Harmony Manor Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Winnemucca, Nevada.
- Location
- 118 East Haskell St, Winnemucca, Nevada 89445
- CMS Provider Number
- 295024
- Inspections on file
- 19
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Harmony Manor Skilled Nursing Facility during CMS and state inspections, most recent first.
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.
A resident with a progressive neurodegenerative disorder was not screened for a PNA vaccine, and the clinical record lacked documentation that the vaccine had been received or offered. The IP said the resident was not screened because of young age, despite confirming the resident had a chronic condition with swallowing difficulty and that the Medical Director said the resident should have been offered the vaccine.
The facility failed to ensure timely initial abuse prevention training for two newly hired staff members, including a Cook and a Dietary Aide. Personnel records showed both employees completed required orientation training late, and the HR Director confirmed the delay. The facility policy required new staff orientation to include abuse prohibition practices, reporting, and what constitutes abuse, neglect, and misappropriation of resident property.
Missing Annual Behavioral Health Training: A CNA assigned to the memory care unit did not have documented annual dementia/behavioral health training completed for the current year. HR confirmed the employee had been assigned the training but had not finished it, despite having direct contact with residents with dementia and Alzheimer’s disease. Facility policy and the facility assessment both required ongoing annual dementia care training for staff with resident contact.
Failure to Document Investigation of Fall-Related Neglect Allegation: A resident with Alzheimer’s disease fell in the dining room after a CNA heard the resident hit the floor while her back was turned. The resident had pain, a skin tear, bruising, and ankle swelling, and x-ray findings showed soft tissue swelling with age-indeterminate fracture fragments. The FRI identified the incident as neglect, but the DON said the investigation only included speaking with the nurse on duty and reviewing the chart, with no documentation of observations or interviews with staff or residents.
A facility failed to accurately document a resident's depression diagnosis in the MDS assessment, potentially affecting the care plan. The resident, with multiple diagnoses including depression, was not on medication but monitored for behavioral changes. The MDS Coordinator confirmed the omission after reviewing physician notes, contrary to facility policy requiring comprehensive and accurate documentation.
The facility failed to employ a qualified Activity Coordinator, leaving the position vacant since September 2024. An Activity Aide, lacking necessary certification and experience, has been acting in the role. A Certified Activity Consultant was hired to work remotely but did not fulfill the responsibilities of the Activity Coordinator. This deficiency was noted alongside an increase in complaints about the activities program.
An LPN left a computer screen unattended and unlocked in a common area, exposing resident information. The screen was visible from the hallway while the LPN disposed of medication, contrary to facility policy. The Infection Preventionist confirmed that private health information should not be visible when staff are away.
An LPN failed to follow infection control protocols by not wearing gloves or performing hand hygiene during the removal and application of transdermal patches on a resident. This was confirmed by the LPN and the facility's Infection Preventionist, highlighting a breach in the facility's infection prevention and control program.
The facility did not update daily nurse staffing information as required, with postings for the memory care unit being outdated. Despite the Infection Preventionist/RN's acknowledgment of the need for daily updates at shift change, observations showed postings were not current, confirmed by a CNA who noted updates were supposed to occur every morning.
The facility did not encode and transmit MDS assessments within the required timeframe for November 2024, with 2 out of 15 assessments submitted late. The MDS Coordinator confirmed the delay, which was against the facility's policy requiring adherence to the RAI Manual timelines.
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.
Failure to Screen Resident for PNA Vaccine
Penalty
Summary
The facility failed to ensure Resident #32 was screened for a pneumococcal (PNA) vaccine. Resident #32 was admitted with diagnoses including Hallervorden-[NAME] Disease, a rare inherited progressive neurodegenerative disorder, and other specified extrapyramidal and movement disorders. The clinical record did not document that the resident had received or been offered a PNA vaccine. During interviews, the Infection Preventionist stated the resident had not been screened to determine whether the resident wanted a PNA vaccine because of the resident's young age. The Infection Preventionist also confirmed the resident had a chronic, degenerative condition that caused trouble swallowing and placed the resident at increased risk for PNA. Later, the Infection Preventionist stated the issue had been discussed with the Medical Director, who said the resident should have been offered a PNA vaccine. The facility policy stated all residents admitted to the facility would be screened to determine whether they were current on adult immunizations, and pneumococcal immunization of all residents would be determined on admission.
