Torrey Pines Post Acute And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 1701 S. Torrey Pines Drive, Las Vegas, Nevada 89146
- CMS Provider Number
- 295045
- Inspections on file
- 22
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Torrey Pines Post Acute And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and significant behavioral issues, requiring one-on-one supervision and assistance with ADLs, was discharged to an independent living facility that could not meet these needs. The receiving facility did not provide ADL support or behavior monitoring, resulting in the resident becoming agitated and requiring emergency intervention shortly after arrival. Facility staff and the receiving facility owner confirmed the discharge was inappropriate and unsafe.
A resident with severe cognitive impairment and no available family or psychiatric support was discharged to an independent living facility without a competency assessment or legal representative in place. Despite staff acknowledging the resident's inability to make informed decisions, the facility failed to follow its policy requiring a psychiatric evaluation and did not secure guardianship or a POA.
A facility failed to protect residents from abuse, resulting in two incidents where one resident was physically aggressive towards another. In the first incident, a resident was struck by another, leading to the aggressor's transfer for psychiatric evaluation. In the second incident, a resident was hit, causing a fall and injury, with the aggressor also transferred to a hospital. Both incidents were verified, and the affected residents reported feeling safe afterward.
A medication cart was left unattended with 20 tablets of Divalproex Sodium DR 500 mg on top, posing a risk of unauthorized access. A RN acknowledged the oversight, and the DON confirmed that medications should be secured in the cart, as per facility policy.
A blood glucose monitor with a used test strip was left unattended on a medication cart in a hallway, posing an infection control risk. A RN acknowledged the glucometer had been used and should not have been left unattended. The DON and Infection Preventionist confirmed that monitors should be cleaned and stored after use, and test strips disposed of immediately.
A resident with hemiplegia and moderately impaired cognition did not receive scheduled showers on four occasions, as required by the facility's policy. Despite the requirement for CNAs to document showers in both shower sheets and the EHR, there was no evidence of showers being provided on these dates. The DON confirmed the showers were missed, highlighting a lapse in adherence to the facility's ADL policy.
During a facility survey, several deficiencies were noted in food storage and handling practices. Expired food items were found in the stand-alone refrigerator and freezer, including unlabeled and undated food stored in Ziploc bags. Juice containers for drink machines were stored inappropriately in the dry storage area, contrary to manufacturer guidelines requiring freezer storage and refrigeration prior to use. In the unit nourishment rooms, expired yogurt was found in the Northeast Unit, unmarked food items in the Northwest Unit used as a staff breakroom, and unlabeled or undated food items in the South Unit resident refrigerator.
The facility failed to complete PASARR level two referrals for two residents with new psychiatric diagnoses, despite the social services department being responsible for this process. The deficiency was confirmed by the Assistant Administrator and the Social Worker.
The facility failed to ensure the MAR was not signed off before medications were administered for two residents. An LPN signed the MAR before administering medications, leading to potential inaccuracies in documentation. The ADON and DON confirmed that the MAR should only be signed off after medication administration, as per facility policy.
The facility failed to ensure proper wound care for two residents, leading to potential risks of delayed healing, worsened wounds, and infection. One resident's wound was not cleansed or dressed as ordered, leaving it exposed to feces. Another resident received wound treatment without documented physician's orders. The facility's wound care policy was not followed, resulting in inadequate care.
The facility failed to ensure proper labeling and administration of tube feeding (TF) and gastrostomy tube (GT) site care for a resident. The TF bag was not labeled as required, and there was a discrepancy between the documented and actual TF rate. Additionally, the GT site dressing was not changed as scheduled, and care orders were not obtained or transcribed. These deficiencies were confirmed by the nursing staff and the Director of Nursing (DON).
The facility failed to manage IV access for two residents admitted with intravenous (IV) lines. One resident had a central venous catheter (CVC) that was not identified or managed, and another had a peripheral IV that was not identified or managed. Both oversights placed the residents at risk for infection.
The facility failed to properly assess and monitor a resident's arteriovenous fistula (AVF) for dialysis access. Despite the AVF being placed two months prior, there were no documented care orders or monitoring of the bruit/thrill. Staff interviews revealed inconsistencies and a lack of clarity in monitoring responsibilities, and the Director of Nursing acknowledged the oversight.
The facility had a medication error rate of 8%, with two errors identified. One resident did not receive Lactobacillus as ordered, and another resident's artificial tears were not spaced correctly. Both incidents involved failure to follow physician orders and facility policies.
