Sandstone Spring Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 5650 South Rainbow Blvd, Las Vegas, Nevada 89118
- CMS Provider Number
- 295095
- Inspections on file
- 34
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Sandstone Spring Valley during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was subjected to abuse when a CNA unplugged the resident's room phone and placed it out of reach after the resident repeatedly called the front desk. The CNA admitted to this action, which was found to be willful punishment resulting in the resident's mental anguish. The incident was substantiated through interviews and documentation, confirming a failure to protect the resident from abuse.
A CNA took a resident's phone away and placed it out of reach after the resident repeatedly called the front desk, causing the resident mental anguish. The facility's policy required ongoing abuse prevention training, but staff did not receive additional training after the incident, and some could not recall when they last had abuse and neglect training.
A resident with multiple health conditions was directed by a CNA to urinate in their incontinence brief, violating their dignity. Interviews revealed that this practice was not isolated, as another resident reported similar experiences. The DON confirmed that such instructions are inappropriate and compromise resident dignity.
A facility failed to clarify discrepancies in an appeal decision, leading to inadequate discharge planning for a resident with mobility issues. The resident was discharged without necessary skilled therapy, and the facility did not review the appeal decision before providing it to the resident. Discussions with the resident and spouse were not documented, and caregiver training did not occur due to the spouse's inability to provide care. The resident was discharged home with hospice services without proper coordination.
A resident with dementia did not receive scheduled showers or bed baths for several weeks, despite requiring minimal assistance. Facility staff failed to document refusals or provide alternative hygiene care, leading to a deficiency in care.
Two free-standing portable oxygen cylinders were improperly stored in a resident's room, one empty and the other half full. The resident and a CNA were unaware of the reason for their presence. An RN stated that cylinders should be on a stand or stored in a closet, as per facility policy. The DON confirmed that cylinders should not be left free-standing without proper storage.
A medication security lapse occurred when a cream was left unattended in a resident's room. The resident, with multiple health conditions, had an order for Moisture Barrier Cream with Zinc 10%, which should only be applied by the Wound Care Nurse. Both the RN and Wound Care Nurse confirmed the cream should not have been left in the room.
The facility did not follow the planned menu for a breakfast service, affecting all residents. On a specific morning, breakfast served included items meant for the following day due to a cook's error in reading the menu. The Dietary Manager acknowledged the mistake and stated that residents would be informed of the change by updating the menus in the hallways.
The facility exhibited several deficiencies in food handling and hygiene practices, including improper storage of personal items with resident food, failure to wear hairnets and wash hands in the kitchen, and inadequate food storage temperatures. Additionally, thermometers were not properly sanitized between uses, increasing the risk of foodborne illnesses among residents.
The facility failed to maintain a homelike environment in four dining rooms by storing medical equipment such as hoyer lifts, vital sign monitors, and wheelchair scales in these areas. Staff, including CNAs, RNs, and the DON, confirmed that the equipment was stored in the dining rooms for convenience, despite available storage areas. Residents and staff acknowledged that this practice detracted from a homelike environment, contrary to the facility's policies.
The facility failed to remove expired, unsealed, and discontinued medications from medication carts and storage rooms. Expired IV solution bags and a vial of Humalog Lispro were found on the Valley unit, while expired Geri-Lanta and Sodium Bicarbonate were found on the Lake unit. An unsealed syringe of Lovenox was discovered on the Mount unit, and discontinued Morphine doses belonging to a discharged resident were not removed from the Lake unit's medication cart. These deficiencies were confirmed by nursing staff and the DON.
The facility failed to inform residents about the rules for leaving on pass, affecting all 129 residents. A resident felt imprisoned after being told they would be discharged if they left. During interviews, residents and staff confirmed that leaving required a physician's order, which was difficult to obtain. The DON admitted the facility did not follow its policy requiring both physician and interdisciplinary team approval for passes, and residents were not informed of these rules upon admission.
A facility failed to provide a resident or their representative with information about the right to formulate an advance directive. The resident, admitted with severe medical conditions, had no documented evidence of an advance directive or information provided about it. The DON confirmed the oversight, which contradicted the facility's policy requiring such information to be given upon admission.
The facility failed to develop care plans for three residents with specific needs, including a resident on hospice, a resident with anxiety, and a resident dependent on a respirator. The absence of care plans for these conditions was confirmed by the DON, highlighting a failure to adhere to the facility's policy requiring comprehensive care plans.
