Green Valley Health And Wellness Suites
Inspection history, citations, penalties and survey trends for this long-term care facility in Henderson, Nevada.
- Location
- 2965 Wigwam Parkway, Henderson, Nevada 89074
- CMS Provider Number
- 295110
- Inspections on file
- 14
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Green Valley Health And Wellness Suites during CMS and state inspections, most recent first.
A resident with a history of congestive heart disease and muscle weakness was not allowed to reenter the facility after returning late from a therapeutic leave, despite expressing a desire to stay. Staff, following direction from the ADON, discharged the resident without providing the required 30-day written notice or notifying the Ombudsman, and the discharge was incorrectly documented as AMA without the resident's signature. Facility leadership later confirmed that proper involuntary discharge procedures were not followed.
The facility did not ensure that resident grievances were investigated or resolved, as required by policy. Multiple complaints, including delayed care, staff rudeness, and missing personal items, were documented in meeting minutes and grievance logs but lacked evidence of investigation or resolution. The DON and Social Worker confirmed that documentation of grievance follow-up was missing, and not all staff had access to the grievance system.
A resident with multiple neurological diagnoses did not receive a scheduled dose of Clonazepam 0.5 mg as ordered, despite the medication being available in the facility's Omnicell system. Documentation cited unavailability and awaiting pharmacy delivery, but staff did not access the medication from the Omnicell or contact the physician for clarification, resulting in the missed administration.
A resident with multiple medical conditions was found with a prescription eye drop medication left unsecured on the bedside table, contrary to physician orders and facility policy. An LPN confirmed the medication should have been stored in the medication cart, and the DON stated that medications are not to be left at the bedside and must be secured.
Staff failed to consistently follow posted infection control precautions for two residents requiring Contact or Enhanced Barrier Precautions. Multiple staff, including CNAs, an LPN, and a housekeeper, entered rooms or provided care without the required PPE, despite clear signage and available supplies. Staff acknowledged the requirements but did not adhere to them, and some expressed confusion about proper PPE use and removal.
A facility failed to implement a person-centered care plan for a resident's PICC line, which was inserted for TPN and antibiotics. The medical records lacked a care plan, and there was a communication breakdown between the MDS department and nursing staff, leading to the oversight.
The facility failed to maintain proper PICC line care for two residents, leading to potential infection and catheter occlusion risks. One resident had a soiled and undated dressing with no physician order for maintenance, while another lacked a saline flushing protocol, resulting in a non-patent line. The facility's policies for PICC line care were not followed, as confirmed by the interim DON and LPNs.
The facility failed to obtain informed consents and monitor behaviors for psychoactive medications for two residents. One resident was prescribed Zoloft without informed consent or monitoring, while another received Hydroxyzine, Seroquel, and Trazodone with undated and unwitnessed verbal consents. The facility's policy for medication management was not followed, leading to deficiencies in monitoring and documentation.
A facility failed to complete an initial PASRR for a resident with depression and anxiety disorder before admission. The resident required 1:1 monitoring due to severe anxiety, and the absence of a PASRR assessment was acknowledged by the Director of Admissions. The last PASRR was from 2008, and the Director of Social Services confirmed that a PASRR level 1 screening should have been conducted to evaluate the resident's mental health needs.
A resident with a spinal injury and overactive bladder was left soiled and wet for several hours despite requesting assistance, leading to a call to 911. The facility failed to provide timely incontinent care, with staff ignoring the resident's pleas and lacking documentation of care provided. Interviews revealed delays in response to call lights and inadequate communication and prioritization of care.
The facility failed to conduct proper nutritional assessments and interventions for residents with significant weight changes. A resident experienced notable weight loss without documented assessments or interventions, while another had missing weight records for two months. A third resident on hospice care had a drastic weight loss that was not immediately verified. The facility did not adhere to its weight monitoring protocols, leading to potential delays in necessary interventions.
A resident with a PICC line was found with a dressing that had not been changed for nearly a month, contrary to the facility's policy of weekly changes. The oversight was confirmed by a nurse, and the resident's medical record lacked documented orders for PICC line care. The Interim DON suggested the omission might be linked to the resident's recent re-admission.
The facility failed to ensure proper dialysis communication and post-treatment assessments for two residents with end-stage renal disease. One resident had incomplete records for 8 days and missing vital signs for 6 days, while another had missing records for 13 days and missing vital signs for 6 days. The interim DON acknowledged the importance of complete records and assessments to ensure residents' safety post-dialysis.
