Canyon Vista Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 6352 Medical Center Street, Las Vegas, Nevada 89148
- CMS Provider Number
- 295093
- Inspections on file
- 27
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Canyon Vista Post Acute during CMS and state inspections, most recent first.
The facility did not have a defined time frame in its Release of Information policy for providing medical records when requested. A home health agency made two requests for a resident's records, which were eventually sent electronically, but there was no documentation of the requests or calls, and the policy lacked specific processing time frames.
A resident with multiple serious diagnoses was discharged without receiving a documented medication list or education about their medications. Staff interviews confirmed that it was the nurse's responsibility to provide and review discharge instructions, including medications, but no documentation was available to show this occurred, in violation of facility policy.
The facility failed to enforce its non-smoking policy and remove smoking materials from residents, posing a fire hazard. A resident was found with a lighter and cigarettes, attempting to dispose of a used cigarette in a trash can with combustible materials. Another resident, a documented smoker with an oxygen concentrator, was involved, and a third resident admitted to smoking with the first resident. The facility did not have smoking care plans for these residents, despite their histories of substance dependence and mental health issues.
The facility failed to properly label and discard opened food items in the refrigerator and freezer, as observed by a surveyor and confirmed by the Director of Dietary Services. Items such as chopped onions, a half-cut tomato, and canned fruits were not labeled or dated correctly, and an undated chocolate cream pie was improperly stored. The dietary staff were responsible for ensuring proper labeling and timely discarding of opened items, as per facility guidelines.
The facility failed to implement baseline care plans for residents within 48 hours of admission. Four residents who smoked did not have smoking care plans, despite documentation of tobacco use. Two residents with language barriers lacked communication care plans, hindering effective communication. Additionally, a resident with an IV catheter did not have a care plan, increasing infection risk. The DON acknowledged these oversights, which were confirmed through interviews and record reviews.
The facility did not develop smoking care plans for three residents identified as tobacco users, despite their MDS assessments indicating current tobacco use. The facility's non-smoking policy led to the assumption that such care plans were unnecessary, resulting in a lack of documented focus, goals, and interventions for these residents, who had significant medical histories.
The facility failed to respond promptly to call lights, affecting multiple residents. A resident waited over an hour for pain medication after activating the call light, while another resident's cries for help were ignored for 15 minutes. Staff acknowledged issues with the call light system and ongoing QAPI projects to address response times.
A resident with acute kidney failure and obstructive uropathy had a Foley catheter that did not match the physician's order, leading to a deficiency. The physician ordered a 14 French catheter, but a 16 French catheter was used instead. This discrepancy was confirmed by an LPN and the ADON, highlighting the importance of following orders to prevent complications.
A resident experienced severe weight loss without a nutritional assessment or interventions upon admission, despite being cognitively intact. The facility's policies on nutritional assessment and weight intervention were not followed, leading to a lack of documented evidence of a nutritional care plan or dietary consultation.
A facility failed to follow tube feeding orders for a resident with dysphagia, resulting in a significant discrepancy in the total dose volume consumed. The resident, at risk for malnutrition, was observed with the enteral pump turned off during the day, despite orders for nocturnal feeding. The RD and LPN confirmed a shortage of 1269 mL and 1800 calories over 72 hours, impacting wound healing and recovery. The RN and DON acknowledged the lack of monitoring and documentation of the resident's nutritional intake.
The facility failed to obtain physician's orders and document IV access for two residents, leading to prolonged use of IV sites without proper monitoring or assessment. One resident had an IV heplock in place for 10 days without documentation, while another had a peripheral IV access for 11 days without orders or monitoring. Facility policies required orders and documentation, which were not followed, increasing infection risk.
The facility failed to consistently assess, manage, and document pain management for two residents, leading to inadequate pain relief. One resident, post-back surgery, reported severe pain and insufficient medication, with no documented assessments in the eMAR. Another resident, with a history of gout and diabetes, experienced severe pain and distress, with delayed response and undocumented medication administration. Staff interviews confirmed the lack of adherence to pain management policies, resulting in unrelieved pain and discomfort.
The facility exceeded the acceptable medication error rate with two errors during a medication pass. One resident received an incorrect dosage of Folic Acid, while another had their Cardizem withheld due to a misunderstanding of blood pressure parameters. The LPN involved acknowledged the errors, and the DON emphasized the importance of following medication administration guidelines.
The facility failed to maintain a functional call light system in the 200 hall, leading to delayed responses to residents' needs. A resident waited 25 minutes for assistance due to a malfunctioning system that produced a constant alarm sound, masking actual alerts. The issue was not reported in the maintenance log, and the facility lacked a specific policy for call light system maintenance.
