Las Vegas Post Acute & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 2832 S. Maryland Parkway, Las Vegas, Nevada 89109
- CMS Provider Number
- 295006
- Inspections on file
- 22
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Las Vegas Post Acute & Rehabilitation during CMS and state inspections, most recent first.
A resident with significant medical conditions, including a thoracic spinal lesion and CKD stage 4, reported being struck on the left hand with a telephone by a roommate after telling the roommate to stop yelling at staff. The injured resident was observed with a bandaged left hand and was documented to have a superficial skin tear with discoloration on the dorsal hand. The aggressor, who had a history of CVA with hemiplegia but was previously assessed with intact cognition and no behaviors, admitted to willfully hitting the other resident with the phone. Facility documentation and staff interviews confirmed that this resident-to-resident altercation met the facility’s definition of physical abuse involving willful infliction of injury with an object.
The facility failed to report two separate allegations of physical abuse to the state agency within the required timeframe. In one incident, a resident with multiple fractures and depression alleged being hit in the face by a CNA after using foul language; the charge nurse documented the event the same evening, but the DON did not review the documentation until days later, and the state report was submitted beyond the 24-hour requirement. In another incident, one resident struck another with a phone, causing a skin tear and prompting law enforcement involvement and a psychiatric evaluation; again, the DON learned of the event days later and the state report was submitted late. The Assistant Administrator stated they believed the 24-hour reporting requirement applied to business days, despite facility policy requiring immediate reporting with specific 2-hour and 24-hour limits.
A resident with multiple chronic conditions did not receive or have documented daily foot wound treatments as ordered by the physician on several dates. The absence of signatures on the TAR was confirmed by both the Wound Care Nurse and DON, indicating the treatments were not performed when the assigned nurse was unavailable.
A multi-dose vial of Applisol PPD TB was found in a medication cart with unclear labeling regarding its open and discard dates. A nurse could not determine the meaning of the date on the box and confirmed the medication should have been stored in a refrigerator, as per facility policy. The medication was not stored at the recommended temperature, and the labeling did not meet professional standards.
Two residents received continuous supplemental oxygen from concentrators that were overdue for annual preventative maintenance. Maintenance staff and nursing confirmed the equipment had not been serviced as required, and the head of maintenance responsible for scheduling biomedical servicing was on leave. Facility policy assigns responsibility for maintaining equipment schedules to the Maintenance Director.
A facility failed to complete a PASARR Level II referral for a resident who was later diagnosed with dementia and exhibited symptoms requiring further evaluation. Initially deemed appropriate for nursing facility placement, the resident's condition changed, necessitating a Level II screening. The social worker responsible for PASARR requests was unaware of the need for this referral, leading to a deficiency in ensuring the resident received necessary behavioral health services.
A facility failed to document a discharge plan for a resident with schizoaffective disorder and suicidal ideations. Despite the care plan's requirement to initiate discharge planning upon admission, there was no evidence of such planning or discussions with the resident or their representative. The Social Services Director confirmed the absence of documentation, and no IDT meeting was scheduled as required by the facility's policy.
The facility failed to limit PRN psychotropic medication orders to 14 days for three residents, with orders for Alprazolam, Lorazepam, and Hydroxyzine HCl exceeding this duration without documented justification. Additionally, consents for these medications were not obtained, violating the facility's policy on medication management and resident rights.
A resident with end-stage renal disease was not provided the correct dietary orders upon readmission, leading to a risk of weight loss. The resident was supposed to be on a renal diet with regular texture, but was instead given a mechanical soft texture diet. The resident expressed dissatisfaction with the food options, and the facility's dietary management process failed to align with the physician's orders.
A facility failed to maintain complete medical records for a resident with major depressive disorder, bipolar disorder, and PTSD. The medical record lacked nurse's notes and a weekly summary form. The DON confirmed that nurses were expected to complete specific charting forms upon admission and weekly. The Medical Records Supervisor and an LPN confirmed the absence of required documentation, which should have been completed according to the facility's policy.
