Silver Hills Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 3450 N Buffalo Dr, Las Vegas, Nevada 89129
- CMS Provider Number
- 295066
- Inspections on file
- 29
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Silver Hills Health Care Center during CMS and state inspections, most recent first.
A resident with dementia reported that a staff member, described as a friend, used the resident's bank card to withdraw cash, resulting in unauthorized withdrawals and missing items. The facility did not thoroughly investigate the incident, failed to document interviews with the CNA involved, and did not report the CNA to the State Board of Nursing as required by policy.
A resident with Alzheimer's disease and dementia had an allegation of misappropriation of property documented by nursing staff, but the facility did not report the incident to the State Agency within the required timeframe. Staff interviews confirmed knowledge of the policy requiring immediate reporting, but the process used—entering information into the electronic health record—resulted in a delay, and the report was not submitted until two days after the allegation was documented.
A resident was found with melatonin gummies at their bedside without a completed assessment or physician's order for self-administration. The RN was unaware of the medication, and the DON confirmed the lack of necessary documentation and approval. Facility policy requires a nurse's evaluation, interdisciplinary assessment, physician's approval, and secured storage for self-administration, which were not followed.
A resident reported rough handling and rude behavior by staff during care, but the facility failed to conduct a thorough investigation. The Social Services Assistant identified the staff member involved, and the Director of Nursing adjusted the staff schedule. However, no interviews with staff or other residents were conducted, and the facility did not complete a thorough investigation as required by their policy.
The facility failed to document adequate discharge planning for two residents, leading to deficiencies in ensuring safe discharges. One resident with multiple medical conditions did not have documented discharge planning before a Medicare Non-Coverage notice, and the second resident with paralysis had discharge planning notes kept on a personal tracker, not in the medical record. The facility lacked a formal discharge planning policy.
A resident with a fracture and muscle weakness required maximal assistance for bathing. The facility failed to adhere to the scheduled twice-weekly bathing, as documentation showed missed bathing days. Staff confirmed the schedule, but records lacked entries for several days, indicating a deficiency in care.
The facility failed to properly label, date, and store food and cleaning agents, and did not maintain clean ice machines. Expired water cartons were found in the cooler, and a spray bottle with an unidentified liquid was improperly stored. Ice machines had debris buildup, indicating a failure to maintain sanitary conditions.
The facility failed to provide necessary assistance with ADLs for three residents, leading to potential health risks. One resident was not repositioned or assisted during night shifts, another was left in urine for hours, and a third was not checked or changed for long periods. The MDS Director and DON confirmed the lack of documentation and assistance.
A resident with a pulmonary embolism did not receive their prescribed Lovenox medication on time due to it being out of stock. An LPN was unable to find the medication in the cart or back-up supply, leading to a delay of more than 12 hours in administration. The physician noted that this delay increased the risk of another embolism. The facility's policy lacked guidance on managing low or unavailable medications.
A resident with muscle wasting and weakness was not administered Gabapentin as scheduled, compromising pain management. The medication was often given outside the prescribed one-hour window, as confirmed by the DON and an LPN, contrary to the facility's policy.
The facility failed to properly label and store personal food items brought in by family or visitors for two residents. Despite being within the manufacturer's expiration date, food items were discarded after three days, causing frustration for residents with specific dietary needs. The facility's policy required prepared food to be consumed within three days, but unopened items with manufacturer dates should not have been relabeled or discarded prematurely. This inconsistency led to the improper handling of residents' food.
A facility failed to follow infection control practices when an LPN administered a contaminated pill to a resident. The pill fell onto the bedding, and the LPN, unaware of the facility's policy, picked it up with bare hands and gave it to the resident. The facility's policy lacked specific guidance on handling contaminated medications.
A resident identified as high risk for falls did not receive appropriate fall interventions upon admission, leading to a fall incident. The facility failed to investigate the fall circumstances or notify the physician and family in a timely manner. Additionally, after the resident returned from the hospital with a fractured wrist, the facility did not complete an assessment or obtain care orders to manage the injury.
A resident with chronic conditions was found unresponsive, and an anonymous report alleged that the DSD did not perform CPR when needed. The Administrator recognized this as an allegation of neglect but did not report it to the state agency, contrary to facility policy. An investigation was conducted, and the DSD was suspended during this process.
A facility failed to develop a baseline care plan within 48 hours for a resident at high risk for falls, who had a history of falling and was diagnosed with conditions like Parkinson's disease and muscle weakness. Despite a high fall risk assessment score, the care plan was not formulated, as confirmed by staff interviews. The facility's policy required such a plan, but it was not implemented, leading to inadequate management of the resident's fall-related injuries.
