Silver Ridge Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 1151 Torrey Pines Dr., Las Vegas, Nevada 89146
- CMS Provider Number
- 295072
- Inspections on file
- 29
- Latest survey
- April 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Silver Ridge Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain safe storage temperatures for perishable food items in the walk-in refrigerator, which consistently registered above the safe range of 35-41°F for several days. Despite being aware of the issue, the Dietary Manager and kitchen staff did not ensure maintenance was notified, leading to a delay in addressing the malfunction. This posed a risk of food-borne illness to residents.
A resident with multiple medical conditions was served meals inconsistent with their prescribed minced/moist diet and dietary preferences, leading to meal refusal and dissatisfaction. Despite a physician's order and documented dislikes, the resident received a pureed diet and meals containing pork, which they disliked. The kitchen manager confirmed the error, acknowledging a misunderstanding by the cook regarding meal consistencies.
A resident who had a fall and was sent to the hospital returned exhibiting confusion and combativeness, refusing care and vital checks. Despite these behaviors, the facility failed to notify the physician, as confirmed by staff interviews and a review of the medical record. This oversight was contrary to the facility's policy requiring communication of changes in condition to the primary care provider.
A resident with a stage 3 pressure ulcer did not have documented evidence of wound care treatments being administered as per physician's orders. The Treatment Administration Record lacked entries for the specified period, and interviews with the Wound Care Nurse and DON confirmed the absence of documentation. The facility's policy required documentation of skin condition and treatments, which was not followed.
The facility failed to properly date and time water bags and tubing systems for gastrostomy feeding hydration for two residents. Feeding formula bottles were dated but not timed, and tubing was undated, which was confirmed by an LPN. This oversight had the potential to compromise patient safety by increasing the risk of contamination and infections.
Expired medications were found in two medication rooms and one medication cart, including Vitamin C and Insulin Lispro. An LPN attempted to administer expired Vitamin C to a resident, and the facility's policy requires checking expiration dates and removing expired medications.
A facility failed to provide mandatory training, including abuse, fire, disaster, and dementia training, to a CNA hired in 2003. The CNA's file lacked documentation of these trainings, confirmed by the HR/Payroll Clerk. The Staff Development Assistant acknowledged the facility's obligation to comply with state and local laws for required training. The deficiency placed residents at risk for inappropriate care.
A facility failed to develop a baseline care plan for a resident admitted with an infected left foot and at risk for pressure ulcers. Despite a Braden scale assessment indicating risk factors, no care plan was initiated within the first 48 hours, leading to delayed interventions and the development of a pressure ulcer and other skin issues. The deficiency was confirmed by the treatment nurse and DON.
A resident at risk for pressure ulcers did not have a care plan developed or implemented, leading to multiple skin breakdowns. Despite assessments indicating risk factors such as limited mobility and moisture exposure, the facility failed to document a care plan for pressure ulcer prevention. The MDS Director and nursing staff did not ensure the inclusion of this critical care plan, contrary to facility policies.
A resident with cellulitis of the left foot was not properly assessed and monitored, leading to potential complications and hospitalization. Despite being admitted with a primary diagnosis of left foot cellulitis, the facility failed to document the condition of the foot or the presence of a CAM boot device in the admission skin assessments and subsequent weekly inspections. This oversight resulted in the development of an arterial wound with eschar and discoloration, which was only identified after a delay, causing severe pain and necessitating hospital transfer.
A resident at risk for pressure ulcers did not receive weekly skin assessments as required, leading to the development of a facility-acquired pressure ulcer. The resident, with limited mobility and other health conditions, was not included in the wound team's case load due to initial assessments showing no skin issues. Missed assessments delayed the identification and intervention for a deep tissue injury, which was eventually discovered by a CNA. Physician orders for wound management were obtained, but the resident was transferred to the hospital before implementation.
Two residents at a facility were able to leave unsupervised due to ineffective elopement measures. One resident, with a history of wandering, was found at a homeless shelter after staff failed to respond to door alarms. Another resident, identified as an elopement risk, left the facility due to delayed implementation of interventions. The facility's surveillance system had dead spots, and staff did not adhere to the elopement policy, leading to potential harm.