The facility failed to develop and implement at least one Performance Improvement Project (PIP) per year. Despite holding monthly QAPI meetings, the facility could not provide documentation of a completed PIP. The DON mentioned a planned PIP to address laboratory result timelines due to sample degradation issues, but lacked documentation of data collection, analysis, or action plan development. This indicates non-compliance with their QAPI plan and regulatory requirements.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Hand Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident willfully struck another with a telephone, causing injury. One resident with a history of complete lesion at thoracic vertebra (T11-T12) and stage four chronic kidney disease reported that a former roommate, described as someone who yelled at staff all day, hit them on the left hand with a telephone after being told to stop yelling. On observation, the injured resident had a bandage on the left hand, and the resident identified this as the site of injury from the altercation. Documentation in a Resident Event form and Incident Narrative confirmed that a resident-to-resident altercation occurred in which the aggressor hit the injured resident’s left hand with a phone, resulting in a skin tear. A Skin/Wound Progress Note recorded a left dorsal hand skin tear measuring 1.5 cm by 0.5 cm, superficial in depth, red with blood tinge, and with small dark red discolorations but no swelling. The aggressor resident, who had diagnoses including idiopathic neuropathy and hemiplegia/hemiparesis due to cerebrovascular accident, had an admission MDS indicating intact cognition and no behaviors, but later physician orders and nursing notes documented that this resident was transferred to the hospital on a mental health crisis hold for physical aggression toward another resident. Facility staff, including social services and nursing leadership, stated that the aggressor admitted to willfully hitting the other resident with the telephone, and the facility’s investigation concluded that physical abuse occurred as defined in the facility’s Patient Abuse and Prevention policy, which includes willful infliction of injury and assault with a weapon likely to produce bodily harm.
Failure to Timely Report Alleged Physical Abuse to State Agency
Penalty
Summary
The facility failed to submit allegations of physical abuse to the state agency within 24 hours of being informed of the incidents for two reviewed reports. In the first case, a resident admitted with multiple fractures from a motor vehicle accident and depression alleged that a CNA hit them in the face after the resident used foul language. The incident occurred in the evening, and the charge nurse on duty completed a Report Event form and an Incident Narrative form dated the same day to communicate the alleged physical abuse to the DON. The DON stated that they did not become aware of the incident until the following Monday when they read the forms, and the initial and final report to the state agency was not submitted until several days after the allegation was made. The DON acknowledged that the report was not submitted within the mandated 24-hour window, and state agency records confirmed receipt of the initial report beyond that timeframe. In the second case, an incident report documented that one resident hit another resident with a phone, causing a skin tear to the victim’s left hand. Law enforcement responded, and the aggressor was ordered to be sent to the hospital for psychiatric evaluation. The DON reported learning of this incident the Monday after it occurred, and the initial and final report to the state agency was submitted several days later, outside the required 24-hour reporting period. The Assistant Administrator stated they believed allegations of abuse were to be reported within 24 business hours rather than calendar hours and confirmed that the allegations of physical abuse involving the residents were submitted late. The facility’s Abuse Investigation and Reporting policy required alleged violations of abuse to be reported immediately, and no later than two hours if involving abuse or serious bodily harm, and within 24 hours if not involving abuse and not resulting in serious bodily harm.
Failure to Document and Administer Ordered Foot Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to provide documented evidence that foot wound treatments were administered according to physician orders for one resident. The resident, who had diagnoses including idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, and arthropathic psoriasis, had physician orders for daily cleansing and application of Clobetasol cream to both feet. Review of the July Treatment Administration Record (TAR) revealed missing documentation for the completion of these treatments on three specific dates. The resident reported that wound care was not provided when the usual staff member was on leave. Interviews with the Wound Care Nurse and the Director of Nursing confirmed that the absence of signatures on the TAR indicated the treatments were not performed on those dates. The facility's policy required wound care to be provided as ordered to promote healing. The lack of documentation and missed treatments were verified by both the Wound Care Nurse and the DON, who acknowledged that the treatments were not completed as required.
