Tlc Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Henderson, Nevada.
- Location
- 1500 W Warm Springs Rd, Henderson, Nevada 89014
- CMS Provider Number
- 295071
- Inspections on file
- 32
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Tlc Care Center during CMS and state inspections, most recent first.
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.
The governing body failed to oversee a contracted behavioral health vendor’s documentation and interventions for two residents in a Medicaid behaviorally complex care program. Behavior tracking sheets contained multiple entries initialed by an unidentifiable individual, and one resident’s records listed numerous unapproved interventions such as detention, seclusion, suspension, and corporal punishment that were not part of the care plan and were not used by facility staff. Facility leadership reported that only contracted behavioral health staff completed these behavior sheets and submitted them to Medicaid, while a vendor supervisor later determined that a single employee had used an AI tool to generate interventions and had signed using other initials instead of obtaining real-time intervention information from facility staff as required.
A resident receiving Quetiapine for bipolar disorder with mood swings was given the antipsychotic for approximately two weeks without required monitoring of target behaviors or side effects. Although facility policy required evaluation and ongoing monitoring of antipsychotic use, the admitting nurse entered the medication order without corresponding behavior and side effect monitoring orders, so no EHR prompts appeared for floor nurses. An LPN, a charge nurse, and the DON all confirmed that behavior and side effect monitoring did not begin until later, when specific orders for monitoring mood swings, non‑pharmacological interventions, and side effects were finally entered.
A resident dependent on staff for bathing, with multiple medical conditions, did not receive scheduled showers or bed baths as required. The resident reported a rash and itching, and review of records confirmed that scheduled bathing was not consistently provided, contrary to facility policy.
A resident with multiple diagnoses did not have monthly weights documented for three consecutive months, despite physician orders and facility policy requiring this monitoring. Staff interviews confirmed that CNAs had not consistently obtained weights, leading to gaps in care planning and delayed interventions.
A resident with a left wrist fracture did not receive a timely orthopedic consult as ordered by the physician. Although the resident returned from the ER with a splint and an order for orthopedic follow-up, staff failed to initiate the insurance authorization process for over a month due to lack of communication and unclear delegation of responsibilities during a staff member's medical leave. The resident was not seen by an orthopedic specialist until nearly two months after the injury.
A resident with lower extremity impairment was improperly transferred without a Hoyer lift, resulting in a fall and injury. Additionally, an unsecured oxygen tank was found in another resident's room, posing a potential hazard. These incidents indicate lapses in staff training and adherence to safety protocols.
The facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program. The administrator, new to the position, could not locate electronic documents related to the QAPI program, despite evidence of meetings on specific dates. The facility's policy required maintaining documentation, but this was not adhered to, violating the State Operations Manual's requirements for a data-driven QAPI program.
The facility failed to maintain a QAPI Committee with the required members and did not document meetings at least quarterly. Key members were absent from meetings on multiple occasions, and the Administrator could not provide evidence of compliance with meeting frequency requirements, potentially affecting resident care quality.
A resident was self-administering Ketotifen Fumarate Ophthalmic Solution without a physician's order, assessment, or care plan in place. The resident kept the eye drops at the bedside, contrary to facility policy, which requires secure storage and an interdisciplinary team's assessment of the resident's ability to self-administer medications safely.
A resident with intact cognition expressed dissatisfaction with the frequency of showers provided, citing personal hygiene concerns. The facility failed to accommodate the resident's preference for more frequent showers due to the unavailability of a Hoyer sling necessary for transfers, resulting in missed showers. The facility's policy to honor resident preferences for type and frequency of baths was not adhered to.
The facility did not document responses to complaints from resident council meetings, where residents reported delays in call light responses and staff distractions. A resident waited up to 45 minutes for assistance, and another had not received a shower in three months. Despite these issues being documented, no written responses or corrective actions were provided.
A resident with severe cognitive impairment was found with both upper and lower bed rails raised, considered physical restraints, without proper physician orders or documented assessments. Staff acknowledged the use of restraints but lacked documentation or orders justifying their use. The facility's policies on physical restraints and fall protocol were not followed, leading to the deficiency.
A resident with severe cognitive deficit and Parkinson's disease was using side rails for bed mobility without a documented care plan or physician order. Despite a side rail assessment and consent being completed over a year prior, the facility failed to update the care plan and obtain a physician order, as confirmed by staff interviews. This oversight was contrary to the facility's policy requiring timely development of care plans.
A facility failed to obtain a physician's order for the removal or use of an IV access for a resident, including assessing and monitoring the site. The resident had an undated IV port, and inspections confirmed the absence of a date on the dressing. There were no current orders for the IV, and the facility's policies on IV removal and dressing changes were not followed, leading to a deficiency.
A facility failed to assess and document the use of bed rails for a resident with severe cognitive impairment and other health issues. The resident's medical record lacked evidence of physician orders, comprehensive assessments, and attempts of less restrictive alternatives. Staff confirmed the use of bed rails but could not provide documentation or recall installation details, placing the resident at risk of injury.
The facility failed to label and date pre-made sandwiches stored in the refrigerator, posing a potential risk to safety and health standards. During a kitchen tour, three sandwiches were found wrapped but not labeled or dated in the walk-in cooler. The Dietary Account Manager acknowledged the oversight, which violated the facility's policy requiring all foods to be labeled and dated to prevent cross-contamination.
