Inspection Reports for El Jen Healthcare and Rehabilitation Services

The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care and safety, and fire safety standards.

The facility was found deficient in ensuring proper reassessment and care planning for a resident who smoked, which resulted in a fire causing actual harm. Additionally, the facility failed to maintain the fire alarm system, portable fire extinguishers, and fire safety plan according to NFPA standards, affecting 36 residents.

The inspection was conducted to investigate complaints related to resident-to-resident physical abuse and elopement incidents at El Jen Skilled Care.

The facility failed to protect residents from physical abuse in incidents involving four residents, resulting in minor injuries and one resident being placed on one-to-one supervision. Additionally, the facility failed to adequately supervise a resident with moderate cognitive impairment who eloped from the facility, though the resident was found unharmed and returned safely. The facility took corrective actions including increased supervision, staff training, and implementation of wander guard devices.

The complaint investigation substantiated physical abuse incidents between residents R3, R53, R113, and R151, with verified injuries and actions taken including one-to-one supervision and removal of the abusive resident. The investigation also substantiated an elopement incident involving resident R113, who was found unharmed after leaving the facility and returned safely. The facility implemented corrective measures including secured unit placement and wander guard monitoring.

The inspection was conducted to evaluate compliance with federal regulations regarding resident rights, informed consent, abuse prevention, supervision, and vaccination policies at El Jen Skilled Care.

The facility was found deficient in multiple areas including failure to obtain resident permission before removing a motorized wheelchair battery, lack of informed consent for psychotropic medication administration, failure to initiate advance directives or guardianship for cognitively impaired residents, inadequate protection from resident-to-resident abuse, insufficient supervision leading to elopement risk, and failure to provide education and documentation regarding vaccinations.

The inspection was conducted due to a complaint investigation regarding an allegation of physical abuse by a Certified Nurse Assistant (E9) against Resident 10 (R10) on 12/19/2024.

The facility substantiated the allegation of physical abuse where E9 struck R10 in the rib area. The police were involved, and E9 was arrested and terminated. The facility took corrective actions including staff education on abuse prevention, monitoring of R10, and ensuring a safe environment. Resident 10 reported no physical or emotional harm and expressed feeling safe after management's intervention.

The allegation of physical abuse by Employee 9 against Resident 10 was substantiated. The police were contacted, and Employee 9 was taken into custody and terminated. Resident 10 denied psychosocial harm and emotional distress from the incident.

The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an alleged incident of verbal abuse involving Resident #11 and failure to follow physician's orders for the application of heel protectors for Resident #5.

The facility failed to report an alleged verbal abuse incident involving Resident #11 to the State Agency within the required timeframe, potentially placing residents at risk. Additionally, the facility did not ensure that physician's orders for bilateral heel protectors were followed for Resident #5, which could lead to skin breakdown.

The complaint involved an alleged verbal abuse incident by Resident #11 on 10/10/2024, which was reported late to the State Agency on 10/15/2024. The facility policy requires reporting within two hours for abuse allegations. The investigation confirmed the late reporting. Additionally, the complaint included failure to follow physician's orders for heel protectors for Resident #5.

The inspection was conducted due to complaints regarding suspected abuse and neglect at El Jen Skilled Care, specifically involving failure to implement abuse prevention policies and failure to timely report and investigate incidents of abuse.

The facility failed to ensure abuse policies and procedures were properly implemented for one resident, and failed to timely report and investigate an incident where a resident with dementia was forced to take medications. The investigation substantiated abuse by a Licensed Practical Nurse who forced medication administration, with delays in reporting and corrective actions taken including staff suspension and resignation.

Complaint NV00070508 and Complaint NV00070507 were investigated. The incident involving forced medication administration was substantiated with delays in reporting to the state agency. The facility reported the incident to the nursing board. Staff involved included CNA1, CNA2, LPN1 (who resigned), and others. Abuse training was documented but staff failed to follow protocols.

The inspection was conducted due to a complaint investigation regarding a resident-to-resident altercation involving physical abuse between two residents on 11/22/2023.

The facility failed to follow its abuse protocol as staff members who witnessed or were aware of the resident-to-resident altercation did not report the incidents to the Abuse Coordinator or Director of Nursing. Multiple incidents of abuse were witnessed but not properly reported, delaying investigation and reporting requirements.

