Life Care Center Of Reno
Inspection history, citations, penalties and survey trends for this long-term care facility in Reno, Nevada.
- Location
- 445 W. Holcomb Lane, Reno, Nevada 89511
- CMS Provider Number
- 295050
- Inspections on file
- 28
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Life Care Center Of Reno during CMS and state inspections, most recent first.
A large number of residents were moved to different rooms without receiving the required written notice or explanation prior to relocation. Documentation was often incomplete or missing, and staff interviews confirmed that the process for notifying residents was not consistently followed, despite facility policy requiring written notification and a stated reason for each room change.
Surveyors found that handwashing stations in both the kitchen and café/gift shop were either nonfunctional or lacked necessary supplies, and staff were unaware of these deficiencies. A scoop was improperly stored in a dry food bin, the griddle grease trap was not cleaned as required, and the café/gift shop refrigerator was not being monitored for temperature, all in violation of facility policies and food safety standards.
The facility did not provide written notification to most residents or their representatives regarding room changes, with 38 out of 49 affected residents lacking documentation. Additionally, the facility failed to document screening for eligibility and education for influenza and pneumonia vaccines for 38 residents, and did not have a process for determining the correct pneumonia vaccine per CDC guidance.
The QAPI committee failed to implement corrective actions after identifying a lack of screening and education for influenza and pneumococcal vaccinations. The Administrator confirmed that, despite recognizing the issue, no steps were taken to address it, contrary to facility policy requiring the QAA committee to respond to quality deficiencies.
The QAPI/QAA Committee did not fully identify or implement effective plans for systemic issues involving resident room changes and the bowel and bladder program. The committee's actions were limited to monitoring notification sheets for room changes, which were not completed with reasons, and restricting the bowel and bladder program to two-hour checks without further interventions.
Surveyors identified that the facility did not consistently screen residents for eligibility, provide required education, or ensure proper completion of consent forms for influenza and pneumococcal vaccinations. Many residents with chronic conditions either did not receive the appropriate vaccines or lacked adequate documentation of consent, education, and vaccine administration, resulting in substandard quality of care.
A resident with multiple mental health diagnoses was administered psychotropic medications, including Sertraline, Quetiapine, and Buspirone, without documented informed consent. The DON confirmed that consent forms explaining the risks and benefits were not completed, despite facility policy requiring such documentation.
Three residents had inaccurate MDS 3.0 assessments, including missing documentation of psychiatric diagnoses for a resident receiving antipsychotic and antidepressant medications, failure to record a fall with injury for another resident, and omission of antianxiety medication administration for a third resident. These inaccuracies were confirmed by the DON and MDS Coordinator.
A resident with multiple mental health diagnoses was admitted without a required PASARR Level 1 screening. Staff were unable to provide current documentation, and interviews revealed confusion about the necessity and purpose of the screening, despite facility policy requiring it prior to admission.
Two residents were admitted without appropriate baseline care plans: one with mental health diagnoses did not have care or interventions for those conditions included, and another with a Foley catheter did not have the catheter type or specific care interventions documented. The DON and Regional Director confirmed these omissions, which resulted in incomplete guidance for staff regarding the residents' immediate care needs.
The facility did not develop individualized, person-centered care plans for residents with Foley catheters, bowel and bladder retraining needs, and pain management requirements. For example, a resident with a Foley catheter had a care plan lacking specific details about the catheter and its care, while two residents needing bowel and bladder retraining had care plans without measurable objectives or tailored interventions. Additionally, a resident with chronic pain did not have all pain management interventions, including non-pharmacological methods, documented in the care plan.
A CNA was found to be working with an expired CPR certification, as confirmed by personnel records and the Staff Development Coordinator RN. The CNA's job description and facility policy both required current CPR certification for staff providing resident care, but this requirement was not met.
A resident receiving hospice care for a malignant brain neoplasm did not have required hospice nurse progress notes consistently placed in their hospice binder, despite weekly visits. Facility staff, including the RN and DON, confirmed that these notes were necessary for ongoing care coordination and were expected to be reviewed during weekly IDT meetings, but the absence of documentation was not identified or addressed.
A resident with multiple medical conditions was found with their bed positioned against an air conditioning unit, creating a significant gap between the mattress and the wall. Staff confirmed that no entrapment risk assessment had been completed, and the DON acknowledged the bed's placement created a potential hazard. Facility policy required accident hazards to be addressed, but this was not done in this case.
Two residents who were incontinent of bowel and bladder were not provided with individualized interventions based on their evaluations, as required by facility policy. Despite assessments indicating they were candidates for toileting and scheduled voiding, only general care such as routine rounds and pericare was provided, and documentation of resident-specific interventions and their effectiveness was lacking. Staff interviews confirmed that interventions were not tailored to individual needs, and key assessment tools were incomplete.
A resident with a known history of significant weight loss was not monitored with weekly weights after readmission, despite facility policy and ongoing severe weight loss. The DON confirmed that required weekly weights were not documented, and the RD was aware of the resident's prior weight loss, but no further monitoring occurred.
A resident with chronic pain and recent surgery did not have their tolerable pain level assessed or documented, and pain medication was not administered according to physician orders. Despite reporting severe pain, the resident received a lower dose of Oxycodone than ordered for their pain level, with no documentation of physician notification or approval for the change. Nursing staff and the DON confirmed the lack of documentation and deviation from pain management protocols.
The facility did not consistently maintain completed dialysis communication forms for three residents receiving offsite dialysis, resulting in missing documentation for multiple treatment dates. Orders for dialysis and access port assessment were also not consistently present in the records, and required communication between the facility and the dialysis center was not reliably documented, as confirmed by the DON and RDC.
A resident with multiple medical and psychiatric conditions was administered medications without proper physician authorization, as the physician's orders were not signed and dated during a required visit. Facility staff confirmed that medications were given based on unsigned orders, and the physician acknowledged not completing the required electronic signature. Facility policy required all orders to be signed before administration, but this was not followed in this instance.
A resident who was relocated to a new room following staff direction did not receive a required psychosocial assessment by social services, despite expressing distress over the move and a desire to remain with their previous roommate. The LSW confirmed that the assessment was not completed, contrary to facility policy.
Expired medications, including Cranberry and Probiotic capsules, as well as a protein supplement with an illegible expiration date, were found on two medication carts during inspection. The ADON and an RN confirmed the presence of these expired or unlabeled items, which had not been removed as required by facility policy. The DON verified that all medications must be properly labeled and expired items should be immediately removed from active storage.
A Medical Records Director accessed and coded a resident's clinical record without having completed the required fingerprinting and background check clearance, in violation of state law and facility policy. The Administrator confirmed the lack of NABS clearance and was unaware of the background check requirement for skilled nursing employees.
