Marquis Care At Centennial Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 6351 N Fort Apache Rd, Las Vegas, Nevada 89149
- CMS Provider Number
- 295089
- Inspections on file
- 21
- Latest survey
- June 27, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Marquis Care At Centennial Hills during CMS and state inspections, most recent first.
A facility failed to update discharge instructions and notify the physician of changes in a resident's discharge plan, potentially affecting the continuation of care. The resident, with multiple diagnoses including a pressure ulcer, was discharged with instructions for home health services. However, the family canceled these services, opting to manage care themselves, which was not communicated to the physician. Staff confirmed the oversight, noting the discharge instructions were not updated as required by facility policy.
A facility failed to document wound care treatments for a resident with an unstageable pressure ulcer, as required by physician's orders. The TAR lacked evidence of treatments on two occasions, and interviews with the wound care nurse and DON confirmed the absence of documentation. Facility policy mandates recording wound care details, but the lack of documentation left the treatments unverified.
A facility failed to document the removal of a midline catheter and perform a site assessment for a resident upon discharge. The resident had a physician's order to discontinue the midline after completing an IV medication regimen, but the medical record lacked evidence of the removal and assessment. A nurse stated that such documentation should have been included in the progress notes, and the DON confirmed it should have been recorded on the MAR.
A facility failed to accurately assess and obtain proper consent for the use of bilateral mitten restraints on a resident with cognitive impairments. The resident, who was nonverbal and confused, was observed with mitts to prevent dislodgment of medical devices. Conflicting information was documented regarding the resident's understanding and consent, and consent was obtained from a significant other instead of the next of kin, contrary to facility policy.
A resident with multiple mental health diagnoses, including PTSD and major depressive disorder, did not receive a required PASARR level two referral. The facility's social services department failed to identify and refer the resident for further screening, despite the diagnoses indicating a need for such action.
The facility failed to accurately document and administer medications and treatments, leading to deficiencies. A resident did not receive scheduled wound care, and the ACE wrap for edema was not applied as ordered, despite being documented as completed. Oxygen therapy was administered at an incorrect flow rate, and a diuretic medication was borrowed from another resident's supply, violating policy.
A resident did not receive wound care treatment as ordered, with inaccurate documentation of treatment refusal. ACE wraps for edema were inconsistently applied, despite being documented as in place. Oxygen therapy was administered at an incorrect flow rate, exceeding the physician's order, with inaccurate documentation of the flow rate.
A resident at moderate risk for pressure sores was not provided with heel protectors or floating heels as required by their care plan and physician's order. Observations revealed the resident's heels were in direct contact with the mattress, contrary to the facility's policy on pressure injury prevention. The RN and DON confirmed the oversight in implementing the necessary nursing intervention.
A resident at risk for falls due to medical conditions reported a fall that was not immediately assessed by the facility. Despite experiencing hip pain, the necessary post-fall assessment and neurological checks were not conducted, as the fall was reported two days later. Staff acknowledged the oversight, which was contrary to the facility's policy requiring assessments regardless of the timing of the report.
A facility failed to provide adequate hydration to a resident dependent on tube feeding due to malfunctioning equipment and lack of communication among staff. The resident did not receive necessary water flushes or hydration for almost 24 hours, despite requests and a speech therapist's assessment allowing small sips of water. Additionally, another resident experienced significant weight loss due to missed weight monitoring, which was not identified in a timely manner.
A resident dependent on tube feeding did not receive the prescribed Diabetisource formula due to malfunctioning pumps and was instead given Glucerna, which caused discomfort. The facility staff failed to notify the physician or RD for new orders, resulting in inadequate nutrition for nearly 24 hours. The TF was only administered once the following day and again the next morning, contrary to the physician's order.
The facility failed to label open food containers with dates and did not dispose of spoiled fruits in the kitchen, potentially exposing residents to health risks. An inspection revealed several open containers without dates and spoiled cantaloupes and watermelon. The Kitchen Manager confirmed these issues, acknowledging that the facility's policy requires proper labeling and disposal.
