Advanced Health Care Of Paradise
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 3455 Pecos-mcleod Interconnect, Las Vegas, Nevada 89121
- CMS Provider Number
- 295107
- Inspections on file
- 20
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Advanced Health Care Of Paradise during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including encephalopathy and anemia, had a physician order for Megestrol Suspension as an appetite stimulant to be given twice daily within specific time windows. During a morning med pass, an RN administered several medications but omitted the ordered Megestrol, later confirming it remained in the med cart and that the order had not been followed, despite facility policy requiring adherence to physician orders. In a separate case, a newly admitted resident with encephalopathy, multiple sclerosis, epilepsy, and dementia had hospital discharge instructions for a Neurology follow-up within one to two weeks, but the facility did not arrange this appointment, even though the admissions process requires reviewing discharge summaries and setting up needed follow-up care.
A resident with multiple chronic conditions was discharged without documented evidence that they were presented with or assisted in choosing among post-acute care providers, as required by their care plan. Staff interviews revealed that while a form existed for selecting the facility's preferred home health agency, there was no consistent documentation that residents were informed of other options or that their preferences were considered.
A facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident with a right hip fracture and syncope, whose Medicare Part A services ended. The resident was discharged without documented evidence of receiving the NOMNC letter, which was expected to be provided three days before the end of benefits. The facility's policy required the NOMNC to be delivered at least two days before services end, with the original signed document retained in the file.
The facility failed to implement care plan interventions for several residents, including the absence of an air mattress for a resident at risk for pressure ulcers, delayed midline dressing changes for two residents, lack of feeding assistance for two residents with malnutrition, and delayed enema administration for a resident with bowel care needs. These deficiencies indicate lapses in following prescribed care protocols.
A facility failed to accurately document care for residents, including the application of antimicrobial wipes, wound care, and midline dressing changes. For one resident, CHG wipes were not applied as ordered, and the RN documented care without verification. Two residents had discrepancies in wound care documentation, with dressings not changed as recorded. Midline dressing changes for two residents were also inaccurately documented, with observed dressings not matching recorded dates. These failures went against professional standards and could compromise patient safety.
Two residents in a facility were not provided with the required one-on-one feeding assistance despite physician orders and clear signage indicating the need. One resident, with metabolic encephalopathy and dementia, was left with untouched meal trays and not seated in a chair as instructed, while another resident with severe malnutrition was incorrectly assumed to be independent in eating. The lack of adherence to feeding assistance orders placed both residents at risk for significant weight loss and malnutrition.
A resident with a multidrug-resistant fungal infection did not receive prescribed Chlorhexidine (CHG) wipes as ordered. The RN documented the application without verifying if CNAs performed the task, leading to discrepancies in the treatment administration record. The DON confirmed this was inappropriate and could be considered an alteration of medical records.
A facility failed to follow a physician's order for an air mattress for a resident at risk for pressure ulcers, and did not provide wound care as per orders for two residents. The air mattress was not delivered or placed, despite documentation indicating otherwise. Additionally, wound care treatments were missed and inaccurately documented, with staff pre-signing treatments that had not been administered. The Director of Nursing acknowledged the discrepancies and the unacceptable practice of signing off on unadministered treatments.
A resident with a history of ulcerative colitis and diverticulitis did not receive appropriate bowel care as per the facility's protocol. Despite a physician's order for a Fleet Enema on the fifth day without a bowel movement, the enema was not administered by the ninth day. The resident's family was not informed about the bowel protocol or the enema order, and the KUB test results were not provided upon request. The facility's failure to follow the bowel protocol led to a deficiency in care.
The facility failed to provide one-on-one feeding assistance for two residents, as ordered by physicians, leading to a risk of significant weight loss and malnutrition. One resident, with metabolic encephalopathy and dementia, was left with untouched meal trays and no staff assistance, despite being dependent on staff for eating. Another resident, with dementia and severe malnutrition, also did not receive the required assistance. The lack of compliance with feeding orders was not communicated to the Registered Dietician, potentially leading to significant weight loss.
The facility failed to ensure proper justification and maintenance of midline catheters for two residents, leading to potential risks of complications. One resident had a midline catheter with no physician's clarification order, and the dressing was not changed as documented. Another resident's midline dressing was also not changed as documented, despite being used for IV administration. The Director of Nursing acknowledged the lack of a specific midline policy and confirmed the facility followed the PICC Dressing Change policy.
A facility failed to implement proper infection control measures for a resident with an indwelling urinary catheter and intravenous midline catheter. Despite a physician's order for enhanced barrier precautions, a therapist did not wear a gown while providing care, only using gloves. This was confirmed by a registered nurse and the infection preventionist nurse, who stated that both gloves and gowns were required according to the facility's policy and CDC guidelines.
The facility failed to ensure proper dialysis care and communication for two residents, leading to potential cross-contamination, inadequate infection control, and lack of monitoring for dialysis-related complications.
The facility failed to obtain a physician order and implement a care plan for a resident's wrist splint. The resident was admitted with a wrist fracture and had a splint in place, but the necessary orders and care plan were not documented or transcribed, leading to the deficiency.
The facility failed to ensure a physician's order for IV insertion and care for a resident admitted with urinary tract infection, sepsis, and dehydration. The IV heplock was old and undated, and there was no documented evidence of a physician's order for the IV insertion or related care.
The facility failed to follow the physician's order for a resident's oxygen administration, resulting in the resident receiving 4 LPM instead of the prescribed 2 LPM. The order lacked clarity on whether the O2 should be continuous or as needed, and titration parameters were not specified. Both the RN and DON acknowledged the oversight.
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 6.25%. One incident involved a nurse administering a standard iron tablet instead of the prescribed delayed-release form, and another involved a nurse applying only one Lidocaine patch instead of the two ordered. The DON acknowledged the errors and emphasized the need for verifying orders prior to administration.
The facility failed to secure medication carts and protect resident information. Two instances were observed where medication carts were left unlocked and unattended, with computer screens displaying resident information visible to passersby. Both nurses involved acknowledged the importance of securing the carts and screens.
