Alpine Skilled Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reno, Nevada.
- Location
- 3101 Plumas St, Reno, Nevada 89509
- CMS Provider Number
- 295043
- Inspections on file
- 27
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Alpine Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Infection control failures occurred when staff caring for residents on COVID-related precautions cleaned goggles for only 90 seconds before placing them with clean PPE, and an OT wore a surgical mask instead of an N95 in a resident's room. An LPN also handled a glucometer without a barrier, placed it on a resident's overbed table, and returned it to the med cart drawer without cleaning it first.
A facility failed to maintain an effective antibiotic stewardship program for 4 residents reviewed. One resident had a urine dipstick and was started on Cipro without documented signs or symptoms, another had Bactrim ordered for UTI without a UA or urine culture, a third had Zyvox continued after hospital treatment without documentation supporting the need, and a fourth was started on cefpodoxime after hospital return even though the urine culture showed mixed flora. The record also showed missing antibiotic time-outs, incomplete documentation, and antibiotics not always given as ordered.
Failure to assess self-administration of a bedside nasal spray. A cognitively intact resident with an order for fluticasone nasal spray was observed with the medication on the over-bed table and stated she was giving it to herself. The care plan did not address self-administration, and the DON stated there was no self-administration form in the record; the DON also noted the nurse had the medication in the cart and had administered it that morning.
A resident with ALS, muscle weakness, and intact cognition stated he preferred showers, but staff documentation showed he received a mix of bed baths and showers instead of his preferred bathing method. The care plan directed staff to offer a bath or shower of choice, yet the resident reported bed baths were not as thorough and that a gurney shower bed had not been used for him; a CNA and the DON confirmed his shower preference was not being met consistently.
A resident admitted with ALS had an activities assessment documenting preferences such as bingo, social events, being outside, one-to-one visits, movies, an iPad, and audiobooks, and was cognitively intact with a BIMS of 15/15. However, the comprehensive care plan contained no activities focus, goal, or interventions. The AD stated an Activity Care Plan should have been developed.
Care Plans Not Updated With Resident-Specific Interventions: The comprehensive care plan was not revised for three residents. One resident with cognitive and behavioral diagnoses had care plans that listed verbal aggression and refusals, but lacked resident-specific interventions for handling those behaviors. A second resident with paraplegia and mood disorders frequently refused to get out of bed, yet the care plan did not address those refusals. A third resident with COPD and functional quadriplegia had generalized interventions for oxygen refusal, but the plan did not include individualized approaches, and observations showed the resident without the nasal cannula in place or positioned correctly while an LPN did not assess or reapply oxygen.
Failure to document and carry out CHF-related orders occurred for a resident with CHF, NSTEMI, pleural effusions, AFib, and CKD. The resident had no HF care plan or documented HF goals, a 1500 mL fluid restriction was not clearly tracked, a six-pound weight gain was not reported to the provider, and intake/output was not documented. IV fluids were ordered for dehydration, but there was no documentation that they were given or why they were not started, and a chest pain episode with lethargy and SOB was not documented in the EMR.
Failure to provide ordered oxygen and nebulizer treatments. A resident with COPD and heart failure was observed without the nasal cannula in place, with the O2 concentrator set below the ordered flow rate, and an LPN did not verify delivery or positioning. Another resident with acute respiratory failure and dementia received a nebulizer treatment while lying flat, with the medication chamber and tubing resting on the chest, no staff monitoring the treatment, and the equipment was later stored without cleaning.
Medication orders and labels did not match the actual route used for a resident with a G-tube. An LPN gave docusate sodium and hydralazine by mouth in pudding even though the orders and labels still showed G-tube administration, and the G-tube was only flushed for patency. The resident had aphasia following cerebral infarction and severe cognitive impairment, and the LPNUM said staff were responsible for checking orders against labels and following the medication rights.
A resident with a history of verbally aggressive behavior used a racial slur during a verbal altercation with another resident who has a history of racial trauma. The incident was confirmed by staff and both residents, but the affected resident's care plan was not updated and documentation of the event was minimal, despite facility policies prohibiting discrimination and requiring prompt reporting.
A verbal altercation involving racial slurs occurred between two residents, one with a history of trauma, and was witnessed by an LPN. The DON did not initiate an official investigation, submit a Facility Reported Incident, or notify required parties, despite facility policy mandating prompt investigation and reporting of all abuse allegations.
A resident with nicotine dependence and on oxygen therapy repeatedly expressed intent to continue smoking and was observed attempting to smoke, but staff did not develop a care plan to address these behaviors. This omission led to an incident where the resident's wheelchair caught fire, resulting in burns, as no interventions or monitoring were in place to manage the risk.
Two residents were involved in a verbal altercation that included racial slurs, but their care plans were not updated to reflect the incident or address new behavioral concerns. Staff, including a CNA and an LPN, were unaware of any changes or new interventions, and the care plans did not document the altercation or provide guidance for managing future interactions.
A resident with nicotine dependence and COPD was not adequately supervised or care planned for continued smoking while using oxygen, despite staff awareness and facility policies prohibiting smoking. The resident was injured when their wheelchair caught fire while smoking with oxygen in place, and other residents had to intervene.