A resident in a facility experienced a breach in infection control practices when a CNA used a brief from another resident's room due to a shortage of bariatric-sized briefs. The Central Supply Clerk confirmed the shortage, and the facility's protocol was not followed, leading to potential cross-contamination risks. The Infection Preventionist and ADON confirmed that such actions were against infection control policies.
A resident with multiple diagnoses was involved in an altercation with a staff member, who blocked the resident's wheelchair and held their arms down, leading to the resident's agitation and kicking. The staff member threatened retaliation, and the incident was witnessed by another employee. The facility's records lacked documentation of social services involvement, and the resident's care plans were not updated following the incident. The facility substantiated the abuse allegation and terminated the staff member.
A facility failed to report an alleged physical abuse incident involving a resident to the State Agency within the required timeframes. The resident, with a history of aggressive behavior, was involved in an incident that was not reported until later in the day, and no final report was submitted. The facility's policy and state regulations require immediate reporting of such incidents, but the Administrator/Abuse Coordinator was unsure if the timelines were met.
The facility failed to provide adequate incontinent care for three residents, leading to potential skin integrity issues. One resident experienced a delay in receiving a brief change due to a supply shortage, while another resident's records showed a lack of documented toileting hygiene. Additionally, a third resident's medical records lacked documentation of toileting care during specific shifts, indicating care was not provided. The facility's policy required documentation of ADLs, which was not followed.
The facility failed to follow physician orders for medication administration, affecting several residents. A resident's insulin order lacked instructions for certain glucose levels, leading to unreported results. Another resident received an incorrect dosage of Calcium Carbonate due to supply issues. Staffing shortages caused missed medications for multiple residents, with no documentation of administration or refusal. The facility lacked a general medication administration policy.
A facility failed to maintain complete and accurate medical records for three residents, leading to potential care issues. One resident's refusal of a drug test was not documented, another resident's critical change in condition was not properly recorded or communicated, and a third resident's medication order was incorrectly transcribed, leading to unsupervised self-administration without proper assessment or care plan.
The facility failed to ensure the Infection Preventionist had specialized training and did not report a COVID-19 outbreak to the state agency. The outbreak involved 55 residents and 12 staff members. Additionally, N-95 respirator fit testing was not completed for staff, leading to improper PPE use.
A resident's grievance was not documented or investigated after a janitor massaged the resident's feet and legs, which was outside the janitor's job duties. Despite being reported to the Administrator and other staff, the incident was not logged in the facility's grievance log, violating the facility's policy on handling grievances.
A resident admitted with a serious infection did not receive Vancomycin as per hospital discharge instructions. The facility's process for ordering medications was not followed promptly, resulting in a delay in administering the antibiotic. Staff interviews revealed that the medication should have been available and administered sooner.
A facility failed to document discharge planning for a resident admitted for short-term rehabilitation after open heart surgery. The resident's medical record lacked evidence of a case manager's assessment for discharge needs, despite facility policy requiring such documentation. Interviews with staff confirmed the absence of a documented discharge plan, which should have been initiated early and updated throughout the resident's stay.
A facility failed to document assistance with activities of daily living (ADL) for a resident dependent on staff for toileting hygiene due to conditions like Parkinson's disease and acute respiratory failure. The resident's care plan required staff assistance for toileting and cleaning the peri-area with each incontinent episode. However, the Admission MDS and ADL Flowsheet showed missing documentation for toileting hygiene during the day shift on multiple dates, indicating a lack of recorded assistance. The MDS Coordinator and a CNA confirmed the resident's dependency and the need for proper documentation, which was not met according to the facility's ADL policy.
The facility failed to complete weekly wound evaluations for a resident with surgical wounds and did not implement a psychiatric consultation for another resident exhibiting aggressive behavior. The resident with wounds had inaccurate skin observations documented, and there was no evidence of weekly evaluations for three weeks. The resident with altered mental status showed combative behavior, but despite orders, no psychiatric consultation was documented or coordinated.
A facility failed to conduct weekly wound evaluations and accurately document skin observations for a resident with multiple skin conditions. Despite having a stage 1 pressure wound, a stage 3 pressure wound, and a deep tissue injury, the resident's medical record showed no weekly wound evaluations from admission to discharge. Interviews with staff confirmed the absence of evaluations and inaccuracies in documentation, contrary to facility policy.
The facility failed to manage sharps containers properly, with containers overfilled beyond the manufacturer's fill line, increasing the risk of needle stick injuries. Additionally, residents were observed smoking without supervision in an area with a propane grill improperly stored, posing a safety risk. The facility did not conduct regular assessments of smoking residents, as required by policy, compromising resident safety.
The facility failed to ensure staff used appropriate equipment for residents on transmission-based precautions, leading to potential cross-contamination. CNAs used personal blood pressure monitors for multiple residents, including those on precautions, and were unaware of the facility's disposable cuffs. Disinfection procedures were not properly followed, as staff did not adhere to the manufacturer's instructions for bleach wipes.
