Green Valley Health And Wellness Suites
Inspection history, citations, penalties and survey trends for this long-term care facility in Henderson, Nevada.
- Location
- 2965 Wigwam Parkway, Henderson, Nevada 89074
- CMS Provider Number
- 295110
- Inspections on file
- 14
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Green Valley Health And Wellness Suites during CMS and state inspections, most recent first.
A resident with a history of congestive heart disease and muscle weakness was not allowed to reenter the facility after returning late from a therapeutic leave, despite expressing a desire to stay. Staff, following direction from the ADON, discharged the resident without providing the required 30-day written notice or notifying the Ombudsman, and the discharge was incorrectly documented as AMA without the resident's signature. Facility leadership later confirmed that proper involuntary discharge procedures were not followed.
The facility did not ensure that resident grievances were investigated or resolved, as required by policy. Multiple complaints, including delayed care, staff rudeness, and missing personal items, were documented in meeting minutes and grievance logs but lacked evidence of investigation or resolution. The DON and Social Worker confirmed that documentation of grievance follow-up was missing, and not all staff had access to the grievance system.
A resident with multiple neurological diagnoses did not receive a scheduled dose of Clonazepam 0.5 mg as ordered, despite the medication being available in the facility's Omnicell system. Documentation cited unavailability and awaiting pharmacy delivery, but staff did not access the medication from the Omnicell or contact the physician for clarification, resulting in the missed administration.
A resident with multiple medical conditions was found with a prescription eye drop medication left unsecured on the bedside table, contrary to physician orders and facility policy. An LPN confirmed the medication should have been stored in the medication cart, and the DON stated that medications are not to be left at the bedside and must be secured.
Staff failed to consistently follow posted infection control precautions for two residents requiring Contact or Enhanced Barrier Precautions. Multiple staff, including CNAs, an LPN, and a housekeeper, entered rooms or provided care without the required PPE, despite clear signage and available supplies. Staff acknowledged the requirements but did not adhere to them, and some expressed confusion about proper PPE use and removal.
A facility failed to implement a person-centered care plan for a resident's PICC line, which was inserted for TPN and antibiotics. The medical records lacked a care plan, and there was a communication breakdown between the MDS department and nursing staff, leading to the oversight.
The facility failed to maintain proper PICC line care for two residents, leading to potential infection and catheter occlusion risks. One resident had a soiled and undated dressing with no physician order for maintenance, while another lacked a saline flushing protocol, resulting in a non-patent line. The facility's policies for PICC line care were not followed, as confirmed by the interim DON and LPNs.
The facility failed to obtain informed consents and monitor behaviors for psychoactive medications for two residents. One resident was prescribed Zoloft without informed consent or monitoring, while another received Hydroxyzine, Seroquel, and Trazodone with undated and unwitnessed verbal consents. The facility's policy for medication management was not followed, leading to deficiencies in monitoring and documentation.
A facility failed to complete an initial PASRR for a resident with depression and anxiety disorder before admission. The resident required 1:1 monitoring due to severe anxiety, and the absence of a PASRR assessment was acknowledged by the Director of Admissions. The last PASRR was from 2008, and the Director of Social Services confirmed that a PASRR level 1 screening should have been conducted to evaluate the resident's mental health needs.
A resident with a spinal injury and overactive bladder was left soiled and wet for several hours despite requesting assistance, leading to a call to 911. The facility failed to provide timely incontinent care, with staff ignoring the resident's pleas and lacking documentation of care provided. Interviews revealed delays in response to call lights and inadequate communication and prioritization of care.
The facility failed to conduct proper nutritional assessments and interventions for residents with significant weight changes. A resident experienced notable weight loss without documented assessments or interventions, while another had missing weight records for two months. A third resident on hospice care had a drastic weight loss that was not immediately verified. The facility did not adhere to its weight monitoring protocols, leading to potential delays in necessary interventions.
A resident with a PICC line was found with a dressing that had not been changed for nearly a month, contrary to the facility's policy of weekly changes. The oversight was confirmed by a nurse, and the resident's medical record lacked documented orders for PICC line care. The Interim DON suggested the omission might be linked to the resident's recent re-admission.
The facility failed to ensure proper dialysis communication and post-treatment assessments for two residents with end-stage renal disease. One resident had incomplete records for 8 days and missing vital signs for 6 days, while another had missing records for 13 days and missing vital signs for 6 days. The interim DON acknowledged the importance of complete records and assessments to ensure residents' safety post-dialysis.