The facility did not provide required written notice to the State Agency when there was a change in DON. The Administrator confirmed that no notification was sent at the time of the change, and a formal letter was only prepared months after the new DON started, contrary to facility policy.
The facility did not ensure that its QAPI committee included the required members, as the DON and MD were repeatedly absent from meetings, contrary to facility policy and regulatory requirements. This deficiency was confirmed through document review and administrator interview.
A resident with an indwelling urinary catheter and an active bladder infection was observed with their catheter bag resting on the floor while seated in a wheelchair. Both an LPN and the DON confirmed that facility policy requires catheter bags to be kept off the ground to prevent contamination, but this protocol was not followed.
The facility did not document the frequency of required staff trainings in its Facility Assessment and failed to identify all staff required for QAPI training, as confirmed by the Administrator and review of facility policy.
Resident-identifiable information was left exposed on a nursing station counter and on an unattended medication cart computer screen. An LPN and the Staff Development Coordinator confirmed that these actions violated facility policy, as resident information should not be visible or accessible without proper authorization.
The facility failed to maintain the outside receptacle area in a sanitary condition, with observations revealing accumulated debris, leaking receptacle containers, and foul odors. Despite acknowledgment from the CDM, the source of the liquid was initially unidentified. A Maintenance Assistant later attributed the thickened liquid to an air conditioner leak mixing with oil. The facility's policy on maintaining cleanliness and odor-free conditions was not followed.
The QAPI committee failed to identify the absence of a bowel and bladder retraining program for residents, impacting their ability to maintain continence. The DON acknowledged the importance of continence but was unsure of the last implementation of such a program. The Regional President noted the discontinuation of the RNA program during the COVID-19 pandemic and suggested audits could have identified the deficiency.
The facility failed to conduct bowel and bladder assessments upon admission for several residents, hindering the determination of their candidacy for retraining programs. Despite some residents being identified as candidates for toileting and scheduled voiding, the facility did not implement these programs, leading to a decline in continence status. The DON confirmed the absence of a bowel and bladder program and the lack of adherence to facility policies on incontinence management.
The facility failed to maintain accurate Controlled Drug Records (CDR) for two medication carts, affecting eight residents. Discrepancies were found between documented and actual medication counts, including tramadol, clonazepam, and oxycodone. Staff confirmed the inaccuracies, which were against the facility's policy requiring documentation at the time of medication removal and prior to administration.
A resident in an LTC facility experienced emotional distress and increased pain due to malfunctioning bed controls that were not repaired despite multiple requests. The resident, with a history of back surgeries and other medical conditions, was unable to adjust the bed independently, leading to significant discomfort. The DON acknowledged that the bed should have been replaced to ensure the resident's comfort and pain management.
A resident with respiratory issues was transferred to a hospital without the required e-Interact form, which is used to communicate essential care information. The facility's policy mandates that this form be completed and sent with the resident during transfers, but the Director of Nursing confirmed that the form was missing from the resident's clinical record.
A resident was readmitted with a new diagnosis of schizophrenia, but the facility failed to submit a required PASRR Level II evaluation. The DON and BOM confirmed the oversight, noting that the PASRR process was not followed despite the facility's policy requiring referrals for significant changes in status.
A resident with COPD was not administered oxygen as ordered, receiving higher flow rates than prescribed. The DON confirmed the discrepancy and stated that nursing staff should have obtained a new physician order if increased oxygen was needed.
The facility did not conduct an annual performance evaluation for a CNA, Employee #13, by their anniversary date. The CNA, hired in October 2022, only had a performance review completed in March 2024. The Staff Development Coordinator confirmed the delay, and the DON stated that reviews were to be conducted annually in April, as per corporate directive and facility policy.
The facility failed to ensure proper labeling and secure storage of medications. Unlabeled medications were found in medication carts, and a pill was left unsecured in a resident's room. The RN and DON confirmed the importance of labeling medications and ensuring they are not left unattended. The resident's record lacked a physician's order for self-administration, violating facility policy.
A facility failed to document the administration of a skin protective ointment for a resident with paraplegia, as per a physician's order. The Treatment Administration Records (TAR) for the resident lacked evidence of the ointment's application on specified dates. The Director of Nursing confirmed the documentation lapse, which was against the facility's policy requiring prompt recording of medication and treatment administration.
A resident with chronic wounds did not have Enhanced Barrier Precautions (EBP) implemented, as required by the facility's infection control policy. Despite having orders for wound care, the resident's room lacked EBP signage and a PPE cart. Staff interviews confirmed that EBP should have been in place to prevent the spread of infection.
A resident in an LTC facility, admitted with serious health conditions, was subjected to an unsanitary environment due to their roommate's inappropriate behaviors, such as urinating on the floor. Despite documentation and staff awareness, the facility failed to effectively address the issue, violating the resident's right to a clean and comfortable environment.
A facility failed to coordinate care for a resident with a terminal prognosis under hospice care. Despite serious health conditions, the facility did not maintain hospice records on-site, and there was no clear communication or documentation process with the hospice provider. The LSW, responsible for hospice coordination, did not review documentation, and the ED acknowledged the lack of communication, contrary to the hospice care agreement and facility policy.
The facility did not maintain proper hand hygiene standards by failing to stock a kitchen hand washing sink with disposable towels. Observations revealed that the sink near the walk-in refrigerator lacked towels, a situation confirmed by staff and the Executive Director. The facility's policy mandates that all sinks be stocked with paper towels.
Failure to Provide Required Written Notice for Resident Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, to a significant number of residents who were relocated within the facility. Documentation revealed that multiple residents experienced room changes without receiving the required written notification prior to the move. In several cases, forms either lacked the reason for the room change, the resident's signature, or any evidence that the resident was informed in advance. For example, one resident was moved to a different room on two occasions, with only one move documented as being at the resident's request and properly signed, while the other lacked any documentation of notification or reason. Interviews with facility staff, including the Administrator, DON, and LSW, confirmed that the process for notifying residents of room changes was not consistently followed. The DON acknowledged that the lack of room change notifications was a pervasive issue in the facility. In one instance, a resident reported being moved against their wishes after being told not to speak to their roommate, and there was no documentation of a room change notification for this event. The Medical Director explained that the move was prompted by privacy concerns and personality conflicts, but again, no written notice was provided to the resident. Facility policy requires that residents receive written notice, including the reason for the change, before any room relocation occurs. Despite this, the clinical records for 37 of 49 residents who were relocated, as well as one discharged resident, lacked the necessary documentation. The widespread nature of this deficiency was confirmed by the Administrator, who stated that all residents with a room change should have a notification with the reason documented, but this was not done for the affected residents.
