Northern Nevada State Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sparks, Nevada.
- Location
- 36 Battleborn Way, Sparks, Nevada 89431
- CMS Provider Number
- 295105
- Inspections on file
- 27
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Northern Nevada State Veterans Home during CMS and state inspections, most recent first.
The facility failed to ensure timely completion of elder abuse prevention training for 10 employees, including the Executive Director, RNs, LPNs, CNAs, and other staff. Despite the facility's policy requiring training during orientation, several employees either lacked documentation of training or completed it late, yet were allowed to work with residents. This oversight potentially placed all residents at risk for abuse and neglect.
A resident with a documented allergy to animal hair and a care plan indicating a preference against pet therapy was approached by a therapy dog handler, leading to the resident feeling disrespected. The facility staff failed to communicate the resident's preference to the pet therapy organization, resulting in a breach of the resident's rights.
A long-term care facility failed to ensure proper medication administration, resulting in deficiencies. A resident with heart failure received Spironolactone despite a heart rate below the prescribed threshold due to an inaccurate transcription of the physician's order. Additionally, an LPN improperly administered eye drops to a resident with dementia, failing to follow the correct technique. The DON confirmed the expectations for medication administration were not met, and the facility's policies were not adhered to.
The facility failed to ensure that two direct care staff members, both RNs, maintained current CPR certification as required by their job descriptions. Employee #11 lacked documented evidence of CPR training, while Employee #12 had an expired CPR certification. The Human Resources Director confirmed the requirement for CPR certification for all direct care staff, as documented in the Facility Assessment.
A resident with PTSD and depression did not receive individualized activities to meet their needs and interests. The resident preferred staying in their room and needed help with electronic devices to alleviate depression. The facility's activities staff failed to engage with the resident or document interactions, despite the care plan acknowledging the resident's preferences. The last documented activity was a self-directed engagement with movies or television.
A medication cart was left unlocked in a unit with residents present, risking unauthorized access. Additionally, expired medications were found in a cart and storage room, including Docusate Sodium, Ondansetron, an IV solution, and Tuberculin Purified Protein Derivative. An RN confirmed the oversight, and the DON emphasized the need for immediate removal of expired medications.
The facility failed to ensure culinary staff checked holding temperatures for all hot foods before meal service in two dining rooms. In the [NAME]/Quail room, mechanical soft fish was served at 128°F, below the required 135°F. In the Aspen/Pinion room, minced vegetables were served at 132°F without rechecking. The facility's policy required hot foods to be held and served at a minimum of 135°F.
A facility failed to maintain accurate EMR and MAR records, leading to discrepancies in a resident's code status and medication orders. One resident's POLST indicated DNR, but the EMR showed full CPR, while another resident's Spironolactone order was incorrectly transcribed to include unnecessary heart rate monitoring. These errors could have compromised resident safety.
The facility failed to offer timely pneumonia vaccines to two residents, one of whom had serious respiratory and cardiac conditions, and another who had previously received a PPV23 vaccine but was not offered the subsequent PCV as recommended. The Infection Preventionist confirmed the lack of documentation and follow-up, indicating a lapse in the facility's immunization practices.
The facility failed to provide education on the risks and benefits of the COVID-19 vaccine and offer the vaccine to two residents. One resident's clinical record lacked documentation of being offered or receiving the vaccine, while another resident refused the vaccine without receiving the necessary education. The Infection Preventionist confirmed these deficiencies, which were not in compliance with the facility's vaccination policy.
A resident with a history of frequent falls and cognitive impairment experienced an unwitnessed fall resulting in head and body injuries. Despite consistently high BP readings and a visible head injury, the LPN did not review or act on the vital signs documented by the CNA, nor notify the physician. The resident was only sent to the hospital after the night shift nurse recognized the concerning findings and contacted the physician, constituting neglect as defined by facility policy and state regulations.
A resident with multiple medical conditions experienced an unwitnessed fall resulting in a subdural hematoma and was transferred for neurosurgical evaluation. Despite the serious injury and facility policy requiring immediate reporting of such incidents, the event and related allegations against the former DON were not reported to the State Agency or thoroughly investigated.
A resident with a history of frequent falls was found on the floor with multiple injuries and was later diagnosed with a subdural hematoma. Despite allegations that the former DON instructed staff not to send the resident to the hospital or provide care, facility leadership did not thoroughly investigate or report the allegations, contrary to facility policy.
The facility did not update nursing staff postings for all units, with the last update being on March 7, 2025. The Staffing Coordinator was responsible for weekday postings, while an RN was responsible for weekends. The RN admitted to not updating the postings for March 8 and 9, 2025, resulting in outdated information and a lack of awareness for residents and visitors about the nursing and direct care staff on duty.
A resident with PTSD and major depressive disorder was verbally abused by a CNA who used profane language during an interaction. The resident, feeling annoyed, yelled at the CNA to leave, prompting the CNA to respond with profanity. The facility's investigation confirmed the verbal abuse, which violated the facility's policies on resident rights and CNA professionalism.
A facility failed to submit an accurate and timely Facility Reported Incident (FRI) regarding verbal abuse towards a resident with major depressive disorder and vascular dementia. The initial report contained an incorrect incident date, and the final report was not submitted within the required timeframe. The Regional Director confirmed these discrepancies, which violated the facility's policy on reporting abuse allegations.