A resident, admitted with a right femur fracture and head contusion, required maximum assistance with bathing. The DON confirmed that the resident's showers were scheduled twice weekly, but there was no documentation of showers or bed baths being provided or refused on two occasions. A family member reported the missed showers, and the facility's ADLs policy required care based on comprehensive assessments.
A facility failed to properly assess and document a resident's surgical incision site and skin condition, resulting in a deficiency. The resident had a right femur fracture with surgical incisions and staples, but the location of the staples was unclear. Physician orders for wound care were not followed with thorough assessments or documentation. Interviews revealed that the wound team did not complete baseline or weekly skin assessments as required by facility policy.
A resident with a surgical wound on the right hip did not receive wound care treatment as ordered, leading to a deficiency in care. The treatment was scheduled for specific days but was not performed on one occasion, despite being documented as completed. The lapse was confirmed by the Wound Coordinator and Wound Care Treatment Nurse, and the importance of timely wound care was emphasized by the Wound Care Nurse Practitioner.
Failure to Investigate and Report Staff Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation and did not report an allegation of misappropriation involving a certified nursing assistant (CNA) to the State Board of Nursing. A resident with Alzheimer's disease and dementia was found to have multiple twenty dollar bills and explained to a nurse that a staff member, identified as a friend, had used the resident's bank card to withdraw cash. The nurse documented the incident and secured the cash, but the debit card was not returned. Further review revealed that the staff member, who was assigned to care for the resident and spouse, had also taken other items such as a garage remote and keys, and significant unauthorized withdrawals and expenses were made from the resident's account. The facility's investigation file lacked documentation of interviews with the CNA, did not identify the CNA as the resident's friend, and did not include a determination of the outcome of the in-house investigation. Additionally, there was no evidence that the CNA was reported to the State Board of Nursing, despite facility policy requiring notification of relevant licensing boards when an employee is found to have committed abuse, neglect, exploitation, or misappropriation. The deficient practice had the potential to place all residents at risk for unreported financial exploitation.
Delayed Reporting of Misappropriation Allegation
Penalty
Summary
The facility failed to ensure that an allegation of misappropriation of resident property involving a certified nursing assistant was reported to the State Agency within the required timeframe. A resident with Alzheimer's disease and dementia was admitted and later had a nursing progress note documenting an allegation of misappropriation on 07/27/2025. However, the facility did not report this allegation to the State Survey Agency until 07/29/2025, exceeding the required reporting window as outlined in facility policy and regulatory requirements. Interviews with staff, including an LPN, the DON, and the Administrator, confirmed knowledge of the abuse reporting policy, which requires immediate reporting of such allegations, defined as within two hours for abuse involving physical harm or within 24 hours for other allegations, including misappropriation. The Administrator explained that the nurse notified the abuse coordinator by entering information into the electronic health record, which only generated an alert for the next user login, rather than immediate notification. The Social Services Director initiated an investigation the following day, and the initial report to the State Agency was delayed, not meeting the facility's policy or regulatory requirements.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to complete an assessment for the self-administration of medication for one resident, leading to a deficiency. The resident, who was admitted with diagnoses including gout, Type 2 diabetes, and generalized muscle weakness, was found with a bottle of melatonin gummies on their bedside table. The resident's family had brought the medication to the facility two days prior, and the resident had taken two gummies the previous night. However, there was no documented evidence of an assessment for self-administration of medication or a physician's order in the resident's medical record. A Registered Nurse confirmed the presence of the medication and was unaware of its existence at the bedside, indicating that the family should have informed the nursing staff about the medication. The Director of Nursing verified the absence of a physician's order and a self-administration assessment. According to the facility's policy, a resident must have a nurse's evaluation, an interdisciplinary team's assessment, physician's approval, and secured bedside storage to self-administer medication, none of which were in place for this resident.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical and verbal abuse involving a resident who reported that two staff members were rough and spoke rudely during care. The incident was documented in a Grievance/Complaint Resolution Report, but the date was initially incorrect. The Social Services Assistant (SSA) attempted to gather more details from the resident, who could not recall specifics due to the incident occurring at night. The SSA identified the staff member based on the resident's description and informed the Director of Nursing (DON), who agreed to remove the staff member from the resident's care. Despite the grievance being confirmed and adjustments made to the staff schedule, the facility did not conduct interviews with the alleged staff or other residents, nor did they complete a thorough investigation as per their policy. The Director of Staff Development (DSD) and the Administrator, who is the Abuse Coordinator, confirmed that no documentation of interviews or a complete investigation was available. The facility's policy requires immediate reporting and thorough investigation of abuse allegations, including interviews with all involved parties, but these steps were not followed in this case.
