Alta Skilled Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reno, Nevada.
- Location
- 555 Hammill Lane, Reno, Nevada 89511
- CMS Provider Number
- 295077
- Inspections on file
- 28
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Alta Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident receiving hospice services for a large, tunneling breast mass did not have a care plan in the facility's records addressing wound care, despite hospice providing this care. Facility staff confirmed the absence of a wound care order and care plan, which was not in accordance with facility policy requiring comprehensive, integrated care planning.
The facility did not update care plans for two residents: one with Parkinson's disease who required a neurology appointment for increased tremors, and another with ongoing nicotine use who stored smoking paraphernalia in their room. Staff were unaware of the status of the neurology appointment and the location of smoking materials, and care plans lacked necessary revisions to address these issues.
A resident with Parkinson's disease and multiple sclerosis experienced increased tremors, prompting repeated requests and physician orders for a neurology referral. Despite these, staff only sent referrals to the resident's previous neurologist, who could not accept the patient due to insurance issues, and did not attempt referrals to other neurologists. The care plan was not updated to reflect the resident's symptoms or referral needs, and clinical leadership did not monitor the referral process, resulting in a delay in care.
Two residents did not receive care in accordance with physician orders and facility policy: one experienced increased tremors without timely neurology referral due to repeated attempts only with a non-contracted provider, and another had a non-healing wound managed by hospice without a facility order or care plan documenting wound care responsibilities.
A resident at risk for pressure injuries developed a Stage III coccyx ulcer, and wound care was not consistently provided as ordered by the physician. Documentation showed multiple missed wound care treatments over several weeks, and both the DON and Wound Care Nurse confirmed that care was not completed as required. Facility policies for skin inspection and wound management were not followed, resulting in a deficiency.
A resident with a G-tube and orders to check gastric residuals before administering medications did not have their residual volume checked by an LPN prior to receiving medication. The LPN and DON confirmed that this step was missed, which was not in accordance with physician orders and facility policy.
A resident had a prescribed bottle of lorazepam present in the medication storage room, but there was no corresponding order in the electronic health record or entry on the MAR. Additionally, an ordered C-PDR cream for nausea or vomiting was not available for the resident. The DON confirmed that all ordered medications should be available, and facility policy required accurate medication order documentation.
A medication cart was found unattended, unlocked, and with the keys left on top in a hallway, making medications accessible to unauthorized individuals. An RN confirmed the cart was left unsecured and out of sight, which was not in accordance with facility policy requiring medication carts to be locked and keys kept with nursing staff.
A resident receiving hospice care did not have coordinated care between the facility and the hospice agency, resulting in discrepancies in medication orders, missing wound care plans, and unavailable prescribed medications. Facility staff and hospice personnel confirmed that medication reconciliation and care plan updates were not completed as required, and the facility lacked a designated hospice coordinator.
A CNA entered a room under Enhanced Barrier Precautions (EBP) to assist a resident with an ESBL urinary tract infection without performing required hand hygiene, despite clear signage and available alcohol-based hand rub. This action was observed by an RN and confirmed by facility leadership as a violation of policy.
A wound cart and a medication cart containing resident medications were left unlocked and unattended in two separate hall entrances, with residents present nearby. An LPN and an RN confirmed the carts were unsecured, and the DON stated that floor nurses are responsible for ensuring carts are locked according to facility policy.
The facility failed to properly screen and offer pneumococcal vaccinations to 28 residents based on medical conditions, only considering age in their screening process. This oversight led to eligible residents not receiving the vaccine as per CDC guidelines.
A resident with multiple diagnoses exhibited significant decline, including bluish discoloration and severe pain in the lower extremity. Despite a physician's order for an ultrasound, the facility's contracted diagnostics company lacked an ultrasound technician, and the family and physician were not informed of the ongoing decline. The resident was eventually sent to the hospital after a week of worsening symptoms.
A facility failed to provide a comfortable, homelike environment for a resident when the AC unit in their room was broken and not promptly repaired. Despite the resident's spouse informing staff, the issue persisted for three days without alternative accommodations. The facility's policy on maintaining a homelike environment was not followed, leading to the deficiency.
The facility failed to provide necessary care for a resident with DVT, leading to severe gangrene and hospitalization, and did not protect residents from physical abuse by another resident. Despite worsening symptoms, the resident with DVT did not receive timely medical intervention, and the facility's documentation lacked consistent assessment of pedal pulses. Additionally, the facility did not implement new interventions for a resident with disruptive behaviors, resulting in an incident of physical abuse.
A resident reported $20 missing from their wallet shortly after admission, but the facility failed to follow its policy for investigating the report. The CNA who received the report did not document it, and the DON was unaware of the issue until the survey team brought it to attention. No follow-up was conducted by Social Services, and the facility's policy on investigating misappropriation was not followed.
A resident with a urinary catheter repeatedly pulled out the catheter, resulting in hospital visits for reinsertion and treatment for hematuria. Despite these incidents, the care plan did not include interventions to prevent this behavior. Both the LPN and DON acknowledged the need for documented interventions, which were not in place at the time of the incidents.
The facility failed to implement interventions for a resident with a urinary catheter who repeatedly pulled it out, did not provide timely care for a resident with a suspected DVT, and did not communicate a hospice physician's order, resulting in the resident not receiving the ordered medication.
The facility failed to ensure that two residents were weighed according to the facility's policy, leading to significant gaps in weight monitoring and documentation. One resident was not weighed for over six months despite significant weight fluctuations, and another resident experienced a drastic weight loss without proper follow-up.
