South Lyon Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Yerington, Nevada.
- Location
- 213 Whitacre St, Yerington, Nevada 89447
- CMS Provider Number
- 295011
- Inspections on file
- 19
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at South Lyon Medical Center during CMS and state inspections, most recent first.
The facility did not employ a qualified Infection Preventionist for several months, resulting in a lack of oversight for infection prevention, antibiotic stewardship, immunization, education, and infection control surveillance. Payroll records and staff interviews confirmed the absence of an IP, and other certified staff did not fulfill the IP role during this period.
A resident with intellectual disabilities and dementia, who was prone to scratching and picking at their skin, did not receive consistent care to address these behaviors. Although interventions such as hydroxyzine and geri sleeves were ordered, staff relied on observing the resident's actions to administer PRN medication, despite the resident's inability to request it. Ongoing skin injuries and bleeding were documented, and staff expressed uncertainty about the appropriateness of PRN orders for this resident.
A resident in need of pain management did not receive safe and appropriate pain management services as required.
A resident requiring hemodialysis did not have a documented physician's order for dialysis, and the facility lacked both a written contract with the dialysis provider and a dialysis care policy. Communication tools between the facility and the dialysis center were often incomplete, and staff interviews revealed uncertainty about responsibilities for monitoring and care, leading to uncoordinated dialysis services.
The facility did not have a full-time DON, as the interim DON split time between the hospital and LTC, dedicating only a small portion of hours to the LTC facility. This resulted in insufficient DON oversight for all residents during the period reviewed.
A resident with chronic respiratory failure and COPD was ordered to receive oxygen at three LPM as needed, but was repeatedly administered oxygen at two LPM according to documentation and direct observation. The resident reported ongoing shortness of breath and did not adjust the oxygen flow independently. An LPN and the DON confirmed the absence of an order for titration and acknowledged the importance of administering medications, including oxygen, at the prescribed dose.
Surveyors found that the Facility Assessment did not include nicotine dependence or addiction among the common diagnoses, despite five residents being current smokers and a designated smoking area in use. The Interim DON confirmed that the FA lacked documentation of residents with substance use disorders, contrary to facility policy and CDC guidance.
A resident with chronic respiratory failure and COPD received oxygen therapy as ordered, but staff failed to document its administration in the MAR over a three-month period. Observations and interviews confirmed the resident wore oxygen regularly, and both an LPN and the DON acknowledged that oxygen was administered but not recorded in the EHR, contrary to facility policy.
The QAPI committee did not identify or address a lapse in tracking and trending infections and antibiotic use within the Antibiotic Stewardship Program after the facility ceased infection prevention monitoring due to not having an Infection Preventionist on staff. This failure was contrary to facility policy, which required ongoing monitoring of medication management and infection prevention.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not maintain or document an Antibiotic Stewardship Program, including tracking and trending of infections and antibiotic use, for an extended period. The IP and interim DON confirmed that while some monitoring occurred, no records were kept as required by facility policy.
The facility did not effectively implement infection control protocols during a COVID-19 outbreak, resulting in 16 staff and 16 residents testing positive. Despite having the ability to isolate COVID-positive residents, leadership failed to enforce isolation, allowing infected residents to mingle with others, including in the dining room. Staff initially used surgical masks and later switched to N95s as the outbreak grew. Confusion among leadership regarding testing and quarantine policies further contributed to the spread, and at least one resident was hospitalized and died during the outbreak.
A COVID-19 outbreak occurred after the facility failed to follow CDC guidance and its own infection control policies, resulting in widespread transmission among staff and residents. Employees with symptoms continued to work, documentation of testing and return-to-work was incomplete, and isolation protocols were not enforced, allowing COVID-positive residents to intermingle with others. One resident with multiple comorbidities developed severe symptoms, was hospitalized, and died.
A resident with multiple chronic conditions was left uncovered and without a brief by a CNA, as observed and reported by an OA. The incident was not reported to the State Agency within the required timeframe, as facility staff delayed internal reporting and subsequent submission of the Facility Reported Incident.
The facility failed to properly administer its influenza and pneumonia vaccination programs, resulting in substandard care. Residents were not screened for vaccine eligibility, nor were they provided with education about the vaccines, preventing informed decision-making. Some residents received vaccines without proper consent, and one resident received a vaccine not approved for their age. The facility's policies were outdated and not followed, contributing to the deficiency.
The facility's Antibiotic Stewardship Program (ASP) was found lacking in essential components, including protocols for prescribing antibiotics and periodic review processes. Education on the ASP was not provided to staff or residents, and the Infection Preventionist (IP) did not effectively monitor or communicate antibiotic use. These deficiencies were confirmed by the Director of Nursing and the IP, highlighting significant gaps in the facility's antibiotic management practices.
The facility's Infection Preventionist (IP) did not complete the required training, failed to provide education on the Antibiotic Stewardship Program (ASP), and did not conduct antibiotic time outs. Additionally, the facility lacked processes for screening and educating residents on vaccines, and the IP did not communicate with prescribing providers, affecting 27 residents.
The facility failed to screen 26 residents for eligibility and provide education on influenza and pneumonia vaccinations, resulting in substandard care. Many residents either declined or received vaccines without proper documentation of screening, education, or consent. The facility's policies were outdated and not aligned with current CDC guidelines.
The facility failed to review its Infection Control and Prevention Plan annually and did not implement Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices. The IPCP was outdated and lacked essential elements, while EBP measures were not observed during an inspection, despite policy requirements for PPE and hand hygiene products.