During a survey, a facility was found to have several deficiencies including handwashing stations with water temperatures at 68°F, black tarry build-up under the stove shelf, food debris under the preparation table, expired thickened apple juice, undated ground beef, and a leaking sanitizer station. The maintenance director mentioned completing temperature adjustments and logs, while the dietitian emphasized the importance of labeling and dating perishable items. Further observations in nourishment rooms revealed expired and unlabeled items in refrigerators, a broken cabinet board with residue, and a lack of proper labeling and dating for food items. The Dietary Manager highlighted the shared responsibility between kitchen and nursing staff for monitoring and restocking nourishment rooms, in line with the facility's policy on food safety standards.
The facility failed to complete a PASARR level two referral for a resident with new diagnoses of schizophrenia, schizoaffective disorder, and unspecified dementia. Staff interviews revealed a lack of clarity and responsibility regarding the PASARR referral process, and the facility did not have a current process for identifying and referring residents for a new level of care.
The facility failed to develop a baseline care plan within 48 hours for a resident admitted with a knee brace. Despite hospital documentation indicating the need to maintain the knee brace in full extension, the facility did not assess or care plan for its use, as confirmed by staff interviews and record reviews.
The facility failed to update a care plan to include a physician's order for a cervical collar for a resident with Parkinson's disease and gastrostomy status. Despite a restorative note and a physician's order, the care plan lacked documentation of this update, which was confirmed as an oversight by the ADON.
A resident at very high risk for pressure ulcers was left in a Geri-chair without a cushion for over eight hours, contrary to the care plan and facility policy. Despite having healed sacral wounds, the resident was not turned, repositioned, or provided with continence care, leading to potential risks of reopening the wounds.
A facility failed to follow a physician's order for a cervical collar for a resident with Parkinson's disease, leading to discomfort and poor neck alignment. The collar remained in the therapy room due to a communication breakdown among staff.
The facility failed to identify, assess, and monitor a full-length knee brace for a resident with a high fall risk. Despite the resident's medical history and fall risk assessment, no care instructions were documented, leading to a fall when the brace's Velcro loosened and became stuck on the top sheet. Staff confirmed the lack of proper management contributed to the incident.
The facility failed to administer tube feeding as ordered for a resident and did not maintain proper bed elevation and timely replacement of the feeding bottle for another resident. The discrepancies in TF administration and bed positioning were confirmed by staff and attributed to communication and implementation failures.
The facility failed to administer oxygen (O2) as ordered for two residents, leading to potential health risks. One resident with acute respiratory distress had O2 flowing at 4 liters per minute (LPM) instead of the ordered 3 LPM. Another resident dependent on supplemental O2 had O2 flowing at 3 LPM and 4 LPM instead of the ordered 2 LPM. Staff confirmed the discrepancies and acknowledged the importance of following the physician's orders.
A facility failed to communicate a resident's Candida auris infection status to the dialysis provider, resulting in the resident receiving dialysis in the general area without necessary contact precautions. This oversight put both staff and other patients at risk for infection transmission.
The facility's pest control program was ineffective, as evidenced by a large quantity of ants discovered in the kitchen. The ants were observed moving from a small hole in the wall to the food preparation station. The presence of ants was confirmed by the dietitian and maintenance director. Despite monthly visits from a pest control company, the facility failed to prevent the infestation.
