Spanish Hills Wellness Suites
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 5351 Montessouri Street, Las Vegas, Nevada 89113
- CMS Provider Number
- 295094
- Inspections on file
- 22
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Spanish Hills Wellness Suites during CMS and state inspections, most recent first.
A facility failed to thoroughly complete a report to the state agency regarding a sexual abuse allegation by a resident with multiple diagnoses. The resident alleged inappropriate touching by a staff member fitting a specific description. Although an RNA matching the description was suspended during the investigation, this was not documented in the final report. The facility's policy required comprehensive investigations, but the report contained inaccuracies and omissions.
The facility's kitchen was found in unsanitary conditions with aged oil, greasy surfaces, and expired food products during an inspection. The fryer, stove, toaster, and mixer were coated with grease and food debris, while the floor was greasy and dusty. Expired food items, including apple juice, sour cream, peanut butter, and hot dogs, were discovered, along with dented cans in storage. The kitchen manager acknowledged these issues, which violated the facility's policies on food safety and cleaning.
A resident was unable to use a urinal bottle independently at night due to the lack of a working over-the-bed light, as the remote control was sent for repair without a replacement. The Maintenance Director and ADON acknowledged the oversight, which contradicted the facility's policy on promoting resident independence.
The facility failed to maintain a clean and sanitary environment in 16 residents' rooms, as dust and debris were found at the edges between the wall and the floor, despite daily cleaning. A resident raised concerns about the cleanliness, and both housekeeping staff and the supervisor confirmed the oversight. The facility's cleaning policy required thorough cleaning, including dusting and moving furniture weekly.
A resident with schizoaffective disorder, anxiety disorder, depression, and PTSD was readmitted to the facility without a completed PASARR Level II referral, despite these diagnoses indicating the need for such a screening. The Social Services Director acknowledged the responsibility for making the referral but failed to do so, as required by the Medicaid Services Manual for Nursing Facilities Policy.
A facility failed to create a baseline care plan for a resident with a nephrostomy tube, leading to improper management of the dressing. The resident, under palliative care, experienced issues with a peeling and soiled dressing that was not changed after becoming wet during a shower. The RN was unsure of the hospice nurse's responsibilities, and the medical records lacked a care plan. The Charge Nurse and DON confirmed the absence of a care plan, which was required by facility policy within 48 hours of admission.
The facility failed to implement and develop comprehensive care plans for several residents, including one who needed restorative hand splinting services, another using side rails, a resident with significant weight loss, and a resident with a heel wound. These deficiencies were acknowledged by the DON and other staff, highlighting lapses in care plan management.
The facility failed to provide an ongoing program of activities to meet residents' interests, as evidenced by the lack of community outings and outdoor activities. Two residents expressed a desire for more trips and improved transportation, with one resident lacking an Activity Evaluation. Activity calendars lacked documentation of outings, and previous months' calendars were unavailable. Despite having transportation resources, outings were not scheduled, and a requested shopping trip had not occurred since August.
A resident with multiple diagnoses, including hypertension, was administered expired Hydralazine HCL 10 mg tablets for elevated blood pressure. The expired medication was found in the medication cart, and both an LPN and the Assistant DON confirmed it should have been discarded. The facility's policy required checking expiration dates before administration, which was not followed in this instance.
A resident with a history of CVA and right-side weakness did not receive appropriate contracture management due to the facility's failure to obtain a new physician order for a hand splint after hospital readmission. The care plan required the use of a splint, but it was not implemented, and staff interviews confirmed the oversight.
A resident with a nephrostomy tube experienced a deficiency in care due to the facility's failure to obtain a physician's order and monitor the insertion site. The resident's dressing was soiled and peeling, and there were no documented care or monitoring orders, despite the resident being on hospice care. This lack of documentation and monitoring was confirmed by facility staff, highlighting a gap in continuity of care.