The facility failed to discard expired thickened orange juice containers, allowed a Cook to eat next to the food tray line, observed a Dietary Aide touching their face with gloved hands while handling food, and did not refill a soap dispenser in the kitchen timely. These actions could have led to contamination and foodborne illnesses.
The facility failed to implement TBP and ensure proper use of PPE for a resident with ESBL and VRE, and did not maintain hand sanitizer dispensers in resident rooms. The resident was transported without adherence to TBP protocols, and multiple hand sanitizer dispensers were observed empty, compromising infection control practices.
The facility failed to document resident council meetings and grievances, as required by their policies. Interviews with the Administrator and a CNA revealed that no meeting minutes were taken, and the facility did not maintain a formal grievance log, despite starting resident council meetings in 2023.
Failure to Administer Ordered Medication and Arrange Required Neurology Follow-Up
Penalty
Summary
The facility failed to administer a prescribed medication as ordered for one resident during a medication pass observation. The resident had diagnoses including encephalopathy, anemia, and long-term use of oral hypoglycemic drugs, and had a physician’s order for Megestrol Suspension 400 mg/10 ml, 5 ml by mouth twice daily between 7:00 AM and 9:00 AM and between 7:00 PM and 9:00 PM as an appetite stimulant. During a morning medication pass, an RN prepared and administered multiple medications, including Amlodipine, Metoprolol, Valsartan, Metformin, Heparin, Milk of Magnesia, Azelastine eye drops, and Nystatin Suspension, but did not include the ordered Megestrol Suspension. Later that morning, the RN confirmed that Megestrol had not been given, located the bottle labeled for the resident in the medication cart, and acknowledged that the physician’s order had not been followed and that the orders should have been verified prior to administration. The DON also confirmed that the medication, scheduled for the 7:00 AM to 9:00 AM window, was not administered as ordered, despite facility policy requiring medications to be given in accordance with physician orders. The facility also failed to facilitate a required neurology follow-up appointment for another resident after admission from an acute care hospital. This resident had diagnoses including encephalopathy, multiple sclerosis, epilepsy, and dementia, and the acute care hospital discharge summary instructed that the patient follow up with Neurology within one to two weeks. The Admissions Nurse described the process for new transfers, which includes reviewing the discharge summary and arranging any required medical follow-up, including notifying the physician, arranging transportation, confirming the appointment, and notifying the resident or power of attorney. After reviewing the discharge summary, the Admissions Nurse confirmed that this resident should have received a neurology follow-up appointment within one to two weeks of admission, but this did not occur. The Administrator stated that the expectation for new admissions from an acute care hospital was to follow the hospital discharge instructions and indicated that potential harm or possible death could occur if such instructions were not followed.
Failure to Document Resident Choice in Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident was appropriately discharged in accordance with their needs and preferences. The resident, who had diagnoses including spondylosis, type 2 diabetes mellitus, hypothyroidism, and hypertension, was admitted with a care plan that required coordinated discharge planning to their home with family. The facility was responsible for assisting the resident and their support person in locating and coordinating post-discharge services, such as home health care, durable medical equipment, oxygen, prescriptions, and other support services. However, documentation revealed that the facility did not provide evidence that the resident was presented with options or assisted in choosing a post-acute care provider that best suited their goals, preferences, needs, and circumstances. Interviews with facility staff indicated that while a form existed for residents to select the facility's preferred home health agency, there was no documented evidence that the resident in question was given a choice or presented with alternative providers. Other residents had signed referral forms for the facility's home health agency, but some did not recall signing them, and the facility did not maintain a list of home health agency providers to offer as options. The Director of Nursing and the Administrator both acknowledged that documentation of discharge planning discussions and options provided was lacking or not consistently recorded in the resident's notes.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) letter to a resident, identified as Resident #99, who was admitted with diagnoses including a fall, right hip fracture, and syncope. The resident's Medicare Part A skilled services episode began on August 30, 2024, and the last covered day for Part A services was September 18, 2024. The resident was discharged home on September 19, 2024. However, the medical record lacked documented evidence that the NOMNC letter was provided to the resident or their representative. On March 19, 2025, the facility's Case Manager was unable to produce evidence that the NOMNC letter was given to the resident. The facility's Administrator confirmed that it was expected to follow CMS guidelines and provide the NOMNC letter three days prior to the end of benefits. The facility's policy stated that the NOMNC should be delivered at least two days before Medicare-covered services end, and the original signed document must be retained in the beneficiary's file. This deficiency resulted in non-compliance with Medicare requirements, potentially affecting the resident's ability to make informed decisions regarding their coverage and care.
Failure to Implement Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for several residents, leading to deficiencies in care. One resident, who was at moderate risk for pressure ulcers, did not receive an air mattress as ordered by the physician. Despite the order being documented and verified in the treatment administration record, the air mattress was not placed on the resident's bed, and the wound care nurse did not ensure its delivery or placement. Additionally, a registered nurse documented the air mattress placement without verifying its presence, indicating a lapse in following the care plan. Another resident with a midline catheter did not receive timely dressing changes as per the physician's order. The dressing was observed to be loose and had not been changed for eight days, despite the care plan specifying weekly changes. Similarly, another resident with a midline catheter also did not receive the required dressing change for nine days. This lack of adherence to the care plan for midline care could potentially compromise the residents' health. Furthermore, two residents with nutritional care plans requiring one-on-one feeding assistance did not receive the necessary support during meal times. Observations revealed that staff members were not present to assist these residents, despite their documented need for assistance due to severe protein-calorie malnutrition. Additionally, a resident with a bowel and bladder care plan did not receive an enema as scheduled, resulting in a delay of four days beyond the prescribed intervention. These failures in implementing care plan interventions highlight significant gaps in the facility's adherence to care protocols.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to ensure accurate documentation of care provided to residents, leading to potential compromises in patient safety. For Resident #92, there was a physician order to apply Chlorhexidine (CHG) wipes daily due to a Candida auris infection. However, the treatment administration record (TAR) was inaccurately signed by a Registered Nurse (RN) without verifying the application by Certified Nursing Assistants (CNAs). The CNAs confirmed that regular wipes and soap were used instead of CHG wipes on certain days, and the RN later documented extemporaneous entries in the TAR, which were not present during the initial review. For Residents #17 and #21, there were discrepancies in the documentation of wound care. Both residents had orders for specific wound care treatments, but observations revealed that the dressings on their heels were not changed as documented in the TAR. The wound care nurse admitted to pre-signing treatments before actual administration, leading to inconsistencies between the documented care and the actual condition of the dressings. This practice was acknowledged by the Director of Nursing (DON) as going against the facility's adopted standards of practice. Additionally, there were issues with the documentation of midline dressing changes for Residents #17 and #21. The dressings observed on both residents did not match the dates of documented care in the Medication Administration Record (MAR). The DON confirmed that nurses were not permitted to sign off on treatments without administering them, and the discrepancies in documentation were against professional standards of practice. These documentation failures had the potential to lead to errors in care and hinder continuity of treatment.
