Sage Creek Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 2350 Ione Road, Las Vegas, Nevada 89123
- CMS Provider Number
- 295098
- Inspections on file
- 24
- Latest survey
- May 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sage Creek Post-acute during CMS and state inspections, most recent first.
A facility failed to provide nephrostomy care as ordered for a resident with bilateral nephrostomy tubes, risking complications. The resident's care was not documented on several shifts, contrary to physician orders and facility policy. The Assistant Regional Director of Clinical Services confirmed the lack of documentation and explained the necessary care procedures, which include ensuring proper drainage and checking for complications.
A facility failed to label an IV medication bag for a resident, as observed when an LPN prepared Ciprofloxacin but an unlabeled Metronidazole bag was found. The ARDCS confirmed the night nurse should have labeled it. Another resident's record lacked documentation for IV line insertion or removal, despite orders for IV medications. The RN couldn't recall the IV access details, and the ARDCS noted missing documentation, violating facility policies.
The facility failed to implement daily wound care orders for two residents, risking further skin breakdown and infections. One resident with rhabdomyolysis and sepsis had multiple wound care orders not documented as completed, while another with muscle weakness and end-stage renal disease also missed regular treatments. Interviews confirmed the lack of documentation and acknowledged the treatments were not performed as ordered.
A resident with a fractured shoulder was not consistently provided with a sling as ordered, leading to a deficiency in care. Despite a physician's order for the sling to be worn at all times, observations and interviews revealed it was not consistently applied, and when used, it was not fitting properly. Staff, including an LPN and the Director of Staff Development, confirmed the inconsistency, and the Director of Rehabilitation Services emphasized the importance of the sling in preventing further injury.
A facility failed to implement fall interventions for a high-risk resident with a history of falls and a shoulder fracture. Despite a care plan requiring the bed to be in a low position, observations showed the bed was often at waist level. Staff interviews revealed inconsistencies in monitoring and applying fall precautions, leading to a deficiency in ensuring the resident's safety.
A resident with an indwelling catheter and UTI history did not receive proper perineal care as per facility procedure. A CNA was observed performing catheter care but failed to wash the resident's perineal area, which is essential to prevent infections. The Infection Preventionist confirmed the CNA's omission, which did not align with the facility's policy aimed at preventing catheter-associated complications.
The facility failed to manage pain effectively for two residents. One resident did not receive pain medication according to prescribed parameters, leading to unmanaged pain. Another resident did not receive pain medication prior to wound care, resulting in severe pain during the procedure. Facility policies on pain management and medication administration were not followed, contributing to these deficiencies.
A resident with chronic pain and opioid dependence was administered Norco outside the prescribed parameters, receiving the medication for pain levels below the ordered threshold. Despite a care plan and facility policy requiring verification of medication administration, the resident received Norco for pain levels as low as 3 and 5, contrary to physician orders.
The facility failed to conduct timely nutritional assessments and weight monitoring for residents, leading to potential delays in nutritional interventions. A resident did not have a baseline weight or weekly weights recorded, resulting in a significant weight loss. Another resident experienced a 7.8% weight loss without a timely nutritional assessment, and a third resident had a 13.3% weight loss with no documented assessment or updated food preferences.
Failure to Provide Nephrostomy Care as Ordered
Penalty
Summary
The facility failed to provide nephrostomy care in accordance with the physician's order and facility policy for one resident. The resident, who was admitted with diagnoses including malignant neoplasm of the bladder and sepsis, had bilateral nephrostomy tubes to allow urine drainage due to a blockage. A physician's order required nephrostomy care every shift, with the option to change the bag as needed. However, the Medication Administration Record (MAR) for September 2024 showed no documented evidence of nephrostomy care being performed on specific shifts over three days. The Assistant Regional Director of Clinical Services confirmed the lack of documentation for nephrostomy care on the specified dates and explained that such care includes emptying the bag, ensuring proper drainage, checking for kinks, and identifying complications. The facility's policy, revised in October 2010, outlined similar procedures and emphasized the importance of following physician orders to prevent complications. The failure to document and perform the required nephrostomy care placed the resident at risk for complications related to the nephrostomy tubes.
