Gardnerville Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gardnerville, Nevada.
- Location
- 1573 South Muller Pkwy, Gardnerville, Nevada 89410
- CMS Provider Number
- 295082
- Inspections on file
- 25
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Gardnerville Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
Two residents with ESBL E. coli UTIs were placed in a shared room under contact precautions, contrary to facility policy and CDC guidelines requiring private room placement for MDRO infections. Despite available private rooms, both residents remained together, and one developed an ESBL UTI after rooming with the other. Staff and documentation confirmed the lapse in infection control practices.
The facility did not follow its own policy and CDC guidelines for infection control, as two residents with ESBL-producing E. coli were placed together in a shared room instead of private rooms, and three residents with wounds or Foley catheters did not have Enhanced Barrier Precautions in place. Staff confirmed the lack of required signage and PPE carts, and acknowledged that the necessary precautions were not implemented.
The facility did not consistently report allegations of abuse, neglect, and serious injury to the State Agency within required time frames. Incidents included verbal and physical abuse by staff, resident-to-resident physical and sexual abuse, and a fall resulting in a hip fracture. Delays in reporting ranged from several days to over a week, contrary to facility policy requiring immediate notification.
A resident with significant neurological diagnoses had their mattress placed on the floor by an LPN without prior device evaluation, physician notification, or obtaining consent from the resident or their representative. This action, which restricted the resident's ability to get up independently, was not communicated to staff or family and was later substantiated as neglect following facility investigation.
A resident with dementia and behavioral disturbances was removed from their room during an episode of agitation and aggression, and left alone in the dining room wearing only a soiled brief and t-shirt. Staff drew back the curtains, exposing the resident to view, and observed from outside the room while the resident continued to display aggressive behaviors. The DON confirmed the resident's dignity was not respected during this incident.
A resident with diabetes and chronic kidney disease was prescribed and administered Eliquis for DVT prophylaxis, but the MDS assessment failed to document the use of this anticoagulant in the appropriate section. The MDS Coordinator confirmed the assessment was inaccurate after reviewing the records.
A resident with newly documented mental health diagnoses was admitted without an updated PASARR Level I or referral for Level II evaluation. Staff interviews revealed a lack of knowledge and training regarding PASARR requirements, and no staff member was overseeing the process, resulting in the facility's failure to follow its own policy for screening and referral.
A resident with chronic obstructive pulmonary disease and congestive heart failure was receiving oxygen therapy, but the care plan did not document the use of oxygen or related diagnoses. Staff observed the resident with varying oxygen delivery and noted the resident often removed the nasal cannula, yet the care plan lacked problems, goals, or interventions for oxygen use and monitoring. The DON confirmed these omissions after reviewing the clinical record.
A resident who required substantial staff assistance for bathing and showering did not receive scheduled showers or baths on multiple occasions, with no documentation of refusals or alternative care provided. The resident reported not receiving regular showers and performed their own bed bath, while staff and the DON confirmed the lack of documentation and missed care.
A resident with COPD and heart failure received oxygen at a higher flow rate than ordered, as staff increased the oxygen from 2 LPM to 2.5–3 LPM without a physician's order or titration instructions. The clinical record did not contain authorization for this change, and facility policy required strict adherence to prescriber orders.
A CNA employed for over one year did not have a documented annual performance review as required by facility policy. The DON confirmed that the evaluation was not completed at the one-year anniversary, resulting in a missed opportunity to identify areas for improvement and training needs.
Two residents did not receive their prescribed medications because the medications were out of stock and not available in the facility, resulting in a medication error rate above 5%. In both cases, RNs identified the missing medications, marked them as 'On Order' from the pharmacy, but did not document physician notification or alternative orders, and the facility lacked a specific policy on medication administration errors.
A multi-dose vial of Tuberculin PPD was found in the medication storage refrigerator without a cap and with a puncture site, but neither the vial nor its box was labeled with the date it was opened, contrary to facility policy and manufacturer instructions. The Infection Preventionist confirmed the vial was open and not dated.
The facility's Facility Assessment was created and implemented solely by the Interim Executive Director without documented review or approval from the QAA Committee or other required leadership. The assessment lacked an attendance sheet and did not follow established procedures for review and input from necessary facility management.
Surveyors found that a nurse administered PRN Acetaminophen to a resident for pain but did not document the administration in the MAR as required by facility policy. In a separate incident, a resident received wound care for a cranial abrasion without a documented physician order, despite the IP stating verbal approval had been obtained. Both deficiencies involved failures in timely and complete documentation of care provided.
The facility did not develop or implement a required Performance Improvement Project (PIP) within the past year. Leadership, including the IED, DON, and LAN, could not provide documentation or details of any PIP, citing loss of access to electronic records after a former administrator's departure. The QAPI committee was not made aware of failures related to reporting abuse, neglect, or other incidents, and there was no evidence of ongoing evaluation of PIPs as outlined in the facility's QAPI Plan.
A resident with chronic health conditions was not offered a timely pneumococcal vaccination to complete the recommended schedule, despite being eligible and having pending immunizations noted in the record. The required vaccine was not administered, and documentation of consent or refusal was missing, contrary to facility policy and CDC guidelines.
A resident with diabetes and hypertension was identified as eligible for the COVID-19 vaccine, but the facility failed to document administration or declination of the vaccine after screening. The clinical record showed only a pending immunization status, and required consent or declination forms were incomplete, resulting in a lack of evidence that the vaccine was offered or given as per facility policy and CDC guidelines.