The facility did not ensure that contact information for State agencies and advocacy groups was posted in a language understandable to all residents. A resident who only spoke Spanish was unaware of where this information was located. The DON confirmed that the postings were not in a language understandable to this resident, despite the facility's policy stating that communication should be in a format and language the resident understands.
A resident with adjustment disorder and anxiety was verbally abused and harassed by another resident with dementia in an LTC facility. Despite complaints and staff witnessing the abuse, the facility failed to protect the resident, as the DON did not initially consider the behavior abusive due to the perpetrator's mental state. The facility's abuse prevention policy was not effectively enforced.
A resident with adjustment disorder and anxiety reported being verbally abused and harassed by another resident with dementia. The accused resident made derogatory comments and accusations of theft. Despite acknowledging the incident as verbal abuse, the DON did not report it to the State Agency, violating the facility's abuse prevention policy.
The facility failed to ensure timely physician visits for three residents, resulting in missed visits during required periods. A resident with traumatic subarachnoid hemorrhage and dementia missed a visit in June, another with diabetes and kidney disease missed a visit in April, and a third with COPD and diabetes missed a visit in March. The DON confirmed these lapses.
The facility did not complete an annual performance evaluation for a CNA hired over a year ago, as required by their policy. The CNA's personnel record lacked documentation of the evaluation, which was confirmed by the HR Supervisor.
A facility failed to ensure a Morphine oral suspension bottle had a measuring guide, hindering accurate reconciliation of controlled substances. The DON confirmed the absence of the guide during a medication cart inspection, and the pharmacist verified this deficiency. The resident involved had multiple diagnoses, including dementia and chronic pain syndrome, with a physician's order for Morphine. Discrepancies in the Controlled Drug Record and the actual bottle content were noted, suggesting potential issues with medication reconciliation.
A resident was administered Buspirone three times daily for anxiety-related behaviors without having a diagnosis of anxiety, contrary to the facility's policy. The DON confirmed the lack of a proper indication for the medication, which was prescribed for behaviors such as yelling and throwing items.
A resident's medication, Norco, was improperly repackaged by nursing staff into plastic envelopes with inadequate labeling, contrary to the facility's policy. The facility's policy lacked guidance on necessary label information, contributing to the deficiency.
A resident with specific dietary dislikes was not provided with a vegetable substitute of equal nutritional value during a meal. Despite the resident's documented dislike for Brussels sprouts, mashed potatoes were served instead, which were not nutritionally comparable. The RD confirmed the inadequacy of the substitution.
A resident with documented dislikes for certain vegetables was served carrots despite their preferences being noted. The facility's dietary staff, including the Dietary Manager and RD, acknowledged that disliked items should not be served, yet the resident received a meal containing carrots, which they refused to eat.
The QAPI committee failed to identify deficiencies in vaccination protocols and infection control. The facility lacked processes for screening and educating residents about pneumococcal and influenza vaccines, and consents were not obtained for new flu vaccines. The Infection Preventionist had not completed required training, and the facility's IPCP and ASP policies were outdated and incomplete. The QAPI committee was unaware of these issues until highlighted by the State Agency.
The facility failed to ensure a CNA and a resident were screened for COVID-19 booster vaccine eligibility, provided with education, and given the opportunity to make informed decisions about vaccination. The DON confirmed the facility was not tracking staff vaccination status and only provided education when new vaccines were available or during clinics.
The facility failed to ensure that a Registered Dietician completed required communication training. Despite a policy mandating annual training, the employee's record lacked documentation of such training. The Human Resources Supervisor confirmed the oversight, noting that all staff were required to complete the training within 30 days of hire and annually.
The facility did not ensure that a Registered Dietician completed the required resident rights training, as confirmed by the Human Resources Supervisor. The facility policy mandates this training within 30 days of hire and annually, but the employee's record lacked evidence of completion.
The facility failed to ensure timely elder abuse training for several employees, including a Registered Dietician, CNAs, an LPN, an RN, a Hospitality Aide, and a Housekeeper. The training was either not completed within 30 days of hire or was missing altogether, as confirmed by the Human Resources Supervisor. The facility's policy lacked a requirement for abuse training upon orientation.
The facility did not ensure that a Registered Dietician, hired in 2003, completed the required Quality Assurance Performance Improvement (QAPI) training. The Human Resources Supervisor confirmed the absence of documented QAPI training for this employee, despite the facility's policy requiring such training within 30 days of hire and annually thereafter.
A Registered Dietician at the facility, hired in 2003, lacked documented evidence of completing required infection control training. The facility's policy mandates annual training for all healthcare personnel, but the Human Resources Supervisor confirmed the dietician had not completed it, highlighting a lapse in the infection prevention and control program.
The facility failed to ensure timely completion of compliance and ethics training for an employee. A Registered Dietician, hired in 2003, lacked documented evidence of completing the required training. The HR Supervisor confirmed that all staff must complete this training within 30 days of hire and annually, but this was not done for the employee. The facility's policy mandates annual compliance and ethics education.
The facility did not ensure timely completion of behavioral health training for an employee hired as a Registered Dietician. The employee's record lacked evidence of the required training, which should have been completed within 30 days of hire and annually, as per facility policy.
