North Las Vegas Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Las Vegas, Nevada.
- Location
- 3215 E. Cheyenne Ave., North Las Vegas, Nevada 89030
- CMS Provider Number
- 295036
- Inspections on file
- 22
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at North Las Vegas Care Center during CMS and state inspections, most recent first.
Two residents, one with bipolar disorder and fall history and another with post-stroke hemiplegia, intellectual disabilities, and contractures, were found barricaded in their beds when an Activities Director observed mattresses placed against the beds and held in place by locked Geri-chairs, blocking the only open side. The assigned nurse stated this was done for safety, but the investigation determined the residents were deliberately confined to bed without consent, constituting involuntary seclusion in violation of the facility’s abuse and neglect policy. One resident later reported feeling that this confinement was not appropriate.
A resident with multiple medical and psychiatric diagnoses was subjected to rough handling by a CNA during personal care, including being tugged on while having their brief changed. The incident was reported, investigated, and substantiated as abuse, indicating the facility failed to ensure the resident was protected from abuse as required by policy.
A resident with Parkinson's Disease and a history of transient ischemic attack did not receive timely doses of prescribed antibiotics for cellulitis due to a delay in pharmacy delivery. Despite the medications being available in the facility's Omnicell system, they were not administered, and the physician was not informed of the delay, contrary to facility policy.
A resident with severe pain was not provided with the appropriate pain medication due to a failure to use the available Omnicell system. Despite the resident's request for Norco, the LPN administered Tylenol, which was ineffective, and failed to document the pain level accurately. The Director of Nursing confirmed that the facility's policy required using the Omnicell for immediate medication needs, which was not followed, leading to inadequate pain control.
The facility failed to conduct PASARR Level 2 evaluations for four residents who exhibited new behavioral changes or diagnoses, including anxiety, depression, and aggressive behaviors. Despite documented psychiatric evaluations and nursing progress notes indicating significant mental health issues, the necessary evaluations were not completed, as confirmed by the Director of Nursing.
A resident receiving Vancomycin for bacterial pneumonia experienced a lapse in care when a night nurse failed to notify the physician of a high trough level before administering a dose. The following morning, an LPN held the next dose without verifying the trough level or obtaining a physician's order. This deficiency in communication and documentation placed the resident at risk for ineffective therapy and side effects.
A facility failed to ensure proper colostomy care for a resident, as there were no documented physician orders for the care and management of the colostomy. The CNA provided basic cleaning, but specific orders were absent, and the LPN generally changed the appliance if needed. Interviews with staff confirmed the lack of care orders, which contradicted the facility's policy requiring physician orders to clarify care type and frequency. This deficiency had the potential to introduce infection and negatively impact the resident's health.
A facility failed to ensure proper G-tube care for a resident, leading to a deficiency. The resident was found with a tube feeding pump off but still attached, and a reddish-brown stain on the gown and gauze dressing. The LPN did not assess the G-tube site, relying on a night nurse's report. Further examination revealed hyper granulation and bleeding, with no care orders in place since admission. This lack of proper assessment and monitoring placed the resident at risk for complications.
A facility reported a medication error rate of 9.38%, exceeding the acceptable threshold. Two residents received Metformin outside the prescribed timeframe, as it was administered more than an hour after meals. Additionally, a missed dose of Risperdal occurred due to unavailability, and the LPN failed to notify the physician or check the medication dispensing system for alternatives.
The facility failed to document influenza and pneumococcal vaccinations for two residents, one with chronic pancreatitis and blindness, and another with diabetes and neurocognitive disorder. The Infection Preventionist confirmed the absence of vaccination records in the EHR, despite facility policy requiring such documentation.
The facility failed to document the COVID-19 vaccination status for two residents, one with chronic pancreatitis and blindness, and another with diabetes and a neurocognitive disorder. Their EHRs lacked data on vaccinations, and the Infection Preventionist confirmed the absence of records in the physician's orders and MAR. Facility policy mandates documentation of vaccination status upon admission and annually.
