Trellis Centennial
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 8565 W Rome Blvd, Las Vegas, Nevada 89149
- CMS Provider Number
- 295106
- Inspections on file
- 20
- Latest survey
- May 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Trellis Centennial during CMS and state inspections, most recent first.
A resident with a hospital-diagnosed anxiety disorder was admitted and exhibited repeated care refusals, aggression, and behavioral symptoms, but the facility failed to document anxiety as an active diagnosis, did not develop a care plan or interventions for anxiety, and did not provide behavioral health services until after the resident expressed suicidal ideation. Staff recognized the behaviors but did not address them through the care planning process, resulting in psychosocial harm.
Staff failed to properly disinfect a shared glucometer with EPA-approved wipes, did not consistently perform hand hygiene or use PPE when entering rooms of residents on contact isolation for C. diff and wound infection, and did not document required education for visitors regarding isolation precautions. These lapses involved both staff and visitors and affected multiple residents with infectious conditions.
A resident with multiple medical conditions was administered Lovenox for deep vein thrombosis without a care plan or physician order for monitoring anticoagulant therapy. Staff did not perform or document routine assessments for bleeding or adverse reactions, and the MAR lacked evidence of monitoring, despite facility policy requiring these actions.
A resident with COPD and acute respiratory failure was administered oxygen via nasal cannula without a physician's order specifying flow rate or care instructions. Nursing staff and the DON confirmed the absence of required orders, and facility policy required such orders for oxygen administration.
A resident with multiple medical conditions did not receive pain management in accordance with physician orders. The MAR showed Hydrocodone-Acetaminophen was given for a pain rating of 4/10, despite orders specifying its use only for severe pain (7-10/10) and no orders covering pain rated 4-6/10. Nursing staff and the DON confirmed the medication was not administered as prescribed, and the physician was not contacted for clarification.
Two residents in the facility did not have documented evidence of receiving assistance with activities of daily living (ADLs) as required by their care plans. One resident, with muscle weakness and a fracture, lacked documentation of oral, toileting, and personal hygiene assistance over several shifts. Another resident, with muscle weakness and hemiplegia, reported being left in a soiled brief for hours, with no documentation of toileting hygiene during multiple shifts. The facility's policy requires documentation of ADL assistance, which was not adhered to, resulting in a deficiency.
A facility failed to record a resident's weight upon admission, which could have compromised their nutritional and medical well-being. The resident, admitted with conditions such as dysphasia and diabetes, had their weight recorded six days later. Staff interviews revealed that the facility's policy required weights to be taken upon admission, with the expectation of entry within 48 hours.
The facility failed to ensure accurate documentation of medications and treatment services for residents, including a Lidocaine patch, ACE wrap, TED hose, and Heparin injections. Errors included not removing a Lidocaine patch as scheduled, not applying an ACE wrap, inaccurately documenting TED hose application, and discrepancies in Heparin vial deliveries versus recorded administrations.
The facility failed to apply an ACE wrap and TED hose as ordered for two residents and did not administer Heparin as prescribed for another resident. The ACE wrap was not applied for over a week, and weekly skin assessments were not completed. TED hose was not provided due to size issues, yet nurses signed off as if it had been applied. Heparin administration records showed discrepancies, with more recorded doses than vials delivered.
The facility failed to ensure proper wound care for a resident with stage IV and stage III pressure ulcers, resulting in the wound being left uncovered and exposed to urine and feces. The CNA did not inform the licensed nurse or wound care treatment nurse about the soiled dressing, and the wound dressings on the resident's heels were undated, contrary to facility policy.
The facility failed to ensure a Lidocaine patch was applied and removed as ordered for a resident with muscle spasm, bacteremia, and a history of liver transplant. The patch was not removed or replaced as required, leading to the resident experiencing pain. The MAR inaccurately documented the removal and application of the patch, and staff confirmed the oversight.
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 10.34%. Errors included incorrect dosages of Sodium Bicarbonate and Zinc Sulfate, and improper administration of a Cyanocobalamin Injection Solution. The DON confirmed these errors and noted the potential for compromised absorption and adverse reactions.
The facility failed to document a narcotic administration in the Narcotics Logbook and found loose pills, personal food items, and an unlabeled white powdery substance in medication carts. The LPN and DON acknowledged these deficiencies and the need for proper medication storage and documentation.