Lack of Defined Time Frame for Release of Medical Records
Penalty
Summary
The facility failed to ensure its Release of Information policy included a defined time frame for providing resident medical records upon request. A home health agency requested medical records for a resident on two occasions, with the first request made on 05/01/2025 and a second on 05/20/2025. The records were sent electronically on 05/20/2025 and 05/21/2025. The Medical Records Director stated that records would not be released without a request and that staff typically documented the portion of the record provided, but was unsure if other staff had documented the requests. There were no documented requests or phone calls from the home health agency regarding the resident, and fax cover sheets and written requests were only kept for 30 days. Review of the facility's Release of Information policy revealed it lacked documented time frames for processing such requests.
Failure to Provide Discharge Medication List and Education
Penalty
Summary
The facility failed to provide a copy of the discharge medication list and education about the medications to a resident upon discharge. The resident, who had been admitted with acute respiratory failure, chronic obstructive pulmonary disease, local infection of the skin and subcutaneous tissue, and sepsis, was discharged without documentation showing that a medication list or medication education was given. Interviews with facility staff, including a registered nurse, social services assistant, and the Director of Nursing (DON), confirmed that it was the nurse's responsibility to review and educate the resident on their discharge medications and instructions, and to ensure the resident understood and signed the discharge instructions. However, no such documentation was available for this resident. Review of the facility's policy titled Discharge Planning indicated that the nursing department was responsible for assessing and coordinating health and medical education needs, and that the discharge packet should include a medication list and prescriptions. The former DON also confirmed that there should have been documentation of medications provided and education given to the resident at discharge. The lack of documentation and education regarding discharge medications constituted a deficiency in the facility's discharge process for this resident.
Failure to Enforce Non-Smoking Policy and Remove Smoking Materials
Penalty
Summary
The facility failed to ensure that interventions were implemented to identify hazards and risks associated with smoking for three residents. Resident 14 was found with a lighter and cigarettes in their room, and attempted to dispose of a used cigarette in a trash can containing combustible materials. Despite being informed of the non-smoking policy, Resident 14 refused to relinquish the smoking materials. The resident had a history of schizophrenia, depression, and suicidal ideations, and was moderately impaired with a BIMS score of 12. The Comprehensive Care Plan did not include a smoking care plan for Resident 14. Resident 34, who was a documented smoker with an oxygen concentrator in their room, was also involved. The resident was observed to have smoked in the courtyard and main entrance with other residents. Despite the potential fire hazard posed by the oxygen concentrator, there was no documented evidence of a smoking care plan for Resident 34. The resident had a history of psychoactive substance dependence, alcohol dependence, and nicotine dependence, and was moderately impaired with a BIMS score of 12. Resident 116 was found with a lighter in their possession and admitted to smoking with Resident 14. The facility had recently put up non-smoking signs and instructed residents to smoke off property, but Resident 116 indicated they were not informed of the non-smoking policy upon admission. The resident was cognitively intact with a BIMS score of 14 and had a history of depression and opioid dependence. The facility's failure to enforce the non-smoking policy and remove smoking materials from residents posed a significant fire hazard, especially with the presence of residents on oxygen.
Improper Food Labeling and Storage in Facility
Penalty
Summary
The facility failed to ensure that opened items in the refrigerator and freezer were properly labeled and discarded upon expiration, as per policy. During an inspection, a surveyor, along with the Director of Dietary Services, observed several items in the walk-in refrigerator and freezer that were not labeled or dated correctly. These included a large bin of chopped onions with an outdated label, a half-cut large tomato wrapped in plastic without a label, and a large plastic bin of canned fruits that was unlabeled. Additionally, an undated chocolate cream pie in the freezer had been opened and cut in half without proper labeling. The Director of Dietary Services confirmed these observations and acknowledged that the dietary staff were responsible for ensuring that partially used or opened items were labeled, dated, and discarded in a timely manner. The facility's guidelines and policies required that all foods stored in the refrigerator or freezer be covered, labeled, and dated, with specific timelines for discarding opened items.
Failure to Implement Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans for several residents within 48 hours of admission, as required by their policy. Four residents who were identified as smokers did not have smoking care plans in place, despite their tobacco use being documented in their medical records. The Director of Nursing (DON) acknowledged that smoking care plans should have been developed, even though the facility had a smoke-free policy. This lack of care planning was confirmed through interviews with the residents and the DON. Two residents with communication deficits due to language barriers also lacked appropriate baseline care plans. One resident, whose primary language was Mandarin, did not have a communication board or any documented interventions to address the language barrier. Another resident, who spoke only Spanish, was unable to communicate effectively with staff who spoke only English. The DON confirmed that care plans addressing these communication barriers were not developed, which hindered effective communication with these residents. Additionally, a resident with a peripheral intravenous (IV) catheter did not have a care plan in place for the IV access. The resident was observed with an IV access that was not properly documented or managed, increasing the risk of infection. The Infection Preventionist and the DON acknowledged the oversight, noting that a care plan should have been developed to manage the IV access, including regular dressing changes and physician orders. This deficiency in care planning was recognized as a risk for potential complications due to infections.