The facility failed to develop baseline care plans for two residents admitted with ileostomies, lacking documentation of care and management interventions. The DON confirmed the absence of these plans, which are required within 48 hours of admission to address immediate care needs. This placed the residents at risk for complications such as stoma infection and skin irritation.
The facility failed to document and execute care orders for the ileostomy care of two residents, leading to a deficiency in their care. One resident was admitted with an ileostomy following a partial colectomy, and another with a history of alcohol abuse and ileostomy creation. Interviews revealed that the facility lacked a designated admission nurse, and the responsibility for entering care orders fell on the admitting nurse. The absence of documented care orders and a specific policy for ileostomy care resulted in inadequate care for the residents.
Failure to Follow Involuntary Discharge Procedures for Resident Returning from Therapeutic Leave
Penalty
Summary
The facility failed to ensure that a resident was not involuntarily discharged without a valid reason and without following required procedures. The resident, who had diagnoses including congestive heart disease and muscle weakness, was admitted for long-term care and had a physician order allowing therapeutic leave for up to four hours at a time. On the date of the incident, the resident left the facility on a pass and returned late, after which staff, under the direction of the Assistant Director of Nursing (ADON), did not allow the resident to reenter the facility. The resident was given their belongings and told they could not stay due to repeated violations of the four-hour pass rule, despite the resident expressing a desire to remain at the facility. Documentation showed that the discharge was recorded as 'against medical advice' (AMA), but the resident did not sign the AMA form, and the form itself lacked a diagnosis. Staff notes indicated that the resident was unhappy with being discharged and did not want to leave. Interviews with facility staff, including the ADON, DON, and Case Manager, revealed that the facility had an ongoing issue with the resident returning late from passes, but there was no written policy supporting automatic AMA discharge for exceeding the pass time. The DON and Administrator acknowledged that the required 30-day written notice of involuntary discharge and notification to the Long-Term Care Ombudsman were not provided to the resident. The facility's actions were based on verbal warnings and frustration with the resident's non-compliance, rather than adherence to established discharge procedures. The resident was not provided with the opportunity to appeal the discharge or receive proper notification, and the discharge was not supported by a physician order or a documented safe discharge plan. The facility's failure to follow its own policies and regulatory requirements resulted in the resident being involuntarily discharged without due process.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly investigated and that determinations or resolutions were provided to residents. Interviews and document reviews revealed that issues raised during Resident Council Meetings were not consistently entered into the grievance program, and there was no documentation of investigations or resolutions for the grievances. The Social Worker stated that not all new staff had access to the computer system to input investigations and resolutions, resulting in a lack of follow-up on reported concerns. The Director of Nursing confirmed the absence of documentation for grievance investigations and resolutions, despite being able to provide meeting agendas where related topics were discussed. Resident Council Meeting Minutes and grievance logs from January through March documented multiple unresolved issues, including staff not performing rounds every two hours, staff being rude or sleeping during shifts, delayed medication administration, call lights not being answered for extended periods, and personal items being taken from residents' rooms. The facility was unable to provide evidence of steps taken to investigate these grievances, summaries of findings, confirmation of grievances, or corrective actions taken, as required by their own grievance policy.
Failure to Administer Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Friedreich ataxia and functional quadriplegia did not receive Clonazepam 0.5 mg as ordered by the physician. The medication was scheduled to be administered twice daily at 8:00 AM and 8:00 PM, but was not given at the scheduled 8:00 PM dose. Documentation on the Medication Administration Record indicated the medication was not administered due to it being unavailable, with a note that the facility was awaiting delivery from the pharmacy for a new admission. Further investigation revealed that the facility had an Omnicell automated medication dispensing system stocked with Clonazepam 0.5 mg, with six tablets available at the time. Staff confirmed that the medication could have been accessed from the Omnicell after verifying the order with the pharmacy, but this was not done. The Director of Nursing confirmed that the medication had not been administered and that staff would have needed to contact the physician for clarification due to the late delivery, but this step was not taken.
