Life Care Center Of South Las Vegas
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 2325 E. Harmon Ave., Las Vegas, Nevada 89119
- CMS Provider Number
- 295076
- Inspections on file
- 26
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of South Las Vegas during CMS and state inspections, most recent first.
The facility failed to secure medications in a central supply room, which was found propped open and accessible. Two unlocked medication carts containing various medications and supplements were observed. Staff confirmed the room should have been locked to prevent unauthorized access, as per facility policy.
A facility failed to document a nutritional assessment and food preferences for a resident admitted with lupus and mild kidney injury. Despite a physician's order for a regular diet, there was no record of food preferences. The Dietary Director indicated that dietary staff should document preferences within 24 hours, but this was not done. The facility's policy required a visit within 72 hours to obtain preferences and complete the nutrition assessment.
A resident with dementia and a history of cholecystectomy experienced a fall, and the facility failed to implement a comprehensive care plan for fall management. Although a physical therapy consultation was suggested, it was not conducted, and the necessary screening and evaluation were delayed for seven weeks, contrary to the facility's policy.
A facility failed to provide scheduled showers to dependent residents, affecting three individuals with conditions such as dementia and hemiplegia. Despite care plans indicating the need for substantial assistance with bathing, there was no documentation of completed showers or refusals on scheduled dates. The facility's policy required assistance for activities of daily living, but this was not adhered to, resulting in a deficiency in hygiene care.
A resident was admitted with a urinary catheter without sufficient medical justification, as the diagnosis of benign prostatic hyperplasia (BPH) alone was not adequate for catheter placement. The resident's medical record lacked documentation of a bladder training program or justification for the catheter's use. The DON acknowledged the deficiency, noting that the facility's policy required a determined need and medical indication for catheter use, which was not met in this case.
A facility failed to follow a physician-ordered fluid restriction for a dialysis-dependent resident with end-stage renal disease and cardiac conditions. Despite a prescribed limit of 1000 ml per day, the resident had access to excess fluids, including a full water pitcher and other beverages. Staff were unaware of the restriction, and the care plan did not reflect it, leading to a lack of monitoring and documentation of fluid intake. The facility's policies required adherence to such orders, but these were not followed, posing a risk of fluid overload.
A facility failed to account for narcotics signed out for a resident, risking delayed pain management. The resident had a prescription for Hydrocodone-Acetaminophen, but the narcotic log was missing for several months, and discrepancies were found between the log and the MAR. Staff interviews revealed that the expected procedure was not followed, leading to the deficiency.
A resident with end-stage renal disease and dependence on dialysis continued to receive Spironolactone, a contraindicated medication, despite a pharmacist's recommendation and physician's agreement to discontinue it. The medication administration record showed the medication was still active, and an LPN confirmed its administration. The DON explained the process for medication review, but the order was not discontinued, indicating a failure in the facility's process.
A facility failed to maintain a medication error rate below five percent, with an observed rate of 7.41%. During a medication pass, an LPN administered incorrect dosages to a resident with chronic kidney disease and neuropathy, failing to give the prescribed amount of Gabapentin and omitting Oxybutynin, despite it being documented as given. The DON confirmed the expectation for nurses to verify medication orders and adhere to the five rights of medication administration.
The facility failed to properly label and date stored foods, and did not adhere to appropriate storage practices, posing potential health risks. Observations revealed unlabeled and undated food items in the freezer and cooler, and employee drinks stored improperly. The facility's Food Safety guidelines were not followed.
The facility failed to ensure a safe discharge for two residents, leading to potential placement in inappropriate settings without necessary care. For one resident, there was no documentation of group home evaluation or family agreement, and key staff were uninvolved. Similarly, the second resident's discharge lacked documentation of family involvement and group home details, with key staff again uninvolved.
Unsecured Medication Storage in Central Supply Room
Penalty
Summary
The facility failed to ensure the security of medications in one of its central supply rooms, which was observed to be unsecured. On the specified date, the central supply room door was found propped open with a dumbbell, allowing unauthorized access. Inside the room, two medication carts were found unlocked, with keys hanging from one of the cart locks. The carts contained various medications and nutritional supplements, including Vitamin C, Benadryl, Omeprazole, and Nexium, among others. An Occupational Therapy student was able to enter the room to retrieve supplies, indicating that the room was accessible to individuals who should not have had access. Interviews with facility staff, including an LPN and a Licensed Nurse, confirmed that the central supply room was supposed to remain locked to prevent unauthorized access to medications and supplies. The Director of Nursing also verified that the room contained over-the-counter medications and wound care supplies and emphasized the importance of keeping the room locked to prevent residents and family members from accessing the medications. The facility's policy on the storage of medications and biologicals, revised in August 2023, mandates that all medications be securely stored in locked compartments, which was not adhered to in this instance.
