Horizon Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 660 Martin Luther King Blvd, Las Vegas, Nevada 89106
- CMS Provider Number
- 295017
- Inspections on file
- 21
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Horizon Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified failures in food storage and temperature control, including refrigerators holding food at temperatures above policy requirements and expired food items present in dry storage. The Kitchen Manager confirmed that staff had not consistently monitored temperatures or removed expired products, contrary to the facility's Food Services Plan.
Residents were denied access to the secured outdoor patio after evening hours due to facility-imposed restrictions following incidents of smoking by a few individuals. Despite requests from residents, including those without cognitive impairment, to use the patio during cooler evening times, staff confirmed the area was closed by 8 PM because of supervision and safety concerns, with no alternatives attempted. The facility lacked a written policy for these restrictions, and the practice conflicted with stated resident rights to self-determination and choice.
A resident with severe cognitive impairment and multiple diagnoses was not provided with information or documentation regarding advance directives. The facility did not identify a primary decision maker or develop a care plan for advance directives, and relied solely on a physician's order for full code status, which is not a valid substitute for an advance directive.
A resident with psychiatric diagnoses exhibited persistent yelling and disruptive behaviors, disturbing the sleep and comfort of nearby residents. Despite staff and leadership being aware of the ongoing issue and attempting interventions such as room changes and relocation, there was no documented communication with the psychiatric provider or effective resolution, resulting in a failure to maintain a peaceful, homelike environment as required by facility policy.
The facility did not coordinate assessments with the PASRR program and failed to refer a resident for necessary services, resulting in noncompliance with assessment and referral requirements.
A resident with a recent psychiatric hospitalization and new diagnosis of PTSD did not have a comprehensive care plan developed or implemented to address their updated mental health needs. The facility failed to conduct or document a PASRR Level 2 evaluation after the resident's acute change in condition, and the resulting recommendations for specialized services were not incorporated into the medical record or care planning process.
A resident with a history of respiratory failure and an ingrown toenail developed a blackened area on the right great toe after a podiatry procedure. Despite reporting the issue and associated pain to multiple staff, the concern was not promptly communicated to the wound care team as required by facility protocol. A CNA observed the impairment and informed an LPN, but the wound care team was not notified until later, and required documentation was not completed, resulting in delayed intervention.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the affected area.
A resident with an indwelling Foley catheter did not receive timely assessment or care as ordered, including weekly drainage bag changes and notification of a physician when foul-smelling, cloudy urine with sediment was observed. Staff failed to document the change in condition or follow facility policy for catheter care and communication.
A resident dependent on gastrostomy tube feeding did not consistently receive the full prescribed volume of enteral nutrition, and staff failed to monitor and document total intake as required. Despite physician orders and facility policy, the actual volume delivered was significantly less than ordered, and the MAR lacked consistent documentation. Interviews with the ADON, RD, and physician confirmed the deficiency in following and recording tube feeding orders.
A resident with insomnia, anxiety disorder, and major depressive disorder exhibited constant yelling and disruptive behaviors that were well-documented and known to staff, yet these behaviors were not communicated to the psychiatric provider, nor was a psychiatric consult or referral for bedside psychotherapy services initiated. Non-pharmacological interventions were attempted without success, and the lack of appropriate referrals resulted in ongoing disruption to other residents.
A resident with PTSD was prescribed Prazosin for night terrors, but staff did not monitor or document the target behaviors as required by facility policy. Both the ADON and DON confirmed that, despite the medication being used for a psychiatric diagnosis, there was no evidence of monitoring for effectiveness or adverse effects.
A medication pass resulted in a 9.68% error rate when an LPN administered Aspirin without a physician order, failed to give a prescribed Multivitamin, and gave Vistaril (hydroxyzine pamoate) at the wrong time to a resident with multiple diagnoses. These errors were confirmed by facility leadership and clinical consultants, and occurred despite clear facility policy on medication administration.
The facility did not have a comprehensive, facility-specific QAPI plan in place, instead relying on a general policy that lacked required elements such as processes for performance improvement and individualized guiding principles. The Administrator confirmed the absence of a tailored QAPI plan and acknowledged that the current policy did not meet regulatory requirements.