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 Oversee Contracted Behavioral Health Documentation and Interventions
Penalty
Summary
The governing body failed to oversee services performed by a contracted behavioral health vendor, including the accuracy of behavior documentation for two residents enrolled in the Medicaid Behaviorally Complex Care Program. The facility used a multi-page Behavior Frequency Documentation Data Sheet to track behaviors and interventions, but review of these sheets for two sampled residents showed entries with initials that could not be linked to any identifiable staff member. For one resident with schizophrenia, dementia, major depressive disorder, and generalized anxiety disorder, behavior sheets for two consecutive months contained multiple entries initialed as "AB" by an unverified staff member; a similar pattern of unverified initials appeared on another resident’s behavior sheets over two months. The behavior documentation for one of these residents included numerous interventions that were not part of the resident’s care plan and were not used by facility staff. These interventions were described as effective, successful, failed, or ineffective and included terms such as loss of privileges, time-out, detention, parent-teacher conferences, suspension, student-teacher conferences, expulsion, seclusion, calm-down corner, and corporal punishment. The Unit Manager stated that facility staff did not have access to the behavior data sheets, did not document on them, and had never used the listed interventions when addressing resident behaviors. The Administrator similarly reported that contracted behavioral health staff were solely responsible for completing the behavior documentation and submitting all related documents to Medicaid. Interviews with facility leadership and contracted vendor staff further showed that the contracted behavioral health staff, not facility staff, controlled the behavior documentation and submission process. The Assistant Administrator and Administrator confirmed that treatment and documentation for residents in the behaviorally complex care program were completed by the vendor’s behavioral health staff. A Lead Behavior Coordinator from the vendor acknowledged awareness that a Behavior Coordinator was using other initials to sign paperwork and that terms such as spanking and corporal punishment had appeared on the sheets. The vendor’s Chief Clinical Officer later determined that a single employee had documented interventions that were not actually implemented at the facility and that this employee had used an AI tool to generate interventions instead of obtaining real-time intervention information from facility staff, contrary to expectations and the consulting agreement that required accurate labeling and verification of patient data for claims submission.
Failure to Monitor Antipsychotic Target Behaviors and Side Effects
Penalty
Summary
The facility failed to ensure that a resident’s antipsychotic drug regimen was monitored for target behaviors and side effects as required. A cognitively intact resident admitted with diagnoses including metabolic encephalopathy, malignant neoplasm of the colon, and non‑traumatic subarachnoid hemorrhage was receiving Quetiapine 25 mg at bedtime for bipolar disorder manifested by mood swings. The admission MDS documented verbally aggressive behaviors and antipsychotic use. A physician order dated 04/15/2025 initiated Quetiapine, but the medical record lacked documented evidence that target behaviors or side effects were monitored from 04/15/2025 through 04/28/2025, despite facility policy that residents admitted on antipsychotics be evaluated for appropriateness and indication for use by the IDT and physician. On 04/29/2025, physician orders were entered to monitor mood swings as the target behavior and to use specified non‑pharmacological interventions with outcome codes every shift, as well as to monitor for specific side effects of Quetiapine (including dry mouth, constipation, blurred vision, confusion, hypotension, EPS, and others) every shift. Interviews with an LPN and a charge nurse confirmed that Quetiapine had been administered starting 04/15/2025 and that behavior and side effect monitoring did not begin until 04/29/2025, likely because the admitting nurse did not enter the monitoring orders at the time the medication was started. The charge nurse explained that if orders are not entered into the EHR, floor nurses are not prompted to complete related tasks. The DON confirmed that the resident was not monitored for target behaviors or potential side effects from the first dose of Quetiapine on 04/15/2025 until 04/29/2025 due to the late entry of monitoring orders, despite facility policy requiring monitoring to guide decisions about continued use, dosage, and GDR of antipsychotic medications.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for bathing due to medical conditions including dysphagia following cerebral infarction, type 2 diabetes mellitus, and essential hypertension, did not receive scheduled bathing as required. The resident reported experiencing a rash and itching, and stated that staff did not bathe or shower them regularly. Review of the facility's bathing schedule and medical records showed that the resident was assigned to receive showers or bed baths twice weekly, specifically on Wednesday and Saturday evenings, but these were not consistently provided as scheduled. A Certified Nurse Assistant confirmed the bathing schedule and that documentation was maintained in the medical record. The Director of Nursing also verified that the resident's scheduled showers were not provided as required. Facility policy stated that residents should be offered at least two full baths or showers per week, but this was not adhered to in the resident's case, as evidenced by gaps in the bathing documentation and the resident's own account of infrequent bathing.
Failure to Obtain and Document Monthly Weights as Ordered
Penalty
Summary
The facility failed to follow physician orders for obtaining monthly weights for a resident diagnosed with Parkinson's disease, dementia, and major depressive disorder. The physician had ordered monthly weights to be taken within the first week of each month for monitoring purposes. However, the medical record lacked documented weights for three consecutive months, specifically September, October, and November. This omission was identified through record review and confirmed by staff interviews, which revealed that Certified Nurse Assistants (CNAs) had not consistently obtained the required monthly weights. Multiple staff members, including the DON, Unit Manager, ADON, and Registered Dietitian, acknowledged ongoing challenges in obtaining accurate and consistent weight measurements. They indicated that missing or inaccurate weights had negatively impacted care planning and delayed timely interventions for residents experiencing weight loss or significant changes. The facility's policy required nursing staff to measure resident weights as ordered by the physician, but this was not consistently followed for the resident in question.
Failure to Timely Obtain Orthopedic Consult Following Physician Order
Penalty
Summary
The facility failed to obtain an orthopedic consult as ordered by the physician for a resident who had suffered a left wrist fracture following a fall. After the fall, the resident was sent to the emergency room, diagnosed with a left wrist fracture, and returned to the facility with a splint and ace wrap. A physician order for an orthopedic follow-up was placed, but the consult was not arranged in a timely manner. Staff interviews and documentation revealed that the process for obtaining insurance authorization for the consult was not initiated until over a month after the order was written. The case manager, who was responsible for obtaining insurance authorization, was unaware of the order and was on medical leave during a critical period, with no clear delegation of responsibility in their absence. The delay in obtaining the orthopedic consult resulted in the resident not being evaluated by an orthopedic specialist until nearly two months after the initial injury and order. Staff interviews indicated confusion and lack of communication regarding who was responsible for securing insurance authorization and scheduling the appointment. The unit manager and transportation coordinator both cited insurance approval as a reason for the delay, but the necessary steps to obtain approval were not taken promptly. Facility documentation confirmed that the insurance authorization request was not made until several weeks after the order, and the resident's nurse practitioner acknowledged that the delay was not acceptable.