Involuntary Seclusion of Two Residents by Barricading Beds
Penalty
Summary
The deficiency involves the involuntary seclusion and confinement of two residents to their beds by staff using physical barriers. One resident had bipolar disorder and a history of falling, and the other had hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, intellectual disabilities, and contractures. Facility reports documented that during early-morning rounds, the Activities Director observed that both residents’ beds, which were permitted to be placed against a wall with one open side, had the open side blocked by a mattress propped up and held in place by a locked Geri-chair, effectively barricading the residents in bed. When questioned, the nurse assigned to the hallway stated this was done for safety. The investigation determined that the residents were deliberately barricaded in bed, resulting in their confinement without consent. One of the residents later recalled the incident and stated that being confined to bed in this manner felt inappropriate at the time. Staff interviews confirmed awareness of the facility’s abuse policy and protocols for reporting allegations, and staff acknowledged that the incident involved involuntary seclusion of the two residents. The facility’s written policy on abuse, neglect, exploitation, mistreatment, and involuntary seclusion prohibited such practices and required thorough investigation of all allegations, including identification and removal of alleged perpetrators, identification of victims, and documentation of where and when the incident occurred and interview summaries.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a certified nursing assistant (CNA) was reported to have been rough while changing the resident's brief, including tugging on the resident. The incident involved a resident with a history of cervical spine fusion, cocaine abuse with cocaine-induced psychotic disorder with hallucinations, depression, and pain. The resident reported the incident, and the CNA was removed from the resident's care for the remainder of the shift due to incompatibility between the resident and the CNA. The CNA resigned from the facility after the allegation was reported. An investigation was conducted, and the facility substantiated the allegation of abuse. The facility's policy prohibits all forms of abuse, neglect, and mistreatment, and requires immediate reporting and investigation of such incidents. The deficiency was identified through interviews, record review, and document review, which confirmed that the resident was not kept safe from abuse as required.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to administer medications timely to a resident, which could potentially render the treatment ineffective. The resident, who was admitted with diagnoses including Parkinson's Disease and a history of transient ischemic attack, had physician orders for Doxycycline Hyclate and Amoxicillin-Pot Clavulate to be administered twice daily for cellulitis. However, the medication administration record (MAR) indicated that the resident missed multiple doses over two days due to the facility awaiting delivery from the pharmacy. Despite the medications being available in the facility's Omnicell automated dispensing system, they were not administered as required. The Licensed Practical Nurse Unit Manager confirmed the availability of the medications in the Omnicell, and the Director of Nursing verified that the facility's policy was to use the Omnicell for unavailable medications. Additionally, the physician was not notified about the delay in starting the medications, which was against the facility's policy for medication procurement and administration.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 4, who was admitted with multiple diagnoses including pain and required specific pain management. On the morning of January 30, 2025, the resident requested Norco, a narcotic pain medication, during the morning medication pass but was informed that the facility had run out of the medication. Instead, the resident was given Tylenol, which was ineffective in managing the pain. The resident expressed a pain level of 9, indicating severe pain, but the Licensed Practical Nurse (LPN3) did not administer the Norco from the Omnicell, an onsite medication dispensing machine, despite its availability. The LPN also failed to document the administration of Tylenol and incorrectly recorded a pain level of 0 in the Medication Administration Review (MAR). The Director of Nursing (DON) confirmed that the facility's policy required the use of the Omnicell for immediate medication needs and emphasized that the nursing staff should have administered Norco from the Omnicell when the resident reported a high pain level. The failure to assess and document the resident's pain level accurately and to administer the appropriate medication as per the physician's order led to inadequate pain control for the resident. The facility's policies on medication procurement and pain management were not followed, resulting in the resident experiencing unmanaged pain until the Norco was eventually administered later in the morning.