A resident with severe dementia and behavioral disturbances was removed from their room during an episode of agitation and placed alone in the dining room, wearing only a soiled brief and t-shirt. Staff closed the door, isolating the resident from others and observing through windows, while the resident continued to display aggressive behaviors. Facility documentation and staff interviews confirmed the resident was involuntarily secluded, contrary to policy and resident rights.
A facility failed to ensure an agency CNA completed required elder abuse prevention training upon hire. The CNA was involved in an incident where a resident, exhibiting signs of psychosis, was left in a public area wearing only a t-shirt and soiled brief, visible to others. The CNA's personnel record lacked documentation of abuse training, in violation of facility policy.
A long-term care facility failed to remove expired COVID-19 test kits from a medication room and cart, despite weekly audits by the DON. Additionally, a resident's Oxycodone tablets went missing after an LPN left the medication cart keys unattended, allowing unauthorized access. The facility's policies on medication storage and access were not followed, leading to these deficiencies.
The facility failed to maintain cleanliness of an ice machine, did not discard expired heavy cream, and a staff member neglected hand hygiene protocols during food preparation. The ice machine had a white, flaky substance despite recent maintenance, and expired heavy cream was found in the refrigerator. A staff member entered the trayline without washing hands or changing gloves, contrary to facility policy.
The facility failed to ensure proper infection control practices, including hand hygiene by an Activities Director, who did not sanitize hands between resident contacts. A glucometer was improperly sanitized by an LPN using an incorrect cleaning method. Additionally, unsanitary laundry practices were observed, with a fan blowing air from the dirty to the clean side of the laundry room, and a blanket placed on a floor cleaner to dry. The IP and DON did not oversee these practices, as they were managed by a contracted agency.
A resident was administered Amitriptyline and Buspirone for anxiety without obtaining informed consent as required by facility policy. The medications were given for several days before the necessary consents were signed, contrary to the policy that mandates consents be completed within 48 hours of admission.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately documented bed rails as restraints, despite confirmation from the resident and staff that they were used for mobility. Another resident's MDS did not reflect a DVT diagnosis, although the resident was receiving anticoagulant treatment for it. The MDS Coordinator acknowledged these discrepancies.
The facility failed to develop care plans for two residents with specific conditions. A resident with DVT did not have a care plan despite receiving anticoagulant therapy, and another resident receiving Trazodone for insomnia lacked a care plan for this condition. The DON confirmed that care plans should be created upon admission and updated within 48-72 hours, highlighting a lapse in protocol adherence.
A resident with Parkinsonism and dementia was confirmed to have a DVT and prescribed Eliquis, but the care plan for DVT was not added until 11 months later. The MDS Coordinator backdated the care plan, which was deemed unprofessional conduct by the DON, as per the Nevada Nurse Practice Act.
The facility failed to ensure that two LPNs were trained and certified in CPR, as required by the facility's policy. The personnel records for these LPNs lacked evidence of current CPR certifications. The BOM, responsible for personnel record review, was unsure about the CPR training policy, including certification requirements and frequency.
A resident received acetaminophen outside of physician-prescribed parameters, with pain levels recorded higher than the ordered range. The LPN confirmed the discrepancy, and the DON acknowledged the failure to follow physician orders, as per the facility's medication administration policy.
A resident was administered Trazodone for insomnia without having a corresponding diagnosis. Despite receiving the medication daily, both an LPN and the DON confirmed the absence of an insomnia diagnosis. The facility's policy required a physician's justification for the use of psychotropic drugs, which was not provided in this instance.
The facility failed to offer timely pneumonia and flu vaccinations to residents, as identified through interviews and record reviews. Several residents with conditions like respiratory failure, diabetes, and hypertension were not screened or offered vaccines upon admission or during their stay. The Infection Preventionist confirmed that vaccines were only offered during quarterly clinics, potentially missing residents admitted and discharged between these times.
The facility failed to offer COVID-19 vaccinations to several residents upon admission and did not provide an updated vaccine to one resident. The Infection Preventionist confirmed that vaccines were only offered during quarterly clinics, leading to missed opportunities for vaccination. The facility's policy required offering vaccinations per CDC and FDA guidelines, but documentation was lacking in the residents' medical records.
The facility failed to maintain a safe temperature in the laundry room, which lacked air conditioning for a year. A fan was used to cool staff by blowing air from the dirty to the clean side. The ambient temperature was recorded at 86°F, exceeding the recommended 71-81°F range.
The facility did not ensure annual elder abuse training for a housekeeper, as required by policy. The housekeeper's record showed training in 2023 but lacked evidence for 2024. The BOM confirmed the oversight and expressed uncertainty about training timeframes, despite policy requirements for annual training.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Failure to Isolate Residents with MDRO UTI According to Infection Control Policy
Penalty
Summary
The facility failed to ensure appropriate care and infection control practices for residents with multidrug-resistant organism (MDRO) urinary tract infections (UTIs), specifically Extended-Spectrum Beta-Lactamase (ESBL) producing E. coli. Two residents, both diagnosed with ESBL E. coli UTIs, were placed in a shared room despite facility policy and CDC guidelines recommending private room placement for residents with MDROs. Clinical records and staff interviews confirmed that both residents were on contact precautions, yet continued to share a room for an extended period, even though the facility had available private rooms. One resident, with a history of chronic respiratory failure and chronic kidney disease, tested positive for ESBL E. coli in the urine and was treated with IV antibiotics. This resident was not placed in a private room upon return from the hospital, as required by infection control policy, but instead continued to share a room with another resident. The second resident, with multiple psychiatric and neurological diagnoses, subsequently developed an ESBL E. coli UTI after sharing the room with the first resident. This resident reported being in isolation for approximately one month, which exacerbated existing anxiety. Facility documentation, including infection line listings and staff schedules, confirmed that the two residents shared a room during the period of infection and that staffing levels were sometimes below the facility's stated minimum. The Infection Preventionist and DON acknowledged that the resident with the initial ESBL infection should have been placed in a private room, and that the failure to do so was not in accordance with facility policy or CDC recommendations. The deficiency was further supported by the presence of empty beds in the facility at the time, indicating that private room placement was feasible.