The facility failed to follow TBP and EBP for two residents, leading to multiple instances where staff and family members entered rooms without required PPE. Additionally, an LPN did not disinfect a medication vial topper before use, contrary to infection control protocols.
Failure to Develop and Implement Behavioral Health Care Plan for Resident with Anxiety
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's hospital-diagnosed anxiety, did not monitor behavioral symptoms, and did not provide necessary behavioral health services. Despite documentation from the hospital discharge summary, physician assessments, and therapy evaluations all identifying anxiety as an active medical condition, the facility did not code anxiety as an active diagnosis in the medical record until several days after admission. The baseline care plan created at admission did not include any focus, goals, or interventions related to anxiety, and there was no evidence of individualized behavioral health interventions being developed or implemented. Throughout the resident's stay, multiple instances of care refusal, verbal aggression, and behavioral symptoms such as yelling and use of abusive language were documented. Staff, including therapy and nursing, observed and reported these behaviors, but there was no documented evidence that these symptoms were addressed through the care planning process or that the interdisciplinary team (IDT) discussed or intervened regarding the resident's anxiety prior to the resident expressing suicidal ideation. The resident also reported to surveyors feelings of depression, hopelessness, and ongoing suicidal thoughts, and stated that requests for medication to address anxiety and sleep issues were denied by staff. Interviews with staff confirmed that the resident's behavioral symptoms and refusals were recognized but not addressed through a care plan or IDT intervention. The facility's own policy required assessment and individualized care planning for behavioral health symptoms, but this was not followed. The lack of timely recognition, documentation, and intervention for the resident's anxiety and behavioral health needs resulted in psychosocial harm, as evidenced by the resident's reported suicidal ideation.
Failure to Adhere to Infection Control Protocols and Contact Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances involving the use of shared medical equipment, adherence to contact isolation protocols, and education of staff and visitors regarding transmission-based precautions. In one case, a registered nurse disinfected a shared glucometer with an alcohol pad after use on a resident with diabetes and chronic kidney disease, despite the availability of EPA-approved disinfectant wipes and facility protocols requiring their use. The nurse believed alcohol pads were acceptable based on previous pharmacy guidance, but both the Director of Nursing and Infection Preventionist later confirmed that only EPA-approved wipes with a specified contact time were appropriate for disinfecting shared glucometers to prevent cross-contamination. In another instance, staff failed to follow contact isolation procedures for a resident on precautions for possible Clostridium difficile infection. Despite clear signage and the availability of personal protective equipment (PPE) at the room entrance, multiple staff members entered and exited the resident's room without donning the required PPE or performing hand hygiene with soap and water, as mandated for C. difficile precautions. Staff later acknowledged that they had not paid attention to the isolation signage and were aware that proper handwashing and PPE use were required but had not been performed. Additionally, the facility did not ensure that visitors and staff consistently adhered to contact precautions for a resident with a wound infection. A visitor entered and remained in the resident's room without wearing the required gown and gloves, stating they were unaware of the need for PPE. The facility's care plan and policies required education for visitors and documentation of such education, but there was no evidence in the medical record that the visitor had been informed about the precautions. Furthermore, a licensed practical nurse was observed entering the same resident's room without donning PPE, despite acknowledging the necessity of these measures to prevent infection spread.
Failure to Implement Care Plan and Monitoring for Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to formulate a care plan for anticoagulant use and did not obtain a physician order for monitoring a resident receiving anticoagulant therapy. The resident, who had diagnoses including dementia, Parkinson's disease, and gait abnormalities, was admitted and prescribed Lovenox for deep vein thrombosis. Although the medication was administered as ordered, there was no documented evidence of a care plan addressing anticoagulant use, nor was there a physician order in place for monitoring the resident for potential bleeding or adverse reactions during the course of therapy. Staff interviews confirmed that routine assessments for signs of bleeding, such as bruising, bleeding gums, hematuria, and black tarry stools, were not conducted or documented prior to or during the administration of Lovenox. The lack of a monitoring order meant that no prompts were generated for staff to implement necessary assessments, and the Medication Administration Record did not reflect any monitoring for bleeding or coagulation issues. The facility's own policy required such monitoring and documentation, but these steps were not followed for this resident.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen therapy for a resident with diagnoses including COPD with exacerbation, acute respiratory failure, and dementia. The resident was observed receiving oxygen via nasal cannula at varying flow rates without a humidifier, and there was no documented physician order specifying the use, flow rate, or care instructions for the oxygen therapy. Medical records did not contain evidence of an order for oxygen or for changing the nasal cannula, despite the resident's continuous dependence on supplemental oxygen. Interviews with nursing staff and the Director of Nursing confirmed that no physician order was in place for the oxygen therapy or related care, and that staff were expected to obtain such orders at the onset of oxygen use. The Physician Assistant also confirmed that a physician's order specifying flow rate, delivery method, and monitoring parameters was required for supplemental oxygen. Facility policies reviewed indicated that a physician's order was necessary for oxygen administration and for all medications and treatments.