Failure to Employ Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was employed at least part time each month from late December 2024 to mid-May 2025. Payroll records confirmed that the previous IP's last day was 12/26/2024, and the next IP did not begin until 05/12/2025. During interviews, the Human Resource Manager verified that no other individual worked as an IP during this period. Although the CEO stated that two other employees held IP certification, it was confirmed that neither performed the duties of the IP, including oversight of the Antibiotic Stewardship Program, immunization, staff and resident education, or infection control surveillance. The interim Director of Nursing also confirmed that there was no IP in place during this time frame, resulting in a lack of oversight for the facility's Infection Prevention and Control Program and Antibiotic Stewardship Program. The absence of an IP was identified through document review and staff interviews, and the deficiency was cross-referenced with F881.
Failure to Provide Necessary Care for Resident with Intellectual Disabilities and Skin Picking
Penalty
Summary
A resident with a history of traumatic subarachnoid hemorrhage, mild intellectual disabilities, and unspecified dementia with agitation was not provided with adequate care and services to address persistent scratching and picking at their arms and legs. The resident's care plan acknowledged communication challenges and included interventions for skin picking, such as the use of hydroxyzine and physical barriers like geri sleeves. Physician orders specified washing and applying lotion to the arms, using geri sleeves or tubi grip, and administering hydroxyzine as needed for itching and skin picking. Despite these interventions, clinical records and observations documented ongoing open areas, scratch marks, and active bleeding on the resident's extremities. Staff interviews revealed that the resident lacked the cognitive ability to request PRN (as needed) medications, and nursing staff administered hydroxyzine only when they observed scratching behavior. Both the LPN and RN confirmed uncertainty about why the medication was ordered as PRN rather than scheduled, given the resident's inability to communicate their needs. The facility's policy required individualized care for residents with intellectual disabilities, but the care provided did not ensure consistent management of the resident's skin picking behavior, resulting in preventable discomfort and risk of skin breakdown.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Lack of Coordination and Policy for Dialysis Care
Penalty
Summary
The facility failed to ensure proper coordination of care for a resident requiring hemodialysis, as evidenced by the absence of a written contract or agreement with the dialysis provider, lack of a facility dialysis policy, and incomplete documentation of dialysis care. The resident, who had end stage renal disease and was dependent on renal dialysis, did not have a physician's order for hemodialysis documented in the clinical record. Additionally, the Dialysis and Nursing Home Handoff Communication Tool forms were found to be incomplete on multiple occasions, with missing documentation from the dialysis center. Interviews with facility staff, including an LPN, the DON, and the CEO, revealed uncertainty regarding staff responsibilities for dialysis care, monitoring of the fistula site, and review of communication forms from the dialysis center. The DON confirmed the absence of a contract with the dialysis center and a facility dialysis policy, while the CEO expressed uncertainty about what was expected of nursing staff in caring for residents on dialysis and acknowledged that staff may not be reviewing the handoff communication forms. These actions and inactions resulted in uncoordinated and unmonitored care for the resident receiving dialysis.
Failure to Maintain Full-Time Director of Nursing Coverage
Penalty
Summary
The facility failed to ensure the presence of a full-time Director of Nursing (DON) as required. During the survey, it was found that the current Chief Nursing Officer (CNO) was acting as the interim DON, but was only present in the facility for 32 hours per week according to the staffing schedule. Further, the DON confirmed working a total of 40 hours per week, but only 20% of that time, or approximately eight hours per week, was dedicated to the long-term care facility, with the remainder spent working for the hospital. The facility assessment indicated a DON was required, but the actual hours worked in the LTC facility did not meet the full-time requirement. This deficiency affected all 27 residents residing in the facility on the date in question.
Failure to Administer Oxygen at Prescribed Dose
Penalty
Summary
A resident with chronic respiratory failure and chronic obstructive pulmonary disease was admitted to the facility with a physician's order for oxygen via nasal cannula at three liters per minute (LPM) as needed for shortness of breath, with the option to remove if breathing was comfortable. Despite this order, multiple entries in the Oxygen Saturations Summary Report documented that the resident received oxygen at two LPM on several occasions. Observations confirmed that the resident's oxygen concentrator was set to two LPM during multiple checks, and the resident reported wearing oxygen continuously and experiencing difficulty breathing. The resident also stated that they did not adjust the oxygen flow themselves and relied on facility staff for administration. Interviews with an LPN and the Interim Director of Nursing (DON) confirmed that the clinical record did not include an order for oxygen titration and that the expectation was for medications, including oxygen, to be administered at the correct dose as prescribed. The DON acknowledged that administering oxygen at an incorrect dose constituted a medication error. Facility policy required nurses to ensure the right dose when administering medications. The deficiency was identified through observation, interview, and record review, showing that the resident did not consistently receive oxygen at the prescribed rate.
Facility Assessment Lacked Documentation of Nicotine Dependence and Substance Use Disorders
Penalty
Summary
The facility failed to ensure that its Facility Assessment (FA) accurately reflected the needs of its resident population, specifically by omitting nicotine dependence and addiction from the list of common diagnoses and conditions. During the survey, it was found that five residents were current cigarette smokers, and the designated smoking area was located off the outside patio accessed through the dining room. The FA, last reviewed in March 2025, did not include nicotine abuse or addiction, nor did it document the number of residents with active or current substance use disorders. This omission was confirmed by the Interim DON, who acknowledged that nicotine addiction was not identified as a diagnosis in the FA and that the number of residents with substance use disorders was not documented. The facility's policy required the FA to include the care required by the resident population, considering the types of diseases and other pertinent facts present within the population. However, the FA did not meet this requirement, as it lacked documentation of residents with nicotine dependence or other substance use disorders. The surveyors referenced CDC guidance that classifies tobacco (nicotine) use as a substance use disorder, further highlighting the deficiency in the facility's assessment process.
