Wingfield Skilled Nursing And Rehabilitation Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Sparks, Nevada.
- Location
- 2350 Wingfield Hills Rd, Sparks, Nevada 89436
- CMS Provider Number
- 295088
- Inspections on file
- 26
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Wingfield Skilled Nursing And Rehabilitation Cente during CMS and state inspections, most recent first.
A resident with reduced mobility and incontinence was left wet overnight due to insufficient brief changes by the night shift staff. Despite the resident's complaints to staff and the social worker, the issue persisted, with the resident often left in wet linens and pads. A CNA confirmed the resident's reports, and the DON acknowledged that such neglect could impact the resident's dignity.
A facility failed to obtain informed consent from a resident before administering a psychotropic medication. The resident, diagnosed with depression, was prescribed Escitalopram Oxalate, but the consent form did not indicate acceptance or refusal. Despite this, the medication was administered, contrary to facility policy requiring consent before initiating psychoactive substances.
A resident with multiple health issues reported inadequate incontinent care overnight, stating they were only changed once, leading to discomfort. Despite informing staff and the Social Worker, no formal grievance was filed. The LSW chose to address the resident's anxiety rather than initiate a grievance, and the Unit Manager and DON were not properly informed. The facility's grievance policy was not followed, as no investigation or communication of findings occurred.
The facility failed to submit PASARR level II screenings for two residents who acquired serious mental disorder diagnoses after admission. One resident was diagnosed with delusional disorder, and another with major depressive disorder, yet neither had the necessary PASARR level II submitted. The LSW acknowledged the oversight, which was contrary to the facility's policy requiring such evaluations for new or changed behaviors indicating serious mental disorders.
The facility failed to address a resident's visual impairment in their activities care plan, resulting in a lack of personalized activities and assistance. Another resident with bilateral lower extremity edema did not have a care plan for monitoring and management, despite a physician's order for medication. Additionally, a resident using bed rails for mobility lacked a care plan documenting this need. These deficiencies were confirmed by the DON and other staff, highlighting gaps in comprehensive care planning.
An LPN in a facility failed to adhere to insulin administration protocols by not rechecking a resident's blood sugar levels before administering insulin, despite being trained in proper procedures. The incident involved a resident with type two diabetes, where the LPN checked blood sugar levels, left to attend to another resident, and returned over an hour later to administer insulin without verifying the current blood sugar levels.
A resident dependent on staff for ADLs reported inadequate overnight care, receiving only one brief change and being left in wet bedding. Staff interviews confirmed the resident's claims, revealing a failure to adhere to facility policies requiring regular checks and changes every two hours to maintain hygiene and comfort.
A visually impaired resident in an LTC facility did not receive individualized activities based on their preferences, leading to a deficiency. The resident, diagnosed with vision loss and depression, expressed a desire for audiobooks and music but lacked access and assistance. The Activities Director failed to include these preferences in the care plan or instruct staff on using the audiobook device. The care plan did not specify the assistance needed or responsible staff, contrary to facility policy.
A resident missed eight doses of pregabalin for neuropathy due to the facility's failure to renew the medication order timely. The resident reported a burning sensation in the feet after not receiving the scheduled medication over a weekend. The lapse was attributed to a lack of communication among staff, and no alternative medication was provided.
A resident with a history of cerebral infarction and muscle weakness was using bed rails daily as a physical restraint without documented attempts of alternative interventions or a comprehensive care plan. The facility's policies required less restrictive interventions to be tried and documented before using bed rails, but these steps were not followed, leading to a deficiency.
A resident with multiple health issues reported inadequate incontinent care during the night, stating they were only changed once and left in wet bedding. Despite informing staff and the social worker, no grievance was filed, and the complaints were not documented or investigated. The LSW did not follow up with the Unit Managers or DON, and the facility's grievance policy was not followed.
A resident with type two diabetes mellitus experienced a significant medication error when an LPN failed to administer insulin timely and accurately. The LPN checked the resident's blood sugar levels but did not administer insulin immediately, returning over an hour later without rechecking the levels. This action was against the physician's order, which required insulin administration based on a sliding scale before meals. The facility's policies and the LPN's training emphasized the importance of verifying blood sugar levels and administering insulin according to orders.
A resident with type II diabetes was found with unsecured glucose tablets on their bedside table, despite lacking an order for the medication or permission to keep it at the bedside. The LPN and DON confirmed the medication should not have been there, as it posed a risk of self-medication. Facility policy mandates secure storage of all medications.
A resident with cognitive deficits was kicked by another resident with a history of aggressive behavior, resulting in a bruise. Despite previous incidents of verbal aggression, the facility did not revise the care plan or take adequate measures to prevent the physical altercation, leading to a deficiency in protecting the resident from abuse.