Failure to Document Nutritional Assessment and Food Preferences
Penalty
Summary
The facility failed to complete a nutritional assessment, including food preferences, within 72 hours of admission for one of the sampled residents. Resident 2, who was admitted with diagnoses including lupus and mild kidney injury, did not have documented nutritional assessment or food preferences in their medical record. A physician's order indicated a regular diet with regular texture and thin liquid consistency, but there was no documentation of food preferences. The Dietary Director stated that dietary staff should meet with newly admitted residents within 24 hours to obtain food preferences, which should be documented in the medical record. However, a staff member from medical records confirmed that Resident 2's medical record lacked this documentation. The facility's policy required the Director of Food and Nutrition Services, Registered Dietician, or designee to visit residents within 72 hours of admission to obtain food and beverage preferences and complete the electronic nutrition assessment.
Failure to Implement Comprehensive Fall Management Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for the management of falls for one resident, identified as Resident 50, who had a history of cholecystectomy and dementia. The resident experienced a fall on March 10, 2024, and the care plan was revised on the same day to address the fall, including goals and interventions. However, the care plan lacked implementation for monitoring and managing the resident's fall risk. A physical therapy consultation was suggested in the care plan to assess the resident's strength and mobility, but this was not carried out. The Director of Rehabilitation explained that when a therapy screening is suggested, it should be scheduled and completed promptly, with documentation stored in the facility's electronic system and a hard copy in therapy. However, there was no record of a screening for this resident. The Director of Nursing confirmed that a screening was requested in the care plan dated March 10, 2024, and stated that it should occur within 3 to 5 business days, ideally within 72 hours. Despite this expectation, the screening and evaluation had not been conducted for seven weeks, indicating a failure to adhere to the facility's fall management policy, which requires monitoring and modifying care plans as necessary.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to ensure scheduled showers were provided to dependent residents, affecting one sampled resident and two unsampled residents. Resident 246, who was admitted with dementia and muscle weakness, was observed to have received only one shower since admission, with no sponge or bed baths provided during missed showers. The resident's care plan required substantial assistance for activities of daily living, including bathing, but there was no documented evidence of a completed shower or refusal on the scheduled date. Resident 215, admitted with dementia and fractures, also did not receive scheduled showers or bed baths on multiple occasions in November 2023. The resident's medical records lacked documentation of any refusal, and the Director of Staff Development confirmed the absence of records for the scheduled showers. The resident required substantial assistance for bathing, as indicated in the assessment, but the facility failed to provide the necessary care. Resident 213, who had hemiplegia and required maximal assistance with bathing, did not receive scheduled showers or baths on several dates in November and December 2023. The ADL flowsheet lacked documentation of showers or baths, and there was no record of refusal. The facility's policy required assistance for residents unable to perform activities of daily living, but the facility did not adhere to this policy, resulting in a deficiency in providing necessary hygiene care.
Inadequate Justification and Care for Urinary Catheter Use
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a urinary catheter, leading to a deficiency. Resident 203 was admitted with a diagnosis of benign prostatic hyperplasia (BPH) without lower urinary tract symptoms and had an indwelling catheter. The resident was unable to explain the need for the catheter, and the medical record lacked documentation of a bladder training program or justification for the catheter's use. The Director of Nursing (DON) acknowledged that BPH alone was not a sufficient diagnosis for catheter placement and that the diagnosis should be associated with urinary retention. The facility's policy required a determined need and medical indication for catheter use, and residents with indwelling catheters should be assessed for removal as soon as possible. However, these protocols were not followed for Resident 203.
Failure to Adhere to Fluid Restriction for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to adhere to a physician-ordered fluid restriction for a dialysis-dependent resident, identified as Resident 14, who was diagnosed with end-stage renal disease and other cardiac conditions. The physician's order specified a daily fluid restriction of 1000 ml, with specific allocations for meals and nursing shifts, and required documentation of the resident's fluid intake. However, observations revealed that Resident 14 had access to a water pitcher containing approximately 1000 ml, along with other beverages such as soda and smoothies, which exceeded the prescribed fluid limit. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and Certified Nursing Assistants (CNAs), indicated a lack of awareness and communication regarding Resident 14's fluid restriction. The CNAs were unaware of the fluid restriction and continued to provide a full water pitcher throughout the day. The LPN confirmed the presence of excess fluids at the resident's bedside and expressed concerns about the lack of monitoring and documentation of fluid intake. The facility's Registered Dietitian (RD) and the dialysis center's RD both confirmed the necessity of the fluid restriction due to the resident's significant fluid retention and risk of complications. The facility's policies required adherence to physician orders and monitoring of fluid intake for residents on dialysis. Despite these policies, the care plan for Resident 14 did not reflect the fluid restriction, and staff failed to monitor and document the resident's actual fluid consumption. The Director of Nursing (DON) acknowledged the need for care planning and education regarding the resident's non-compliance with fluid restrictions, which posed a risk of fluid overload.