A resident experienced significant weight loss without a proper nutritional assessment due to the absence of a Registered Dietitian. Despite being at nutritional risk, the resident's nutritional needs were not evaluated or documented, leading to a lack of interventions. The facility's policy requiring comprehensive nutritional assessments was not followed.
A facility failed to provide proper dialysis care for a resident requiring hemodialysis. The Dialysis Communication Records were not consistently completed, and assessments of the shunt or dialysis access and vital signs were not consistently conducted pre- and post-dialysis. Despite the resident's intact cognitive status and a care plan requiring monitoring, vital signs were inconsistently taken upon arrival at the facility. The DON confirmed the lack of documented evidence for shunt assessments and vital signs, increasing the risk of complications.
A resident with Parkinson's disease and other conditions was observed using bed side rails without a physician order. The facility's policy required obtaining and transcribing physician orders, but the medical record lacked such documentation. Both a nurse and the DON confirmed the oversight, acknowledging that a physician order should have been obtained when the side rails were reviewed and consented.
An expired punch card of Hydralazine HCL 10 mg tablets was found in a medication cart, which was confirmed by an LPN and the Assistant DON. The facility's policy mandates the immediate removal and disposal of outdated medications.
The facility failed to implement proper infection control measures for two residents, leading to potential cross-contamination. A resident with a dialysis shunt was not provided with appropriate enhanced barrier precautions (EBP), and staff did not follow hand hygiene protocols. Another resident with a nephrostomy lacked EBP signage and PPE. Additionally, empty hand sanitizer dispensers were found near resident rooms, compromising hand hygiene compliance.
A facility failed to establish a baseline care plan for a resident requiring an Aspen collar for a cervical vertebra fracture. Despite documentation of the collar's necessity, there was no physician order or care plan in place. Staff interviews revealed that the admitting nurse should have initiated the care plan within 48 hours, but this was not done, contrary to facility policy.
A facility failed to document a physician order for a cervical (Aspen) collar for a resident with a cervical vertebra fracture. Despite recommendations for the collar to be worn at all times, there was no care plan or physician order in place. The facility's policies required documentation of such devices, but the medical record lacked evidence of compliance, as confirmed by the DON.
Incomplete Reporting of Sexual Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough completion of a report submitted to the state agency regarding an allegation of sexual abuse involving a resident. The resident, who was admitted with diagnoses including a closed fracture of the right femur, schizoaffective disorder, major depressive disorder, and an anxiety disorder, alleged being touched inappropriately by a staff member described as a white male with a ponytail. The initial report submitted to the state agency did not substantiate the allegation, stating that no staff member matched the description provided by the resident. However, it was later revealed that a Restorative Nurse Assistant (RNA) with a beard and ponytail, who had provided services to the resident, was suspended for one day due to the investigation. The Director of Nursing confirmed the suspension was related to the investigation, as the RNA was the only male staff member fitting the description. The facility's final report lacked documentation of the RNA's suspension, and the Director of Nursing acknowledged the report contained inaccurate information. The facility's policy required prompt and comprehensive investigations, but the report failed to include all relevant details, compromising the thoroughness of the investigation.
Unsanitary Kitchen Conditions and Expired Food Products
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an inspection with the Kitchen Manager. The fryer was found with visibly aged and contaminated oil, and food debris was prevalent, contributing to unsanitary conditions. The surfaces of the fryer, stove, toaster, and mixer were coated with grease and food debris. The floor under the stove and oven was greasy, dusty, and littered with food debris. Additionally, the potable water dispenser and ice maker machine showed white calcium buildup, and the exhaust vent of the dishwasher was heavily soiled with dust. Expired food products and dented cans were also found during the inspection. A breadcrumbs container, cartons of thickened apple juice, containers of sour cream, peanut butter, and hot dogs were all past their expiration dates. Two dented cans of cheese sauce and a can of sliced pickled beets were found in dry storage. A container of gravy was found on the food preparation table without a date. The kitchen manager acknowledged these findings as unsanitary conditions that should have been corrected timely. The facility's policies on food safety and cleaning were not adhered to, as evidenced by the presence of expired food and unsanitary equipment and surfaces.