Deficiencies in Food Service Sanitation and Equipment Maintenance
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations. Observations revealed that handwashing stations in both the primary kitchen dish room and the café/gift shop were not properly maintained; one station had no water flow, while another lacked soap and disposable hand towels. Staff, including the Registered Dietician (RD), Dietary Manager (DM), and a Certified Nursing Assistant (CNA), confirmed these issues and acknowledged the importance of functional handwashing stations for food safety. Facility policies and the FDA Food Code require handwashing sinks to be stocked and operational, but these standards were not met at the time of the survey. Additional deficiencies were found in food storage and equipment maintenance. A scoop was observed stored inside a rice cereal bin with its handle in contact with the food, contrary to facility policy requiring scoops to be stored to prevent contamination. The primary kitchen's griddle grease trap was covered in charred grease, and staff were unclear on cleaning frequency, with no cleaning log maintained. Furthermore, the café/gift shop refrigerator lacked a temperature log, and staff confirmed that temperature monitoring had not begun despite serving residents from this area. Facility policies require regular temperature documentation to ensure food safety, but these procedures were not followed.
Failure to Provide Written Notification of Room Changes and Proper Vaccination Program
Penalty
Summary
The facility failed to administer its operations effectively and efficiently by not ensuring a process was in place for providing written notification to residents or their representatives regarding room changes. Specifically, there was no documented evidence that 38 out of 49 residents who experienced a room change received written documentation explaining the reason for the change. This lack of documentation was confirmed through observation, document review, and interview, and the issue was acknowledged by the Administrator, who stated that the process for written notification was still being monitored and ongoing issues persisted. Additionally, the facility did not have a documented process for its influenza and pneumonia vaccination program. There was no evidence that 38 residents eligible or potentially eligible for the influenza vaccine were screened for eligibility or provided with education about the 2024/2025 flu vaccines. Similarly, for the pneumonia vaccine, there was no documentation that residents were screened for eligibility or provided with education regarding the vaccine they were eligible to receive. The Administrator confirmed that no current action plan was in place for the vaccination program at the time of the survey.
Failure to Implement Corrective Action for Vaccination Screening and Education
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee did not implement corrective actions after identifying a problem with the lack of screening and education for influenza and pneumococcal vaccinations. During a QAPI review, the Administrator acknowledged that the issue had been recognized but confirmed that no steps had been taken to address the deficiency. Facility policy states that the Quality Assessment and Assurance (QAA) committee is responsible for identifying and responding to quality deficiencies, but in this instance, the committee failed to act on the identified concern regarding vaccination screening and education.
QAPI Committee Failed to Address Systemic Issues in Room Changes and Bowel/Bladder Program
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) Committee failed to adequately identify, develop, and implement plans of action for systemic issues related to resident room changes and the facility's bowel and bladder program. Specifically, the QAPI Committee began addressing resident notifications for room changes in May 2025, but did not revise corrective actions when it was found that notification sheets were not completed with reasons for the room changes. Additionally, while the QAPI Committee identified and developed a plan for the bowel and bladder program, the plan only included two-hour resident and bed checks, without further measures to address the program's effectiveness. These deficiencies were identified through observation, clinical record review, document review, and interviews.
Failure to Properly Screen, Educate, and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that all residents reviewed for immunizations were appropriately screened for eligibility to receive influenza and pneumococcal vaccines. Surveyors found that the facility did not consistently determine the correct vaccine for each resident, did not provide education regarding the specific vaccines for which residents were eligible, and did not ensure that informed consent forms were properly completed and signed. In several cases, residents who were eligible to receive influenza or pneumococcal vaccines did not consistently receive the vaccinations as required. Documentation was often incomplete or missing, with forms lacking critical information such as the type of vaccine offered, the date of administration, and evidence that the CDC Vaccine Information Statement (VIS) was provided. Multiple residents' records showed deficiencies in the consent process. Some residents or their representatives signed blank or incomplete consent forms, and in other cases, forms did not include documentation of eligibility screening, the specific vaccine offered, or confirmation that education was provided. For example, several residents' records included only a verbal consent or lacked any documentation of consent or declination. Additionally, some immunization records documented that vaccines were administered or refused without corresponding consent forms or eligibility screenings, and in some cases, the reason for vaccine refusal was not documented or dated. The facility's policies required annual documentation of consents and declinations, provision of the most current CDC VIS, and assessment for contraindications, but these procedures were not consistently followed. Residents with significant comorbidities, such as chronic heart failure, diabetes, end-stage renal disease, and chronic respiratory conditions, were among those affected by these documentation and process failures. The lack of proper screening, education, and documentation resulted in substandard quality of care and placed residents at increased risk for vaccine-preventable illnesses, as directly stated in the report.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
A deficiency was identified when the facility failed to obtain informed consent for psychotropic medications for one resident. The resident, who had diagnoses including bipolar disorder, depression, anxiety disorder, and dementia, was prescribed Sertraline, Quetiapine, and Buspirone for depression, bipolar disorder, and anxiety, respectively. Physician's orders and care plans documented the use of these medications for the resident's mental health conditions, but the clinical record did not contain psychotropic consent forms indicating that the resident or their representative had been informed of, and accepted, the medications, including their risks and benefits. During an interview, the DON confirmed that the resident was receiving these psychotropic medications daily without a completed consent form. Facility policy required that consent be obtained and documented for the use of psychotropic medications, including information about the intended benefits and potential risks, as well as confirmation of understanding from the resident or representative. The absence of these consent forms constituted a failure to ensure the resident was fully informed and had agreed to the treatment as required by facility policy and resident rights.
Inaccurate MDS Assessments for Diagnoses, Falls, and Medication Administration
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) 3.0 assessments for three residents, resulting in incomplete or incorrect documentation of diagnoses, events, and medication administration. For one resident with a history of bipolar disorder and depression, the MDS assessment did not document these psychiatric diagnoses, despite active physician orders and ongoing administration of Quetiapine Fumarate and Sertraline HCl for these conditions. Both the DON and MDS Coordinator confirmed that these diagnoses should have been included in the MDS to accurately reflect the resident's care needs. Another resident who experienced a fall resulting in a right hip fracture and subsequent hospital transfer had an MDS assessment that failed to indicate the occurrence of a fall, with Section J1800 incorrectly coded as 'No.' The MDS Coordinator acknowledged this error. Additionally, a third resident receiving Hydroxyzine HCl for anxiety was not documented as having received an antianxiety medication in the MDS assessment, despite clear physician orders and medication administration records. The MDS Coordinator confirmed the omission and the need for accurate MDS documentation to convey resident needs.