Failure to Provide Required Feeding Assistance
Penalty
Summary
The facility failed to provide necessary one-on-one feeding assistance to two residents, Resident 21 and Resident 11, who were assessed to require such assistance. Resident 21, diagnosed with metabolic encephalopathy, dementia, and a history of craniotomy, was observed on multiple occasions with meal trays left untouched and no staff present to assist with feeding. Despite a physician's order for one-on-one feeding assistance and instructions to sit the resident up in a chair during meals, these directives were not followed. Certified Nursing Assistants (CNAs) reported that the resident refused to eat, defining refusal as a lack of response from the resident, and did not seek help from other staff or inform the nurse of the refusal. Similarly, Resident 11, with diagnoses including unspecified dementia and severe protein-calorie malnutrition, was also not provided with the required one-on-one feeding assistance. Although a physician's order was in place due to the resident's increased fatigue and poor meal intake, the CNA assigned to the resident was unaware of this requirement and incorrectly believed the resident was independent with eating. This oversight resulted in the resident consuming only a minimal portion of their meal. The Director of Nursing (DON) and Registered Dietician (RD) confirmed the lack of adherence to the feeding assistance orders and the potential impact on the residents' nutritional status. The RD noted that Resident 21 had experienced a two-pound weight loss, which, while not yet significant, could become so if interventions were not implemented. The facility's failure to follow physician orders and ensure proper feeding assistance placed the residents at risk for significant weight loss and malnutrition.
Failure to Administer Prescribed Antimicrobial Wipes
Penalty
Summary
The facility failed to ensure that prescribed antimicrobial wipes were used for the treatment of a multidrug-resistant fungal infection in a resident. The resident, who was admitted with multiple diagnoses including dementia and a Candida auris infection, had a physician order for daily application of Chlorhexidine (CHG) wipes. However, the treatment administration record (TAR) indicated discrepancies in the application of these wipes. On several occasions, the wipes were not applied as ordered, and regular wipes with soap and water were used instead. The RN responsible for documenting the application of the CHG wipes admitted to charting the administration without verifying if the CNAs had actually performed the task. The RN later made extemporaneous entries in the TAR to reflect the actual application status after discovering the oversight. The Director of Nursing confirmed that these actions were inappropriate and could be considered an alteration of medical records. This deficiency in care had the potential to increase the risk of complications for the resident and compromise the overall quality of care within the facility.
Deficiency in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that a physician's order for an air mattress was followed for a resident, leading to a deficiency in pressure ulcer care. The resident, who was at moderate risk for pressure ulcers due to multiple co-morbidities, did not have the ordered air mattress in place. Despite the physician's order and care plan specifying the need for an air mattress, it was not delivered or placed on the resident's bed. The wound care nurse acknowledged the oversight and the failure to verify the placement of the air mattress, which was documented as verified in the treatment administration record without actual confirmation. Additionally, the facility did not provide wound care treatment as per physician's orders for two residents. One resident reported inconsistent care for heel ulcers and a coccyx wound, with the treatment administration record showing missed wound care on several dates. The registered nurse and wound care nurse both acknowledged the discrepancies in documentation and the failure to administer wound care as scheduled. The wound care nurse admitted to pre-signing treatments that had not yet been administered, leading to inaccurate documentation. For another resident, the facility also failed to administer wound care as ordered, with the treatment administration record indicating missed treatments. The wound care nurse and registered nurse both confirmed the lack of documentation and the practice of pre-signing treatments. The Director of Nursing acknowledged the unacceptable practice of signing off on treatments that were not administered and the misalignment between observed dressings and documented care.
Failure to Follow Bowel Protocol for Constipated Resident
Penalty
Summary
The facility failed to follow its bowel protocol for a resident who was constipated, leading to a deficiency in care. The resident, who had a history of ulcerative colitis and diverticulitis, had not had a bowel movement since March 11, 2025. Despite having a physician's order for a Fleet Enema to be administered on the fifth day without a bowel movement, the enema was neither offered nor administered by March 20, 2025, which was nine days without a bowel movement. The facility's bowel protocol, known as the Bowel Brigade, was not followed, as the resident did not receive the prescribed interventions, including Milk of Magnesia and Dulcolax suppository, in a timely manner. The resident's family member, who visited daily, expressed concerns about the lack of bowel movements and was not informed about the bowel protocol or the physician's order for an enema. The family member was also not provided with the results of a KUB test, which showed mild increased feces throughout the colon, despite requesting them. The Infection Preventionist confirmed that the enema was not administered as per the protocol, and the Director of Nursing acknowledged that the facility's standing orders were not followed. This oversight placed the resident at risk for bowel complications.
