Canyon Vista Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 6352 Medical Center Street, Las Vegas, Nevada 89148
- CMS Provider Number
- 295093
- Inspections on file
- 26
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Canyon Vista Post Acute during CMS and state inspections, most recent first.
The facility did not have a defined time frame in its Release of Information policy for providing medical records when requested. A home health agency made two requests for a resident's records, which were eventually sent electronically, but there was no documentation of the requests or calls, and the policy lacked specific processing time frames.
A resident with multiple serious diagnoses was discharged without receiving a documented medication list or education about their medications. Staff interviews confirmed that it was the nurse's responsibility to provide and review discharge instructions, including medications, but no documentation was available to show this occurred, in violation of facility policy.
The facility failed to enforce its non-smoking policy and remove smoking materials from residents, posing a fire hazard. A resident was found with a lighter and cigarettes, attempting to dispose of a used cigarette in a trash can with combustible materials. Another resident, a documented smoker with an oxygen concentrator, was involved, and a third resident admitted to smoking with the first resident. The facility did not have smoking care plans for these residents, despite their histories of substance dependence and mental health issues.
The facility failed to properly label and discard opened food items in the refrigerator and freezer, as observed by a surveyor and confirmed by the Director of Dietary Services. Items such as chopped onions, a half-cut tomato, and canned fruits were not labeled or dated correctly, and an undated chocolate cream pie was improperly stored. The dietary staff were responsible for ensuring proper labeling and timely discarding of opened items, as per facility guidelines.
The facility failed to implement baseline care plans for residents within 48 hours of admission. Four residents who smoked did not have smoking care plans, despite documentation of tobacco use. Two residents with language barriers lacked communication care plans, hindering effective communication. Additionally, a resident with an IV catheter did not have a care plan, increasing infection risk. The DON acknowledged these oversights, which were confirmed through interviews and record reviews.
The facility did not develop smoking care plans for three residents identified as tobacco users, despite their MDS assessments indicating current tobacco use. The facility's non-smoking policy led to the assumption that such care plans were unnecessary, resulting in a lack of documented focus, goals, and interventions for these residents, who had significant medical histories.
The facility failed to respond promptly to call lights, affecting multiple residents. A resident waited over an hour for pain medication after activating the call light, while another resident's cries for help were ignored for 15 minutes. Staff acknowledged issues with the call light system and ongoing QAPI projects to address response times.
A resident with acute kidney failure and obstructive uropathy had a Foley catheter that did not match the physician's order, leading to a deficiency. The physician ordered a 14 French catheter, but a 16 French catheter was used instead. This discrepancy was confirmed by an LPN and the ADON, highlighting the importance of following orders to prevent complications.
A resident experienced severe weight loss without a nutritional assessment or interventions upon admission, despite being cognitively intact. The facility's policies on nutritional assessment and weight intervention were not followed, leading to a lack of documented evidence of a nutritional care plan or dietary consultation.
A facility failed to follow tube feeding orders for a resident with dysphagia, resulting in a significant discrepancy in the total dose volume consumed. The resident, at risk for malnutrition, was observed with the enteral pump turned off during the day, despite orders for nocturnal feeding. The RD and LPN confirmed a shortage of 1269 mL and 1800 calories over 72 hours, impacting wound healing and recovery. The RN and DON acknowledged the lack of monitoring and documentation of the resident's nutritional intake.
The facility failed to obtain physician's orders and document IV access for two residents, leading to prolonged use of IV sites without proper monitoring or assessment. One resident had an IV heplock in place for 10 days without documentation, while another had a peripheral IV access for 11 days without orders or monitoring. Facility policies required orders and documentation, which were not followed, increasing infection risk.
The facility failed to consistently assess, manage, and document pain management for two residents, leading to inadequate pain relief. One resident, post-back surgery, reported severe pain and insufficient medication, with no documented assessments in the eMAR. Another resident, with a history of gout and diabetes, experienced severe pain and distress, with delayed response and undocumented medication administration. Staff interviews confirmed the lack of adherence to pain management policies, resulting in unrelieved pain and discomfort.