Failure to Develop Smoking Care Plans for Tobacco-Using Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents who were identified as tobacco users. Despite the residents' tobacco use being documented in their Minimum Data Set (MDS) assessments, the facility did not create smoking care plans that included focus, goals, and interventions. This oversight was noted for three residents, each with significant medical histories, including schizophrenia, depression, psychoactive substance dependence, and opioid dependence. The absence of these care plans was attributed to the facility's policy of being non-smoking, which led to the assumption that smoking care plans were unnecessary. The MDS Coordinator and the Director of Nursing (DON) acknowledged the lack of smoking care plans, despite the MDS indicating current tobacco use. The facility's policy on comprehensive, person-centered care plans requires measurable objectives and timeframes, services to maintain the resident's well-being, and reflection of recognized standards of practice. However, the facility did not adhere to this policy for the residents in question, as no smoking care plans were developed, potentially depriving them of necessary interventions.
Delayed Response to Call Lights in Facility
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner, affecting one sampled resident and two unsampled residents. On February 26, 2025, a call light in a resident's room was activated at 8:38 AM, but it was not answered until 9:03 AM, despite staff being present in the vicinity. The resident had activated the call light to request an adjustment to the room temperature. A CNA eventually responded, acknowledging that call lights were everyone's responsibility, but it seemed that only CNAs were expected to answer them. An LPN at the nursing station noted that the call light system had been malfunctioning since February 24, 2025, causing a constant alarm sound that masked the real call light alarm, and it was unclear if the issue had been reported to maintenance. Another incident involved a resident, identified as Resident 17, who was observed in distress at the nursing station on the 100 hall. The resident, who had a history of gout, type 2 diabetes mellitus with hyperglycemia, and spondylosis, reported severe pain and had activated the call light over an hour earlier to request pain medication. Despite the presence of four staff members at the nursing station, the resident's request was not acknowledged until a nurse approached and administered pain medication. The nurse stated that no one had reported the resident's pain to them. Additionally, on March 6, 2025, a resident in a room across from the 200-hall nursing station was heard emitting loud cries for help, which were ignored by passing staff members. The cries continued for approximately 15 minutes before a staff member attended to the resident. A Resident Council Log from January 15, 2025, documented a resident's complaint about delayed responses to call lights, and a subsequent meeting response indicated that education was provided to staff on the importance of timely call light responses. The Director of Nursing and the Administrator acknowledged ongoing Quality Assurance and Performance Improvement (QAPI) projects related to call light response times.
Failure to Follow Physician's Order for Foley Catheter Size
Penalty
Summary
The facility failed to ensure proper assessment and documentation of a Foley catheter for a resident, leading to a deficiency. The resident, who was admitted with acute kidney failure and obstructive uropathy, had a Foley catheter in place that was not in accordance with the physician's order. The physician had ordered a 14 French catheter with a 10 ml water balloon, but the resident had a 16 French catheter instead. This discrepancy was confirmed by an LPN and the Assistant Director of Nursing (ADON), who noted that the catheter size should match the physician's order to prevent potential trauma or leakage. The facility's documentation consistently indicated the use of a 14 French catheter, despite the actual use of a 16 French catheter. The ADON and the physician both emphasized the importance of following the physician's order for catheter size to avoid complications. The facility's policy on catheter care, revised in August 2022, required accurate documentation of catheter assessments, including urine characteristics, to prevent complications such as urinary tract infections. However, the failure to adhere to the physician's order and accurately document the catheter size in the medical record led to the identified deficiency.
Failure to Conduct Nutritional Assessment and Address Severe Weight Loss
Penalty
Summary
The facility failed to conduct an impaired nutrition assessment or a comprehensive nutritional assessment for a resident upon admission, which led to a lack of interventions for severe weight loss. The resident, who was cognitively intact, experienced a significant weight loss of 35.70 pounds, equating to a 12.80% decrease, over a period from early July to early August. Despite the facility's policy requiring a nutritional assessment upon admission, there was no documented evidence of such an assessment or a nutritional care plan in the resident's comprehensive care plan. The Registered Dietician confirmed the absence of a nutritional assessment and interventions for the resident's weight loss, which should have prompted a dietary consultation. The Director of Nursing and the Director of Staff Development acknowledged the lack of documentation regarding a change of condition or dietary consultation. The facility's policies on nutritional assessment and weight intervention were not followed, as there was no evaluation or intervention for the resident's undesirable weight change, which was necessary to address the resident's nutritional needs and potential causes of weight loss.