Inadequate Discharge Planning Documentation
Penalty
Summary
The facility failed to provide and document adequate discharge planning for two residents, leading to a deficiency in ensuring safe transfers or discharges. For the first resident, who had multiple medical conditions including a urinary tract infection and chronic obstructive pulmonary disease, the discharge planning process was not initiated until after a Notice of Medicare Non-Coverage was issued. Despite the resident's family successfully appealing two previous discharge notices, the facility did not document any discharge planning prior to the third notice. The Social Services Director only became involved after conflicts arose between the family and the Case Manager, and the medical record lacked evidence of discharge planning before the notice was issued. For the second resident, who had partial left-side paralysis due to a stroke, the facility also failed to document discharge planning prior to the resident's insurance coverage ending and subsequent discharge. The Case Manager admitted to keeping discharge planning notes on a personal tracker, which were not included in the electronic medical record and were destroyed after discharge. The Director of Nursing confirmed that the medical record lacked documentation of discharge planning, and the facility did not have a formal policy for discharge planning, relying instead on a best practice document that was not followed.
Failure to Adhere to Scheduled Bathing for a Resident
Penalty
Summary
The facility failed to provide scheduled bathing for a resident, identified as Resident 1, who was admitted with diagnoses including a displaced intertrochanteric fracture of the right femur, muscle weakness, and difficulty walking. The Admission Minimum Data Set indicated that Resident 1 required maximal assistance for bathing activities. The facility's records showed that Resident 1 was scheduled to receive showers twice a week, specifically on Wednesdays and Sundays. However, documentation revealed that Resident 1 only received a bed bath on two occasions and a shower on two other occasions during the month of May 2024, missing several scheduled bathing days. Interviews with facility staff, including a Registered Nurse, a Restorative Nurse Assistant, and a Certified Nursing Assistant, confirmed the twice-weekly bathing schedule. The Director of Nursing also confirmed that shower activities were to be documented in the electronic medical record and on shower day skin inspection sheets. Despite this, there was a lack of documentation for several scheduled bathing days, indicating a failure to adhere to the resident's bathing schedule, which could potentially impact the resident's overall well-being.
Deficiencies in Food Storage and Ice Machine Sanitation
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of food and cleaning agents, as well as the cleanliness of ice machines. During a walkthrough of the kitchen, surveyors observed a box of thickened liquid lemon-flavored water cartons in the walk-in cooler with an expiration date of the previous day. The Dietary Manager acknowledged that the water cartons should have been discarded and had them disposed of during the survey. Additionally, a spray bottle containing an unidentified liquid was found in the utility room, which the Dietary Manager identified as a de-limer and stated it would be labeled and stored properly. Further observations revealed issues with the cleanliness of ice machines. A water/ice machine in the kitchen and an ice machine in the 200-hall nourishment room both had a wet brownish debris buildup on the ice spouts. The Dietary Manager explained that the ice machines are cleaned periodically and had been recently cleaned. However, the presence of debris indicated a failure to maintain sanitary conditions as outlined in the facility's Ice Machine Sanitation policy. These deficiencies posed a potential risk to safety and health standards, potentially leading to contamination and foodborne illness.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to potential risks for their health and well-being. Resident 225, who was admitted with conditions such as muscle wasting and weakness, required assistance with bed mobility, transfer, and toilet use. However, there was no documented evidence of repositioning or assistance during the night shifts on specific dates, and the resident expressed feeling insecure and neglected. The Minimum Data Set (MDS) Director confirmed the lack of documentation and noted that the resident had not refused assistance. Resident 226, admitted with muscle weakness and chronic pain, required substantial assistance with toileting hygiene. The resident's family member reported that the resident was often left lying in urine for extended periods. A review of the ADL Flowsheet revealed no documented evidence of toileting hygiene assistance during several night shifts. The MDS Director confirmed these findings, indicating the resident's need for help with toileting hygiene, including changing adult briefs. Resident 229, who had a BIMS score indicating cognitive intactness, required assistance with bed mobility and toileting hygiene. The resident reported not being checked by staff for long periods, especially during night shifts, and having to wait for hours without being changed, even after a bowel movement. The ADL Flowsheet review confirmed the lack of documented assistance on a specific night shift. The Director of Nursing (DON) acknowledged that the resident was not using a low air loss mattress, which could have aided in repositioning.