Failure to Complete PASARR Level 1 Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that an initial Preadmission Screening and Resident Review (PASARR) Level 1 was completed prior to the admission of a resident with multiple mental health diagnoses, including bipolar disorder, depression, anxiety disorder, and unspecified dementia. Upon review of the resident's clinical record, no PASARR Level 1 documentation could be located, and the only submission provided was from 2008, which was deemed inappropriate due to potential changes in the resident's diagnoses. The resident's care plan indicated the use of psychotropic medications for behavior management, mood swings, depression, and anxiety, further highlighting the need for proper screening. Interviews with facility staff revealed a lack of awareness and understanding regarding the necessity and purpose of the PASARR Level 1 screening. The Regional Director of Clinical Services and the Business Office Manager both confirmed that a current PASARR Level 1 was required for admission, and that the absence of this documentation meant the facility could not determine the appropriateness of the resident's placement. The facility's policy also required a PASARR Level 1 to be completed and retained in the resident's medical record prior to admission, which was not followed in this case.
Failure to Develop Baseline Care Plans for Mental Health and Foley Catheter Care
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents with specific care needs. For one resident with diagnoses of bipolar disorder, depression, anxiety disorder, and dementia, the baseline care plan did not address the care, treatment, or interventions required for the resident's mental health conditions, despite physician orders for medications to manage these diagnoses. The Director of Nursing confirmed that the care plan omitted these mental health diagnoses and acknowledged that including them would be beneficial for understanding and meeting the resident's care needs. For another resident admitted with urinary retention, benign prostatic hyperplasia, and chronic heart failure, the baseline care plan failed to specify the type of catheter in use and did not include appropriate interventions for Foley catheter care. Although the resident had a physician's order for an indwelling catheter and the Minimum Data Set documented its presence, the care plan used a placeholder instead of specifying the catheter type and lacked details such as type and size, care instructions, and monitoring for complications. Both the Director of Nursing and the Regional Director of Clinical Services confirmed these omissions and stated that the care plan should have included this critical information.
Failure to Develop Person-Centered Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for several residents with specific care needs. For one resident with a Foley catheter, the care plan did not specify the type of catheter, its size, or detailed interventions for catheter care, such as monitoring for pain, discomfort, or placement. The care plan used non-specific language and was not revised to reflect the resident's actual needs, despite facility policy requiring individualized care plans based on daily monitoring and assessment for complications. Two residents who were candidates for bowel and bladder retraining did not have individualized, measurable objectives or specific interventions documented in their care plans. Their care plans lacked resident-specific goals or preferences and did not include interventions such as scheduled toileting or timed voiding, even though assessments indicated these were appropriate. The interventions listed were generic, such as assisting with toileting as needed and providing pericare, without addressing the potential to maintain or restore continence. Another resident with chronic pain did not have all pain management interventions, particularly non-pharmacological methods, included in the care plan. Although physician orders and staff interviews indicated the use of both medication and non-medication interventions for pain, the care plan did not reflect these non-pharmacological strategies. Facility policy required that all interventions used to manage a resident's pain be documented in the care plan, but this was not done, resulting in incomplete care planning for pain management.
Expired CPR Certification for CNA
Penalty
Summary
A Certified Nursing Assistant (CNA) was found to have an expired cardiopulmonary resuscitation (CPR) certification, as documented in their personnel record. The Staff Development Coordinator, a Registered Nurse (RN), confirmed responsibility for ensuring all staff maintained required certifications and acknowledged that the CNA's CPR certification had expired. The CNA's job description, which was signed by the employee, required current CPR certification throughout employment. Additionally, the facility's CPR policy stated that employees providing care to residents must maintain current CPR certification. Despite these requirements, the CNA continued employment without current CPR training, as verified by record review and staff interview.
Failure to Maintain Communication and Documentation with Hospice Agency
Penalty
Summary
The facility failed to maintain communication with the hospice agency providing care to a resident who had been admitted with diagnoses including metabolic encephalopathy, incomplete paraplegia, and malignant neoplasm of the brain. The resident was admitted to hospice care for glioblastoma, and facility policy required that hospice nurse progress notes be placed in the resident's hospice binder after each visit. However, upon review, only one hospice nurse progress note was found in the binder, despite the expectation of weekly visits and corresponding documentation. Both the RN and the DON confirmed that these notes were essential for facility staff to stay informed about the resident's care and any changes in condition or physician orders. The DON stated that the Interdisciplinary Team (IDT) reviewed hospice patient care weekly, using the hospice nurse progress notes as a reference during meetings. The absence of these notes in the binder was not identified during these reviews, resulting in a lack of updated information regarding the resident's care from the hospice agency. The facility's own policy documented that the IDT was responsible for ensuring communication between the facility and hospice, but this process was not followed as required.
Failure to Assess and Address Bed Entrapment Risk
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards by not assessing and addressing the risk of entrapment for one resident. The resident, who had diagnoses including acute diastolic heart failure, muscle weakness, and cognitive communication deficit, was observed on two consecutive days with their bed positioned so that the right side was pushed up against an air conditioning unit, leaving a gap of approximately six to eight inches between the mattress and the window and wall. The headboard was also positioned about two feet away from the wall. These observations were confirmed by staff interviews, with the Registered Nurse unable to confirm if an entrapment risk assessment had been completed for the resident. A review of the clinical record revealed that there was no assessment to determine the resident's risk for entrapment. The Director of Nursing confirmed that the bed's position created a potential danger and that the resident had not been assessed for entrapment risk. Facility policy indicated that the environment should be free from accident hazards and that supervision and assistive devices should be provided to prevent avoidable accidents, but this was not followed in this instance.
Failure to Implement and Document Resident-Specific Bowel and Bladder Interventions
Penalty
Summary
The facility failed to ensure that evaluations for bowel and bladder retraining were used to select and implement resident-specific interventions to maintain or restore normal bowel and/or bladder function for two residents. For one resident admitted with pneumonia due to gram-negative bacteria, the Minimum Data Set (MDS) indicated the resident was always incontinent of both bladder and bowel, and no toileting program was attempted or in use. An evaluation determined the resident was a candidate for toileting and scheduled voiding, but the Director of Nursing (DON) confirmed that person-centered interventions were lacking, and it was unclear if rounding every two hours was appropriate or effective. The DON was also unable to determine if the resident's continence level changed during their stay. Another resident, admitted after digestive system surgery and with acute ischemia of the small intestine, reported frequent bowel incontinence and loose stools, requiring staff assistance for cleanup and expressing concern about attending appointments due to unpredictable bowel movements. The MDS showed frequent incontinence of both urine and bowel, with no toileting program attempted. An evaluation indicated candidacy for toileting and scheduled voiding, but the care plan only included general interventions such as assistance with toileting and pericare as needed. The Urinary Incontinence Tool was incomplete, missing information on medications, lab testing, cognitive patterns, referrals, and additional comments, despite the resident being on medications that could affect continence. Interviews with staff revealed that rounds were performed every two to four hours, and interventions to improve or maintain continence were limited to asking the resident about bowel movements. The DON acknowledged that resident-specific interventions were not documented, offered, or evaluated for effectiveness, and was unfamiliar with the use of the Urinary Incontinence Tool. Facility policy required individualized treatment and services for incontinence, but documentation and implementation of such interventions were lacking for both residents.