The facility exceeded the acceptable medication error rate with two errors during a medication pass. One resident received an incorrect dosage of Folic Acid, while another had their Cardizem withheld due to a misunderstanding of blood pressure parameters. The LPN involved acknowledged the errors, and the DON emphasized the importance of following medication administration guidelines.
The facility failed to maintain a functional call light system in the 200 hall, leading to delayed responses to residents' needs. A resident waited 25 minutes for assistance due to a malfunctioning system that produced a constant alarm sound, masking actual alerts. The issue was not reported in the maintenance log, and the facility lacked a specific policy for call light system maintenance.
Lack of Defined Time Frame for Release of Medical Records
Penalty
Summary
The facility failed to ensure its Release of Information policy included a defined time frame for providing resident medical records upon request. A home health agency requested medical records for a resident on two occasions, with the first request made on 05/01/2025 and a second on 05/20/2025. The records were sent electronically on 05/20/2025 and 05/21/2025. The Medical Records Director stated that records would not be released without a request and that staff typically documented the portion of the record provided, but was unsure if other staff had documented the requests. There were no documented requests or phone calls from the home health agency regarding the resident, and fax cover sheets and written requests were only kept for 30 days. Review of the facility's Release of Information policy revealed it lacked documented time frames for processing such requests.
Failure to Provide Discharge Medication List and Education
Penalty
Summary
The facility failed to provide a copy of the discharge medication list and education about the medications to a resident upon discharge. The resident, who had been admitted with acute respiratory failure, chronic obstructive pulmonary disease, local infection of the skin and subcutaneous tissue, and sepsis, was discharged without documentation showing that a medication list or medication education was given. Interviews with facility staff, including a registered nurse, social services assistant, and the Director of Nursing (DON), confirmed that it was the nurse's responsibility to review and educate the resident on their discharge medications and instructions, and to ensure the resident understood and signed the discharge instructions. However, no such documentation was available for this resident. Review of the facility's policy titled Discharge Planning indicated that the nursing department was responsible for assessing and coordinating health and medical education needs, and that the discharge packet should include a medication list and prescriptions. The former DON also confirmed that there should have been documentation of medications provided and education given to the resident at discharge. The lack of documentation and education regarding discharge medications constituted a deficiency in the facility's discharge process for this resident.
Failure to Enforce Non-Smoking Policy and Remove Smoking Materials
Penalty
Summary
The facility failed to ensure that interventions were implemented to identify hazards and risks associated with smoking for three residents. Resident 14 was found with a lighter and cigarettes in their room, and attempted to dispose of a used cigarette in a trash can containing combustible materials. Despite being informed of the non-smoking policy, Resident 14 refused to relinquish the smoking materials. The resident had a history of schizophrenia, depression, and suicidal ideations, and was moderately impaired with a BIMS score of 12. The Comprehensive Care Plan did not include a smoking care plan for Resident 14. Resident 34, who was a documented smoker with an oxygen concentrator in their room, was also involved. The resident was observed to have smoked in the courtyard and main entrance with other residents. Despite the potential fire hazard posed by the oxygen concentrator, there was no documented evidence of a smoking care plan for Resident 34. The resident had a history of psychoactive substance dependence, alcohol dependence, and nicotine dependence, and was moderately impaired with a BIMS score of 12. Resident 116 was found with a lighter in their possession and admitted to smoking with Resident 14. The facility had recently put up non-smoking signs and instructed residents to smoke off property, but Resident 116 indicated they were not informed of the non-smoking policy upon admission. The resident was cognitively intact with a BIMS score of 14 and had a history of depression and opioid dependence. The facility's failure to enforce the non-smoking policy and remove smoking materials from residents posed a significant fire hazard, especially with the presence of residents on oxygen.