Failure to Administer Blood-Thinning Medication Timely
Penalty
Summary
The facility failed to follow physician's orders for a resident diagnosed with a pulmonary embolism, which required the administration of blood-thinning medication, Lovenox, every 12 hours. On the morning of September 5, 2024, an LPN was unable to locate the resident's Lovenox medication and found none in the back-up supply. The LPN was uncertain about when the medication would arrive, resulting in a delay in administration. The medication was eventually delivered at 4:00 PM, more than 12 hours after the last dose was administered the previous evening. The physician confirmed that the resident was placed on Lovenox because Warfarin alone was not providing adequate therapeutic effects. The physician emphasized that missing a dose for more than 12 hours significantly increased the risk of another pulmonary embolism. The Director of Nursing acknowledged that the medication should have been reordered by the nurse who administered the last dose, and the situation could have been avoided with timely ordering. The facility's medication administration policy did not provide guidance on handling situations when medications were running low or unavailable.
Failure to Administer Pain Medication as Scheduled
Penalty
Summary
The facility failed to administer pain medication as scheduled for a resident, identified as R228, which compromised the effectiveness of the resident's pain management. R228 was admitted with diagnoses including muscle wasting, atrophy, muscle weakness, and malaise, and was prescribed Gabapentin to be taken three times daily at specific times. However, the Medication Administration Audit Report revealed that the medication was frequently administered outside the prescribed one-hour window before or after the scheduled times, as per the facility's policy. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the discrepancies in medication administration times. The DON acknowledged that the medication was not consistently given within the required timeframe, which could lead to increased pain for the resident. The facility's policy required medications to be administered within 60 minutes of the scheduled time unless otherwise ordered by a physician, but this was not adhered to in the case of R228.
Improper Handling of Residents' Personal Food Items
Penalty
Summary
The facility failed to ensure that personal food items brought in by family or visitors for two residents were properly labeled and stored. Resident #77, who has a history of hypertension, protein-calorie malnutrition, type 2 diabetes, and chronic kidney disease, reported that their vegetarian food items, such as ice cream and cottage cheese, were discarded after three days despite being within the manufacturer's expiration date. Similarly, Resident #84, with diagnoses including peripheral vascular disease, type 2 diabetes, depression, and protein-calorie malnutrition, expressed frustration over their food items, like bread and butter pickles, being thrown away within three days even though they were not expired according to the manufacturer's date. The facility's policy required that prepared food items brought in by family or visitors be labeled, dated, and consumed within three days of preparation, after which they would be discarded. However, the policy also stated that unopened food in original containers with manufacturer expiration dates did not need to be relabeled and should be discarded only if past the expiration date. The Dietary Manager and other staff confirmed that they followed a three-day rule for open items, regardless of the manufacturer's date, leading to the unnecessary disposal of residents' food items. This inconsistency between the facility's policy and practice resulted in the improper handling of residents' personal food items.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration for an unsampled resident, identified as Resident 276. The resident was admitted with a diagnosis including a urinary tract infection and had a care plan that included strategies to reduce infection risk. On the morning of September 5, 2024, an LPN was observed administering pills to the resident using a medication cup. During the process, one pill fell onto the bedding. The LPN picked up the pill with bare hands and gave it to the resident, who ingested it. The LPN was unaware of the facility's policy regarding handling contaminated medications. The Infection Control Preventionist later confirmed that the expectation was to discard any medication that touched an unclean surface. The facility's Medication Administration Policy, revised in October 2023, stated that medications should be administered in a manner to prevent contamination, but it did not provide specific guidance on handling contaminated medications.
Failure to Implement Fall Prevention and Management
Penalty
Summary
The facility failed to implement fall interventions and management for a resident identified as high risk for falls upon admission. Despite the resident's high-risk status, no fall precautions were in place, such as low bed positioning or fall mats, which contributed to a fall incident. The Assistant Director of Nursing (ADON) confirmed that the facility had not implemented fall indicators or precautions for high-risk residents, and staff training on these measures was only beginning. The facility also failed to thoroughly investigate a post-fall incident involving the same resident. Documentation indicated the resident fell during peri-care, but the fall circumstances and root cause analysis were not determined, and no interventions were implemented based on actual causal factors. The ADON acknowledged the lack of investigation and discussion with the Interdisciplinary Team (IDT) regarding the fall incident, and there was no documented evidence of attempts to determine the root cause or implement interventions. Additionally, the facility did not timely notify the physician and family following the post-fall incident, as required by policy. The resident's medical records lacked documentation of family notification, and the attending physician was only informed about the fall after the resident's return from the hospital. Furthermore, upon the resident's return from the hospital with a fractured wrist, the facility failed to complete an assessment or obtain care orders to manage the resident's cast, resulting in inadequate management of the fall-related injury.