The facility failed to maintain a clean kitchen environment and proper refrigeration, risking foodborne illnesses. Observations revealed greasy and dusty equipment, improper fan use, and unsafe refrigerator temperatures. The kitchen manager acknowledged inadequate cleaning and reliance on incorrect temperature readings, leading to unsafe food storage.
A malfunctioning walk-in refrigerator in the facility was not maintained at a safe temperature, with internal readings between 54 to 58 degrees Fahrenheit. The kitchen manager failed to report the issue promptly, and food products remained at unsafe temperatures, risking foodborne illnesses. The Maintenance Director was unaware of the problem due to a lack of communication from the kitchen staff.
A resident on anticoagulants was not monitored for signs of bleeding as required. Despite receiving Heparin as prescribed, there was no documented evidence of monitoring for bleeding symptoms until a month later. The resident was later observed with minimal bleeding and bruising, which was confirmed by an LPN. Both the ADON and DON acknowledged the need for monitoring orders, which were not timely obtained, leading to this deficiency.
A resident at risk for pressure ulcers developed a stage 4 ulcer due to the facility's failure to perform and document regular skin assessments and repositioning. Despite a care plan requiring daily skin inspections and hourly repositioning, these actions were not documented for a significant period. Staff interviews confirmed lapses in expected care practices, contributing to the ulcer's development.
The facility failed to obtain and implement physician orders for splinting for two residents with contractures, despite recommendations from the rehabilitation department. One resident was observed with fingers digging into palms, and family members applied rolled towels, while another resident had a contracture with no splint in place. Delays in order transcription and lack of updated care plans contributed to the deficiency.
A facility failed to complete a nutritional assessment and obtain care orders for a resident with a PEG tube upon readmission. The resident, with anoxic brain injury and dysphagia, was observed with a non-infusing tube feeding and bloating. The necessary care orders for managing the PEG tube were not documented, and the staff did not follow the policy for obtaining physician orders for enteral feedings.
The facility did not post daily staffing information in an accessible location for residents and visitors. Staffing details were placed on small paper near nursing stations, difficult to read due to small font size, and lacked total Patient Per Day (PPD) hours. The Administrator acknowledged the requirement for more prominent and readable postings, including PPD information.
A facility failed to maintain a medication error rate below five percent, with two errors identified out of 30 opportunities. An LPN did not administer vitamin B12 and Refresh eye drops to a resident as ordered, incorrectly documenting a refusal without consulting the resident. The resident later confirmed they had not refused the medications and wished to receive them. The LPN also failed to notify the physician of the supposed refusal, contrary to facility policy.
Deficient Food Storage and Temperature Control in Kitchen and Dry Storage
Penalty
Summary
During a kitchen inspection, surveyors observed that the facility failed to maintain proper food storage and temperature control practices. One refrigerator used for storing tray line salads, ham, salami, and cheeses displayed a temperature of 42°F, but internal checks showed food items ranging from 45-50°F. A bag of shredded cheese was measured at 50°F and a packet of salami at 45°F. The temperature log for the month did not document any readings above 40°F, and the refrigerator lacked an internal thermometer for verification. The Kitchen Manager confirmed these findings. A second refrigerator used for beverages and dairy products also displayed a temperature of 42°F, but an internal thermometer measured 50°F, with a container of whole milk at 42°F. Ice was observed covering the condenser, and the Kitchen Manager acknowledged the need for defrosting. In the dry storage area, several expired food items were found, including sugar, oatmeal, white rice, and flour, with expiration dates ranging from July 2024 to February 2025. One container of brown rice did not have an expiration date documented. The Kitchen Manager stated that staff should have been regularly inspecting and labeling food items to ensure expired products were identified and removed in a timely manner. The facility's Food Services Plan required refrigerator temperatures to be maintained at 40°F, functional and calibrated thermometers, regular temperature monitoring, and removal of food items past their use-by date.