The facility failed to maintain comfortable temperatures in communal shower rooms, with temperatures recorded at 62.1°F, 62.4°F, and 67.6°F. Residents expressed discomfort and reluctance to use the shower rooms, opting for personal hygiene in their rooms instead. Staff acknowledged the issue, and the Maintenance Director and Engineering Manager confirmed the low temperatures. Facility policies require temperatures between 71°F and 81°F, which were not met, leading to widespread resident discomfort.
The facility failed to remove expired medications from two medication storage rooms and left a wound care cart unlocked near the 400 Hall nurses' station. Expired Iron Liquid Supplement and Tubersol vials were found, and the wound care cart contained potentially hazardous opened items. An LPN confirmed the cart was unlocked and acknowledged the potential hazard. Facility policy required outdated drugs to be returned or destroyed and carts to be locked when not in use.
A resident's personal and medical records were left visible on an unattended computer attached to a medication cart, violating confidentiality protocols. The RN responsible admitted to leaving the information accessible while attending to another resident. The DON confirmed the breach of privacy and emphasized the importance of protecting electronic health records.
A resident with a Foley catheter did not have a comprehensive care plan developed in a timely manner, despite having an indwelling catheter documented in their MDS assessments. Facility staff acknowledged that the care plan should have included specific interventions to prevent complications, but these were not implemented as required by facility policy.
A resident at high risk for falls experienced two falls, but the care plan was not updated with new interventions after the second incident. Despite the facility's policy requiring care plan updates following falls, the DON confirmed that the care plan lacked necessary revisions, such as ensuring the resident's belongings were within reach.
A resident with a right elbow wound did not receive physician-ordered daily wound care, as documented in the facility's records. An LPN assigned to the resident was unaware of the wound and did not provide care on a specific date. The DON confirmed the lack of documentation and acknowledged the oversight, which contradicted the facility's policy on wound management.
A resident with a history of type II diabetes and sepsis repeatedly requested a dental appointment for broken teeth and pain, but the facility failed to schedule it. Despite documentation of oral pain in the resident's care plan and MDS notes, the process involving social services and transportation services did not result in an appointment. The Director of Nursing acknowledged the importance of addressing the resident's dental needs.
The facility failed to address low ambient temperatures in three communal shower rooms, with temperatures recorded at 62.1°F, 62.4°F, and 67.6°F. The Administrator was unaware of the issue, while the Director of Engineering had been aware of a thermostat problem since December 19, 2024, but believed it was resolved. Maintenance staff did not communicate the ongoing issue, highlighting a lapse in communication and oversight.
The facility failed to document wound care treatments for four residents, resulting in incomplete clinical records. An LPN admitted to providing care but forgetting to document it, which was confirmed by the DON. The facility's policies require all treatments to be recorded, but the lack of documentation indicates a failure to adhere to these policies.
A Social Services employee entered a resident's room on contact-based isolation precautions without donning the required PPE, despite the room being clearly marked with a sign indicating the need for such precautions. The employee acknowledged awareness of the precautions but believed PPE was unnecessary as no direct care was provided. The incident was observed by an LPN, who reiterated the PPE requirement, and the DON confirmed the need for PPE to prevent infection spread.
The facility did not update the nursing staff posting daily as required, with the last update being two days old. The DON confirmed the posting was only in one location, not on each unit, and the Administrator acknowledged the oversight, confirming the posting was outdated and not compliant with the facility's policy.
A resident with chronic hepatic failure was subjected to verbal and physical abuse by a CNA, who yelled at them and threw a pillow. The resident's roommate witnessed the incident. The facility's DON confirmed the abuse and reported it to the Nevada State Board of Nursing, substantiating the allegations.
A resident with severe protein-calorie malnutrition and a stage four pressure ulcer did not receive a timely dietary evaluation or the prescribed Pro-Stat supplement. Despite a physician's order and confirmation by an RN, the January MAR lacked documentation of Pro-Stat administration. The facility's policies required a comprehensive nutrition assessment for such cases, which was not completed.
A resident with chronic conditions was asked by a Housekeeper to borrow money, which was against facility policy. Although the money was repaid, this action violated the resident's right to be free from misappropriation of property. An investigation confirmed the incident, and other residents reported no similar requests.
The facility failed to administer medications per physician's orders for two residents. An LPN administered the wrong dosage of Calcium Citrate-Vitamin D to one resident and applied a Lidocaine patch to the wrong shoulder for another. Both errors were confirmed by the LPN and acknowledged by the DON and Administrator.