Deficiencies in Resident Transfer and Oxygen Tank Safety
Penalty
Summary
The facility failed to ensure that the plan of care was followed regarding transfers for a resident, leading to a fall with injury. The resident, who had a history of lower extremity impairment and required a Hoyer lift for transfers, was improperly transferred by a CNA without the necessary equipment. The CNA attempted to transfer the resident independently, resulting in the resident's knee buckling and a fall to the floor, causing a nondisplaced fracture of the proximal tibia. The CNA did not check the resident's care plan or consult with the assigned nurse, leading to the improper transfer method being used. Additionally, the facility failed to secure an oxygen tank for another resident, creating a potential hazard. The oxygen cylinder was observed unsecured beside the resident's bed, contrary to the facility's policy requiring oxygen tanks to be stored in sturdy portable carts or approved stands. The CNA confirmed the tank was not secured and acknowledged the need for a holder to prevent it from falling. The facility's policies on fall protocols and oxygen safety were not adhered to, as evidenced by the lack of a comprehensive investigation and documentation following the fall incident, and the unsecured oxygen tank. The deficiencies highlight lapses in staff training and adherence to established safety protocols, which could lead to resident injuries.
Failure to Maintain QAPI Documentation
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program. During an interview and document review, the administrator acknowledged the inability to produce documentation showing the development, implementation, and maintenance of an effective, comprehensive QAPI program. Although evidence of QAPI meetings on specific dates was provided, the administrator, who had been in the position for a short time, could not locate where the electronic documents were filed or if they were filed at all. The facility's policy on QAPI Committee, which was undated, stated that the facility would maintain documentation and demonstrate evidence of its ongoing QAPI program. The State Operations Manual requires facilities to develop, implement, and maintain a data-driven QAPI program, with documentation to demonstrate its ongoing implementation, which was not adhered to in this case.
QAPI Committee Composition and Meeting Frequency Deficiency
Penalty
Summary
The facility failed to maintain documented evidence of a Quality Assurance and Performance Improvement (QAPI) Committee that meets the required composition and frequency. Specifically, the QAPI Committee was missing key members during its meetings on several occasions. On 02/27/2025, the meeting lacked the presence of the Director of Nursing and an Administrator, Owner, or Board Member. On 09/24/2024, the meeting was missing the Medical Director or his/her designee and an Administrator, Owner, or Board Member. Additionally, the meeting on 07/30/2024 did not include the Medical Director or his/her designee. These omissions indicate a failure to comply with the regulatory requirements for the composition of the QAPI Committee. Furthermore, the facility did not maintain documentation of the QAPI Committee meeting at least quarterly, as required. The Administrator acknowledged the absence of documented evidence for meetings on the specified dates and admitted to being unable to locate electronic documents or confirm if they were filed. This lack of documentation and adherence to meeting frequency requirements has the potential to negatively impact the quality of resident care and life. The facility's policy and the state operations manual both stipulate the necessity of maintaining a QAPI Committee with specific members and meeting at least quarterly, which the facility failed to uphold.
Failure to Obtain Physician's Order and Assessment for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a physician's order was obtained, an assessment was completed, and a care plan was developed for the self-administration of medication for one resident. The resident, who was admitted with diagnoses including peripheral vascular disease and age-related physical debility, was self-administering Ketotifen Fumarate Ophthalmic Solution for eye itching without the necessary physician's order or assessment. During a medication administration pass observation, it was noted that the resident kept and self-administered the eye drops, which were stored in a purse at the bedside, contrary to the facility's policy. The Licensed Practical Nurse (LPN) and the Regional Director of Clinical Services confirmed that there were no physician's orders, assessments, or care plans in place for the resident's self-administration of the eye drops. The facility's policy required that an interdisciplinary team determine the clinical appropriateness and safety of self-administration, including a specific skill assessment of the resident's abilities. The policy also mandated that self-administered medications be stored securely, which was not adhered to in this case.
Failure to Accommodate Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that residents have the right to make choices about significant aspects of their life, as evidenced by the case of a resident with intact cognition who expressed dissatisfaction with the frequency of showers provided. The resident, who was admitted with diagnoses of nontraumatic intracerebral hemorrhage and hemiplegia and hemiparesis following cerebral infarction, reported that two showers per week were insufficient and expressed concerns about personal hygiene issues such as sweating, greasy hair, and body odor due to the infrequent showers. The facility's failure to accommodate the resident's preference for more frequent showers was compounded by the unavailability of a Hoyer sling necessary for shower transfers, resulting in missed showers. The Administrator-In-Training and the Assistant Director of Nursing confirmed that the resident's shower days were scheduled for Tuesday, Thursday, and an additional day on Sunday, but acknowledged the lack of a Hoyer sling on a scheduled shower day and the absence of documentation for another scheduled shower. The facility's policy stated that residents should be offered at least two full baths per week, with preferences for type and frequency honored, which was not adhered to in this case.