During a tour of the secured memory care unit, various potentially harmful substances and items were found accessible to residents with severe cognitive impairments. Items such as alcohol-based hand rub, antibacterial hand soap, medications, sharp objects, and potentially toxic cleaning solutions were discovered in resident rooms and common areas. These residents, diagnosed with dementia and cognitive impairments, require a secure environment due to impaired safety awareness. The presence of these hazardous items poses a risk of ingestion or harm. The DON acknowledged that these items should not have been accessible, highlighting a lapse in adherence to the facility's policy on Memory Care Accident Hazards/Supervision.
A maintenance worker entered a resident's room without knocking or asking for permission, violating the resident's right to dignity and self-determination. The facility's policy requires staff to knock and ask for permission before entering a resident's room, but this was not followed in this instance.
A resident with Alzheimer's and severe dementia was found with a severe leg wound requiring emergency treatment. The facility failed to promptly investigate and report the injury to the State agency, as required by their abuse policy. The investigation was delayed, and the policy lacked specific timeframes for reporting.
A resident with Alzheimer's and severe dementia was found with a large, bleeding wound on their lower leg that required emergency treatment and sutures. The facility failed to report the injury of unknown origin to the State Agency immediately, as required by their policy, delaying the investigation into the cause of the injury.
A facility failed to include oxygen therapy in the baseline care plan for a resident with COPD, despite hospital discharge instructions and nursing notes indicating the need for chronic oxygen therapy. Observations confirmed the resident was using an oxygen concentrator, and both a Registered Nurse and the Director of Nursing acknowledged the omission in the care plan.
The facility failed to update a resident's care plan to match the physician's order for oxygen therapy and had inappropriate care plan interventions for three residents in the memory care unit. The care plans for these residents were not aligned with the facility's policy on comprehensive and person-centered care.
A resident with dementia and anxiety did not ingest their prescribed Metoprolol Succinate as required. A pill was found on the resident's side table, and it was confirmed that the nurse did not stay to ensure the medication was swallowed, violating the facility's medication administration policy.
The facility failed to ensure that an LPN was trained and certified to perform CPR, as required by facility policy. The Human Resources Director confirmed the lack of current CPR certification for the LPN, despite it being a requirement upon hire.
The facility failed to ensure a resident's medication orders were coordinated with the contracted hospice agency, resulting in discrepancies between the facility's orders and the hospice's Client Medication Report. Interviews revealed that medication reconciliation was not effectively implemented, and the designated Hospice Coordinator had limited interaction with hospice agencies after residents were admitted to hospice services.
The facility failed to follow physician's orders for respiratory care for two residents. One resident received oxygen at higher rates than prescribed, and another had an incomplete oxygen therapy order. Staff confirmed the discrepancies.
The facility failed to ensure MMRs were completed within the required timeframe for two residents. Both the Pharmacist and the DON confirmed that the MMRs for August 2023 were not completed within the stipulated 30 to 31 days as per the facility's policy.
The facility had a medication error rate of 8%, involving two residents. One resident's lidocaine patch was not removed as scheduled, and another resident's insulin pen was not prepared according to protocol. The DON confirmed the correct procedures were not followed.
The facility failed to ensure an employee wore appropriate hair restraints in the kitchen and did not perform hand hygiene before and after resident contact during a lunch service. A CNA was observed without a hair restraint covering their beard, and another CNA did not perform hand hygiene between delivering plates to residents.
The QAA Committee failed to identify the lack of timely training for staff. The Administrator confirmed that trainings were completed according to the online training company's standards, not regulatory standards, resulting in late completions.
The facility failed to ensure proper infection control practices during insulin administration and COVID-19 testing. An RN did not disinfect the rubber seal on an insulin pen before use, and a used COVID-19 test was found in a common area, used by a symptomatic staff member. These actions have the potential to spread communicable diseases.
The facility failed to ensure timely completion of elder abuse prevention training for three employees. A Registered Dietitian completed training one month past the anniversary date, while a CNA and an RN lacked documented evidence of annual training for 2024. The HR Director confirmed these deficiencies, noting that training is required upon hire and annually thereafter.
The facility failed to ensure annual behavioral health training for six employees, including the Administrator, DON, Recreation Director, a CNA, an RN, and the Infection Preventionist/LPN. Despite the policy requiring annual training, these employees only had dementia training documented for 2023, with no records for 2024.
The facility failed to update the Facility Assessment to reflect accurate staffing needs for the memory care unit. The FA documented a staffing plan of 1 staff member to 16 residents but did not include the memory care unit, which required a ratio of one staff member to eight residents. The Director of Nursing and the Administrator confirmed the discrepancy.
Delayed Elder Abuse Prevention Training for Staff
Penalty
Summary
The facility failed to ensure that initial elder abuse prevention training was completed in a timely manner for 10 out of 20 sampled employees. This deficiency was identified through personnel record review, interviews, and document review. Employees, including the Executive Director, Social Services Director, Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Culinary Staff, and Housekeepers, either lacked documented evidence of elder abuse prevention training or completed the training significantly late. The Human Resources Director confirmed that these employees had been working with residents prior to completing the required training. The facility's policy, revised in January 2023, mandates that all employees receive elder abuse prevention training during orientation and ongoing sessions, with training to be completed no less frequently than annually. Despite this policy, the facility did not adhere to its own guidelines, as evidenced by the delayed or missing training documentation for several employees. This oversight had the potential to place all residents at risk for abuse and neglect, as employees were not adequately trained before interacting with residents.
