Trellis Paradise
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 4375 S. Eastern Avenue, Las Vegas, Nevada 89119
- CMS Provider Number
- 295109
- Inspections on file
- 13
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Trellis Paradise during CMS and state inspections, most recent first.
Nursing staff did not document physician notification, change in condition, or nursing interventions for a resident who developed a high fever, despite facility policy requiring such actions. The resident, with a history of respiratory illness and pneumonia, had a temperature of 102.9°F recorded, but no further temperature checks or interventions were documented for over 15 hours. Interviews with LPNs, CNAs, an RN, and the DON confirmed that standard practice would have included prompt notification, interventions, and documentation, none of which occurred in this case.
A resident with chronic respiratory failure, COPD, and pneumonia experienced a significant fever, but the facility failed to ensure timely and complete documentation of nursing interventions, provider notification, and follow-up monitoring. Although a physician progress note acknowledged the fever and recommended monitoring, this note was not promptly transferred to the facility's software, and staff could not clarify the timing or provide documentation as required by policy.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended, which posed a risk of unauthorized access to medications and supplies. A treatment cart was left outside a nourishment room, and a medication cart was found unsecured in front of a resident's room. Staff acknowledged the carts should be locked, citing lost keys and potential lock issues.
A resident with multiple health conditions was discharged with a plan for follow-up care from a home health agency, but the agency never contacted the resident. The case manager failed to follow up with the agency or the resident, despite known issues with the agency's performance. The facility's policy required a post-discharge plan, which was not effectively executed.
A facility failed to protect a resident's PHI when a medication cart was left unattended with a laptop screen displaying sensitive information. The RN responsible was in training and did not lock the screen. Both an LPN and another RN confirmed that nurses are trained to secure laptops to protect PHI, as per the facility's confidentiality policy.
The facility failed to maintain proper linen handling procedures, risking patient exposure to infections. CNAs were observed carrying clean linen against their uniforms, contrary to facility policy requiring linen to be protected from contamination. The ADON confirmed the correct procedure was not followed.
A resident with malnutrition was not adequately monitored for hydration, leading to visible signs of dehydration such as dry, cracked lips and sunken eyes. Despite these symptoms, nursing staff failed to report the condition to the medical provider or document it, resulting in a significant fluid intake deficit. The Registered Dietician was unaware of the issue due to a lack of communication, and the Medical Director was not informed, preventing timely intervention.
A resident with severe malnutrition and other health issues received TPN through a midline IV catheter instead of a central line, contrary to manufacturer's recommendations. Despite the risks of complications due to high osmolarity, the facility proceeded with midline administration after consulting with a pharmacist and physician, leading to pain and edema in the resident's arm.
A resident with muscle weakness and recent back surgery was not repositioned as required, leading to discomfort and potential skin integrity issues. The resident also expressed a preference against using incontinence briefs, but this was not documented or communicated effectively by staff. The facility's policies did not adequately address these issues, resulting in a deficiency related to resident rights.
A resident's privacy was compromised when their body weight was posted on a board visible from the hallway. The resident, who was alert and oriented, expressed concern over this privacy issue. A nurse confirmed the visibility and removed the information. The DON mentioned a family request for the posting, but no documentation supported this. Facility policy prohibits posting clinical information without resident or family request.
A resident with severe malnutrition and other conditions received TPN administered by LPNs instead of RNs, contrary to state regulations. The facility's DON was unaware of this requirement, and LPNs documented administering TPN despite it not being in their job description.
A resident with multiple health issues was not discharged to a licensed group home as per physician's order. Despite the resident's agreement to move to a group home with hospice services, the discharge summary indicated a different address, which was not a licensed group home. The facility's case manager did not verify the home's licensing, leaving it to the insurance social worker, resulting in a deficiency.