Improper Labeling and Storage of Medication
Penalty
Summary
Surveyors observed that a multi-dose vial of Applisol purified protein derivative (PPD) Tuberculosis (TB) was found in the 300 Hall medication cart with a box labeled only with the date '7/10.' The nurse responsible for the cart was unable to clarify whether this date represented the date the vial was opened or the discard date. The nurse confirmed that the labeling was unclear and acknowledged that the vial should have been labeled with both an open and discard date. Additionally, the nurse stated that the medication should have been stored in the medication refrigerator, and that storing it outside the recommended temperature would render it unsafe for administration. Facility policy requires that drugs and biologicals be stored in locked compartments under proper temperature, light, and humidity controls.
Failure to Perform Annual Preventative Maintenance on Oxygen Concentrators
Penalty
Summary
The facility failed to ensure that annual preventative maintenance (PM) was performed on medical equipment, specifically oxygen concentrators, for two residents. One resident, with a history of cerebral infarction and physical debility, was receiving continuous supplemental oxygen via a concentrator that had a PM sticker indicating the last service was over a year overdue. Maintenance personnel confirmed that the equipment had not been serviced as required. Another resident, diagnosed with atherosclerotic heart disease and myocardial infarction, was also receiving continuous oxygen from a concentrator that was past its scheduled PM date. The nurse caring for this resident confirmed the equipment was overdue for maintenance. Further investigation revealed that the head of maintenance, who was responsible for coordinating annual biomedical servicing of medical equipment, was on leave at the time. Maintenance staff acknowledged that the oxygen concentrators throughout the facility were not up to date with their annual PM. According to facility policy, the Maintenance Director is responsible for maintaining a schedule to ensure all equipment is kept in a safe and operable condition. The lack of timely maintenance had the potential to impact the intended function of the medical devices used by the residents.
Failure to Complete PASARR Level II Referral
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II referral was completed for one of the sampled residents. The resident in question was admitted with primary diagnoses including hypertension, neuropathy, atrial fibrillation, and a right hip fracture. Initially, a PASARR Level I document indicated that the resident did not have dementia, mental illness, intellectual disability, or any related condition, and was deemed appropriate for nursing facility placement. However, the resident was later diagnosed with dementia, and a psychiatry note revealed a neurocognitive disorder with intermittent agitation and behavioral disturbances, for which the resident was prescribed medications. Despite these developments, the medical record lacked evidence of a PASARR Level II referral, which is required when a resident exhibits behavioral, psychiatric, or mood-related symptoms suggesting a mental disorder. The social worker responsible for completing PASARR requests admitted to not being aware of some residents who should have been identified for a PASARR Level II review, including this resident. This oversight had the potential to prevent the resident from receiving necessary behavioral health services.