Deficiencies in IV Medication Labeling and Documentation
Penalty
Summary
The facility failed to ensure proper labeling of intravenous (IV) medication bags, as observed in the case of a resident who was administered Metronidazole without a label bearing their name. The Licensed Practical Nurse (LPN) was observed preparing to administer Ciprofloxacin to the resident, following the facility's process of affixing a sticker label from the original package onto the IV bag. However, an empty IV bag of Metronidazole was found without a label, which the LPN confirmed. The Assistant Regional Director of Clinical Services (ARDCS) acknowledged that the night nurse should have labeled the IV bag, as per facility practice, to ensure the six rights of medication administration were followed. Another deficiency was noted in the case of a resident who was admitted with a history of malignant neoplasm of the bladder and sepsis. The resident's medical record lacked documentation of a physician's order for the insertion or removal of a peripheral IV line, despite orders for IV medication administration and saline flushes. The Charge Registered Nurse (RN) could not recall if the resident was admitted with an IV access or if it was inserted at the facility. The ARDCS confirmed the absence of documentation for the IV line's insertion or removal, which was against the facility's policy requiring documentation of such procedures. The facility's policies on peripheral IV catheter insertion and removal, dated 2001, require documentation of the provider's order, procedure details, and communication with the physician. The lack of adherence to these policies in the case of the second resident highlights a failure in maintaining proper documentation and following established protocols for IV access management, which could lead to medication errors and complications related to IV access.
Failure to Implement Daily Wound Care Orders
Penalty
Summary
The facility failed to implement daily wound care physician orders for two residents, increasing the risk of further skin breakdown and infections. Resident 1, who was admitted with conditions including rhabdomyolysis and sepsis, had multiple physician orders for wound care that were not documented as completed on specified dates. These orders included treatments for various wounds on the resident's body, such as the application of ace wraps and specific wound dressings. The medical records lacked evidence of these treatments being performed on several occasions, indicating a failure to adhere to the prescribed care regimen. Resident 2, admitted with muscle weakness and end-stage renal disease, also did not receive regular wound care as ordered. The medical records showed missing documentation for wound care on multiple dates, suggesting that the treatments were not completed. Interviews with a wound care LPN and the DON confirmed the absence of documentation and acknowledged that wound care was not performed as ordered. The facility was in the process of replacing a wound nurse during this period, which may have contributed to the oversight. The facility's policy required documentation of wound care, but this was not followed, leading to the identified deficiency.
Inconsistent Application of Sling for Resident with Fractured Shoulder
Penalty
Summary
The facility failed to ensure that a splint was consistently applied to treat a fractured shoulder as ordered for a resident. The resident, who had a history of falling and a nondisplaced fracture of the greater tuberosity of the left humerus, was admitted with a physician's order to wear a sling at all times to immobilize the shoulder. However, observations and interviews revealed that the sling was not consistently applied, and the resident reported that it was not used daily. On multiple occasions, the resident was found without the sling, and staff members, including an LPN and the Director of Staff Development, confirmed the absence of the sling and the inconsistency in its application. Further observations indicated that when the sling was applied, it was not fitting properly and was not the correct type to aid the resident's condition. The Director of Rehabilitation Services confirmed the resident's need for maximum assistance and the importance of the sling in preventing further injury. Despite the facility's policy on maintaining and supervising the use of assistive devices, the staff failed to ensure the proper and consistent application of the sling as ordered, leading to a deficiency in care for the resident.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions and management for a resident identified as high risk for falls. The resident, who had a history of falling and a nondisplaced fracture of the left humerus, was admitted with a care plan that included keeping the bed in a low position. However, observations revealed that the resident's bed was often at waist level, contrary to the care plan's directives. The resident reported a recent fall at the facility, and staff confirmed the bed was not consistently kept in the lowest position, which was a critical intervention for fall prevention. The facility's fall protocols were not adequately followed, as indicated by the use of a yellow star fall indicator instead of the appropriate red star for high-risk residents. Staff interviews revealed inconsistencies in monitoring and implementing fall precautions, such as hourly checks and the use of fall mats. Despite the resident's high fall risk and recent fall history, the necessary precautions were not consistently applied, leading to a deficiency in ensuring a safe environment for the resident.