Failure to Administer Pain Medication per Physician Orders
Penalty
Summary
The facility failed to ensure that pain medication was administered according to physician orders for a resident with multiple diagnoses, including cellulitis of both lower limbs, muscle weakness, and acute and chronic respiratory failure with hypoxia. The resident had physician orders specifying Tylenol for mild pain rated 1-3/10 and Hydrocodone-Acetaminophen for severe pain rated 7-10/10, but there was no order for pain rated 4-6/10. Despite this, the Medication Administration Record (MAR) showed that Hydrocodone-Acetaminophen was administered for a pain rating of 4/10 on several occasions. Interviews with nursing staff and the Director of Nursing confirmed that the medication was not administered as per the physician's orders and that there was a lack of physician orders for pain rated 4-6/10. Staff did not contact the physician for clarification or new orders when the resident reported pain in this range, as required by facility policy. The facility's policy stated that medications should be administered safely, timely, and as prescribed, but this was not followed in the case of this resident.
Deficiency in Documenting ADL Assistance for Residents
Penalty
Summary
The facility failed to provide documented evidence of assistance with activities of daily living (ADLs) for two residents, leading to a deficiency in care. Resident 1, who was admitted with muscle weakness and a displaced intertrochanteric fracture of the left femur, required assistance with oral hygiene, toileting hygiene, and personal hygiene. Despite the care plan indicating the need for assistance, there was no documentation of these services being provided during several shifts in July, August, and September 2024. The Minimum Data Set (MDS) Director and the Director of Nursing (DON) confirmed the lack of documentation, which should have been recorded at least once per shift. Resident 2, admitted with muscle weakness, hemiplegia of the right dominant side, and respiratory failure, also required assistance with ADLs. The resident reported being left in a soiled brief for extended periods, particularly between 4:00 AM and 10:00 AM, and often while waiting for physical therapy. The ADL Documentation Survey Report for October and November 2024 showed no evidence of toileting hygiene being provided during several shifts. The MDS Director and DON confirmed the absence of documentation, which should have been recorded if the resident refused or was unavailable for care. The facility's policy on ADLs, revised in March 2018, mandates that residents unable to perform ADLs independently should receive appropriate support for hygiene, mobility, elimination, dining, and communication. However, the lack of documentation for the care provided to Residents 1 and 2 indicates a failure to adhere to this policy, resulting in a deficiency in the care provided to these residents.
Failure to Record Resident's Weight Upon Admission
Penalty
Summary
The facility failed to ensure that a resident's weight was taken and recorded upon admission, which could have compromised the nutritional and medical well-being of the resident. The resident, who was admitted with diagnoses including dysphasia, chronic kidney disease, and diabetes mellitus, had their weight recorded six days after admission. The medical record lacked evidence of the weight being obtained upon admission. Interviews with facility staff, including a CNA, a Charge Nurse, and the DON, revealed that the facility's policy required weights to be taken upon admission, with the expectation that this information be entered within 48 hours. The facility's Weight Assessment and Intervention policy specified that residents were to be weighed upon admission and weekly thereafter.