Improper Food Labeling and Storage in Facility
Penalty
Summary
The facility failed to ensure that opened items in the refrigerator and freezer were properly labeled and discarded upon expiration, as per policy. During an inspection, a surveyor, along with the Director of Dietary Services, observed several items in the walk-in refrigerator and freezer that were not labeled or dated correctly. These included a large bin of chopped onions with an outdated label, a half-cut large tomato wrapped in plastic without a label, and a large plastic bin of canned fruits that was unlabeled. Additionally, an undated chocolate cream pie in the freezer had been opened and cut in half without proper labeling. The Director of Dietary Services confirmed these observations and acknowledged that the dietary staff were responsible for ensuring that partially used or opened items were labeled, dated, and discarded in a timely manner. The facility's guidelines and policies required that all foods stored in the refrigerator or freezer be covered, labeled, and dated, with specific timelines for discarding opened items.
Failure to Implement Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans for several residents within 48 hours of admission, as required by their policy. Four residents who were identified as smokers did not have smoking care plans in place, despite their tobacco use being documented in their medical records. The Director of Nursing (DON) acknowledged that smoking care plans should have been developed, even though the facility had a smoke-free policy. This lack of care planning was confirmed through interviews with the residents and the DON. Two residents with communication deficits due to language barriers also lacked appropriate baseline care plans. One resident, whose primary language was Mandarin, did not have a communication board or any documented interventions to address the language barrier. Another resident, who spoke only Spanish, was unable to communicate effectively with staff who spoke only English. The DON confirmed that care plans addressing these communication barriers were not developed, which hindered effective communication with these residents. Additionally, a resident with a peripheral intravenous (IV) catheter did not have a care plan in place for the IV access. The resident was observed with an IV access that was not properly documented or managed, increasing the risk of infection. The Infection Preventionist and the DON acknowledged the oversight, noting that a care plan should have been developed to manage the IV access, including regular dressing changes and physician orders. This deficiency in care planning was recognized as a risk for potential complications due to infections.
Failure to Develop Smoking Care Plans for Tobacco-Using Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents who were identified as tobacco users. Despite the residents' tobacco use being documented in their Minimum Data Set (MDS) assessments, the facility did not create smoking care plans that included focus, goals, and interventions. This oversight was noted for three residents, each with significant medical histories, including schizophrenia, depression, psychoactive substance dependence, and opioid dependence. The absence of these care plans was attributed to the facility's policy of being non-smoking, which led to the assumption that smoking care plans were unnecessary. The MDS Coordinator and the Director of Nursing (DON) acknowledged the lack of smoking care plans, despite the MDS indicating current tobacco use. The facility's policy on comprehensive, person-centered care plans requires measurable objectives and timeframes, services to maintain the resident's well-being, and reflection of recognized standards of practice. However, the facility did not adhere to this policy for the residents in question, as no smoking care plans were developed, potentially depriving them of necessary interventions.
Delayed Response to Call Lights in Facility
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner, affecting one sampled resident and two unsampled residents. On February 26, 2025, a call light in a resident's room was activated at 8:38 AM, but it was not answered until 9:03 AM, despite staff being present in the vicinity. The resident had activated the call light to request an adjustment to the room temperature. A CNA eventually responded, acknowledging that call lights were everyone's responsibility, but it seemed that only CNAs were expected to answer them. An LPN at the nursing station noted that the call light system had been malfunctioning since February 24, 2025, causing a constant alarm sound that masked the real call light alarm, and it was unclear if the issue had been reported to maintenance. Another incident involved a resident, identified as Resident 17, who was observed in distress at the nursing station on the 100 hall. The resident, who had a history of gout, type 2 diabetes mellitus with hyperglycemia, and spondylosis, reported severe pain and had activated the call light over an hour earlier to request pain medication. Despite the presence of four staff members at the nursing station, the resident's request was not acknowledged until a nurse approached and administered pain medication. The nurse stated that no one had reported the resident's pain to them. Additionally, on March 6, 2025, a resident in a room across from the 200-hall nursing station was heard emitting loud cries for help, which were ignored by passing staff members. The cries continued for approximately 15 minutes before a staff member attended to the resident. A Resident Council Log from January 15, 2025, documented a resident's complaint about delayed responses to call lights, and a subsequent meeting response indicated that education was provided to staff on the importance of timely call light responses. The Director of Nursing and the Administrator acknowledged ongoing Quality Assurance and Performance Improvement (QAPI) projects related to call light response times.