Failure to Follow Tube Feeding Orders and Monitor Nutritional Intake
Penalty
Summary
The facility failed to ensure that the tube feeding order for a resident with dysphagia and a gastrostomy was followed, leading to a significant discrepancy in the total dose volume consumed. The resident, who had a history of aspiration pneumonia and was at risk for malnutrition, was observed with the enteral pump turned off during the day, despite orders for nocturnal feeding. The Registered Dietitian and Licensed Practical Nurse confirmed that the total dose delivered over 72 hours was significantly less than ordered, resulting in a shortage of 1269 mL and 1800 calories, which was significant for the resident's wound healing and recovery. The Registered Nurse and Director of Nursing acknowledged that the tube feeding should have been monitored to ensure completion, but there was no documentation of the total dose consumed. The facility's policy required adequate nutritional support through enteral nutrition, but the staff failed to monitor and document the resident's nutritional intake as ordered. The Director of Nursing attributed the resident's significant weight loss to multiple factors, including a history of Clostridium difficile and family interference, but confirmed that the actual dose of tube feeding consumed was not documented.
Failure to Obtain Physician's Orders and Document IV Access
Penalty
Summary
The facility failed to obtain a physician's order for the use of intravenous (IV) access or heplock for two residents, Resident 104 and Resident 325, and did not properly assess, monitor, or document the IV sites. For Resident 104, who was admitted with diagnoses including anemia and malignant neoplasm of the rectum, an IV heplock was observed to be 10 days old, soiled, and not documented in the medical record until 10 days after insertion. The charge nurse and Assistant Director of Nursing confirmed the lack of documentation and the failure to change the IV heplock every two to three days as required to prevent infection. Resident 325, admitted with diagnoses including bipolar disorder and acute respiratory failure, had a peripheral IV access on the left hand that was covered with an adhesive transparent dressing dated 11 days prior to observation. The resident's medical record lacked documentation of whether the IV access was present upon admission or inserted afterward, and there were no physician orders for placement, monitoring, or discontinuation. The IV nurse confirmed the IV access was used only once for a Banana bag administration and had not been monitored or assessed since. The facility's policies on Peripheral IV Catheter Insertion and Removal required a provider's order and documentation of the procedure, including the condition of the IV site and the resident's response. The Director of Nursing acknowledged the lack of documentation and orders, which increased the risk of infection and complications for the residents. The Infection Preventionist also noted the failure to identify and assess IV access upon admission and the need for regular dressing changes to prevent infection.
Inadequate Pain Management and Documentation for Two Residents
Penalty
Summary
The facility failed to consistently assess, manage, and document pain management for two residents, leading to inadequate pain relief. Resident 273, who had undergone back surgery and was experiencing severe pain, reported that requests for pain medication were ignored, and the pain medication provided was insufficient. The facility's policy required pain to be assessed every 30-60 minutes after onset, but there was no documented evidence of such assessments or reassessments in the electronic Medication Administration Record (eMAR). Staff interviews confirmed that the pain assessments were not consistently conducted or documented, and the system-generated prompts for follow-up were not adhered to. Resident 17, who had a history of gout, diabetes, and spondylosis, was observed in visible distress and reported severe pain to staff at the nursing station. Despite activating the call light over an hour prior, the resident's pain was not addressed until later, and the administration of pain medication was not documented in the eMAR. The facility's policy required documentation of medication administration and reassessment of pain within 30-60 minutes, but these steps were not followed, as confirmed by the Director of Nursing and other staff members. The lack of consistent pain assessment and documentation for both residents highlights a failure to adhere to the facility's pain management policies. This deficiency resulted in unrelieved pain and discomfort for the residents, as their pain levels were not adequately monitored or managed according to the established protocols. The staff's failure to document and reassess pain management interventions contributed to the inadequate care provided to the residents.
Medication Error Rate Exceeds 5% Due to Dosage and Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during a medication pass, resulting in an 8% error rate. This was observed through 25 medication administration opportunities, where two errors were identified. One error involved a resident who was prescribed 1 mg of Folic Acid daily but was administered only 400 mcg. The LPN responsible for the administration acknowledged the mistake, noting that there were two bottles of Folic Acid available and the dosage should have been double-checked. The pharmacist confirmed that the correct dosage was not administered, and the Director of Nursing emphasized the importance of adhering to the resident's rights, including the correct dosage. Another error involved a resident with a prescription for Cardizem 120 mg to be administered daily for hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110. The LPN withheld the medication when the resident's SBP was exactly 110, misunderstanding the parameter. The LPN later confirmed that the medication should have been administered, as the SBP was not below the threshold. The Director of Nursing reiterated the expectation for licensed nurses to follow medication administration parameters and consult the physician if there is any doubt.