Failure to Document Oxygen Administration in MAR
Penalty
Summary
The facility failed to document the administration of oxygen therapy for a resident with chronic respiratory failure and chronic obstructive pulmonary disease, as required by physician orders and facility policy. Although the resident had a physician's order for oxygen via nasal cannula at three liters per minute as needed for shortness of breath, the medication administration records (MARs) for May, June, and July did not contain any documentation of oxygen administration. Observations showed the resident wearing oxygen via nasal cannula on multiple occasions, with the oxygen concentrator set to two liters per minute. The resident reported wearing oxygen continuously and stated that all oxygen was administered by facility staff. Interviews with an LPN and the interim DON confirmed that oxygen was being administered but not documented in the electronic health record. The DON acknowledged that oxygen is considered a medication and should be documented on the MAR at the time of administration, in accordance with facility policy. The lack of documentation was confirmed by both the LPN and the DON, who stated that there was no record of oxygen administration for the resident during the three-month period reviewed.
Failure to Track Infections and Antibiotic Use in QAPI/ASP
Penalty
Summary
The facility's QAPI committee failed to identify and address a lapse in tracking and trending infections and antibiotic use as part of the Antibiotic Stewardship Program (ASP). According to interviews and document review, the facility stopped monitoring infection prevention and control from August 2024 through May 2025 due to the absence of an Infection Preventionist on staff. As a result, the QAPI committee did not recognize or act upon the lack of antibiotic stewardship tracking for resident antibiotics. Facility policy required the performance improvement plan to monitor systems of care, including medication management and infection prevention and control, but these measures were not followed during the specified period.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Document and Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an Antibiotic Stewardship Program (ASP) that included the tracking and trending of infections and antibiotic use from August 2024 through May 30, 2025. During a survey, the facility was unable to provide documented evidence of an ASP for this period. The Infection Preventionist (IP) confirmed that while infections and antibiotic use were monitored for trends, no documentation of these findings was maintained. The IP began employment at the facility on May 12, 2025, and only started documenting tracking and trending of infections and antibiotic use on May 30, 2025. The interim Director of Nursing (DON) also confirmed the absence of documented evidence for the ASP, including tracking and trending activities during the specified period. According to the facility's policy, the ASP should have included proactive monitoring of antimicrobial prescriptions, record-keeping of antibiotic use, and monthly documentation of all infections. However, these procedures were not followed or documented as required, resulting in the deficiency.
Failure to Implement Effective COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to ensure effective administration and implementation of infection control protocols in accordance with CDC guidance, resulting in a widespread COVID-19 outbreak among both staff and residents. Documentation showed that 16 employees and 16 out of 22 residents tested positive for COVID-19 during the outbreak period. The Chief Nursing Officer (CNO) confirmed that although the facility had designated isolation rooms that could be separated by fire doors, these were not utilized due to the interim Director of Nursing (DON) refusing to implement isolation measures. The CNO acknowledged having the authority to direct the DON but failed to enforce the isolation of COVID-positive residents, allowing them to intermingle with others, including in the dining room, which contributed to the spread of the virus. Staff initially used surgical masks for source control, but as the outbreak worsened, they switched to N95 respirators. The Infection Preventionist agreed with the initial use of surgical masks, but the decision to switch to N95s was made after further discussion. The Medical Director noted confusion and lack of clarity in the facility's COVID testing and quarantine policies, with ongoing debate among leadership about testing frequency and isolation procedures. Testing was conducted every 48 hours for a period, and at least one resident was hospitalized and subsequently died during the outbreak. The CNO stated that CDC guidance was followed, but the failure to isolate COVID-positive residents and unclear policies contributed to the outbreak.
Failure to Implement and Document COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to ensure that CDC guidance and its own Infection Prevention and Control Plan (IPCP) were followed in the management of a COVID-19 outbreak, resulting in 16 employees and 16 out of 22 residents becoming infected. Documentation revealed that employees who tested positive for COVID-19 were not consistently tracked regarding additional testing or return-to-work dates, and the facility's tracking spreadsheets lacked critical information. Staff with symptoms continued to work while symptomatic, and there was inconsistent use of appropriate source control, with surgical masks being used initially and N95 respirators only adopted as the outbreak worsened. The facility's leadership, including the Chief Nursing Officer (CNO) and interim Director of Nursing (DON), failed to enforce isolation protocols and did not utilize available isolation pods, allowing COVID-positive residents to intermingle with others, including in communal dining areas. Interviews with facility leadership confirmed that, despite available policies and CDC guidance, there was confusion and debate about testing frequency and quarantine procedures. The CNO acknowledged that the DON, who was a subordinate, refused to implement isolation measures, and the CNO did not override this decision, resulting in COVID-positive residents not being separated from others. The Medical Director also noted that the facility's policies were unclear regarding when to stop testing, contributing to inconsistent practices during the outbreak. Staff and residents were tested every other day, but the documentation did not always reflect adherence to recommended testing intervals or return-to-work criteria. Several residents with significant comorbidities, such as dementia, COPD, diabetes, and heart failure, contracted COVID-19 during the outbreak. One resident, who had multiple complex medical conditions including quadriplegia, hydrocephalus, and respiratory failure, developed severe COVID-19 symptoms, was transferred to an acute care hospital, and subsequently died. The facility's failure to implement and document appropriate infection prevention and control measures, including isolation, source control, and testing protocols, directly contributed to the widespread transmission of COVID-19 among both staff and residents.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of neglect and abuse involving a resident was reported to the State Agency (SA) within the required timeframe. The incident involved a resident with diagnoses including type two diabetes mellitus with diabetic polyneuropathy and chronic obstructive pulmonary disease. On the evening of the incident, an Observation Aide (OA) observed the resident uncovered from the waist down and without a brief after the resident had called for help and reported that a CNA had left the resident in that state. The OA was informed of the incident by the resident and subsequently reported it to the Director of Nursing Secretary (DON Secretary) three days later. According to facility policy, any person identifying signs of abuse or neglect must immediately report to the charge nurse, who then notifies the DON and Chief Risk Officer, with the DON or Chief Risk Officer responsible for reporting to the SA within 24 hours. In this case, the DON Secretary reported the allegation to the Chief Nursing Officer (CNO) on the same day it was received from the OA, as there was no DON at the time. However, the Facility Reported Incident (FRI) was not submitted to the SA until five days after the alleged incident occurred, resulting in a failure to meet the required reporting timeframe.