Failure to Implement Transmission-Based and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) according to its own policy and CDC recommendations for several residents. Specifically, two residents with confirmed ESBL-producing E. coli infections in their urine were placed in the same shared room, despite facility policy and CDC guidelines indicating that such residents should be placed in private rooms to prevent the spread of multidrug-resistant organisms (MDROs). Documentation showed that one resident tested positive for ESBL E. coli after sharing a room with another resident who had the same organism, and both were kept on contact precautions in a shared room. Staff interviews confirmed that the residents were not separated, and the Infection Preventionist and DON acknowledged that a private room should have been used. Additionally, the facility did not implement EBP for three residents who met the criteria for these precautions. These residents had conditions such as open wounds and indwelling Foley catheters, which, according to facility policy and CDC guidance, require EBP regardless of confirmed MDRO status. Observations during facility tours revealed that there was no EBP signage or PPE carts outside the rooms of these residents, and staff confirmed that EBP was not in place for them. The DON and IP verified that these residents should have been under EBP but were not. The facility's own infection control policies, as well as CDC guidelines, were not followed in these cases. The policies specified the need for private rooms for residents with certain infections and the use of EBP for residents with specific medical devices or wounds. Despite having available private rooms, the facility did not adhere to these protocols, and staff schedules indicated periods of minimal staffing, which may have contributed to the lapses in infection control practices.
Failure to Timely Report Allegations of Abuse, Neglect, and Serious Injury
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse, neglect, and serious bodily injury to the State Agency (SA) as required by both facility policy and federal regulations. In seven out of ten Facility Reported Incidents (FRIs) reviewed, initial reports were submitted to the SA outside the mandated time frames. Specific incidents included allegations of verbal abuse by a Certified Nursing Assistant, resident-to-resident physical and sexual abuse, neglect resulting in a fall with a hip fracture, and employee-to-resident physical and verbal abuse. Documentation showed delays ranging from several days to over a week between the occurrence of the incidents and the submission of initial reports to the SA. Facility policy required immediate reporting, but interviews with facility leadership confirmed that the process was not consistently followed. The incidents involved various forms of abuse and neglect, including physical altercations between residents, inappropriate sexual contact, and a fall resulting in serious injury. Progress notes and interviews indicated that staff did not always report incidents to facility leadership immediately, and leadership did not always report to the SA within the required two-hour or 24-hour windows, depending on the severity of the allegation.
Mattress Used as Restraint Without Evaluation or Consent
Penalty
Summary
A deficiency occurred when a resident with metabolic encephalopathy and idiopathic normal pressure hydrocephalus had their mattress placed directly on the floor by an LPN without prior evaluation or consent. The LPN removed the resident's bed frame and placed the mattress on the floor without notifying other staff, the physician, or the resident's family. This action was witnessed by a CNA and later reported after the resident had been discharged. The facility's investigation substantiated the allegation of neglect, noting that the mattress on the floor acted as a restraint, as the resident was unable to get up unassisted, whereas previously the resident had been able to get out of bed independently. Facility policy required a device evaluation and consent from the resident or their representative before implementing any device that could act as a restraint. The policy also mandated physician notification and an order specifying the type, reason, and duration of use for any restraint. In this case, none of these steps were followed prior to the intervention, and the resident and their family were not informed of the risks and benefits associated with the change. The lack of a barrier between the mattress and the floor and the absence of required notifications and evaluations led to the substantiated finding of neglect.
Resident Left in Soiled Brief and T-Shirt in Dining Room During Behavioral Episode
Penalty
Summary
A resident with diagnoses including severe unspecified dementia with behavioral disturbances, anxiety disorder, cognitive communication deficit, seizures, and difficulty walking experienced a behavioral episode while being assisted with a brief change. The resident became verbally agitated, exhibited signs of psychosis, and began yelling and making accusations against staff. During the episode, the resident grabbed and injured a CNA, attempted to strike staff with a call light, and threw items in the room. In response, staff, including an LPN and CNA, removed the resident from the room and transferred the resident to the dining room as a behavioral intervention. The resident was left in the dining room wearing only a soiled brief and a t-shirt, with the curtains drawn back, exposing the resident to view. Staff left the resident alone in the dining room, closed the door, and observed the resident through the windows. While in the dining room, the resident continued to display aggressive behaviors, including attempting to remove the television from the wall, swinging the television cord at staff, and throwing the remote control. The LPN attempted to calm the resident by offering food, drink, and medication, with the resident eventually accepting medication and calming down. Throughout the incident, the resident remained in a soiled brief and t-shirt in a common area, with the curtains open, which was confirmed by the DON as disrespectful to the resident's dignity. Facility documentation and staff interviews confirmed that the resident was secluded in the dining room and not treated with respect and dignity during the behavioral episode.