Failure to Respect Resident's Refusal of Pet Therapy
Penalty
Summary
The facility failed to honor a resident's right to refuse pet therapy, despite the resident having a documented allergy to animal hair and a care plan specifying the resident's preference not to be approached for pet therapy. On a specific occasion, a therapy dog handler approached the resident's room and asked if the resident would like a visit from the dog. The resident, who had previously communicated their allergy and preference to avoid pet therapy, expressed frustration and felt disrespected by the repeated inquiries. The handler was unaware of the resident's preference due to a lack of communication among the facility staff and the pet therapy organization. The resident's electronic health record documented an allergy to animal hair/dander, and the care plan was revised to reflect the resident's preference against pet therapy. However, the LPN and CNA responsible for the resident were not informed about the pet therapy schedule or the need to avoid certain residents. The Volunteer Services Director/Interim Activities Director acknowledged that the pet therapy organization should have been informed about residents who did not wish to participate, and the DON confirmed that the resident should not have been approached, indicating a breakdown in communication and adherence to the facility's policies on resident rights and pet therapy.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that nurses adhered to professional standards of medication administration, as outlined in the State Board of Nursing Nurse Practice Act. Specifically, there was a failure to verify the appropriateness of a medication order for a resident diagnosed with heart failure. The resident's medication administration record (MAR) documented the administration of Spironolactone, which was supposed to be held if the resident's heart rate was below 60 beats per minute. However, the medication was administered on multiple occasions when the resident's heart rate was below this threshold. This discrepancy was due to an inaccurate transcription of the physician's order during a change of ownership, which led to the incorrect documentation in the electronic health record (EMR). Another deficiency was observed in the administration of eye drops to a resident with a diagnosis of unspecified moderate dementia. An LPN administered Artificial Tears without following the correct technique, resulting in a portion of the medication falling below the resident's eye. The LPN failed to draw the resident's lower eyelid down before administration, which is a necessary step to ensure the medication is properly instilled. This improper technique could potentially lead to reduced effectiveness of the medication or an increased risk of infection. The Director of Nursing (DON) confirmed the expectations for medication administration, which include verifying the right person, time, route, dosage, medication, and documentation. The DON also acknowledged the transcription error during the change of ownership and the lack of documentation for physician clarification regarding the Spironolactone order. The facility's policies on medication administration and eye medication instillation were not adhered to, leading to these deficiencies.
Deficiency in CPR Certification for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff maintained current Cardio-Pulmonary Resuscitation (CPR) certification for two of eleven sampled direct care employees. Employee #11, a Registered Nurse (RN), was hired without documented evidence of CPR training and certification in their personnel record. Employee #12, an RN/Infection Preventionist, had an expired CPR certification documented in their personnel record. Both employees' job descriptions required CPR certification as a minimum job requirement. The Human Resources Director confirmed that CPR certification was required for all direct care staff and acknowledged that Employees #11 and #12 did not have current CPR certifications. The Facility Assessment also documented that licensed nurses and certified nursing assistants were expected to maintain CPR certification.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities to meet the needs and interests of a resident diagnosed with post-traumatic stress disorder and chronic and major depressive disorder. The resident expressed a preference for staying in their room rather than participating in group activities and desired assistance with using electronic devices, such as a smartphone and a tablet, to alleviate feelings of depression. Despite these expressed needs, the facility's activities staff did not consistently engage with the resident or document individualized interactions, as evidenced by the lack of activity documentation in the electronic health record for a 14-day period. The Activities/Life Enrichment care plan for the resident acknowledged the resident's preference for solitary activities and included goals to engage the resident in activities of interest. However, the facility's activities staff did not follow through with daily check-ins or provide the necessary assistance with electronic devices, which could have helped the resident pursue personalized interests and reduce feelings of isolation. The Director of Volunteer Services/Interim Activities Director confirmed that the activities program could have supported the resident's needs but failed to do so, as the last documented activity was a self-directed engagement with movies or television.
Medication Security and Expiration Management Deficiency
Penalty
Summary
The facility failed to ensure the security and proper management of medications in one of its units. On March 11, 2025, a medication cart was observed left unlocked in the Tahoe/Truckee unit with five residents present in the area, posing a risk of unauthorized access to medications. A Registered Nurse (RN) confirmed the cart was unsecured and acknowledged the potential for residents to access the medications. The facility's policy mandates that all drugs and biologicals must be stored in locked compartments, which was not adhered to in this instance. Additionally, on March 13, 2025, expired medications were found in a medication cart and storage room on the Pinion/Aspen unit. The expired items included Docusate Sodium capsules, Ondansetron tablets, an IV solution bag, and a vial of Tuberculin Purified Protein Derivative. The RN confirmed these items had expired and should have been removed and destroyed. The Director of Nursing (DON) stated that expired medications should be immediately removed to prevent administration to residents, as they could be ineffective or harmful.