Deficiency in Vaccination Program Administration
Penalty
Summary
The facility failed to effectively administer its influenza and pneumonia vaccination programs, resulting in substandard quality of care. The facility did not screen 23 out of 26 residents for eligibility to receive the influenza vaccine, nor did it provide education about the risks and benefits of the vaccine to the residents or their representatives. This lack of documentation and education prevented residents from making informed decisions about receiving the vaccine. Additionally, some residents were administered the flu vaccine without proper screening or consent, and one resident received a vaccine not approved for their age group. Similarly, the facility did not screen any of the 26 residents for eligibility to receive the pneumonia vaccine, nor did it provide education about the vaccine to the residents or their representatives. Thirteen residents declined the pneumonia vaccine without documented evidence of being screened or educated, and seven residents received the vaccine without proper screening or education. The facility's policy on pneumococcal vaccination was outdated, lacking current CDC guidance, which contributed to the deficiency. The facility's policies for both influenza and pneumonia vaccinations were not followed, as evidenced by the lack of documentation for screening, education, and consent. The influenza vaccination policy was revised in December 2023, but it was not effectively implemented. The pneumonia vaccination policy, last revised in 2017, was based on outdated CDC recommendations, further exacerbating the issue. These failures in policy implementation and adherence led to residents not being able to make informed decisions about their vaccinations, putting them at risk of adverse reactions.
Deficiencies in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to ensure the proper implementation and review of its Antibiotic Stewardship Program (ASP) policy. The policy, revised in October 2023, lacked essential components such as protocols for prescribing antibiotics, documentation of indication, dosage, and duration, and a process for periodic review of antibiotic use by prescribing practitioners. Additionally, there was no system for providing feedback reports on antibiotic use and resistance patterns. The Director of Nursing confirmed these deficiencies, highlighting the absence of a structured approach to antibiotic management. The facility also did not provide education related to the ASP to staff and residents. The Infection Preventionist (IP) confirmed that no education was provided because the IP was not clinical. Despite the policy stating that education should be provided, there was no documented evidence of such training. This lack of education contributed to the facility's inability to effectively manage antibiotic use and ensure compliance with the ASP. Furthermore, the facility's process for monitoring antibiotic use was inadequate. The IP did not review residents' antibiotic use upon admission, relying instead on a pharmacist who visited only once a month. The IP was not informed of new infections or cultures sent to the lab until results were returned, and an antibiotic time out was not performed. The IP also did not communicate with prescribing providers regarding antibiotic usage or prescribing habits, as the IP was not involved in clinical decision-making. These gaps in communication and monitoring processes further exacerbated the facility's failure to adhere to the ASP guidelines.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) completed the required specialized training course. The IP had not completed all the necessary modules of the Centers for Disease Control and Prevention (CDC) Infection Preventionist Training Course, lacking the full 19.75 Continuing Education Units (CEUs) required for course completion. Despite this, the IP had been working in the role without having completed an approved specialized training course, as confirmed by the Director of Nursing (DON). The facility also did not provide documented evidence of education related to the Antibiotic Stewardship Program (ASP) to the staff. The IP was responsible for providing such education but failed to do so. Additionally, the IP did not conduct or understand the process of an antibiotic time out, which is crucial for reassessing antimicrobial prescriptions. The IP relied on the pharmacist, who was only present once a month, for reviewing antibiotic use, and did not track isolation needs or changes in medications. Furthermore, the facility lacked a process for screening and educating residents about influenza and pneumonia vaccines. The DON confirmed that no residents had been screened for vaccine eligibility or provided with education on the risks and benefits of the vaccines. The IP was not involved in the vaccination process and did not communicate with prescribing providers, as the IP was not clinical. This lack of communication and process potentially affected the entire census of 27 residents.