Failure to Provide 1:1 Feeding Assistance
Penalty
Summary
The facility failed to follow physician's orders to provide one-on-one feeding assistance for two residents, leading to a risk of significant weight loss and malnutrition. Resident 21, who was admitted with diagnoses including metabolic encephalopathy and dementia, was observed on multiple occasions with meal trays left untouched and without staff assistance, despite a clear order for 1:1 feeding assistance. The resident was dependent on staff for eating, and the lack of assistance was attributed to CNAs being too busy or shy to ask for help. The resident's condition improved when seated in a chair, but this intervention was not consistently implemented. Similarly, Resident 11, diagnosed with unspecified dementia and severe protein-calorie malnutrition, was also not provided with the required 1:1 feeding assistance. The resident was observed with a meal tray in front but no staff present to assist, despite a physician's order due to the resident's increased fatigue and poor meal intake. The DON confirmed that the physician's orders were not followed, and the CNAs failed to report meal refusals to the nurse, preventing further attempts to assist the residents. The Registered Dietician noted that both residents had issues with alertness and poor consumption, necessitating the 1:1 feeding assistance. The RD was not informed of the lack of compliance with the feeding orders, which could potentially lead to significant weight loss. The facility's policy required necessary services to maintain good nutrition for residents unable to carry out activities of daily living, but this was not adhered to in the cases of Residents 21 and 11.
Deficient Midline Catheter Management for Two Residents
Penalty
Summary
The facility failed to ensure proper justification and maintenance of midline catheters for two residents, leading to potential risks of complications such as occlusion and infection. Resident 17 was admitted with a midline catheter in the right upper arm, but there was no documented evidence of a physician's clarification order regarding whether the midline should be maintained or removed. The midline dressing was observed to be dated 03/10/2025, with ends coming loose, despite a physician's order for weekly dressing changes. The Medication Administration Record (MAR) inaccurately documented a dressing change on 03/16/2025, which did not align with the actual observation. The Infection Preventionist confirmed the lack of a nurse-physician discussion about the midline's status. Resident 21 was admitted with a double lumen midline used for IV electrolyte administration. The midline dressing was dated 03/09/2025, with ends coming loose, and the MAR inaccurately documented care on 03/16/2025. The Clinical Nurse Manager confirmed the discrepancy and described the dressing as not appearing new. The Director of Nursing acknowledged the lack of a specific midline policy and confirmed that the facility followed the PICC Dressing Change policy, which required dressings to be labeled with date, time, and initials. The failure to perform midline care as documented placed residents at risk for infection, as noted by the Director of Nursing.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control measures for a resident with an indwelling urinary catheter and an intravenous midline catheter. The resident, who was admitted with serious conditions including septic shock and pneumonia, was placed on enhanced barrier precautions as per a physician's order. However, during an observation, a therapist did not adhere to these precautions while providing care. Specifically, the therapist used gloves but failed to wear a gown when emptying the urinary bag connected to the resident's catheter. This oversight was confirmed by a registered nurse who acknowledged that the therapist should have used both gloves and a gown during the procedure. The facility's infection preventionist nurse also reiterated that enhanced barrier precautions, which include the use of gloves and gowns, should have been followed during the care of the resident's indwelling catheter. The facility's policy, aligned with CDC guidelines, mandates these precautions for residents with indwelling medical devices to prevent the spread of multi-drug-resistant organisms.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper dialysis care and communication for two residents requiring such services. For Resident 28, the facility did not maintain documented evidence of communication or collaboration of care between the facility and the dialysis center. The facility driver, who transported Resident 28, did not have the dialysis communication paper post-dialysis treatment and was unaware of the resident's contact isolation precautions, leading to potential cross-contamination. Additionally, the facility did not communicate Resident 28's infection status to the dialysis center, which could have compromised infection control measures at the dialysis center and during transport. For Resident 27, the facility also failed to maintain documented evidence of communication or collaboration of care between the facility and the dialysis center. The resident's medical records lacked documentation of pre- and post-dialysis vital signs and weights, as well as care orders and management for the resident's arteriovenous fistula (AVF). The facility did not obtain, transcribe, or implement care orders for monitoring the AVF for signs of bleeding, infection, and drainage until several days after the resident's admission. The Infection Preventionist and Director of Nursing confirmed the lack of communication and documentation regarding dialysis care for both residents. The facility's policies and agreements with the dialysis center emphasized the importance of communication and collaboration of care, but these were not followed, leading to potential risks for the residents' health and safety.
Failure to Obtain Physician Order and Care Plan for Splint
Penalty
Summary
The facility failed to ensure a physician order was obtained for the use of a splint, care orders on how to manage the resident's splint were transcribed and implemented, and a care plan was initiated for one resident. The resident was admitted with a wrist fracture and had a splint in place, but the medical records lacked documented evidence of a physician's order, instructions for managing the splint, and a care plan. The resident's splint was identified during an evaluation by the Certified Occupational Therapy Assistant, but it was not included in the therapy treatment plan, and the nursing staff did not obtain the necessary physician order or care plan for the splint's management. The Director of Nursing confirmed that the admission nurse was responsible for obtaining the orders for the splint, which were missed and not transcribed. The splint was in place at all times, but no care orders had been obtained or transcribed, and no care plan had been initiated. The facility's Splint Management Policy documented that splints would be applied per physician orders, but this was not followed in the case of the resident, leading to the deficiency.
Failure to Obtain Physician's Order for IV Insertion and Care
Penalty
Summary
The facility failed to ensure a physician's order for peripheral intravenous (IV) insertion and care orders were obtained, transcribed, and implemented for one resident. Resident 138 was admitted with diagnoses including urinary tract infection, sepsis, and dehydration. The nursing progress notes documented the initiation of IV fluids, but there was no documented evidence of a physician's order for the IV insertion or related care. On observation, the IV heplock appeared old and undated, with the dressing edges peeling off, and the resident reported that the IV access had been in place for four days without use. A registered nurse confirmed the absence of an order for IV access insertion or related care and noted that the IV heplock was old and the dressing was undated and peeling off. The resource nurse and the director of nursing indicated that any IV access required an order for insertion and management, including flushing and monitoring of the insertion site. Facility policies also documented the need for a physician's order for IV therapy, maintenance, and removal of any peripheral IV catheter that is no longer essential.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to ensure the Oxygen (O2) flow rate was followed as ordered or the titration rate and frequency of the administration were clarified for Resident 137. Resident 137 was admitted with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic pulmonary edema. The physician's order specified O2 per nasal cannula at 2 liters per minute (LPM) to maintain SpO2 of more than 90%, with the possibility to titrate or discontinue O2 as tolerated. However, the order did not specify whether the O2 should be administered continuously or as needed, nor did it provide titration rate parameters. Observations on multiple occasions revealed that Resident 137 was receiving O2 at 4 LPM, contrary to the prescribed 2 LPM. The resident was unsure of the amount of O2 being received and indicated dependency on O2, with no signs of respiratory distress noted during the observations. A Registered Nurse (RN) confirmed that the O2 was flowing at 4 LPM and acknowledged that the active order did not specify continuous administration or titration parameters. The RN explained that the physician's order should have been followed to avoid potential O2 toxicity. The Director of Nursing (DON) also indicated that O2 administration required an order and that staff were expected to verify and follow these orders. The DON acknowledged that the titration parameters and frequency should have been clarified. The facility's Oxygen Administration policy stated that O2 should be administered in accordance with a physician's order, with appropriate safety precautions to ensure safe administration.