Failure to Provide Working Over-the-Bed Light
Penalty
Summary
The facility failed to provide a working over-the-bed light for a resident, identified as Resident 125, which impacted the resident's ability to use a urinal bottle independently overnight. Resident 125, who was admitted with diagnoses including hemiplegia affecting the left nondominant side, hereditary and idiopathic neuropathy, and cerebrovascular disease, reported moving into a new room two weeks prior without being provided a remote control for the over-the-bed light. The resident explained that the lack of light prevented independent use of the urinal bottle at night, necessitating assistance from staff. The issue was confirmed by the Maintenance Director, who acknowledged that the remote control had been sent for repair without an expected completion date. The Maintenance Director also noted that a remote control could have been sourced from an empty room or the resident could have been moved to another room to avoid disruption of care. The Assistant Director of Nursing confirmed that the resident should have been provided with a light to maintain independence and self-care. The facility's policy on resident room environment emphasized promoting and preserving resident independence and self-sufficiency, which was not adhered to in this case.
Failure to Ensure Proper Floor Cleaning Procedures
Penalty
Summary
The facility failed to provide a clean and sanitary homelike environment by not ensuring proper floor cleaning procedures in 16 of 90 residents' rooms, specifically rooms 406 to 422. This deficiency was identified through observations, interviews, and document reviews. A resident expressed concerns about the cleanliness of their room, noting that dust and debris remained at the edges between the wall and the floor at the baseboard, despite daily cleaning. A housekeeping staff member confirmed that the room had been cleaned but acknowledged that the edges were not addressed. The housekeeping supervisor corroborated these observations and confirmed that all surfaces should have been cleaned according to the facility's policy. The facility's cleaning policy, dated March 2006, required routine cleaning and disinfection to ensure a clean and safe environment, including dusting areas above eye level and moving furniture weekly to clean underneath and behind.
Failure to Complete PASARR Level II Referral for Resident
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II referral was completed for one of the sampled residents, identified as Resident 69. This resident was readmitted with multiple diagnoses, including schizoaffective disorder, anxiety disorder, depression, and post-traumatic stress disorder (PTSD). Despite these diagnoses, a PASARR Level I document from 2021 indicated that the resident did not have any mental illness, intellectual disability, or related condition, and was deemed appropriate for nursing facility placement. However, the resident's medical notes revealed diagnoses of schizoaffective disorder and PTSD, which should have triggered a PASARR Level II screening. The Social Services Director (SSD) acknowledged responsibility for referring residents who meet the criteria for PASARR Level II by completing the online request. The SSD agreed that the resident's diagnoses would indicate the need for such a referral. The Medicaid Services Manual for Nursing Facilities Policy requires a PASARR Level II screening when indicators of mental illness or related conditions are present. The medical record for Resident 69 lacked documented evidence of a referral for a PASARR Level II screening, indicating a failure in the facility's process to ensure necessary behavioral health services were considered for the resident.