Medication Not Secured in Locked Storage
Penalty
Summary
A deficiency occurred when a prescription medication, Latanoprost 0.005% eye drops, was found unsecured on a resident's bedside table. The medication was intended to be administered at bedtime as per a physician's order. The resident, who had diagnoses including cellulitis of the right lower limb, type 2 diabetes mellitus with hyperglycemia, and difficulty walking, reported that the nurse had left the medication at the bedside the previous night. This was confirmed by an LPN the following morning, who acknowledged the medication should have been stored in the medication cart due to its specific administration schedule and safety concerns. Further, the Director of Nursing confirmed that facility policy requires all medications to be secured in locked compartments and not left at the bedside. The facility's policy, revised recently, mandates that all drugs and biologicals be stored in locked compartments under proper conditions. The failure to secure the medication as required by policy and regulation led to the deficiency identified during the survey.
Failure to Adhere to Infection Control Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents who required either Contact Precautions or Enhanced Barrier Precautions. In one instance, a certified nurse assistant entered a resident's room with gloves but without a gown, despite signage indicating both were required, and then exited the room carrying a meal tray. The same resident's room was later entered by a licensed practical nurse and another certified nurse assistant without any gloves or gown, and a housekeeper was observed mopping in the room without a gown, even though the posted sign specified the need for both gloves and gown. All staff acknowledged the signage and the requirements but did not adhere to them, despite the availability of personal protective equipment (PPE) outside the room. For another resident on Enhanced Barrier Precautions, staff were observed providing care without the required PPE. One certified nurse assistant was at the room threshold with gloves but no gown, and another was inside the room without gloves or gown, both having removed their PPE after care activities but before leaving the room. Staff expressed confusion about when and where PPE should be worn or removed, particularly during resident transport. The infection prevention nurse confirmed that staff were educated on infection control and that the expectation was for staff to follow the posted signage, which was specific to each resident's needs. Facility policy required clear signage and periodic monitoring of infection control procedures.
Failure to Implement Person-Centered Care Plan for PICC Line
Penalty
Summary
The facility failed to implement a person-centered care plan for the utilization and maintenance of a PICC line for one resident. This resident was admitted with diagnoses including dysphagia, dementia, protein-calorie malnutrition, and failure to thrive. A PICC line was inserted for total parenteral nutrition and antibiotics administration, with specific physician orders for its use. However, the medical records lacked evidence of a formulated care plan for the PICC line's utilization and maintenance. The interim DON confirmed that no care plan had been formulated when the PICC line was inserted. The responsibility for care plan formulation was unclear, with the MDS department expected to create the plan if the PICC line was inserted post-admission, and licensed nurses responsible if the resident was admitted with a PICC line. The Director of MDS was unaware of the PICC line insertion due to a lack of communication and did not perform routine visual assessments. The facility's policy required the development of a baseline and comprehensive care plan for each resident, which was not adhered to in this case.
Deficient PICC Line Care and Maintenance
Penalty
Summary
The facility failed to ensure proper maintenance and care of a peripherally inserted central catheter (PICC) line for two residents, leading to potential risks of infection and catheter occlusion. Resident 1, who was admitted with diagnoses including diabetes mellitus and chronic hepatitis, had a PICC line in the right upper arm with a dressing that was undated, peeling, and soiled with dried blood-like residues. There was no documented evidence of a physician order for the maintenance of the dressing changes, and the dressing had not been changed since the PICC line was inserted. The interim Director of Nursing confirmed that the dressing should have been changed weekly, and the absence of a physician's order meant that licensed nurses were not prompted to complete the task. Resident 2, admitted with conditions such as dysphagia, dementia, and protein-calorie malnutrition, had a PICC line inserted for total parenteral nutrition (TPN) and antibiotics. However, there was no documented evidence of a physician order for the PICC line saline flushing protocol, which is essential to ensure patency. The PICC line was not patent or flushing, leading to the need for a replacement. Licensed Practical Nurses confirmed that a flushing protocol should have been in place, and the absence of such an order meant that the licensed nurses were not prompted to perform the necessary flushing. The facility's policies required licensed nurses to perform procedures related to PICC line care, including dressing changes and obtaining and transcribing physician orders. However, these protocols were not followed, as evidenced by the lack of orders and documentation for both residents. The interim Director of Nursing acknowledged the deficiencies and confirmed that the necessary orders were not obtained or implemented, leading to the potential for infection and catheter occlusion.