Failure to Ensure Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that culinary staff checked the holding temperatures for all hot foods before beginning meal service in the [NAME]/Quail dining room. During a lunch service, a culinary staff member did not check the temperature of all hot food items, including mashed potatoes and mechanical soft fish, before plating them for residents. The Dietary Manager later found that the mechanical soft fish was at 128 degrees Fahrenheit, below the required holding temperature of at least 135 degrees Fahrenheit. This oversight had the potential to result in foodborne illness due to improper food temperature management. In the Aspen/Pinion dining room, a similar issue occurred where a culinary staff member recorded the temperature of minced and moist texture vegetables at 132 degrees Fahrenheit, which was out of the safe range. Despite recognizing the temperature was too low, the staff member did not recheck the temperature before serving the food to residents. The Dietary Manager later confirmed that the food should have been reheated to 165 degrees Fahrenheit for at least 15 seconds before serving. The facility's policy required all hot food items to be held and served at a temperature of at least 135 degrees Fahrenheit, which was not adhered to in these instances.
Inaccurate EMR and MAR Transcription Errors
Penalty
Summary
The facility failed to ensure that the electronic medical record (EMR) accurately reflected a resident's code status, leading to a discrepancy between the EMR and the Physician's Order for Life-Sustaining Treatment (POLST) for one resident. This resident, diagnosed with unspecified dementia and anxiety, had a POLST indicating a do not resuscitate (DNR) status, while the EMR incorrectly documented full treatment cardiopulmonary resuscitation (CPR). The Director of Nursing (DON) confirmed that the EMR was not updated in a timely manner, which could have led to staff not honoring the resident's wishes in an emergency. Another deficiency was identified in the transcription of physician orders into the Medication Administration Record (MAR) and EMR for a resident with heart failure. The resident's MARs and EMR included an incorrect order to hold Spironolactone if the heart rate was less than 60 beats per minute. The DON later clarified that the original order did not require monitoring of the pulse rate for Spironolactone, indicating a transcription error during a change of ownership when orders were transferred between EMR systems. These deficiencies highlight the facility's failure to maintain accurate medical records and ensure that physician orders are correctly transcribed and reflected in the EMR. The discrepancies in the residents' records could have led to significant medication errors and compromised resident safety, as staff relied on inaccurate information to make clinical decisions.
Failure to Offer Timely Pneumonia Vaccines
Penalty
Summary
The facility failed to ensure that residents were offered timely pneumonia vaccines, which is a deficiency in their immunization practices. Specifically, Resident #21, who was admitted with serious respiratory and cardiac conditions, did not have documentation in their clinical record of being offered or receiving a pneumonia vaccine. The Infection Preventionist (IP) confirmed that there was no documentation of the vaccine being offered or administered, and acknowledged that the consent for vaccinations was not completed. This oversight indicates a lapse in following up with the resident or their representative to provide necessary education and offer the vaccine. Similarly, Resident #22, who had a history of heart disease and had previously received the 23-valent pneumococcal polysaccharide (PPV23) vaccine, was not offered the subsequent pneumococcal conjugate vaccines (PCV) as recommended by the CDC. The clinical record lacked documentation of the resident being educated on or offered the next PCV in the series, which should have occurred at least one year after the PPV23 vaccine. The IP confirmed that the resident should have been offered one of the PCV vaccines to complete the pneumococcal vaccine series, as per the facility's policy and CDC guidelines.
Failure to Educate and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that two residents were provided with education on the risks and benefits of the COVID-19 vaccination and were offered the vaccine. Resident #21, who was admitted with diagnoses including acute respiratory failure and heart failure, did not have documentation in their clinical record indicating that they were offered or received a COVID-19 vaccine. The Infection Preventionist (IP) confirmed that the consent for vaccinations was not completed, and there was no follow-up with the resident or their representative to provide education and offer the vaccine. Resident #22, who was admitted and later readmitted with diagnoses such as atherosclerotic heart disease and ischemic cardiomyopathy, refused a COVID-19 vaccination. However, there was no documentation that education on the vaccine was provided to the resident or their representative at the time of refusal. The IP confirmed that the resident should have been given education on the risks and benefits of the vaccination when it was offered. The facility's policy on vaccination requirements, revised in June 2022, mandates compliance with federal mandates, which was not adhered to in these cases.
Failure to Monitor and Respond to Resident's Condition After Fall
Penalty
Summary
A deficiency occurred when a resident with a history of frequent falls, chronic subdural hemorrhage, hepatic encephalopathy, and alcohol-induced persisting dementia experienced an unwitnessed fall in their room. The resident was found face down on the floor with their head touching the ground, exhibiting a red spot on the forehead, a large red scrape to the right chest, a skin tear on the lower right arm, and purple, swollen fingers. The resident was confused at baseline and unable to accurately recall recent events. After the fall, the resident was assisted to the shower and a skin assessment was performed. Neurological checks and vital signs were initiated, with blood pressure readings consistently elevated, reaching as high as 195/79. The LPN responsible for the resident did not review or act upon the vital signs documented by the CNA, despite the CNA notifying the LPN of the resident's high blood pressure. The LPN focused on other aspects of the neuro check, such as eyes and handgrips, and did not follow up with the CNA regarding the vital signs or review the documentation before initialing the neuro assessment flowsheet. The LPN did not notify the physician of the elevated blood pressure or the head injury, and the resident was not sent to the hospital until the night shift nurse identified the concerning findings and contacted the physician, who then ordered the resident's transfer for further evaluation. Interviews with staff and review of facility policies confirmed that the nurse was expected to assess the resident, obtain and review vital signs, perform neuro checks, and notify the physician based on assessment findings. The failure to review and act on the resident's vital signs, as well as the lack of timely physician notification and intervention, constituted neglect. This neglect was further supported by the facility's own policies and state regulations, which require nurses to supervise delegated tasks, monitor outcomes, and intervene appropriately when a resident's condition changes.