Failure to Formulate Baseline Care Plan for Nephrostomy Tube
Penalty
Summary
The facility failed to ensure a baseline care plan was formulated for a resident with a nephrostomy tube, which is crucial for managing the resident's care. The resident, who was admitted and readmitted with diagnoses including palliative care, dysuria, and malignant neoplasm of the prostate, experienced issues with the nephrostomy dressing. On a specific date, the resident complained to a Registered Nurse (RN) about a peeling and soiled dressing, which had become wet during a shower and was not changed, leading to itchiness on the surrounding skin. The RN was unsure if the hospice nurse was responsible for changing the dressing, and the resident's medical records lacked documented evidence of a baseline care plan for the nephrostomy management. The Charge Nurse and the Director of Nursing (DON) confirmed the absence of a baseline care plan, which should have included management instructions for the nephrostomy tube. The facility's policy, dated May 2023, required the development and implementation of a baseline care plan within 48 hours of admission to provide effective, person-centered care. However, this was not done, and the DON indicated that licensed nurses were responsible for formulating the care plan, which should have been overseen by nursing leadership. The lack of a baseline care plan could have led to an increased risk of complications related to improper management and a lack of continuity in care.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility failed to implement a care plan for restorative hand splinting services for a resident who had a cerebrovascular accident and was at risk for contractures. The resident was observed without the prescribed hand splint, and the care plan indicated the need for a splint to be worn up to eight hours a day. However, after the resident's discharge and readmission, the physician's order for the splint was not renewed, and the restorative program was not performed. The Director of Nursing and the Physical Therapy Director acknowledged the oversight, noting that the resident was not reassessed upon readmission. The facility also failed to develop comprehensive care plans for three other residents. One resident, who used side rails for bed mobility, did not have a care plan addressing the use of side rails, despite a consent form being completed. Another resident experienced significant weight loss, but a care plan addressing nutritional needs was not developed until after the weight loss occurred. The Director of Nursing confirmed the absence of a timely care plan could have impacted the resident's care. Additionally, a resident with a right heel wound did not have a comprehensive care plan developed for wound care. The wound, which was positive for MRSA, was being treated according to a physician's order, but the lack of a care plan was acknowledged by the Director of Nursing. The absence of these care plans placed residents at risk for worsening health conditions related to their specific needs.
Deficiency in Resident Activity Programming
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests of its residents, as evidenced by the lack of community outings and outdoor activities for two sampled residents and seven unsampled residents. Resident 26, who had been at the facility for about six years, expressed a desire for more trips out of the facility to events and shopping places. An Activity Evaluation for this resident indicated a need for programming focused on community outings, large groups, independent activities, and outdoor activities. Resident 117, who had been at the facility for about two months, also expressed a desire for improved transportation to facilitate outings, noting that the facility had not taken residents out for shopping trips in a while. The medical record for Resident 117 lacked an Activity Evaluation to document the resident's identified needs. The activity calendars for December and January lacked documentation of any outdoor activities or outings, and previous months' activity calendars were unavailable. The Activity Director explained that outings were not scheduled due to the need to coordinate with in-house transportation, despite the facility having two buses/vans and two drivers, as well as access to outside transportation contractors. The Resident Council Minutes from December documented a request for an outing to a specific shopping center, which was agreed to be added to the January schedule, but residents acknowledged that no such trip had occurred since August. The facility's policy on Activity/Recreation Programming emphasized the importance of resident-centered activities to maintain and improve various aspects of well-being, which was not being met according to the findings.
Expired Medication Administered to Resident
Penalty
Summary
The facility failed to ensure that an expired medication was not administered to a resident, identified as Unsampled Resident 02 (UR2). UR2 was admitted with diagnoses including sequelae of cerebral infarction, anxiety disorder, chronic kidney disease stage 3, and dementia with mood disturbance. During an observation, a punch card of Hydralazine HCL 10 mg tablets, which had expired, was found in the medication cart. A Licensed Practical Nurse (LPN) and the Assistant Director of Nursing confirmed the expiration and acknowledged that the medication should have been discarded for resident safety. The expired Hydralazine HCL 10 mg tablets were documented to have been administered to UR2 for elevated blood pressure. The physician's order specified that the medication should be given as needed for systolic blood pressure greater than 160. The facility's policy on medication management required nurses to check expiration dates before administering medications. Despite this policy, the expired medication was administered, indicating a lapse in adherence to the facility's procedures for medication management.