Inaccurate MDS Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) 3.0 assessment for one resident. The resident, who had a diagnosis of type one diabetes mellitus with diabetic chronic kidney disease, was prescribed and administered Eliquis, an anticoagulant, for deep vein thrombosis (DVT) prophylaxis. Review of the resident's Medication Administration Record (MAR) confirmed that the medication was given consistently throughout the month. However, the MDS assessment completed for the resident did not indicate that the resident was receiving an anticoagulant in Section N, which is designated for documenting high-risk medications. The MDS Coordinator acknowledged that the assessment was inaccurate after reviewing the documentation and confirmed that the omission occurred despite the resident's ongoing anticoagulant therapy.
Failure to Implement PASARR Screening and Referral Process
Penalty
Summary
The facility failed to ensure that there was a process in place to identify and refer residents for Preadmission Screening and Resident Review (PASARR) Level II, and did not initiate a PASARR Level I submission for one of thirteen sampled residents. Specifically, a resident was admitted with diagnoses including unspecified psychosis and depression, but the PASARR Level I on file was completed years prior and did not reflect the current mental health diagnoses. The resident's active diagnoses, including psychosis and cognitive symptoms, were documented after admission, but there was no evidence that a new or updated PASARR Level I or a referral for Level II evaluation was initiated. Interviews with facility staff revealed a lack of understanding and training regarding PASARR processes. The Licensed Social Worker stated they had no responsibilities related to PASARR, and the Admissions Director admitted to not knowing what PASARR was or the required timeframes for completion. The Administrator confirmed that no staff member was overseeing PASARR procedures and acknowledged that the process was not being followed. The facility's policy required validation and tracking of PASARR Level I and referral for Level II when indicated, but this was not implemented for the resident in question.
Failure to Include Oxygen Therapy and Related Diagnoses in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a complete care plan was developed and implemented for a resident with chronic obstructive pulmonary disease, chronic systolic (congestive) heart failure, and asthma. The resident was observed receiving oxygen via nasal cannula, with the oxygen concentrator set at varying rates, and staff reported the resident often removed the cannula at night, requiring adjustments to oxygen delivery. Despite a physician's order for continuous oxygen at 2 liters per minute, the resident's care plan did not include documentation related to oxygen use or the associated diagnoses. Interviews and record reviews confirmed that the care plan lacked problems, goals, or interventions addressing the resident's need for oxygen therapy and monitoring for respiratory symptoms. The DON acknowledged that the care plan should have included these elements and confirmed their absence prior to a later update. This omission meant that staff may not have been fully aware of the resident's needs regarding oxygen administration and monitoring.
Failure to Provide Scheduled Showers or Baths for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required substantial to maximal assistance with activities of daily living, specifically bathing and showering, did not receive scheduled showers or baths as required. The resident, who had diagnoses including intervertebral disc degeneration, muscle weakness, and atrial fibrillation, reported not receiving regular showers and resorted to giving themselves a bed bath. The resident expressed feeling itchy and bad about themselves due to the lack of regular scheduled showers. The resident's care plan and Minimum Data Set (MDS) indicated a need for staff assistance with bathing and showering. A review of the resident's medical records for a three-month period revealed multiple dates where there was no documented evidence that a shower, bath, or bed bath was provided as scheduled. There was also no documentation indicating the resident refused care or that alternative arrangements were made to compensate for missed showers or baths. Staff interviews confirmed that showers were scheduled twice weekly and that refusals or completed showers were to be documented in both paper and electronic records. The Director of Nursing confirmed the absence of documentation for the missed dates and acknowledged that there was no evidence the resident had refused or was unavailable for care on those occasions.
Oxygen Administration Not in Accordance with Physician Order
Penalty
Summary
The facility failed to ensure that oxygen was administered according to a physician's order for one resident with chronic obstructive pulmonary disease and chronic systolic heart failure. The resident was observed receiving oxygen via nasal cannula at a rate of 2.5 to 3 liters per minute, despite a physician's order specifying continuous oxygen at 2 liters per minute. Staff reported that the resident often removed the nasal cannula at night, and in response, staff increased the oxygen flow rate without obtaining a new physician's order or titration instructions. Review of the clinical record confirmed there was no order to increase or titrate the oxygen flow rate based on oxygen saturation readings. The facility's policy required medications, including oxygen, to be administered strictly according to prescriber orders, and any changes or clarifications were to be documented. The Director of Nursing confirmed that staff increased the oxygen flow rate without proper authorization or documentation, and the clinical record lacked any order supporting this change.
Annual CNA Performance Review Not Completed
Penalty
Summary
The facility failed to complete an annual performance review for a Certified Nursing Assistant (CNA) who had been employed for more than one year. Review of personnel records showed that the CNA, hired on 08/31/2023, did not have documentation of a performance review for 2024. During an interview, the Director of Nursing confirmed responsibility for conducting CNA performance evaluations and acknowledged that the required review had not been completed at the one-year mark. Facility policy requires employee reviews every 12 months to identify areas for improvement and necessary competencies.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with a calculated error rate of 7.69% based on 26 observed opportunities and two errors. The errors involved two residents who did not receive their prescribed medications due to the medications being out of stock. In both cases, the registered nurses identified that the medications were not available in the medication cart and attempted to locate them in the medication storage room and automated dispensing system. When the medications were not found, the nurses indicated they would contact the pharmacy, but the medications were not administered as ordered. One resident, with a history of cerebral infarction, intracardiac thrombosis, and ventricular tachycardia, did not receive a scheduled dose of Pradaxa because it was not available in the facility. The nurse documented the medication as 'On Order' from the pharmacy but did not provide documentation of physician notification or alternative orders. Another resident, with diagnoses including obstructive and reflux uropathy and post-surgical aftercare, did not receive a scheduled dose of Finasteride for similar reasons, with the medication also marked as 'On Order' and no documentation of physician notification or alternative instructions. The Director of Nursing confirmed that there was no facility policy specifically addressing medication administration errors and that staff were expected to follow the rights of medication administration. The DON also acknowledged that there was no documentation of physician notification or pharmacy contact for the missed doses. Facility policy required medications to be administered as prescribed and for any withheld or missed doses to be documented with an explanatory note, which was not done in these cases.