Failure to Obtain Informed Consents and Monitor Psychoactive Medications
Penalty
Summary
The facility failed to obtain informed consents, monitor behaviors, and document non-pharmacological interventions for the use of psychoactive medications for two residents. Resident 46 was admitted with diagnoses including schizoaffective disorder, insomnia, and depression. A physician order was given for Zoloft to be administered for depression, but there was no evidence of a physician order to monitor behavior or side effects, nor was there an informed consent obtained prior to the use of Zoloft. The interim Director of Nursing (DON) acknowledged that informed consent should have been obtained and that the facility's process for monitoring behaviors and side effects was not followed. Resident 38 was admitted with diagnoses including psychotic disorder with delusions, anxiety disorder, and schizophrenia. The resident was prescribed Hydroxyzine, Seroquel, and Trazodone, but informed consents were obtained verbally via telephone and were undated and unwitnessed. The DON explained that verbal consents required documentation and signatures from two licensed nurses as witnesses, which were not present. Additionally, there was no monitoring of the effectiveness of the medications. The facility's policy required obtaining physician orders and consent forms for each prescribed psychotropic medication, as well as monitoring and documenting the resident's response to the medication, which was not completed for Resident 38.
Failure to Complete PASRR Prior to Resident Admission
Penalty
Summary
The facility failed to ensure an initial Preadmission Screening and Resident Review (PASRR) was completed prior to the admission of a resident with diagnoses including depression and anxiety disorder. The resident was admitted with a history of psychiatric issues, requiring 1:1 monitoring due to severe anxiety behavior. Despite the presence of a Level of Care (LOC) assessment dated 07/08/2022, there was no documented evidence of a PASRR assessment in the resident's medical record. The Director of Admissions acknowledged the absence of a PASRR assessment and noted that the last completed assessment was from 2008, which was not retrievable due to a system upgrade. The Director of Social Services confirmed that the resident should have undergone a PASRR level 1 screening to evaluate any related diagnoses from the previous hospitalization. The resident exhibited behavioral issues during the hospital stay, and a newer PASRR could have identified any new mental illness diagnosis, potentially altering the determination or recommendations for care. The facility's policy requires all applicants to a Medicaid-certified nursing facility to be evaluated for mental illness or intellectual disability prior to admission, but this was not adhered to in this case.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide incontinent care to a dependent resident, identified as Resident 229, who was left soiled and wet despite requesting assistance. The resident, who was admitted with diagnoses including overactive bladder and a spinal injury, was totally dependent on assistance for care. On December 12, 2024, the resident experienced a bladder spasm and urinated in bed, pressing the call light for help. However, no assistance arrived for several hours, and staff were observed ignoring the resident's repeated pleas for help. The resident eventually called the facility operator and later 911 when no staff responded, leading to police involvement. The medical record lacked documented evidence of incontinent care being provided on December 12 and 13, 2024. Interviews with the interim Director of Nursing, a Licensed Practical Nurse, and a Certified Nursing Assistant revealed that there were delays in responding to the resident's call light and a lack of communication and prioritization in providing care. The staff were expected to provide care within 5-10 minutes of a call light being activated, but this did not occur. The CNA assigned to the resident on the day of admission confirmed that bowel and bladder care was not provided during their shift and was left for the night shift, which also failed to provide the necessary care. The Administrator confirmed that the delays in response and care were unacceptable, although no intentional neglect was observed. The facility's policy on Activities of Daily Living required staff to develop and implement interventions based on the resident's assessed needs and preferences, which was not adhered to in this case.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure proper nutritional assessments and interventions for residents experiencing significant weight changes. Resident 14, who was at risk for malnutrition, experienced a notable weight loss from 160 lbs. to 129.3 lbs. over several months without a documented nutritional assessment or intervention. The Director of Dietary Services and the Registered Dietitian confirmed that weight monitoring protocols were not followed, as weights were not documented for July, and no re-weighs were conducted after the weight loss was identified in August. Additionally, the interim Director of Nursing acknowledged the lack of a nutritional assessment during this period. Resident 16 also experienced lapses in weight monitoring, with no weights recorded for July and November. The Registered Dietitian and the Director of Nursing confirmed the absence of documentation for these months, indicating a failure to adhere to the facility's policy of obtaining and documenting weights as scheduled. This oversight in weight monitoring could have delayed necessary interventions for maintaining the resident's health. Resident 39, who was on hospice care, experienced a significant weight loss from 411.2 lbs. to 151.8 lbs. in December, which was not immediately re-weighed to verify accuracy. The Registered Dietitian noted the drastic weight change and requested a re-weigh, which was eventually conducted, confirming the weight loss. The interim Director of Nursing acknowledged that the resident's weight was not taken in November, contrary to the physician's order for monthly weights. The facility's policy required re-weighing in the presence of licensed personnel if a significant weight change was observed, which was not initially followed.