Failure to Follow Physician's Order for Foley Catheter Size
Penalty
Summary
The facility failed to ensure proper assessment and documentation of a Foley catheter for a resident, leading to a deficiency. The resident, who was admitted with acute kidney failure and obstructive uropathy, had a Foley catheter in place that was not in accordance with the physician's order. The physician had ordered a 14 French catheter with a 10 ml water balloon, but the resident had a 16 French catheter instead. This discrepancy was confirmed by an LPN and the Assistant Director of Nursing (ADON), who noted that the catheter size should match the physician's order to prevent potential trauma or leakage. The facility's documentation consistently indicated the use of a 14 French catheter, despite the actual use of a 16 French catheter. The ADON and the physician both emphasized the importance of following the physician's order for catheter size to avoid complications. The facility's policy on catheter care, revised in August 2022, required accurate documentation of catheter assessments, including urine characteristics, to prevent complications such as urinary tract infections. However, the failure to adhere to the physician's order and accurately document the catheter size in the medical record led to the identified deficiency.
Failure to Conduct Nutritional Assessment and Address Severe Weight Loss
Penalty
Summary
The facility failed to conduct an impaired nutrition assessment or a comprehensive nutritional assessment for a resident upon admission, which led to a lack of interventions for severe weight loss. The resident, who was cognitively intact, experienced a significant weight loss of 35.70 pounds, equating to a 12.80% decrease, over a period from early July to early August. Despite the facility's policy requiring a nutritional assessment upon admission, there was no documented evidence of such an assessment or a nutritional care plan in the resident's comprehensive care plan. The Registered Dietician confirmed the absence of a nutritional assessment and interventions for the resident's weight loss, which should have prompted a dietary consultation. The Director of Nursing and the Director of Staff Development acknowledged the lack of documentation regarding a change of condition or dietary consultation. The facility's policies on nutritional assessment and weight intervention were not followed, as there was no evaluation or intervention for the resident's undesirable weight change, which was necessary to address the resident's nutritional needs and potential causes of weight loss.
Failure to Follow Tube Feeding Orders and Monitor Nutritional Intake
Penalty
Summary
The facility failed to ensure that the tube feeding order for a resident with dysphagia and a gastrostomy was followed, leading to a significant discrepancy in the total dose volume consumed. The resident, who had a history of aspiration pneumonia and was at risk for malnutrition, was observed with the enteral pump turned off during the day, despite orders for nocturnal feeding. The Registered Dietitian and Licensed Practical Nurse confirmed that the total dose delivered over 72 hours was significantly less than ordered, resulting in a shortage of 1269 mL and 1800 calories, which was significant for the resident's wound healing and recovery. The Registered Nurse and Director of Nursing acknowledged that the tube feeding should have been monitored to ensure completion, but there was no documentation of the total dose consumed. The facility's policy required adequate nutritional support through enteral nutrition, but the staff failed to monitor and document the resident's nutritional intake as ordered. The Director of Nursing attributed the resident's significant weight loss to multiple factors, including a history of Clostridium difficile and family interference, but confirmed that the actual dose of tube feeding consumed was not documented.
Failure to Obtain Physician's Orders and Document IV Access
Penalty
Summary
The facility failed to obtain a physician's order for the use of intravenous (IV) access or heplock for two residents, Resident 104 and Resident 325, and did not properly assess, monitor, or document the IV sites. For Resident 104, who was admitted with diagnoses including anemia and malignant neoplasm of the rectum, an IV heplock was observed to be 10 days old, soiled, and not documented in the medical record until 10 days after insertion. The charge nurse and Assistant Director of Nursing confirmed the lack of documentation and the failure to change the IV heplock every two to three days as required to prevent infection. Resident 325, admitted with diagnoses including bipolar disorder and acute respiratory failure, had a peripheral IV access on the left hand that was covered with an adhesive transparent dressing dated 11 days prior to observation. The resident's medical record lacked documentation of whether the IV access was present upon admission or inserted afterward, and there were no physician orders for placement, monitoring, or discontinuation. The IV nurse confirmed the IV access was used only once for a Banana bag administration and had not been monitored or assessed since. The facility's policies on Peripheral IV Catheter Insertion and Removal required a provider's order and documentation of the procedure, including the condition of the IV site and the resident's response. The Director of Nursing acknowledged the lack of documentation and orders, which increased the risk of infection and complications for the residents. The Infection Preventionist also noted the failure to identify and assess IV access upon admission and the need for regular dressing changes to prevent infection.