A resident with a right humerus fracture was not provided with the prescribed arm brace and sling, as per physician orders and the care plan. The resident reported significant pain and indicated that the brace helped alleviate discomfort. The Physical Therapy Director confirmed the necessity of the brace and sling, which should have been in place at all times. The facility's policy required the maintenance and supervision of assistive devices, but the resident was found without the prescribed equipment, potentially impacting their recovery.
The facility failed to maintain sanitary conditions in the kitchen, potentially exposing residents to foodborne illnesses. Observations included a cook without a beard cover, soiled kitchen equipment, undated and spilled milk, dented cans, and a dirty ice machine. A fan was improperly placed in the food prep area, and another cook was observed without a beard cover.
Failure to Document and Respond to Resident's High Temperature
Penalty
Summary
Nursing staff failed to document physician notification, a change in condition, nursing interventions, or attempts to obtain a physician order to manage a resident's high temperature, as required by facility policy. The resident, who had a history of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and pneumonia, was admitted with these diagnoses. On the evening of 08/14/2025, the resident's oral temperature was recorded at 102.9°F, but there was no further temperature documented until the following afternoon, over 15 hours later. During this period, there was no documentation of any interventions, physician or family notification, or a change in condition assessment in the medical record. Interviews with nursing staff, including LPNs, CNAs, an RN, and the DON, revealed that the facility's standard practice was to consider a temperature above 100.3°F as high and to implement interventions such as cooling measures, hydration, and notifying the physician for further orders, including medication like Tylenol. Staff also indicated that a change in condition assessment would be completed, the physician and family would be notified, and the temperature would be rechecked within an hour. However, in this case, none of these actions were documented for the resident with the high temperature. A review of the facility's policy on changes in a resident's condition confirmed that prompt notification of the physician, resident, and representative was required, along with detailed documentation of observations and interventions. The DON and physician both confirmed that the medical record lacked evidence of a change in condition, nursing interventions, or physician notification related to the resident's high temperature. The absence of documentation and follow-up actions was inconsistent with both facility policy and staff statements regarding standard procedures.
Incomplete and Delayed Medical Record Documentation Following Change in Condition
Penalty
Summary
The facility failed to ensure complete and accessible medical record documentation for one resident with multiple serious diagnoses, including chronic respiratory failure, COPD, and pneumonia. The resident experienced a significant change in condition, evidenced by an elevated oral temperature of 102.9°F, which was documented by an LPN. However, the medical record lacked evidence of timely and complete documentation of nursing interventions, follow-up monitoring, and provider notification related to this change in condition. Although a physician progress note acknowledged the fever and recommended monitoring and Tylenol as needed, this note was not transferred to the facility's software until several days later, and the Director of Nursing was unable to clarify the timing of the note's entry. Additionally, the DON refused to provide a copy of the note, citing HIPAA privacy, despite policy allowing surveyor access. Interviews with nursing staff and the physician confirmed that a temperature above 100.3°F should have triggered provider notification, interventions, and documentation, but the medical record did not contain evidence of these actions. The physician also expected documentation of interventions and rechecking of the temperature, but did not recall being updated by the covering physician. The facility's policies required documentation of changes in condition and provider notification, but there was no evidence in the record that these requirements were met. Furthermore, the physician services policy did not address accountability for timely electronic documentation or software transfers.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to secure medication and treatment carts, which were left unlocked and unattended, posing a risk of unauthorized access to medications and treatment supplies. On multiple occasions, a treatment cart was observed outside the nourishment room, unlocked and unattended, with contents such as scissors, ointments, creams, and dressings easily accessible to residents or visitors. A Certified Nursing Assistant confirmed the cart was unlocked and expressed concerns about resident safety due to the unsecured contents. A Registered Nurse acknowledged the cart was unsecured and mentioned that the key was lost, indicating the cart should be locked to prevent unauthorized access. Additionally, a medication cart was found unattended and unsecured in front of a resident's room, with an intravenous bag of Saline and Meropenem left on the counter. The Registered Nurse responsible for the cart was inside the room and not in view of the cart, and it was noted that the nurse was new and in training. Another medication cart was also found unlocked, with a Registered Nurse confirming the lock system might be broken and acknowledging the need for the cart to be locked to prevent residents from accessing medications. The Assistant Director of Nursing confirmed the medication cart should have been locked and was unaware of the inability to lock the carts in the south hallway. The facility's policy requires medication carts to be securely locked when out of the nurse's view.