The facility failed to ensure a CNA had an annual performance evaluation completed timely. A CNA hired over a year ago had their last evaluation documented late, missing the required annual review date. The Human Resources Manager confirmed the delay, violating the facility's policy for annual reviews.
A resident with chronic pancreatitis and muscle spasms missed several doses of prescribed medications due to the facility's failure to reorder them in a timely manner. The facility's policy required medications to be reordered at least three days before running out, but this was not followed, leading to missed doses and increased pain for the resident.
The facility failed to ensure timely ultrasounds for residents due to the contracted diagnostics company not having an ultrasound technician available for onsite visits. The Administrator was unsure when first notified about the issue and could not provide documented evidence that the lack of an ultrasound technician was addressed or that any direction was given to the nursing staff. The DON was aware of the issue and had instructed to send residents to the hospital for ultrasounds but was not aware if the nursing staff had been informed of this need prior to their tenure as DON.
The facility failed to ensure complete medical records for two residents. One resident missed several required weekly weight measurements, and another resident's G-Tube flushes were not documented as per physician orders. The DON confirmed these deficiencies.
The QAPI committee failed to identify that the contracted diagnostics company lacked an ultrasound technician, leading to a delay for a resident with a physician's order for an ultrasound. The Administrator was unsure when notified and could not provide documented evidence of addressing the issue. The DON knew about the lack of a technician and instructed to send residents to the hospital but was unaware if nursing staff had been informed.
A facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for a resident with a jejunostomy tube (J-tube). An LPN did not wear a gown or gloves while disconnecting the tube feeding, despite the requirement indicated by a sign outside the resident's room and the resident's care plan. The Director of Nursing confirmed the necessity of gown and gloves to prevent infections, as outlined in the facility's Infection Prevention and Control Program (IPCP) policy.
A resident with a history of wandering and wearing a Wanderguard device followed a CNA out of an alarmed exit door, but the alarm failed to activate, allowing the resident to wander into the parking lot. The facility's policy required staff to prevent such incidents, but the alarm system malfunctioned, and maintenance did not detect the issue during weekly checks.
A resident with hydrocephalus and difficulty walking experienced a loss of dignity when a PT verbally confronted them for walking in the facility. The resident felt disrespected and embarrassed, leading to emotional distress. An RN witnessed the incident and reported it to the Administrator and DON. The resident expressed a desire to leave against medical advice rather than work with the PT again.
A resident was verbally abused by an RN at the nurse's station, witnessed by a CNA and a family member. The RN was suspended and later terminated, but the investigation was incomplete as not all witnesses were interviewed, and documentation was lacking. The resident did not report psychosocial harm, but the facility's investigation did not meet its own standards.
A resident with chronic health conditions reported being roughly handled and slapped by a CNA. Despite the facility's policy requiring prompt investigation and reporting of abuse allegations, the Administrator and DON did not investigate or report the incident, citing the resident's history of unfounded allegations. The CNA continued to work with the resident, contrary to policy requirements.
A resident with chronic health conditions reported being roughly handled and slapped by a CNA. The facility's Administrator and DON failed to report or investigate the allegation, citing the resident's history of unfounded claims, despite policy requirements for prompt reporting and investigation.
A facility failed to investigate and report abuse allegations involving a CNA and an RN. A resident alleged a CNA slapped and handled them roughly, but the facility did not suspend the CNA or report the incident. Another incident involved an RN verbally abusing a resident, witnessed by a CNA and a family member. The facility's investigation was incomplete, lacking interviews with all involved parties and proper documentation.
An LPN at the facility was observed leaving premixed doses of MiraLAX unattended on a medication cart, posing a risk of ingestion by others. The DON confirmed that medications should not be left unattended and should be prepared individually. The facility lacked competency checklists for new nurses, contributing to the deficiency.
A resident's medications were left unsupervised at the bedside, resulting in a 100% medication error rate. The medications, documented as administered, were not taken by the resident. An LPN confirmed the error, and the physician highlighted the risk of drug interactions. The facility's policy on medication administration was not adhered to.
The facility failed to properly store and supervise medications, with an LPN leaving premixed MiraLAX unattended on a medication cart, posing a risk of ingestion by others. Additionally, medication carts were left unlocked and unattended, allowing access by staff, residents, and visitors, contrary to facility policy.
Failure to Integrate Hospice Wound Care into Resident Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's care plan was integrated with the hospice plan of care and did not include a care plan addressing the resident's wound care needs. The resident, who was admitted with diagnoses including palliative care and abnormal diagnostic findings, developed a large, tunneling breast mass that required wound care. The resident's representative stated that hospice was providing wound care, and hospice documentation confirmed ongoing wound management. However, there was no corresponding order for wound care or a care plan in the facility's electronic health record. Interviews with facility staff, including an RN, the Unit Manager, and the DON, confirmed that the resident did not have a care plan for wound care provided by hospice, and that such care should have been documented and integrated into the facility's care planning process. The facility's policy required comprehensive, person-centered care plans that incorporate all identified problem areas and professional services, but this was not followed in the resident's case.
Failure to Update Care Plans for Neurology Needs and Smoking Safety
Penalty
Summary
The facility failed to update and revise care plans for two residents, resulting in deficiencies related to the management of a resident's neurological needs and another resident's smoking habits. For one resident with Parkinson's disease and multiple sclerosis, the care plan did not reflect the resident's increased tremors or the need for a neurology appointment, despite repeated requests from the resident's representative and a physician's order indicating the necessity for such an appointment. Staff communicated verbally about the appointment status, but no appointment had been scheduled, and the care plan was not updated to address the resident's changing condition. For another resident with a history of tobacco use and hemiplegia, the care plan failed to address the resident's ongoing nicotine use and did not include interventions for the safe storage and use of smoking paraphernalia. The resident was observed smoking outside the facility and storing cigarettes and a lighter in the bedside table, but staff were unaware of the location of these items. The care plan only referenced a reminder of the facility's no smoking policy and had not been revised to address the resident's current smoking behaviors or associated safety concerns.