The facility failed to develop baseline care plans for two residents admitted with ileostomies, lacking documentation of care and management interventions. The DON confirmed the absence of these plans, which are required within 48 hours of admission to address immediate care needs. This placed the residents at risk for complications such as stoma infection and skin irritation.
The facility failed to document and execute care orders for the ileostomy care of two residents, leading to a deficiency in their care. One resident was admitted with an ileostomy following a partial colectomy, and another with a history of alcohol abuse and ileostomy creation. Interviews revealed that the facility lacked a designated admission nurse, and the responsibility for entering care orders fell on the admitting nurse. The absence of documented care orders and a specific policy for ileostomy care resulted in inadequate care for the residents.
Failure to Follow Involuntary Discharge Procedures for Resident Returning from Therapeutic Leave
Penalty
Summary
The facility failed to ensure that a resident was not involuntarily discharged without a valid reason and without following required procedures. The resident, who had diagnoses including congestive heart disease and muscle weakness, was admitted for long-term care and had a physician order allowing therapeutic leave for up to four hours at a time. On the date of the incident, the resident left the facility on a pass and returned late, after which staff, under the direction of the Assistant Director of Nursing (ADON), did not allow the resident to reenter the facility. The resident was given their belongings and told they could not stay due to repeated violations of the four-hour pass rule, despite the resident expressing a desire to remain at the facility. Documentation showed that the discharge was recorded as 'against medical advice' (AMA), but the resident did not sign the AMA form, and the form itself lacked a diagnosis. Staff notes indicated that the resident was unhappy with being discharged and did not want to leave. Interviews with facility staff, including the ADON, DON, and Case Manager, revealed that the facility had an ongoing issue with the resident returning late from passes, but there was no written policy supporting automatic AMA discharge for exceeding the pass time. The DON and Administrator acknowledged that the required 30-day written notice of involuntary discharge and notification to the Long-Term Care Ombudsman were not provided to the resident. The facility's actions were based on verbal warnings and frustration with the resident's non-compliance, rather than adherence to established discharge procedures. The resident was not provided with the opportunity to appeal the discharge or receive proper notification, and the discharge was not supported by a physician order or a documented safe discharge plan. The facility's failure to follow its own policies and regulatory requirements resulted in the resident being involuntarily discharged without due process.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly investigated and that determinations or resolutions were provided to residents. Interviews and document reviews revealed that issues raised during Resident Council Meetings were not consistently entered into the grievance program, and there was no documentation of investigations or resolutions for the grievances. The Social Worker stated that not all new staff had access to the computer system to input investigations and resolutions, resulting in a lack of follow-up on reported concerns. The Director of Nursing confirmed the absence of documentation for grievance investigations and resolutions, despite being able to provide meeting agendas where related topics were discussed. Resident Council Meeting Minutes and grievance logs from January through March documented multiple unresolved issues, including staff not performing rounds every two hours, staff being rude or sleeping during shifts, delayed medication administration, call lights not being answered for extended periods, and personal items being taken from residents' rooms. The facility was unable to provide evidence of steps taken to investigate these grievances, summaries of findings, confirmation of grievances, or corrective actions taken, as required by their own grievance policy.
Failure to Administer Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Friedreich ataxia and functional quadriplegia did not receive Clonazepam 0.5 mg as ordered by the physician. The medication was scheduled to be administered twice daily at 8:00 AM and 8:00 PM, but was not given at the scheduled 8:00 PM dose. Documentation on the Medication Administration Record indicated the medication was not administered due to it being unavailable, with a note that the facility was awaiting delivery from the pharmacy for a new admission. Further investigation revealed that the facility had an Omnicell automated medication dispensing system stocked with Clonazepam 0.5 mg, with six tablets available at the time. Staff confirmed that the medication could have been accessed from the Omnicell after verifying the order with the pharmacy, but this was not done. The Director of Nursing confirmed that the medication had not been administered and that staff would have needed to contact the physician for clarification due to the late delivery, but this step was not taken.