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 6.25%. One incident involved a registered nurse administering a standard iron tablet instead of the prescribed delayed-release iron tablet to a resident. The nurse was uncertain about the difference between the two forms, and the pharmacist later confirmed that the standard iron tablet has quicker absorption compared to the delayed-release form, which releases iron gradually in the intestines. The Director of Nursing acknowledged the error and indicated that the correct dosage form should have been verified to prevent such medication errors. Another incident involved a registered nurse preparing and offering a Lidocaine 4% patch to a resident, who preferred to receive it later after therapy. When the patch was eventually administered, only one patch was applied instead of the two patches ordered by the physician. The Director of Nursing indicated that licensed nurses were expected to verify the order prior to administration to ensure the correct dosage was administered. The facility's policy on medication errors emphasized following the six rights of medication administration to minimize errors.
Unsecured Medication Carts and Resident Information
Penalty
Summary
The facility failed to ensure resident personal information was protected and that medication carts were secured. On 05/22/2024 at 2:10 PM, a medication cart near a resident's room was observed unattended with the computer screen on, displaying resident pictures and names, and the cart was unlocked. The nurse admitted to leaving the cart and computer screen unattended while obtaining supplies. Similarly, on 05/22/2024 at 8:21 AM, a registered nurse left a medication cart unlocked and unattended in the hallway while administering medication in a resident's room. The computer screen on the cart was also left on, displaying resident information, and was visible to anyone passing by. Both nurses acknowledged the importance of locking the medication cart and securing the computer screen to protect resident privacy and prevent unauthorized access to medications. The Director of Nursing confirmed that the medication carts should have been locked when unattended and the computer screens secured. The facility's policies on medication storage and administration indicated that medication carts should be locked when out of view and that electronic medication administration records should be logged out before leaving the cart.
Multiple Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to discard five expired thickened orange juice containers stored in the nourishment room. The expired containers were observed on two separate occasions, and the Nutritional Services Director confirmed the expiration dates and acknowledged that expired food items needed to be discarded to prevent foodborne illnesses. Additionally, a Cook was observed eating next to the food tray line, which is against the facility's policy. The Cook admitted to the mistake and explained that staff were supposed to eat away from the kitchen to prevent contamination. The Nutritional Services Director confirmed that staff were not to eat in the food preparation area according to the facility's policy. A Dietary Aide was observed touching their face and nose with gloved hands while handling food during the tray line. The Dietary Aide acknowledged the error and explained that, according to policy, they should have washed their hands and changed gloves after touching their face to prevent contamination. Furthermore, a soap dispenser at the sink closest to the kitchen entrance was observed empty on two separate occasions. The Nutritional Services Director confirmed the soap dispenser was empty and reported that housekeeping had been notified to provide soap. The Housekeeping Supervisor explained that staff were to request refills from housekeeping, and it was important to refill soap dispensers quickly to prevent any infection control issues.
Failure to Implement TBP and Maintain Hand Sanitizer Dispensers
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) and ensure proper use of personal protective equipment (PPE) for a resident diagnosed with ESBL and VRE. The resident, who required strict contact isolation, was transported to and from a dialysis center without adherence to TBP protocols. The facility driver, unaware of the resident's contact precautions, did not clean hands or wear PPE when assisting the resident, despite the presence of precaution signage. This lapse in protocol was confirmed by both a Certified Nursing Assistant and a Registered Nurse, who acknowledged the necessity of PPE and hand hygiene to prevent contamination and infection spread. Additionally, the facility did not maintain hand sanitizer dispensers in resident rooms, which were observed empty on multiple occasions. This issue was confirmed by a nurse and the Housekeeping Supervisor, who explained that staff were responsible for requesting refills. The lack of readily available hand sanitizer compromised the ability of staff and visitors to perform necessary hand hygiene, particularly in rooms with enhanced barrier precautions. The facility's Alcohol-Based Hand Sanitizer Policy emphasized the importance of hand hygiene to prevent infection transmission, highlighting a significant deficiency in infection control practices.
Failure to Document Resident Council Meetings and Grievances
Penalty
Summary
The facility failed to ensure a written record of resident council meetings was kept, documenting any responses to concerns raised by the Resident Council group, and a report of actions taken and the rationale to the Resident Council. Additionally, the facility did not maintain a written record of grievances, documenting any responses and the rationale for responses to grievances regarding resident issues or grievances concerning care and life in the facility. This deficiency was identified during interviews with the Administrator and a Certified Nursing Assistant (CNA), who confirmed that no meeting minutes were taken and kept by the facility, and that the facility did not have a formal grievance log. The Administrator admitted that the facility was not good at keeping up with the logs and may have copies of resident grievances. The CNA explained that the Ombudsman suggested regular monthly resident council meetings be held, and that the facility started having resident council meetings in 2023. However, the facility did not document these meetings or maintain a grievance log. The facility's Resident's Rights policy and Grievance Policy both require documentation of grievances and responses, but the facility failed to comply with these policies.