Failure to Monitor Weight Loss in Readmitted Resident
Penalty
Summary
A resident with a history of significant weight loss was readmitted to the facility following a hospitalization for enterocolitis due to clostridium difficile, cognitive and emotional deficits after a cerebral infarction, and type 2 diabetes mellitus. Upon review, it was found that the resident experienced a weight loss of 13.4 lbs (7.39%) between 04/11/2025 and 05/10/2025, and a further loss of 11 lbs (6.5%) by 5/30/2025. Despite this ongoing and severe weight loss, the facility did not obtain or document weekly weights for the resident after readmission, as required by facility policy. The Director of Nursing confirmed that the facility's policy mandates residents be weighed upon admission and then weekly for four weeks to establish baseline weight and monitor stability. The Registered Dietitian was aware of the resident's prior severe weight loss, but there was no documentation of continued weekly weight monitoring after the resident's return. This lack of monitoring prevented timely identification of further weight loss and the implementation of necessary interventions, constituting a failure to provide adequate nutritional monitoring for a resident at risk.
Failure to Assess and Document Tolerable Pain Level and Follow Pain Medication Orders
Penalty
Summary
The facility failed to determine and document a resident's tolerable level of pain and did not administer pain medication according to the physician's order for one resident. The resident, who had a history of chronic pain syndrome and recent surgery, reported experiencing severe pain that was not adequately managed. The resident stated that the facility was not providing the same amount of pain medication as previously used at home and described an incident where a nurse declined to administer the usual dose of pain medication due to low blood pressure, while still administering medication to lower blood pressure. The resident rated their pain as a ten on a 0-10 scale, which prevented mobility. Review of the resident's clinical records showed that the physician's orders specified different dosages of pain medication based on the resident's reported pain level. Despite orders for two tablets of Oxycodone for pain rated 7-10, the Medication Administration Record documented that only one tablet was administered on multiple occasions when the resident reported pain levels of seven or higher. There was no documentation that the physician was contacted regarding the resident's low blood pressure or to obtain approval for altering the pain medication dosage. Additionally, the clinical record lacked documentation of an assessment or determination of the resident's tolerable pain level. Interviews with nursing staff and the DON confirmed that pain assessments were conducted using a 0-10 scale and that the resident was able to communicate their pain level. The DON acknowledged that the resident's tolerable pain level should be determined and documented, and that the physician's orders for pain medication were not followed as written. The facility's policy and procedures required collaboration with the resident and physician to develop and document individualized pain management plans, including the resident's tolerable pain level, but this was not reflected in the resident's record.
Failure to Maintain Dialysis Communication Documentation
Penalty
Summary
The facility failed to maintain completed dialysis communication forms for three residents who required offsite dialysis services. For each of these residents, the clinical records lacked documented evidence of completed dialysis communication transfer forms for multiple dates when the residents attended dialysis treatments. The absence of these forms was confirmed by the Director of Nursing (DON) and the Regional Clinical Director (RDC), who acknowledged that the forms were either missing or not consistently placed in the residents' hard charts or electronic health records. One resident's order summary report did not include an order for renal dialysis or for care and assessment of the access port site, which meant that necessary assessments would not be entered onto the Treatment Administration Record (TAR) and would not alert nursing staff to perform or document these assessments. The DON confirmed that without these orders, the required assessments would not be completed or documented. Additionally, the facility's policy required ongoing communication and coordination between the facility and the dialysis center, including the initiation and maintenance of pre/post dialysis communication forms, which was not consistently followed. Interviews with nursing staff and review of facility policy further revealed that the expectation was for nursing staff to complete the communication form before transport to dialysis and upon the resident's return, and to ensure the form was returned and filed appropriately. The lack of completed and maintained communication forms was acknowledged by facility leadership, who confirmed that the available documentation was incomplete and not inclusive of all required communication for the residents' dialysis treatments.
Medications Administered Without Signed Physician Orders
Penalty
Summary
A deficiency was identified when a resident was administered medications without proper physician authorization, as the physician's orders were not signed and dated during a required visit. The resident in question had multiple complex diagnoses, including bipolar disorder, depression, anxiety disorder, unspecified dementia, and other medical conditions requiring a comprehensive medication regimen. The physician's orders included numerous medications and care directives, but the clinical record review revealed that these orders lacked the physician's signature and date at the time of the visit. Interviews with facility staff confirmed that the resident was receiving medications based on unsigned orders. The Regional Director of Clinical Services acknowledged that the physician had not electronically signed off on the orders, and the Registered Nurse confirmed that the orders were being communicated to the pharmacy and considered valid, despite the absence of a signature. The physician later admitted that it was their responsibility to access the electronic system and sign the orders, and confirmed that this had not been done for the resident in question. Facility policy required that medications and biologicals should only be administered upon the order of a physician or prescriber lawfully authorized to prescribe and treat human illness, with orders signed either in writing or electronically. The lack of a physician's signature and date on the orders meant that the medications were administered without proper authorization, constituting a failure to comply with facility policy and regulatory requirements.
Failure to Assess Psychosocial Impact of Room Change
Penalty
Summary
The facility failed to ensure that social services staff assessed the psychosocial impact of a room relocation for a resident who experienced a room change. The resident, admitted with a primary diagnosis of an unspecified nondisplaced fracture of the surgical neck of the right humerus, underwent a room change as documented in the facility's records. There was no documented evidence in the clinical record that an assessment by social services was completed regarding the impact of this room change on the resident's psychosocial status, as required by facility policy. During interviews, the resident reported being moved from their previous room after being told not to speak to their roommate, with whom they were friends, and expressed not wanting to move. The Licensed Social Worker confirmed responsibility for completing room change assessments but acknowledged that no assessment was completed at the time of the resident's relocation. Facility policy specifically required social services staff to assess the impact of room relocations on residents' psychosocial status, but this was not followed in this instance.