The facility failed to update the facility assessment and involve department heads when staffing levels were reduced starting in October 2023. Despite a policy requiring annual and as-needed reviews, the assessment was not updated to reflect changes in staffing, particularly for nocturnal shifts. The reduction was a corporate decision due to budgetary reasons, and department heads were not consulted, potentially impacting resident care.
A facility failed to protect a resident from abuse when an RN pushed the resident, causing a fall. The resident, with multiple cognitive impairments, was assessed with no physical harm. The incident was witnessed by other staff, and the RN was terminated and reported to the board of nursing.
Unsafe Discharge to Inappropriate Setting for Resident with High Care Needs
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident with severe cognitive impairment and significant behavioral issues. The resident, diagnosed with schizoaffective disorder bipolar type, psychosis, and manic episodes, required one-on-one supervision and substantial assistance with activities of daily living (ADLs) such as eating, toileting, and mobility. Despite these needs, the resident was discharged to an independent living facility that did not provide assistance with ADLs or behavior monitoring. The discharge summary and care plan documented the resident's need for close supervision and support due to behaviors including agitation, violence, and hallucinations. Upon arrival at the independent living facility, the resident became agitated and destructive, leading to a call to emergency services and subsequent transfer to a hospital. Interviews with facility staff and the independent living facility owner confirmed that the discharge was inappropriate, as the receiving facility was not equipped to meet the resident's care needs. The facility's own discharge policy required that all necessary information be provided to ensure a safe transition, but this was not followed, resulting in an unsafe discharge.
Failure to Assess Competency and Secure Guardianship for Severely Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, diagnosed with schizoaffective disorder bipolar type, psychosis, and a manic episode, was admitted and later readmitted to the facility. The resident's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment, and the psycho-social assessment noted severely impaired decision-making skills and no available family or psychiatric facility support. Despite these findings, the resident was listed as their own responsible party, and there was no documentation of a Power of Attorney (POA) or guardianship in the medical record. The facility's policy required referral to a psychiatrist for capacity assessment in such cases, but this was not done. Staff interviews confirmed that the resident could not make their own decisions and required a legal representative, yet no competency assessment was completed to determine the need for guardianship or a representative. The resident was ultimately discharged to an independent living facility based on their own verbal consent, despite staff acknowledging the resident's inability to make informed decisions. The facility failed to follow its own policy and state-specific laws regarding guardianship and consent for residents with impaired cognition.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect Resident 2 from physical abuse by Resident 3, who was observed being physically aggressive and striking Resident 2's body. This incident occurred despite the presence of staff, as a Certified Nurse Assistant had to intervene to separate the residents. Resident 3 was subsequently placed on one-to-one supervision and transferred to an acute care hospital for psychiatric evaluation. The incident was verified, and Resident 2 expressed feeling more comfortable after Resident 3 was removed from the facility. In another incident, Resident 4 was not protected from physical abuse by Resident 5, who struck Resident 4's face, causing a fall and a bleeding nose. The residents were immediately separated, and Resident 5 was placed on one-to-one monitoring and transferred to an acute hospital. The incident was verified, and Resident 4 was sent to the hospital for evaluation. Despite the incident, Resident 4 reported feeling safe upon returning to the facility. Both incidents highlight the facility's failure to prevent resident-to-resident altercations, which had the potential to cause emotional and physical harm.
Unsecured Medication on Cart
Penalty
Summary
The facility failed to ensure the security of medications, as observed on 03/12/2025. A medication cart was left unattended at the entrance of the northeast hallway, with a medication card containing 20 tablets of Divalproex Sodium DR 500 mg on top. This occurred while staff, visitors, and residents were present in the hallway. A Registered Nurse later acknowledged the oversight, stating that the pills should not have been left unattended, as it posed a risk of unauthorized access. The Director of Nursing confirmed that medications should be secured in the cart when not being administered, aligning with the facility's policy on the storage of medication, which mandates that all drugs and biologicals be stored safely and securely.