Failure to Conduct PASARR Level 2 Evaluations for Residents with Behavioral Changes
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level 2 evaluation for four residents who exhibited new behavioral changes or diagnoses. This deficiency was identified through observations, interviews, and record reviews. The residents involved were found to have significant behavioral health issues that were not addressed with the necessary PASARR Level 2 evaluations, which are required for residents with newly evident or possible serious mental disorders. Resident 115 was admitted with chronic pancreatitis and blindness, and later exhibited behaviors such as talking to self, refusing medications, and being confrontational with staff. Despite these behaviors and a psychiatric diagnosis of anxiety and major depressive disorder with psychotic symptoms, the facility did not complete a PASARR Level 2 evaluation. Similarly, Resident 81, with a history of schizoaffective disorder and neurocognitive disorders, displayed aggressive and non-compliant behaviors, yet no PASARR Level 2 evaluation was conducted. Resident 139, who had a history of dementia and cerebral infarction, showed aggressive behaviors and required close monitoring, but was not referred for a PASARR Level 2 evaluation. Lastly, Resident 119, with new diagnoses of anxiety and depressive disorders, was also not referred for the necessary evaluation. The Director of Nursing confirmed the oversight and acknowledged the need for PASARR Level 2 evaluations for these residents, as per the facility's policy.
Failure to Communicate High Vancomycin Trough Level
Penalty
Summary
The facility failed to ensure proper communication and documentation regarding a high Vancomycin trough level for a resident being treated for bacterial pneumonia. The resident, who had been admitted with diagnoses including intracranial injury and bacterial pneumonia, was prescribed Vancomycin intravenously every eight hours. On one occasion, the night nurse administered a dose of Vancomycin without notifying the physician of a high trough level that was available prior to the administration. This oversight was due to the nurse's unfamiliarity with the laboratory book and electronic health record (EHR) system. The following morning, an LPN decided to hold the resident's scheduled Vancomycin dose based on a verbal report from the night nurse, without verifying the trough levels in the EHR or contacting the physician for guidance. The medical record lacked evidence of communication with the physician regarding the high trough level, and there was no physician order to hold the medication. The LPN acknowledged the error in not verifying the results or obtaining a physician's order before holding the dose. The Director of Nursing confirmed that Vancomycin requires close monitoring due to its narrow therapeutic index and potential toxicities. The pharmacy guidelines emphasized the importance of laboratory monitoring and timely administration of doses. The failure to communicate the high trough level and the decision to hold the medication without a physician's order placed the resident at risk for ineffective antibiotic therapy and serious side effects.
Deficient Colostomy Care Management
Penalty
Summary
The facility failed to ensure proper care and management of a colostomy for one resident, identified as Resident 69. The resident was unsure when the colostomy barrier wafer was last changed, and the medical record lacked documented evidence of physician orders for colostomy care. Observations and interviews revealed that the Certified Nursing Assistant (CNA) provided basic cleaning care but did not have specific orders to follow. The CNA was responsible for cleaning around the colostomy site and changing the collection bag if needed, while the Licensed Practical Nurse (LPN) would generally change the appliance if necessary. However, there were no documented physician orders specifying the type of care, frequency of cleaning, or appliance changes for the resident. Interviews with facility staff, including the Unit Manager and Director of Nursing (DON), confirmed the absence of care and management orders for the resident's colostomy. The DON stated that a physician order should be obtained upon admission to clarify the type of care needed and the frequency of changing the colostomy appliance. The facility's policy on ostomy care indicated that appliances should stay on for five to seven days unless there is leakage, burning, or pain, in which case they should be changed immediately. The lack of documented orders and adherence to the facility's policy had the potential to introduce infection and negatively impact the resident's health.