Failure to Support Resident Choice in Patio Access
Penalty
Summary
The facility failed to honor residents' rights to make choices about significant aspects of their lives, specifically regarding access to the outdoor patio area. Multiple residents, including one with no cognitive impairment and a history of paraplegia, cellulitis, and a puncture wound, reported that they were not allowed to use the secured patio after 7:00 or 7:30 PM during the summer, despite this being the most comfortable time to be outside. Residents expressed frustration that the restriction was due to a few individuals violating the no-smoking policy, resulting in all residents being denied access to the outdoor space after a certain hour. Interviews with the Administrator, Activity Director, and DON confirmed that the patio was closed by 8:00 PM due to lack of staff to supervise and concerns about residents smoking. None of the staff interviewed were aware of any alternatives being tried to allow non-smoking residents access to the patio after hours, and there was no written policy regarding the patio restrictions. The facility's own Resident Rights document states that residents have the right to make choices about their activities and schedules, but this was not upheld in practice.
Failure to Provide Advance Directive Information to Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide a resident with information regarding the right to formulate an advance directive. Upon admission, the resident, who had diagnoses including diffuse traumatic brain injury, bipolar disorder, anxiety disorder, and unspecified dementia, was identified as having severe cognitive impairment with a BIMS score of three. The facility did not have any documentation of advance directives, such as Power of Attorney paperwork, Guardian paperwork, or a POLST form, for this resident. The only documentation present was a physician's order indicating full code status, which the Director of Social Services acknowledged is not a valid advance directive. Interviews revealed that no discussion regarding advance directives took place with the resident due to their low cognitive status and lack of decisional capacity. The facility's policy requires that upon admission, the resident's decision-making capacity be determined, the primary decision maker identified, and existing choices reviewed with the resident or legal representative. However, this process was not followed, and no care plan was developed regarding advance directives for the resident, resulting in a failure to honor the resident's rights as outlined in facility policy.
Failure to Address Disruptive Resident Behaviors Affecting Homelike Environment
Penalty
Summary
The facility failed to address a resident's persistent yelling and disruptive behaviors, which deprived other residents of their right to a peaceful and homelike environment with comfortable noise levels. The resident in question had a history of insomnia, anxiety disorder, and major depressive disorder, and was documented by nursing staff to yell almost daily. Multiple residents and staff reported that the yelling occurred both day and night, disturbing sleep and causing distress to those nearby. Staff attempted interventions such as room changes and temporarily relocating the resident to other areas, but these measures did not resolve the issue. Despite the ongoing nature of the disruptive behaviors and their impact on other residents, there was no documented evidence that the behaviors were communicated to the psychiatric provider for further evaluation or intervention. Facility leadership, including the ADON, DON, and Administrator, were aware of the situation and acknowledged the negative effects on other residents, but no effective plan was documented or implemented to address the root cause of the behaviors. The facility's own policy stated that each resident had the right to a homelike atmosphere with comfortable noise levels, which was not maintained in this case.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements.
Failure to Develop and Implement Comprehensive Care Plan for PTSD Following PASRR Level 2 Determination
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with newly diagnosed post-traumatic stress disorder (PTSD) following a recent psychiatric hospitalization. The resident, who had a history of neurological and psychiatric conditions including hemiplegia, seizure disorder, anxiety, and bipolar disorder, experienced an acute exacerbation of mental health symptoms, including severe depression and suicidal ideation. After expressing suicidal thoughts and being placed on a legal hold, the resident was hospitalized and subsequently diagnosed with PTSD. Upon the resident's return to the facility, documentation showed that the baseline care plan referenced the need to implement PASRR recommendations for mental health needs. However, there was no evidence in the medical record that a comprehensive care plan specifically addressing PTSD was developed or implemented. Additionally, the facility did not conduct or document a PASRR Level 2 evaluation after the resident's acute change in condition, despite the previous PASRR Level 1 screening being outdated and no longer reflective of the resident's current mental health status. Further review revealed that a PASRR Level 2 determination had been completed by the hospital and indicated the need for specialized services, but this information was not incorporated into the resident's medical record or the most recent MDS assessment. The MDS Coordinator was unaware of the PASRR Level 2 process and confirmed that the new diagnoses and recommendations were not included in the care planning process, resulting in the absence of a comprehensive plan to address the resident's updated mental health needs.