Failure to Update Discharge Instructions and Notify Physician
Penalty
Summary
The facility failed to update discharge instructions and notify the physician of changes in the discharge plan for a resident, leading to a potential gap in the continuation of care. The resident was admitted with diagnoses including a urinary tract infection, atrial fibrillation, and an unstageable pressure ulcer. The physician's discharge summary indicated that the resident was to be discharged with home health services, including nursing, physical therapy, occupational therapy, and wound care. However, the resident's family canceled the home health consult, opting to manage wound care themselves, which was not communicated to the physician. The Director of Nursing and other staff confirmed that the change in the discharge plan was known prior to discharge, but the discharge instructions were not updated to reflect this change. The facility's policy required that discharge instructions communicate the resident's needs for a safe transition, which was not adhered to in this case. Staff interviews revealed that the physician should have been notified of the change, and there was a suggestion that Adult Protective Services could have been contacted to ensure the resident's safety post-discharge.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to provide documented evidence that wound care treatments were administered according to the physician's orders for one resident. This resident, who had been diagnosed with an unstageable pressure ulcer, was supposed to receive specific wound care treatments involving the application of Silvadene External Cream and other procedures to the sacrum. However, the Treatment Administration Record (TAR) lacked documentation of these treatments being completed on two specific dates. Interviews with the wound care nurse and the Director of Nursing (DON) confirmed the absence of documentation for the treatments on the specified dates. The facility's policy required that wound care be documented in the resident's medical record, including the date, time, and the name of the individual performing the care. The lack of documentation meant there was no way to verify whether the treatments were performed, potentially placing the resident at risk for delayed healing of the wound.
Failure to Document Midline Removal and Site Assessment
Penalty
Summary
The facility failed to provide documented evidence of the removal of a midline catheter and a site assessment for a resident upon discharge. The resident was admitted with diagnoses including a urinary tract infection, atrial fibrillation, and an unstageable pressure ulcer. A physician's order was issued to discontinue the midline after the completion of an IV medication regimen. However, the resident's medical record lacked documentation confirming the midline's removal and the performance of a site assessment. A Registered Nurse indicated that such documentation should have been included in the progress notes, detailing the condition of the site and any concerns. The Director of Nursing confirmed that the removal should have been recorded on the Medication Administration Record and accompanied by a progress note reflecting the site assessment and the resident's tolerance of the process.
Failure to Obtain Proper Consent for Restraint Use
Penalty
Summary
The facility failed to ensure an accurate assessment and obtain proper consent for the use of bilateral mitten restraints on a resident. The resident, who was admitted with multiple diagnoses including acute respiratory failure, dementia, and was ventilator-dependent, was observed wearing bilateral hand mitts to prevent the dislodgment of medical devices. The care plan indicated the use of mitts to prevent pulling on tubing, and a physician's order supported their use for preventing dislodgment of lifesaving devices. However, the assessment conducted documented conflicting information regarding the resident's understanding and consent for the use of these restraints. The assessment noted the resident's cognitive status as confused and nonverbal, and it was unclear if the resident understood the implications of removing the tracheostomy tube. Despite this, the nurse completing the assessment checked boxes indicating both that the resident requested the devices and understood the risks and benefits, which was inconsistent with the resident's cognitive abilities. Additionally, verbal consent was obtained from the resident's significant other rather than the next of kin, contrary to the facility's policy requiring consent from the resident or their representative. The Resident Care Manager and charge nurse confirmed the resident's inability to request or understand the use of the devices, highlighting a failure in the facility's consent process.
Failure to Complete PASARR Level Two Referral
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) level two referral for one of the sampled residents, identified as Resident #36. This resident was readmitted with multiple diagnoses, including pulmonary edema, acute respiratory failure with hypoxia, anxiety disorder, mood disorder, generalized anxiety disorder, post-traumatic stress disorder (PTSD), and major depressive disorder. Despite these diagnoses, which are indicative of mental illness, there was no documented evidence of a PASARR level two screening being conducted. The resident had been at the facility for about eight years and expressed satisfaction with the care received. The deficiency was identified through interviews and document reviews, revealing a lack of awareness and action by the facility's social services department. The Social Services Director and Social Worker were responsible for completing PASARR requests but were not aware of their role in identifying and referring residents for PASARR level two screenings unless the mental disorder significantly interfered with daily living or resulted in hospitalization for psychiatric issues. The facility's policy required social services to track each resident's PASARR screening status and make necessary referrals, which was not adhered to in this case.