A resident's medication was left unsecured at their bedside by an LPN, who exited the room without ensuring the medication was taken. The resident, with acute osteomyelitis and COPD, was at risk of not receiving the therapeutic benefits of the medication. The DON confirmed that staff should remain with residents until all medications are taken, as per facility policy.
The facility failed to ensure accurate documentation of DNR status in electronic health records for four residents, who were incorrectly listed as 'full code' despite having POLST forms indicating DNR. Staff relied on these records during emergencies, leading to potential violations of residents' wishes. The DON confirmed the discrepancies, which contradicted the facility's policy on respecting and documenting advance directives.
A resident with type two diabetes mellitus was not provided with the ordered heart healthy consistent carbohydrate (CCHO) diet due to a failure in updating the meal card. The facility's electronic system update led to manual entry of diets, and the resident's therapeutic diet was missed, resulting in the resident receiving a regular diet instead. This discrepancy was confirmed by staff and highlighted the importance of adhering to diet orders for diabetic residents.
A resident receiving hemodialysis did not have dialysis communication forms maintained in their clinical record, as required by facility policy. Despite being sent to dialysis with a binder containing these forms, the binder did not return with the resident. The DON confirmed the absence of these forms, which are crucial for monitoring any complications during dialysis. The facility's policy mandates coordination with the dialysis center and obtaining communication sheets after each appointment, which was not followed.
A resident received an unnecessary medication due to the facility's failure to discontinue it after receiving a physician's order. The resident was prescribed two medications from the same drug class for bladder issues. Despite a physician's instruction to discontinue one of the medications, the order was not documented, and both medications continued to be administered. An LPN discovered the oversight, and the DON confirmed the expectation for staff to document and follow physician orders.
A resident with anxiety disorder was prescribed Hydroxyzine Pamoate for 14 days, but it was administered for 20 days without proper side effect or behavior monitoring. Staff interviews revealed a lack of adherence to monitoring requirements, and the DON incorrectly believed the 14-day limit did not apply to long-term residents.
A facility failed to maintain a medication error rate below 5%, with a reported rate of 19.35%. An RN administered medications to a resident with acute respiratory failure and seizures at 11:04 AM, beyond the scheduled 9:00 AM time, violating the policy of administering within one hour before or after the scheduled time. The DON confirmed this timing as late, contributing to the high error rate.
A facility failed to maintain complete and accurate records for a resident with chronic kidney disease and malnutrition due to inconsistent weighing methods. The resident's weight was recorded using different scales, leading to inaccuracies in monitoring significant weight changes. The facility's policy required consistent use of the same weighing device, which was not followed, and the CNA responsible for weighing was unavailable during the survey.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic wounds, as required by their policy, and did not ensure proper hand hygiene during medication administration for another resident. The lack of EBP signage and PPE cart for the resident with wounds and the failure of an LPN to perform hand hygiene after glove removal and between resident interactions were identified as deficiencies.
A Certified Nursing Assistant at the facility did not complete mandatory training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation since their hire. This oversight was confirmed by the Director of Human Resources, despite the facility's policy requiring such training.
Resident Not Protected from Abuse by CNA
Penalty
Summary
A resident with multiple chronic conditions, including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure, was re-admitted to the facility. The resident reported that a Certified Nursing Assistant (CNA) took away their room phone after the resident repeatedly called the front desk. The CNA admitted to unplugging the phone and placing it out of the resident's reach, instructing the resident to stop calling downstairs. The facility's investigation substantiated the allegation of abuse, documenting that the CNA willfully inflicted punishment, resulting in the resident's mental anguish. The resident described the CNA as being bossy and giving attitude, stating that the CNA was upset due to frequent use of the call light and phone. The resident's behavioral care plan noted distress related to feelings of powerlessness and difficulty adjusting to life in the facility, with interventions focused on calm communication and staff professionalism. During the incident, the resident still had access to their cell phone and call light. The facility's policy requires an environment free from abuse, corporal punishment, involuntary seclusion, and other forms of mistreatment. The deficiency was identified through interviews, record review, and documentation, confirming that the resident was not protected from abuse as required.