Failure to Timely Act on Neurology Referral for Resident with Parkinson's Disease
Penalty
Summary
The facility failed to ensure that a physician's order for a neurology referral was acted upon in a timely manner and monitored for completion for a resident with Parkinson's disease and multiple sclerosis. Despite repeated requests from the resident's representative at care conferences over several months, and documentation in care conference notes and progress notes indicating the need for a neurology appointment due to increased tremors, the facility did not schedule an appointment. The care plan was not revised to address the resident's increased symptoms or the need for a neurology referral. Referrals were sent twice to the resident's previous neurologist, but both times the neurologist's office responded that they could not see the patient due to insurance issues and lack of recent visits. No referrals were sent to other neurologists in the area. The Transportation Coordinator, responsible for coordinating referrals, only sent referrals to the previous neurologist as directed by information from nursing staff, and this process was not monitored by clinical leadership. The Director of Nursing and Unit Manager confirmed that the resident did not have an appointment scheduled and that the referral process was not adequately overseen or documented.
Failure to Coordinate Timely Specialist Referral and Wound Care Documentation
Penalty
Summary
The facility failed to ensure timely management of a resident's increased tremors as ordered by the physician. Despite repeated requests from the resident's representative and documentation in care conference notes and physician orders, the facility did not secure a neurology appointment for the resident experiencing worsening tremors related to Parkinson's disease. Referrals were only sent to the resident's previous neurologist, who no longer accepted the resident's insurance, and no attempts were made to contact other neurologists in the area. Communication between nursing staff and the transportation coordinator was limited to a spreadsheet, and there was no oversight to ensure the referral process was completed as ordered. The resident's care plan was not updated to reflect the need for neurology follow-up or the increased symptoms. Additionally, the facility did not monitor or document wound care for another resident who was on hospice and had a non-healing breast wound. The resident's representative reported that hospice was providing wound care, but there was no physician order or care plan in the facility's records addressing the wound or the facility's role in the care process. The facility's own policy required care planning and documentation for wound management, but this was not followed. The care plan was not integrated with the hospice plan of care, and facility staff did not have clear documentation of their responsibilities regarding the resident's wound care. These deficiencies were identified through observation, interviews with staff and resident representatives, and review of clinical records and facility policies. The lack of timely specialist referral and absence of wound care documentation and planning demonstrated a failure to provide care and services in accordance with physician orders, resident needs, and facility protocols.
Failure to Provide Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with multiple diagnoses, including adult failure to thrive, chronic kidney disease, and sequelae of cerebral infarction, was admitted to the facility and assessed as being at risk for pressure-related skin impairment due to factors such as shear friction and bed confinement. The care plan included interventions like keeping the resident clean and dry, providing peri care after incontinence, and weekly skin checks by a licensed nurse. Despite these measures, a Stage III pressure injury was identified on the resident's coccyx during a post-shower skin check, which had not been previously observed. Following the identification of the pressure injury, physician orders were written for specific wound care treatments, including cleansing with normal saline, applying skin prep or medi-honey and zinc oxide, and covering or leaving the wound open to air as directed. These orders specified the frequency of care, including every shift and as needed for soiling or dressing dislodgement. However, review of the Wound Care Treatment Administration Records (TAR) for April and May revealed multiple dates and shifts where there was no documented evidence that wound care was provided as ordered. The DON and Wound Care Nurse confirmed that the blanks in the TAR indicated the wound care was not completed on those dates and that the care was not provided according to the physician's orders. Facility policies required daily skin inspections during personal care, prompt identification and documentation of skin changes, and adherence to prescribed wound care treatments. The failure to provide wound care as ordered and to follow the facility's own policies for prevention and monitoring of pressure injuries resulted in a deficiency, as the resident did not receive the necessary care to prevent the development and progression of a pressure injury.
Failure to Check Gastric Residual Prior to G-Tube Medication Administration
Penalty
Summary
A deficiency was identified when a resident with a history of dysphagia, gastroparesis, and gastrostomy status did not have their gastric residual volume checked prior to the administration of medication via a gastrostomy tube (G-tube). The resident had a physician's order specifying that residuals should be checked before administering water, medications, or formula through the G-tube. Despite this order, an LPN administered levetiracetam solution through the G-tube without performing the required residual check. The LPN confirmed that the residual was not checked prior to medication administration, and the Director of Nursing also acknowledged that residuals should be checked before administering anything through a G-tube, in accordance with facility policy. The facility's policy on enteral feedings and safety precautions also documented the requirement to check tube placement and gastric residual volume prior to medication administration. This lapse was observed and confirmed through interviews and record reviews.
Medication Documentation and Availability Discrepancies
Penalty
Summary
The facility failed to ensure that there were no discrepancies between a resident's available medications, the resident's medication orders, and the medication administration record (MAR). During a review of a resident's medications, a bottle of lorazepam was found in the medication storage room with a label indicating it was prescribed for the resident, with specific administration instructions. However, the facility's electronic health record did not include an order for lorazepam, and the medication was not listed on the resident's MAR. The RN confirmed that the medication had been delivered by the hospice agency's pharmacy, but it was not properly documented in the facility's records. Additionally, the resident had an order for C-PDR cream to be applied as needed for nausea or vomiting, which was part of the hospice comfort package. The RN stated that the facility did not have the C-PDR cream available for the resident. The Director of Nursing confirmed that all medications ordered for a resident should be available in the facility. Facility policy required that a current list of orders be maintained in the clinical record for each resident, and the pharmacy services contract required regular medication regimen reviews by a consultant pharmacist.