Infection Control Breach with Unattended Glucometer
Penalty
Summary
The facility failed to ensure proper infection control practices were followed when a blood glucose monitor with a used test strip was left unattended on top of a medication cart. On March 12, 2025, at 12:24 PM, the medication cart was parked unattended at the entrance of the northeast hallway in front of a resident room, with staff, visitors, and residents present in the hallway. The blood glucose monitor had a test strip inserted, which had a dark red substance visible, indicating it had been used. At 12:27 PM, a Registered Nurse (RN) acknowledged that the glucometer had been used to obtain a resident's blood sugar and that the test strip needed to be discarded, and the monitor disinfected. The RN admitted that the glucometer should not have been left unattended. Later, at 2:15 PM, the Director of Nursing (DON) confirmed that for infection control, blood glucose monitors should be cleaned and stored away after use and not left unattended on top of the medication cart. At 3:12 PM, the Director of Staff Development/Infection Preventionist stated that blood glucose monitor testing strips should be disposed of immediately after use to prevent the spread of infection.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that showers were provided as scheduled for one resident, identified as Resident 1 (R1), who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction. R1 had moderately impaired cognition and required partial to moderate assistance with bathing. The facility's shower schedule indicated that R1 was to receive two showers a week on Tuesdays and Fridays. However, there was no documented evidence that R1 received showers on four specific dates: 07/02/2024, 07/09/2024, 07/16/2024, and 07/19/2024. Interviews and document reviews revealed that the facility's process required CNAs to document showers on shower sheets and in the electronic health record (EHR). Despite this, the Director of Staff Development and the corporate EHR specialist confirmed the absence of documentation for the specified dates. The Director of Nursing acknowledged that the showers were missed or not provided on those dates, emphasizing that showers must be provided as scheduled, with any changes or refusals documented. The facility's Supporting ADL policy stated that residents unable to perform ADLs independently should receive necessary services to maintain personal hygiene.
Food Storage and Handling Deficiencies Identified
Penalty
Summary
During a facility survey conducted on [DATE], several deficiencies were identified related to food storage and handling practices at the long-term care facility. Observations revealed expired food items in the stand-alone refrigerator and freezer, including unlabeled and undated food items stored in Ziploc bags. Additionally, juice containers for drink machines were found stored inappropriately in the dry storage area, contrary to manufacturer guidelines which specified freezer storage and refrigeration prior to use. The report also highlighted issues in the unit nourishment rooms, such as expired yogurt in the Northeast Unit, unmarked food items in the Northwest Unit used as a staff breakroom, and unlabeled or undated food items in the South Unit resident refrigerator.
Failure to Complete PASARR Level Two Referrals
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for two residents. Resident 22 was admitted with diagnoses including major depressive disorder, bipolar disorder, and psychotic disorder. Despite these diagnoses, the medical record lacked evidence of a PASARR level two referral. The social worker confirmed that the resident was diagnosed with bipolar disorder after admission and should have been referred for a PASARR level two review, which was not done. Resident 28 was readmitted with primary diagnoses including anxiety disorder, depression, bipolar disorder, schizophrenia, and a psychotic disorder. The resident's medical record also lacked evidence of a PASARR level two referral despite new diagnoses of brief psychotic disorder, manic episode, and paranoid personality disorder. The Assistant Administrator and the Social Worker confirmed that the resident had new psychiatric diagnoses that met the criteria for a PASARR level two referral, which was not completed. The report highlights that the admissions department deferred to the social services department for PASARR level two referrals, but the social worker was not aware of their responsibility in this process. The Assistant Administrator confirmed that social services were responsible for identifying and referring residents for PASARR level two reviews, but this was not effectively communicated or executed, leading to the deficiency.
Premature Signing of MAR Before Medication Administration
Penalty
Summary
The facility failed to ensure the medication administration record (MAR) was not signed off before the medications were administered for two residents. For Resident 246, an LPN prepared eight medications and signed the MAR before administering them. The resident refused two medications, but the MAR had already been signed off. The LPN explained that the MAR was signed off early to avoid forgetting later. The Assistant Director of Nursing (ADON) confirmed that the MAR should not be signed off until after the medications are administered, as residents might refuse or not successfully receive the medications. For Resident 75, an LPN prepared four medications and signed the MAR before administering them, explaining that this practice was customary in their previous job out of state. The Director of Nursing (DON) indicated that staff members are expected to sign off on the MAR only after completing the medication administration to ensure accurate documentation. The facility's policy on administering medications states that medications should be administered safely, timely, and as prescribed, with the MAR being signed off only after each medication is given.