Failure to Communicate New Skin Impairment to Wound Care Team
Penalty
Summary
A deficiency occurred when a new skin impairment on a resident's right great toe was not promptly communicated to the wound care team according to facility protocol. The resident, who had a history of acute and chronic respiratory failure and an ingrown nail, developed a blackened area on the toe after a podiatrist attempted but was unable to fully remove the ingrown nail due to pain. The resident reported the toe discoloration and pain to multiple staff members, but did not receive a response. A CNA noticed the blackened area and reported it to an LPN, but there was no evidence that the LPN communicated this to the wound care team. The CNA also did not complete the required 'Stop and Watch' form to document the change in condition. The wound care nurse and the assistant director of nursing confirmed that the facility's protocol required immediate reporting of new skin impairments to the wound care team for timely intervention. The delay in communication resulted in a delay in the wound care team being notified and in the initiation of appropriate interventions. Facility policy required daily skin checks by CNAs and weekly evaluations by licensed nurses, but these protocols were not followed, leading to a delay in addressing the resident's skin impairment.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Timely Catheter Care and Physician Notification
Penalty
Summary
The facility failed to provide appropriate care and timely assessment for a resident with an indwelling Foley catheter. The resident, who had diagnoses including neoplasm of the kidney, obstructive and reflux uropathy, and benign prostatic hyperplasia, had physician orders for weekly changes of the urinary drainage bag and as-needed catheter changes for obstruction or dislodgement. Observations revealed the resident had a Foley catheter and drainage bag in place with dark yellow, cloudy urine containing visible sediment and a foul odor. The resident reported the catheter and drainage bag had not been changed in over a month, and staff attributed moisture in the resident's diaper to leakage from the catheter insertion site. The LPN confirmed the presence of sediment, an old and discolored drainage bag, and cloudy, foul-smelling urine, but there was no evidence in the medical record that the catheter was assessed in a timely manner, the physician was notified of the foul-smelling urine, or that the change in condition was documented. Further review showed that although the treatment administration record indicated weekly catheter changes, these were not performed as ordered. The Assistant Director of Nursing and Director of Nursing both confirmed that staff were expected to follow physician orders, assess for changes in condition, and document findings, including using the SBAR process for communication. However, there was no documentation of leakage, symptoms of urinary tract infection, or physician notification. Facility policy required monitoring and documentation of urine characteristics and prompt notification of abnormal findings, but these procedures were not followed for this resident.
Failure to Follow and Document Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that enteral feeding orders for a resident with a gastrostomy tube were followed as prescribed, and that the total volume delivered was consistently monitored and documented. The resident, who was entirely dependent on tube feeding due to dysphagia and had diagnoses including risk for malnutrition, diabetes mellitus, and dementia, had a physician order for Nepro 1.8 at 35 mL/hour for 15 hours daily, totaling 525 mL per day. Observations revealed that the tube feeding was not always flowing as ordered, and the total volume delivered over a 30-day period was 1,927 mL less than prescribed. The Medication Administration Record (MAR) lacked consistent documentation of the total tube feeding volume administered. Interviews with nursing staff, the Assistant Director of Nursing, the Registered Dietitian, and the physician confirmed that the ordered volume was not fully administered and that monitoring and documentation were insufficient. The Registered Dietitian noted that the resident's tube feeding met only 88.9% of daily caloric needs and 72.8% of protein needs, and that requests to nursing staff to document total volume delivered had not been implemented. Facility policy required daily monitoring and documentation of enteral nutrition intake, but this was not consistently followed for the resident in question.