Failure to Address Resident Council Complaints
Penalty
Summary
The facility failed to document a written response to complaints raised during resident council meetings, which had the potential to leave resident concerns unresolved. During meetings held in February and March 2025, residents expressed dissatisfaction with the timeliness of call light responses and reported that staff were often distracted by their phones. One resident mentioned waiting up to 45 minutes for assistance, while another reported not having received a shower in three months. Despite these complaints being documented in the meeting minutes, no written responses or corrective actions were provided by the facility. Resident 57, who served as the Resident Council President, confirmed that the facility did not consistently respond to concerns raised in the meetings. The Activities Assistant noted that while meeting notes were shared with department heads, responses were not consistently returned to the activities department. The Administrator, who had recently commenced employment, acknowledged the absence of written responses and was unable to locate any documentation addressing the complaints. The Regional Director of Clinical Services confirmed that concerns should have been investigated and documented, as per the facility's policy on grievances and complaints.
Failure to Ensure Resident is Free from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that Resident 168 was free from the use of physical restraints not needed for medical treatment. The resident, who had severe cognitive impairment and was at risk for falls, was found with both upper and lower bed rails raised, which were considered physical restraints. The facility did not have physician orders or documented assessments justifying the use of these restraints, and the resident's care plan lacked documentation of alternatives considered before implementing the restraints. Observations and interviews revealed that the staff, including a CNA and an LPN, were aware of the use of bed rails and floor mats for safety but did not have proper documentation or orders for their use. The LPN acknowledged that the lower bed rails were considered restraints and could not recall how long they had been in place. The facility's Assistant Director of Nursing and Regional Director of Clinical Services confirmed the lack of physician orders and care plan documentation for the use of the rails, and the Director of Maintenance was unaware of the installation of lower rails until identified by the survey team. The facility's policies on physical restraints and fall protocol were not followed, as there was no documented evidence of a comprehensive investigation or root cause analysis for the use of restraints or past falls involving the resident. The facility's failure to conduct proper assessments, obtain necessary orders, and document the use of restraints led to the deficiency, which could have resulted in harm to the resident.
Failure to Revise Care Plan and Obtain Physician Order for Side Rails
Penalty
Summary
The facility failed to ensure a resident-centered care plan was revised and a physician order obtained for the use of side rails for one resident. The resident, who was admitted with diagnoses including Parkinson's disease and required assistance with personal care, had a severe cognitive deficit as indicated by a BIMS score of 5/15. Observations revealed that the resident was using side rails for bed mobility and transfers, but there was no documented care plan or physician order for the use of these side rails prior to specific dates. The resident's medical record showed a side rail assessment and consent were completed over a year before the deficiency was noted, but the care plan and physician order were not updated accordingly. Interviews with facility staff, including an LPN and the Unit Manager, confirmed that side rails were being used as an enabler for the resident's transfers and bed mobility. However, the staff acknowledged that the necessary care plan and physician order were not in place. The facility's policy required a baseline care plan to be developed within 48 hours of admission and a comprehensive care plan within seven days of the comprehensive assessment, but these protocols were not followed in this case, leading to a lack of communication and potential risk for the resident.
Failure to Obtain Physician's Order for IV Access Management
Penalty
Summary
The facility failed to obtain a physician's order for the removal or use of an intravenous (IV) access for a resident, including assessing and monitoring the site. This deficiency was identified for one resident who was initially admitted with diagnoses including anoxic brain damage, seizures, and a carrier of carbapenem-resistant Enterobacter. During an observation, the resident was found with an undated IV port on the right arm, and subsequent inspections by the Director of Nursing (DON) and an Assistant Director of Nursing (ADON) confirmed the absence of a date on the dressing. The ADON noted that the dressing appeared to need changing and that there were no current orders for an IV. A review of the resident's physician orders revealed an order to insert the IV on a previous date for IV antibiotics, but there were no orders to flush the IV line or monitor the dressing. The DON acknowledged that there should have been orders to flush the IV line, change and monitor the dressing weekly, and remove the IV line after the completion of the antibiotics. The facility's policies on IV removal and dressing changes were not followed, as there was no documentation of the dressing change or monitoring, which is essential to prevent catheter-related infections.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that Resident 168 was properly assessed and reviewed for risks and benefits before the installation of bed rails. The resident, who was admitted with diagnoses including muscle weakness, lack of coordination, and severe cognitive impairment, was observed with full bed rails raised without documented evidence of physician orders or a comprehensive assessment. The facility's policy requires a Side Rail and Entrapment Risk Assessment, which was not completed after the resident's readmission, and there was no documentation of less restrictive alternatives being attempted prior to the use of bed rails. The medical record for Resident 168 lacked evidence of a physician's order for the use of bed rails and floor mats, and the care plan did not document the use of these interventions. Additionally, the Side Rail Consent form was incomplete, missing the resident's name and signature, as well as the signature of a resident representative. The facility's staff, including a CNA, LPN, and ADON, confirmed the use of bed rails but were unable to provide documentation or recall when the rails were installed. The facility's policy on bed rails requires an interdisciplinary assessment, consultation with the attending physician, and input from the resident or legal representative, none of which were documented in this case. The facility also failed to conduct in-service training on bed rail guidelines, and the Director of Maintenance confirmed that the facility did not track when bed rails were installed. This lack of documentation and adherence to policy placed Resident 168 at risk of injury from falls, entrapment, and other potential harm.