Unattended and Unlocked Medication Cart with Keys Left Accessible
Penalty
Summary
A medication cart was observed unattended and unlocked in the 300 hall, with the keys left on top of the cart and no staff members in sight. The drawers of the cart, which contained drugs and biologicals, were facing the hallway, making the medications accessible to unauthorized individuals. This was directly observed by surveyors at 7:22 AM, and shortly after, a Registered Nurse confirmed that the cart had been left in this unsecured state while unattended and out of sight. The Director of Nursing later confirmed that the facility's policy requires medication carts to be locked when not in use and that the keys should always remain with the nurse. The facility's written policy, adopted in 2019, also specifies that only authorized personnel should have access to medication storage and that carts should not be left unattended if open or accessible. The observed incident was not in compliance with these established procedures.
Failure to Coordinate Hospice Care and Medication Orders
Penalty
Summary
The facility failed to coordinate care and services with a hospice agency for a resident who was receiving hospice care, resulting in discrepancies between the facility's records and the hospice agency's plan of care. The resident, admitted with diagnoses including palliative care and anxiety disorder, had a significant wound on the right breast that was being managed by hospice staff. However, the facility's electronic health record (EHR) did not include an order for wound care, nor did it have a care plan addressing the resident's wound or the use of certain medications prescribed by hospice. There were notable inconsistencies between the facility's medication orders and those from the hospice agency. The facility's EHR listed a different dosage of metronidazole than the hospice agency, included pravastatin which was not on the hospice list, and omitted lorazepam, which was prescribed by hospice for symptom management. Additionally, the facility did not have PDR cream available, despite it being ordered by both the facility and hospice. Interviews with facility staff and hospice personnel confirmed these discrepancies and revealed a lack of medication reconciliation and care plan updates. The facility's policy required coordination with hospice, including reconciling medication orders and care plans, but this was not followed. The Director of Nursing acknowledged that staff should have reconciled medications and care plans with hospice, and the facility did not have a designated hospice coordinator. The process for receiving and communicating new hospice orders was not effectively implemented, resulting in the resident not having appropriate care plans or access to all prescribed medications and therapies.
Failure to Perform Hand Hygiene Before Entering EBP Room
Penalty
Summary
A Certified Nursing Assistant (CNA) entered a room designated for Enhanced Barrier Precautions (EBP) without performing required hand hygiene, either by using alcohol-based hand rub (ABHR) or washing hands. The room was clearly marked as being on EBP, and an ABHR dispenser was available outside the room. The CNA entered to assist a resident with their meal tray and later acknowledged forgetting to use ABHR before entering, despite the resident being on EBP due to an extended-spectrum beta-lactamase (ESBL) urinary tract infection. A Registered Nurse (RN) observed the CNA's failure to perform hand hygiene and confirmed the resident's EBP status due to ESBL in the urine. The facility's policy, updated in March 2024, requires all individuals to clean their hands with ABHR before entering any room on EBP. The Administrator also confirmed that the CNA should have performed hand hygiene prior to entry. The incident was identified through observation, interview, and document review, and the deficiency was noted as having the potential to affect the resident population.
Unsecured Medication and Wound Carts Left Unattended
Penalty
Summary
A wound cart containing resident medications was observed left unlocked in the 200 hall entrance, with four residents sitting nearby. An LPN later confirmed the cart was unsecured and acknowledged that residents could have accessed the medications. Additionally, a medication cart was found unlocked and unattended in the 100 hall entrance, which was confirmed by an RN. The Director of Nursing stated that floor nurses are responsible for ensuring carts are locked and not left unattended. Facility policy requires all compartments containing drugs and biologicals to be locked when not in use and not left unattended if open or accessible.
Failure to Properly Screen and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility to receive a pneumococcal vaccination, provided with education regarding the vaccine, and offered the vaccine for administration or declination. Specifically, 28 residents were not screened for eligibility based on criteria other than age, despite having medical conditions that could make them eligible for the vaccine. The facility's policy and flowchart used for screening only considered age, leading to the exclusion of residents under 65 who had conditions such as diabetes or were immunocompromised, which should have made them eligible for the vaccine according to CDC guidelines. For instance, Resident #104, who had type two diabetes mellitus, was not offered the pneumococcal vaccine because the screening process only considered age. The Infection Control Preventionist (ICP) and the Vice President of Clinical Services (VPCS) confirmed that the resident should have been offered the vaccine based on their medical condition. This oversight was consistent across the other 27 residents, who were also not screened for additional eligibility criteria beyond age. The facility's policy, adopted in 2019, stated that all residents should be offered pneumococcal vaccines to prevent pneumonia/pneumococcal infections. However, the policy was not followed correctly, as the screening process did not align with CDC guidelines, which recommend the vaccine for individuals with certain medical conditions regardless of age. This failure to properly screen and offer the vaccine to eligible residents represents a significant deficiency in the facility's vaccination protocol.