Failure to Maintain Functional Call Light System
Penalty
Summary
The facility failed to maintain a functioning call light system in the 200 hall, which compromised the safety and responsiveness to residents' needs. On multiple occasions, the call light in a resident's room was activated but not promptly answered, despite staff being present in the vicinity. The resident expressed discomfort due to the room temperature and had to wait 25 minutes before a CNA responded. The CNA indicated that there was a misunderstanding among staff regarding the responsibility for answering call lights. The call light system had been malfunctioning since 02/24/2025, producing a constant alarm sound that masked the actual call light alerts. This malfunction was not reported in the maintenance log, and the LPN at the nursing station confirmed the issue was not visible from their location. The system's failure was discovered by maintenance staff while addressing an unrelated issue. Additionally, the call light activators in the bathrooms of two other rooms were found to be non-functional, but these issues were not documented in the maintenance log. The facility lacked a specific policy for the call light system's requirements or maintenance, as confirmed by the DON. The Administrator was unaware of the call light system issue until informed during the survey. Staff had been attempting to reset the system by unplugging it, which was ineffective. The absence of a documented policy and the failure to report and address the malfunctioning system contributed to the deficiency, leaving residents at risk of delayed assistance.
Latest citations in Nevada
A resident with multiple medical conditions, including ESBL resistance and neuromuscular bladder dysfunction, was injured when a roommate pushed or slammed a bedside table toward their face during an argument about television volume, causing a cut lip and a loose tooth. The incident occurred in a shared room, involved resident-to-resident physical contact, and required assessment and law enforcement notification, demonstrating a failure to protect the resident from physical abuse.
An unauthorized male intruder repeatedly gained access to the facility through unsecured or inadequately controlled entry points, including following someone into the kitchen, bypassing the front lobby visitor kiosk, and entering through a window that was not fully locked. On one occasion he entered a resident’s room, identified himself as kitchen staff, and stole the resident’s cellphone containing personal identification and financial cards; on other occasions he stole personal items from staff, including a cellphone, wallet, and keys. Door alarms did not sound when he entered during at least one event, and staff initially considered the resident’s report possibly delusional before connecting it to prior and subsequent thefts and video evidence showing the same individual inside the building and on the grounds.
Multiple residents with psychiatric and behavioral histories physically assaulted other residents, including those with impaired cognition and significant medical conditions, resulting in documented injuries such as facial redness, bleeding, skin tears, abrasions, swelling, and periorbital discoloration. In separate episodes, one resident was slapped and nearly burned with a lit cigarette in a smoking area, another was pushed to the floor and kicked after entering a room, and two different roommates were punched on consecutive nights by the same hostile, non-redirectable resident. Facility leadership acknowledged a high behavior population, confirmed these events met the definition of willful infliction of injury and physical abuse, and reported that the aggressors had intact cognition, prior psychiatric hospitalizations, refusal of psychotropic medications, and a history that included homicidal ideation and threats with a weapon.
The facility failed to provide necessary behavioral health services, including trauma evaluations and meaningful interventions, for several residents involved in physical altercations and with significant psychiatric histories. After two residents were physically assaulted by roommates and sustained injuries, psychiatric providers were notified but did not document trauma-focused evaluations or address contributing behaviors such as wandering. Two other residents with schizophrenia, schizoaffective disorder, violent behavior, and documented noncompliance with psychotropic medications were involved in repeated aggressive incidents toward peers and staff, yet records showed only routine refusals of medication without evidence of effective, individualized behavioral interventions. The facility acknowledged a high-behavior population and a pattern of resident altercations, along with dissatisfaction with the psychiatric NP’s limited and delayed evaluations.
Failure to report resident-to-resident physical abuse: A resident with Alzheimer's disease was documented slapping another resident, and the other resident slapped back. The on-call manager was notified, but the incident was not reported to the SA. The DON later stated it was probably mutual combat and the MDS Coordinator, who was the DON at the time, confirmed physical abuse includes hitting and slapping and denied the incident was reported.
A resident with MS and polyneuropathy developed new occasional urinary incontinence after previously being continent, but the care plan did not include a focused care area or interventions to address the change. The resident reported not recalling staff prompting toileting at timed intervals, and the DON confirmed the care plan lacked urinary incontinence interventions and that the facility did not have a bladder training or retraining policy.
Failure to address new urinary incontinence: A resident with MS and polyneuropathy, previously continent of bladder, began having occasional urine incontinence but did not recall staff prompting toileting at timed intervals. The MDS later documented occasional bladder incontinence, yet the care plan had no focused interventions for the change in condition. The CNA was unaware of any bladder training/retraining program, and the DON confirmed the care plan lacked related interventions and the facility had no bladder training/retraining policy.
The facility failed to complete a required annual CNA performance review for one CNA, Employee #8, whose personnel record had no documented evaluation. The HR Director stated CNA evaluations were done each year on Oct. 1 to review the prior year and confirmed this CNA was not reviewed 12 months after starting at the facility. The Facility Assessment stated weaknesses identified in CNA performance reviews and annual competency assessments would be addressed through in-service training.