Expired and Unlabeled Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that expired medications were not removed from two out of three medication carts inspected. Specifically, a box of Cranberry capsules with an expiration date of 01/2023 and a box of Probiotic capsules with an expiration date of 02/2025 were found on one cart. On another cart, a box of Probiotic capsules with an expiration date of 02/2025 and a bottle of ProSource Plus protein supplement with an illegible expiration date were found. These findings were confirmed by the Assistant Director of Nursing (ADON) and a Registered Nurse (RN), who acknowledged that the medications were expired or lacked a legible expiration date and should not have been available for administration. The Director of Nursing (DON) confirmed that facility policy requires all medications to be labeled with the resident's name, frequency of administration, and an expiration date, and that expired medications should be removed immediately from medication carts and storage areas. The DON also stated that failure to remove expired medications could result in their administration to residents. The facility's policy on the disposal and destruction of expired or discontinued medications requires such items to be placed in a designated, secure location for destruction.
Failure to Complete Required Background Check for Medical Records Director
Penalty
Summary
The facility failed to comply with Nevada Revised Statute (NRS) 449.174 by not ensuring that a Medical Records Director (Non-Nurse) had completed fingerprinting and received clearance through the Nevada Automated Background System (NABS) before accessing resident records. The Medical Records Director had been assisting with the coding of resident records for several months and had entered multiple diagnoses into a resident's clinical record. Review of the personnel file for this employee revealed no documented evidence of fingerprinting or background check clearance. The Administrator confirmed that the Medical Records Director had accessed resident records without the required NABS clearance and stated unawareness of the state requirement for background checks for skilled nursing employees. The employee's job description indicated a responsibility to perform duties in accordance with applicable laws and regulations, and facility policy required background checks for all employees, including those providing services on behalf of the facility. The deficiency was identified through clinical and personnel record review, document review, and interviews.
Failure to Notify State Agency of Change in DON
Penalty
Summary
The facility failed to provide written notification to the State Agency (SA) regarding a change in the Director of Nursing (DON), as required by both regulation and facility policy. Document review showed that the DON was hired on 10/07/2024, but the Administrator confirmed during interview that no written notice was sent to the SA at the time of the change. The Administrator stated unawareness of the requirement to notify the SA. A letter formally notifying the SA of the DON change was only prepared and dated on 07/01/2025, well after the DON's start date. Facility policy specifies that written notice must be provided to the SA in advance or at the time of such changes, including the identity of the new individual and the effective date.
Failure to Maintain Required QAPI Committee Membership and Attendance
Penalty
Summary
The facility failed to maintain the required membership and attendance for its Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement (QAPI) committee. Document review showed that the QAPI committee was missing required members, specifically the Director of Nursing (DON) and the Medical Director (MD), at multiple meetings. Sign-in sheets for several meetings confirmed that the DON was absent from all meetings between July 2024 and January 2025, and the MD was absent from meetings between January and April 2025. The facility's own policy requires the QAPI committee to include, at a minimum, the DON, MD or designee, Administrator, Infection Preventionist, and at least two other staff members. The Administrator confirmed that the required members were not present at the identified meetings. No information about residents or their medical conditions is included in the report, and the deficiency is based solely on committee composition and attendance as documented and confirmed by facility leadership.
Catheter Bag Found on Floor in Violation of Infection Control Protocols
Penalty
Summary
A deficiency was identified when a resident with a history of urinary retention, benign prostatic hyperplasia, and chronic heart failure was observed seated in a wheelchair with their urinary catheter bag resting on the floor. The resident had an active bladder infection and was being treated with antibiotics at the time. The facility had a physician's order for an indwelling catheter with instructions for care, including maintaining a closed system unless clogging or dislodgement occurred. Interviews with an LPN and the Director of Nursing confirmed that catheter bags are required to be kept off the ground at all times to prevent contamination and infection. Facility policies also specified that catheter tubing and drainage bags should not be placed on the floor to reduce the risk of contamination and catheter-associated urinary tract infections. Despite these protocols, the resident's catheter bag was found on the floor, indicating a failure to adhere to established infection control procedures.
Facility Assessment Lacked Required Training Frequency Documentation
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately documented the training requirements for all direct care staff. Specifically, the Facility Assessment completed on 05/30/2025 listed required training topics and the staff groups to be trained but did not include documentation of the frequency for these trainings. During interviews, the Administrator confirmed that the Facility Assessment was current and acknowledged that it did not specify how often staff needed to be trained, despite this being a requirement. Additionally, the Administrator stated that only Facility Leadership was required to complete QAPI training, not all staff, and was unaware of the requirement for broader staff participation in this training. The facility's policy, reviewed on 05/06/2025, requires the Facility Assessment to be updated with training requirements to meet resident needs and regulatory standards. However, the lack of documentation regarding training frequency and incomplete identification of required staff for certain trainings resulted in a deficiency. There is no mention of specific residents or their conditions in relation to this deficiency.
Failure to Protect Resident Health Information at Nursing Station and Medication Cart
Penalty
Summary
The facility failed to safeguard resident-identifiable information in accordance with accepted professional standards. On one occasion, a consultation report containing patient information was left upright and exposed on the counter of the 200-hall nursing station, making it visible to anyone passing by. An LPN later confirmed the report contained resident information and acknowledged it should have been covered or flipped over to prevent unauthorized viewing. Additionally, a computer screen on a medication cart in the 100-hallway was observed displaying medication information for a resident while unattended. An LPN confirmed the computer was left on and displaying resident information, stating that the screen should have been locked to prevent exposure. The Staff Development Coordinator also confirmed that resident documentation should not be left exposed and that medication cart computers should be locked when unattended, as per facility policy.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the outside receptacle area in a sanitary condition, as observed on two separate occasions. On the first observation, the area was found to have an accumulation of leaf debris and medical care gloves. The receptacle container was leaking, resulting in a dried puddle of liquid waste on the cement. Additionally, a wet liquid puddle was present in the corner of the gated area, with an unidentified source. The Certified Dietary Manager (CDM) acknowledged the need for cleaning but could not identify the source of the liquid. On a subsequent observation, the conditions remained unchanged, with the addition of a thickened substance forming in the liquid puddle, accompanied by a foul odor and the presence of flies. The Maintenance Assistant later identified the source of the thickened liquid as a leak from the air conditioner, suggesting that the water mixed with oil from underneath the leaking trash compactor. The facility's policy on garbage and refuse disposal, which mandates cleanliness and the absence of foul odors, was not adhered to, resulting in this deficiency.