Infection control failures during PPE handling and glucometer use
Penalty
Summary
The facility failed to follow infection control guidelines during care of residents on droplet or contact/droplet precautions. R34 was admitted with Parkinson's disease and severe protein calorie malnutrition and later tested positive for COVID-19. During observation, a CNA and a housekeeper exited R34's room after providing care and removed the goggles they had worn inside the room, then wiped the goggles with a Sani-Cloth wipe from the orange-top container for 90 seconds before placing them directly into the isolation cart with clean, unused PPE. During the same resident's care, an OT was observed in the room assisting the resident while wearing a surgical mask. The Infection Preventionist later confirmed that the goggles should have been cleaned with a wet Sani-Cloth from the orange-top container for four minutes and that the OT should have worn an N95 mask instead of a surgical mask. R51 was admitted with unspecified sequelae of other nontraumatic intracranial hemorrhage and atrial fibrillation and later tested positive for COVID-19. The physician ordered contact/droplet isolation with 10-day monitoring. During observation, the CNA exited R51's room after care, removed the goggles worn in the room, wiped them with a Sani-Cloth wipe from the orange-top container for 90 seconds, and placed them directly into the isolation cart with clean PPE. R77 was admitted with COPD and later tested positive for COVID-19, with a physician order for contact/droplet isolation and 10-day monitoring. During observation, the same CNA exited R77's room, removed the goggles worn in the room, wiped them with a Sani-Cloth wipe from the orange-top container for 90 seconds, and placed them directly into the isolation cart with clean PPE. The facility also failed to ensure glucometer checks were performed in a manner to prevent infection for R60, who was admitted with diabetes. An LPN removed the glucometer from the medication cart drawer and placed it on top of the cart without a barrier, then placed it into her pocket and applied gloves without using hand sanitizer before entering the resident's room. In the room, the glucometer was placed on the resident's overbed table. After obtaining the blood sugar result, the LPN returned the glucometer to the medication cart drawer without cleaning it. The LPN later confirmed she should have cleaned the glucometer with the specialized wipes on the cart, and the unit manager confirmed the infection control practices were not maintained during the glucometer check.
Antibiotic stewardship deficiencies with unsupported UTI treatment
Penalty
Summary
The facility failed to have an Antibiotic Stewardship Program consistent with current standards of practice for 4 of 4 residents reviewed for antibiotic stewardship: R83, R33, R126, and R85. The report states that these residents received antibiotics without documentation supporting the indication, without required diagnostic testing in some cases, and without documentation of an antibiotic time-out or review of culture results to confirm the need for continued therapy. The facility’s Infection Control Surveillance Log also indicated these residents did not meet McGeer’s criteria for the infections documented in the record review. For R83, nursing documentation showed a urine dipstick was performed after leukocytes were noted, but there were no documented signs or symptoms supporting the test. Ciprofloxacin was ordered for three days, but the first dose was not given because the medication had not arrived from the pharmacy, and the resident received only part of the ordered course. A urine culture later showed usual skin flora and advised recollection, but there was no further documentation of another culture. The Infection Preventionist and VPCS confirmed there was no nursing documentation of signs and symptoms to support the dipstick, no repeat urine culture, and the antibiotic was not administered as ordered. For R33, a verbal order was given to collect a UA, but the record did not show UA results or a urine culture before Bactrim DS was ordered for UTI. The resident then received the antibiotic course as documented in the MAR. For R126, the record showed Zyvox was ordered for UTI after hospital treatment, but there was no documentation of a time-out, no UA or culture results from the hospital to support the diagnosis, and the resident received only three days of the five-day order. For R85, the resident was sent to the hospital with fever, muscle aches, migraine, nausea, and feeling generally unwell, then started on cefpodoxime for UTI after return; the IP later produced a urine culture showing mixed flora, which would not have required an antibiotic. The facility policy stated antibiotics should be used when clinical criteria for active infection or suspected sepsis are met and when culture and sensitivity support therapy, with documentation of the specific criteria in the resident’s record.
Failure to Assess Self-Administration of Bedside Medication
Penalty
Summary
The facility failed to ensure medication at the bedside was assessed for self-administration for one resident. The resident was admitted with allergic rhinitis and had an order for fluticasone propionate nasal suspension, 1 spray in both nostrils in the morning for allergies. The quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. During an observation and interview, the resident was seen with a bottle of fluticasone nasal spray on the over-bed table and stated that she administered the medication herself. She also stated that she thought she had signed a form, but staff did not watch her. The comprehensive care plan did not include a focus, goal, or intervention for self-administration of the medication. The DON reviewed the record and stated there was not a self-administration form. In a later interview, the resident stated the nasal spray had been on her over-bed table until staff removed it. The DON stated the facility’s process was to obtain a physician order, complete an assessment for safety, provide a lock box, update the care plan, and mark the eMAR for self-administration, and also stated that the nurse had the medication in her cart and had administered it that morning.
Failure to Honor Resident Shower Preference
Penalty
Summary
The facility failed to ensure that one sampled resident, who had ALS, muscle weakness, and needed assistance with personal care, was given the opportunity to make choices regarding shower preference. The resident’s admission interview showed he considered choosing between bath types somewhat important and stated that he preferred a shower. His MDS indicated intact cognition with a BIMS score of 15 out of 15, range of motion impairment in both upper extremities and one lower extremity, and a need for substantial assistance with bathing and showering. The resident’s care plan directed staff to offer a bath or shower of choice on scheduled days and as needed, and to provide a sponge bath only when a full bath or shower could not be tolerated. However, task documentation showed that between 02/08/26 and 04/01/26 he received a mix of partial bed baths, full bed baths, and showers, and refused one shower/bed bath. During interview, the resident stated he had been getting bed baths that were not as thorough, wanted his hair washed, and said he preferred a shower and had recently learned about a gurney shower bed that had not been used for him. A CNA stated the resident had been physically tired, that the facility was really struggling, and that the gurney shower bed had not been used yet. The DON confirmed the resident had not been getting his shower preference consistently.