Inadequate Pain Management and Documentation for Two Residents
Penalty
Summary
The facility failed to consistently assess, manage, and document pain management for two residents, leading to inadequate pain relief. Resident 273, who had undergone back surgery and was experiencing severe pain, reported that requests for pain medication were ignored, and the pain medication provided was insufficient. The facility's policy required pain to be assessed every 30-60 minutes after onset, but there was no documented evidence of such assessments or reassessments in the electronic Medication Administration Record (eMAR). Staff interviews confirmed that the pain assessments were not consistently conducted or documented, and the system-generated prompts for follow-up were not adhered to. Resident 17, who had a history of gout, diabetes, and spondylosis, was observed in visible distress and reported severe pain to staff at the nursing station. Despite activating the call light over an hour prior, the resident's pain was not addressed until later, and the administration of pain medication was not documented in the eMAR. The facility's policy required documentation of medication administration and reassessment of pain within 30-60 minutes, but these steps were not followed, as confirmed by the Director of Nursing and other staff members. The lack of consistent pain assessment and documentation for both residents highlights a failure to adhere to the facility's pain management policies. This deficiency resulted in unrelieved pain and discomfort for the residents, as their pain levels were not adequately monitored or managed according to the established protocols. The staff's failure to document and reassess pain management interventions contributed to the inadequate care provided to the residents.
Medication Error Rate Exceeds 5% Due to Dosage and Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during a medication pass, resulting in an 8% error rate. This was observed through 25 medication administration opportunities, where two errors were identified. One error involved a resident who was prescribed 1 mg of Folic Acid daily but was administered only 400 mcg. The LPN responsible for the administration acknowledged the mistake, noting that there were two bottles of Folic Acid available and the dosage should have been double-checked. The pharmacist confirmed that the correct dosage was not administered, and the Director of Nursing emphasized the importance of adhering to the resident's rights, including the correct dosage. Another error involved a resident with a prescription for Cardizem 120 mg to be administered daily for hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110. The LPN withheld the medication when the resident's SBP was exactly 110, misunderstanding the parameter. The LPN later confirmed that the medication should have been administered, as the SBP was not below the threshold. The Director of Nursing reiterated the expectation for licensed nurses to follow medication administration parameters and consult the physician if there is any doubt.
Failure to Maintain Functional Call Light System
Penalty
Summary
The facility failed to maintain a functioning call light system in the 200 hall, which compromised the safety and responsiveness to residents' needs. On multiple occasions, the call light in a resident's room was activated but not promptly answered, despite staff being present in the vicinity. The resident expressed discomfort due to the room temperature and had to wait 25 minutes before a CNA responded. The CNA indicated that there was a misunderstanding among staff regarding the responsibility for answering call lights. The call light system had been malfunctioning since 02/24/2025, producing a constant alarm sound that masked the actual call light alerts. This malfunction was not reported in the maintenance log, and the LPN at the nursing station confirmed the issue was not visible from their location. The system's failure was discovered by maintenance staff while addressing an unrelated issue. Additionally, the call light activators in the bathrooms of two other rooms were found to be non-functional, but these issues were not documented in the maintenance log. The facility lacked a specific policy for the call light system's requirements or maintenance, as confirmed by the DON. The Administrator was unaware of the call light system issue until informed during the survey. Staff had been attempting to reset the system by unplugging it, which was ineffective. The absence of a documented policy and the failure to report and address the malfunctioning system contributed to the deficiency, leaving residents at risk of delayed assistance.
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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