The facility failed to report an allegation of abuse within the required timeframe. A resident reported being kicked by another resident, but the incident was not reported to the State Agency until several hours later, violating the two-hour reporting requirement.
The facility failed to maintain daily kitchen equipment temperature logs and ensure hand hygiene supplies were available, potentially compromising food safety and infection control for all 119 residents.
The facility failed to include essential information in the written Notice of Transfer or Discharge for eight residents discharged in January 2024. The notices lacked the reason for transfer or discharge, the effective date, and/or the location of the transfer or discharge. This deficiency was confirmed by the Discharge Planner and the DON.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by the lack of adequate incontinence care provided to a resident during the night shift. The resident, who was admitted with conditions including rhabdomyolysis, muscle weakness, and reduced mobility, reported being left wet overnight due to insufficient brief changes. The resident expressed that the night shift staff only changed their brief once overnight, leaving them in wet linens and disposable pads, which were not replaced. This situation was corroborated by a CNA who worked with the resident and confirmed that the resident was often left damp and had complained about the lack of care multiple times. The resident communicated their concerns to trusted staff and the social worker, who acknowledged receiving complaints about the lack of overnight care. The Licensed Social Worker confirmed that the resident had reported these issues at least once a week. The Director of Nursing stated that incontinent residents should be changed every two hours or as needed, emphasizing that neglecting this care could impact the resident's dignity. The facility's policies on resident rights and incontinence management highlighted the importance of maintaining dignity and comfort, which were not upheld in this case.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident provided informed consent before administering a psychotropic medication. Resident #80, who was admitted with a diagnosis of unspecified depression, was prescribed Escitalopram Oxalate to be taken orally each morning. However, the Psychoactive Medications Disclosure and Consent form, signed on 12/05/2023, did not indicate whether the resident accepted or declined the medication. Despite this, the medication was administered to the resident. The Director of Nursing confirmed that the consent form should have documented the resident's decision prior to administration. The facility's policy on psychoactive medication use requires that consent be obtained from the resident or guardian before initiating such medications, and the resident rights policy mandates that residents be informed of the risks and benefits of proposed care in advance.
Failure to Address Resident's Grievance on Incontinent Care
Penalty
Summary
The facility failed to ensure a grievance process was initiated and an investigation was conducted regarding a resident's concerns about inadequate incontinent care overnight. Resident #36, who had multiple diagnoses including rhabdomyolysis and pressure ulcers, reported being ignored by night shift staff and only receiving a brief change once overnight, leading to discomfort from wet linens. Despite informing trusted staff and the Social Worker, the resident's complaints were not formally addressed as grievances. The Licensed Social Worker (LSW) acknowledged being informed of the resident's concerns weekly but chose not to file a grievance, believing the resident's anxiety might be influencing their perception of care. The LSW focused on addressing the resident's psychosocial needs rather than initiating a formal grievance process. The LSW did not document the concerns or follow up with the Unit Managers or the Director of Nursing (DON) for an investigation outcome, assuming the complaints were unfounded. The Unit Manager and DON were not adequately informed of the resident's ongoing complaints. The Unit Manager recalled being made aware of the concerns only twice and did not remember the actions taken. The DON was unaware of the complaints and stated that an investigation would have been initiated if informed. The facility's grievance policy required grievances to be investigated and findings communicated to the resident, which was not followed in this case.
Failure to Submit PASARR Level II for Residents with New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to ensure that residents with an acquired serious mental disorder diagnosis after admission were submitted for a pre-admission screening and resident review (PASARR) level II screening. This deficiency was identified for two residents. Resident #80 was admitted with a PASARR level I and later diagnosed with delusional disorder. Despite meeting the requirements for a PASARR level II submission, the Licensed Social Worker (LSW) did not submit the necessary documentation for review, even after taking responsibility for submissions. Similarly, Resident #57 was admitted with a PASARR level I and later diagnosed with major depressive disorder. The LSW confirmed that a PASARR level II was not submitted, despite the resident meeting the criteria for submission. The facility's policy on Behavioral Assessment, Intervention, and Monitoring required that new or changed behaviors indicating a serious mental disorder be referred for a PASARR level II evaluation, which was not adhered to in these cases.