Failure to Develop an Activities Care Plan
Penalty
Summary
The facility failed to develop a care plan related to activities for R114, who was admitted with a diagnosis of amyotrophic lateral sclerosis (ALS). The Activities Initial Assessment documented that R114 enjoyed bingo, social events, being outside, one-to-one visits, movies, using an iPad, and audiobooks. The MDS with an ARD of 02/12/26 showed a BIMS score of 15 out of 15, indicating R114 was cognitively intact. Review of the 02/16/26 comprehensive care plan revealed no focus, goal, or interventions/approaches for activities. During interview, the Activity Director stated that an Activity Care Plan should have been developed and noted that R114 still liked to get up in his wheelchair and go to therapy first thing in the morning and come to activities later. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Care Plans Not Updated With Resident-Specific Interventions
Penalty
Summary
The comprehensive care plan was not updated or revised for 3 of 33 sampled residents. For R8, who was admitted with diagnoses including cognitive communication deficit and adjustment disorder with mixed disturbance of emotions and conduct, the behavior care plan listed verbally aggressive behaviors such as inappropriate language, racial slurs, accusatory statements, and yelling, while the comprehensive care plan listed resistive behaviors such as refusing medications, brief changes, peri care, meals, bathing, and turning. The record showed both plans contained generalized interventions, but they did not include resident-specific interventions for handling refusals or behaviors. The quarterly MDS showed a BIMS score of 11, verbal behaviors, and rejection of care one to three days out of seven. For R56, who had diagnoses including paraplegia, muscle weakness, major depressive disorder, unspecified mood disorder, and anxiety, the care plan addressed ADL performance deficit and altered physical mobility, including use of a mechanical lift and two staff for transfers. Interviews with CNAs showed that he often refused to get out of bed, would request to get up and then change his mind, and staff expected these refusals to be care planned because they occurred frequently. The DON stated that R56 refused to get out of bed often and that it should be care planned, but the care plan did not contain resident-specific interventions related to those refusals. For R68, who was re-admitted with diagnoses including COPD, hypertensive heart disease with heart failure, and functional quadriplegia, the care plan last revised 07/31/25 addressed resistive behaviors including resisting ADL care, medications, and wearing oxygen, but the interventions were generalized and did not include individualized approaches specific to oxygen refusal. Observations showed R68 in bed without the nasal cannula in place while oxygen was running, with tubing out of reach, and later with the nasal cannula incorrectly positioned next to the nose. An LPN entered the room to give medications without assessing for or reapplying oxygen, and later stated that R68 always removes the nasal cannula and could not identify how long the oxygen had been off or improperly worn.
Failure to Document and Carry Out CHF-Related Orders
Penalty
Summary
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals occurred for a resident with CHF, NSTEMI, bilateral pleural effusions, atrial fibrillation, and CKD stage III. The resident was admitted with a discharge order for a 1500 mL daily fluid restriction after thoracentesis removed 1.2 L of fluid. The admission assessment identified heart failure as the primary diagnosis for the most recent hospitalization, but the facility documented that HF goals had not been established, there were no comments about coordinating care, and the HF care plan had not been initiated. The baseline care plan also did not document CHF or the 1500 mL fluid restriction. The resident’s weight increased from 156 pounds on admission to 162 pounds five days later, but the physician was not notified of the six-pound gain. The weekly weight order did not specify when to notify the provider for weight gain. The record also showed an order for the 1500 mL fluid restriction without a breakdown of how much fluid was to be provided by nursing and dietary. CNA documentation showed fluids provided and consumed each shift, but there was no documentation of fluids given by nurses during medication passes and no documentation of output. A provider later ordered IV fluids for the resident after noting diarrhea, severe dehydration, fatigue, lethargy, low urine output, dry lips, and skin tenting. The MAR showed the IV fluid order was pending confirmation, but there was no documentation that the resident received the IV fluids, no nursing documentation explaining why the order was not started, and no documentation that the emergency contact was notified of the change in condition. In addition, when the resident complained of chest pain and appeared lethargic and short of breath, the nurse took vital signs and reported the resident to the NP, but the vital signs, the chest pain complaint, the provider notification, and the NP visit were not documented in the EMR. The DON and NP both confirmed that the chest pain episode and the lack of documentation were issues, and the NP stated she was not aware that the weight gain, lack of intake/output recording, and non-administration of IV fluids had not been documented or communicated.
Failure to Provide Ordered Oxygen and Nebulizer Treatments
Penalty
Summary
The facility failed to ensure oxygen therapy was administered according to physician orders for a resident with COPD, hypertensive heart disease with heart failure, and functional quadriplegia. The resident had an order for oxygen at 4 liters per minute continuously and a care plan intervention for oxygen via nasal prongs as ordered continuously and humidified continuously. During observation, the resident was found in bed without the nasal cannula in place, the oxygen concentrator was set at 2 liters per minute, and the tubing was out of reach. An LPN entered the room to give medications but did not assess oxygen use, ensure the cannula was in place, or verify the ordered flow rate. The LPN later stated the resident always removes the cannula and confirmed the oxygen was set at 2 liters per minute, while the physician order was for 4 liters per minute. The facility also failed to ensure the resident’s oxygen was properly positioned during a later observation. The resident was seen with the nasal cannula prongs placed to the left side of the nose, and the LPN agreed to assist but could not state how long the oxygen had been worn improperly. The DON stated that the resident always refused oxygen. For another resident with acute respiratory failure with hypoxia and unspecified dementia, the facility failed to ensure nebulizer treatment was delivered effectively. The resident had a nebulizer order and was observed receiving treatment while lying flat on her back in bed, with the medication chamber and tubing resting on her chest rather than positioned upright. No staff were present to monitor the treatment, and the nurse did not return until prompted by the surveyor. When the treatment was stopped, the LPN wrapped the tubing around the machine and placed it in the bedside drawer without cleaning the equipment. The LPN stated the resident should have been positioned upright and acknowledged that failure to clean nebulizer equipment can lead to bacterial growth and increase the risk of respiratory infection.