Failure to Maintain Safe Food Storage Temperatures
Penalty
Summary
The facility failed to store perishable food items in a sanitary manner, as evidenced by the walk-in refrigerator maintaining temperatures above the safe range of 35-41 degrees Fahrenheit for several days. On multiple occasions, the internal thermometer of the walk-in refrigerator registered temperatures as high as 55 degrees Fahrenheit, with perishable items such as sliced ham and chicken salad also found at unsafe temperatures. This issue persisted from April 4, 2025, to April 8, 2025, without being adequately addressed, posing a risk of food-borne illness to all residents. The Dietary Manager (DM) acknowledged the temperature discrepancies and admitted to not checking the temperature log due to being busy. Despite the temperature log indicating a pattern of unsafe temperatures, the issue was not escalated to the Maintenance Director until April 8, 2025. The Assistant Dietary Manager and other kitchen staff were aware of the temperature issues but failed to ensure that maintenance was properly notified and that corrective actions were taken. The Maintenance Assistant did not recall being informed of the issue, and the Maintenance Director was only made aware on April 8, 2025, when a service company was called to address the problem. The facility's policy required that refrigerator temperatures be checked and recorded daily, with any deviations reported immediately to the Dietary Manager or maintenance. However, this protocol was not followed, leading to a delay in addressing the malfunctioning refrigerator. The Registered Dietician confirmed that storing food above 41 degrees Fahrenheit could allow harmful bacteria to grow, potentially causing nausea, vomiting, and diarrhea in residents consuming the spoiled food.
Failure to Honor Resident's Dietary Preferences and Consistency
Penalty
Summary
The facility failed to comply with the prescribed meal consistency and dietary preferences for a resident, leading to a deficiency in honoring the resident's right to self-determination and choice. The resident, who had a history of hypertension, chronic debility, hypothyroidism, atrial fibrillation, type 2 diabetes, and chronic obstructive pulmonary disease, was observed refusing meals due to incorrect consistency and unwanted food items. Despite a physician's order for a minced and moist texture diet, the resident was repeatedly served a pureed diet, which they had previously been removed from. Additionally, the resident's meal ticket indicated a dislike for pork, yet meals containing ham were served, further disregarding the resident's documented preferences. The kitchen manager confirmed the discrepancy between the prescribed minced/moist diet and the pureed diet being served, acknowledging the misunderstanding by the cook who considered both consistencies the same. The facility's policy on resident food preferences, which mandates awareness of resident preferences and allergies, was not adhered to, resulting in the resident's dissatisfaction and meal refusal. The resident's nutritional care plan highlighted the risk of altered nutrition and hydration due to their medical conditions, emphasizing the importance of adhering to dietary preferences to prevent significant weight changes and ensure adequate nutritional intake.
Failure to Notify Physician of Resident's Post-Fall Behavior
Penalty
Summary
The facility failed to notify the physician regarding a resident's post-fall behavior and refusal of care, which was a deficiency identified during the survey. The resident, who had been admitted with diagnoses including chronic obstructive pulmonary disease and chronic pulmonary edema, experienced a fall and was sent to the hospital for evaluation. Upon returning from the hospital, the resident exhibited confusion, combativeness, and refusal of care, including vital sign checks. Despite these significant changes in behavior, there was no documented evidence that the physician was notified of the resident's condition. Interviews with facility staff, including LPNs and the Supervising Nurse, confirmed that the resident's refusal of care and aggressive behavior were not communicated to the physician, contrary to the facility's policy. The facility's policy required that any change in condition, such as refusal of care, should be assessed, documented, and communicated to the primary care provider. The lack of notification to the physician about the resident's condition post-fall was a critical oversight, as confirmed by the Director of Nursing and other staff members.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to provide documented evidence that wound care treatments were administered according to the physician's orders for one resident. This resident, who was admitted with diagnoses including type 2 diabetes mellitus with circulatory complications, a stage 3 pressure ulcer in the sacral region, and atrial fibrillation, had a physician's order for specific wound care treatment. The order required cleansing the wound with normal saline, applying Medihoney and Triad cream, and covering it with gauze daily. However, the Treatment Administration Record (TAR) lacked documentation of these treatments being completed from March 25, 2025, through March 31, 2025. Interviews with the Wound Care Nurse and the Director of Nursing (DON) confirmed the absence of documentation for the wound care treatments during the specified period. The Wound Care Nurse explained that the Admission Nurse was responsible for the initial skin assessment, while the wound care staff was to perform further assessments and obtain treatment orders. The DON stated that staff were expected to document treatments on the TAR. The facility's policy on pressure ulcer prevention required licensed nurses to record the condition of the skin and the treatment provided, which was not adhered to in this case.