Deficiencies in Care Planning for Activities, Edema, and Bed Rails
Penalty
Summary
The facility failed to ensure that the activities care plan for a resident with visual impairment addressed the need for staff support and assistance with personalized activities. The resident expressed a desire to participate in group activities when accessible and had specific interests in mystery and history audiobooks and oldies music. However, the activities care plan did not include these individualized activities, and the resident reported difficulty using an audiobook device due to visual impairment and a lack of assistance from staff. The Activities Director acknowledged the omission and confirmed that the care plan did not reflect the resident's preferences or the need for staff assistance. Another deficiency was identified in the care planning for a resident with bilateral lower extremity edema. Despite a physician's order for medication to manage the edema, the resident's clinical record lacked a care plan for monitoring and managing the condition. The Director of Nursing confirmed the absence of a care plan, acknowledging the risk of fluid retention and the potential for worsening symptoms due to inadequate monitoring. Additionally, the facility did not develop a care plan for the use of bed rails for a resident with mobility issues. The resident used bed rails daily for mobility, but the comprehensive care plan did not document this need. Both the Director of Nursing and the Regional MDS Registered Nurse confirmed the lack of a care plan for bed rails, which was necessary for coordinating proper care. The facility's policy on comprehensive person-centered care plans emphasized the importance of including all necessary care elements to maintain residents' well-being.
Failure to Follow Insulin Administration Protocol
Penalty
Summary
The facility failed to ensure that an LPN adhered to the State Board of Nursing Nurse Practice Act regarding safe medication administration. Specifically, the LPN did not check a resident's blood sugar levels before administering insulin, as required by the physician's sliding scale order. This oversight involved a resident with type two diabetes mellitus, who was admitted to the facility with a diagnosis that necessitated careful monitoring and management of blood sugar levels. On the day of the incident, the LPN checked the resident's blood sugar levels at 12:51 PM but did not administer insulin immediately. Instead, the LPN walked away to attend to another resident and returned over an hour later to administer insulin without rechecking the blood sugar levels. The resident's daughter confirmed that the insulin was administered after the resident had already eaten lunch, and the LPN did not verify the blood sugar levels again before giving the insulin. The facility's policies and the LPN's training emphasized the importance of checking blood sugar levels immediately before insulin administration. The Director of Nursing confirmed that the LPN was trained in proper insulin administration protocols, which included verifying blood sugar levels and following the physician's sliding scale order. Despite this training, the LPN failed to follow the correct procedure, resulting in a medication error as defined by the facility's policy on adverse consequences and medication errors.
Inadequate Overnight Care for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for Activities of Daily Living (ADLs), received adequate brief changes overnight. This deficiency was identified for one resident, who was admitted with conditions including rhabdomyolysis, muscle weakness, and a pressure ulcer. The resident reported being ignored by the night shift staff, receiving only one brief change overnight, and being left in wet bedding, which was not changed, leading to discomfort. Interviews with staff confirmed the resident's claims. A Certified Nursing Assistant (CNA) acknowledged that the resident was incontinent and required maximum assistance for all ADLs, including the use of a Hoyer lift for transfers. The CNA believed the resident's reports of inadequate care and informed the Unit Manager nurses of the resident's concerns. Another CNA corroborated that incontinent residents should be checked and changed every two hours, but the resident reported being changed only once overnight. The facility's policies on Activities of Daily Living and Urinary Continence and Incontinence emphasized the need for regular checks and changes to maintain dignity, comfort, and skin protection. Despite these policies, the resident's care plan and Minimum Data Set (MDS) assessment indicated a need for substantial assistance, which was not adequately provided. The Director of Nursing confirmed the expectation for two-hour checks and changes, highlighting a gap between policy and practice.
Failure to Provide Individualized Activities for Visually Impaired Resident
Penalty
Summary
The facility failed to provide individualized activities for a visually impaired resident, leading to a deficiency in meeting the resident's needs. The resident, who had diagnoses including unqualified vision loss and depression, expressed a desire to participate in group activities when accessible but lacked individual activities they could engage in alone. An activity interview highlighted the resident's preference for mystery and history audiobooks and oldies music, yet the care plan did not reflect these preferences. The resident reported having difficulty using an audiobook device due to their vision impairment and had not received assistance, resulting in the resident ceasing attempts to listen to audiobooks. Additionally, the resident did not have access to music or a radio in their room, leading to feelings of boredom. The Activities Director acknowledged the lack of instruction provided to staff on operating the audiobook player and confirmed that the resident's care plan did not include the individualized activities the resident had communicated as important. The care plan also failed to specify the assistance needed by the resident or the staff responsible for providing it. The facility's policy required individualized activities reflecting residents' interests and preferences, with documentation in the medical record, but this was not adhered to in the case of the resident. The Director of Nursing confirmed that the Activities Director was responsible for personalizing the resident's activities care plan, which should have included the necessary assistance and responsible staff positions.