Latest citations in Nevada
A resident with multiple medical conditions, including ESBL resistance and neuromuscular bladder dysfunction, was injured when a roommate pushed or slammed a bedside table toward their face during an argument about television volume, causing a cut lip and a loose tooth. The incident occurred in a shared room, involved resident-to-resident physical contact, and required assessment and law enforcement notification, demonstrating a failure to protect the resident from physical abuse.
An unauthorized male intruder repeatedly gained access to the facility through unsecured or inadequately controlled entry points, including following someone into the kitchen, bypassing the front lobby visitor kiosk, and entering through a window that was not fully locked. On one occasion he entered a resident’s room, identified himself as kitchen staff, and stole the resident’s cellphone containing personal identification and financial cards; on other occasions he stole personal items from staff, including a cellphone, wallet, and keys. Door alarms did not sound when he entered during at least one event, and staff initially considered the resident’s report possibly delusional before connecting it to prior and subsequent thefts and video evidence showing the same individual inside the building and on the grounds.
Multiple residents with psychiatric and behavioral histories physically assaulted other residents, including those with impaired cognition and significant medical conditions, resulting in documented injuries such as facial redness, bleeding, skin tears, abrasions, swelling, and periorbital discoloration. In separate episodes, one resident was slapped and nearly burned with a lit cigarette in a smoking area, another was pushed to the floor and kicked after entering a room, and two different roommates were punched on consecutive nights by the same hostile, non-redirectable resident. Facility leadership acknowledged a high behavior population, confirmed these events met the definition of willful infliction of injury and physical abuse, and reported that the aggressors had intact cognition, prior psychiatric hospitalizations, refusal of psychotropic medications, and a history that included homicidal ideation and threats with a weapon.
The facility failed to provide necessary behavioral health services, including trauma evaluations and meaningful interventions, for several residents involved in physical altercations and with significant psychiatric histories. After two residents were physically assaulted by roommates and sustained injuries, psychiatric providers were notified but did not document trauma-focused evaluations or address contributing behaviors such as wandering. Two other residents with schizophrenia, schizoaffective disorder, violent behavior, and documented noncompliance with psychotropic medications were involved in repeated aggressive incidents toward peers and staff, yet records showed only routine refusals of medication without evidence of effective, individualized behavioral interventions. The facility acknowledged a high-behavior population and a pattern of resident altercations, along with dissatisfaction with the psychiatric NP’s limited and delayed evaluations.
Failure to report resident-to-resident physical abuse: A resident with Alzheimer's disease was documented slapping another resident, and the other resident slapped back. The on-call manager was notified, but the incident was not reported to the SA. The DON later stated it was probably mutual combat and the MDS Coordinator, who was the DON at the time, confirmed physical abuse includes hitting and slapping and denied the incident was reported.
A resident with MS and polyneuropathy developed new occasional urinary incontinence after previously being continent, but the care plan did not include a focused care area or interventions to address the change. The resident reported not recalling staff prompting toileting at timed intervals, and the DON confirmed the care plan lacked urinary incontinence interventions and that the facility did not have a bladder training or retraining policy.
Failure to address new urinary incontinence: A resident with MS and polyneuropathy, previously continent of bladder, began having occasional urine incontinence but did not recall staff prompting toileting at timed intervals. The MDS later documented occasional bladder incontinence, yet the care plan had no focused interventions for the change in condition. The CNA was unaware of any bladder training/retraining program, and the DON confirmed the care plan lacked related interventions and the facility had no bladder training/retraining policy.
The facility failed to complete a required annual CNA performance review for one CNA, Employee #8, whose personnel record had no documented evaluation. The HR Director stated CNA evaluations were done each year on Oct. 1 to review the prior year and confirmed this CNA was not reviewed 12 months after starting at the facility. The Facility Assessment stated weaknesses identified in CNA performance reviews and annual competency assessments would be addressed through in-service training.
Facility Assessment did not match actual night shift staffing. The assessment stated Harmony Manor and Quail Corner each required an LPN on nights, with consistent staffing prioritized in the memory care unit, but the April schedule showed both units sharing one licensed nurse on multiple nights. The DON confirmed one nurse was responsible for all 32 residents on those nights and acknowledged the assessment needed to reflect the staffing schedule.
Unsanitary Kitchen Floor Drain: A kitchen floor drain was observed with a buildup of debris and grime, and the Kitchen Mgr confirmed it was dirty and could spread contamination. The Mgr stated floor cleaning was the responsibility of Maintenance, and the Maint Mgr later confirmed the drain had not been recently cleaned and was not sanitary. The facility policy required strict sanitary conditions in Dietary and Nutrition to prevent food contamination and growth of disease-producing organisms.
Failure to Protect Resident From Roommate’s Physical Abuse During Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. The resident was admitted with diagnoses including local infection of the skin and subcutaneous tissue, ESBL resistance, and neuromuscular dysfunction of the bladder. On the evening of 04/10/2026, while in a shared room, the roommate pushed or slammed a bedside table toward the resident during a dispute about the television volume being too loud. The bedside table struck the resident in the face, resulting in a bleeding lip and a loose tooth. The resident reported that the roommate became angry about the television volume and then pushed the bedside table toward their face. Following the incident, the resident was observed with blood on the face and lip, and a loose tooth was noted. The resident declined transfer to the hospital. Law enforcement was contacted, and both residents provided statements to the responding officer, with the injured resident declining to press charges. The roommate later stated that the bedside table had been positioned on the side of the bed and that they were pushing it back toward the other side, claiming they were simply returning the bedside table to its proper place. The facility’s failure to prevent this resident-to-resident physical altercation and resulting injury constituted a failure to protect the resident from physical abuse.