Multi-Dose Vial of Tuberculin PPD Not Dated Upon Opening
Penalty
Summary
Surveyors observed that a multi-dose vial of Tuberculin Purified Protein Derivative (PPD) was stored in the medication storage refrigerator without a cap and with a visible puncture site in the rubber stopper. Neither the vial nor its manufacturer box was labeled with the date the vial was opened, despite manufacturer instructions to discard the vial within 30 days of opening. The Infection Preventionist confirmed that the vial was open and lacked an open date, acknowledging that it would need to be destroyed. Facility policy required that the date opened and the initials of the first person to use the vial be recorded on all multi-dose vials, but this was not followed in this instance.
Facility Assessment Lacked Required Review and Approval
Penalty
Summary
The facility failed to ensure that the Facility Assessment (FA) was properly reviewed, updated, and approved by the required facility leadership and management, including the Quality Assessment and Assurance (QAA) Committee. The FA dated 03/25/2025, which was presented by the Interim Executive Director (IED), did not include documented evidence of review or approval by the QAA Committee, nor did it have an attendance sheet indicating participation from the necessary leadership members. The IED confirmed that the FA was created and implemented solely by themselves without input or review from other required members of facility leadership or management. Additionally, the facility did not have a policy or procedure in place regarding the review, updating, or implementation of the FA, nor did it specify the required attendees for such processes. The previous FA, dated 08/29/2024, did include an attendance sheet with various facility leaders, but the IED stated that this version was considered null and void. The lack of proper review and approval processes for the FA was acknowledged by the IED, who admitted that the 03/25/2025 FA did not meet federal regulations and requirements.
Failure to Timely Document PRN Medication and Wound Care Orders
Penalty
Summary
A deficiency was identified when a registered nurse administered two tablets of Acetaminophen 325 mg to a resident who complained of back pain, but failed to document the administration in the resident's Medication Administration Record (MAR) at the time of administration. The nurse confirmed the omission during a review of the MAR, acknowledging that the medication had been given but not recorded. Facility policy required immediate documentation of medication administration, including PRN medications, specifying the need to record the date, time, dose, symptoms, results, and the signature or initials of the administering staff. Another deficiency occurred when a resident returned from the emergency room with a cranial abrasion and had a dressing applied to the head. The Infection Preventionist (IP) and an LPN evaluated and treated the abrasion, with the IP applying Xeroform and wrapping the resident's head. However, the clinical record for this resident lacked a physician's order for the wound care that was provided. The IP later confirmed that, although verbal approval from the physician had been obtained, the order was not documented in the resident's record as required by facility policy. Both deficiencies were confirmed through observation, interview, and record review. The facility's policies on medication administration and skin integrity required timely and complete documentation of all care provided, including obtaining and recording physician orders for treatments and documenting all medication administrations in the MAR.
Failure to Develop and Implement Required Performance Improvement Project
Penalty
Summary
The facility failed to develop and implement at least one Performance Improvement Project (PIP) within the past year, as required. During interviews, the Interim Executive Director (IED), Director of Nursing (DON), and Lead Administrator of Nevada (LAN) confirmed that while monthly Quality Assurance Performance Improvement (QAPI) committee meetings were held, they were unable to provide documentation or describe any PIP completed in the last year. The LAN explained that the facility's electronic system for documenting PIPs became inaccessible after the former Administrator left, leaving the QAA committee without access to necessary records. The IED, who had only recently assumed the role, was unable to confirm the existence of any current PIPs or locate related documentation. Additionally, the QAPI committee had not been informed of the facility's failure to follow policies and regulations regarding the reporting of abuse, neglect, mistreatment, misappropriation of property, and exploitation. The facility's QAPI Plan indicated that PIPs should be evaluated on an ongoing basis by the QAA committee, but there was no evidence that this process had occurred in the past year.
Failure to Offer and Document Timely Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was offered a timely pneumococcal vaccination to complete the recommended vaccine schedule. The resident, who had a history of type two diabetes mellitus with circulatory complications and chronic diastolic (congestive) heart failure, had previously received the PPSV23 vaccine on three occasions. However, there was no documentation in the clinical record or immunization audit report indicating that the resident had received any of the other recommended pneumococcal vaccines, such as PCV13, PCV15, or PCV20. The resident's record listed these vaccines as pending, and a multi-vaccine consent form indicated eligibility but lacked a signature for consent or declination. Interviews with the Infection Preventionist (IP) revealed that the facility determined vaccine eligibility based on consent, vaccination history, and CDC recommendations. The IP confirmed that the resident had not received the PCV vaccines and that pending immunization status indicated the resident was due and had given consent. The facility's policy required vaccination upon admission and as per CDC guidelines, with documentation of administration, refusal, or non-vaccination in the electronic health record. Despite these procedures, the required pneumococcal vaccine was not administered, and proper documentation of consent or refusal was not present.