Medication Orders and Labels Did Not Match Actual Route of Administration
Penalty
Summary
The facility failed to update physician orders and ensure medication labels accurately reflected the current route of administration for a resident with a feeding tube who had begun taking medications by mouth. The resident was admitted with diagnoses including aphasia following cerebral infarction and gastrostomy status, and the quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment. The MAR showed twelve medications scheduled by mouth and three medications scheduled via G-tube, including docusate sodium 100 mg daily, hydralazine HCl 100 mg twice daily, and atorvastatin 80 mg at bedtime, along with G-tube flushes twice daily. During observation, an LPN administered the docusate sodium and hydralazine by mouth in pudding, while the medication labels for both medications still reflected administration via G-tube. The LPN confirmed that the physician orders and labels indicated G-tube administration but stated the resident did not receive anything by G-tube and that the G-tube was only flushed for patency. The LPN also stated nursing staff were responsible for ensuring medication orders and labels reflected the correct route of administration and for obtaining physician clarification when discrepancies were identified. The LPNUM stated she was unaware of the inconsistency and that nurses were responsible for following the medication rights and validating orders against labels before administration.
Failure to Protect Resident from Racial Discrimination During Verbal Altercation
Penalty
Summary
The facility failed to protect a resident's right to a dignified existence and freedom from discrimination when a verbal altercation between two residents involved the use of racial slurs. One resident, with a diagnosis of bipolar disorder and a history of verbally aggressive behaviors, walked past another resident's room and, after being yelled at to leave, responded with a racial slur. The incident was confirmed by both residents and staff, with documentation indicating that the resident who used the slur had a care plan addressing verbally aggressive behaviors, but not specifically racial discrimination. The other resident, who has a history of post-traumatic stress disorder related to racial trauma, did not have their care plan updated following the incident. Staff interviews revealed that the incident was known to some, but not all, staff members, and that the facility's policies prohibit discrimination and require prompt reporting of such incidents. The Director of Nursing acknowledged the incident as racially abusive language and bullying, and noted that racism was a pervasive issue in the facility. Despite this, the clinical record for the resident who experienced the slur lacked documentation of the incident beyond a single communication note, and there was no evidence of additional interventions or care plan updates related to the racial discrimination event.
Failure to Investigate and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of verbal abuse involving two residents, one of whom had a history of post-traumatic stress disorder related to prior abuse and racial trauma. On the date of the incident, one resident walked past another resident's room, resulting in a verbal altercation where racial slurs were exchanged. The incident was witnessed by an LPN, who intervened after hearing the commotion from another hallway. Documentation shows that the social worker met with both residents the following day to discuss the incident, but the care plan for the resident with a history of trauma was not updated, and there was no further documentation or investigation into the event. The Director of Nursing (DON), who also served as the Abuse Coordinator, determined after a verbal conversation with the LPN that the incident did not constitute abuse and did not initiate an official investigation, submit a Facility Reported Incident (FRI) report, or notify the State Agency, Ombudsman, residents' families, or Medical Director. The facility's policy required that all allegations of abuse be investigated and reported within two hours, including interviews with all involved parties and appropriate notifications. However, the DON did not interview the residents involved or any potential witnesses, and the incident was not documented as an abuse allegation, resulting in a failure to follow established procedures.
Failure to Care Plan for Smoking Risk with Oxygen Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's ongoing nicotine dependence and stated intent to continue smoking, despite the resident's use of oxygen therapy and multiple documented behaviors indicating a desire to smoke. The resident, who had diagnoses including nicotine dependence and chronic obstructive pulmonary disease, repeatedly expressed intentions to smoke while on oxygen and was observed attempting to obtain cigarettes and expressing frustration over smoking restrictions. Staff were aware of the resident's behaviors and risk factors, as evidenced by nursing and behavioral notes, but did not include these issues in the resident's care plan. This lack of care planning resulted in staff being unaware of or unprepared for the resident's actions, culminating in a serious incident where the resident's wheelchair caught fire while the resident was outside, leading to burns on the resident's upper legs, abdomen, nostrils, and hands. Documentation shows that the resident had been counseled about the dangers of smoking with oxygen and had been prescribed nicotine replacement therapy, but no formal interventions or monitoring were established in the care plan to address the risk of smoking while using oxygen.