Inadequate Wound Care Management
Penalty
Summary
The facility failed to ensure proper wound care for two residents, leading to potential risks of delayed healing, worsened wounds, and infection. For one resident, the facility did not cleanse the wound or replace the dressing as ordered, resulting in the wound being soaked with urine and feces. The resident, who was blind, confused, and dependent on staff for daily activities, had a wound on the right buttock that was not properly managed. The family reported that the staff failed to turn and reposition the resident on schedule, and observations confirmed that the wound dressing was not applied, leaving the wound exposed to feces. The CNA and RN both confirmed that they were not informed when the wound dressing needed to be changed, leading to the wound being soaked in feces for an extended period of time. The WCTN also confirmed that they were not notified about the soiled dressing and emphasized the importance of keeping the wound covered to promote healing and prevent infection. For another resident, the facility did not obtain and transcribe wound treatment orders before providing the treatment. This resident had a surgical amputation and stage 3 pressure ulcers on the right and left buttocks. During a wound observation, it was found that the old dressings on the right leg stump and left foot were undated. The WNP confirmed that the dressings were undated and that the wounds had been treated the previous day. However, the medical records lacked documented evidence of the physician's orders for wound treatments until several days later. The DON and wound physician both indicated that the wound treatment required an order and that the staff were expected to ensure orders were in place before providing the treatment. The facility's policy on wound care, revised in 2010, indicated that the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. The policy required verification of a physician's order for the procedure and providing wound care treatment as ordered. The failure to follow these guidelines resulted in inadequate wound care for the residents, potentially leading to further complications.
Failure to Ensure Proper Labeling and Administration of Tube Feeding and GT Site Care
Penalty
Summary
The facility failed to ensure proper labeling and administration of tube feeding (TF) for a resident, identified as Resident 55 (R55). On multiple occasions, the TF bag or container and water bag were not labeled with the resident's name, TF rate, date/time, and nurse's initials as ordered by the physician. This was confirmed by a Registered Nurse (RN) who acknowledged the risk of misidentification due to the lack of labeling. Additionally, there was a discrepancy between the TF rate documented in the Medication Administration Record (MAR) and the actual rate being administered, which was not updated in the electronic record as per the new physician's order. The Director of Nursing (DON) confirmed that the staff failed to verify, transcribe, and update the MAR to match the actual TF rate delivered by the pump, leading to confusion and improper administration of the TF rate for R55. The Registered Dietitian (RD) also confirmed that the new order was not transcribed and the MAR was not updated accordingly. The facility policy required that all aspects of the resident's care be provided in accordance with physician orders, which was not followed in this case. Furthermore, the facility failed to obtain, transcribe, and implement care orders for the gastrostomy tube (GT) site and dressing change for R55. The GT site dressing was observed to be dated 04/30, indicating that it had not been changed as scheduled. The RN confirmed that the GT site should have been cleansed and the dressing changed daily at night, but this was not done. The wound nurse practitioner (WNP) and the Assistant Director of Nursing (ADON) indicated that both the Licensed Nurses and the Wound Care Team were responsible for the GT site care and management. However, the medical record lacked documented evidence of care orders for the GT site, and the dressing change was not implemented as required. The facility's policies on Physician Orders and Enteral Feeding Tube Care were not adhered to, resulting in the failure to provide adequate care and services to R55. The policies required that physician orders be documented and transcribed accurately, and that the GT site be monitored and the dressing changed to prevent infection. The DON acknowledged that the staff skipped the process, leading to confusion and non-compliance with the facility's policies. The failure to follow these policies could have jeopardized the resident's health and well-being.
Failure to Manage IV Access for Admitted Residents
Penalty
Summary
The facility failed to ensure care and management orders were obtained, transcribed, and carried out for residents admitted with intravenous (IV) access. Resident 65 was admitted with a double-lumen central venous catheter (CVC) in the left upper chest, which was not identified during the admission assessment. The CVC dressing was observed to be half off, exposing the insertion site, and there were no documented care orders for the CVC. The Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON) confirmed the oversight, acknowledging that the CVC had not been properly managed, placing the resident at risk for infection. The Director of Nursing (DON) indicated that the admission nurse should have performed a full head-to-toe assessment and obtained appropriate care orders from a physician. Resident 245 was admitted with a peripheral intravenous (IV) access in the left forearm, which was also not identified during the admission assessment. The IV line had a transparent dressing that was coming loose, and the resident indicated that the IV had not been used, flushed, or dressed since admission. The Infection Preventionist (IP) confirmed the resident's account and indicated that the admission nurse should have obtained a removal order from the physician. The Assistant Director of Nursing (ADON) reviewed the medical record and confirmed that the peripheral IV was not identified, and care orders were not obtained, placing the resident at risk for infection. The Director of Nursing (DON) reiterated that the admission nurse should have identified the IV and clarified its management with the physician. The facility's policies on Nursing Admission Assessment and Maintaining Patency of Peripheral Lines were not followed, as the licensed nurses failed to assess the residents' IV therapy needs and obtain necessary care orders. The Dressing Change for Vascular Access Devices policy was also not adhered to, as the CVC and peripheral IV dressings were not changed as required. These oversights in the admission process and failure to follow established protocols resulted in the residents being placed at risk for infection.