Facility Assessment did not match actual night shift staffing. The assessment stated Harmony Manor and Quail Corner each required an LPN on nights, with consistent staffing prioritized in the memory care unit, but the April schedule showed both units sharing one licensed nurse on multiple nights. The DON confirmed one nurse was responsible for all 32 residents on those nights and acknowledged the assessment needed to reflect the staffing schedule.
Unsanitary Kitchen Floor Drain: A kitchen floor drain was observed with a buildup of debris and grime, and the Kitchen Mgr confirmed it was dirty and could spread contamination. The Mgr stated floor cleaning was the responsibility of Maintenance, and the Maint Mgr later confirmed the drain had not been recently cleaned and was not sanitary. The facility policy required strict sanitary conditions in Dietary and Nutrition to prevent food contamination and growth of disease-producing organisms.
Failure to Protect Resident From Roommate’s Physical Abuse During Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. The resident was admitted with diagnoses including local infection of the skin and subcutaneous tissue, ESBL resistance, and neuromuscular dysfunction of the bladder. On the evening of 04/10/2026, while in a shared room, the roommate pushed or slammed a bedside table toward the resident during a dispute about the television volume being too loud. The bedside table struck the resident in the face, resulting in a bleeding lip and a loose tooth. The resident reported that the roommate became angry about the television volume and then pushed the bedside table toward their face. Following the incident, the resident was observed with blood on the face and lip, and a loose tooth was noted. The resident declined transfer to the hospital. Law enforcement was contacted, and both residents provided statements to the responding officer, with the injured resident declining to press charges. The roommate later stated that the bedside table had been positioned on the side of the bed and that they were pushing it back toward the other side, claiming they were simply returning the bedside table to its proper place. The facility’s failure to prevent this resident-to-resident physical altercation and resulting injury constituted a failure to protect the resident from physical abuse.
Unauthorized Intruder Repeatedly Accesses Facility and Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment for residents and staff when an unauthorized male intruder repeatedly gained access to the building and entered resident and staff areas, including a resident room. One resident, identified as R94, had been admitted with anxiety disorder, major depressive disorder, and left knee pain, and was alert and oriented at the time of the incident. Around 5:00 AM in December 2025, R94 observed an unknown man enter the resident’s room, state that he was kitchen staff checking the table for breakfast, and then take the resident’s cellphone, which contained a driver’s license, debit card, health insurance card, and bus card. R94 reported that the door alarms did not sound when the man entered the facility and that the resident typically heard alarms when someone entered without using the correct code. After the theft, there were two unauthorized charges on the resident’s debit card. Staff interviews revealed that this was not an isolated security breach. An LPN reported that in December 2025, R94’s report of a man entering the room and taking the cellphone was initially considered possibly delusional due to the resident’s history of seeing a person, but during the same IDT discussion another nurse reported that the day before R94’s report, a stranger had entered the kitchen and stolen a dietary staff member’s iPhone around 5:30 PM. Security camera footage showed the same man entering through a kitchen door by following someone from behind, indicating that he was able to bypass normal access controls. The same individual was later seen twice in the parking lot, and staff contacted police on those occasions. A CNA also recalled interacting with a man who claimed he was there to pick up belongings of a discharged resident and asked for the Wi‑Fi password, which the CNA provided; during the subsequent investigation, this man was identified as the same individual seen on video breaking into the building. The Administrator’s review of the January 24–25, 2026 incident documented that during a night shift, an unauthorized individual gained access by exploiting a window on the south side of the building that was not fully seated in the locked position, allowing him to shimmy the frame open and enter an unoccupied case management office. From there, he exited into the hallway, went to the nurse station, and took a nurse’s wallet and keys. As he attempted to exit through a west door, the door alarm sounded, but he was able to reach a vehicle and flee before staff arrived. The Administrator also confirmed a prior December 24, 2025 security breach in which an unauthorized male bypassed the front lobby visitor kiosk, entered the facility, and went into R94’s room, where he removed the resident’s cellphone and attached personal items from the bedside. Investigation of that December incident showed the individual was not an authorized visitor, family member, or vendor, and that he had been able to enter the building and a resident room without being stopped at the kiosk or by staff. The DON stated that R94’s report was handled as a grievance and resolved, but there were no IDT notes related to the incident, and the Administrator was not aware of the earlier kitchen theft when first discussing the December event.