Failure to Update Care Plans After Resident Altercation Involving Racial Slurs
Penalty
Summary
The facility failed to update the care plans for two residents following a resident-to-resident altercation involving the use of racial slurs. One resident, with a diagnosis of bipolar disorder, was documented to have yelled a racial slur at another resident after being yelled at to leave the area. Both residents had a history of negative interactions, including police involvement. Despite documentation of the incident in nursing and social work notes, neither resident's care plan was revised to reflect the altercation or to address the new behavioral concerns that arose from the incident. Staff interviews revealed that direct care staff were unaware of any new interventions or changes to the care plans following the altercation. The care plans for both residents had not been updated to include the incident or to address the specific needs related to racial trauma and behavioral issues, as required by facility policy. The lack of care plan updates was confirmed by the Assistant Director of Nursing, who acknowledged that care plans should have been revised to document the incident and guide staff in preventing further occurrences.
Failure to Supervise Resident Smoking with Oxygen Resulting in Fire and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident with a history of nicotine dependence and chronic obstructive pulmonary disease who continued to smoke while using oxygen. Despite multiple documented instances where the resident expressed intent to smoke and was observed smoking on facility property, the care plan did not address the resident's risk factors related to smoking while on oxygen. Staff were aware of the resident's behavior, and there were several notes indicating the resident's frustration with smoking restrictions and attempts to smoke, including while on oxygen. The facility's policies required comprehensive care planning and strict adherence to oxygen and smoking safety, but these were not effectively implemented for this resident. On the date of the incident, the resident's wheelchair caught fire in the facility parking lot while the resident was smoking with oxygen in place, resulting in burns to the resident's upper legs, abdomen, nostrils, and hands. Other residents witnessed the event and intervened to help the resident. Staff interviews confirmed prior knowledge of the resident's unsafe smoking practices and lack of care plan interventions addressing these risks. The facility's smokefree policy and procedures for handling residents who refuse to follow safe smoking practices were not enforced in this case.
Inadequate Shower Room Temperatures
Penalty
Summary
The facility failed to ensure a comfortable ambient air temperature in the communal shower rooms, affecting multiple residents. Observations and interviews revealed that the temperatures in three shower rooms were recorded at 62.1°F, 62.4°F, and 67.6°F, which were considered too cold for comfortable use. Residents expressed discomfort and reluctance to use the shower rooms due to the chilly conditions, with some opting to perform personal hygiene in their rooms instead. Staff, including CNAs, RNs, and LPNs, acknowledged the residents' complaints and agreed that the shower rooms were too cold. The Maintenance Director and Engineering Manager confirmed the low temperatures and expressed that they would not want to shower in such conditions. The Administrator and Owner were aware of the issue, with the Owner noting that the facility had been waiting for a vendor to address the problem. The Director of Engineering became aware of a thermostat issue in December 2024 and believed it had been resolved, but maintenance staff did not communicate the ongoing problem. Facility policies guarantee residents the right to a safe, clean, comfortable, and homelike environment, with specified temperature ranges between 71°F and 81°F. The failure to maintain these temperatures in the shower rooms violated these policies, leading to widespread discomfort among residents. The report highlights the lack of effective communication and timely resolution of maintenance issues, contributing to the deficiency.
Expired Medications and Unsecured Wound Care Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from two of three medication storage rooms. During an observation, expired Geri Care Iron Liquid Supplement and Tubersol tuberculin purified protein derivative vials were found in the medication storage rooms. The Unit Manager confirmed the expiration of the Iron Liquid Supplement and the lack of opening dates on the Tubersol vials, which were considered expired. The Director of Nursing also confirmed the expiration of the Iron Liquid Supplement and acknowledged the potential adverse effects of administering expired medications. The facility's policy stated that outdated drugs should not be used and must be returned to the pharmacy or destroyed. Additionally, a wound care cart located near the 400 Hall nurses' station was found unlocked and unattended, containing potentially hazardous opened treatment items. These items included a bottle of sodium hypochlorite solution, a jar of Silver Sulfadiazine cream, and a tube of diclofenac sodium gel, all labeled for topical use only. An LPN confirmed the cart was unlocked and acknowledged the potential hazard if the items were consumed by residents. The LPN did not have a key to the cart, which was left open for scheduled wound care treatments. The facility policy required medication carts to be locked when not in use and not left unattended if opened.
Confidentiality Breach of Resident's Health Records
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records by leaving an electronic health record open and accessible on a computer attached to a medication cart. This incident involved a resident who was admitted with diagnoses including major depressive disorder and bipolar disorder. On the morning of January 6, 2025, the computer displayed the resident's name, picture, and current medications with associated diagnoses, while no staff member was present to monitor the cart. A Certified Nursing Assistant confirmed that the Registered Nurse responsible for the cart was attending to another resident on a different hall. The RN admitted to leaving the resident's information visible and unattended. The Director of Nursing acknowledged that the resident's personal information should not have been visible and emphasized the responsibility of staff to protect electronic health records from unauthorized access. The facility's policy on Protected Health Information mandates that such information should be managed and protected to prevent unauthorized disclosure.