Failure in Coordination of Care for Discharged Resident
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Summary
The facility failed to ensure proper coordination of care for a resident discharged to a home health agency, leading to a potential risk for an unsafe discharge. The resident, who had multiple health conditions including chronic obstructive pulmonary disease, muscle weakness, and multiple sclerosis, was discharged with a plan for follow-up care involving physical therapy, occupational therapy, and nursing services from a specified home health agency. However, the resident reported not being contacted by the agency within the expected 24 to 48 hours post-discharge, and the agency confirmed that the resident was never under their care. The case manager admitted to not following up with the home health agency or the resident to ensure services were provided, despite acknowledging previous issues with the agency's performance. The Director of Nursing confirmed the importance of follow-up calls to maintain continuity of care. The facility's policy required the care planning team to develop a post-discharge plan with arrangements for follow-up care, which was not effectively executed in this case.
Failure to Protect Resident's Protected Health Information
Penalty
Summary
The facility failed to protect a resident's protected health information (PHI) when a medication cart was left unattended and unsecured in front of a resident's room. On the cart, a laptop computer screen was left open, displaying the resident's name, medication profile, and diagnoses, which were visible to the public or other residents passing by. The Registered Nurse (RN) responsible for the cart was in the resident's room and had not locked the computer screen to safeguard the resident's medical information. The RN explained that this was only the employee's fourth day and they were still in training. Both a Licensed Practical Nurse (LPN) and another RN confirmed that nurses are trained to lock or close laptops to protect PHI. The facility's policy on confidentiality, revised in October 2017, mandates the protection and safeguarding of residents' personal and medical records.
Improper Linen Handling Procedures
Penalty
Summary
The facility failed to maintain proper linen handling procedures, which placed patients at risk for exposure to infections. On March 26, 2025, a Certified Nursing Assistant (CNA1) was observed carrying clean linen beneath their left arm and against their uniform while entering a resident's room. Later that morning, two CNAs were seen exiting the linen room with clean linen held against their chests and uniforms, confirming they were transporting it to resident rooms. CNA2 acknowledged that staff should hold clean linen away from their bodies or use a plastic bag during transport to prevent contamination. The Assistant Director of Nursing (ADON) observed the incident and indicated that the CNAs should have transported the clean linen away from their bodies to prevent contamination from potentially unclean uniforms. The facility's policy on Soiled Laundry and Bedding, revised in September 2022, requires that clean linen be protected from dust and soiling during transport and storage to ensure cleanliness.
Failure to Monitor and Maintain Resident Hydration
Penalty
Summary
The facility failed to adequately monitor and maintain the hydration status of Resident 255, who was admitted with diagnoses including malnutrition. Observations on multiple occasions revealed the resident exhibited signs of dehydration, such as dry, cracked lips, sunken eyeballs, and dry flaking skin on the lower extremities. Despite these visible symptoms, the nursing staff, including a CNA and an LPN, did not report the resident's condition to the medical provider or document the symptoms in the resident's records. The Registered Dietician (RD) had not completed a full dietary evaluation for Resident 255, and the resident was receiving 700ml less fluid per day than the recommended intake of 1975ml. The RD was unaware of the resident's dehydration symptoms as the nursing staff had not communicated this information. The facility's Medical Director confirmed that they were not informed of the resident's condition, which prevented timely medical intervention such as intravenous hydration. The resident's care plan identified a risk for dehydration and included interventions like encouraging increased oral fluids and monitoring for signs of dehydration. However, these interventions were not effectively implemented, as evidenced by the lack of documentation and communication regarding the resident's fluid intake deficits and dehydration symptoms. The facility's policies on change in condition and hydration were not followed, as there was no notification to the physician or the resident's representative about the significant change in the resident's condition.