Documentation Failures in Medication and Treatment Services
Penalty
Summary
The facility failed to ensure documentation accurately reflected medications and treatment services provided to residents. For Resident 166, a Lidocaine patch was not removed as scheduled, and the Medication Administration Record (MAR) inaccurately documented its application and removal. The patch was left on for more than 12 hours, contrary to the physician's order, and the MAR indicated it was removed when it was still in place. This discrepancy was confirmed by both the resident and the Licensed Practical Nurse (LPN), who acknowledged the error in documentation and the failure to follow the physician's order for timely removal of the patch. Resident 9 had an active physician's order for an ACE wrap to be applied to the left foot amputation surgical site every shift. However, the resident reported that the ACE wrap had not been applied for more than a week, despite the MAR indicating otherwise. The Wound Care Treatment Nurse (WCTN) and the Director of Nursing (DON) confirmed that the ACE wrap was not applied as ordered and that the MAR was inaccurately documented. The WCTN was unsure of the indication for the ACE wrap, and the DON emphasized the importance of accurate documentation and adherence to physician's orders. Resident 43 had orders for TED hose to be applied for edema management and Heparin injections for deep vein thrombosis (DVT) prophylaxis. The TED hose was not applied as ordered, and the MAR inaccurately documented its application. The charge Registered Nurse (RN) admitted to signing off on the TED hose application despite the hose being too small for the resident. Additionally, there was a significant discrepancy in the number of Heparin vials delivered versus the number of recorded administrations, indicating missed doses. The DON and the Consultant Pharmacist confirmed the discrepancy and the failure to follow the facility's medication administration and documentation policies.
Failure to Apply ACE Wrap, TED Hose, and Administer Heparin as Ordered
Penalty
Summary
The facility failed to ensure proper application and clarification of an ACE wrap for a resident who had undergone a surgical amputation. Despite a physician's order for the ACE wrap to be applied every shift, the resident reported that the wrap had not been applied for more than a week. The wound care treatment nurse and the director of nursing confirmed that the ACE wrap was an active order but had not been applied as required. Additionally, the facility did not complete weekly head-to-toe skin assessments as ordered, which led to unmonitored swelling in the resident's left foot. The wound care treatment nurse acknowledged the lack of assessment and indicated that the physician would be notified for new orders to treat the edema. Another resident was not provided with TED hose as ordered for edema management. The resident had a physician's order for TED hose to be applied twice a day, but the resident reported not having used compression stockings since admission. The certified nursing assistant and licensed practical nurse assigned to the resident were unaware of the TED hose order, and the charge nurse admitted that the facility did not have appropriately sized TED hose for the resident. Despite this, multiple nurses had been signing off on the medication administration record as if the TED hose had been applied. The facility also failed to administer Heparin as ordered for a resident. The resident was supposed to receive Heparin injections twice a day, but the medication administration records showed discrepancies between the number of recorded administrations and the number of Heparin vials delivered. The director of nursing and the consultant pharmacist confirmed that there were 57 more recorded administrations than the number of vials delivered, indicating missed doses. The facility's policies on medication administration and documentation were not followed, leading to inaccurate records and potential harm to the resident.
Failure to Ensure Proper Wound Care and Communication
Penalty
Summary
The facility failed to ensure proper wound care for a resident with stage IV pressure ulcers on the sacral region and stage III pressure ulcers on the right and left buttocks. The resident's wound was found uncovered and soaked with urine and feces during incontinent care. The CNA responsible for the resident's care did not inform the licensed nurse or wound care treatment nurse about the soiled dressing, leading to the wound being left exposed. The WCTN confirmed that the wound should not be left open to prevent contamination and potential worsening of the wound or infection. Additionally, the facility's policy required wound dressings to be dated, which was not followed in this case, as the dressings on the resident's heels were undated. The facility's failure to follow wound care protocols and ensure proper communication among staff members resulted in the resident's wound being left exposed to contaminants. The WCTN and the wound physician emphasized the importance of following wound care orders to promote healing and prevent complications. The Director of Nursing also confirmed that staff members were expected to cover wounds to prevent exposure to feces and urine. The facility's policies on wound care and prevention of pressure injuries were not adhered to, leading to the identified deficiencies.