Failure to Refill Neuropathy Medication Timely
Penalty
Summary
The facility failed to ensure timely refilling of a resident's medication for neuropathy, resulting in the resident missing eight doses. The resident, who was admitted with diagnoses including chronic pain and neuropathy, reported not receiving scheduled pain medication over a weekend. The medication, pregabalin, was prescribed to be taken three times a day to manage pain in the resident's feet. The resident experienced a burning sensation in the feet and was informed by the nursing staff that the medication renewal had been overlooked, and an on-call provider was not available to write a new order. The facility's policy required narcotic medications to be reassessed every 30 days, with renewal orders requested three days before expiration. However, the order for pregabalin expired and was not renewed in time, leading to missed doses. The Director of Nursing confirmed the lapse was due to a lack of communication among staff and acknowledged that alternative medication could have been requested in the interim. The facility's pain management policy emphasized a proactive approach with scheduled medications, which was not adhered to in this instance.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to attempt appropriate alternative interventions and create a comprehensive care plan before installing and using bed rails for a resident. The resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, and generalized muscle weakness, was using bed rails daily as a physical restraint. The facility's documentation did not show evidence of any alternative interventions being tried before the bed rails were installed, nor was there a comprehensive care plan documenting the use of bed rails. The Director of Nursing and the Regional MDS Registered Nurse confirmed that no prior interventions were attempted before the installation of the bed rails, despite the facility's policy requiring less restrictive interventions to be tried first. The facility's policy also required documentation of unsuccessful less restrictive approaches before considering bed rails. The resident's clinical record and care plan lacked documentation of these necessary steps, leading to a deficiency in the facility's compliance with its own policies and procedures.
Failure to Address Resident's Incontinence Care Complaints
Penalty
Summary
The facility failed to ensure that a social services staff member followed up on complaints from a resident regarding inadequate incontinent care during the night. Resident #36, who was admitted with conditions such as rhabdomyolysis, muscle weakness, and pressure ulcers, reported being ignored by night shift staff and only receiving a brief change once overnight. The resident expressed discomfort due to wet linens and underpads, despite the brief being changed. The resident communicated these concerns to trusted staff and the social worker, who promised to investigate. The Licensed Social Worker (LSW) acknowledged being informed by the resident about the lack of care at least once a week but did not file a grievance, believing the resident's concerns were not genuine. The LSW did not document the complaints or follow up with the Unit Managers or the Director of Nursing (DON) for an investigation outcome. The LSW verbally notified the Unit Manager nurses and the DON but did not receive any feedback or results from them. The Unit Manager and the DON were not adequately informed about the resident's complaints. The Unit Manager only became aware of the issue on the day of the interview and once in October, but could not recall any specific actions taken. The DON confirmed not being notified of the complaints and expected to be informed immediately. The facility's grievance policy allows residents to file grievances orally or in writing, and the Grievance Coordinator is responsible for investigating and reporting findings, which was not adhered to in this case.
Failure to Administer Insulin Timely and Accurately
Penalty
Summary
The facility failed to ensure timely blood sugar testing and insulin administration for a resident with type two diabetes mellitus, leading to a significant medication error. Resident #212, who was admitted with a diagnosis of type two diabetes mellitus without complications, experienced a delay in insulin administration. On the day of the incident, the resident's blood sugar levels were checked at 12:45 PM, but the nurse did not administer insulin immediately and returned over an hour later without rechecking the blood sugar levels before administering four units of insulin. The physician's order required insulin administration based on a sliding scale, with specific units to be administered according to the resident's blood sugar levels before meals. The nurse, however, failed to adhere to this protocol by not administering the insulin promptly after checking the blood sugar levels and not rechecking the levels before administering the insulin later. This oversight was confirmed by the Licensed Practical Nurse (LPN) involved, who admitted to walking away from the resident after checking the blood sugar levels and returning later without rechecking them. The Director of Nursing (DON) confirmed that the proper procedure for insulin administration involves checking blood sugar levels immediately before administering insulin, as per the sliding scale. The facility's policy on insulin administration and adverse consequences of medication errors also emphasized the importance of verifying blood sugar levels and administering insulin according to physician orders. The LPN involved had been trained in these procedures, as documented in their training records and job description, yet failed to follow them, resulting in a significant medication error.