Failure to Communicate Behavioral Health Needs and Refer for Psychotherapy Services
Penalty
Summary
The facility failed to ensure that a resident with a history of insomnia, anxiety disorder, and major depressive disorder received necessary behavioral health care and services. The resident was observed and reported by staff and other residents to be yelling constantly, both day and night, which disrupted the sleep and well-being of nearby residents. Nursing staff documented these behaviors almost daily, and multiple staff members, including LPNs and the ADON, were aware of the ongoing disruptive behaviors. Despite this, there was no documented evidence that these behaviors were communicated to the psychiatric provider, nor was a psychiatric consult requested to address the resident's behavioral health needs. Interviews with staff revealed that non-pharmacological interventions, such as room changes and separating the resident from others, were attempted but proved ineffective. The psychiatric nurse practitioner confirmed only seeing the resident once for an unrelated issue and was not informed of the ongoing disruptive behaviors. The DON acknowledged awareness of the behaviors and their negative impact on other residents but admitted that no one had thought to refer the resident for a psychiatric consult, which could have allowed for further evaluation and intervention. Additionally, the facility failed to refer the resident for bedside psychotherapy services through their contracted Behavioral Health Services provider. The process required identification by the interdisciplinary team (IDT) and a referral for Medicaid approval, but the resident was neither identified nor referred, despite being classified as a Tier one resident due to disruptive behaviors. The facility's own policy required documentation of provided or attempted behavioral health services, but the medical record lacked evidence of such referrals or services for this resident.
Failure to Monitor Target Behaviors for Medication Used to Treat PTSD
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not monitoring target behaviors for a medication prescribed to treat Post Traumatic Stress Disorder (PTSD). The resident, who had a history of chronic respiratory failure with hypercapnia and PTSD, was prescribed Prazosin to address night terrors associated with PTSD. Although the physician’s order specified that the medication was for night terrors, there was no documented evidence in the resident’s medical record that these target behaviors were being monitored as required. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that Prazosin, while not classified as a psychotropic medication, was being used off-label for a psychiatric diagnosis and should have been monitored for effectiveness and adverse effects. Both the ADON and DON acknowledged that the resident’s night terrors, the target behavior for the medication, were not being tracked. The facility’s policy required monitoring and documentation of residents’ responses to psychotropic medications, including symptoms, behaviors, and side effects, but this was not followed in this case.
Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication pass, resulting in a calculated error rate of 9.68% based on 31 observed opportunities and three identified errors. During the medication administration, an LPN gave a resident Aspirin 81 mg without a physician order, did not administer the prescribed Multivitamin 18 mg with iron and folic acid, and administered Vistaril (hydroxyzine pamoate) 25 mg at the incorrect time, contrary to the physician's specific instructions. The LPN acknowledged mistaking the Aspirin bottle for the Multivitamin and confirmed the errors in medication administration and timing. The resident involved had diagnoses including hemiplegia, major depressive disorder, and generalized anxiety disorder, and was under a care plan that included monitoring for complications related to blood thinning medications. The errors were confirmed by the LPN, the Assistant Director of Nursing, the Pharmacist Consultant, and the Nurse Practitioner, all of whom verified that the medications were not administered as ordered. Facility policy required staff to follow the eight medication rights, including administering the right drug at the right time, which was not adhered to in this instance.
Failure to Develop and Implement a Facility-Specific QAPI Plan
Penalty
Summary
The facility failed to ensure that a Quality Assurance Performance Improvement (QAPI) plan was in place, as required by regulations. During an interview, the Administrator acknowledged that there was no specific QAPI plan, and that the facility was relying on its QAPI policy as a substitute. Document review revealed that the existing policy, titled 'Quality Assurance and Performance Improvement Program Committee Guidelines' and last revised in 2019, did not include the necessary elements for a QAPI plan, such as processes for guiding performance improvement efforts, tracking and measuring performance, or identifying and correcting quality deficiencies. Further, the Administrator confirmed that the QAPI plan should be individualized to the facility, including vision, mission, and purpose statements, as well as guiding principles tailored to the specific units, programs, departments, and population served. The lack of a comprehensive and facility-specific QAPI plan was acknowledged by the Administrator, and it was noted that the current policy did not meet the requirements outlined in the state operations manual.