Failure to Report Suspected Neglect and Serious Injury to State Agency
Penalty
Summary
The facility failed to report an allegation of neglect and a fall resulting in serious bodily injury to the State Agency as required. A resident with a history of nontraumatic chronic subdural hemorrhage, hepatic encephalopathy, and alcohol-induced persisting dementia was found on the floor of their room, face down, with injuries including a large red scrape to the chest, a skin tear on the arm, and purple, swollen fingers. The fall was unwitnessed, and neurological checks were initiated. The resident's blood pressure remained high, and redness was noted on the forehead. The resident was later sent to the emergency room, where a subdural hematoma was diagnosed, and subsequently transferred for neurosurgical evaluation due to a new acute hemorrhage. Despite the serious nature of the injuries and the requirement to report such incidents, the facility did not notify the State Agency about the fall or the resulting injury. Interviews with facility leadership confirmed that the incident was not reported. Additionally, allegations were made against the former DON regarding instructions not to send the resident to the hospital or provide care, but these allegations were not thoroughly investigated or reported to the State Agency either. Facility policy required immediate reporting of alleged violations involving abuse, neglect, or injuries of unknown source, especially those resulting in serious bodily injury. However, the facility did not follow this policy in the case of the resident's fall and subsequent injury, nor in response to the allegations against the former DON. The lack of reporting and investigation was confirmed by both the Executive Director and the Regional Director of Quality and Clinical Services.
Failure to Investigate Alleged Neglect Following Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was found on the floor in their room with injuries, including a large red scrape to the chest, a skin tear on the lower right arm, and purple, swollen fingers. The resident had a history of frequent falls and was found face down, with no initial signs of head injury, but later developed redness to the forehead and elevated blood pressure. The resident was eventually sent to the emergency room, where a subdural hematoma was diagnosed, and subsequently transferred for neurosurgical evaluation. Despite the incident and the resulting injury, the facility did not initiate a thorough investigation into allegations that the former DON instructed staff not to send the resident to the hospital or provide care. The Regional Director of Quality and Clinical Services (RDQCS) acknowledged being informed of these allegations but did not consider them to be neglect and did not report or investigate them further. The RDQCS reviewed the resident's record and determined the allegations lacked merit, leading to no formal investigation or reporting to the State Agency (SA). Facility policy required that all allegations of abuse, neglect, or exploitation be thoroughly investigated and reported to the Administrator and SA within five working days. However, in this case, the facility did not follow its own policy or regulatory guidelines, as the allegations against the former DON were neither investigated nor reported, despite being communicated to facility leadership.
Failure to Post Current Nursing Hours
Penalty
Summary
The facility failed to ensure that current nursing hours were posted daily for all six units, as required. On March 10, 2025, it was observed that the nursing staff postings were outdated, showing the date of March 7, 2025. Interviews with the Staffing Coordinator and a Registered Nurse (RN) revealed that the Staffing Coordinator was responsible for posting the direct care staff information from Monday through Friday, while the RN was responsible for posting on Saturdays and Sundays. However, the RN confirmed that the postings for March 8 and March 9, 2025, were not updated. Both the Staffing Coordinator and the RN acknowledged that the nursing staff postings had not been updated since March 7, 2025, leading to a lack of awareness for residents and visitors regarding the number of nursing and direct care staff on duty.
Verbal Abuse by CNA Towards Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who had been admitted with diagnoses including post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. On the evening of the incident, the resident reported being called a profanity by the CNA while in their room. The resident expressed annoyance with the CNA and yelled for them to leave, which led to the CNA responding with profane language. This interaction was confirmed by the resident and the CNA admitted to using the profanity out of frustration. The facility's investigation substantiated the verbal abuse claim. The Regional Director of Quality and Clinical Services confirmed that the CNA had verbally abused the resident. The facility's policies on abuse and resident rights, which were revised in January 2023, clearly state that residents have the right to be free from verbal abuse and should be treated with dignity and respect. The CNA's actions were in direct violation of these policies, as well as the job description that emphasizes maintaining professionalism and composure when interacting with residents.
Failure to Submit Accurate and Timely Abuse Report
Penalty
Summary
The facility failed to submit a Facility Reported Incident (FRI) with accurate and complete information and did not provide a final report to the State Agency (SA) within the required five-day timeframe for a resident. The resident, who was admitted with diagnoses including major depressive disorder, vascular dementia, and anxiety disorder, was involved in an incident of employee to resident verbal abuse during medication administration. The initial FRI, submitted by the Administrator, inaccurately documented the incident date as occurring on a different date than reported. The Regional Director of Quality and Clinical Services confirmed the discrepancy and acknowledged that the final FRI was not submitted within the required timeframe. The facility's policy mandates that allegations of abuse, neglect, or exploitation be thoroughly investigated and reported to the appropriate State Agency within five working days of the alleged violation.