Failure to Screen and Educate Residents on Vaccinations
Penalty
Summary
The facility failed to ensure that 26 out of 27 residents were screened for eligibility to receive influenza and pneumonia vaccinations, and did not provide education related to these vaccines. This resulted in substandard quality of care. The report highlights that the facility lacked documented evidence of screening and education for the influenza vaccine for 23 residents, and for the pneumonia vaccine for all 26 residents. The Director of Nursing confirmed the absence of a process for screening and educating residents about these vaccines. Several residents either declined or received the influenza vaccine without proper documentation of eligibility screening, education, or consent. For instance, eight residents declined the flu vaccine without documented evidence of being informed about the vaccine, while others received the vaccine without proper consent or education. One resident was administered a flu vaccine that was not approved for their age group, using a hospital consent form that was improperly filled out. Similarly, the facility failed to document eligibility screening, education, and consent for the pneumonia vaccine for all 26 residents. Some residents declined the vaccine without documented evidence of being informed, while others had signed consents but lacked documentation of screening and education. The facility's policies on vaccinations were outdated and did not align with current CDC guidelines, further contributing to the deficiency.
Infection Control and EBP Deficiencies
Penalty
Summary
The facility failed to ensure that its Infection Control and Prevention Plan (IPCP) was reviewed annually and appropriately tailored to the long-term care setting. The IPCP policy was last reviewed in October 2022, and the facility could not provide evidence of any subsequent review or revision. The policy incorrectly referred to the hospital's IPCP and included duties for hospital staff, lacking specific language for the long-term care facility. Additionally, the IPCP was missing critical elements such as a list of reportable communicable diseases, a process for reporting to state agencies, and guidelines for prohibiting employees with communicable diseases from direct contact with residents. It also lacked procedures for communication during resident transfers and receipt of pertinent notes upon return from other facilities. The facility also failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices. Both residents had medical conditions requiring such precautions, but the facility did not initiate or implement EBP for them. During an inspection, it was observed that Transmission-Based Precautions, including EBP, were not in place for any resident rooms. The facility's policy on EBP, revised in July 2024, required staff training on personal protective equipment (PPE) and the availability of PPE and hand hygiene products at the point of care, but these measures were not observed to be in practice.
Failure to Provide Multilingual Contact Information
Penalty
Summary
The facility failed to ensure that the contact information for pertinent State agencies and advocacy groups was posted in a language understandable to all residents. During a Resident Council Interview, a resident who only read and spoke Spanish expressed, through a translator device, that they were unaware of where this information was located. The Director of Nursing confirmed that none of the postings were understandable for residents who only read and spoke Spanish. The facility's policy on Resident Communication Rights, revised in July 2015, states that residents have the right to receive communication in a format and language they understand.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse and harassment by another resident. Resident #16, who was admitted with diagnoses including adjustment disorder with anxiety and chronic obstructive pulmonary disease, reported being harassed and called derogatory names by Resident #15. Resident #15, who has unspecified dementia and other mental health issues, accused Resident #16 of stealing a picture and used slurs against them, knowing it was offensive. Despite Resident #16's complaints to the Director of Nursing (DON), the issue persisted, and the DON advised Resident #16 to try to get along with Resident #15 due to their mental state. Multiple staff members, including an Observation Aide and Activity Aides, witnessed the verbal abuse and harassment. They reported incidents where Resident #15 accused Resident #16 of theft and used derogatory language, including slurs related to sexual orientation. Staff attempted to redirect Resident #15, but the behavior continued. The DON was aware of the situation but did not initially consider it abuse due to Resident #15's dementia. Documentation, including a Communication Note and a Patient Grievance Form, detailed incidents where Resident #15 entered Resident #16's room, made accusations, and used offensive language. The facility's policy on abuse prevention, revised in May 2023, states that residents should be free from abuse by other residents. However, the facility did not effectively address the ongoing harassment and verbal abuse experienced by Resident #16.
Failure to Report and Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report and investigate an allegation of resident-to-resident verbal abuse and harassment involving Resident #16. Resident #16, who was admitted with diagnoses including adjustment disorder with anxiety and chronic obstructive pulmonary disease, reported being harassed and called names by Resident #15. Resident #15, who has unspecified dementia and other conditions, accused Resident #16 of stealing a picture and made derogatory comments about Resident #16's sexual orientation. Despite these allegations, the Director of Nursing (DON) did not report the incident to the State Agency (SA) as required by the facility's abuse prevention policy. The DON acknowledged that the accusations and name-calling constituted verbal abuse and harassment, which should have been reported immediately. The facility's policy, revised in May 2023, mandates that all alleged, suspected, or observed abuse be reported immediately and investigated. However, the DON did not report the incident, citing Resident #15's dementia as a reason. This oversight allowed the allegations to go unreported and uninvestigated, contrary to the facility's policy and regulatory requirements.
Missed Physician Visits for Residents
Penalty
Summary
The facility failed to ensure timely physician visits for three residents, leading to deficiencies in their care. Resident #26, who was admitted with traumatic subarachnoid hemorrhage, fall, and unspecified dementia, did not have a documented physician visit in June 2024, despite the requirement for visits every 30 days during the first 90 days of admission. The Director of Nursing (DON) confirmed the absence of this visit, acknowledging the oversight in the resident's care schedule. Similarly, Resident #19, with diagnoses including type two diabetes mellitus, diabetic chronic kidney disease, and retinal edema, lacked a physician visit in April 2024. The DON confirmed this lapse. Additionally, Resident #7, diagnosed with chronic obstructive pulmonary disease, type II diabetes mellitus, and hypothyroidism, did not have a documented physician visit in March 2024, although visits were expected every 60 days after the initial 90 days. These omissions highlight a pattern of missed physician visits for residents, as confirmed by the DON.