Failure to Monitor Dialysis Access
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident's arteriovenous fistula (AVF) for dialysis access. The resident, who had chronic kidney disease and was dependent on renal dialysis, had an AVF placed in the left upper arm approximately two months prior. Despite this, the facility did not have documented evidence of assessment or care orders for the AVF, nor was the bruit/thrill monitored as required. The resident's medical records lacked documentation of the AVF assessment, and the facility staff confirmed that there were no care and monitoring orders in place until a later date. Interviews with facility staff, including registered nurses and licensed practical nurses, revealed a lack of clarity and consistency in monitoring the AVF. The staff indicated that while the dialysis center was responsible for dressing changes on dialysis days, the facility nursing staff were responsible for monitoring the bruit/thrill. However, due to the absence of proper orders and prompts, the AVF was not consistently monitored. The Director of Nursing acknowledged the oversight and confirmed that there should have been an assessment and care orders in place for the AVF. The facility's policy on dialysis care, which required licensed nurses to monitor and document pre- and post-dialysis observations, was not followed in this case.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure their medication error rate was below five percent, with two errors identified out of 25 opportunities, resulting in an error rate of 8%. One deficiency involved a resident who was admitted with diagnoses including osteomyelitis and anemia. On the specified date, an LPN in the Northeast unit failed to administer Lactobacillus as ordered by the physician. The LPN acknowledged the error and was uncertain about the next steps. The Director of Nursing confirmed that the missed medication was an error and should have been administered within one hour of the prescribed time, as per facility policy. Another deficiency involved a resident with diagnoses including cataract and dry eye syndrome. An RN in the Southeast unit failed to follow the physician's order to space the administration of artificial tears by five minutes. The RN administered the eye drops to both eyes without the required spacing. The Director of Nursing indicated that the nurses were expected to follow the medication instructions or clarify the order, and the eye drops should have been instilled with the specified interval to ensure proper absorption. Both incidents highlight a failure to follow physician orders and facility policies, leading to medication administration errors.
Failure to Update Facility Assessment and Involve Department Heads in Staffing Changes
Penalty
Summary
The facility failed to ensure the facility assessment was reviewed and updated when staffing levels were reduced starting in October 2023. The facility's policy required a designated team to conduct a facility-wide assessment annually and as needed to ensure resources were available to meet the specific needs of the residents. The assessment included a detailed review of the resident population, including resident acuity and available resources such as staff type and staffing plan. Despite a reduction in staffing levels, particularly licensed nurses on the nocturnal shift, the facility assessment was not updated to reflect these changes. The Assistant Administrator confirmed that the reduction in staffing levels was a corporate decision due to budgetary reasons, and the Administrator acknowledged that the staffing plan, a substantial component of the facility assessment, should have been reviewed and updated accordingly. Additionally, the facility assessment policy required input from all department heads during the review of resident needs and facility resources. However, the department heads were neither involved nor consulted on the changes in the staffing plan. The Administrator confirmed that the input of staff and department heads should have been taken into consideration in line with the facility assessment policy. This failure to update the facility assessment and involve department heads had the potential to impact the facility's ability to meet residents' care needs effectively.
Failure to Protect Resident from Abuse by Staff Member
Penalty
Summary
The facility failed to ensure that a resident was free from abuse by a staff member. Specifically, an incident occurred where a Registered Nurse (RN) was witnessed pushing a resident, resulting in the resident falling to the ground. The resident, who had a diagnosis including bipolar disorder, unspecified psychosis, anxiety disorder, unspecified dementia, and altered mental status, was assessed and found to have no signs of physical harm or mental anguish following the incident. The resident was unable to remember the details of the incident due to their cognitive condition. The incident was observed by a Certified Nursing Assistant (CNA) and a Housekeeper/Floor Technician, who reported that the RN engaged in a verbal dispute with the resident and then pushed the resident, causing the fall. The RN did not follow the facility's training on how to handle potential situations with residents and was subsequently suspended, terminated, and reported to the board of nursing. The facility's policy on abuse prevention was not adhered to by the RN, leading to the deficiency in protecting the resident from abuse.
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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