Failure to Notify Physician and Family of Resident's Decline
Penalty
Summary
The facility failed to ensure that a resident's representative and physician were notified of a significant change in the resident's condition. Resident #305, who had multiple diagnoses including pulmonary embolism and peripheral vascular diseases, exhibited bluish discoloration and cold, clammy skin on the right lower extremity. Despite the physician ordering a bilateral leg arterial ultrasound, the facility's contracted diagnostics company did not have an ultrasound technician available. The resident's condition worsened over several days, with increased pain and continued discoloration, but the family and physician were not informed of the ongoing decline and the inability to perform the ultrasound in-house. The resident's condition continued to deteriorate, leading to severe pain and behavioral changes. It was only on 05/07/2024 that the physician was notified, and the resident was subsequently sent to the hospital. Interviews with the Unit Manager and Director of Nursing confirmed that there was no documentation of the physician being informed about the lack of an ultrasound technician or the resident's declining condition. The facility's policy required prompt notification of changes in a resident's condition to the healthcare provider and resident representative, which was not adhered to in this case.
Failure to Provide Comfortable Environment Due to Broken AC Unit
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for Resident #257 when the air conditioning (AC) unit in the resident's room was broken and not promptly repaired. Despite the resident's spouse informing the Administrator and staff about the issue, the AC unit remained unfixed for three days. During this period, the room was reported to be uncomfortably warm, and no alternative accommodations, such as moving the resident to another room or providing a fan, were offered. The Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) were unaware of any restrictions on using fans in the room, and the Head Operations Manager (HOM) confirmed that there were no such restrictions. The HOM acknowledged the broken AC unit and stated that a replacement unit had to be ordered from the home office, which arrived and was installed on the third day. The facility's policy on providing a homelike environment was not adhered to, as the staff failed to ensure a comfortable and safe temperature in the resident's room. The Administrator admitted that the resident was not experiencing a comfortable environment due to the broken AC unit and high temperatures. A work order for the AC repair was not created until the third day, and the HOM confirmed that no prior work order had been made. The facility's delay in addressing the broken AC unit and lack of immediate accommodations for the resident led to the deficiency in providing a homelike environment as required by their policy.
Failure to Provide Necessary Care and Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure a resident with a deep vein thrombosis (DVT) received the necessary care to prevent the resident from developing gangrene in a lower extremity and requiring hospitalization. Resident #305 was admitted with multiple diagnoses, including other pulmonary embolism and peripheral vascular diseases. On 04/30/2024, a nurse noticed bluish discoloration and cold, clammy skin on the resident's right lower extremity and informed the physician, who ordered a bilateral leg arterial ultrasound. However, the facility's contracted diagnostics company did not have an ultrasound technician available, leading to a delay in the ultrasound. Despite the resident's worsening condition, including increased pain and further discoloration, the resident was not sent to the hospital until 05/07/2024, resulting in severe gangrene and the need for an above-the-knee amputation or end-of-life care. The facility's documentation lacked consistent assessment of pedal pulses, and the physician was not informed of the resident's clinical decline in a timely manner, contributing to the delay in appropriate care and treatment for the resident's condition. The facility also failed to protect residents from physical abuse by another resident. Resident #83, who had a history of schizophrenia and anxiety disorder, was involved in an incident on 04/09/2024, where the resident spit on and threw a cup of water at their roommate, Resident #122, while the roommate was asleep. Despite Resident #83's documented potential for disruptive behaviors and the need for monitoring and intervention, the facility did not implement new interventions to address the resident's increased behaviors. Resident #83 was eventually transferred to a behavioral health center for additional services, and Resident #122 was moved to another room. The facility's policy on abuse prevention was not effectively implemented to protect residents from abuse by other residents. The Director of Nursing (DON) and the Unit Manager (UM) acknowledged the deficiencies in care and communication. The DON confirmed that the resident should have been sent to the hospital earlier and that the facility failed to notify the physician about the lack of an ultrasound technician and the resident's declining condition. The UM admitted that the facility should have monitored pedal pulses daily for a suspected DVT and that the resident's increasing pain and discoloration were indicative of loss of blood flow. The facility's failure to provide timely and appropriate care resulted in significant harm to Resident #305 and inadequate protection for Resident #122 from abuse by another resident.
Failure to Investigate Missing Money Report
Penalty
Summary
The facility failed to investigate a resident's report of missing money according to its policy. Resident #149, who was admitted with diagnoses including anxiety disorder and homelessness, reported to a CNA that $20 was missing from their wallet shortly after admission. Despite this report, no follow-up was conducted by the facility staff. The resident's clinical record noted the missing money, but the Review and Inventory of Valuable Items was completed seven days after the report and did not include any money in the wallet. The CNA who received the report did not document it and only verbally informed the DON, who was unaware of the issue until the survey team brought it to attention. The DON stated that the correct process would involve documenting the concern as a grievance and having Social Services follow up, which did not occur in this case. The Director of Social Services confirmed that no follow-up had been conducted with the resident or the CNA who received the initial report. The facility's policy on Abuse Investigation and Reporting requires thorough investigation of all reports of misappropriation, including reviewing documentation and interviewing all relevant parties. This process was not followed, leading to the deficiency noted by the surveyors.
Failure to Update Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident with a urinary catheter and a behavior of pulling out the catheter had an updated care plan to include interventions to prevent this behavior. Resident #98, who was admitted with diagnoses including benign prostatic hyperplasia and urinary retention, had pulled out the catheter multiple times since admission, resulting in hospital visits for reinsertion and treatment for hematuria. Despite these incidents, the care plan initiated on 06/03/2024 did not document any interventions to address the resident's behavior of pulling out the catheter. On 06/12/2024, both the LPN and the DON confirmed that the resident had pulled out the catheter for the third time that day and acknowledged the need for documented interventions to prevent this behavior. The LPN noted that the resident previously had a leg strap to secure the catheter, but it was not in place during the incidents. The facility's policy on comprehensive person-centered care plans emphasized the need for ongoing assessments and revisions as the resident's condition changed, which was not adhered to in this case.
