Advanced Health Care of Summerlin: Abuse Response Failure - NV
The resident, identified as R1 in inspection documents, required maximum assistance from two to three staff members for turning and repositioning due to their medical condition. R1 was "always in pain and complained when being turned and repositioned," according to a certified nursing assistant who cared for the resident.
On two separate occasions while changing R1 in bed, the resident asked the nursing assistant to "be gentle because the resident was in a lot of pain." R1 specifically complained that "other people, especially on night shift, were rough with the resident," the CNA told inspectors.
Despite these direct allegations of physical abuse, no investigation was conducted. The incident was documented in nurse's notes on May 18, 2025, at 4:10 PM, but the information never reached facility administrators.
The Director of Nursing confirmed being unaware of R1's allegations until federal inspectors arrived months later. "The DON acknowledged R1's allegation was not reported to the DON," inspection records state. "The DON revealed there was no documentation in the progress notes about the follow-up made regarding the R1's allegation."
RN1, who served as supervisor on May 18, 2025, should have initiated an immediate investigation, the Director of Nursing told inspectors. Instead, the allegation was never followed through because administrators remained unaware of the resident's complaints.
The facility's own abuse policy required immediate notification of the Administrator and Director of Nursing for any suspected or reported abuse. The policy mandated that administrators "ensure the safety of the residents, begin the investigation, and if necessary, report the information to the police, Department of Health and Welfare, family, physician, and/or any other appropriate agency."
None of these required steps occurred.
The Director of Nursing explained to inspectors what should have happened: "The DON and the Administrator would have initiated an investigation immediately which included interviewing the residents and staff or possible witnesses. The alleged perpetrator, if a staff member, would have been suspended pending investigation. The facility would ensure the resident's safety. The Administrator would have reported the incident to the State."
For physical abuse allegations, facility protocol required a complete head-to-toe skin assessment documented in progress notes. This assessment was never performed for R1.
The Administrator confirmed to inspectors on September 24, 2025, that they were never informed of the alleged incident documented in the nurse's notes from May 18. "The Administrator acknowledged there was no investigation conducted regarding R1's allegation," inspection records state.
Had proper procedures been followed, the investigation would have been extensive. The Director of Nursing told inspectors they would have asked the Administrator to review closed-circuit television footage to identify staff members who entered R1's room before May 18. R1 and other residents who might have witnessed incidents should have been interviewed.
The resident's family should have been notified about the abuse allegation, the Director of Nursing acknowledged. Staffing schedules should have been reviewed to determine which certified nursing assistants and nurses were assigned to R1, and those staff members should have been interviewed.
"The DON acknowledged these actions were not done and the abuse allegation was not investigated," inspectors documented.
The facility's written policy outlined clear procedures for handling abuse allegations. Charge nurses were required to complete incident reports when indicated, reporting immediately to the Administrator and Director of Nursing. The Administrator or Director of Nursing was supposed to complete a full investigation within five working days, including a written summary of findings.
The investigation summary was required to include interview notes, the incident report, and written, signed, and dated statements from the accused person, witnesses, and the person reporting the incident.
None of these documentation requirements were met in R1's case.
The nursing assistant who cared for R1 described the resident's condition and needs in detail. R1 required maximum assistance and multiple staff members for basic care activities like turning and repositioning. The resident's pain was constant, making even routine care difficult.
When R1 specifically requested gentle handling and complained about rough treatment from night shift staff, the allegations represented serious concerns about the resident's safety and well-being. The resident was vulnerable, requiring extensive assistance and unable to protect themselves from potential mistreatment.
The failure to investigate left R1 potentially exposed to continued abuse while violating fundamental protections that nursing home residents depend on for their safety. Federal regulations require facilities to protect residents from abuse and to investigate all allegations promptly and thoroughly.
The inspection was conducted as part of a complaint investigation, suggesting that concerns about the facility's handling of abuse allegations reached state regulators through other channels. By the time federal inspectors arrived on November 25, 2025, more than six months had passed since R1's allegations were first documented.
The resident who reported being handled roughly by night shift staff never received the protection and investigation that facility policies promised and federal regulations required.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Advanced Health Care of Summerlin from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ADVANCED HEALTH CARE OF SUMMERLIN in LAS VEGAS, NV was cited for abuse-related violations during a health inspection on November 25, 2025.
R1 was "always in pain and complained when being turned and repositioned," according to a certified nursing assistant who cared for the resident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.