Failure to Apply and Remove Lidocaine Patch as Ordered
Penalty
Summary
The facility failed to ensure the Lidocaine patch was applied and removed as ordered for Resident 166, who was admitted with diagnoses including muscle spasm, bacteremia, and a history of liver transplant. The physician's order specified the application of a Lidocaine patch, 5% topically, daily to the affected area at 9:00 AM and removal at 8:59 PM. However, on 06/04/2024, it was observed that the patch applied on 06/02/2024 was still in place, and no new patch had been applied on 06/03/2024. The Medication Administration Record (MAR) inaccurately documented the removal and application of the patch on 06/02/2024 and 06/03/2024, respectively. The Licensed Practical Nurse (LPN) confirmed the patch had not been removed or replaced as required, and the resident reported experiencing pain due to this oversight. Interviews with the Physician Assistant (PA), Director of Nursing (DON), and Pain Specialist highlighted the importance of timely application and removal of the Lidocaine patch for effective pain management. The PA and DON acknowledged that the staff were expected to follow the orders for the effectiveness of the pain medication. The Pain Specialist emphasized that the patch should be removed after 12 hours to prevent skin irritation and mentioned a previous incident where a resident's skin was burned due to untimely removal. The facility's pain management policy, dated 10/2022, indicated a commitment to appropriate assessment and treatment of pain based on professional standards of practice, which was not adhered to in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was below five percent, resulting in an error rate of 10.34%. This was based on three errors identified out of 29 opportunities observed. The first error involved an LPN administering 650 mg of Sodium Bicarbonate to a resident instead of the prescribed 325 mg. The LPN acknowledged the mistake and confirmed that the correct procedure would have been to cut the 650 mg tablet in half. The Director of Nursing (DON) confirmed the error and noted that the resident should have been monitored for adverse reactions. The second error involved the same LPN administering a Cyanocobalamin Injection Solution subcutaneously instead of intramuscularly as ordered. The LPN admitted to the mistake and acknowledged that medications should be administered per physician orders. The DON confirmed the error and explained that incorrect administration could compromise absorption. The third error involved the LPN administering 200 mg of Zinc Sulfate to another resident instead of the prescribed 220 mg. The LPN acknowledged the mistake and reported that the ordering provider should have been contacted for clarification. The DON confirmed the error and noted that the resident received a lower dose than prescribed.
Medication Documentation and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and storage of medications, as observed during an inspection of two medication carts. At Station 1, loose pills, including half of a white pill, half of a yellow pill, and a full pink pill, were found under medication packets. The LPN present admitted to not checking under the medication packets while cleaning the cart at the start of the shift and acknowledged that the cart should have been free of loose pills. At Station 2, a narcotic medication administration was not logged in the Narcotics Logbook. Additionally, personal food items such as a bag of cheese crackers and multiple small chocolate bars were found in a drawer next to clean supplies. An unlabeled and uncovered white powdery substance, identified as thickener for fluids, was found in a clear plastic cup on top of clean supplies. The LPN confirmed the narcotic was administered but not documented, acknowledged the personal food items were theirs, and admitted awareness of the policy against storing food in medication carts. The DON confirmed the need for proper logging of narcotics and adherence to storage policies.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to ensure that transmission-based precautions (TBP) and Enhanced Barrier Precautions (EBP) were followed for two residents. For Resident 166, who was on contact precautions due to a Methicillin-resistant Staphylococcus aureus (MRSA) infection, multiple instances were observed where staff, family members, and a housekeeper entered the room without wearing the required personal protective equipment (PPE). The Certified Nursing Assistant (CNA) and family members were not informed about the need for PPE, and the housekeeper admitted to not paying attention to the precaution signage. The Infection Preventionist (IP) confirmed that the failure to follow precautions posed a risk of cross-contamination and exposure to other residents and staff members. Similarly, for Resident 33, who was on contact precautions due to a Clostridium difficile (C. diff) infection, a family member and the admissions director were observed entering the room without donning the required gown and gloves. The family member was not educated about the need for PPE, and the admissions director ignored the contact isolation signage. Both individuals failed to perform hand hygiene upon leaving the room, which the IP confirmed increased the risk of cross-contamination. Additionally, the facility failed to follow proper infection control procedures during medication administration for Resident 34. A Licensed Practical Nurse (LPN) accessed a medication vial without disinfecting the vial topper, believing it was unnecessary for new sterile vials. The Director of Nursing (DON) confirmed that all medication vials, regardless of their condition, needed to be wiped with alcohol to disinfect the vial topper. This failure to adhere to infection control protocols could potentially lead to contamination and infection.
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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