility's failure to perform regular and thorough assessments, as well as to document these assessments, meant that critical changes in R3's condition were not communicated effectively to the medical provider. Interviews with facility staff, including LPNs and the Director of Nurses (DON), revealed a lack of awareness and adherence to protocols for managing residents with chest pain and congestive heart failure. The DON acknowledged that the nurses did not perform necessary assessments and that the medical provider relied on detailed clinical information from the nursing staff to make informed decisions. The absence of a facility policy for nursing standards of practice and the reliance on the Nevada Nurse Practice Act further highlighted the deficiencies in the facility's approach to resident care. Ultimately, R3 was transported to the hospital, where they passed away due to cardiogenic shock, a condition that might have been mitigated with timely and appropriate interventions by the facility staff.
Failure to Assist Resident with Hygiene Needs
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect by not assisting with the resident's hygiene needs. The resident, who was admitted with diagnoses including traumatic hemorrhage of the cerebrum, type 2 diabetes mellitus, chronic obstructive pulmonary disease, muscle wasting and atrophy, and dysphagia, was observed in bed wearing a clean medical gown but had not been shaved, resulting in a thick beard. The resident expressed that they were admitted with very few clothes and preferred to wear the facility-provided gowns. The resident also mentioned that they had been shaved about three weeks ago during a shower but not during the most recent shower, despite the expectation that shaving occurs on shower days. Interviews with facility staff, including a CNA and an LPN, confirmed that the resident did not have personal clothing upon admission and was provided with donated clothing. The staff also confirmed that the resident's shower days were scheduled for Tuesdays and Fridays, and that shaving should occur on these days. However, the facility's daily shower monitoring logs did not provide evidence that the resident was being shaved on these scheduled shower days. The facility's policy and procedure manuals emphasize the importance of assisting residents with grooming and dressing after showers, as well as treating residents with respect, kindness, and dignity.
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Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
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