Failure to Conduct Timely Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) received an annual performance evaluation in a timely manner. This deficiency was identified during a personnel record review, which revealed that one of the two CNAs employed for more than a year, specifically Employee #7, did not have documented evidence of a completed annual performance evaluation. Employee #7 was hired on April 1, 2023, and the facility's policy, revised in June 2019, mandates that employees be evaluated annually in the month of their hire date. The Human Resources Supervisor confirmed the absence of the evaluation documentation during an interview conducted on July 17, 2024.
Deficiency in Morphine Labeling and Reconciliation
Penalty
Summary
The facility failed to ensure that a bottle of Morphine oral suspension for a resident included a measuring guide on its label, which is necessary for accurate reconciliation of controlled substances. This deficiency was identified during an inspection of a medication cart by the Director of Nursing (DON), who confirmed that the bottle did not have the required measurement guide. The absence of this guide made it difficult for the facility to determine if the medication was correctly reconciled in the Narcotics Reconciliation log or if it had been diverted. The pharmacist also confirmed that the bottle lacked a measuring guide, which is a standard requirement for such medications. The resident involved had been admitted with multiple diagnoses, including unspecified dementia and chronic pain syndrome, for which Morphine Sulfate was prescribed. The physician's order specified a dosage of 0.1 ml every two hours as needed. However, discrepancies were noted in the Controlled Drug Record, which documented a different concentration of Morphine Sulfate than what was found in the bottle. The DON observed that the remaining quantity in the bottle was less than expected, suggesting a possible leak or other issue. The manufacturer's instructions emphasized the importance of careful record-keeping for controlled substances like Morphine, highlighting the facility's failure to adhere to these guidelines.
Psychotropic Medication Prescribed Without Proper Indication
Penalty
Summary
The facility failed to ensure that a psychotropic medication was prescribed to a resident with a diagnosed indication for use. Resident #9, who was admitted with diagnoses including vascular dementia with behavioral disturbances and unspecified depression, was administered Buspirone three times a day for behaviors such as yelling, banging fists, and throwing items. However, the resident did not have a diagnosis of anxiety, which was the indicated use for the medication as per the physician's order dated 10/19/2023. The Director of Nursing confirmed that Resident #9 received Buspirone for anxiety without having a diagnosis for it, which was against the facility's policy. The facility's policy on psychotropic medication use, revised in 08/2018, required that such medications be ordered by a physician when medically necessary and that attending physicians must certify the necessity of the medication to treat a specific condition or behavior. This oversight led to the administration of a psychotropic medication without a proper indication for use.
Improper Repackaging of Medications
Penalty
Summary
The facility failed to ensure that medications were not repackaged, as observed in the case of a resident who was admitted with multiple diagnoses including a fracture and osteoporosis. A physician's order had prescribed hydrocodone-acetaminophen (Norco) for chronic arthritic pain. During an inspection, it was found that the Norco tablets were improperly repackaged into plastic see-through envelopes, with only the resident's last name and the medication name and strength written on them. This repackaging was confirmed by the Director of Nursing (DON) to have been done by the nursing staff. The facility's policy on medication administration, dated January 2021, explicitly stated that medications should never be transferred from one container to another. However, the policy did not provide guidance on what information should be included on a medication label, such as the prescribed dose, strength, resident's name, route of administration, or any precautions. This lack of detailed labeling and adherence to policy led to the deficiency observed during the survey.
Inadequate Nutritional Substitution for Resident
Penalty
Summary
The facility failed to provide a vegetable substitute of equal nutritive value for a resident who had documented dislikes for Brussels sprouts. The resident, who was admitted with diagnoses including heart failure, chronic obstructive pulmonary disease, and gastro-esophageal reflux disease, was served a lunch menu that included roast turkey, Brussels sprouts, and corn pudding. Despite the resident's documented dislike for Brussels sprouts, mashed potatoes were substituted instead, which were not comparable in nutritional value. This was confirmed by the Registered Dietician, who stated that a substitute of equal nutritional value should have been offered.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to provide meals based on a resident's preferences, specifically for a resident with dislikes documented on their tray card. The resident, who was admitted with diagnoses including heart failure, chronic obstructive pulmonary disease, and gastro-esophageal reflux disease, had expressed a dislike for carrots and Brussels sprouts. Despite this, the lunch menu included carrots, and the resident was served a plate containing carrots. The Dietary Manager and Registered Dietician both acknowledged that items disliked by residents should not be served, and the facility's policy required screening residents for food preferences at admission. However, the resident was still served carrots, which they verbalized disliking and refused to eat.
Deficiencies in Vaccination Protocols and Infection Control
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify several deficiencies related to vaccination protocols and infection control. The Director of Nursing (DON) confirmed that the facility lacked a process for screening residents for eligibility to receive pneumococcal (PNA) and influenza vaccinations. Additionally, education related to these vaccines was not provided to residents, and consents were not obtained prior to administering new flu vaccines. The QAPI committee was unaware of these issues until they were highlighted by the State Agency. The Infection Preventionist (IP) had not completed the required specialized training course, as evidenced by the lack of a completion certificate. The transcript provided by the IP showed that the course was not fully completed, and the DON confirmed that the IP should have completed the course before assuming the role. The QAPI committee was also unaware of this training deficiency. The facility's Infection Control and Prevention Plan (IPCP) and Antibiotic Stewardship Program (ASP) policies were outdated and lacked essential components. The IPCP policy had not been reviewed or revised since October 2022 and contained references to hospital staff rather than long-term care facility staff. It also lacked a list of reportable communicable diseases and processes for reporting and communication during resident transfers. Similarly, the ASP policy lacked protocols for antibiotic use and feedback systems. The QAPI committee was not informed about these outdated policies.