Unauthorized Intruder Repeatedly Accesses Facility and Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment for residents and staff when an unauthorized male intruder repeatedly gained access to the building and entered resident and staff areas, including a resident room. One resident, identified as R94, had been admitted with anxiety disorder, major depressive disorder, and left knee pain, and was alert and oriented at the time of the incident. Around 5:00 AM in December 2025, R94 observed an unknown man enter the resident’s room, state that he was kitchen staff checking the table for breakfast, and then take the resident’s cellphone, which contained a driver’s license, debit card, health insurance card, and bus card. R94 reported that the door alarms did not sound when the man entered the facility and that the resident typically heard alarms when someone entered without using the correct code. After the theft, there were two unauthorized charges on the resident’s debit card. Staff interviews revealed that this was not an isolated security breach. An LPN reported that in December 2025, R94’s report of a man entering the room and taking the cellphone was initially considered possibly delusional due to the resident’s history of seeing a person, but during the same IDT discussion another nurse reported that the day before R94’s report, a stranger had entered the kitchen and stolen a dietary staff member’s iPhone around 5:30 PM. Security camera footage showed the same man entering through a kitchen door by following someone from behind, indicating that he was able to bypass normal access controls. The same individual was later seen twice in the parking lot, and staff contacted police on those occasions. A CNA also recalled interacting with a man who claimed he was there to pick up belongings of a discharged resident and asked for the Wi‑Fi password, which the CNA provided; during the subsequent investigation, this man was identified as the same individual seen on video breaking into the building. The Administrator’s review of the January 24–25, 2026 incident documented that during a night shift, an unauthorized individual gained access by exploiting a window on the south side of the building that was not fully seated in the locked position, allowing him to shimmy the frame open and enter an unoccupied case management office. From there, he exited into the hallway, went to the nurse station, and took a nurse’s wallet and keys. As he attempted to exit through a west door, the door alarm sounded, but he was able to reach a vehicle and flee before staff arrived. The Administrator also confirmed a prior December 24, 2025 security breach in which an unauthorized male bypassed the front lobby visitor kiosk, entered the facility, and went into R94’s room, where he removed the resident’s cellphone and attached personal items from the bedside. Investigation of that December incident showed the individual was not an authorized visitor, family member, or vendor, and that he had been able to enter the building and a resident room without being stopped at the kiosk or by staff. The DON stated that R94’s report was handled as a grievance and resolved, but there were no IDT notes related to the incident, and the Administrator was not aware of the earlier kitchen theft when first discussing the December event.
Failure to Prevent Resident-on-Resident Physical Abuse in High-Behavior Population
Penalty
Summary
The facility failed to protect residents from physical abuse when multiple residents with known psychiatric and behavioral histories physically assaulted other residents on several occasions. In the first incident, one resident with fibromyalgia and an unspecified intracranial injury reported being slapped, cursed at, and nearly struck in the face with a lit cigarette by another resident in the smoking area, resulting in redness to the mandible area and involvement of law enforcement. The aggressor stated the victim was being annoying and deserved the assault. In a separate incident, a resident with moderately impaired cognition and no documented aggressive or wandering behaviors was pushed to the floor and kicked by another cognitively intact resident with schizophrenia and paranoid personality disorder after entering that resident’s room, causing a bleeding nose, a skin tear to the left forearm, and redness of the left forehead. Additional incidents involved a resident with moderately impaired cognition who reported being punched by a roommate, resulting in mild forehead swelling, and another resident with chronic obstructive pulmonary disease, heart failure, and schizoaffective disorder who was punched by the same aggressor after being moved into the room, sustaining discoloration around the left eye socket, a nose bridge abrasion, and a skin tear to the left forehead. Documentation showed that the aggressive resident was screaming violently, hostile, physically aggressive, and non-redirectable toward both residents and staff. The wound care team’s head-to-toe assessments confirmed the physical injuries sustained by the assaulted residents. Interviews with the DON, SSD, and DSD confirmed that these incidents met the facility’s own definition of willful infliction of injury and were classified as physical abuse. The DON stated that the aggressors had intact cognition, histories of inpatient psychiatric stays, and, in one case, a history of homicidal ideation and prior psychiatric hospitalization for chasing a person with a knife and threatening police. Facility leadership acknowledged a high behavioral population, an average of 45 residents with behavioral issues, and identified a pattern of resident altercations and physical abuse. They reported that the aggressors were refusing psychotropic medications and that concerns about psychiatric support, admission screening, and limitations on use of IM psychotropics had been communicated to the psychiatric provider and medical director, but these issues remained unresolved at the time of the incidents.
Failure to Provide Trauma Evaluations and Effective Behavioral Health Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including trauma evaluations, following resident-to-resident physical abuse incidents. One resident with psychosis, schizophrenia, and major depressive disorder was found on the floor with a bleeding nose, a skin tear, and forehead redness after being pushed and kicked by another resident. A psychiatry progress note documented that the psychiatric NP saw the resident per staff request, but the record lacked documentation that the altercation or physical abuse incident was discussed or that the resident’s newly identified wandering behavior, which led to the altercation, was addressed. Another resident with COPD, heart failure, and schizoaffective disorder was punched by a roommate, resulting in discoloration around the eye, a nose bridge abrasion, and a forehead skin tear. Although the care plan for emotional distress included a psychiatry evaluation and the NP was informed of the incident, there was no documented evidence that a psychiatric trauma evaluation was completed. The facility also failed to implement meaningful behavioral health interventions for residents with psychiatric histories, aggressive behaviors, and refusal of psychotropic medications. One resident with schizophrenia and paranoid personality disorder, intact cognition, and a history of violent behavior and homicidal ideation, including chasing a person with a knife and threatening police, was involved in multiple physical altercations. This resident punched another resident in the smoking area and later admitted to pushing and kicking a different resident who entered the room. The care plan identified behavioral problems such as irritability, anger, violent behavior, homicidal ideations, mood swings, and a tendency to push and kick other residents, with interventions including attempts to identify underlying causes. However, the medical record showed the resident routinely refused medications, and there was no documentation of effective, meaningful interventions addressing this ongoing refusal and associated behaviors. Another resident with neuroleptic-induced Parkinsonism, schizoaffective bipolar type, and psychosis, recently transferred from a psychiatric hospital after an exacerbation of schizophrenia symptoms and noncompliance with psychotropic medications, was also involved in a physical altercation. Progress notes documented that this resident punched a roommate, was screaming violently, hostile, physically aggressive, and non-redirectable toward residents and staff. A social services note indicated that when staff attempted to discuss the altercation, the resident became agitated, screamed, yelled, and used inappropriate language, preventing further information gathering. A refusal of treatment form showed the resident had declined medications after being informed that refusal could affect mood stabilization and worsen behaviors. Despite the facility’s acknowledgment of a high-behavior population and multiple resident altercations, the report describes a pattern of inadequate psychiatric support and lack of thorough evaluations and timely, effective behavioral interventions for these residents.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure an incident of resident-to-resident physical abuse was reported to the State Agency for 1 of 12 sampled residents. Resident #10, who was admitted with diagnoses including Alzheimer's disease and episodic tension-type headache, was documented in a nursing progress note as having been seen by a CNA slapping another resident, after which the other resident slapped Resident #10 back. The on-call manager was notified and directed staff to keep the residents apart and maintain them in eyesight if together. A physician progress note later documented that Resident #10 had been involved in a behavioral disturbance in which a heated exchange led to physical aggression between the two residents, with each resident physically striking the other. The DON stated the incident would probably not be considered resident-to-resident abuse because it was mutual combat and said the DON did not know whether either resident had been assessed for pain, injury, or mental anguish. The MDS Coordinator, who was the DON at the time of the incident, confirmed physical abuse includes hitting and slapping, denied being aware of the incident at the time, and denied that it was reported to the SA.