Failure to Document and Administer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to ensure that one of five sampled residents received or declined an updated or booster dose of the COVID-19 vaccine after being screened for eligibility. The resident, who had diagnoses including type two diabetes mellitus without complications and hypertension, was admitted to the facility and identified as eligible for the COVID-19 vaccine. However, the Immunization Audit Report only documented a status of pending immunization, and the Resident Multi-Vaccine Consent Form lacked a signature indicating consent or declination. There was no documented evidence in the clinical record that the vaccine was administered or declined. Interviews with the Infection Preventionist (IP) confirmed that the resident's record did not contain documentation of previous COVID-19 vaccination and that the vaccine had not been administered. The facility's policy required that residents be offered recommended COVID-19 vaccinations upon admission and as eligible, with documentation of acceptance or declination. Despite these requirements and CDC recommendations, the necessary documentation and administration or declination of the vaccine for this resident were not completed.
Resident Subjected to Involuntary Seclusion During Behavioral Episode
Penalty
Summary
A deficiency occurred when a resident with severe dementia, anxiety disorder, cognitive communication deficit, and other medical conditions was subjected to involuntary seclusion. During an episode of behavioral disturbance, the resident became verbally agitated, exhibited signs of psychosis, and physically aggressive behaviors, including grabbing and scratching a CNA and attempting to strike staff with a call light. In response, staff removed the resident from their room and transferred them to the community dining room while the resident was only wearing a soiled brief and a t-shirt. Once in the dining room, staff closed the door, isolating the resident from others, and observed the resident through the windows with the curtains drawn back. The resident continued to display agitated behaviors, such as attempting to rip the television from the wall, swinging the television cord at staff, and throwing objects. Staff offered food, drink, and medication, with the resident eventually accepting medication and calming down. The resident was then returned to their room. Facility documentation and interviews confirmed that the resident was left alone in the dining room with the door closed, separated from other residents, and exposed to view while in a state of distress and undress. The facility's own policies and resident rights documents define involuntary seclusion as the separation or isolation of a resident against their will, which occurred in this incident. The DON acknowledged that the situation was handled poorly and that the resident was isolated from the community during the episode.
Failure to Provide Timely Elder Abuse Training to Agency CNA Involved in Resident Incident
Penalty
Summary
The facility failed to ensure that an agency contracted Certified Nursing Assistant (CNA), identified as Employee #24, completed initial elder abuse prevention training upon hire. Employee #24 was hired on 11/08/2024 and terminated on 03/05/2025, but their personnel record lacked documented evidence of elder abuse training completion at any point during employment. Facility policy required all staff, including agency staff, to complete abuse training upon hire and annually thereafter. An incident occurred in which Employee #24 was involved with a resident who became verbally agitated and exhibited signs of psychosis during assistance with a brief change. The CNA removed the resident from their room and transferred them to the community dining room while the resident was wearing only a t-shirt and a soiled brief. The resident was left in the dining room with the curtains drawn back, visible to others, while staff observed from outside the room. As a result of this incident, three employees were terminated for policy violations. The lack of required abuse prevention training for Employee #24 was confirmed by both the Director of Nursing and the Administrator.
Expired Supplies and Missing Narcotics in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, leading to expired COVID-19 testing supplies being present in the medication room and on a medication cart. During an inspection, it was observed that the medication storage room contained a box of COVID-19 test kits that had expired, and the same was found in the medication cart for the 200 hall. The Resident Care Manager and the LPN confirmed the expiration of these supplies. Although the Director of Nursing (DON) claimed to conduct weekly audits to remove expired items, the expired test kits were not removed because the expiration date had been extended, as per the Administrator's documentation. However, the Administrator later confirmed that the test kits were indeed expired. Additionally, the facility failed to store narcotic medications appropriately, resulting in the loss of a resident's narcotic pain medication. Resident #188, who was admitted with diagnoses requiring pain management, had a physician order for Oxycodone. However, 38 tablets of the medication went missing from the medication cart. The LPN responsible for the cart reported the missing medication to the DON and admitted to leaving the keys on top of the cart, which could have allowed unauthorized access. The facility was unable to determine who accessed the medication, and the missing Oxycodone was not recovered. The facility's policy stated that only authorized personnel should have access to controlled medications, and the medication nurse should maintain possession of the keys, which was not adhered to in this case.
Deficiencies in Ice Machine Cleanliness, Food Storage, and Hand Hygiene
Penalty
Summary
The facility failed to maintain cleanliness standards for an ice machine, as observed on June 24, 2024. The ice machine in the kitchen had a hard, white, flaky substance around the outside and inside of the door. Despite a task sheet indicating routine maintenance was completed on June 4, 2024, including door gasket cleaning, the Nutrition Services Supervisor could not locate the contractor's cleaning log or the schedule for the next deep cleaning. The facility's policy required monthly cleanings of the ice machine, which were to be documented, but this was not adhered to. Additionally, the facility did not follow its policy for discarding expired food. On June 24, 2024, a cardboard case containing seven unopened and one opened one-quart cartons of heavy cream with expiration dates of June 16, 2024, was found in the walk-in refrigerator. The Nutrition Services Supervisor confirmed these should have been discarded. Furthermore, during a lunch trayline observation on June 25, 2024, a staff member failed to perform hand hygiene as required. The staff member entered the trayline from the kitchen prep area without washing hands or changing gloves, despite knowing the policy required handwashing and new gloves before handling food. The Nutrition Services Supervisor confirmed the breach in protocol.