Failure to Implement Abuse Prevention Policies Following Substantiated Abuse Incident
Penalty
Summary
A deficiency occurred when a staff member failed to implement the facility's abuse prevention policies and procedures for a resident who had multiple medical conditions, including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure. The incident involved a Certified Nursing Assistant (CNA) who admitted to taking away the resident's room phone and placing it out of reach after the resident repeatedly called the front desk. This action was substantiated as abuse, as it resulted in the resident experiencing mental anguish. Interviews and record reviews revealed that, despite the facility's policy requiring ongoing abuse prevention training, staff did not receive additional abuse training following the incident. While some staff recalled completing annual abuse and neglect training, others could not remember when such training last occurred. The Director of Nursing acknowledged that ongoing abuse training should have been provided in response to the event, as outlined in the facility's policy, but this did not happen.
Resident Directed to Urinate in Brief, Violating Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect, as evidenced by staff directing a resident to urinate in their incontinence brief. This deficiency was observed in one of the sampled residents, who was admitted with diagnoses including hypertension, end-stage renal disease with hemodialysis, and congestive heart failure. During interviews, a CNA acknowledged that staff are not supposed to instruct incontinent residents to use their briefs as a bathroom, but admitted it does occur. Another resident confirmed having been told to urinate on themselves in the past, expressing feelings of upset and noting that other residents have experienced similar instructions. The affected resident reported that a CNA on the night shift instructed them to urinate in their brief if they had to wait for assistance, which caused emotional distress. The Director of Nursing confirmed that such instructions are inappropriate and result in dignity issues.
Discharge Planning Deficiency Due to Appeal Decision Discrepancy
Penalty
Summary
The facility failed to clarify discrepancies in the appeal decision for a resident's discharge, resulting in a lack of well-coordinated discharge planning. The resident, who had difficulty walking and other lower extremity issues, was discharged without the necessary skilled therapy to improve functional ability. The appeal decision inaccurately stated that the resident could walk 100 feet without an assistive device, which was not consistent with the resident's actual condition as documented by the Director of Rehabilitation and the Interdisciplinary Team. The facility did not review the appeal decision before providing it to the resident, leading to a discharge without proper coordination of care. The case manager did not document discussions with the resident and their spouse regarding the discharge plan, and caregiver training did not occur because the spouse was unable to provide care. The resident was financially overqualified for Medicaid services and declined additional placement options, leading to a decision to discharge home with hospice services. The lack of documentation and coordination in the discharge process resulted in a deficiency, as the facility did not ensure the resident received the necessary provisions for continuation of care.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that showers were provided as scheduled for a resident diagnosed with major vascular neurocognitive disorder-dementia. The resident required minimal assistance with showering and was scheduled to receive showers twice a week, on Mondays and Thursdays. However, documentation revealed that the resident did not receive a shower or bed bath on the scheduled days for several weeks, including the week of January 11 through January 15, and on January 18 and January 22. The only recorded instances of hygiene care were a bed bath on January 8 and a shower on January 16. Interviews with staff members indicated that if a resident refused a shower or bed bath, the CNAs were expected to notify the nurse and document the event. However, there was no documentation of refusals or alternative hygiene care being provided on the missed days. The Director of Nursing confirmed that the facility's policy was to accommodate residents' preferences and provide bed baths if showers were refused. Despite this policy, the resident's hygiene needs were not met according to the established schedule, leading to a deficiency in care.
Improper Storage of Oxygen Cylinders in Resident Room
Penalty
Summary
The facility failed to ensure the safe storage of two free-standing portable oxygen cylinders in a resident's room, which were left unattended. During an observation, it was noted that one cylinder was empty and the other was half full. The resident was unaware of the reason for the presence of the oxygen cylinders in their room. A Certified Nursing Assistant (CNA) confirmed that the cylinders were placed correctly but should have been stored in the closet with other oxygen cylinders. The CNA was not aware of the status of the cylinders, whether they were empty or not. A Registered Nurse (RN) stated that oxygen cylinders should be on a stand or taken by Respiratory Therapy to be stored in the closet with empty cylinders. Another RN explained that oxygen cylinders are typically left in the oxygen storage room unless needed for resident transport, and if kept in a resident's room, they should be placed on a stand for storage. The facility's policy on oxygen handling and storage, last revised in 2024, requires that oxygen cylinders be secured to a wall with a chain or cable or stored in a stationary rack. The Director of Nursing (DON) confirmed that oxygen cylinders should never be left free-standing inside a resident's room or hallway without proper storage.