Medication Not Secured in Locked Storage
Penalty
Summary
A deficiency occurred when a prescription medication, Latanoprost 0.005% eye drops, was found unsecured on a resident's bedside table. The medication was intended to be administered at bedtime as per a physician's order. The resident, who had diagnoses including cellulitis of the right lower limb, type 2 diabetes mellitus with hyperglycemia, and difficulty walking, reported that the nurse had left the medication at the bedside the previous night. This was confirmed by an LPN the following morning, who acknowledged the medication should have been stored in the medication cart due to its specific administration schedule and safety concerns. Further, the Director of Nursing confirmed that facility policy requires all medications to be secured in locked compartments and not left at the bedside. The facility's policy, revised recently, mandates that all drugs and biologicals be stored in locked compartments under proper conditions. The failure to secure the medication as required by policy and regulation led to the deficiency identified during the survey.
Failure to Adhere to Infection Control Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents who required either Contact Precautions or Enhanced Barrier Precautions. In one instance, a certified nurse assistant entered a resident's room with gloves but without a gown, despite signage indicating both were required, and then exited the room carrying a meal tray. The same resident's room was later entered by a licensed practical nurse and another certified nurse assistant without any gloves or gown, and a housekeeper was observed mopping in the room without a gown, even though the posted sign specified the need for both gloves and gown. All staff acknowledged the signage and the requirements but did not adhere to them, despite the availability of personal protective equipment (PPE) outside the room. For another resident on Enhanced Barrier Precautions, staff were observed providing care without the required PPE. One certified nurse assistant was at the room threshold with gloves but no gown, and another was inside the room without gloves or gown, both having removed their PPE after care activities but before leaving the room. Staff expressed confusion about when and where PPE should be worn or removed, particularly during resident transport. The infection prevention nurse confirmed that staff were educated on infection control and that the expectation was for staff to follow the posted signage, which was specific to each resident's needs. Facility policy required clear signage and periodic monitoring of infection control procedures.
Failure to Implement Person-Centered Care Plan for PICC Line
Penalty
Summary
The facility failed to implement a person-centered care plan for the utilization and maintenance of a PICC line for one resident. This resident was admitted with diagnoses including dysphagia, dementia, protein-calorie malnutrition, and failure to thrive. A PICC line was inserted for total parenteral nutrition and antibiotics administration, with specific physician orders for its use. However, the medical records lacked evidence of a formulated care plan for the PICC line's utilization and maintenance. The interim DON confirmed that no care plan had been formulated when the PICC line was inserted. The responsibility for care plan formulation was unclear, with the MDS department expected to create the plan if the PICC line was inserted post-admission, and licensed nurses responsible if the resident was admitted with a PICC line. The Director of MDS was unaware of the PICC line insertion due to a lack of communication and did not perform routine visual assessments. The facility's policy required the development of a baseline and comprehensive care plan for each resident, which was not adhered to in this case.
Deficient PICC Line Care and Maintenance
Penalty
Summary
The facility failed to ensure proper maintenance and care of a peripherally inserted central catheter (PICC) line for two residents, leading to potential risks of infection and catheter occlusion. Resident 1, who was admitted with diagnoses including diabetes mellitus and chronic hepatitis, had a PICC line in the right upper arm with a dressing that was undated, peeling, and soiled with dried blood-like residues. There was no documented evidence of a physician order for the maintenance of the dressing changes, and the dressing had not been changed since the PICC line was inserted. The interim Director of Nursing confirmed that the dressing should have been changed weekly, and the absence of a physician's order meant that licensed nurses were not prompted to complete the task. Resident 2, admitted with conditions such as dysphagia, dementia, and protein-calorie malnutrition, had a PICC line inserted for total parenteral nutrition (TPN) and antibiotics. However, there was no documented evidence of a physician order for the PICC line saline flushing protocol, which is essential to ensure patency. The PICC line was not patent or flushing, leading to the need for a replacement. Licensed Practical Nurses confirmed that a flushing protocol should have been in place, and the absence of such an order meant that the licensed nurses were not prompted to perform the necessary flushing. The facility's policies required licensed nurses to perform procedures related to PICC line care, including dressing changes and obtaining and transcribing physician orders. However, these protocols were not followed, as evidenced by the lack of orders and documentation for both residents. The interim Director of Nursing acknowledged the deficiencies and confirmed that the necessary orders were not obtained or implemented, leading to the potential for infection and catheter occlusion.