Deficient Food Safety Practices in Kitchen and Refrigeration
Penalty
Summary
The facility failed to maintain a clean food preparation environment and ensure proper refrigeration of food products, potentially exposing residents to foodborne illnesses. During an inspection, it was observed that the kitchen's exhaust hood and oven were greasy and dusty, with food debris on the floor behind cooking equipment. The preparation area floor was soiled, and a fan was improperly used, blowing air onto food. Additionally, the air conditioning vents were dusty and corroded. The kitchen manager admitted that the cleaning schedule was inadequate and acknowledged the improper use of fans. The walk-in refrigerator's temperature was not maintained within the safe range, with internal thermometers reading significantly higher than the required 34 to 40 degrees Fahrenheit. Despite the external thermometer showing a lower temperature, the internal readings indicated unsafe conditions for food storage. The kitchen manager confirmed the discrepancy and noted that staff relied on the external thermometer for documentation. Food items, including dairy products and frozen goods, were found at unsafe temperatures, leading to their disposal. The facility's policy required maintaining the refrigerator's ambient temperature between 34 and 40 degrees Fahrenheit, which was not adhered to.
Refrigerator Malfunction Leads to Unsafe Food Storage
Penalty
Summary
The facility failed to maintain a walk-in refrigerator in proper working condition, resulting in unsafe temperature levels for stored food products. On multiple occasions, the internal thermometers of the refrigerator indicated temperatures significantly above the safe range, with readings of 54 to 58 degrees Fahrenheit. Despite the external thermometer showing a lower temperature, the internal readings were consistently high, indicating a malfunction. The kitchen manager acknowledged the issue but did not immediately relocate the food products to a safer environment, which could have prevented the exposure of residents to foodborne illnesses. The kitchen manager failed to report the malfunctioning refrigerator to the maintenance department promptly. The Maintenance Director confirmed that no report was received regarding the refrigerator issue on the dates in question. Additionally, the facility's Engineering Repair Request form lacked documentation of any concerns reported by the kitchen staff about the refrigerator. The last preventive maintenance check, conducted a day before the issue was observed, did not identify any problems, suggesting a lack of immediate follow-up or communication regarding the malfunction.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to monitor the signs and symptoms of bleeding for a resident on anticoagulants, which was identified as a deficiency. Resident 2, who was admitted with diagnoses including anoxic brain damage and iron deficiency anemia, was prescribed Heparin Solution to be administered subcutaneously every 12 hours for deep vein prophylaxis. Although the medication was administered as ordered, the medical records lacked documented evidence of monitoring for signs and symptoms of bleeding until a month after the prescription was given. On observation, the resident was found to have minimal bleeding and bruising in the lower abdomen, which was confirmed by an LPN. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both acknowledged that residents on anticoagulant medications should be monitored for signs of bleeding, and an order for such monitoring should have been in place. The facility's policy on anticoagulation monitoring emphasized individualized management to reduce harm, but the necessary monitoring orders were not obtained and transcribed in a timely manner, leading to this oversight.
Failure to Prevent Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate care to prevent a stage 4 pressure ulcer in one resident, who was at risk due to conditions such as paraplegia and muscle wasting. The resident was admitted with a Braden Scale score indicating a risk for pressure ulcers, and the care plan included daily skin inspections and repositioning every hour. However, the facility did not document any skin evaluations from late January until the end of February, when the ulcer was identified. Additionally, the record showed that repositioning was not documented for two weeks prior to the ulcer's discovery. Interviews with staff revealed that CNAs were expected to check skin daily and report changes, while nurses were to perform weekly skin checks. The Wound Care Nurse confirmed that the ulcer was unstageable when first identified and later classified as stage 4. The DON acknowledged that the Point of Care system failed to display repositioning options after mid-February, but staff should have continued the practice regardless. The lack of documented skin assessments and repositioning contributed to the development of the pressure ulcer, which was deemed avoidable if the processes had been followed.