Failure to Provide Proper Perineal Care for Resident with Catheter
Penalty
Summary
The facility failed to provide appropriate perineal care for a resident with an indwelling catheter and a history of urinary tract infections (UTIs). The resident, who was admitted with diagnoses including Alzheimer's disease, chronic kidney disease stage four, and a UTI, was observed on a specific date with a kinked urinary catheter tubing, which was causing urine obstruction. A Certified Nursing Assistant (CNA) was observed performing catheter care but failed to wash the resident's perineal area, which is a crucial step in preventing infections. The CNA acknowledged the omission of perineal care, which is part of the facility's procedure for catheter care. The Infection Preventionist confirmed that the CNA did not follow the facility's policy, which includes washing the urethral meatus to prevent catheter-associated complications such as UTIs. The resident had previously been transferred to the hospital for UTI treatment and returned with antibiotic therapy, indicating a heightened risk for recurrent infections due to the deficient practice.
Failure in Pain Management for Two Residents
Penalty
Summary
The facility failed to manage pain effectively for two residents, leading to unmanaged and prolonged pain. Resident 12, who had diagnoses including urinary tract infection and immunodeficiencies, was not administered pain medication according to the ordered parameters. Despite having a care plan that included administering medication as ordered, the resident frequently experienced pain levels outside the prescribed range for the medications Norco and Tylenol. Observations and interviews revealed that the resident was in frequent pain, and the staff did not adhere to the physician's orders, administering medication at inappropriate pain levels. Resident 20, with diagnoses including a stage 4 pressure ulcer and chronic pain, did not receive pain medication prior to wound care treatment, resulting in severe pain during the procedure. The resident was observed grimacing and groaning in pain while being turned for wound care, and the pain medication was only requested after the procedure had begun. The Wound Care Treatment Nurse assumed the medication had been administered post-therapy, but it was confirmed that the medication should have been given at least an hour before the wound care to ensure comfort. The facility's policies on pain assessment and management, as well as medication administration, were not followed, contributing to the deficiencies. Staff interviews confirmed the failure to adhere to prescribed pain management protocols, which were intended to alleviate pain based on clinical conditions and treatment goals. The attending physician emphasized the importance of following prescribed parameters for effective pain management, which was not done in these cases.
Resident Administered Unnecessary Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically pain medication. Resident 60, who was admitted with diagnoses including metabolic encephalopathy, opioid dependence, and chronic pain, was administered Norco (Hydrocodone-Acetaminophen) outside the physician-ordered parameters. The care plan for the resident, initiated on May 27, 2024, included interventions to assess pain every shift and offer nonpharmacological interventions. However, the Medication Administration Record for June 2024 showed that Norco was administered on multiple occasions when the resident's pain level was below the prescribed threshold of 7-10. The facility's policy on administering medications, revised in April 2019, requires staff to verify the right resident, medication, dosage, time, and method before administration. Despite this policy, the resident received Norco for pain levels as low as 3 and 5, contrary to the physician's orders. On June 27, 2024, the Medical Director emphasized the importance of adhering to prescribed parameters for effective pain management, indicating that staff should not have administered opioids unless the pain level was moderate to severe, as ordered.
Failure to Conduct Timely Nutritional Assessments and Weight Monitoring
Penalty
Summary
The facility failed to ensure proper weight management and nutritional assessments for several residents, leading to potential delays in implementing necessary nutritional interventions. Resident 168 was admitted and readmitted with significant medical conditions, including amputations, but the facility did not obtain a baseline weight upon admission or conduct weekly weight checks as required. The Registered Dietitian (RD) confirmed that the weight was not obtained until 19 days after admission, resulting in a documented weight loss of 16 pounds. The RD acknowledged the importance of obtaining a baseline weight and weekly weights to monitor changes and prevent delayed interventions. Resident 20 experienced a significant weight loss of 7.8% over a short period, yet the facility did not conduct a nutritional assessment following this change. The RD noted the weight loss but did not report a change of condition or reassess the resident, citing the resident's overweight status as a reason for not being concerned. The RD confirmed that a nutritional assessment was not completed until over a month later, which could have impacted the resident's health status. Resident 16 also experienced a significant weight loss of 13.3% within a month, but the facility failed to complete a nutritional assessment when the weight change was identified. The RD and dietary manager did not document the resident's food preferences and dislikes, which could have contributed to the resident's poor meal consumption. The RD confirmed that a nutritional assessment was not initiated or completed despite the significant weight change, and the dietary manager's revisits were not documented in the resident's medical record.
Latest citations in Nevada
Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
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