Failure to Obtain Informed Consents and Monitor Psychoactive Medications
Penalty
Summary
The facility failed to obtain informed consents, monitor behaviors, and document non-pharmacological interventions for the use of psychoactive medications for two residents. Resident 46 was admitted with diagnoses including schizoaffective disorder, insomnia, and depression. A physician order was given for Zoloft to be administered for depression, but there was no evidence of a physician order to monitor behavior or side effects, nor was there an informed consent obtained prior to the use of Zoloft. The interim Director of Nursing (DON) acknowledged that informed consent should have been obtained and that the facility's process for monitoring behaviors and side effects was not followed. Resident 38 was admitted with diagnoses including psychotic disorder with delusions, anxiety disorder, and schizophrenia. The resident was prescribed Hydroxyzine, Seroquel, and Trazodone, but informed consents were obtained verbally via telephone and were undated and unwitnessed. The DON explained that verbal consents required documentation and signatures from two licensed nurses as witnesses, which were not present. Additionally, there was no monitoring of the effectiveness of the medications. The facility's policy required obtaining physician orders and consent forms for each prescribed psychotropic medication, as well as monitoring and documenting the resident's response to the medication, which was not completed for Resident 38.
Failure to Complete PASRR Prior to Resident Admission
Penalty
Summary
The facility failed to ensure an initial Preadmission Screening and Resident Review (PASRR) was completed prior to the admission of a resident with diagnoses including depression and anxiety disorder. The resident was admitted with a history of psychiatric issues, requiring 1:1 monitoring due to severe anxiety behavior. Despite the presence of a Level of Care (LOC) assessment dated 07/08/2022, there was no documented evidence of a PASRR assessment in the resident's medical record. The Director of Admissions acknowledged the absence of a PASRR assessment and noted that the last completed assessment was from 2008, which was not retrievable due to a system upgrade. The Director of Social Services confirmed that the resident should have undergone a PASRR level 1 screening to evaluate any related diagnoses from the previous hospitalization. The resident exhibited behavioral issues during the hospital stay, and a newer PASRR could have identified any new mental illness diagnosis, potentially altering the determination or recommendations for care. The facility's policy requires all applicants to a Medicaid-certified nursing facility to be evaluated for mental illness or intellectual disability prior to admission, but this was not adhered to in this case.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide incontinent care to a dependent resident, identified as Resident 229, who was left soiled and wet despite requesting assistance. The resident, who was admitted with diagnoses including overactive bladder and a spinal injury, was totally dependent on assistance for care. On December 12, 2024, the resident experienced a bladder spasm and urinated in bed, pressing the call light for help. However, no assistance arrived for several hours, and staff were observed ignoring the resident's repeated pleas for help. The resident eventually called the facility operator and later 911 when no staff responded, leading to police involvement. The medical record lacked documented evidence of incontinent care being provided on December 12 and 13, 2024. Interviews with the interim Director of Nursing, a Licensed Practical Nurse, and a Certified Nursing Assistant revealed that there were delays in responding to the resident's call light and a lack of communication and prioritization in providing care. The staff were expected to provide care within 5-10 minutes of a call light being activated, but this did not occur. The CNA assigned to the resident on the day of admission confirmed that bowel and bladder care was not provided during their shift and was left for the night shift, which also failed to provide the necessary care. The Administrator confirmed that the delays in response and care were unacceptable, although no intentional neglect was observed. The facility's policy on Activities of Daily Living required staff to develop and implement interventions based on the resident's assessed needs and preferences, which was not adhered to in this case.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure proper nutritional assessments and interventions for residents experiencing significant weight changes. Resident 14, who was at risk for malnutrition, experienced a notable weight loss from 160 lbs. to 129.3 lbs. over several months without a documented nutritional assessment or intervention. The Director of Dietary Services and the Registered Dietitian confirmed that weight monitoring protocols were not followed, as weights were not documented for July, and no re-weighs were conducted after the weight loss was identified in August. Additionally, the interim Director of Nursing acknowledged the lack of a nutritional assessment during this period. Resident 16 also experienced lapses in weight monitoring, with no weights recorded for July and November. The Registered Dietitian and the Director of Nursing confirmed the absence of documentation for these months, indicating a failure to adhere to the facility's policy of obtaining and documenting weights as scheduled. This oversight in weight monitoring could have delayed necessary interventions for maintaining the resident's health. Resident 39, who was on hospice care, experienced a significant weight loss from 411.2 lbs. to 151.8 lbs. in December, which was not immediately re-weighed to verify accuracy. The Registered Dietitian noted the drastic weight change and requested a re-weigh, which was eventually conducted, confirming the weight loss. The interim Director of Nursing acknowledged that the resident's weight was not taken in November, contrary to the physician's order for monthly weights. The facility's policy required re-weighing in the presence of licensed personnel if a significant weight change was observed, which was not initially followed.