Failure to Implement Physician Orders for Splinting
Penalty
Summary
The facility failed to ensure that a physician order for splint application was obtained and implemented for two residents with contractures. Resident 2 was admitted with contractures of the hands and atrophy, and despite a care plan indicating the need for palm protector splints or hand rolls, there was no documented evidence of a physician order for these interventions. Observations revealed that Resident 2 was in bed with fingers digging into the palms, and family members were applying rolled towels to the hands. The Director of Rehabilitation Services and the lead Restorative Nursing Assistant acknowledged the delay in obtaining and transcribing the necessary orders, which was attributed to challenges in processing paperwork in a timely manner. Resident 77, who was admitted with hemiplegia, hemiparesis, and a right-hand contracture, also did not have a splint in place despite recommendations for rehabilitation services and a right-hand splint. The Director of Rehabilitation Services confirmed that the implementation of the splinting was delayed, and the Assistant Director of Nursing acknowledged the lack of an updated care plan and the delay in order transcription. Observations showed that Resident 77 was in bed with a contracture on the right arm and a closed fist, and the resident reported not having received rehabilitation services. The facility's policies on joint mobility and restorative nursing emphasized the importance of implementing a restorative program through the care plan to maintain or improve joint mobility. However, the failure to obtain and implement physician orders for splinting as recommended by the rehabilitation department led to deficiencies in the care provided to the residents. The Director of Nursing highlighted the need for better communication among staff to ensure the prompt implementation of splinting to prevent further contracture or injury.
Failure to Complete Nutritional Assessment and Obtain Care Orders for PEG Tube
Penalty
Summary
The facility failed to complete a nutritional assessment for a resident with a percutaneous endoscopic gastrostomy (PEG) tube upon readmission, as required by policy. The resident, who had anoxic brain injury and dysphagia, was readmitted with a PEG tube for feeding. Observations revealed that the tube feeding was not infusing, and the nutritional assessment was outdated from the resident's previous stay. The Licensed Practical Nurse and Assistant Director of Nursing confirmed that the assessment should have been completed by the Registered Dietitian upon readmission, but it was not done until several days later. Additionally, the facility did not obtain and transcribe care orders to manage the resident's PEG tube upon readmission. The resident's medical records lacked documentation of care orders such as verification of PEG tube placement, elevating the head of the bed, and monitoring for complications. The Wound Care Certified Nurse and Director of Nursing indicated that these orders should have been obtained and implemented by the assigned licensed nurses. The resident was observed to be bloated, and the family expressed concerns about the resident's condition. The facility's policy required physician orders for all enteral feedings and monitoring for complications. However, the necessary care orders were not in place, and the staff did not follow the policy to ensure proper management of the resident's PEG tube. This oversight could potentially compromise the resident's safety and well-being, as the care orders were essential for managing the resident's nutritional needs and preventing complications.
Failure to Post Accessible Daily Staffing Information
Penalty
Summary
The facility failed to post daily staffing information in a location accessible to residents and visitors, as required. During a tour of the facility, it was observed that the staffing information, including licensed nurses and Certified Nurse Assistant assignments, was posted on small-sized paper near the nursing stations. The postings were affixed to the corridor wall at a height of four to five feet above the floor, with text in approximately size-14 font, making it difficult to read unless viewed up close. Additionally, the staffing documents did not include the total Patient Per Day (PPD) hours information. The Director of Nursing confirmed that this was the customary practice for daily staffing postings. The Administrator acknowledged the requirement for the staffing information to be posted in a prominent place, such as the front lobby, and in a larger font for ease of review, including the PPD information.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two errors identified out of 30 opportunities, resulting in an error rate of 6.67%. The deficiency involved a resident who was admitted with diagnoses including muscle weakness and spasms. On a specific date, an LPN prepared the resident's medications but failed to administer vitamin B12 tablets and Refresh eye drops as ordered by the physician. The Medication Administration Record inaccurately documented that the resident refused these medications. Upon further investigation, the resident confirmed that they had not refused the medications and expressed a desire to receive them, particularly the eye drops for eye dryness. The LPN admitted to missing the administration of the medications and incorrectly documenting the refusal without consulting the resident. Additionally, the LPN did not notify the physician of the supposed refusal, as required by the facility's policy. The Director of Nursing confirmed that staff are expected to accurately document medication administration, missed doses, or actual refusals.
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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