Medication Security Lapse for a Resident
Penalty
Summary
The facility failed to ensure the security of medications for one resident, which was identified during an observation. A white/pink cream in a medication cup was left unattended on the dresser of a resident's room. The resident had been admitted with multiple diagnoses, including type II diabetes mellitus with diabetic neuropathy, hypertension, and chronic kidney disease. The Registered Nurse confirmed that the medication cup should not have been left in the resident's room. The Wound Care Nurse also stated that only they were authorized to apply the Moisture Barrier Cream with Zinc 10% and that it should not be left in the resident's room. The treatment administration record indicated that the cream was applied by the wound care nurse earlier that morning.
Menu Not Followed for Breakfast Service
Penalty
Summary
The facility failed to adhere to the planned menu for a breakfast service, which had the potential to affect all residents. On the morning of September 26, 2024, breakfast was delivered to residents in the Valley of Fire Unit, consisting of cereal, fruit, pancakes, and sausage. However, the menu for that day was supposed to include assorted juice, a choice of hot or cold cereal, cheesy eggs, hashbrowns, banana, toast, margarine or jelly, and milk or another beverage. The breakfast served was actually intended for the following day, Friday, which included pancakes and sausage. The Dietary Manager explained that the cook mistakenly prepared the Friday menu instead of the Thursday menu due to looking at the wrong day on the menu. The facility's policy on Honoring Resident Choice and Self-Directed Living at Meals stated that residents should be offered all food and beverage components planned in the approved menu. This error in following the menu was acknowledged by the Dietary Manager, who mentioned that residents would be informed of the change by updating the menus in each unit hallway.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food storage and handling practices, as evidenced by multiple observations and interviews. A dietary aide's purse was found stored with resident food in the dry storage area, despite previous warnings from the Dietary Manager. This practice was acknowledged by both the Dietary Aide and the Administrator as a potential source of contamination, yet no specific policy was in place to prevent personal items from being stored with food. Additionally, staff failed to comply with hygiene protocols in the kitchen. An LPN entered the kitchen without wearing a hairnet and did not wash hands upon entry, contrary to the facility's policy on employee hygiene. Similarly, a Dietary Aide donned gloves without washing hands first, which was confirmed as a breach of protocol by the Dietary Manager. These lapses in hygiene practices increase the risk of foodborne illnesses among residents. The facility also did not maintain safe food storage temperatures, as observed with a refrigerator in the satellite kitchen. The refrigerator's thermometer was malfunctioning, and internal temperatures of stored food items were above the safe threshold of 41°F. Furthermore, the improper sanitation of thermometers between uses was noted, with a Dietary Aide using a dirty rag to wipe the thermometer, potentially contaminating food. These deficiencies in food handling and storage practices pose a significant risk to resident safety.
Inappropriate Storage of Medical Equipment in Dining Rooms
Penalty
Summary
The facility failed to maintain a comfortable, homelike environment in four dining rooms by storing medical equipment in these areas, which is against the facility's policies. Observations revealed that various medical equipment, including hoyer lifts, vital sign monitors, wheelchair scales, and other items, were stored in the Lake [NAME], Red Rock, Valley of Fire, and Mount [NAME] dining rooms. Interviews with staff, including CNAs, RNs, and the Director of Nursing, confirmed that the equipment was stored in the dining rooms for staff convenience, despite the availability of designated storage areas such as cubbies in hallways and rooms adjacent to the dining areas. Residents and staff acknowledged that the presence of medical equipment in the dining rooms detracted from a homelike environment. A resident eating breakfast in the Lake [NAME] dining room noted the constant presence of medical equipment, while a CNA and a Respiratory Therapist confirmed the inappropriate storage practices in the Red Rock dining room. The Director of Nursing and the Administrator admitted that storing medical equipment in dining areas was a common practice, which they had not previously considered as detrimental to creating a homelike environment for residents. The facility's policies emphasize the importance of maintaining residents' dignity and providing comfortable dining areas, which were not adhered to in this instance.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that expired medications were removed from medication carts and storage rooms, as observed during inspections. On the Valley of Fire unit, three IV solution bags containing Pantoprazole and a vial of Humalog Lispro were found to be expired. These items were confirmed by an LPN to be past their expiration dates and were subsequently moved to a designated bin for expired or discontinued medications. Additionally, on the Lake unit, a bottle of Geri-Lanta and a bottle of Sodium Bicarbonate were found to be expired and should have been removed from the medication carts prior to their expiration dates. An unsealed medication was also found during an inspection of a medication cart on the Mount unit. A syringe of Lovenox was discovered with a broken seal, which was confirmed by an LPN to be inappropriate for storage in the medication cart. The LPN explained that the medication should have been discarded as the broken seal could indicate contamination or compromise the safety of the medication. Furthermore, discontinued medications were not removed from a medication cart on the Lake unit. Four doses of Morphine belonging to a resident who had been discharged were found stored in the cart. The RN present during the inspection explained that the Morphine was discontinued and was being stored until it could be given to a unit manager for disposal. However, there was no specific timeframe for when this should occur, and the medication had been discontinued the previous month. The facility's Director of Nursing confirmed that it was the facility's process to discard outdated, expired, or discontinued medications, and that medications belonging to discharged residents should have been removed and discarded.