Failure to Report Alleged Neglect Incident
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a resident to the state agency. The resident, who had chronic kidney disease, diabetes mellitus, and atherosclerotic heart disease, was admitted with a Physician's Order for Life Sustaining Treatment indicating a full code status. A certified nursing assistant found the resident unresponsive, and despite the initiation of CPR and the arrival of emergency services, the resident was declared deceased. An anonymous report alleged that the Director of Staff Development (DSD) did not perform CPR when necessary, which was recognized by the Administrator as an allegation of neglect. The Administrator conducted an investigation, including verbal interviews and written statements from staff, but did not report the incident to the state survey agency, believing it was not reportable at the time. The facility's policy required immediate reporting of such allegations to the state agency, but this was not done. The DSD was suspended during the investigation, and written statements were collected from staff members. The failure to report the incident as required by policy constituted a deficiency in the facility's handling of the situation.
Failure to Develop Baseline Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a person-centered baseline care plan within 48 hours of admission for a resident at high risk for falls. This deficiency was identified for one of the sampled residents, who had a history of falling and was diagnosed with conditions such as Parkinson's disease, muscle wasting, and weakness. The resident's cognitive status was moderately impaired, and a fall risk assessment indicated a high risk of falling with a score of 75. Despite these indicators, the facility did not formulate a baseline care plan to manage the resident's fall risk, which was confirmed by a Registered Nurse and the Assistant Director of Nursing. Interviews with facility staff, including the Director of Staff Development, revealed that the admission nurse was responsible for initiating the care plan upon the resident's admission. However, the baseline care plan was not developed, and fall risk indicators had not been implemented at the time. The facility's policy required the development of a baseline care plan within 48 hours of admission, but this was not adhered to, resulting in inadequate management of the resident's fall-related injuries.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to ensure that showers were provided as scheduled for one of the sampled residents, identified as Resident 5. Resident 5 was admitted with diagnoses including a right femur fracture and head contusion, and the admission minimum data set indicated that the resident required maximum substantial assistance with bathing. The Director of Nursing confirmed that Resident 5's showers were scheduled for Wednesdays and Sundays during the day shift. However, the medical record lacked documented evidence that Resident 5 was provided a shower or bed bath on two specific dates, May 8 and May 12, 2024. The Director of Nursing also recounted that a family member of Resident 5 had called the facility regarding the missed showers, and upon review, confirmed the absence of documentation indicating that the showers or bed baths were offered, provided, or refused on those dates. The facility's Activities of Daily Living policy, revised in October 2022, stated that care and services would be provided based on the resident's comprehensive assessment, which included bathing.
Deficient Skin Assessment and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and documentation of a resident's surgical incision site and skin condition, leading to a deficiency in care. The resident, who was admitted with a displaced intertrochanteric fracture of the right femur, had three surgical incisions on the right hip with staples. However, the location of these staples was not clearly documented. Physician orders were in place for cleansing and dressing the surgical incisions, but the medical records lacked evidence of thorough assessments and documentation of the resident's skin condition both before and after the removal of the staples. Interviews with the Assistant Director of Nursing and the Wound Care Treatment Nurse revealed that the wound team was responsible for assessing and treating surgical wounds. However, the baseline skin assessment was incomplete, and weekly skin assessments were not conducted as per protocol. The Wound Care Treatment Nurse confirmed that there were no follow-through assessments of the surgical site, and the condition of the surgical site with the staples was inadequately documented. The facility's policy required routine assessments and documentation of skin integrity issues, which were not adhered to in this case.
Failure to Provide Timely Wound Care Treatment
Penalty
Summary
The facility failed to provide wound care treatment as ordered for a resident with a surgical wound on the right hip, leading to a deficiency in care. The resident, who was admitted with diagnoses including right hip arthritis due to bacteria and surgical aftercare, had a care plan initiated to address impaired skin integrity. A physician's order required the wound to be cleansed and dressed every Tuesday, Thursday, and Saturday. However, during an observation on June 13, 2024, it was discovered that the wound dressing was dated June 8, 2024, indicating that the treatment scheduled for June 11, 2024, was not performed despite being documented as completed. The Wound Coordinator and Wound Care Treatment Nurse confirmed the lapse in treatment, acknowledging that the wound care was not provided as ordered. The resident, who was alert and cognitively intact, confirmed that the last wound treatment was provided five days prior to the observation. The Wound Care Nurse Practitioner emphasized the importance of timely wound care to promote healing and prevent complications. The Assistant Director of Nursing and Director of Nursing both acknowledged the expectation for accurate documentation and timely provision of wound care treatments. The facility's policy on skin integrity, dated August 2014, highlighted the need for active management of risk and appropriate interventions to achieve positive clinical outcomes.
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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