Failure to Prevent Resident-on-Resident Physical Abuse in High-Behavior Population
Penalty
Summary
The facility failed to protect residents from physical abuse when multiple residents with known psychiatric and behavioral histories physically assaulted other residents on several occasions. In the first incident, one resident with fibromyalgia and an unspecified intracranial injury reported being slapped, cursed at, and nearly struck in the face with a lit cigarette by another resident in the smoking area, resulting in redness to the mandible area and involvement of law enforcement. The aggressor stated the victim was being annoying and deserved the assault. In a separate incident, a resident with moderately impaired cognition and no documented aggressive or wandering behaviors was pushed to the floor and kicked by another cognitively intact resident with schizophrenia and paranoid personality disorder after entering that resident’s room, causing a bleeding nose, a skin tear to the left forearm, and redness of the left forehead. Additional incidents involved a resident with moderately impaired cognition who reported being punched by a roommate, resulting in mild forehead swelling, and another resident with chronic obstructive pulmonary disease, heart failure, and schizoaffective disorder who was punched by the same aggressor after being moved into the room, sustaining discoloration around the left eye socket, a nose bridge abrasion, and a skin tear to the left forehead. Documentation showed that the aggressive resident was screaming violently, hostile, physically aggressive, and non-redirectable toward both residents and staff. The wound care team’s head-to-toe assessments confirmed the physical injuries sustained by the assaulted residents. Interviews with the DON, SSD, and DSD confirmed that these incidents met the facility’s own definition of willful infliction of injury and were classified as physical abuse. The DON stated that the aggressors had intact cognition, histories of inpatient psychiatric stays, and, in one case, a history of homicidal ideation and prior psychiatric hospitalization for chasing a person with a knife and threatening police. Facility leadership acknowledged a high behavioral population, an average of 45 residents with behavioral issues, and identified a pattern of resident altercations and physical abuse. They reported that the aggressors were refusing psychotropic medications and that concerns about psychiatric support, admission screening, and limitations on use of IM psychotropics had been communicated to the psychiatric provider and medical director, but these issues remained unresolved at the time of the incidents.
Failure to Provide Trauma Evaluations and Effective Behavioral Health Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including trauma evaluations, following resident-to-resident physical abuse incidents. One resident with psychosis, schizophrenia, and major depressive disorder was found on the floor with a bleeding nose, a skin tear, and forehead redness after being pushed and kicked by another resident. A psychiatry progress note documented that the psychiatric NP saw the resident per staff request, but the record lacked documentation that the altercation or physical abuse incident was discussed or that the resident’s newly identified wandering behavior, which led to the altercation, was addressed. Another resident with COPD, heart failure, and schizoaffective disorder was punched by a roommate, resulting in discoloration around the eye, a nose bridge abrasion, and a forehead skin tear. Although the care plan for emotional distress included a psychiatry evaluation and the NP was informed of the incident, there was no documented evidence that a psychiatric trauma evaluation was completed. The facility also failed to implement meaningful behavioral health interventions for residents with psychiatric histories, aggressive behaviors, and refusal of psychotropic medications. One resident with schizophrenia and paranoid personality disorder, intact cognition, and a history of violent behavior and homicidal ideation, including chasing a person with a knife and threatening police, was involved in multiple physical altercations. This resident punched another resident in the smoking area and later admitted to pushing and kicking a different resident who entered the room. The care plan identified behavioral problems such as irritability, anger, violent behavior, homicidal ideations, mood swings, and a tendency to push and kick other residents, with interventions including attempts to identify underlying causes. However, the medical record showed the resident routinely refused medications, and there was no documentation of effective, meaningful interventions addressing this ongoing refusal and associated behaviors. Another resident with neuroleptic-induced Parkinsonism, schizoaffective bipolar type, and psychosis, recently transferred from a psychiatric hospital after an exacerbation of schizophrenia symptoms and noncompliance with psychotropic medications, was also involved in a physical altercation. Progress notes documented that this resident punched a roommate, was screaming violently, hostile, physically aggressive, and non-redirectable toward residents and staff. A social services note indicated that when staff attempted to discuss the altercation, the resident became agitated, screamed, yelled, and used inappropriate language, preventing further information gathering. A refusal of treatment form showed the resident had declined medications after being informed that refusal could affect mood stabilization and worsen behaviors. Despite the facility’s acknowledgment of a high-behavior population and multiple resident altercations, the report describes a pattern of inadequate psychiatric support and lack of thorough evaluations and timely, effective behavioral interventions for these residents.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure an incident of resident-to-resident physical abuse was reported to the State Agency for 1 of 12 sampled residents. Resident #10, who was admitted with diagnoses including Alzheimer's disease and episodic tension-type headache, was documented in a nursing progress note as having been seen by a CNA slapping another resident, after which the other resident slapped Resident #10 back. The on-call manager was notified and directed staff to keep the residents apart and maintain them in eyesight if together. A physician progress note later documented that Resident #10 had been involved in a behavioral disturbance in which a heated exchange led to physical aggression between the two residents, with each resident physically striking the other. The DON stated the incident would probably not be considered resident-to-resident abuse because it was mutual combat and said the DON did not know whether either resident had been assessed for pain, injury, or mental anguish. The MDS Coordinator, who was the DON at the time of the incident, confirmed physical abuse includes hitting and slapping, denied being aware of the incident at the time, and denied that it was reported to the SA.