Failure to Inform Residents of Leave Policies
Penalty
Summary
The facility failed to inform residents both orally and in writing about the rules related to leaving the premises on pass, which had the potential to affect all 129 residents. Resident #347, admitted for surgical aftercare, expressed feeling imprisoned due to being told they would be discharged if they left the facility. During a resident council interview, five residents reported being informed that leaving the facility would be considered against medical advice (AMA) and result in discharge unless they obtained a physician's permission. Staff, including a CNA and an LPN, confirmed that residents needed a physician's order to leave and that recent changes had made it difficult for residents to obtain such permission. The Director of Nursing (DON) acknowledged that the facility's policy required both the physician and the interdisciplinary team to determine if a resident could leave on pass, but this was not being followed. The DON admitted that residents were not informed of the facility's rules regarding leaving on pass upon admission, nor was there documentation to support that residents were informed of these rules. The facility's admission packet lacked evidence of written communication about the rules and processes for going out on pass, and the facility policy indicated that the decision should involve both the physician and the interdisciplinary team.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that a resident or their representative was provided with information about the right to formulate an advance directive. This deficiency was identified for one of the 29 sampled residents, who was admitted with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, and severe persistent asthma with acute exacerbation. The clinical record for this resident lacked documented evidence of an advance directive or any information provided to the resident or their representative regarding the right to formulate one. On a specific date, the Director of Nursing confirmed that the facility had not determined if the resident had an advance directive or if the necessary information had been provided. The facility's policy, adopted earlier in the year, required that residents and/or their representatives be informed of advance directive options upon admission, with documentation of this information in the resident's record.
Deficient Care Planning for Residents with Specific Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents with specific needs, leading to deficiencies in care. Resident #57, who was admitted with diagnoses including psychotic disorder and depression, was placed on hospice care without a corresponding care plan. This lack of documentation left the resident confused about the care being provided and was confirmed by the Director of Nursing (DON) as a potential health risk. Similarly, Resident #15, diagnosed with an anxiety disorder and prescribed Hydroxyzine Pamoate for anxiety management, did not have a care plan addressing their anxiety or the medication. Both a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) acknowledged the absence of a care plan for anxiety, which was expected to be included according to the DON. Resident #69, who was dependent on a respirator due to acute respiratory failure and pneumonia, also lacked a care plan addressing their respiratory needs. The care plan had not been updated to include objectives, goals, and interventions for the resident's respirator dependence. The DON confirmed that without a care plan, staff would be unable to implement the necessary care and services for the resident. The facility's policy required the interdisciplinary team to develop and revise comprehensive care plans as residents' needs changed, which was not adhered to in these cases.
Medication Administration Deficiency
Penalty
Summary
The facility failed to meet professional standards of medication administration by leaving medications unsecured at a resident's bedside. Specifically, a Licensed Practical Nurse (LPN) prepared medications for a resident, including ClearLax mixed in water, and placed them on the resident's bedside table. The LPN remained with the resident while they took oral tablet medications but left the room with the ClearLax still on the bedside table, contrary to the facility's policy and the Director of Nursing's (DON) expectations. The resident involved had been admitted and readmitted to the facility with diagnoses including acute osteomyelitis and chronic obstructive pulmonary disease. The incident occurred when the LPN exited the room without ensuring the resident had taken the ClearLax, which was left unsecured. The DON confirmed that nursing staff are expected to remain with residents until all medications are taken to ensure they receive the therapeutic benefits prescribed. The facility's policy mandates that medications should only be accessible to authorized staff and stored securely.