Improper Administration of TPN via Midline IV
Penalty
Summary
The facility failed to ensure the safe administration of total parenteral nutrition (TPN) for a resident, leading to complications. The resident, who had severe protein-calorie malnutrition, dementia, dysphagia, and a history of venous thrombosis and embolism, was initially admitted with a recommendation for TPN through a central line. However, due to unsuccessful attempts to insert a central line, the TPN was administered through a midline IV catheter, which is not recommended for solutions with high osmolarity like TPN. Despite the manufacturer's recommendation for central line administration due to the high osmolarity of the TPN solution, the facility proceeded with midline administration after consulting with a pharmacist and the attending physician. The resident experienced pain and edema in the arm where the midline was inserted, indicating potential complications. The decision to use a midline was made after the resident returned from the hospital with a midline instead of a central line, and the family requested TPN administration before hospice care. The facility's actions were based on the inability to place a central line and the family's wishes, but this led to the administration of TPN in a manner contrary to the manufacturer's guidelines. The pharmacist and physician acknowledged the risks associated with midline administration of high osmolarity solutions, yet the TPN was continued temporarily. This practice resulted in the resident experiencing pain and potential complications, highlighting a deficiency in adhering to safe administration protocols for TPN.
Failure to Honor Resident Rights in Repositioning and Incontinence Care
Penalty
Summary
The facility failed to honor resident rights related to repositioning and the use of incontinence briefs for one resident, identified as R252. The resident was admitted with diagnoses including muscle weakness and was at risk for pain following recent back surgery. The care plan for R252 included goals for comfort using non-pharmaceutical methods and interventions such as repositioning every two hours to prevent skin integrity impairment. However, observations and interviews revealed that R252 was not repositioned as required, with the resident expressing discomfort from lying on their back continuously. The Turn and Reposition daily log showed multiple instances where R252 was not repositioned during various shifts. Additionally, the facility did not adequately address the resident's preferences regarding the use of incontinence briefs. R252, who was alert and able to communicate, stated a preference for not using the briefs, although they were willing to do so for the convenience of the staff. The CNA caring for R252 was unaware of the resident's preferences and did not know how to check them on the computer. The care plan lacked documentation regarding the use of incontinence briefs, and the facility's policy on urinary incontinence did not address resident preferences for using such briefs.
Privacy Breach: Resident's Weight Information Publicly Displayed
Penalty
Summary
The facility failed to safeguard the privacy of a resident by posting their body weight on a room's board that was visible from the hallway. This incident involved a resident who was alert, oriented, and capable of making their own decisions. The resident, who had been admitted with diagnoses including COPD, acute hypoxic respiratory failure, prediabetes with steroid-induced hyperglycemia, and sleep apnea, expressed concern that their weight information should not be visible to everyone due to privacy issues. A Registered Nurse confirmed the visibility of the weight information and removed it from the board. The Director of Nursing later indicated that a family member had requested the weight to be documented on the board, but there was no documented evidence of such a request in the medical record. The facility's policy on dignity stated that signs indicating a resident's clinical status or care needs should not be openly posted unless requested by the resident or family member.
Improper Administration of TPN by LPNs
Penalty
Summary
The facility failed to ensure that total parenteral nutrition (TPN) was administered by qualified Registered Nurses (RNs) for one of the sampled residents. The resident, who was admitted with severe protein-calorie malnutrition, dementia, dysphagia, and a history of venous thrombosis and embolism, had a physician's order for TPN to be administered intravenously. However, the medication administration record (MAR) for August and September revealed that TPN was documented as administered by Licensed Practical Nurses (LPNs) on multiple occasions, despite the Nevada Nursing Practice Act specifying that LPNs are not authorized to administer TPN. Interviews with LPNs and the Director of Nursing (DON) confirmed that LPNs had documented administering TPN, although they were only supposed to monitor the infusion. The DON was unaware that LPNs could not administer TPN according to state regulations. A review of personnel records showed that TPN administration was not included in the LPNs' job descriptions. This oversight in ensuring compliance with professional standards of quality had the potential to expose the resident to medication errors and health complications.