Failure to Implement Bowel and Bladder Program
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the absence of a process to ensure bowel and bladder assessments were completed upon admission. This deficiency resulted in the lack of a bowel and bladder retraining program for residents who were candidates for such a program. The Director of Nursing (DON) acknowledged the importance of continence for residents' quality of life and the risks associated with incontinence, such as urinary tract infections and skin breakdown. However, the DON was uncertain about the last implementation of a bowel and bladder program, noting that no such program had been in place during their one-year tenure at the facility. The Regional President confirmed that the QAPI committee had not recognized the absence of a bowel and bladder program. The discontinuation of the Restorative Nurse Aide (RNA) program during the COVID-19 pandemic contributed to this oversight, as it had not been reinstated. The Regional President suggested that the facility could have identified this deficiency through audits, such as reviewing resident admission assessments. The facility's QAPI plan emphasized a resident-centered approach and a proactive, data-driven strategy to improve residents' quality of life and care, yet it failed to address this critical aspect of resident care.
Failure to Implement Bowel and Bladder Programs
Penalty
Summary
The facility failed to complete bowel and bladder assessments upon admission for 12 of 24 sampled residents, which is crucial for determining candidacy for a bowel and/or bladder retraining program. This oversight was confirmed by the Director of Nursing (DON) and was evident in the clinical records of residents who were admitted with various diagnoses, such as infections, fractures, and respiratory issues. The Minimum Data Set (MDS) assessments for these residents indicated that trials of toileting programs had not been attempted, and the residents were consistently incontinent of bladder and/or bowel. The lack of documented evidence of bowel and bladder evaluations on admission highlights a significant gap in the facility's admission process. Additionally, the facility did not offer a bowel and bladder retraining program to residents who were assessed as candidates for such programs. This affected 10 of the 24 sampled residents, who had been evaluated and identified as suitable for toileting and timed or scheduled voiding. Despite this, the facility did not implement the necessary programs to manage their incontinence. Interviews with staff and residents revealed that some residents, who were initially continent or had the potential to maintain continence, were not provided with appropriate alternatives to incontinence briefs, leading to a decline in their continence status. The facility's policies on urinary incontinence management and incontinence management were not followed, as confirmed by the DON. The policies required comprehensive assessments and the implementation of appropriate bladder retraining programs, which were not conducted. The DON acknowledged the absence of a bowel and bladder program since their tenure began, and evaluations were not consistently completed for all residents marked incontinent on admission assessments. This lack of adherence to policy and procedure contributed to the deficiency in providing adequate care for residents' continence needs.
Inaccurate Controlled Drug Records in Medication Carts
Penalty
Summary
The facility failed to ensure that Controlled Drug Records (CDR) were accurately completed for two of three inspected medication carts, affecting eight of 24 sampled residents. This deficiency was identified through observation, clinical record review, interviews, and document review. The discrepancies were found in the medication counts documented in the CDRs compared to the actual number of medications available in the carts. For instance, Resident #96's CDR indicated eight tablets of tramadol were available, but only seven were present. Similar discrepancies were noted for other residents, including incorrect counts for medications such as clonazepam, lacosamide, tramadol, Lyrica, hydrocodone-acetaminophen, and oxycodone. The issue was confirmed by the Staff Development Coordinator RN (SDC RN) and other nursing staff, who acknowledged that the documented counts did not match the actual medication counts. The SDC RN explained that nurses are expected to document the amount of each medication remaining at the time of removal from the medication cart and before administration to ensure accurate accounting and prevent medication diversion. However, the failure to document accurately led to discrepancies in the medication counts, which could not be reconciled. The facility's policy, titled Medication Storage and Administration Quick Reference Guide, requires that the controlled medication count record be documented at the time the dose is removed and prior to administration. Despite this policy, the failure to adhere to these procedures resulted in inaccurate CDRs, as confirmed by the SDC RN and other staff members. This deficiency highlights a lapse in the facility's medication management practices, particularly in maintaining accurate records of controlled substances.
Failure to Repair Bed Controls Causes Resident Distress
Penalty
Summary
The facility failed to ensure that the bed controls for Resident #94 were in working order and that the resident was physically able to operate them. This deficiency resulted in emotional distress and increased pain for the resident. Resident #94, who was admitted with multiple diagnoses including type II diabetes mellitus, difficulty in walking, and age-related debility, experienced significant discomfort due to the malfunctioning bed controls. Despite multiple repair requests documented in the facility's maintenance log, the bed controls remained non-functional, causing the resident to suffer from back pain and emotional distress. On several occasions, Resident #94 expressed frustration and pain due to the inability to adjust the bed independently. The resident reported that staff occasionally assisted by resetting the bed control, but the issue persisted, and the resident was unable to fix it independently. The resident's pain was exacerbated by the inability to reposition the bed, leading to a pain level of 10 out of 10 on the pain scale. The resident also expressed feelings of anger and depression due to the situation and the perceived lack of response from the facility staff. The Director of Nursing (DON) acknowledged that the bed should have been replaced to address the resident's comfort and pain concerns. Despite the resident's repeated requests and the facility's policy on servicing medical equipment, the bed control issue was not resolved, and the resident continued to experience significant pain and emotional distress. The facility's failure to address the malfunctioning bed controls violated the resident's rights to a comfortable and safe environment, as outlined in the facility's policy on resident rights.
Failure to Document and Communicate Resident Transfer Information
Penalty
Summary
The facility failed to provide the required documentation for the discharge of a resident who was emergently transferred to an acute care hospital. The deficiency involved a resident who was admitted to the facility with multiple diagnoses, including acute and chronic respiratory failure, chronic obstructive pulmonary disease, acute pulmonary edema, and asthma. On the day of the incident, the resident was found in distress with a low oxygen saturation level of 67%, which improved to 88% after being placed on a non-rebreather mask with oxygen. The resident was then transferred to the hospital by paramedics. The facility's policy required that an e-Interact form, which is used to communicate essential care information between facilities, be completed and sent with the resident during transfers. However, the Director of Nursing confirmed that the resident's clinical record lacked evidence of this form or any other method of communication being provided to the hospital. This failure to document and convey necessary information during the transfer was a violation of the facility's policy and federal guidance, which mandates that all pertinent information be communicated to the receiving healthcare provider.
Failure to Submit PASRR Level II for New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to submit a Pre-Admission Screening and Annual Resident Review (PASRR) Level II evaluation for a resident who was readmitted with a new diagnosis of schizophrenia. This oversight was identified during a review of records, interviews, and document analysis. The resident, who had been admitted and readmitted multiple times, had a history of acute and chronic respiratory failure with hypoxia and bipolar disorder. Upon the most recent readmission, schizophrenia was added to the resident's diagnoses, but the PASRR Level II evaluation was not completed as required. The Director of Nursing (DON) and the Business Office Manager (BOM) confirmed that the PASRR process was not followed correctly. The DON explained that the Medical Records team entered diagnoses based on the History and Physical (H&P) from the sending facility, while the BOM stated that PASRRs were reviewed after diagnoses were entered into the clinical record. Despite this process, the necessary PASRR Level II submission was not made for the resident's new diagnosis of schizophrenia. The facility's policy required referrals for Level II reviews upon significant changes in status, but this was not adhered to in this case.