Failure to Label and Date Pre-Made Foods in Refrigerator
Penalty
Summary
The facility failed to ensure that pre-made foods were stored, labeled, dated, and used within seven days in the refrigerator, which posed a potential risk to safety and health standards. During a follow-up tour of the kitchen and dietary areas, three sandwiches were found in a plastic tub in the walk-in cooler. These sandwiches were wrapped but not labeled or dated. The Dietary Account Manager acknowledged that the sandwiches should have been labeled and dated to inform the kitchen staff of how long the items had been stored in the cooler. A Healthcare Services Group Policy, revised in February 2023, stated that all foods should be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross-contamination.
Infection Control Breach Due to Supply Shortage
Penalty
Summary
The facility failed to maintain proper infection control practices for one resident, identified as Resident 25, who was admitted with a displaced bicondylar fracture of the right tibia. On a specific date, Resident 25 requested assistance with a brief change and was informed by staff that the facility was out of the required bariatric-sized briefs. The Central Supply Clerk confirmed the shortage, attributing it to a lack of ordering by the backup supply clerk during their absence. The facility placed an order for the briefs, but they were not expected to arrive until two days later. In the interim, the facility's transportation driver was tasked with purchasing the necessary briefs. In an attempt to address the immediate need, a CNA obtained a brief from another resident's room to use for Resident 25, which was confirmed by both the CNA and Resident 25. This action was against the facility's infection control policy, as confirmed by the Infection Preventionist and the Assistant Director of Nursing (ADON), who stated that taking items from one resident's room to another could lead to cross-contamination and the spread of infections. The ADON explained that the proper protocol when out of supplies was to notify the charge nurse and central supply, and if necessary, the Administrator would be informed to purchase the required items.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a staff member and a resident. The resident, who was admitted with diagnoses including encephalopathy, urinary tract infection, hypothyroidism, and hypertension, was involved in an altercation with a staff member. The incident occurred when the resident, in a wheelchair, was arguing with a staff member and attempting to return to a previous room. The staff member blocked the resident's movement and held the resident's arms down against the wheelchair, leading to the resident becoming agitated and kicking at the staff member. The staff member threatened to retaliate if kicked by the resident. The incident was witnessed by another employee, who observed the staff member repeatedly holding the resident's hands down against the wheelchair while the resident yelled to be released. The facility's records lacked documentation of social services involvement in the situation, aside from a referral to psychiatric services for the resident's agitation. Additionally, the resident's care plans were not updated or revised following the incident. The facility substantiated the allegation of physical abuse, suspended the staff member involved, and subsequently terminated their employment.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical abuse involving a resident to the State Agency (SA) within the required timeframes. The incident involved a resident who was admitted with diagnoses including encephalopathy, urinary tract infection, hypothyroidism, and hypertension. On a specific date, the resident exhibited aggressive behavior, including kicking at staff and verbal aggression. The Director of Social Services notified the Administrator-In-Training of the potential abuse allegation via email, and the Administrator acknowledged receipt shortly after. However, the initial Facility Reported Incident was not submitted to the SA until later that evening, and no final report was received by the SA. The facility's policy and the State Operations Manual for Long Term Care require that alleged abuse incidents be reported immediately, but not later than two hours if they involve abuse or result in serious bodily injury, or within 24 hours if they do not. Additionally, the results of all investigations must be reported to the State Survey Agency within five working days. The Administrator/Abuse Coordinator, who was not working at the facility at the time of the event, was unsure if the incident was reported within the required timeframes. This deficiency had the potential to place residents at risk for incidents of physical abuse not being adequately protected.
Inadequate Incontinent Care and Documentation Issues
Penalty
Summary
The facility failed to provide adequate incontinent care for three residents, leading to potential compromise of their skin integrity. Resident 25 experienced a delay in receiving a brief change from 6:00 AM until approximately 10:30 AM due to the facility running out of the specific bariatric-sized briefs required. The Central Supply Clerk confirmed the shortage was due to an oversight in ordering supplies, and a substitute was not available until later that day. The CNA eventually found a brief from another resident's room to address the immediate need. Resident 468's records indicated a lack of documented evidence of toileting hygiene being provided consistently. The Admission Minimum Data Set (MDS) and care plan documented the resident's incontinence and need for maximal assistance, yet the ADL documentation showed 'not applicable' for several days, suggesting that care was not provided. The MDS Director and Assistant Director of Nursing confirmed the documentation errors and acknowledged that the 'not applicable' entries indicated the task was not completed. Resident 417's medical records also lacked documentation of toileting hygiene during specific day shifts, as confirmed by the MDS Nurse and Regional Director of Clinical Services. The absence of documentation suggested that care was not provided during these times. The facility's policy required that activities of daily living and personal care be documented in the clinical record, which was not adhered to in these cases.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure physician orders were followed in medication administration for several residents, leading to potential therapeutic inefficacy. Resident 469 was admitted with diagnoses including metabolic encephalopathy and type 2 diabetes. The physician's order for Humalog insulin lacked instructions for blood glucose levels between 71-149 mg/dL. On two occasions, the resident's blood glucose levels fell within this range, but there was no documentation of physician notification, as required by the facility's policy. Resident 219 received an incorrect dosage of Calcium Carbonate due to a lack of supply of the prescribed 600 mg tablets. The LPN administered a 500 mg tablet instead, acknowledging the error and the need to clarify the order with the physician. The facility's policy mandates verification of medication orders prior to administration, which was not adhered to in this instance. Additionally, several residents did not receive their medications in a timely manner due to staffing issues. Employee 28 was tasked with covering two separate halls, leading to missed medication administrations for multiple residents. The facility lacked a general medication administration policy, and the Director of Nursing stated that medications should be administered within an hour of the scheduled time unless documented otherwise. This oversight resulted in numerous medications being marked as missed, with no documentation of administration or refusal by the residents.