Failure to Date and Time Feeding Tubes and Water Bags
Penalty
Summary
The facility failed to ensure proper dating and timing of water bags and tubing systems used for gastrostomy feeding hydration for two residents. For one resident, the feeding formula bottle was dated but not timed, and the tubing was undated and disconnected from the gastrostomy tube. Additionally, a water bag was present but undated and untimed. A Licensed Practical Nurse confirmed that the feeding tubing and water bag should have been dated upon initiation to ensure they were changed every 48 hours, as per the physician's order. For the second resident, the feeding formula bottle was dated but not timed, and the tubing was undated. The resident was observed receiving feeding formula at a specified rate, but the water bag and tubing were undated and untimed. The facility's policy indicated that prefilled formula containers and tubing should be changed every 48 hours or per manufacturer guidelines. The failure to date and time these items had the potential to compromise patient safety by increasing the risk of contamination and infections.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to remove expired medications from two of three medication rooms and one of five medication carts, which could potentially compromise patient safety. During an inspection on April 10, 2025, a Licensed Practical Nurse (LPN) was observed attempting to administer a 250-milligram tablet of Vitamin C to a resident. The Vitamin C had expired in December 2024, and the LPN acknowledged that the expiration date should have been checked before administration. This incident occurred on the 200 Hall medication cart. Further inspection of the medication rooms revealed additional expired medications. In one medication room, a bottle of Vitamin C 250 mg was found to have expired in December 2024. In another medication room, an opened vial of Insulin Lispro, dated February 14, 2025, was found. According to the label, this medication should have been discarded within 28 days of opening, but it had not been. The facility's policy, dated November 2011, requires that nurses check expiration dates before administering medications and that expired medications be removed and destroyed. The policy also specifies that vials should be discarded 30 days after being opened.
Failure to Provide Mandatory Training to CNA
Penalty
Summary
The facility failed to ensure that mandatory training, including abuse, fire, disaster, and dementia training, was provided to a Certified Nursing Assistant (CNA), identified as Employee 10 (E10). E10 was hired on March 4, 2003, and a review of their employee file revealed a lack of documentation for the required training. On April 11, 2025, the Human Resource/Payroll Clerk confirmed that E10 had no record of completing these mandatory trainings. The Staff Development Assistant acknowledged that the facility was expected to comply with state and local laws, which included providing state-required training such as care of dementia residents, abuse, fire, and disaster training. The Covenant Care Employee Training Requirements, updated in December 2022, outlined the necessity for new hires and annual compliance-related training for all employees, including abuse and neglect, safety-related training, and training required by federal and state requirements specific to Nevada. The State Operations Manual for Long Term Care Facilities mandates in-service training for nurse aides, including dementia management and resident abuse prevention training. The deficiency placed residents at risk for inappropriate care.
Failure to Develop Baseline Care Plan for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was admitted with an infected left foot and assessed to be at risk for developing pressure ulcers. The resident, who had a history of left toe cellulitis, peripheral vascular disease, and diabetes mellitus, was admitted without a care plan addressing pressure ulcer prevention and skin integrity maintenance. A Braden scale assessment indicated the resident was at risk due to factors such as limited mobility and skin exposure to moisture. Despite this assessment, the medical record lacked evidence of a baseline care plan being developed within the first 48 hours of admission. The deficiency was confirmed by the treatment nurse and the Director of Nursing, who acknowledged that a care plan should have been initiated. The absence of a care plan potentially delayed necessary interventions, leading to the development of a pressure ulcer, groin rash, and complications to the resident's left foot and toes. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not adhered to, resulting in the identified issues.