Deficiency in Foley Catheter Care Planning
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a Foley catheter, which was identified as a deficiency. The resident, who had been admitted and readmitted with diagnoses including an unstable burst fracture and paraplegia, had an indwelling catheter documented in their Minimum Data Set (MDS) assessments. Despite this, the care plan lacked specific focus areas, goals, or interventions related to the catheter's care, such as monitoring for infection, cleaning the insertion site, and ensuring proper positioning of the drainage bag. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that a care plan for a resident with a Foley catheter should include specific interventions to prevent complications. The DON confirmed that a care plan should have been developed for the resident's catheter care, but it was not done in a timely manner. The facility's policy required the Interdisciplinary Team (IDT) to develop and update comprehensive, person-centered care plans, but this was not adhered to in the case of the resident with the Foley catheter.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update the care plan for a resident identified as high risk for falls, following two documented falls. The resident, who was admitted with diagnoses including metabolic encephalopathy and osteonecrosis of the right femur, experienced falls on two separate occasions. Despite being identified as high risk for falls in evaluations conducted on three different dates, the care plan was not updated with new interventions after the second fall. The care plan initially included reminders for the resident to ask for help with transfers and to follow the facility's fall protocol, but it lacked updates after the second fall to include additional preventive measures. The Director of Nursing (DON) confirmed that the care plan was not revised after the resident's fall on the second occasion, despite the facility's policy requiring such updates. The DON acknowledged that an intervention to place the resident's belongings within reach should have been added to the care plan. The facility's policy on fall prevention and management mandates that individualized precautions be noted for high-risk residents and that care plans be updated with appropriate interventions following a fall to prevent recurrence or minimize injury.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that physician-ordered wound care was performed for a resident, identified as Resident #448, which had the potential to worsen the resident's wound or delay healing. Resident #448 was admitted with diagnoses including metabolic encephalopathy and osteonecrosis of the right femur. On a specific date, it was observed that the dressing on the resident's right elbow was dated the previous day, indicating a lapse in daily wound care. The Treatment Administration Record (TAR) for January lacked documentation of wound care being provided on another specific date, despite an active physician's order for daily treatment. Interviews with facility staff revealed that the LPN assigned to the resident on the date in question was unaware of the wound and did not provide the necessary care. The Director of Nursing confirmed the absence of documentation for the required wound care and acknowledged that the resident should have received treatment according to the physician's order. The facility's policy on Skin and Wound Management emphasized the importance of providing services and treatment to prevent infection and promote healing, which was not adhered to in this instance.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to address a resident's repeated requests for a dental appointment to address broken teeth and pain with chewing food. The resident, who was admitted with diagnoses including type II diabetes mellitus and other specified sepsis, had been asking to see a dentist since May 2024. Despite verbalizing these concerns to nursing staff and social services, the resident did not receive confirmation of any efforts made to schedule a dental appointment or any barriers to receiving dental care. The resident's Minimum Data Set (MDS) notes and care plan documented oral pain and chipped teeth, yet no dental appointment was scheduled. The facility's process for scheduling dental appointments involved notifying social services, who would then send a referral to the Social Work Coordinator (SWC). However, the SWC's request to Transportation Services (TS) was not documented, and TS did not have a record of scheduling a dental appointment for the resident. The Transportation Log showed two entries requesting dental appointments, but one was crossed out as a duplicate, and there was no documentation indicating the resident still needed an appointment. The Director of Nursing acknowledged the importance of dental care for the resident's well-being and the need for documentation if there were delays in scheduling appointments.
Failure to Address Low Temperatures in Shower Rooms
Penalty
Summary
The facility failed to effectively manage its resources by not addressing low ambient temperatures in three communal shower rooms. On January 7, 2025, temperatures were recorded at 62.1°F, 62.4°F, and 67.6°F in the Boundary Peak, [NAME], and [NAME] Peak communal shower rooms, respectively. The Administrator was unaware of these low temperatures and admitted discomfort with the idea of showering in such conditions. The Director of Engineering had been aware of a thermostat issue since December 19, 2024, and had contacted a repair company, believing the problem was resolved. However, the maintenance staff did not communicate the ongoing issue to the Director of Engineering. The job descriptions for both the Administrator and the Director of Engineering outline their responsibilities in maintaining facility operations and ensuring quality care. The Director of Engineering is tasked with managing contracts, overseeing facility maintenance, and ensuring timely completion of work orders. The Administrator's role includes consulting with department managers to address and correct problem areas. Despite these outlined responsibilities, the failure to address the low temperatures in the shower rooms indicates a lapse in communication and oversight between the facility's administration and maintenance departments.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure proper documentation of wound care treatments for four residents, leading to deficiencies in maintaining accurate clinical records. Resident #3, diagnosed with spastic quadriplegic cerebral palsy and a stage 3 pressure ulcer, had multiple instances of undocumented wound care treatments in November and December 2024, and January 2025. The LPN Wound Care Nurse admitted to providing care but forgetting to document it, which was confirmed by the Director of Nursing (DON). Resident #198, with a history of spinal fusion and other lumbar conditions, also had missing documentation for wound care treatments in December 2024 and January 2025. The LPN Wound Care Nurse was responsible for documenting these treatments but failed to do so, leaving no proof that the care was provided on specific dates. Similarly, Resident #448, who had a skin tear on the right elbow, and Resident #133, with a right hip wound, both had missing documentation for wound care treatments in January 2025. The LPN Wound Care Nurse acknowledged providing the care but did not document it. The facility's policies on charting and documentation, as well as wound care, require that all services and treatments be recorded in the resident's medical record. The DON emphasized the expectation for nursing staff to document care as soon as possible and before the end of their shift. However, the lack of documentation for these residents indicates a failure to adhere to these policies, resulting in incomplete clinical records.