Unsecured Medication Found at Resident's Bedside
Penalty
Summary
The facility failed to ensure that a resident did not have a bottle of over-the-counter medication unsecured on the bedside table. This incident involved a resident who was admitted with diagnoses including type II diabetes mellitus with diabetic neuropathy and long-term use of insulin. During an observation, a bottle of glucose tablets was found on the resident's bedside table, despite the resident not having an order for these tablets or permission to keep medications at the bedside. The Licensed Practical Nurse confirmed that the medication should not have been at the bedside, as it posed a risk of the resident self-medicating without the facility's knowledge. The Director of Nursing also confirmed the presence of the medication and stated that medications were not supposed to be stored in a resident's room without an order and an assessment to determine if the resident could safely self-administer. The facility's policy on the storage of medications required that all drugs and biologicals be stored securely and not left unattended.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from being kicked by another resident. Resident #5, who had cognitive communication deficit and major depressive disorder, reported to the Licensed Social Worker (LSW) that they were kicked in the leg by Resident #6, resulting in a bruise. Resident #6 had a history of unspecified dementia, vascular dementia with agitation, and schizoaffective disorder, and had exhibited verbally aggressive behaviors prior to the incident. Despite these behaviors, the care plan for Resident #6 was not revised to address the ongoing aggression effectively. The Director of Nursing (DON) and the Administrator were aware of the incident and acknowledged that Resident #6 had been verbally aggressive towards staff and other residents before. However, the facility's interventions, such as redirection and offering snacks, were not sufficient to prevent the physical altercation. The facility's policy on abuse prevention and resident-to-resident altercations required staff to monitor and document aggressive behaviors and make necessary changes to care plans, which was not adequately done in this case. The LSW and the Regional Director of Social Services (RDSS) confirmed that abuse includes any willful intent to cause harm, such as unwanted physical acts. The LSW also noted that Resident #5 had asked for assistance in ending their relationship with Resident #6 a week before the incident. Despite this, the facility did not take adequate measures to separate the residents or revise the care plan to prevent further incidents, leading to the deficiency in protecting Resident #5 from abuse.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) within the required timeframe. Resident #5, who has diagnoses including cognitive communication deficit and major depressive disorder, reported to the Licensed Social Worker (LSW) that they were kicked in the leg by another resident. This incident was documented on 01/16/24 at 9:25 AM. However, the initial Facility Reported Incident (FRI) was not submitted to the SA until 6:51 PM on the same day, which is later than the two-hour reporting requirement for allegations of physical abuse. The Administrator confirmed that all types of abuse are required to be reported to the SA within two hours of becoming aware of the allegation. The Administrator was notified of the incident in the afternoon on 01/16/24 but did not submit the report until 6:51 PM. The facility's policies on abuse prevention, resident-to-resident altercations, and abuse investigation and reporting all stipulate that allegations of abuse must be reported immediately but no later than two hours if the alleged violation involves reasonable suspicion of a crime or results in serious bodily injury. The failure to report within the required timeframe constitutes a deficiency in the facility's compliance with federal requirements.
Failure to Maintain Kitchen Equipment Logs and Hand Hygiene Supplies
Penalty
Summary
The facility failed to ensure that kitchen equipment temperature logs were completed daily and that hand hygiene supplies were available for dietary staff. During a tour of the kitchen, it was observed that temperature logs for various kitchen equipment, including refrigerators and dishwashing machines, were not up to date. The Food Services Manager confirmed that the logs were not current and expressed uncertainty about the proper functioning of the kitchen equipment. Facility policies required daily temperature checks and recordings, but these were not adhered to, potentially compromising food safety for all 119 residents. Additionally, the tour revealed that none of the three hand washing sinks in the kitchen had paper towels available. The Assistant Food Services Manager, who was responsible for stocking paper towels, confirmed the absence of paper towels and acknowledged the importance of having them to ensure proper hand hygiene. Facility policy emphasized the necessity of accessible hand hygiene supplies to prevent healthcare-associated infections, but this was not followed, potentially affecting the health and safety of the residents.
Incomplete Transfer or Discharge Notices
Penalty
Summary
The facility failed to include essential information in the written Notice of Transfer or Discharge provided to residents. Specifically, for eight residents discharged in January 2024, the notices lacked the reason for transfer or discharge, the effective date, and/or the location of the transfer or discharge. This deficiency was identified through clinical record review, document review, and interviews with the Discharge Planner and the Director of Nursing (DON). Both confirmed that the notices were incomplete and acknowledged that the required information should have been documented. The affected residents had various medical conditions, including chronic obstructive pulmonary disease, diabetes, respiratory failure, heart failure, cognitive deficits, and other serious health issues. Despite these conditions, the facility did not provide complete transfer or discharge notices, which is a violation of their policy titled 'Bed-Holds and Returns.' This policy mandates that written information explaining the details of the transfer must be given to residents and their representatives prior to a transfer. The deficiency was confirmed by both the Discharge Planner and the DON, who admitted that the nursing staff had failed to include the necessary details in the notices provided to the residents.
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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