Oxygen Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen as ordered for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and dependent on supplemental oxygen. The resident was admitted with a physician's order for oxygen to be administered at four liters per minute (LPM) via nasal cannula (NC) continuously. However, observations on two separate occasions revealed that the resident was receiving oxygen at higher rates than prescribed: six LPM on one occasion and five LPM on another. A registered nurse confirmed that the oxygen flow did not match the physician's order, and the Director of Nursing (DON) acknowledged that the nursing staff did not follow the physician's order. The DON stated that if the resident required an increased amount of oxygen, the nursing staff should have assessed the resident and obtained a new physician order. The facility's policy on oxygen administration emphasized the need for adherence to specific liter flow orders for residents requiring respiratory care.
Failure to Conduct Timely Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) received an annual performance evaluation as required. Employee #13, who was hired on October 11, 2022, did not have a performance evaluation completed by their anniversary date in October 2023. The only performance review documented for Employee #13 was dated March 8, 2024. During an interview, the Staff Development Coordinator confirmed the absence of a timely performance evaluation for Employee #13. The Director of Nursing stated that it was a corporate directive to conduct performance reviews for all CNAs annually in April. The facility's policy on performance evaluations, reviewed in December 2023, also required annual reviews for all associates.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications, as observed during an inspection of medication carts and a resident's room. In the Station Two Medication Cart, a loose, unidentified pill was found in the controlled substance drawer, and the RN assigned to the cart could not identify the medication or its owner. Additionally, the Station Two Back Hall Medication Cart contained unlabeled medications, including two albuterol sulfate inhalers and ampules of ipratropium bromide/albuterol sulfate inhalation solution. The Staff Development Coordinator RN confirmed these medications should have been labeled before being placed in the cart to ensure correct administration and prevent expired medications from being used. In the case of a resident with end-stage renal disease, a white, unknown pill was found unsecured on the resident's side table. The resident indicated the pill had not been there long, and two CNAs did not address the unsecured medication upon entering the room. An RN later confirmed the pill's presence and acknowledged that it was unacceptable to leave medications unattended and unsecured. The resident's clinical record lacked a physician's order for self-administration of the medication, and the Director of Nursing emphasized the expectation for nurses to observe residents taking their medications and not leave them unsecured. The facility's policy required staff to remain with residents until medications were swallowed and prohibited leaving medications at the bedside.
Failure to Document Administration of Skin Protective Ointment
Penalty
Summary
The facility failed to complete Treatment Administration Records (TAR) for the administration of a skin protective ointment for one of the sampled residents. The resident, who was admitted with a diagnosis of paraplegia, had a physician's order dated May 15, 2024, for the application of skin protective ointment to the perianal area at each brief change, to be confirmed every shift. However, the TAR for this resident, dated May 20, 2024, and June 26, 2024, lacked documented evidence that the ointment had been administered as per the physician's order. On August 1, 2024, the Director of Nursing (DON) confirmed the absence of documentation in the TAR for the specified dates. The DON stated that it was expected for nursing staff to document in the resident's clinical record immediately upon administration of a medication or treatment. The facility's policy on documentation, although undated, required that the administration of medications and treatments be documented as soon as possible in the resident's electronic health record to ensure accuracy and reflect ongoing care.
Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic wounds, leading to a deficiency in infection prevention and control. Resident #26, who was admitted with diagnoses of unspecified open wounds on the abdominal wall and right thigh, had been receiving wound care as per physician's orders. Despite the presence of chronic, non-healing wounds, the resident's room lacked EBP signage and a Personal Protective Equipment (PPE) cart, which are essential components of EBP to prevent the spread of infection. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that EBP should have been in place for Resident #26. The Infection Preventionist (IP) also acknowledged that EBP is necessary for residents with extensive wound care or open wounds to reduce the transmission of Multi-Drug Resistant Organisms (MDROs). The facility's policy on EBP, reviewed in June 2024, mandates the use of gown and glove during high-contact resident care activities for residents with wounds, which was not adhered to in this case.
Failure to Maintain a Clean Environment Due to Roommate's Behavior
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for a resident due to the actions of their roommate. The resident, who was admitted with serious health conditions including spontaneous bacterial peritonitis and severe protein-calorie malnutrition, was subjected to an unsanitary living situation. The roommate, diagnosed with unspecified dementia and other mental health issues, exhibited behaviors such as urinating in inappropriate places, including the garbage can and on the floor. Despite documentation of these behaviors over several months, the facility did not effectively address the issue, leading to the resident's request for a room change. The facility's records show multiple instances of the roommate's inappropriate behavior, with notes indicating urination in the garbage can and on the floor, as well as defecation in bed. Staff, including a CNA and the DON, acknowledged these behaviors and attempted to monitor and redirect the roommate. However, the facility's failure to promptly and effectively manage the situation resulted in a violation of the resident's right to a clean and comfortable environment, as outlined in the facility's policy on resident rights.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to coordinate care for a resident with a terminal prognosis who was under hospice care. The resident was admitted with serious health conditions, including spontaneous bacterial peritonitis, sepsis, and severe malnutrition. Despite being under hospice care, the facility did not maintain any hospice records on-site, and there was no clear communication or documentation process between the facility and the hospice provider. The Licensed Social Worker, who was the hospice coordinator, did not review hospice documentation and was unaware of who was responsible for this task. The Executive Director acknowledged the lack of communication and documentation, which was contrary to the hospice care agreement and facility policy. The facility's failure to maintain hospice documentation and coordinate care was confirmed by multiple staff members, including the Medical Records Director and a Registered Nurse. The facility did not have a plan of care, hospice orders, or any documentation from the hospice agency for the resident. The Executive Director later received only four documents from the hospice agency, which were insufficient to ensure proper coordination of care. The hospice care agreement and facility policy required documented communication to address and meet the resident's needs, which was not adhered to in this case.
Failure to Stock Hand Washing Sink with Disposable Towels
Penalty
Summary
The facility failed to ensure that a hand washing sink in the kitchen was stocked with disposable hand towels, which is a requirement for maintaining proper hand hygiene. On March 13, 2024, at 9:30 AM, it was observed that the hand washing sink near the walk-in refrigerator in the kitchen did not have disposable hand towels in the wall dispenser. This was confirmed by a staff member at 9:35 AM, who stated that the hand towels had not been stocked for a couple of days. The Executive Director also confirmed at 9:41 AM that the dispenser was empty and acknowledged that it should have been stocked to ensure proper hand hygiene. The facility's policy, reviewed on June 4, 2023, requires all sinks to be well stocked with paper towels for hand washing.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