Incomplete and Inaccurate Medical Records for Three Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for three residents, leading to potential care issues. Resident 98 was admitted with chronic obstructive pulmonary disease, Type 2 diabetes mellitus, and dependence on supplemental oxygen. A physician ordered a drug test for the resident, but the facility could not produce the test results. The Regional Director of Clinical Services stated that the resident refused the test, but there was no documentation of this refusal in the medical record. The Assistant Director of Nursing confirmed the lack of documentation regarding the resident's refusal. Resident 467, who had diagnoses including venous insufficiency and Down Syndrome, experienced a significant change in condition with an oxygen saturation level dropping to the 60s. A Nurse Practitioner ordered the resident to be sent to the emergency room, but the transfer did not occur, and there was no documentation of the low oxygen saturation or the provider being notified of the resident not being sent to the hospital. The Assistant Director of Nursing confirmed the absence of documentation regarding the change in condition and the lack of communication with the Nurse Practitioner. Resident 469 had a physician order for Metformin self-administration, but the Medication Administration Record indicated unsupervised self-administration, which was not allowed. The Director of Nursing acknowledged that there was no assessment or care plan for self-administration, and the order was incorrectly transcribed. The Director confirmed that the order needed clarification with the physician and proper documentation was required.
Inadequate Infection Control and Reporting in COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that the appointed Infection Preventionist (IP) had the necessary specialized training in infection control prior to assuming the role. The IP, who was appointed at the end of September 2024, did not have the required training and was not aware of the need to report a COVID-19 outbreak to the state agency. The outbreak involved 55 COVID-19 positive residents and 12 positive staff members. The IP was also unable to work full-time due to health issues and there was no designated backup to oversee the infection control program during their absence. The facility did not report a significant COVID-19 outbreak to the appropriate state agency, despite being aware of the outbreak's progression. The outbreak began with two residents testing positive, followed by additional cases over a two-week period. Although the facility reported the outbreak to the National Healthcare Safety Network (NHSN), it failed to notify the state agency as required. Additionally, the facility did not complete N-95 respirator fit testing for staff, as observed in several instances where staff members were either improperly using or not using the required personal protective equipment (PPE). Staff members, including a Housekeeping Aide, a CNA, and an RN, were either not fit-tested or were unaware of where to find N-95 respirators in the facility. The Infection Preventionist confirmed that fit testing had not been conducted, which was a critical responsibility outlined in their job description.
Failure to Document and Investigate Resident Grievance
Penalty
Summary
The facility failed to ensure a grievance report was initiated and followed through for a resident who was involved in an incident where a nonclinical staff member performed a task outside their scope of duties. The resident, who had been admitted with acute post-traumatic pain and fractures, had their feet and legs massaged by a janitor, as reported by the resident's significant other. This incident was not documented in the facility's grievance log, despite being reported to the Administrator and other staff members. Interviews with various staff members, including a CNA, Case Manager, and the alleged housekeeper, confirmed the occurrence of the incident. The housekeeper admitted to applying medicated ointment and socks to the resident, which was outside their job duties. The facility's policy required all grievances to be documented and investigated, but this was not done in this case, leading to a deficiency in handling resident grievances appropriately.
Failure to Administer Vancomycin Upon Admission
Penalty
Summary
The facility failed to initiate Vancomycin medication upon admission for a resident with a serious infection, as per the hospital discharge instructions. The resident was admitted with diagnoses including infection following a procedure and enterocolitis due to Clostridium difficile. The hospital discharge instructions specified the continuation of Vancomycin IV 750 mg once daily. However, the medication administration record showed that the first dose of Vancomycin was not given until several days after admission. Interviews with facility staff revealed that the process for ordering medications involved using hospital discharge instructions to electronically send orders to the pharmacy. The Unit Manager and Nurse Supervisor indicated that the process should take less than a day, and emergency medications, including Vancomycin, were available on hand. Despite this, the resident did not receive the medication at the next required dose, which was due shortly after admission. The delay in administering the antibiotic was acknowledged by the consultant pharmacist, who emphasized the importance of maintaining dosing levels to ensure effective treatment.
Lack of Documented Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide documented evidence of discharge planning for one resident, identified as Resident 10, who was admitted for short-term rehabilitation following open heart surgery. The resident's medical record did not contain documentation of a case manager's assessment for discharge needs during their stay. Interviews with the Licensed Social Worker and the Case Manager revealed that discharge assessments should be documented within twenty-four hours of admission and continually updated, but no such documentation was found for Resident 10. The Director of Nursing confirmed the absence of a documented discharge plan in the resident's medical record, which was contrary to the facility's policy requiring early initiation and documentation of discharge planning.
Failure to Document ADL Assistance for Resident
Penalty
Summary
The facility failed to provide documented evidence of assistance with activities of daily living (ADL) for one resident, identified as Resident 3 (R3), who was dependent on staff for toileting hygiene. R3 was admitted with diagnoses including abnormalities of gait and mobility, and osteomyelitis of the vertebra, sacral, and sacrococcygeal region. The resident's care plan indicated a self-care performance deficit due to Parkinson's disease and acute respiratory failure, requiring staff assistance for toileting and cleaning the peri-area with each incontinent episode. However, the Admission Minimum Data Set (MDS) and ADL Flowsheet for February and March 2024 showed that documentation for toileting hygiene during the day shift was marked as Not Applicable (NA) on multiple dates, indicating a lack of recorded assistance. The MDS Coordinator confirmed that R3 was dependent on ADLs and required help from staff with toileting hygiene, including changing adult briefs. A Certified Nursing Assistant (CNA) acknowledged that the documentation should have reflected the resident's dependency and the assistance provided. The Director of Nursing (DON) stated that CNAs were expected to document ADL assistance every shift. The facility's policy on ADLs emphasized that residents unable to perform activities of daily living should receive necessary services to maintain good nutrition, grooming, and personal hygiene. The lack of documentation for R3's toileting hygiene assistance during the specified periods constituted a deficiency in care.