Failure to Implement Contracture Management for Resident
Penalty
Summary
The facility failed to provide appropriate contracture management for a resident who had experienced a cerebrovascular accident (CVA) resulting in weakness on the right side of the body. The resident was observed without a hand splint, which was previously used to prevent contractures. The care plan indicated the resident should have been wearing a resting hand splint for up to eight hours a day, but this was not implemented. The physician's order for the splint was discontinued when the resident was transferred to a hospital, and no new order was obtained upon the resident's readmission to the facility. Interviews with facility staff revealed that the oversight occurred because the order for the splint was not carried over after the resident's hospital discharge and subsequent readmission. The Director of Nursing and the PT Director acknowledged the lapse in reassessment and the absence of a new physician order for the splint. The facility's policy required assessments for joint mobility upon admission, re-admission, and with significant changes, but this was not followed, leading to the deficiency in care for the resident.
Failure to Document and Monitor Nephrostomy Tube
Penalty
Summary
The facility failed to ensure proper management and documentation for a resident with a nephrostomy tube. The resident, who was receiving hospice care, had a nephrostomy tube with a soiled and peeling dressing that had not been changed after becoming wet during a shower. The resident's medical records lacked a physician's order for the nephrostomy tube, and there were no documented care or monitoring orders in place. This oversight was confirmed by a Registered Nurse and the Director of Nursing, who acknowledged the absence of necessary orders and monitoring for signs of infection. The facility's policy required a qualified licensed nurse to obtain and transcribe physician orders upon a resident's admission, including routine care orders. However, in this case, the orders were not documented in the resident's electronic records, leading to a lack of continuity in care and shared responsibility between hospice and facility staff. The Director of Nursing confirmed that the nephrostomy tube had not been monitored for signs of infection, and dressing changes were inconsistent, increasing the risk of infection and complications.
Failure to Assess Nutritional Status During Significant Weight Loss
Penalty
Summary
The facility failed to assess a resident's nutritional status during a period of substantial weight loss. A resident was admitted with diagnoses including encephalopathy, nausea with vomiting, and drug-induced subacute dyskinesia. Upon admission, the resident weighed 150 pounds, but by the following month, the weight had decreased to 120.1 pounds, indicating a significant weight loss of 19.93%. Despite a positive score for nutritional risk on a Malnutrition Screening Tool, the Nutritional Assessment at Admissions lacked critical information such as estimated nutritional needs, nutritional diagnosis, interventions, goals, monitoring, and evaluation. The medical record showed no documented evidence of a nutritional assessment or review from the time of admission until three months later, despite the resident's significant weight loss. The Director of Nursing acknowledged the absence of documented nutritional assessments during this period, attributing it to the Registered Dietitian being on medical leave. The Administrator also recognized the issue, noting that excessive weight loss needed to be addressed with dietary needs, food preferences, intake percentages, and supplements, in collaboration with the physician. The facility's policy required a comprehensive nutritional assessment upon admission, annually, and whenever a significant change in status occurred, which was not adhered to in this case.
Failure to Ensure Proper Dialysis Care for a Resident
Penalty
Summary
The facility failed to ensure proper dialysis care for a resident, identified as Resident 16, who required hemodialysis treatment. The deficiency was identified through observation, interviews, and record reviews, revealing that the Dialysis Communication Records were not consistently completed. Additionally, assessments of the shunt or dialysis access and vital signs were not consistently conducted pre- and post-dialysis. This lapse in protocol was noted from October 2024 to January 2025, during which the resident received dialysis treatments multiple times each month. The Director of Nursing confirmed the lack of documented evidence for shunt assessments and vital signs, despite staff being aware of the protocol. Resident 16 was admitted with chronic kidney disease, hypertension, and dependence on renal dialysis. The resident's cognitive status was intact, and they were receiving dialysis treatment three times a week. The care plan required monitoring the patency of the shunt and vital signs as ordered. However, the resident reported that vital signs were inconsistently taken upon arrival at the facility. The physician emphasized the importance of assessing the dialysis access for patency, signs of infection, and monitoring for bleeding post-dialysis, which was not consistently done, increasing the risk of complications.