Failure to Discharge Resident to Licensed Group Home
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 161, was discharged to a licensed group home as per the physician's order. Resident 161 had multiple diagnoses, including restless leg syndrome, generalized muscle weakness, diabetes mellitus, unspecified protein-calorie malnutrition, legal blindness, and adult failure to thrive. The resident was admitted to the facility after being discharged from the emergency department due to uncontrolled muscle spasms and reported not having food at home. The resident required assistance with placement and expressed a desire to be discharged to a group home in a specific area of town. Throughout the resident's stay, various notes documented the resident's condition and discharge planning. The interdisciplinary team and case management were involved in discussing discharge options with the resident, who was agreeable to moving into a group home with hospice services. The resident's family was willing to assist with group home expenses, and the resident was evaluated and accepted to a group home. However, the discharge summary indicated that the resident was discharged to a home, and a review of the Bureau of Health Care Quality and Compliance Health Facility Locator website revealed that there was no licensed group home at the address provided. The facility's case manager indicated that the resident was alert and oriented and chose the discharge address. However, the case manager did not verify if the home was a licensed group home, leaving it to the insurance social worker to ensure compliance with the physician's order. The medical record lacked documented evidence that the resident was discharged to a licensed group home, as required, or that the discharge plan was altered based on the resident's preference to go to a private residence with hospice services.
Failure to Provide Prescribed Arm Brace and Sling
Penalty
Summary
The facility failed to ensure that a resident with a right humerus fracture was provided with the necessary arm brace and sling as per the physician's orders and care plan. The resident, identified as Resident #98, was admitted with a diagnosis of a right humerus fracture and had a physician's order dated 09/05/2024, which specified the use of a [NAME] brace and a sling with an abduction pillow at all times. On 09/17/2024, it was observed that the resident was not wearing the prescribed brace and sling, which had been removed by a staff member the previous night and could not be located. The resident reported significant pain and indicated that the brace helped alleviate the discomfort caused by the fracture. The care plan dated 08/30/2024, and a physician progress note from 09/12/2024, confirmed the necessity of the brace and sling for the resident's condition. The Physical Therapy Director also confirmed that the brace and sling should have been in place at all times until 10/14/2024. The facility's policy on Assistive Devices and Equipment required the maintenance and supervision of assistive devices as dictated by the resident's care plan. The failure to adhere to these orders and policies resulted in the resident not receiving the appropriate treatment and care, as evidenced by the absence of the prescribed brace and sling, potentially leading to complications in the resident's recovery process.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially expose residents to foodborne illnesses. During an inspection, it was observed that a cook was preparing meals without wearing a beard cover, despite having facial hair. The top surfaces of both the oven and the dishwasher were visibly soiled with greasy matter, dust, and yellowish debris. Additionally, an open bottle of milk was found undated in the walk-in refrigerator, and a milk carton was found spilled on the floor under a rack with dairy products. In the dry storage area, a 4-pound can of tuna and two 6-pound cans of pineapple chunks were visibly dented. The ice machine lid had white stains, and the inside rim was dirty and stained, despite the kitchen manager's claim that it was cleaned two weeks prior. Further observations during a tray line inspection revealed a fan placed on the floor blowing air into the food preparation area, which the kitchen manager acknowledged could lead to potential food contamination with dust. Additionally, another cook with a beard was observed setting up meal trays without wearing a beard cover. The kitchen manager confirmed these observations and acknowledged that the beard cover should have been worn, and the fan should not have been placed in the preparation area.
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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