Discrepancy in Code Status Documentation for DNR Residents
Penalty
Summary
The facility failed to ensure that the code status of 'Do Not Resuscitate' (DNR) was accurately documented in the electronic health records for four residents. These residents were documented as 'full code' in their electronic charts, which indicated they were to receive cardiopulmonary resuscitation (CPR) in an emergency, despite having Provider Orders for Life-Sustaining Treatment (POLST) forms indicating DNR status. This discrepancy was identified for residents with various medical conditions, including psychotic disorder, anoxic brain damage, cerebrovascular disease, and surgical aftercare. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that staff relied on the electronic health records to determine a resident's code status during emergencies. The DON confirmed that the POLST forms and electronic health records should match, and acknowledged the discrepancies for the four residents. The facility's policy on advance directives stated that a resident's choice should be respected and accurately documented, but this was not adhered to, leading to the potential for residents with DNR status to receive unwanted life-saving measures.
Failure to Provide Ordered Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident diagnosed with type two diabetes mellitus. The resident was admitted and readmitted with a physician's order for a heart healthy consistent carbohydrate (CCHO) diet. However, the resident's meal card documented a regular diet instead of the prescribed CCHO diet. This discrepancy was confirmed by both a Certified Nursing Assistant and the Dietary Manager, who acknowledged that the resident was served a regular diet, contrary to the physician's order. The Dietary Manager explained that the facility's electronic system, which transfers diet orders from the electronic health record to the kitchen's system, had undergone an update that disrupted the automatic updating of diet orders. As a result, the kitchen staff had to manually enter diets, and the resident's therapeutic diet was missed. The Dietician emphasized the importance of serving CCHO diets to stabilize sugar levels for diabetic residents. The facility's policy required regular verification of diet orders, but this was not adhered to, leading to the resident receiving an inappropriate diet.
Failure to Maintain Dialysis Communication Forms
Penalty
Summary
The facility failed to obtain and maintain dialysis communication forms for a resident receiving hemodialysis, which is essential for ensuring continuity of care. The resident, who was admitted with diagnoses including end-stage renal disease and heart failure, had a physician's order for hemodialysis three times a week. Despite this, the clinical record lacked evidence of dialysis communication forms being sent with the resident to dialysis appointments and returned to the facility. This deficiency was identified during a review of the resident's care plan and clinical records. The Director of Nursing (DON) confirmed that the facility could not locate any dialysis communication forms for the resident. The resident was reportedly sent to dialysis with a binder containing these forms, but the binder did not return with the resident. A call to the dialysis clinic revealed that the resident did not bring the binder to the appointment. The DON acknowledged that the absence of these forms could put the resident's health at risk, as staff would be unaware of any complications during dialysis that needed monitoring. The facility's policy required coordination with the dialysis center and obtaining communication sheets after each appointment, which was not adhered to in this case.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to discontinue a medication for a resident after receiving an order to do so, resulting in the resident receiving an unnecessary medication. The resident, who was admitted with diagnoses including osteomyelitis of the vertebra and neuromuscular dysfunction of the bladder, was prescribed two medications from the same drug class: Oxybutynin Chloride and Tolterodine Tartrate. Both medications were intended to treat the resident's overactive bladder and urinary issues. Despite receiving a physician's order on 08/29/2024 to discontinue Tolterodine and continue Oxybutynin, the order was not entered into the resident's clinical record, and both medications continued to be administered until 09/25/2024. The deficiency was identified when an LPN, upon reviewing the resident's medication orders, noticed the duplication and contacted the physician for clarification. The LPN found a previous message on the unit's mobile phone indicating the physician's instruction to discontinue Tolterodine. However, this order was not documented in the resident's record, nor was a progress note made. The Director of Nursing confirmed that the expectation was for staff to enter such orders into the clinical record and follow them accordingly. The facility's policy on drug administration, adopted earlier in the year, required medications to be administered as prescribed by the physician.