Failure to Obtain Physician Order for Bed Side Rails
Penalty
Summary
The facility failed to obtain a physician order for the use of bed side rails for one resident, identified as Resident 62. This resident was admitted with diagnoses including Parkinson's disease, chest pain, and syncope. On a specific date, the resident was observed in a wheelchair beside their bed, with bed side rails raised on both sides. The resident indicated that the side rails were used to facilitate movement. A review and consent form dated prior to the observation documented the consideration of side rails for conditions such as syncope and hypertension to aid with repositioning and transfers. However, the medical record did not contain documented evidence of a physician order for the use of these side rails. During interviews, a nurse confirmed the use of side rails for the resident's bed mobility and acknowledged the absence of a physician order in the medical record. The Director of Nursing also confirmed the lack of a physician order and stated that such an order should have been obtained when the side rails review and consent were completed. The facility's policy on physician orders, revised earlier, required that a qualified licensed nurse obtain and transcribe orders according to facility guidelines, including confirming orders with a physician and requesting additional orders as needed.
Expired Medication Not Discarded
Penalty
Summary
The facility failed to ensure that an expired punch card of medications was discarded, which could potentially lead to the administration of non-viable medication to a resident. During an observation, a punch card of Hydralazine HCL 10 mg tablets was found expired in the 400-hall medication cart. A Licensed Practical Nurse confirmed the expiration and acknowledged that the medication should have been discarded for resident safety. The Assistant Director of Nursing also verified the expiration and the need for disposal. The facility's policy on medication storage requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures for medication destruction.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were implemented for two residents, leading to potential cross-contamination and transmission of infectious diseases. Resident 16, who had a dialysis shunt access, was not provided with appropriate enhanced barrier precautions (EBP) during care. A registered nurse assisted the resident without wearing personal protective equipment (PPE), and a certified nursing assistant (CNA) failed to perform hand hygiene, wore gloves without a gown, and handled the privacy curtain with soiled gloves. The CNA admitted to not following the infection control protocol despite recent education on the matter. Resident 98, who had a nephrostomy, did not have EBP signage or PPE available at the door entry. The charge nurse and infection preventionist confirmed that EBP was required for residents with devices such as catheters or wounds. Additionally, three hand sanitizer dispensers near resident rooms were found empty, and the housekeeping supervisor acknowledged that they should have been refilled to ensure compliance with hand hygiene protocols.
Failure to Implement Baseline Care Plan for Aspen Collar
Penalty
Summary
The facility failed to establish and implement a baseline care plan for a resident who required an Aspen collar for the management of a cervical vertebra fracture. The resident was admitted with multiple fractures, including a cervical vertebra fracture, and was documented to have a neck collar in place. However, there was no physician order documented for the use of the Aspen collar, and the medical record lacked evidence of care orders or a baseline care plan regarding the collar's management. Interviews with facility staff revealed that the admitting nurse was responsible for initiating the baseline care plan, which should have included immediate care needs within 48 hours of admission. The Director of Nursing acknowledged the absence of a baseline care plan for the Aspen collar and explained that the admission assessment should identify areas for the baseline care plan, including special devices like the Aspen collar. The facility's policy required the development and implementation of a baseline care plan to provide effective and person-centered care, which was not followed in this case.
Failure to Document Physician Order for Cervical Collar
Penalty
Summary
The facility failed to ensure that a cervical (Aspen) collar was ordered as recommended for a resident who had sustained multiple fractures, including a cervical vertebra fracture, following a motor vehicle accident. The resident was admitted with a recommendation for non-operative management with an Aspen collar to be worn at all times for 8-10 weeks. However, there was no physician order documented for the resident to wear the collar, nor was there a care plan in place for its use. The facility's policies required that residents be assessed for joint mobility limitations upon admission and that necessary devices be documented in the care plan. Despite the resident wearing the collar, the medical record lacked evidence of a physician's order or a care plan detailing the collar's use, skin assessment procedures, or wearing schedule. The Director of Nursing confirmed these omissions, indicating that the special instructions should have been included in the care plan to guide nursing staff.
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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