Failure to Implement Interventions and Provide Timely Care
Penalty
Summary
The facility failed to implement interventions for a resident with a urinary catheter who had a history of pulling out the catheter, resulting in repeated physical trauma. Despite the resident pulling out the catheter multiple times, the care plan lacked documentation of measures to prevent this behavior. Observations and interviews revealed that the resident did not have a leg strap or a StatLock in place, which were previously used to secure the catheter. The Director of Nursing confirmed the need for documented interventions to prevent the resident from pulling out the catheter again. The facility also failed to provide timely care for a resident with a suspected deep vein thrombosis (DVT). The resident exhibited symptoms such as bluish discoloration and cold, clammy skin on the right lower extremity. Although an ultrasound was ordered, it was not performed due to the unavailability of an ultrasound technician. The resident's condition worsened, but the facility did not send the resident to the hospital promptly. The Director of Nursing and the Unit Manager acknowledged that the resident should have been sent to the hospital earlier and that pedal pulses should have been monitored daily. Additionally, the facility did not communicate a hospice physician's order for a resident to the facility's physician, resulting in the resident not receiving the ordered medication. The hospice order for Potassium Chloride ER was scanned into the resident's clinical record but was not entered into the electronic medical record (EMR) or the Medication Administration Record (MAR). The Director of Nursing confirmed that the order was not communicated to the facility's physician and was not administered as required. The facility lacked a designated hospice coordinator, leading to communication gaps between hospice and facility staff.
Failure to Adhere to Weight Monitoring Policy
Penalty
Summary
The facility failed to ensure that two residents were weighed according to the facility's policy. Resident #37, who had diagnoses including type II diabetes mellitus, unspecified dementia, and adult failure to thrive, was not weighed monthly as required. The resident's weight records showed significant fluctuations, and there was no documented weight for August 2023. The clinical record lacked evidence of any weight measurements between November 2023 and June 2024. Despite a significant weight gain noted in October 2023, no follow-up weights were documented, and the resident was not weighed for over six months. The facility's staff, including an LPN, RN, RD, and the DON, confirmed the failure to adhere to the monthly weighing policy and the absence of documented reasons for not weighing the resident, such as resident refusal. Resident #143, who had diagnoses including acute duodenal ulcer with hemorrhage and age-related cognitive decline, also experienced a failure in weight monitoring. The resident was supposed to have weekly weights for four weeks and then monthly if stable, as per physician's orders. However, the resident's weight records showed only one weight measurement since admission, which indicated a drastic and questionable weight loss of 71 lbs. The RD used a hospital weight as a baseline instead of obtaining a new admission weight, and despite the significant weight loss, weekly weights were not performed as ordered. The DON and RD confirmed the failure to follow the weight monitoring orders and the lack of follow-up on the weight monitoring. The facility's policy on Weight Assessment and Intervention required residents to be weighed upon admission, the following day, and weekly for two weeks, with monthly weights thereafter if no concerns were identified. Any weight change of 5% or more required re-weighing the following day for confirmation. The policy also mandated immediate notification of the RD for significant weight changes. The facility staff failed to adhere to these policies for both residents, leading to deficiencies in weight monitoring and documentation.
Late Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for one of the two CNAs employed for more than one year. Employee #8, who was hired on 05/18/2022, had their last performance evaluation documented on 07/11/2023. However, the annual performance evaluation was due by 05/18/2023. During an interview on 06/11/2024, the Human Resources Manager and Regional Human Resources confirmed that the annual performance evaluation for Employee #8 was completed late, failing to adhere to the facility's policy that mandates annual reviews from the date of employment.
Failure to Ensure Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that ordered medications were available and administered for a resident with chronic pancreatitis, chronic pain, and muscle spasms. The resident reported running out of medication for muscle spasms and pancreatitis, which exacerbated their chronic pain. The physician had ordered Cyclobenzaprine for muscle spasms and Creon for chronic pancreatitis, but the resident missed several doses of both medications in May 2024 due to the facility's failure to reorder them in a timely manner. A Registered Nurse confirmed that the resident missed multiple administrations of both medications and that the medications had to be reordered from the pharmacy. The facility's policy required medications to be reordered at least three days before running out, but there was no evidence that this was done. The Director of Nursing confirmed the missed doses and acknowledged that the medications were not reordered within the required timeframe, as per the facility's policy.
Failure to Ensure Timely Ultrasounds Due to Lack of Technician
Penalty
Summary
The facility failed to ensure timely ultrasounds for residents due to the contracted diagnostics company not having an ultrasound technician available for onsite visits. The Administrator was unsure when first notified about the issue, possibly at the end of April 2024, and could not provide documented evidence that the lack of an ultrasound technician was addressed or that any direction was given to the nursing staff. The Director of Nursing (DON) was aware of the issue and had instructed to send residents to the hospital for ultrasounds when working in the Rehabilitation Department before becoming the DON. However, the DON was not aware if the nursing staff had been informed of this need prior to their tenure as DON. The facility's Quality Assurance and Performance Improvement (QAPI) Program policy indicated that the committee would oversee the implementation of the QAPI Plan and identify and correct quality deficiencies, but this was not effectively demonstrated in this instance.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure that the medical records for two residents were complete and in accordance with physician orders. Resident #143, who was admitted with diagnoses including acute duodenal ulcer with hemorrhage and age-related cognitive decline, had physician orders for weekly weight measurements. However, the clinical record showed only one weight measurement for April and May 2024, missing several required weekly weights. The Director of Nursing (DON) confirmed that the resident should have been weighed weekly for four weeks and then monthly if stable, but this was not done. The Registered Dietician (RD) also confirmed that the weekly weights had not occurred as ordered. Resident #205, admitted with diagnoses including unspecified protein-calorie malnutrition and dysphagia following cerebral infarction, had physician orders for gastrostomy tube (G-Tube) flushes. The Treatment Administration Record (TAR) and Medication Administration Record (MAR) lacked documented evidence that the G-Tube was flushed per the physician orders on multiple occasions. The DON confirmed the absence of documentation for the G-Tube flushes as required by the physician orders. The facility's policy on Charting and Documentation required that medications administered and treatments performed be documented in the resident's clinical record, which was not adhered to in these cases.