Failure to Monitor and Limit Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring and limitation of a psychotropic medication for a resident diagnosed with anxiety disorder. The resident was prescribed Hydroxyzine Pamoate 25 mg to be administered as needed for anxiety, with an expected duration of 14 days. However, the medication was administered beyond this period, from 08/14/2024 through 09/15/2024, and the order remained active until 09/26/2024. There was no evidence of side effect or behavior monitoring related to the medication, and the resident's comprehensive care plan lacked documentation for anxiety management, including the use of Hydroxyzine Pamoate. Interviews with facility staff, including a CNA, an LPN, and the DON, revealed a lack of awareness and adherence to the requirements for monitoring psychotropic medications. The CNA was unaware of the need to monitor the resident's anxiety, while the LPN and DON confirmed the absence of orders for side effect and behavior monitoring, as well as a care plan related to the medication. The DON mistakenly believed that the 14-day limitation for as-needed psychotropic medications did not apply to long-term residents. The facility's policy on psychoactive drug use, which mandates a 14-day limit and monitoring of adverse reactions, was not followed in this case.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 19.35% based on 31 medication administration opportunities and 6 errors. This deficiency was identified through observation, interviews, clinical record reviews, and document reviews. Specifically, the report highlights an incident involving a resident who was admitted with acute respiratory failure with hypoxia and other seizures. On a particular day, a Registered Nurse (RN) prepared and administered several medications to this resident through a feeding tube, including Cholecalciferol, Docusate Sodium, Enoxaparin Sodium, Keppra, Valproic Acid, and Metoprolol. These medications were scheduled to be administered at 9:00 AM. However, the RN administered the medications at 11:04 AM, which was beyond the facility's policy of administering medications within one hour before or after the scheduled time. The Director of Nursing (DON) confirmed that medications administered after 11:00 AM, with a scheduled time of 9:00 AM, would be considered late. The facility's policy, adopted in May 2024, required medications to be administered in accordance with the physician's orders and within the specified time frame unless otherwise directed by the physician. This failure to adhere to the scheduled administration times contributed to the high medication error rate identified in the facility.
Inconsistent Weighing Methods Lead to Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for one of the sampled residents, identified as Resident #80. This deficiency was identified through interviews, clinical record reviews, and document reviews. Resident #80, who had diagnoses including chronic kidney disease, severe protein-calorie malnutrition, and muscle wasting, was admitted and readmitted to the facility on unspecified dates. The resident's weight records showed inconsistencies in the method used for weighing, alternating between a sitting scale, weights taken during dialysis, and a wheelchair scale. This inconsistency in weighing methods led to inaccurate weight records, which are crucial for monitoring the resident's nutritional status and determining significant weight changes. The facility's policy required that weights be obtained using the same device on each weigh date to ensure accuracy. However, the Registered Dietician confirmed that Resident #80 was not weighed using a consistent method, making it impossible to determine accurate weight gain or loss. Additionally, the CNA responsible for taking resident weights was not located in the facility at the time of the survey. The facility's documentation policy also required that all services and care be documented completely and accurately, which was not adhered to in this case, leading to the deficiency.
Infection Control Deficiencies in EBP and Hand Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic wounds, identified as Resident #292. This resident was admitted with diagnoses including localized swelling and chronic venous hypertension with ulcers. Observations revealed that the resident's room lacked EBP signage and a personal protective equipment (PPE) cart, which are necessary to limit the spread of infections. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that EBP was required for residents with chronic wounds, but it was not implemented for Resident #292 upon admission, despite the facility's policy indicating the need for such precautions. Additionally, the facility did not ensure proper hand hygiene during medication administration for another resident, identified as Resident #82. An LPN failed to perform hand hygiene after exiting the resident's room, before donning gloves, and after doffing gloves, which is against the facility's hand hygiene policy. The DON confirmed that hand hygiene was required before and after nursing interventions and after glove removal. These lapses in infection control practices had the potential to spread infectious illnesses to all residents.
Failure to Complete Abuse Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant, hired on 10/17/2023, completed mandatory training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation. This deficiency was identified during a review of employee records, document review, and interviews. Specifically, Employee #8's record lacked documented evidence of having completed the required abuse training since their hire date. The Director of Human Resources confirmed this oversight on 09/25/2024. The facility's policy, revised on 09/13/2022, mandates that staff receive training related to the prohibition, prevention, identification, recognition, and reporting of resident abuse, neglect, misappropriation of property, and exploitation.
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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