Late Abuse Prevention Training for New Employees
Penalty
Summary
The facility failed to ensure elder abuse prevention training was completed timely for 2 of 18 sampled employees, Employee #16 and Employee #17. Employee #16 was hired as a Cook with a start date of 11/19/2025, and the personnel record showed elder abuse prevention training was completed on 11/28/2025, 9 days late. Employee #17 was hired as a Dietary Aide with a start date of 12/15/2025, and the personnel record showed elder abuse prevention training was completed on 12/31/2025, 16 days late. During an interview on 04/22/2026 at 1:45 PM, the HR Director stated all staff were required to take initial elder abuse prevention training upon hire and confirmed both employees completed the training late. The facility policy titled Freedom from Abuse/Abuse Prohibition, revised 01/19/2026, stated employees would receive orientation upon hire to include training on abuse prohibition practices, including appropriate interventions, reporting, signs of burnout, frustration and stress, and what constitutes abuse, neglect, and misappropriation of resident property.
Missing Annual Behavioral Health Training
Penalty
Summary
Behavioral health care training was not completed annually for 1 of 18 sampled employees, Employee #7, a CNA hired on 06/17/2019. The personnel record showed annual behavioral health care training completed on 04/11/2025, but there was no documented evidence that the training had been completed in 2026. During interview on 04/22/2026, the HR Director stated that dementia care training was required annually for all staff on or before the date of last completion and confirmed that Employee #7 had been assigned the 2026 behavioral health care training but had not yet completed it. The HR Director also confirmed that Employee #7 worked in the facility's memory care unit and had contact with residents diagnosed with dementia and Alzheimer's disease. The facility policy for staff training in Alzheimer and dementia care required all staff with direct contact with residents with dementia to complete continuing education related to dementia every year after the first year of employment, and the facility assessment stated that staff would receive ongoing annual training in dementia care.
Failure to Document Investigation of Fall-Related Neglect Allegation
Penalty
Summary
The facility failed to provide documented evidence that a fall involving Resident #10 was thoroughly investigated to determine whether the incident was the result of neglect. Resident #10 was admitted with diagnoses including Alzheimer's disease and episodic tension-type headache, not intractable. On 02/25/2026, the resident was last seen sitting at a dining room table when a CNA, with her back turned at the sink in the dining room, heard the resident hit the floor. The CNA observed that the resident appeared to have attempted to get up and lost footing or become tangled in the chair. The resident had verbal complaints of pain and sustained a 3-centimeter skin tear to the left elbow, bruising to the left knee, and swelling to the left ankle. A post-fall x-ray of the left ankle on 02/26/2026 showed soft tissue swelling and age-indeterminate fracture fragments at the lateral malleolus tip, lateral talus, and extensor digitorum brevis origin. The facility submitted a final FRI identifying the incident type as neglect. The DON stated the incident was different from other falls because of the ankle fracture and said the investigation included speaking with the nurse on duty and reviewing the clinical record, but denied having documentation of observations made or interviews conducted with residents and/or staff. The facility policy titled Freedom From Abuse/Abuse Prohibition stated residents have the right to be free from abuse and neglect and described neglect as indifference or disregard for resident care, comfort, or safety resulting in, or possibly resulting in, physical harm, pain, mental anguish, or emotional distress.
Inaccurate MDS Assessment for Resident with Depression
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for one resident, which had the potential to impact the care plan by omitting current needs, services, and monitoring. The resident in question was admitted with diagnoses including depression, hypertension, hyperlipidemia, and type two diabetes mellitus. A Physician Progress Note documented the resident's diagnosis of depression, but the quarterly MDS assessment did not reflect this diagnosis in Section I - Active Diagnoses. The MDS Coordinator, who completed this section, confirmed the omission after reviewing the physician's note. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the MDS Coordinator, revealed that the resident was not on medication for depression but was being monitored for behavioral changes. The LPN noted that the resident occasionally needed encouragement to get out of bed, indicating potential signs of depression. The facility's policy required that all relevant information be documented accurately in the resident's clinical record during the lookback period, which was not adhered to in this case, leading to an inaccurate MDS assessment.