Failure to Implement Pressure Ulcer Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who was at risk for developing pressure ulcers. The resident, who was admitted with conditions including cellulitis, peripheral vascular disease, and diabetes mellitus, was assessed using the Braden scale and found to be at risk due to factors such as limited mobility and exposure to moisture. Despite these assessments, the medical record did not contain evidence of a care plan for pressure ulcer prevention or skin integrity maintenance. The deficiency was identified when a change of condition document revealed multiple areas of skin breakdown, including excoriation and skin tears. The MDS Director confirmed that the pressure ulcer care area was triggered but not addressed in the care plan. The Director of Nursing clarified that the responsibility for initiating the care plan lay with the admission nurse or any assigned nurse, and the MDS Director should have ensured its inclusion in the comprehensive care plan. The facility's policies required a baseline care plan to be used until a comprehensive care plan was developed, but this was not followed in this case.
Failure to Monitor and Document Resident's Foot Condition
Penalty
Summary
The facility failed to adequately assess and monitor a resident's left foot, which was being treated for cellulitis, leading to potential complications and hospitalization. The resident was admitted with a primary diagnosis of left foot cellulitis, along with other conditions such as diabetes mellitus, peripheral vascular disease, and a history of above-the-knee amputation. Despite these conditions, the admission skin assessments and subsequent weekly skin inspections did not document the condition of the resident's left foot or the presence of a CAM boot device. This lack of documentation and monitoring resulted in the resident's left foot developing an arterial wound with eschar and discoloration, which was only identified after a significant delay. The treatment nurse and the Director of Nursing confirmed that weekly skin checks were missed or completed late, which could have identified issues with the resident's left foot earlier. The facility's policy required documentation of skin integrity issues post-admission, including wound location, size, and signs of infection, but these were not followed. The deficiency in monitoring and documentation led to the resident experiencing severe pain and discoloration in the left leg, prompting a transfer to the hospital for further evaluation and management.
Failure to Conduct Weekly Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to ensure that weekly skin assessments were conducted for a resident at risk for developing pressure ulcers. The resident, who was admitted with a right above-the-knee amputation and other conditions such as peripheral vascular disease and diabetes mellitus, was identified as being at risk for pressure ulcers due to limited mobility and chairfast status. Despite this, the medical record lacked documented evidence of weekly skin checks on three occasions, which were confirmed by the treatment nurse and the Director of Nursing (DON). This oversight potentially contributed to the development of a facility-acquired pressure ulcer on the resident's left hip, which was identified by a CNA and assessed by a nurse. The deficiency was further highlighted when the treatment nurse confirmed that the resident was not included in the wound team's case load due to the initial assessment showing no skin issues. The missed weekly skin checks delayed the identification and intervention for the resident's skin breakdown, which was eventually noted to be a deep tissue injury. Physician orders for wound management were obtained, but the resident was transferred to the hospital before they could be implemented. The facility's policy required weekly skin assessments to identify new skin impairments and ensure timely interventions, which were not adhered to in this case.
Failure to Implement Effective Elopement Measures
Penalty
Summary
The facility failed to effectively execute elopement measures for two residents, leading to incidents where both residents were able to leave the facility unsupervised. Resident 1, who had a history of wandering and was equipped with a Wanderguard, was last seen by staff at 6:15 PM near the front entry. Despite being on frequent monitoring and having a comprehensive care plan in place, Resident 1 was discovered missing at 7:10 PM and was later found at a local homeless shelter. Staff members reported not hearing or responding to any door alarms around the time of the incident, indicating a lapse in the facility's monitoring and response protocols. Resident 2, who was admitted with altered mental status and homelessness, was identified as a potential elopement risk but did not have the necessary interventions implemented in a timely manner. On one occasion, Resident 2 was found outside the facility after being reported missing by a CNA. The elopement risk assessment tool had flagged Resident 2 as at risk, but the care plan and interventions were not completed until after the elopement incident occurred. This delay in implementing the necessary measures contributed to the resident's ability to leave the facility unsupervised. The facility's elopement and missing resident policy, dated December 2017, required ongoing evaluation and adequate planning for residents identified at risk of elopement. However, the facility's failure to adhere to these protocols, including the lack of effective monitoring and response to door alarms, as well as the incomplete implementation of care plans for at-risk residents, resulted in the potential for harm to the residents involved. The facility's surveillance system also had limitations, with several dead spots not covered by cameras, further complicating the ability to monitor and prevent elopements.