Failure in G-tube Care and Monitoring
Penalty
Summary
The facility failed to ensure proper gastrostomy (G-tube) care for Resident 79, who was admitted with diagnoses including metabolic encephalopathy, gastroparesis, and gastrostomy malfunction. The deficiency was identified when the facility did not enter or carry out G-tube care orders in accordance with protocol. On observation, the resident was found with a tube feeding pump off but still attached, and a reddish-brown stain was noted on the gown and gauze dressing. The Licensed Practical Nurse (LPN) did not assess the G-tube site during the termination of feeding, relying instead on a report from the night nurse, which led to a lack of proper assessment and monitoring of the site. Further examination by the Wound Registered Nurse and the Director of Nursing (DON) revealed hyper granulation and bleeding at the G-tube site, which had not been reported or addressed. The DON confirmed that no care orders were in place for the G-tube site care since the resident's admission, which should have included regular assessment and monitoring. The failure to have care orders and proper assessment placed the resident at risk for complications. The facility's protocol, as per the Lippincott Nursing Procedures, was not followed, which required inspection for signs of infection and other issues.
Medication Administration Errors and Missed Dose
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported rate of 9.38% during a medication administration pass. This deficiency involved two residents, one of whom was unsampled. The errors were primarily related to the administration of Metformin, an antidiabetic medication, which was not given in accordance with the physician's orders. The orders specified that Metformin should be administered with meals to ensure proper absorption and efficacy. However, the medication was given more than an hour after breakfast, which was outside the prescribed timeframe. For Resident 58, the LPN administered Metformin at 8:21 AM, despite the breakfast being finished about an hour earlier. Similarly, for Resident 61, Metformin was administered at 8:37 AM, also more than an hour after breakfast. The LPN admitted to combining the 7:00 AM and 8:00 AM medication passes to save time, which led to the late administration of Metformin. The Unit Manager and DON confirmed that the medication was not administered as per the physician's orders, and the facility's policy required medications to be given within one hour of the scheduled time. Additionally, there was a missed dose of Risperdal for Resident 61 due to the medication being unavailable. The LPN did not reorder the medication in time and failed to notify the physician about the missed dose. The Unit Manager indicated that the LPN should have checked the medication dispensing system for an alternative supply or contacted the physician for guidance. The DON confirmed that the missed dose was not handled properly, as the facility's policy required immediate action to obtain unavailable medications and to report missed doses to the physician.
Failure to Document Vaccinations for Residents
Penalty
Summary
The facility failed to provide documented evidence of influenza and pneumococcal vaccinations for two of five sampled residents, which could potentially prevent ensuring residents have had the necessary vaccines to fight off diseases. Resident 115, who was admitted with chronic pancreatitis and blindness, had no data available in their Electronic Healthcare Records (EHR) under Preventive Health Care; Vaccinations, Tests & Results. Similarly, Resident 81, admitted with diagnoses including diabetes and neurocognitive disorder, also had no vaccination data available in their EHR. On September 11, 2024, the Infection Preventionist (IP) confirmed that the vaccine records section for these residents was blank after reviewing the EHR, physician's orders, and medication administration record (MAR). The facility's policy, dated May 15, 2023, requires documentation of all vaccines given, historical, or offered but refused, in the residents' EHR.
Failure to Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to provide documented evidence that the COVID-19 vaccine was offered or administered to two of the five sampled residents, identified as Resident 115 and Resident 81. Resident 115 was admitted with diagnoses including chronic pancreatitis and blindness, while Resident 81 had diagnoses significant for diabetes and a neurocognitive disorder. Upon review of their Electronic Healthcare Records (EHR), it was found that there was no data available under the Preventive Health Care section for vaccinations, tests, and results for both residents. On September 11, 2024, the Infection Preventionist (IP) confirmed that the vaccine records section for these residents was blank. The IP checked the physician's orders and the medication administration record (MAR) for any documentation of the COVID-19 vaccine but found no results. The IP indicated that all vaccines, whether given, historical, or offered but refused, should be documented in the residents' EHR. The facility's policy on Standing Orders for Immunizations requires the evaluation of residents' vaccination status upon admission and annually, with documentation of the date, time, and injection site or declination in the medical record.
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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