Hazardous Substances Found Accessible in Memory Care Unit
Penalty
Summary
The facility failed to ensure the secured memory care unit was free from potentially harmful and hazardous substances for vulnerable, cognitively impaired residents. During a tour of the memory care unit, various substances and items were found in resident rooms and accessible areas, including alcohol-based hand rub, antibacterial hand soap, medications, sharp objects, and potentially toxic items like cleaning solutions and personal care products. These items were accessible to residents with severe cognitive impairments, posing a risk of ingestion or harm. Residents in the memory care unit, such as Resident #88, Resident #31, and Resident #43, had documented diagnoses of dementia and cognitive impairments, requiring the safety of a secure unit due to impaired safety awareness and decision-making abilities. Despite these known vulnerabilities, hazardous items like alcohol-based hand rub, sharp objects, and medications were found in their living areas. The presence of these substances could lead to adverse health outcomes, including ingestion and potential hospitalization for these residents with severe cognitive impairments. The Director of Nursing acknowledged that residents in the memory care unit should not have had access to certain hazardous items, such as an Automated External Defibrillator and potentially dangerous personal care products. The facility's policy on Memory Care Accident Hazards/Supervision emphasized the importance of providing an environment free from accident hazards and ensuring supervision to prevent avoidable accidents for the high-risk population in the memory care unit. However, the findings from the survey indicated a lack of adherence to these policies, putting residents at risk of harm due to the presence of hazardous substances and materials in their living areas.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain a resident's dignity when a maintenance worker entered a resident's room without knocking or asking for permission. Resident #60, who has diagnoses including cerebral infarction, bipolar disorder, and chronic post-traumatic stress disorder, reported that staff did not always wait for a reply when knocking on the door. On one occasion, a maintenance worker entered the resident's room without knocking and proceeded to check a light fixture in the bathroom. The resident questioned the maintenance worker, who admitted to forgetting to knock and ask for permission. The facility's policy on Resident Rights-Respect and Dignity, last reviewed in December 2023, emphasizes the importance of treating residents with respect and dignity. Both the Administrator and a Registered Nurse confirmed that the expectation is for all staff to knock and ask for permission before entering a resident's room. Despite this policy, the maintenance worker failed to adhere to these guidelines, resulting in a breach of the resident's right to a dignified existence and self-determination.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy to investigate and report a resident's injury of unknown origin. Resident #4, who has Alzheimer's disease and severe dementia with agitation, was found with a large wound on their lower leg that required emergency treatment and stitches. Despite the severity of the injury, the facility did not conduct a thorough investigation immediately, nor did it report the incident to the State agency within the required timeframes. The injury was first documented by nursing staff in the early morning, and the resident was sent to the emergency department later that morning due to profuse bleeding. The investigation into the root cause of the injury was not documented until two days later. The Director of Nursing confirmed that such an injury should have prompted a thorough investigation, including interviews and written statements from staff. The Administrator acknowledged that the incident was reported as an injury of unknown origin but was not reported to the State agency as required. The facility's policy on abuse did not include specific timeframes for investigation and reporting, which contributed to the delay in addressing the incident. The failure to follow the policy and report the incident promptly could result in continued resident harm.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report a resident's injury of unknown origin to the State Agency in a timely manner. Resident #4, who had diagnoses including Alzheimer's disease and severe dementia with agitation, was found with a large wound on their lower leg. The wound, which was profusely bleeding, required emergency department treatment and 12 sutures to close. Despite the severity and unknown origin of the injury, the facility did not report the incident to the State Agency immediately as required by their policy. The investigation into the root cause of the injury was not concluded until two days later, on 02/28/2024. The facility's policy on preventing and prohibiting abuse mandates that any suspicious injury be reported immediately to the Administrator, State Agency, and other required agencies. However, the Administrator confirmed that the injury was not reported to the State Agency at the time it was discovered. This failure to report in a timely manner could potentially allow injuries of unknown origin to go uninvestigated for potential abuse. The facility's inaction in this case represents a significant lapse in adhering to their own policies and regulatory requirements.
Failure to Include Oxygen Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan was developed to address the care and interventions for oxygen therapy for a resident with chronic obstructive pulmonary disease (COPD). The resident was admitted with diagnoses including COPD, heart-valve replacement, and aortic stenosis. Despite the hospital discharge plan and nursing notes indicating the resident required chronic oxygen therapy at 3 liters per minute (lpm) via nasal cannula, the baseline care plan dated 04/12/2024 did not include any care plan for oxygen therapy. This omission was confirmed by both a Registered Nurse and the Director of Nursing, who acknowledged that the baseline care plan should have included oxygen therapy interventions. Observations on 04/15/2024 and 04/16/2024 confirmed the resident was using an oxygen concentrator at 2.0 lpm and verbalized the need for continuous oxygen due to COPD. The facility's policy on respiratory care required a practitioner's order for oxygen therapy and a care plan identifying interventions based on the resident's assessment and orders. However, the resident's baseline care plan lacked these essential details, which could result in staff being unaware of the resident's chronic oxygen needs.
Inaccurate and Inappropriate Care Plans
Penalty
Summary
The facility failed to ensure the Comprehensive Care Plan was updated to include the care and interventions for oxygen therapy for one resident and that the care plan interventions were appropriate for three residents residing in the specialized care unit. Specifically, Resident #145's care plan did not match the physician's order for oxygen therapy, which indicated a range of 1-3 liters per minute (lpm) to maintain oxygen saturation levels above 90%. The care plan only documented oxygen therapy at two lpm. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged that the care plan should have been updated to reflect the current physician's order. Additionally, the care plans for three residents in the memory care unit (Residents #9, #56, and #67) were found to be inappropriate. These residents were documented as being able to leave the locked unit independently and were instructed not to open the doors for other residents. However, the DON and the Administrator confirmed that it was not the intention for these residents to be responsible for the oversight of other residents. The care plans lacked dates, and the facility's policy on comprehensive care plans emphasized that care plans should be person-centered and drive the type of care and services a resident receives.