Deficiencies in Handwashing Stations, Food Labeling, and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper handwashing stations with hot water, labeled and dated food items, and a clean kitchen environment, as observed during a survey. The initial tour of the kitchen revealed handwashing stations with a temperature of 68 degrees Fahrenheit, black tarry build-up under the stove shelf, food debris under the preparation table, expired thickened apple juice, undated ground beef, and a leaking sanitizer station. The maintenance director mentioned completing temperature adjustments and logs, while the dietitian emphasized the importance of labeling and dating perishable items in storage areas. Further observations in the nourishment rooms on different units identified expired and unlabeled items in refrigerators, a lack of proper labeling and dating for food items, and maintenance issues such as a broken cabinet board with residue. The Dietary Manager stressed the necessity of labeling and dating food items to prevent foodborne illness and spoilage, with responsibilities shared between kitchen and nursing staff for monitoring and restocking nourishment rooms. The facility's policy outlined procedures for checking expiration and use-by dates, repackaging food, and labeling containers to maintain food safety standards.
Failure to Complete PASARR Level Two Referral
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for one resident. The resident was admitted with primary diagnoses including bipolar disorder, new schizophrenia, schizoaffective disorder, and a secondary diagnosis of unspecified dementia. Despite these diagnoses, the resident's PASARR level one document indicated no mental illness, intellectual disability, or related condition, and the resident was deemed appropriate for nursing facility placement. Subsequent assessments and psychiatry notes revealed new diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia, but there was no documented evidence of a PASARR level two referral being made. Interviews with facility staff, including the MDS Director, Admissions Director, and Social Services Director (SSD), revealed a lack of clarity and responsibility regarding the PASARR referral process. The MDS Director confirmed the resident's new diagnoses but indicated that MDS nurses were not involved in the referral process. The Admissions Director stated responsibility for initial PASARR assessments but not for ongoing referrals. The SSD, who had been employed for three months, was unaware of the need to identify and refer residents for PASARR level two. The Director of Nursing (DON) and Assistant DON, along with a charge nurse, confirmed that the facility did not have a current process for identifying and referring residents for a new level of care or PASARR level two, as the former SSD who handled this task was no longer employed at the facility.
Failure to Develop Baseline Care Plan for Knee Brace
Penalty
Summary
The facility failed to ensure a baseline care plan was developed within 48 hours for the use of a leg brace following the admission of Resident 189. Resident 189 was admitted with diagnoses including the presence of a left artificial knee joint, cellulitis of the left lower limb, left knee pain, and unsteadiness of feet. Despite the hospital's Transfer/Discharge Summary and the History and Physical documentation indicating the need to maintain the knee brace in full extension at all times, the facility did not assess the knee brace or develop a care plan for its use following the resident's admission. This oversight was confirmed through observations, interviews, and record reviews, revealing that the knee brace was not identified in the admission assessment and was not care planned accordingly. Interviews with the Registered Nurse, Charge Nurse, Director of Rehabilitation Services, and Assistant Director of Nursing confirmed that the knee brace should have been assessed and care planned upon admission. The facility's policy on Baseline Care Plan, dated 10/2022, mandates the development and implementation of a baseline care plan within 48 hours of a resident's admission, including the necessary instructions to provide effective and person-centered care. However, this policy was not followed, resulting in a lack of documented evidence and care planning for Resident 189's knee brace, which was essential for the resident's post-surgery care and safety.