Care Plan Missing Interventions for New Urinary Incontinence
Penalty
Summary
The facility failed to develop a care plan with interventions to assist Resident #24 in maintaining continence after the resident, who had previously been continent, began experiencing occasional urinary incontinence. Resident #24 was admitted and later readmitted with diagnoses including multiple sclerosis and unspecified polyneuropathy. On 04/20/2026, the resident stated they had recently started having occasional urinary incontinence but could still get to the bathroom once they realized they were urinating, and the resident could not recall staff prompting them to toilet at timed intervals. An MDS assessment dated 07/07/2025 documented the resident was always continent of bladder, while an MDS assessment dated 04/06/2026 documented the resident was occasionally incontinent of bladder. The care plan did not include a focused care area or interventions related to the resident’s new urinary incontinence. On 04/22/2026, the DON stated the resident had become increasingly incontinent over the last several months and believed it was related to the resident’s multiple sclerosis. The DON also stated the facility could try offering assistance with a toileting schedule and confirmed the care plan did not include a care area or interventions related to the resident’s urinary incontinence, and that the facility did not have a policy for a bladder training or retraining program.
Failure to Address New Urinary Incontinence
Penalty
Summary
The facility failed to ensure a previously continent resident received assistance or interventions to maintain or improve urinary continence after the resident began experiencing occasional urinary incontinence. Resident #24 was admitted with diagnoses including multiple sclerosis and unspecified polyneuropathy. The resident stated that the resident had recently started having occasional urinary incontinence but could still reach the bathroom once the resident realized the resident was urinating, and the resident could not recall staff prompting bathroom use at timed intervals. Record review showed an MDS dated 07/07/2025 documented the resident was always continent of bladder, while an MDS dated 04/06/2026 documented the resident was occasionally incontinent of bladder. The care plan did not include a focused care area or interventions related to the new urinary incontinence. The CNA stated the resident had begun experiencing incontinence several months earlier and was not aware of any bladder training or retraining program, while the DON stated the resident had become increasingly incontinent over the last several months and that the facility could try a toileting schedule; the DON also confirmed the care plan lacked interventions related to the resident's new urinary incontinence and that the facility did not have a policy for a bladder training or retraining program.
Missing Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure a nurse aide performance review was completed at least once every 12 months and that areas of weakness were identified and addressed for 1 of 2 sampled CNAs, Employee #8. Employee #8 was hired as a CNA on 10/21/2024, and the personnel record lacked documented evidence of a nurse aide performance evaluation. During interview on 04/22/2026, the HR Director stated CNA performance evaluations were completed every year on October 1st to review the prior year and explained that, because of the date of hire, Employee #8 was not reviewed for performance. The HR Director confirmed Employee #8's nurse aide performance review was not completed 12 months after starting at the facility. The Facility Assessment, updated 03/2026, documented that areas of weakness identified in nurse aide performance reviews and annual competency assessments would be addressed through in-service training.
Facility Assessment Did Not Match Night Shift Staffing
Penalty
Summary
The facility failed to ensure its Facility Assessment accurately reflected current staffing needs. The Facility Assessment, updated 03/26/2026, stated the staffing plan included one licensed nurse on night shift for Harmony Manor and one licensed nurse on night shift for Quail Corner, and that consistent staffing would be prioritized in the memory care unit, with staffing levels not adjusted for low census or low acuity so resident needs would be met during call-ins and other staffing shortages. However, the April 2026 staffing schedule showed Quail Corner and Harmony Manor sharing a licensed nurse during night shift on multiple nights. During an interview on 04/24/2026, the DON stated that on Saturday, Sunday, Monday, and Tuesday nights, both units shared one licensed nurse during night shift, and that the nurse was responsible for all 32 residents in the facility. The DON confirmed the Facility Assessment indicated each unit required a licensed nurse during night shift and stated the Facility Assessment needed to be updated to reflect the staffing schedule.
Unsanitary Kitchen Floor Drain
Penalty
Summary
The facility failed to ensure staff maintained sanitary floor drains in the kitchen. On 04/20/2026 at approximately 10:45 AM, a kitchen floor drain was observed with a buildup of debris and grime. At approximately 10:50 AM the same day, the Kitchen Manager confirmed the drain had buildup of grime and acknowledged the potential spread of contamination, and stated that cleaning of the floor was the responsibility of the Maintenance Department. On 04/23/2026 at approximately 9:15 AM, the Maintenance Manager confirmed the kitchen floor drain had not been recently cleaned, was not sanitary, and acknowledged the potential spread of contamination. The facility policy titled, Maintenance of Strict Sanitary Conditions, dated 07/12/2022 and reviewed 07/08/2024, stated that maintaining strict sanitary conditions was of paramount importance in the Dietary and Nutrition Departments to eliminate food contamination and prevent growth of disease producing organisms, and to ensure maximum cleanliness and sanitation in the department.
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