Deficiencies in Medication and Treatment Documentation
Penalty
Summary
The facility failed to ensure accurate documentation and administration of medications and treatments for residents, leading to several deficiencies. For Resident 48, the wound care treatment was not provided as scheduled, and the Treatment Administration Record (TAR) was inaccurately documented to reflect that the treatment was completed. The wound dressing was observed to be old and peeling, and the wound care nurse admitted to not providing the treatment and failing to notify the physician about the missed treatment. Additionally, the ACE wrap for edema was not applied as ordered, despite being documented as applied in the Medication Administration Record (MAR). The nursing staff failed to ensure the ACE wrap was in place before signing off on the documentation. Resident 48 also experienced issues with oxygen therapy. The oxygen was administered at a higher flow rate than prescribed, and the MAR inaccurately documented the flow rate. The LPN confirmed the discrepancy and admitted to not verifying the oxygen flow meter before documenting. This failure to administer and document oxygen therapy accurately could have significant implications for the resident's respiratory condition. For Resident 56, the facility failed to administer the prescribed diuretic medication, Lasix, as the medication was not available in the medication cart. The nurse documented that the medication was administered, but it was later revealed that the Lasix was borrowed from another resident's supply, which is against the facility's medication administration policy. The Director of Nursing confirmed that the medication was not obtained from the Pyxis or the pharmacy, highlighting a significant lapse in medication management and documentation practices.
Deficiencies in Wound Care, Edema Treatment, and Oxygen Administration
Penalty
Summary
The facility failed to provide wound care treatment as ordered for a resident with a skin tear on the right forearm. The treatment was supposed to be administered every three days, but it was not provided on the scheduled date. The Treatment Administration Record (TAR) was inaccurately documented as completed, and the physician was not notified of the missed treatment. The wound care nurse later admitted to editing the record to indicate the resident refused treatment, which was not the case, as the resident was asleep at the time. The facility also failed to apply ACE wraps as ordered for the resident's bilateral lower extremity edema. Although the Medication Administration Record (MAR) documented that the ACE wraps were applied, they were observed lying on the resident's bedside table. The nursing staff, including Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs), were unclear about their responsibilities regarding the application of ACE wraps, leading to inconsistent treatment. Additionally, the facility did not administer oxygen therapy as ordered for the resident with chronic obstructive pulmonary disease (COPD). The oxygen flow rate was set at 5 liters per minute (LPM), exceeding the physician's order of 2-4 LPM. The MAR inaccurately documented the oxygen flow rate as 3 LPM. The nursing staff failed to verify and document the correct oxygen flow rate, which could potentially suppress the resident's respiratory drive.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement the necessary preventive measures for pressure ulcers for one resident, who was at moderate risk for developing pressure sores. The resident, who had a history of hypertension, diabetes, epilepsy, CVA, and chronic hypoxia, was observed on two separate occasions without heel protectors, and their heels were not floating as required. A physician's order and the resident's care plan both specified the need for floating heels to maintain skin integrity and prevent pressure ulcers. However, during observations, the resident's bed was in a flat position, allowing the heels to come into direct contact with the mattress, contrary to the care plan's instructions. The registered nurse confirmed the observations and acknowledged that the resident's heels should have been floating. The Director of Nursing also confirmed that the floating heels procedure was a necessary nursing intervention that should have been implemented according to the care plan. The facility's policy on the prevention of pressure injuries emphasized the importance of keeping heels off the bed using pillows or a Keen Heel Float device, which was not adhered to in this case.