Medication Administration Deficiency
Penalty
Summary
The facility failed to meet professional standards of medication administration for one resident diagnosed with unspecified dementia and anxiety. A physician's order required the resident to take Metoprolol Succinate Extended Release 25 mg, 1.5 tablets by mouth once a day. On the morning of 04/15/2024, a pill was found on the resident's side table, indicating that the medication had not been ingested as required. The Assistant Director of Nursing (ADON) confirmed that the medication was Metoprolol and that it had been administered the previous night according to the Medication Administration Record (MAR). The ADON acknowledged that the nurse administering the medication did not stay with the resident to ensure the medication was swallowed, which is against the facility's policy and professional standards of practice. The Director of Nursing (DON) also confirmed that medications should not be left unsecured at a resident's bedside and that nurses are expected to stay with the resident until the medication is effectively administered. The facility's policy on medication administration, reviewed in December 2023, mandates that medications be administered following the six rights of medication administration and in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards. The incident was documented as a medication error, highlighting a lapse in adherence to these standards and policies.
Failure to Ensure CPR Certification for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest. Specifically, one of the four sampled licensed nurses, Employee #15, who was hired as a Licensed Practical Nurse (LPN), did not have documented evidence of CPR training and certification in their personnel record. The Human Resources Director confirmed that CPR certification was required for all licensed nurses upon hire and acknowledged that Employee #15 did not have current CPR certification. The facility's policy on Cardiopulmonary Resuscitation, last reviewed on a specified date, stated that all licensed nursing staff would maintain current CPR certification.
Failure to Coordinate Medication Orders with Hospice Agency
Penalty
Summary
The facility failed to ensure a resident's medication orders were coordinated with the contracted hospice agency providing end-of-life care. This deficiency was identified for one resident who had diagnoses including Alzheimer's disease, unspecified cirrhosis of the liver, and other chronic pain. Discrepancies were found between the facility's Order Summary Report and the hospice agency's Client Medication Report. These discrepancies included differences in orders for medications such as Famotidine, Omeprazole, Lorazepam, and oxygen administration, as well as the presence of an order for Venelex ointment in the facility orders but not in the hospice orders. Interviews with facility staff and the hospice agency's RN Case Manager revealed that medication reconciliation was supposed to occur weekly, but the discrepancies indicated this process was not effectively implemented. The Director of Social Services, who was identified as a Hospice Coordinator, was not familiar with the term and had limited interaction with hospice agencies after residents were admitted to hospice services. The Director of Nursing confirmed that medication changes should be reconciled in real time to ensure consistency between facility and hospice orders. The facility's contract with the hospice agency and its policy on hospice care both emphasized the need for coordination and communication to resolve any inconsistencies in physician orders.
Failure to Follow Physician's Orders for Respiratory Care
Penalty
Summary
The facility failed to obtain and/or follow a physician's order for respiratory care for two residents. Resident #145 was observed receiving oxygen at 4.0 and 4.5 liters per minute (lpm) on different occasions, despite a physician's order specifying oxygen administration at 1-3 lpm. The Registered Nurse (RN) and Director of Nursing (DON) confirmed that the oxygen should not exceed 3.0 lpm without a change in the physician's order, and the physician should be notified if the resident's oxygen saturation was not above 90 percent at 3.0 lpm. Resident #295 was observed receiving oxygen at 2.0 lpm, although the hospital discharge plan indicated the resident required 3.0 lpm. The physician's order for Resident #295 lacked a specified flow rate and a range to maintain the resident's oxygen saturation. The RN and DON confirmed the deficiency in the oxygen therapy order. The facility's policy required a practitioner's order for oxygen therapy, including specific flow rates and monitoring instructions, which was not followed in this case.
Failure to Complete Monthly Medication Reviews on Time
Penalty
Summary
The facility failed to ensure Monthly Medication Reviews (MMR) were completed within the required timeframe for two residents. Resident #66, diagnosed with dementia and other conditions, did not have an MMR completed within thirty days for August 2023, as the review was done on 09/01/2023 instead of within the month. Similarly, Resident #51, with diagnoses including adjustment disorder and insomnia, also lacked an MMR within the required timeframe for August 2023, with the review completed on 09/01/2023. Both the Pharmacist and the Director of Nursing confirmed that the MMRs were not completed within the stipulated 30 to 31 days as per the facility's policy, which mandates monthly reviews by a licensed pharmacist.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medication was administered with an error rate of less than 5%. There were 25 opportunities and two medication errors, resulting in a medication error rate of 8%. One incident involved a resident with dementia and other conditions, where a Registered Nurse (RN) failed to remove a lidocaine patch as scheduled, leading to the application of a new patch without removing the old one. The RN confirmed the error, and the Director of Nursing (DON) acknowledged that the patch should have been removed to prevent skin irritation. Another incident involved a resident with type two diabetes mellitus, where an RN did not follow proper protocol for preparing an Insulin Glargine (Lantus) pen. The RN did not swab the pen tip with alcohol before attaching the needle, contrary to the manufacturer's instructions and facility policy. The DON confirmed the correct procedure, which includes swabbing the pen tip with alcohol before attaching the needle. The facility's policy on medication administration emphasizes following the six rights of medication administration and adhering to accepted professional standards and practices.