The complaint investigation revealed that staff did not report a resident-to-resident altercation involving physical abuse between Residents 1 and 2 on 11/22/2023. The Abuse Coordinator confirmed the failure to report and emphasized mandatory reporting requirements for all staff.

The inspection was conducted due to a complaint regarding the facility's failure to ensure a physician order was obtained or transcribed, and consent was granted for a resident's transition to a secured unit.

The facility failed to obtain a physician order and resident consent for transitioning Resident 104 to a secured unit, which led to resident frustration and potential harm. The resident was relocated without proper authorization, and staff acknowledged the placement was inappropriate given the resident's alert and oriented status.

The complaint investigation focused on Resident 104's unauthorized placement in a secured unit without physician order or consent. The resident was alert and oriented, refused the secured unit placement, and the facility lacked documentation supporting the transition. The Director of Nursing and Unit Manager confirmed the placement was inappropriate and that the resident was later moved back to the retirement unit.

The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, medication administration, resident care, safety, and facility operations.

The facility was found deficient in multiple areas including failure to honor residents' dignity, inadequate medication administration and documentation, improper catheter and IV care, failure to follow oxygen orders, insufficient response to resident council concerns, unsecured hazardous items and medications, and failure to ensure food was served palatably and at appropriate temperatures.

The inspection was conducted due to complaints regarding the facility's failure to provide documented evidence of thorough investigations for internal and self-reported incidents involving resident elopements and failure to report an incident within 5 working days.

The facility failed to provide complete internal investigations for 4 incidents involving 3 residents and failed to report one incident timely. Additionally, the facility failed to develop and implement individualized, measurable elopement risk care plans for the residents involved, with care plans lacking measurable objectives, timeframes, and proper monitoring.

The complaint investigation revealed failures in timely reporting and thorough investigation of elopement incidents involving Residents #1, #2, and #3. The facility also failed to care-plan for elopement risk prior to incidents despite documented indicators of wandering.

The inspection was conducted due to complaints and facility-reported incidents involving failure to timely report abuse, neglect, wandering, resident-to-resident altercations, failure to provide emergency first aid to a choking resident, failure to activate emergency medical services for a choking resident, and failure to complete an elopement risk assessment for a resident exhibiting exit seeking behaviors.

The facility failed to timely report incidents of abuse and altercations to the state agency, failed to provide emergency first aid including abdominal thrusts to a choking resident, failed to activate emergency medical services when unable to clear the airway, and failed to complete an elopement risk assessment for a resident with exit seeking behavior. These deficiencies posed risks of harm to residents and compromised their safety and well-being.

Complaint #NV00068335 and Complaint #NV00067675 were investigated. The complaints involved failure to timely report abuse and altercations, failure to provide emergency first aid to a choking resident, failure to activate emergency medical services, and failure to complete elopement risk assessment. Facility Reported Incidents #NV00068081, NV00067318, NV00067656, NV00067902, and #NV00067044 were also reviewed.

The inspection was conducted based on complaints alleging failure to ensure resident dignity and privacy, failure to report significant changes to family, failure to screen contracted employees, failure to develop person-centered care plans, failure to provide scheduled showers, failure to administer medications as ordered, failure to provide pressure ulcer care, failure to provide restorative services, failure to prevent accident hazards, failure to assess Foley catheter use, failure to provide nutritional assessments and communicate dietitian recommendations, failure to ensure safe IV fluid administration, failure to provide dialysis care, failure to ensure medication availability, failure to maintain medication error rates below 5%, and failure to ensure food safety and allergy accommodations.

The facility was found deficient in multiple areas including failure to maintain resident dignity by not covering urinary catheter bags, failure to notify family of significant changes, failure to screen contracted staff for background and training, failure to develop person-centered care plans for nutrition, failure to provide scheduled showers, failure to administer IV antibiotics timely, failure to apply heel protectors, failure to provide restorative services timely, failure to prevent tripping hazards, failure to assess and monitor Foley catheter use, failure to complete nutritional assessments and implement dietitian recommendations, failure to change IV midline dressings timely, failure to provide safe dialysis care and medication administration, failure to ensure medication availability during passes, medication errors exceeding 5%, failure to discard expired medications, and failure to ensure food safety including honoring food allergies and covering food during delivery.

Complaint #NV00065930 regarding failure to notify family of resident's COVID positive status, room change, and change in condition. Complaint #NV00066365 regarding failure to honor resident food allergy.