Failure to Conduct Post-Fall Assessment and Neurological Checks
Penalty
Summary
The facility failed to complete a post-fall assessment and neurological checks for a resident after an unwitnessed fall. The resident, who was admitted with diagnoses including polyneuropathy, unilateral primary osteoarthritis of the right hip, and dizziness, was identified as being at risk for falls due to muscle weakness and a history of falls. Despite this, when the resident reported a fall that occurred while sitting on the bed, the necessary post-fall protocols were not followed. The resident experienced right hip pain following the fall, which was not immediately assessed due to the delay in reporting. The Director of Nursing and other staff acknowledged that the fall protocol was not followed because the fall was reported two days after it occurred. However, the facility's policy required that post-fall assessments and neurological checks be completed regardless of when the fall was reported or whether it was witnessed. The lack of documentation in the resident's medical record for the post-fall assessment and neurological checks highlights the deficiency in adhering to the facility's policies on fall management and accident reporting.
Failure to Provide Adequate Hydration and Timely Weight Monitoring
Penalty
Summary
The facility failed to provide adequate hydration to a resident who was dependent on tube feeding. Upon admission, the resident's tube feeding equipment was malfunctioning, leading to a delay in administering both the tube feeding and necessary water flushes. Despite the resident's requests for water due to a dry mouth and discomfort, the LPN did not provide hydration, and the water flushes were not administered as ordered. The resident's medical records lacked documentation of the water flushes, and the attending physician was not notified of the hydration issue. The resident, who had a history of dysphagia and cancer affecting saliva production, was assessed by a speech therapist who determined it was safe for the resident to sip water. However, this information was not communicated effectively to the nursing staff, resulting in the resident not receiving hydration for almost 24 hours. The registered dietitian confirmed that the resident's hydration needs were not met, and the water bag prepared upon admission remained full and unused. Additionally, the facility failed to obtain timely weight measurements for another resident, who experienced significant weight loss over a period of months. The resident's weight was not tracked in April, and the dietitian noted that the weight loss was not identified sooner due to the lack of documentation. The facility's policy required regular weight monitoring, but the restorative nursing assistants did not document why the weight was missed, and the dietitian could not confirm the reason for the oversight.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to provide adequate tube feeding (TF) formula to a resident, identified as Resident 188, who was dependent on tube feeding. Upon admission, the resident was supposed to receive a specific TF formula, Diabetisource, but instead, Glucerna was provided, which caused stomach discomfort. The TF was not administered immediately due to malfunctioning pumps, and there was no documented physician order for the Glucerna formula. The resident's medical records lacked evidence of a physician order for the TF, and the resident expressed discomfort and refusal of the Glucerna formula. The facility's staff did not notify the physician or registered dietitian (RD) when the TF could not be administered as ordered. The resident's family reported concerns about the inadequacy of the resident's nutrition for almost 24 hours following admission. The TF was only administered once on the day following admission and again the next morning, which was not in accordance with the physician's order. The attending physician and registered nurse confirmed that the TF was not administered timely, and there was no notification to the physician or RD for new orders. The facility's policy on enteral nutrition required that adequate nutritional support be provided as ordered, and any interruptions should be addressed by obtaining new orders. However, the staff failed to adhere to this policy, resulting in the resident not receiving the necessary nutritional support in a timely manner. The registered dietitian and director of nursing confirmed that the resident's nutritional needs were not met, and the staff did not follow the expected protocol of notifying the physician or RD when the TF was not administered as ordered.
Food Labeling and Spoilage Issues in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and disposal of food products in the kitchen, which could have exposed residents to potential health risks. During an inspection, it was observed that several open containers of food, including beef base, coleslaw dressing, low-fat cottage cheese, mild chunky salsa, and golden Italian dressing, were not labeled with the date they were opened. Additionally, 11 cantaloupes and one watermelon in the walk-in refrigerator showed signs of spoilage, with black spots, white patches, softness, and mushiness. The Kitchen Manager confirmed these observations and acknowledged that the open containers should have been dated and the spoiled fruits discarded. The facility's policy on the storage of frozen and refrigerated foods requires food to be labeled with the product name and expiration or discard date.
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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