Failure to Ensure Hair Restraints and Hand Hygiene
Penalty
Summary
The facility failed to ensure an employee wore the appropriate hair restraints when working in the kitchen and did not perform hand hygiene before and after resident contact during a lunch service. On 04/17/2024, a Certified Nursing Assistant (CNA) was observed entering the kitchen area without a hair restraint covering their full beard. The Dietary Services Director (DSD) confirmed that the facility's policy required hair restraints to cover all hair on the head, but the policy did not address facial hair. The DSD expected employees to cover all hair on the head and face while working in the kitchen to maintain sanitary conditions. Additionally, on 04/15/2024, during a lunch service, a CNA was observed delivering multiple plates to residents without performing hand hygiene between each interaction. The CNA confirmed that they had not performed hand hygiene between passing plates to residents, despite the facility's policy requiring hand hygiene before and after contact with residents. The Infection Preventionist (IP) also confirmed that hand hygiene should be performed after delivering a tray or plate to a resident and before picking up the next one to reduce the risk of spreading pathogens.
QAA Committee Failed to Identify Timely Training Deficiency
Penalty
Summary
The Quality Assessment and Assurance (QAA) Committee failed to identify the lack of timely training for staff. During an interview, the Administrator acknowledged that the QAA Committee had not recognized concerns regarding the timeliness of training. The Administrator explained that the online training system allowed for trainings to be completed by the end of the month they were due, which resulted in trainings being completed late. The Administrator confirmed that trainings were being completed according to the online training company's standards rather than regulatory standards. The facility's QAPI Plan emphasized systemic improvement and education but did not address the specific issue of timely training compliance.
Infection Control Deficiencies in Insulin Administration and COVID-19 Testing
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the administration of insulin and COVID-19 testing. Specifically, a Registered Nurse (RN) did not disinfect the rubber seal on an insulin pen with alcohol before attaching a needle and administering insulin to a resident with type two diabetes mellitus. The RN explained that the pen tip was not swabbed because it had been covered by the cap. The Director of Nursing (DON) confirmed the correct procedure was to swab the pen tip with alcohol before attaching the needle, as documented in the facility's policy and the manufacturer's instructions. Additionally, a used COVID-19 test was found in a common area near the nursing desk, which had been used by a symptomatic staff member. The Infection Preventionist (IP) confirmed that the test should have been performed in a designated testing room and not in a resident area. The facility's policy stated that symptomatic staff should be restricted from the facility pending COVID-19 test results. These deficiencies have the potential to cause the spread of communicable diseases within the facility.
Failure to Ensure Timely Elder Abuse Prevention Training
Penalty
Summary
The facility failed to ensure timely completion of elder abuse prevention training for three employees. Employee #4, a Registered Dietitian, was hired on 04/21/2022, but did not complete the required abuse prevention training until 05/22/2023, one month past the employee's anniversary date. Employee #7, a Certified Nursing Assistant, was hired on 04/10/2023, and while initial training was documented on the hire date, there was no evidence of annual abuse prevention training for 2024. Similarly, Employee #9, a Registered Nurse hired on 05/06/2019, had documented abuse prevention training on 03/27/2023, but lacked evidence of annual training for 2024. The Human Resources Director confirmed these deficiencies, noting that training is required upon hire and annually thereafter. The facility's policy, last reviewed on 12/18/2023, mandates training upon hire, annually, and as needed.
Failure to Ensure Annual Behavioral Health Training
Penalty
Summary
The facility failed to ensure annual behavioral health training was completed for six of twenty sampled employees. The employees in question included the Administrator, Director of Nursing, Recreation Director, a Certified Nursing Assistant, a Registered Nurse, and the Infection Preventionist/Licensed Practical Nurse. Despite the facility's policy requiring all staff to undergo behavioral health training upon hire and annually, these employees did not have documented evidence of completing the required training for 2024. The personnel files for these employees only showed dementia training completed in 2023, with no records for 2024 training. On April 17, 2024, the Human Resources Director confirmed that the six employees had not received the required behavioral health training for 2024 by their respective anniversary dates. The facility's policy, last reviewed in December 2023, mandates that staff members who have direct contact with and provide care to persons with dementia must complete continuing education specifically related to dementia. The lack of compliance with this policy was identified through personnel record reviews, interviews, and document reviews.
Failure to Update Facility Assessment for Memory Care Unit
Penalty
Summary
The facility failed to ensure the Facility Assessment (FA) was updated to reflect accurate and current staffing needs of the facility's special care unit (memory care). The FA dated [DATE] documented a staffing plan for direct care staff as 1 staff member to 16 residents, but did not include staffing levels required for the memory care unit. On 04/17/2024, the Director of Nursing verbalized that the staffing ratio in the memory care unit was one staff member to eight residents. On 04/18/2024, the Administrator confirmed that the FA staffing plans did not address the staffing needs of the memory care unit. The facility policy titled Facility Assessment, revised on 02/2024, documented that the Pyramid/[NAME] household was designated as a special care unit specific to memory care.
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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