Failure to Address Lack of Ultrasound Technician
Penalty
Summary
The facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify that the contracted diagnostics company lacked an ultrasound technician, resulting in a delay for a resident with a physician's order for an ultrasound. The Administrator was unsure when they were first notified about the lack of an ultrasound technician but believed it was possibly at the end of April 2024. The Administrator could not provide documented evidence that the issue was addressed or that any direction or instruction was given to the nursing staff. The Director of Nursing (DON) was aware of the lack of an ultrasound technician and had instructed to send residents to the hospital for ultrasounds if needed. However, the DON was not aware if the nursing staff had been informed of this need prior to becoming the DON. The facility's policy stated that the QAPI committee would oversee the implementation of the QAPI Plan and identify and correct quality deficiencies, which was not done in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented when providing care to a resident's jejunostomy tube (J-tube). Specifically, a Licensed Practical Nurse (LPN) did not wear a gown or gloves while disconnecting the tube feeding from the resident's J-tube, despite a sign outside the resident's room indicating the need for EBP. The LPN confirmed the requirement for gown and gloves and acknowledged the failure to adhere to the precautions. The resident's care plan also documented the need for EBP due to the presence of the J-tube, with interventions including EBP per facility policy. The Director of Nursing (DON) explained that gown and gloves were required for residents with feeding tubes to prevent the introduction of bacteria and potential infections. The facility's Infection Prevention and Control Program (IPCP) policy stated that EBP served to reduce the transmission of multidrug-resistant organisms (MDRO) and applied to residents with indwelling medical devices. The policy required staff to wear a gown and gloves when performing high-contact resident care activities, including indwelling medical device care.
Failure to Prevent Resident Elopement Due to Alarm Malfunction
Penalty
Summary
The facility failed to provide protective supervision for a resident who was at risk of elopement. The resident, who had a history of wandering and was wearing a Wanderguard device, followed a Certified Nursing Assistant out of an alarmed exit door. The alarm system failed to activate, allowing the resident to wander into the parking lot. This incident was discovered when the resident's significant other found them outside and brought them back into the facility. The resident's care plan had identified them as an elopement risk and included interventions such as one-on-one supervision and the use of a Wanderguard device to alert staff of any attempts to exit the building. The Director of Nursing (DON) confirmed that the elopement was preventable and explained that all staff were trained annually on elopement prevention. The facility's policy required staff to prevent residents from leaving the premises and to report any such attempts to a nurse. However, the investigation revealed that the alarm system had malfunctioned at all exits, and the maintenance team had not detected this issue during their weekly checks. The Administrator confirmed that the alarm system was replaced following the incident.
Resident Dignity Compromised by PT's Verbal Confrontation
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #9, who was admitted with diagnoses including hydrocephalus and difficulty walking. An incident occurred where a Physical Therapist (PT) was reported to have verbally berated the resident at the nurse's station. The resident expressed that the interaction was a misunderstanding but noted that the PT's demeanor needed to be gentler. The resident's comprehensive care plan highlighted the risk for loss of dignity due to stern instructions from staff and included measures to maintain dignity, such as notifying the physician and next of kin if instructions were perceived as harsh. During a subsequent interview, the resident recounted being confronted and yelled at by the PT for walking around the facility, which led to the resident breaking down into tears and feeling disrespected and embarrassed in front of others. A Registered Nurse (RN) corroborated the resident's account, stating that the PT forcefully escorted the resident back to their room, preventing them from picking out a book. The RN reported the incident to the Administrator and Director of Nursing (DON), and the resident expressed a desire to leave against medical advice rather than work with the PT again.
Verbal Abuse Incident Involving RN and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Registered Nurse (RN), who was witnessed verbally berating a resident at the nurse's station. The incident involved Resident #7, who was admitted with diagnoses including unspecified chronic bronchitis, severe protein-calorie malnutrition, and depression. The verbal abuse was reported by a Certified Nursing Assistant (CNA) and a family member of another resident, who observed the RN cursing and throwing medication bottles around the nurse's station, with comments directed at Resident #7. The Director of Nursing (DON) was notified of the incident and initiated an investigation. The RN was immediately suspended and later terminated due to misconduct. Despite the trauma screening conducted on Resident #7, which did not indicate psychosocial harm, the investigation was deemed incomplete. The Administrator acknowledged that the investigation lacked interviews with all involved parties, including Resident #19 and another resident mentioned by the CNA, and the statement from Resident #19's family member was not included in the Facility Reported Incident (FRI) documentation. The facility's policy on abuse investigation and reporting requires thorough investigation and documentation of all reports of resident abuse, including interviews with witnesses. However, the investigation into this incident did not meet these standards, as not all witnesses were interviewed, and the documentation was incomplete. The RN had a history of disciplinary action for verbal misconduct, which was not adequately addressed prior to this incident.