Facility Lacks Qualified Activity Coordinator
Penalty
Summary
The facility failed to employ a qualified Activity Coordinator, which is a requirement for ensuring the activities program is directed by a trained professional. The personnel roster provided to the State Agency did not include documentation of an Activity Coordinator. Interviews with facility staff revealed that the previous Activity Coordinator left the facility in September 2024, and since then, an Activity Aide has been acting in the role without the necessary certification. The facility had hired a Certified Activity Consultant to work remotely, but the consultant had not signed the Activity Coordinator position description and was not fulfilling the role's responsibilities. The Human Resources Manager confirmed that the Activity Coordinator position remained vacant, and the Activity Aide had only begun the required training in January 2025, despite being in the role since September 2024. The Activity Aide also lacked the two years of experience required to be a qualified Activity Coordinator. The facility's position description for the Activity Coordinator did not include the role and responsibilities of a certified Activity Consultant during the period a new Activity Coordinator was obtaining certification. The deficiency was further highlighted by an increase in complaints regarding the activities program since the previous Activity Coordinator's departure.
Unattended Computer Screen with Resident Information Visible
Penalty
Summary
The facility failed to ensure the security of resident-identifiable information by leaving a computer screen unattended and unlocked, with resident information visible. On multiple occasions, an LPN was observed preparing medications for residents using a desktop computer located in a common area near the nurses' station. The computer screen was facing the hallway, making it possible for unauthorized individuals to view the information. The LPN left the computer screen on and unlocked while disposing of medication in the storage room, leaving resident information exposed. The LPN acknowledged the oversight and admitted that the computer screen should have been minimized or locked before leaving the workstation. The Infection Preventionist/Registered Nurse confirmed that private health information should not be visible when staff are not present at the workstation. The facility's policy on workstation use, reviewed in 2024, mandates that electronic protected health information must be secured, and any breach of this policy could lead to disciplinary action. This deficiency highlights a lapse in safeguarding residents' protected health information, as observed by the surveyors.
Infection Control Breach During Transdermal Patch Administration
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) adhered to the infection prevention and control protocols during the administration of transdermal patches. On the morning of February 5, 2025, during a medication pass, the LPN was observed removing a transdermal patch from a resident's chest without wearing gloves and did not perform hand hygiene afterward. Subsequently, the LPN applied a new transdermal patch on the resident's right arm, again without wearing gloves. This practice was confirmed by the LPN, who acknowledged the oversight and recognized the importance of wearing gloves to prevent potential transfer of medication and bacteria. The facility's Infection Preventionist/Registered Nurse (IP/RN) confirmed that the nursing staff were expected to perform hand hygiene and wear gloves when handling transdermal patches, as per the facility's policy. The facility's policy on Transdermal Patch Application, revised in May 2024, and the Hand Hygiene policy, reviewed in August 2024, both emphasize the necessity of hand hygiene and glove use to reduce the risk of transmitting organisms. The failure to follow these protocols was identified as a deficiency in the facility's infection prevention and control program.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current nursing hours were posted daily, as required, which could lead to a lack of awareness for residents and visitors regarding the number of nursing staff on duty. On multiple occasions, the nursing staff postings for the memory care unit were outdated, with the last update being on 01/23/2025, despite observations on 02/04/2025 and 02/05/2025. The Infection Preventionist/Registered Nurse acknowledged that nurse staffing hours should be updated daily at shift change to ensure adequate staffing and inform resident families. However, on 02/06/2025, the postings were still not current, as confirmed by a Certified Nursing Assistant who stated that updates were supposed to occur every morning but were not reflecting the current date.
Late Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set 3.0 (MDS) assessments were encoded and transmitted within the required timeframe for November 2024. Specifically, 2 out of 15 MDS assessments, accounting for 13.3%, were submitted late. This deficiency was identified through interviews and document reviews, where the MDS Coordinator acknowledged the delay in completing and submitting the assessments. The facility's policy, as reviewed on January 14, 2025, mandates that MDS completion, locking, submission, and transmission adhere to the timelines outlined in the Resident Assessment Instrument (RAI) Manual.
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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