Failure in PICC Line Maintenance for a Resident
Penalty
Summary
The facility failed to ensure proper care and maintenance of a peripherally inserted central catheter (PICC) line for a resident, identified as Resident 35. The resident was observed with a PICC line dressing dated nearly a month prior, indicating it had not been changed according to the facility's policy, which requires weekly dressing changes. A registered nurse confirmed the oversight and acknowledged that the dressing should have been changed and documented in the medication and administration record (MAR). The resident's medical record lacked documented orders for the care and maintenance of the PICC line, which was confirmed by the Interim Director of Nursing. Resident 35 was admitted with diagnoses including hemiplegia and cellulitis of the abdominal wall. The resident's family member reported that no intravenous antibiotics or fluids had been administered for over a month. The Interim Director of Nursing suggested that the missing orders might have been due to the resident's recent re-admission. The facility's policy, revised in May 2023, outlines that licensed nurses are responsible for assessing and performing dressing care of a PICC line, including labeling the dressing with the date of the procedure or the next due date for a change.
Incomplete Dialysis Communication and Assessment
Penalty
Summary
The facility failed to ensure proper dialysis communication and post-treatment assessments for two residents, leading to a deficiency in care. Resident 5, diagnosed with end-stage renal disease and generalized anxiety, attended dialysis treatments 24 times. However, the Hemodialysis Communication Record was incomplete, with 8 days missing records, 6 days missing return vital signs and/or dialysis site information, and 2 days where the resident refused treatment. This lack of documentation could impair continuity of care and prevent the identification of adverse reactions post-dialysis. Similarly, Resident 8, with diagnoses including end-stage renal disease and heart failure, attended dialysis treatments on 20 occasions. The communication record was missing for 13 days, and 6 days lacked return vital signs and/or dialysis site observations. Additionally, one day was missing information from the dialysis center. The interim DON acknowledged the importance of complete communication records and post-dialysis assessments, as per the facility's policy, to ensure residents are not experiencing latent effects of dialysis and to check for bleeding at access sites.
Failure to Develop Baseline Care Plans for Ileostomy Management
Penalty
Summary
The facility failed to develop a baseline care plan for two residents who were admitted with ileostomies, which are surgical openings created by bringing the end of the small intestine to the skin's surface. This deficiency was identified through interviews, record reviews, and document reviews. Resident 1 was admitted with diagnoses including malignant neoplasm of the endometrium and an ileostomy following a partial colectomy. Similarly, Resident 3 was admitted with a history of alcohol abuse and an ileostomy creation. Both residents' medical records lacked documentation of a baseline care plan addressing the care and management of their ileostomies. The Director of Nursing confirmed the absence of baseline care plans for the residents' ileostomies, acknowledging that the admitting nurse was responsible for initiating such plans to address immediate care needs. The Director of Clinical Services also emphasized the importance of including ileostomy care in the baseline care plan, as it is an immediate care need. The facility's policy requires a baseline care plan to be developed within 48 hours of admission to guide staff in providing necessary treatment and care. The lack of a baseline care plan for the ileostomies placed the residents at risk for complications such as stoma infection, skin irritation, and discomfort.
Failure to Document Ileostomy Care Orders for Two Residents
Penalty
Summary
The facility failed to ensure that care orders were entered and executed for the ileostomy care of two residents. Resident 1 was admitted with diagnoses including malignant neoplasm of the endometrium and an ileostomy, following a partial colectomy. Despite the need for specific care, the medical record for Resident 1 lacked documented evidence that care orders for the ileostomy were transcribed and carried out. Similarly, Resident 3, who was admitted with a history of alcohol abuse and an ileostomy creation, also had no documented care orders for their ileostomy in the medical record. Interviews with facility staff, including the Director of Nursing (DON), a wound nurse, and a Licensed Practical Nurse (LPN), revealed that the facility did not have a designated admission nurse, and the responsibility for entering care orders fell on the admitting nurse. The DON confirmed the absence of care orders for the ileostomies of both residents and acknowledged the lack of a specific policy for ileostomy care. The facility's practice was to follow professional standards for ostomy care, which include monitoring, emptying, and replacing the ostomy appliance as needed. However, these standards were not documented in the residents' care plans, leading to a deficiency in providing necessary care for the residents' ileostomies.
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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