Failure to Account for Narcotics in Controlled Drug Record
Penalty
Summary
The facility failed to properly account for narcotics signed out on the controlled drug record for a resident, which had the potential to delay pain management and increase the risk for harm. The resident, who had been admitted with conditions including hemiplegia and hemiparesis following a cerebral infarction, had a physician's order for Hydrocodone-Acetaminophen to be administered as needed for moderate pain. However, the facility could not locate the narcotic log for several months, and the available records showed discrepancies between the narcotic log and the Medication Administration Record (MAR), indicating that the medication was signed out but not documented as administered. Interviews with facility staff, including the Assistant Director of Nursing (ADON), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), revealed that the expected procedure was for nurses to document in the narcotic log every time a narcotic was pulled from stock and to reconcile this with the MAR. The facility's policy required maintaining a system for accounting controlled medications and conducting periodic reconciliations. However, the failure to maintain accurate records and reconcile the narcotic log with the MAR led to the deficiency identified by the surveyors.
Failure to Discontinue Contraindicated Medication
Penalty
Summary
The facility failed to ensure that a physician's order to discontinue a medication was completed for one of the sampled residents, leading to the potential for adverse effects and unnecessary medication administration. Resident 14, who was admitted with end-stage renal disease and dependence on renal dialysis, was prescribed Spironolactone, a medication contraindicated for individuals on dialysis. A pharmacist reviewed the resident's medication regimen and recommended discontinuing Spironolactone on July 23, 2024. The physician agreed with this recommendation and indicated that the medication would be discontinued on July 29, 2024. Despite the physician's agreement to discontinue the medication, the medication administration record showed that Spironolactone was still active, with the most recent dose given on August 8, 2024. An LPN confirmed that the resident was still receiving the medication. The Director of Nursing explained the process for pharmacist review and noted that the Unit Manager was responsible for ensuring that physician responses were documented and acted upon. However, the Spironolactone order was not discontinued as recommended, indicating a failure in the facility's process to prevent unnecessary medication administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a medication administration pass observation that revealed a 7.41% error rate. During the observation, 27 medication administration opportunities were noted, with two errors identified. One of the errors involved a resident who was prescribed Gabapentin 100 mg, two capsules to be taken three times a day for neuropathy, but was only administered one capsule. Additionally, the resident was supposed to receive Oxybutynin 5 mg, which was not administered, although it was documented as given in the Medication Administration Record (MAR). The resident involved had a medical history that included chronic kidney disease, acute kidney failure, and polyneuropathy. The Licensed Practical Nurse (LPN) responsible for the medication pass confirmed the errors, acknowledging that the correct dosage of Gabapentin and the Oxybutynin were not administered as per the physician's orders. The Director of Nursing (DON) indicated that nurses are expected to verify the five rights of medication administration, including the right dosage and medication, and to check the MAR and physician's orders before administering medications. The facility's policy on medication administration emphasizes the importance of adhering to physician orders to ensure safe and appropriate medication administration.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of stored foods, as well as appropriate storage practices, which posed a potential risk to safety and health standards. During an observation on August 6, 2024, open bags of green beans, asparagus, and peppers & onion mix were found in the walk-in freezer without any indication of when they were opened. Additionally, a bottle of lemon juice, Jello packets, and canned pimentos in the dry storage area were missing received-on dates, and a milk substitute was stored in the reach-in cooler without a lid. The Dietary Manager acknowledged that these items should have been dated and properly stored. Further observations on August 7, 2024, revealed a jug of pink liquid in the reach-in cooler without a label or date, and employee drinks were improperly stored in the same cooler. Additionally, cookie dough ice cream was found in a container of cookie dough in the ice cream shop's reach-in freezer, with the Activity Director unable to explain how it got there. The facility's Food Safety document, reviewed on May 1, 2024, outlined proper food storage and labeling procedures, which were not followed in these instances.
Failure to Ensure Safe Discharge for Two Residents
Penalty
Summary
The facility failed to ensure a safe discharge for two unsampled residents, R214 and R219, which could have resulted in them being placed in inappropriate home settings without the necessary care. For Resident 214, the discharge process was inadequately documented. Although the discharge summary indicated that the resident was cleared for discharge to a group home with home health services, there was no evidence that a representative from the group home evaluated the resident, nor was there documentation of the resident's or family's agreement to the discharge plan. Additionally, the Case Manager and Director of Social Services were not involved in the discharge process, and the former Social Worker who handled the case was no longer employed at the facility. Similarly, for Resident 219, the discharge process lacked proper documentation and involvement of key personnel. The resident was discharged to a group home, but there was no record of the spouse's involvement in the discharge process or confirmation that the group home representative evaluated the resident. Furthermore, the resident's file did not contain the address of the group home or its name. The Case Manager and Director of Social Services were also not involved in this discharge, and the former Social Worker was no longer with the facility. The facility's discharge policy, which requires resident and representative involvement and documentation of referrals, was not adhered to in these cases.
Latest citations in Nevada
Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
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