Infection Control Deficiencies in Hand Hygiene, Glucometer Use, and Laundry Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by a staff member, specifically the Activities Director (AD), who did not perform hand hygiene between contact with residents and environmental surfaces. The AD was observed touching a resident's hand and bedding, then placing hands on the nurse's station counter, and subsequently greeting another resident without performing hand hygiene. The Infection Preventionist (IP) confirmed that hand hygiene should be completed before and after contact with residents, but had not provided education to the AD on this matter, as the IP only provided infection control education to nursing staff. The Director of Nursing (DON) stated that all staff received training on hand hygiene at the time of hire, yet the AD did not adhere to these practices. The facility also failed to properly sanitize a glucometer between resident uses. A Licensed Practical Nurse (LPN) used the same glucometer for two residents and cleaned it with a 70 percent isopropyl alcohol prep pad instead of the required Sani-Cloth germicidal disposable wipe. The DON confirmed that the glucometer should be cleansed with a Sani-Cloth and remain wet for two minutes, following the manufacturer's instructions to prevent the spread of blood-borne pathogens. The facility's policy and the manufacturer's instructions specified the use of specific disinfectant wipes and procedures, which were not followed by the LPN. Additionally, the facility's laundry practices were found to be unsanitary. A fan was observed blowing air from the dirty side of the laundry room to the clean side, potentially contaminating clean laundry. Industrial floor cleaners were stored on the clean side, and a blanket was placed on a floor cleaner to dry, which was then stored on a wire rack without a solid bottom. The IP and DON did not oversee the infection control practices of the laundry room, as these services were provided by a contracted agency. The facility's policy required soiled laundry to be handled in a manner preventing microbial contamination, which was not adhered to in this instance.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consents were obtained prior to administering two psychotropic medications to a resident. The resident, who was admitted with diagnoses including unspecified dementia, obstructive sleep apnea, and anxiety disorder, was prescribed Amitriptyline and Buspirone for restlessness related to anxiety. These medications were administered from June 18, 2024, through June 24, 2024, without obtaining the necessary informed consents beforehand. The facility's policy required informed consents for psychotropic drugs to be completed within 48 hours of admission. However, the consents for Amitriptyline and Buspirone were only signed and dated on June 24, 2024, after the medications had already been administered. The Director of Nursing confirmed that the medications were given prior to obtaining the informed consent documentation, which was a violation of the facility's policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment inaccurately documented the use of bed rails as restraints. The resident, along with a CNA and an LPN, confirmed that the bed rails were used to assist with mobility and did not restrict movement. The MDS Coordinator also acknowledged that the bed rails were not used as restraints, despite being coded as such in the MDS assessment. The facility's policy stated that bed rails are not considered restraints unless they prevent the resident from getting out of bed. For another resident, the MDS assessment failed to reflect an active diagnosis of Deep Vein Thrombosis (DVT), despite the resident receiving anticoagulant medication for this condition. The resident's clinical record lacked documentation of a DVT diagnosis in the active diagnosis list, although a Nurse Practitioner Progress Note and a physician's order indicated the presence of a DVT. The MDS Coordinator confirmed that the MDS should have been updated to include the DVT diagnosis.
Failure to Develop Care Plans for DVT and Insomnia
Penalty
Summary
The facility failed to develop a care plan for two residents with specific medical conditions. Resident #13, who was admitted with diagnoses including Parkinsonism and unspecified dementia, was confirmed to have a deep vein thrombosis (DVT) on 07/24/2023. Despite receiving anticoagulant therapy with Eliquis as per a physician's order, a care plan addressing the DVT was not initiated until 06/25/2024. The care plan should have included interventions such as leg elevation, monitoring for color changes, and assessing anticoagulant therapy to prevent clot dislodgment. Similarly, Resident #20, admitted with anxiety and cellulitis, was receiving Trazodone for insomnia as per a physician's order dated 03/12/2024. However, the resident's comprehensive care plan did not include a plan for managing insomnia. The Director of Nursing confirmed that care plans should be created upon admission and updated within 48-72 hours as new problems or interventions arise, indicating a lapse in the facility's adherence to this protocol.
Backdating of Care Plan for DVT
Penalty
Summary
The facility failed to meet professional standards for accurate recording as per the Nevada Nurse Practice Act when the Minimum Data Set Coordinator, a Registered Nurse, backdated a resident's care plan for deep vein thrombosis (DVT) by 11 months. The resident, who was admitted with diagnoses including Parkinsonism and unspecified dementia, was confirmed to have a DVT on July 24, 2023, and was prescribed Eliquis, an anticoagulant, on July 26, 2023. However, the resident's Comprehensive Care Plan did not include a care plan for DVT or the anticoagulant until June 25, 2024, despite the medication being administered from June 1, 2024, to June 25, 2024. The MDS Coordinator admitted to adding the care plan for DVT on June 25, 2024, and backdating it to July 24, 2023, based on a progress note. The Director of Nursing confirmed that backdating the care plan was unacceptable and that care plans should be created upon admission and updated within 48-72 hours as new problems or interventions arise. The Director of Nursing provided an audited copy of the Comprehensive Care Plan, which documented that the DVT care plan was indeed created on June 25, 2024. This action was considered unprofessional conduct under the Nevada Nurse Practice Act, which prohibits inaccurate recording or falsifying records.