Care Plan Missing Interventions for New Urinary Incontinence
Penalty
Summary
The facility failed to develop a care plan with interventions to assist Resident #24 in maintaining continence after the resident, who had previously been continent, began experiencing occasional urinary incontinence. Resident #24 was admitted and later readmitted with diagnoses including multiple sclerosis and unspecified polyneuropathy. On 04/20/2026, the resident stated they had recently started having occasional urinary incontinence but could still get to the bathroom once they realized they were urinating, and the resident could not recall staff prompting them to toilet at timed intervals. An MDS assessment dated 07/07/2025 documented the resident was always continent of bladder, while an MDS assessment dated 04/06/2026 documented the resident was occasionally incontinent of bladder. The care plan did not include a focused care area or interventions related to the resident’s new urinary incontinence. On 04/22/2026, the DON stated the resident had become increasingly incontinent over the last several months and believed it was related to the resident’s multiple sclerosis. The DON also stated the facility could try offering assistance with a toileting schedule and confirmed the care plan did not include a care area or interventions related to the resident’s urinary incontinence, and that the facility did not have a policy for a bladder training or retraining program.
Failure to Address New Urinary Incontinence
Penalty
Summary
The facility failed to ensure a previously continent resident received assistance or interventions to maintain or improve urinary continence after the resident began experiencing occasional urinary incontinence. Resident #24 was admitted with diagnoses including multiple sclerosis and unspecified polyneuropathy. The resident stated that the resident had recently started having occasional urinary incontinence but could still reach the bathroom once the resident realized the resident was urinating, and the resident could not recall staff prompting bathroom use at timed intervals. Record review showed an MDS dated 07/07/2025 documented the resident was always continent of bladder, while an MDS dated 04/06/2026 documented the resident was occasionally incontinent of bladder. The care plan did not include a focused care area or interventions related to the new urinary incontinence. The CNA stated the resident had begun experiencing incontinence several months earlier and was not aware of any bladder training or retraining program, while the DON stated the resident had become increasingly incontinent over the last several months and that the facility could try a toileting schedule; the DON also confirmed the care plan lacked interventions related to the resident's new urinary incontinence and that the facility did not have a policy for a bladder training or retraining program.
Missing Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure a nurse aide performance review was completed at least once every 12 months and that areas of weakness were identified and addressed for 1 of 2 sampled CNAs, Employee #8. Employee #8 was hired as a CNA on 10/21/2024, and the personnel record lacked documented evidence of a nurse aide performance evaluation. During interview on 04/22/2026, the HR Director stated CNA performance evaluations were completed every year on October 1st to review the prior year and explained that, because of the date of hire, Employee #8 was not reviewed for performance. The HR Director confirmed Employee #8's nurse aide performance review was not completed 12 months after starting at the facility. The Facility Assessment, updated 03/2026, documented that areas of weakness identified in nurse aide performance reviews and annual competency assessments would be addressed through in-service training.
Facility Assessment Did Not Match Night Shift Staffing
Penalty
Summary
The facility failed to ensure its Facility Assessment accurately reflected current staffing needs. The Facility Assessment, updated 03/26/2026, stated the staffing plan included one licensed nurse on night shift for Harmony Manor and one licensed nurse on night shift for Quail Corner, and that consistent staffing would be prioritized in the memory care unit, with staffing levels not adjusted for low census or low acuity so resident needs would be met during call-ins and other staffing shortages. However, the April 2026 staffing schedule showed Quail Corner and Harmony Manor sharing a licensed nurse during night shift on multiple nights. During an interview on 04/24/2026, the DON stated that on Saturday, Sunday, Monday, and Tuesday nights, both units shared one licensed nurse during night shift, and that the nurse was responsible for all 32 residents in the facility. The DON confirmed the Facility Assessment indicated each unit required a licensed nurse during night shift and stated the Facility Assessment needed to be updated to reflect the staffing schedule.
Unsanitary Kitchen Floor Drain
Penalty
Summary
The facility failed to ensure staff maintained sanitary floor drains in the kitchen. On 04/20/2026 at approximately 10:45 AM, a kitchen floor drain was observed with a buildup of debris and grime. At approximately 10:50 AM the same day, the Kitchen Manager confirmed the drain had buildup of grime and acknowledged the potential spread of contamination, and stated that cleaning of the floor was the responsibility of the Maintenance Department. On 04/23/2026 at approximately 9:15 AM, the Maintenance Manager confirmed the kitchen floor drain had not been recently cleaned, was not sanitary, and acknowledged the potential spread of contamination. The facility policy titled, Maintenance of Strict Sanitary Conditions, dated 07/12/2022 and reviewed 07/08/2024, stated that maintaining strict sanitary conditions was of paramount importance in the Dietary and Nutrition Departments to eliminate food contamination and prevent growth of disease producing organisms, and to ensure maximum cleanliness and sanitation in the department.
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