Failure in PICC Line Maintenance for a Resident
Penalty
Summary
The facility failed to ensure proper care and maintenance of a peripherally inserted central catheter (PICC) line for a resident, identified as Resident 35. The resident was observed with a PICC line dressing dated nearly a month prior, indicating it had not been changed according to the facility's policy, which requires weekly dressing changes. A registered nurse confirmed the oversight and acknowledged that the dressing should have been changed and documented in the medication and administration record (MAR). The resident's medical record lacked documented orders for the care and maintenance of the PICC line, which was confirmed by the Interim Director of Nursing. Resident 35 was admitted with diagnoses including hemiplegia and cellulitis of the abdominal wall. The resident's family member reported that no intravenous antibiotics or fluids had been administered for over a month. The Interim Director of Nursing suggested that the missing orders might have been due to the resident's recent re-admission. The facility's policy, revised in May 2023, outlines that licensed nurses are responsible for assessing and performing dressing care of a PICC line, including labeling the dressing with the date of the procedure or the next due date for a change.
Incomplete Dialysis Communication and Assessment
Penalty
Summary
The facility failed to ensure proper dialysis communication and post-treatment assessments for two residents, leading to a deficiency in care. Resident 5, diagnosed with end-stage renal disease and generalized anxiety, attended dialysis treatments 24 times. However, the Hemodialysis Communication Record was incomplete, with 8 days missing records, 6 days missing return vital signs and/or dialysis site information, and 2 days where the resident refused treatment. This lack of documentation could impair continuity of care and prevent the identification of adverse reactions post-dialysis. Similarly, Resident 8, with diagnoses including end-stage renal disease and heart failure, attended dialysis treatments on 20 occasions. The communication record was missing for 13 days, and 6 days lacked return vital signs and/or dialysis site observations. Additionally, one day was missing information from the dialysis center. The interim DON acknowledged the importance of complete communication records and post-dialysis assessments, as per the facility's policy, to ensure residents are not experiencing latent effects of dialysis and to check for bleeding at access sites.
Failure to Develop Baseline Care Plans for Ileostomy Management
Penalty
Summary
The facility failed to develop a baseline care plan for two residents who were admitted with ileostomies, which are surgical openings created by bringing the end of the small intestine to the skin's surface. This deficiency was identified through interviews, record reviews, and document reviews. Resident 1 was admitted with diagnoses including malignant neoplasm of the endometrium and an ileostomy following a partial colectomy. Similarly, Resident 3 was admitted with a history of alcohol abuse and an ileostomy creation. Both residents' medical records lacked documentation of a baseline care plan addressing the care and management of their ileostomies. The Director of Nursing confirmed the absence of baseline care plans for the residents' ileostomies, acknowledging that the admitting nurse was responsible for initiating such plans to address immediate care needs. The Director of Clinical Services also emphasized the importance of including ileostomy care in the baseline care plan, as it is an immediate care need. The facility's policy requires a baseline care plan to be developed within 48 hours of admission to guide staff in providing necessary treatment and care. The lack of a baseline care plan for the ileostomies placed the residents at risk for complications such as stoma infection, skin irritation, and discomfort.
Failure to Document Ileostomy Care Orders for Two Residents
Penalty
Summary
The facility failed to ensure that care orders were entered and executed for the ileostomy care of two residents. Resident 1 was admitted with diagnoses including malignant neoplasm of the endometrium and an ileostomy, following a partial colectomy. Despite the need for specific care, the medical record for Resident 1 lacked documented evidence that care orders for the ileostomy were transcribed and carried out. Similarly, Resident 3, who was admitted with a history of alcohol abuse and an ileostomy creation, also had no documented care orders for their ileostomy in the medical record. Interviews with facility staff, including the Director of Nursing (DON), a wound nurse, and a Licensed Practical Nurse (LPN), revealed that the facility did not have a designated admission nurse, and the responsibility for entering care orders fell on the admitting nurse. The DON confirmed the absence of care orders for the ileostomies of both residents and acknowledged the lack of a specific policy for ileostomy care. The facility's practice was to follow professional standards for ostomy care, which include monitoring, emptying, and replacing the ostomy appliance as needed. However, these standards were not documented in the residents' care plans, leading to a deficiency in providing necessary care for the residents' ileostomies.
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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