Deficiency in CPR Certification for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest. This deficiency was identified for two of the five sampled licensed nurses, specifically two Licensed Practical Nurses (LPNs). The personnel records for these LPNs lacked documented evidence of current CPR certifications. During the survey process, the Business Office Manager (BOM) confirmed responsibility for personnel record review but was unsure about the policy for CPR training, including who was required to be certified and how often training was required. The facility's policy on CPR, updated on a specified date, required licensed nurses to have current CPR certification.
Failure to Administer Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the administration of acetaminophen outside of physician-prescribed parameters. Resident #288, who was admitted with diagnoses including encephalopathy, hypothyroidism, and hypertension, had a physician's order for acetaminophen to be administered for pain levels between one and four. However, the medication administration record (MAR) documented that acetaminophen was given on multiple occasions when the resident's pain levels exceeded these parameters, with pain levels recorded as high as ten. The Licensed Practical Nurse (LPN) confirmed that the administration of acetaminophen did not adhere to the physician's order, and the Director of Nursing (DON) acknowledged that the medication was not administered as prescribed. The facility's policy on medication administration, dated January 2021, required that medications be administered as prescribed, and the DON emphasized the importance of following physician orders to ensure medications are given based on resident needs. Despite this, the facility could not confirm whether the medication was necessary, highlighting a failure to adhere to prescribed medication protocols.
Psychotropic Medication Prescribed Without Diagnosis
Penalty
Summary
The facility failed to ensure that a psychotropic medication was prescribed with a diagnosed indication for use for one of the residents. Resident #20 was admitted with diagnoses including anxiety and cellulitis of the left lower limb. However, the resident was receiving Trazodone for insomnia without having a diagnosis of insomnia. A Licensed Practical Nurse confirmed that the resident did not have a diagnosis for insomnia, despite receiving Trazodone daily for this condition. The Director of Nursing also confirmed the absence of an insomnia diagnosis for Resident #20, acknowledging that the resident should have had one. The facility's policy required a physician to provide justification for the continued use of psychotropic drugs, including a diagnosis and description of symptoms, which was not adhered to in this case.
Failure to Offer Timely Vaccinations
Penalty
Summary
The facility failed to ensure that certain residents were offered necessary vaccinations, specifically the pneumonia and influenza vaccines, upon admission or during their stay. This deficiency was identified through interviews, clinical record reviews, and document reviews. Four residents were not offered a pneumonia vaccine upon admission, and one resident was not offered a flu vaccine during the 2023 to 2024 influenza season. The residents involved had various medical conditions, including respiratory failure, diabetes, obesity, atrial fibrillation, chronic kidney disease, encephalopathy, and a history of COVID-19, which could increase their susceptibility to illnesses. The Infection Preventionist (IP) confirmed that the facility's practice was to offer vaccinations only during quarterly vaccine clinics provided by a contracted pharmacy. This practice resulted in some residents not being offered vaccines if they were admitted and discharged between these clinics. The facility's policies on pneumococcal and influenza vaccinations required determining each resident's vaccination status upon admission and obtaining informed consent, with documentation of refusals. However, these policies were not effectively implemented, leading to the identified deficiency.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to ensure that four out of fifteen residents reviewed for vaccinations were offered a COVID-19 vaccine upon admission, and one resident was not offered an updated 2023 to 2024 COVID vaccine. The residents involved had various medical conditions, including acute and chronic respiratory failure, type two diabetes mellitus, heart failure, atrial fibrillation, chronic kidney disease, encephalopathy, and end-stage renal disease. The clinical records for these residents lacked documentation indicating they were screened for or offered a COVID vaccination. The Infection Preventionist (IP) confirmed that residents had not been offered COVID vaccinations because the facility only provided them during vaccine clinics conducted quarterly by a contracted pharmacy. This scheduling meant that a resident could be admitted and discharged without being offered a vaccine. Additionally, one resident missed the opportunity to receive an updated vaccine because the clinic coincided with their dialysis appointment. The facility's policy stated that COVID-19 vaccinations and recommended boosters should be offered to all residents per CDC and FDA guidelines, with documentation maintained in the residents' medical records.
Unsafe Temperature in Laundry Room
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature in the laundry room, which had been without air conditioning for the past year. During a tour, it was observed that a fan was used to blow air from the dirty side to the clean side of the room to prevent staff from overheating. The Housekeeper confirmed the fan's use due to the lack of air conditioning. The Administrator also confirmed the absence of air conditioning, and the Maintenance Director noted that the temperature should be maintained between 71- and 81-degrees Fahrenheit. However, when the washing machine and dryers were not operating, the ambient temperature in the laundry room was recorded at 86-degrees Fahrenheit.
Failure to Complete Annual Elder Abuse Training
Penalty
Summary
The facility failed to ensure that annual elder abuse training was completed for one of the sampled employees, specifically a housekeeper. The housekeeper was hired on September 17, 2019, and their personnel record showed that elder abuse training was completed on May 4, 2023. However, there was no documented evidence of elder abuse training being completed in 2024. During the survey process, the Business Office Manager (BOM) confirmed their responsibility for personnel record review and acknowledged that all staff were required to complete elder abuse training upon hire and annually thereafter. The BOM expressed uncertainty about the expected timeframes for elder abuse training and confirmed that the housekeeper's personnel record lacked evidence of training in 2024. The facility's policy, updated in October 2022, stated that staff were to be trained on abuse prevention, reporting, and intervention upon hire, annually, and periodically thereafter.
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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