Deficiency in COVID-19 Vaccination Protocol for Staff and Residents
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was screened for eligibility to receive a COVID-19 booster vaccine, provided with education regarding the vaccine, and given the opportunity to make an informed decision to receive or decline the vaccination. The CNA, hired on 10/25/2020, had received previous doses of the COVID vaccine on 10/13/2021 and 02/03/2021. However, there was no documented evidence that the CNA was informed about updated COVID vaccines, screened for eligibility, or had completed a declination for the vaccine. The Director of Nursing (DON) confirmed that the facility was no longer tracking COVID vaccination status for staff and that education related to COVID vaccines was only provided when new vaccines were available or during vaccination clinics. Additionally, the facility failed to ensure that one of six residents reviewed for immunization with a COVID booster vaccine was screened for eligibility, provided with education regarding the vaccine, and given the opportunity to make an informed decision to receive or decline the vaccine. The DON acknowledged that education related to COVID vaccines was not being provided to residents or staff outside of specific circumstances, such as the availability of new vaccines or vaccination clinics. This lack of documentation and education represents a deficiency in the facility's vaccination protocol.
Failure to Ensure Communication Training for Staff
Penalty
Summary
The facility failed to ensure that communication training was completed by a staff member, specifically Employee #4, who was hired as a Registered Dietician on September 11, 2003. A review of Employee #4's personnel record revealed a lack of documented evidence of communication training. On July 23, 2024, the Human Resources Supervisor confirmed that all staff were required to complete communication training within 30 days of hire and annually thereafter, but Employee #4 did not have this training documented. The facility's policy, effective April 2022, mandated that employees complete communication training at least annually.
Failure to Ensure Resident Rights Training for Staff
Penalty
Summary
The facility failed to ensure that all staff members completed the required resident rights training, as evidenced by the personnel record review of a Registered Dietician, hired on 09/11/2003, who did not have documented evidence of completing this training. The Human Resources Supervisor confirmed that all staff were required to complete Resident Rights training within 30 days of hire and annually thereafter, but Employee #4 did not meet this requirement. The facility's policy, effective 08/2022, mandates that employees complete Resident Rights education at least annually.
Failure to Ensure Timely Elder Abuse Training
Penalty
Summary
The facility failed to ensure timely completion of elder abuse training for seven out of twenty sampled employees. Employee #4, a Registered Dietician, had completed elder abuse training in 2022 but lacked documentation for 2023. Employee #7, a CNA, completed the training more than 30 days after being hired. Employee #10, an LPN, and Employee #17, a CNA, both lacked initial elder abuse training before starting work on the floor. Employee #11, an RN, completed the training more than 30 days after hire. Employee #19, a Hospitality Aide, and Employee #20, a Housekeeper, also lacked timely completion of the training, with Employee #20 completing it more than 30 days after hire. The Human Resources Supervisor confirmed that all staff were required to complete elder abuse training within 30 days of hire and annually thereafter. However, the facility's abuse prevention policy, revised in May 2023, did not include a requirement for abuse training upon orientation. This oversight contributed to the delay in training for the identified employees, as confirmed by the Human Resources Supervisor during the survey.
Failure to Complete QAPI Training for Registered Dietician
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) training was completed for all staff, specifically for one of the sampled employees, a Registered Dietician hired on September 11, 2003. The personnel record for this employee lacked documented evidence of QAPI training. On July 23, 2024, the Human Resources Supervisor confirmed that all staff were required to complete QAPI training within 30 days of hire and annually thereafter, but acknowledged that the Registered Dietician did not have the required training. The facility's policy, revised in November 2017, mandates annual training on the QAPI program for all staff.
Infection Control Training Lapse for Registered Dietician
Penalty
Summary
The facility failed to provide timely infection control training to all staff, as evidenced by the case of a Registered Dietician, hired on September 11, 2003, who did not have documented evidence of completing the required infection control training. According to the facility's policy, effective January 2021, all healthcare personnel are required to receive infection control training annually. During an interview on July 23, 2024, the Human Resources Supervisor confirmed that all staff must complete this training within 30 days of hire and annually thereafter. However, it was confirmed that the Registered Dietician had not completed the necessary infection control training, indicating a lapse in adherence to the facility's infection prevention and control program.
Failure to Complete Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that compliance and ethics training was completed in a timely manner for one of the sampled employees. Employee #4, who was hired as a Registered Dietician on September 11, 2003, did not have documented evidence of having completed the required compliance and ethics training. According to the Human Resources Supervisor, all staff are required to complete this training within 30 days of hire and annually thereafter. However, it was confirmed that Employee #4 did not have the necessary training documented in their personnel record. The facility's policy, effective October 2022, mandates that all employees complete compliance and ethics continuing education annually.
Failure to Complete Behavioral Health Training
Penalty
Summary
The facility failed to ensure that behavioral health training was completed in a timely manner for one of the sampled employees, specifically Employee #4, who was hired as a Registered Dietician. Employee #4's personnel record did not contain documented evidence of having completed the required behavioral health training. According to the Human Resources Supervisor, all staff were mandated to complete this training within 30 days of hire and annually thereafter. However, it was confirmed that Employee #4 had not completed the training as required by the facility's policy, which was effective from July 2022.
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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