Failure to Investigate and Report Abuse Allegation
Penalty
Summary
The facility failed to implement its policy on abuse investigations and reporting, as evidenced by an uninvestigated and unreported allegation of abuse involving a resident. The resident, who had been admitted with chronic congestive heart failure, type 2 diabetes mellitus with diabetic neuropathy, and anxiety disorder, reported to an Adult Protective Services (APS) Social Worker that a Certified Nursing Assistant (CNA) had handled them roughly and slapped them on the cheek. Despite being informed of this allegation by the APS Social Worker, the facility's Administrator and Director of Nursing (DON) did not investigate the claim or report it to the State agency or law enforcement, citing the resident's history of unfounded allegations as the reason for inaction. The facility's policy, adopted in 2019, mandates that all reports of resident abuse be promptly reported and thoroughly investigated, with any accused employee being suspended pending the investigation's outcome. However, the Administrator and DON admitted that the abuse allegation was not investigated, and the CNA continued to work directly with the resident after the allegation was made. This failure to act according to the established policy placed the resident at continued risk of physical abuse by the staff member.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse against a resident by a staff member within the required two-hour time frame. The incident involved a resident who had been admitted with chronic congestive heart failure, type 2 diabetes mellitus with diabetic neuropathy, and anxiety disorder. The resident reported to an Adult Protective Services (APS) Social Worker that a Certified Nursing Assistant (CNA) had handled them roughly and slapped them on the cheek. This information was communicated to the facility's Administrator by the APS Social Worker. Despite being informed of the allegation, the Administrator and the Director of Nursing (DON) did not report the incident to the State agency or law enforcement, nor did they conduct an investigation. The Administrator justified the inaction by citing the resident's history of unfounded allegations. However, the facility's policy required all new allegations of abuse to be investigated and reported promptly. The failure to adhere to this policy resulted in a deficiency, as the facility did not ensure the allegation was reported and investigated as mandated.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident who claimed a CNA slapped and handled them roughly. Despite being informed of the allegation by an APS Social Worker, the facility did not suspend the CNA or report the incident to the State Survey Agency or law enforcement. The CNA continued to work with the resident and others in the facility, which posed a risk of further abuse. The facility's policy required immediate suspension of any employee accused of abuse and a thorough investigation, which was not followed in this case. Another incident involved a Registered Nurse allegedly verbally abusing a resident at the nurse's station. The incident was witnessed by a CNA and a family member of another resident. The RN was reportedly cursing and throwing medication bottles, which was overheard by a family member who expressed concern. The facility's investigation into this incident was incomplete, as not all involved parties were interviewed, and the family member's statement was not included in the investigation documentation. The Administrator and DON shared responsibility for abuse investigations but failed to conduct thorough investigations in both cases. The lack of complete documentation and interviews with all involved parties led to an incomplete investigation, which was acknowledged by the Administrator. The facility's failure to adhere to its own policies and procedures for handling abuse allegations resulted in deficiencies in protecting residents from potential harm.
LPN Medication Administration Competency Deficiency
Penalty
Summary
The facility failed to ensure that an LPN had the necessary competencies to safely perform medication administration. During an observation, the LPN was found to have premixed doses of Polyethylene Glycol 3350 (MiraLAX) in clear plastic cups and left them on top of the medication cart. These cups, containing a clear liquid, were indistinguishable from plain water and were left unattended in the hallway, posing a risk of being ingested by other residents or visitors. The LPN continued to leave the cups on the cart while attending to residents in their rooms, indicating a lack of proper medication administration practices. The Director of Nursing (DON) confirmed that medications should not be left on top of the medication cart and should be prepared for one resident at a time, not premixed. Furthermore, the facility did not have competency checklists for new nurses, nor did it have a medication administration competency checklist for the LPN involved. This lack of oversight and training contributed to the deficiency observed during the survey.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered, resulting in a medication error rate of 100%. A resident was found with two medication cups at their bedside, containing a total of ten medications that were supposed to be administered at specific times. These medications were documented as administered in the Medication Administration Record (MAR), despite the resident not having taken them. The medications included Baclofen, Buspirone HCl, Melatonin, Senokot S, Simvastatin, Lisinopril, and Venlafaxine, which were left unsupervised at the resident's bedside. The Licensed Practical Nurse (LPN) confirmed that the medications should not have been documented as administered if the resident had not taken them and acknowledged that leaving medications at the bedside was against protocol. The physician emphasized that medications should be given at the ordered time to avoid high-risk practices and potential drug interactions. The facility's policy on medication administration, which aligns with the National Institute of Health's five rights of medication administration, was not followed, leading to this deficiency.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure proper storage and supervision of medications, specifically a laxative powder dissolved in water, which was left unattended on top of a medication cart. An LPN was observed administering medications on the 400 hall, where three cups containing a clear liquid, identified as MiraLAX, were left on the cart. The LPN admitted to premixing the doses and acknowledged that the cups could be mistaken for plain water, posing a risk of ingestion by other residents or visitors. The cups remained unattended on the cart while the LPN entered various rooms, contrary to the facility's policy that medications should be prepared for one resident at a time and not premixed. Additionally, the facility did not secure medication carts, leaving them unlocked and unattended in the 300/400 hall. This was observed when a medication cart was left unlocked, allowing staff, residents, and visitors to pass by it. An RN later noticed the unlocked cart and confirmed that it should have been secured, especially given the presence of residents with dementia who could access the medications. Another instance involved a different LPN who also left a medication cart unlocked, acknowledging their responsibility for securing it. These actions violated the facility's policy on medication storage and security.
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.