Failure to Complete Wound Evaluations and Psychiatric Consultations
Penalty
Summary
The facility failed to ensure weekly wound evaluations were completed and documented accurately for a resident with multiple surgical wounds. The resident was admitted with acute post-traumatic pain and fractures, and initial evaluations noted several surgical incisions with staples. However, subsequent weekly skin observations inaccurately documented no skin conditions, and there was a lack of documented weekly wound evaluations for three consecutive weeks. The Director of Nursing confirmed the absence of these evaluations and acknowledged the inaccuracies in the resident's skin observations. Additionally, the facility did not implement a physician's order for a psychiatric consultation for another resident exhibiting aggressive and inappropriate behaviors. The resident, diagnosed with altered mental status due to metabolic encephalopathy, displayed combative and sexually inappropriate behavior towards staff. Despite two orders for a psychiatric evaluation, there was no documentation of the consultation being completed or coordinated by the nursing staff. The Unit Manager and Director of Nursing confirmed the lack of documentation and coordination for the psychiatric consultation. These deficiencies highlight the facility's failure to adhere to its policies regarding wound care and psychiatric evaluations, potentially delaying necessary assessments and interventions for the residents involved.
Failure to Conduct Weekly Wound Evaluations and Accurate Skin Observations
Penalty
Summary
The facility failed to ensure that weekly wound evaluations were completed and weekly skin observations were documented accurately for one resident. This deficiency was identified for a resident who was admitted with multiple skin conditions, including a stage 1 pressure wound on the right heel, a stage 3 pressure wound on the right buttock, and a deep tissue injury on the left iliac crest. Despite these conditions, the resident's medical record lacked documented evidence of weekly wound evaluations from admission to discharge. The weekly skin observations documented in the resident's medical record inaccurately reported no skin conditions, which contradicted the initial wound care consultation notes. Interviews with the Wound Care Nurse, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed the absence of weekly wound evaluations and the inaccuracies in the weekly skin observations. The facility's policy required nursing staff to complete weekly wound evaluations and skin observations to monitor residents' skin conditions. However, the wound care team did not fulfill this responsibility, and the charting did not accurately reflect the resident's skin conditions, as acknowledged by the DON.
Failure to Manage Sharps Containers and Supervise Smoking Area
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by not properly managing sharps containers. On multiple occasions, sharps containers were observed to be overfilled beyond the manufacturer's recommended fill line, with sharp objects such as used razors protruding from the containers. This was confirmed by various staff members, including an LPN and the Assistant Director of Nursing, who acknowledged that the containers should have been replaced when they reached three-quarters of their capacity. Despite having an adequate supply of empty sharps containers, the facility did not adhere to its policy of replacing them in a timely manner, thereby increasing the risk of needle stick injuries. Additionally, the facility did not ensure adequate supervision in the designated smoking area, which posed a safety risk to residents. Several residents were observed smoking without staff supervision in an area where a propane-fueled gas grill was improperly stored with its controls set to a low position, which could potentially start a flame. The Administrator acknowledged that the grill should have been removed after a barbeque event and that the area should have been cleaned of cigarette butts. Furthermore, residents were not consistently assessed for their ability to smoke independently, with many not having received a quarterly assessment as required by the facility's policy. The lack of supervision and failure to conduct regular assessments of smoking residents were confirmed by various staff members, including a Nursing Supervisor and the Director of Nursing. The facility's policy required that all smoking residents be evaluated for their ability to smoke independently and that these evaluations be reviewed monthly by the interdisciplinary team. However, the facility did not comply with these requirements, as evidenced by the outdated assessments and unsupervised smoking sessions, compromising the safety and well-being of the residents.
Improper Use of Personal Blood Pressure Monitors for Residents on Transmission-Based Precautions
Penalty
Summary
The facility failed to ensure that staff used appropriate equipment for residents on transmission-based precautions, leading to a potential risk of cross-contamination. On December 4, 2024, a CNA was observed using a personal electronic blood pressure monitor to take vital signs for residents, including those on transmission-based precautions. The CNA confirmed using the same equipment for multiple residents and was unaware of the facility's disposable blood pressure cuffs. The CNA attempted to disinfect the equipment with bleach wipes but was not familiar with the required contact time for effective disinfection, and the equipment was wiped dry with a tissue after cleaning. Another CNA also used a personal blood pressure monitor for residents and disinfected it with bleach wipes, allowing it to air dry or wiping it with a tissue. The Director of Nursing confirmed that residents on transmission-based precautions should have dedicated equipment, and staff were expected to follow the manufacturer's instructions for disinfecting wipes. The facility's policy stated that non-critical resident-care equipment should be dedicated to a single resident when possible, and if reuse was necessary, it should be cleaned and disinfected according to guidelines. The manufacturer's instructions for the disinfecting wipes specified different kill times for various pathogens, which were not followed by the 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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