Care Plan Update Failure for Cervical Collar
Penalty
Summary
The facility failed to ensure a care plan for range of motion was updated to include a physician's order for a cervical collar for one resident. The resident was admitted with diagnoses including Parkinson's disease and gastrostomy status. A restorative note indicated the resident would benefit from a soft collar for neck repositioning, and a physician's order was later documented for the use of the collar. However, the care plan initiated earlier lacked documented evidence of this update. The Assistant Director of Nursing confirmed the oversight during a review of the care plan.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident identified as having a very high risk of developing pressure ulcers was turned and repositioned per policy and provided with a cushion while seated in the Geri-chair. Resident 191, who had diagnoses including stages two and three pressure ulcers in the sacral region, hemiplegia, and hemiparesis, was observed in the Geri-chair without a cushion for extended periods. Despite the care plan indicating the need for a Roho cushion and repositioning every two hours, the resident was left in the Geri-chair from 7:00 AM to 3:00 PM without being turned, repositioned, or provided with continence care. This neglect was confirmed by both a Registered Nurse and a Certified Nursing Assistant, who admitted that the resident had not been attended to for over eight hours. The wound coordinator and the Wound Care Treatment Nurse confirmed that the resident's sacral wound had healed but emphasized the importance of using a Roho cushion to prevent reopening the wound. The facility's policy on skin integrity, which mandates turning and repositioning residents at least every two hours, was not followed. The interdisciplinary team was unaware that the resident had been placed in the Geri-chair for such an extended period, highlighting a communication breakdown within the care team. The primary physician also stressed the importance of turning, repositioning, and offloading pressure to prevent wound development and promote healing.
Failure to Follow Physician's Order for Cervical Collar
Penalty
Summary
The facility failed to ensure a physician's order for a cervical collar was followed for a resident diagnosed with Parkinson's disease and gastrostomy status. The resident had a tendency to lean to one side, and a soft cervical collar was recommended and ordered to maintain proper neck alignment and increase comfort. Despite the order being placed and the collar being delivered, the resident was observed on multiple occasions without the cervical collar, leading to discomfort and poor alignment of the head and neck. The cervical collar was found to have remained in the therapy room due to a communication breakdown among therapy staff and restorative nurse aide services. On two separate observations, the resident was seen with their head leaning to the left side without the cervical collar. The Director of Staff Development confirmed the absence of the collar in the resident's room, and the Certified Nursing Assistant assigned to the resident was unaware of the order for the cervical collar. The Director of Rehabilitation later confirmed that the collar had been delivered but not provided to the resident due to miscommunication. The facility's policy on cervical collars indicated they should be used as directed by a physician's order, which was not followed in this case.
Failure to Identify and Manage Knee Brace for Resident
Penalty
Summary
The facility failed to ensure the use of a full-length knee brace or immobilizer was identified, assessed, monitored, and care orders were obtained for Resident 189. Resident 189 was admitted with diagnoses including the presence of a left artificial knee joint, cellulitis of the left lower limb, left knee pain, and unsteadiness of the feet. Despite being at high risk for falls, the facility did not document the knee brace in the medical records, nor were there any care instructions for its management. The resident experienced a fall when the brace's Velcro loosened and became stuck on the top sheet, contributing to the fall. The resident's fall risk assessment indicated a high risk for falls, but no interventions were implemented to manage the knee brace properly. On multiple occasions, staff confirmed that the knee brace was not identified, assessed, or monitored following the resident's admission. The Charge Nurse and the Director of Rehabilitation Services acknowledged that the lack of identification and management of the knee brace contributed to the fall incident. The Assistant Director of Nursing also confirmed that the fall was avoidable and that the resident needed assistance with mobility and transfer. The facility's policy on Fall Prevention and Response was not followed, as the resident did not receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.