Failure to Follow Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed when a Social Services employee entered the room of a resident on contact-based isolation precautions without donning the required personal protective equipment (PPE). The resident, who was admitted with diagnoses including methicillin-resistant staphylococcus aureus (MRSA) and a recurrent urinary tract infection, was in a room clearly marked with a sign indicating the need for contact-based precautions. Despite this, the employee entered the room without wearing PPE, only using alcohol-based hand rub, and later confirmed awareness of the isolation precautions but believed PPE was unnecessary as no direct care was provided. The incident was observed by a Licensed Practical Nurse (LPN) who reiterated the requirement for PPE to the Social Services employee. The Director of Nursing (DON) also confirmed that the employee should have donned PPE to prevent infection spread. The facility's policy on isolation and transmission-based precautions, adopted in 2019, mandates that staff and visitors adhere to proper hand hygiene and wear gloves and disposable gowns when entering rooms under contact precautions. The resident expressed uncertainty about whether all individuals entering the room complied with the PPE requirements.
Failure to Post Current Nursing Staff Information
Penalty
Summary
The facility failed to ensure that current nursing hours were posted daily, as required by their policy. On January 5, 2025, it was observed that the nursing staff posting, located in the hallway near the entrance, was dated January 3, 2025, indicating it was not updated daily. The Director of Nursing (DON) acknowledged that the staffing information was only posted in one location and not on each unit. The Administrator confirmed that the posting was supposed to be updated daily and admitted that the current posting was outdated and not in compliance with the facility's policy, which mandates daily updates of nursing personnel responsible for direct care to residents.
Failure to Protect Resident from Verbal and Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Aide (CNA). The incident involved a resident who was admitted with a primary diagnosis of chronic hepatic failure without coma. The resident reported that the CNA was rude, yelled at them, threw a pillow at them, and shoved a pillow under their back. The resident expressed fear of asking for help due to the treatment received from the CNA. A witness statement from the resident's roommate corroborated the resident's account, observing the CNA yelling and throwing a pillow at the resident. The facility's Director of Nursing/Abuse Coordinator confirmed that the incident was reported to the Nevada State Board of Nursing and substantiated the allegations of abuse. The CNA's job description required treating residents with courtesy, respect, and dignity, which was not adhered to in this case. The facility's policies on recognizing signs of abuse and the abuse prevention program emphasized protecting residents from abuse by staff, which was not effectively implemented in this instance.
Failure to Administer Nutritional Supplement and Conduct Timely Dietary Evaluation
Penalty
Summary
The facility failed to ensure timely evaluation and administration of nutritional supplements for a resident with a stage four pressure ulcer. The resident, who was admitted with severe protein-calorie malnutrition and a stage four pressure ulcer of the sacral region, had a physician's plan that included a dietary evaluation and the administration of Pro-Stat, a concentrated liquid protein drink. However, the resident's clinical record lacked evidence of a dietary evaluation being completed in January or February, and the January Medication Administration Record (MAR) showed no documentation of Pro-Stat being administered. The Director of Nursing (DON) and the Administrator confirmed the absence of a timely dietary evaluation and the lack of Pro-Stat administration, despite a physician's order and confirmation by a registered nurse. The facility's policies required a comprehensive nutrition and hydration assessment for residents with stage two or greater pressure ulcers, which was not completed in this case. The DON explained that Pro-Stat was intended to help residents who might not be getting enough protein or to aid in wound healing, but it was not delivered or administered as required.
Misappropriation of Resident Property by Housekeeper
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a Housekeeper asked the resident for money. The incident involved a resident with chronic obstructive pulmonary disease, major depressive disorder, and anxiety, who was approached by a Housekeeper requesting to borrow money. The resident provided the money, and although the Housekeeper repaid the amount in full, this action was against the facility's policy. The facility's investigation revealed that the Housekeeper had indeed asked the resident for money, which was confirmed by both the resident and the Director of Nursing. The facility's policy clearly states that residents have the right to be free from misappropriation of property, and the Housekeeper's actions violated this policy. The incident was reported as a Facility Reported Incident (FRI), and the facility conducted interviews with 16 other residents, who confirmed they had not been asked for money by staff.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications per a physician's order for two residents. For Resident #2, the LPN administered a Calcium Citrate-Vitamin D tablet with a dosage of 400 mg-12.5 mcg instead of the prescribed 500 mg-10 mcg. This discrepancy was confirmed by the LPN upon reviewing the medication orders. Resident #2 had diagnoses including vitamin D deficiency and mild protein-calorie malnutrition at the time of the incident. For Resident #3, the LPN applied a Lidocaine patch to the resident's right shoulder instead of the prescribed left shoulder. The LPN acknowledged the error and confirmed that the order should have been verified prior to administration. Resident #3 had a diagnosis of unspecified pain. Both the Director of Nursing and the Administrator confirmed that these actions did not follow the physician's orders, as per the facility's policies and the Nevada Nurse Practice Act.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