Failure to Administer Tube Feeding as Ordered and Maintain Proper Bed Elevation
Penalty
Summary
The facility failed to ensure that tube feeding (TF) was administered as ordered for Resident 191 and that the head of the bed was elevated during TF administration for Resident 54. For Resident 191, the TF was ordered to be administered at 65 ml/hr but was observed to be infusing at 60 ml/hr, resulting in a total volume delivered of 1200 ml instead of the prescribed 1300 ml. This discrepancy was confirmed by a Registered Nurse (RN) and attributed to a failure in communication and implementation of the updated order. The resident was non-verbal and dependent on TF due to dysphagia and post-stroke status, with the TF increase intended to address weight loss and promote wound healing. The failure to adjust the TF rate as ordered was acknowledged by the Charge Nurse and the Assistant Director of Nursing (ADON), who indicated that the Licensed Nurses were expected to verify and deliver the ordered dose accurately. For Resident 54, the facility did not ensure that the head of the bed was elevated above 30 degrees during TF administration, and the TF bottle was used beyond the 24-hour limit. The resident, diagnosed with protein-calorie malnutrition and muscle weakness, was observed with the bed in a low position and the TF bottle labeled with a date indicating it had been in use for more than 24 hours. A Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) confirmed these observations. The ADON and LPN both stated that the head of the bed should be raised at least 30 degrees to prevent aspiration and that the TF bottle should be discarded after 24 hours. The facility's policy also documented that feeding containers, tubing, and syringes should be changed every 24 hours, which was not adhered to in this case.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen (O2) was administered as ordered for two residents, leading to potential health risks. Resident 44 was admitted with acute respiratory distress and chronic obstructive pulmonary disease, with a physician's order for O2 at 3 liters per minute (LPM) via nasal cannula. However, observations on 04/23/2024 revealed that the O2 was flowing at 4 LPM. The registered nurse confirmed the discrepancy and acknowledged that the incorrect flow rate could cause hypoxemia or carbon dioxide retention. The charge nurse indicated that licensed nurses were expected to check the ordered O2 flow rate during shift changes and rounds to ensure residents' safety. Similarly, Resident 131, who was admitted with shortness of breath and dependence on supplemental O2, had a physician's order for O2 at 2 LPM. Observations on 04/23/2024 and 04/24/2024 showed that the O2 was flowing at 3 LPM and 4 LPM, respectively. The registered nurse confirmed the incorrect flow rate and noted that the resident's O2 saturation was 99% with no signs of respiratory distress. The assistant director of nursing indicated that licensed nurses were expected to verify and follow the O2 flow rate as ordered. The facility's policy on medication administration emphasized that medications, including O2, should be administered as ordered by the physician and in accordance with professional standards of practice.
Failure to Communicate Infection Status to Dialysis Provider
Penalty
Summary
The facility failed to ensure that a resident's infection status was communicated with the dialysis provider, leading to a significant deficiency. Resident 99, who was admitted with end-stage renal disease and required dialysis, tested positive for Candida auris, a highly contagious fungal infection. Despite the positive test result, there was no documented evidence that the facility communicated this critical information to the dialysis provider. As a result, the resident continued to receive dialysis treatments in the general area without the necessary contact precautions, putting both staff and other patients at risk for transmission of the infection. On multiple occasions, staff at the dialysis facility, including the primary nurse, charge nurse, and facility administrator, confirmed that they were unaware of Resident 99's C. auris status. The dialysis facility had specific protocols for managing patients with C. auris, including cohorting infected patients and employing full personal protective equipment (PPE). The lack of communication from the skilled nursing facility meant that these protocols were not followed, further increasing the risk of infection spread. The Infection Preventionist and Director of Nursing at the skilled nursing facility acknowledged the oversight and confirmed that the resident's infection status should have been communicated to the dialysis provider. The facility's policies and agreements with the dialysis provider explicitly required the exchange of information regarding significant changes in a resident's health status, including infections. The failure to adhere to these policies resulted in a serious lapse in infection control measures, endangering both dialysis staff and patients.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to ensure the pest control program was effective, as evidenced by the discovery of a large quantity of ants in the kitchen. During an initial tour, ants were observed on the side wall next to the dishwasher, moving in a line from a small hole in the wall to the food preparation station. The presence of ants was confirmed by the dietitian and maintenance director. The Dietary Manager indicated that pest control concerns were reported verbally to the maintenance department, which was responsible for the pest control program. The Maintenance Director explained that the pest control company visited monthly and would address concerns the same day or the next day if identified. Despite these measures, the facility's pest control program was not effective in preventing the ant infestation in the kitchen. The facility's policy on pest control documented a program for controlling insects and rodents, but it was not adequately implemented in this instance.
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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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