Lack of Documented Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide documented evidence of a discharge plan for a resident, identified as Resident 190, who was admitted with diagnoses including schizoaffective disorder (bipolar type) and suicidal ideations. The admission care plan indicated that discharge planning should begin upon admission. However, the medical record for Resident 190 lacked documentation of any discharge plan initiation or discussion with the resident or their representative. The Social Services Director acknowledged that there was no documentation of the discharge planning process, including discussions with the resident or their representative, interdisciplinary team (IDT) notes, or social services progress notes in the resident's medical record. Interviews with facility staff revealed that the Social Services Assistant was responsible for scheduling IDT meetings every 14 days upon admission, quarterly, and as needed. However, there was no IDT meeting scheduled for Resident 190 within the specified timeframe. The facility's policy on discharge planning, dated October 2012, required that discharge planning be developed at the time of admission and reviewed quarterly, with documentation in the resident's clinical record. The policy also stated that the resident and/or family should be involved in the formulation of discharge plans and post-discharge care, which was not evidenced in Resident 190's case.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were initially ordered for a duration not exceeding 14 days for three residents. Resident 11 was prescribed Alprazolam for anxiety with an initial order duration of 30 days, which exceeded the 14-day limit. The Director of Nursing (DON) and the Consultant Pharmacist confirmed that the medication should not have been ordered for more than 14 days initially. Similarly, Resident 188 was prescribed Lorazepam for anxiety with a 30-day PRN order, lacking documented justification for extending beyond 14 days. The DON acknowledged the oversight and confirmed that a consent for the administration of Lorazepam was not obtained. Resident 64 was prescribed Hydroxyzine HCl for anxiety with a 30-day PRN order, also lacking documented justification for the extended duration. The DON and Medical Records Supervisor confirmed the absence of consent for the medication. The facility's policy required that PRN orders for psychotropic medications beyond 14 days needed documented rationale, and consents should be obtained to inform residents or their representatives about the medication's effects and potential side effects. The failure to adhere to these policies resulted in deficiencies related to medication management and resident rights.
Failure to Follow Dietary Orders for Resident on Renal Diet
Penalty
Summary
The facility failed to ensure dietary orders were followed for a resident on a renal diet, which placed the resident at risk for weight loss. The resident, who was readmitted with diagnoses including end-stage renal disease, was supposed to be on a renal diet with regular texture and thin liquids as per the physician's order. However, the meal ticket documented a renal diet with mechanical soft texture, which was not in accordance with the physician's order. The resident expressed dissatisfaction with the food, noting it was always the same and chopped up, and complained about the lack of salads due to the ordered diet. The Dietary Manager confirmed that the kitchen received a written notification of the diet, but the resident frequently requested a salad, which was not allowed under the mechanical soft texture requirements. The Speech Therapist acknowledged that there was no order for a diet evaluation after the resident's readmission. A Registered Dietician noted that the resident had been on a mechanical soft diet for a long time before leaving for rehabilitation, and it was possible the facility continued with the last known diet from before the resident's departure. The facility's policy indicated that each resident should receive a diet based on a multidisciplinary assessment, but this was not adhered to in this case.
Failure to Maintain Complete Medical Records
Penalty
Summary
The facility failed to ensure that the medical record for one resident, identified as Resident 188, contained the necessary nurse's notes and weekly summary form. Resident 188 was admitted with diagnoses including major depressive disorder, bipolar disorder, and post-traumatic stress disorder. Upon review, it was found that there were no nurse's notes or weekly summary form completed and filed in the resident's medical record. The Director of Nursing confirmed that nurses were expected to complete the 72-Hour Nurses Charting form every shift upon a resident's admission and a weekly summary form for each resident. Additionally, the Medical Records Supervisor confirmed the absence of the required documentation in the medical record of Resident 188. A Licensed Practical Nurse indicated that the 72-Hour Nurses Charting form, Daily Skilled Nursing Notes, and Weekly Summary charting should have been completed and filed in the resident's medical record, as per the facility's policy.
Failure to Implement Performance Improvement Project
Penalty
Summary
The facility failed to develop and implement at least one Performance Improvement Project (PIP) per year, as required. During an interview on June 28, 2024, the Administrator confirmed that Quality Assurance Performance Improvement (QAPI) committee meetings were held monthly, with usual attendees including the Administrator, the Medical Director, and the Director of Nursing (DON). However, the facility was unable to provide documentation of a completed PIP within the past year. The DON reported a planned PIP aimed at improving laboratory result timelines due to issues with sample degradation through hemolysis, but was unable to provide documentation of the method of data collection, analysis, action plan development, implementation, evaluation, or any modifications to the plan. The QAPI Plan dated January 12, 2023, indicated that PIPs were to be established based on potential negative outcomes, the number of residents affected, and recurrence of issues. Data was to be reviewed, and the PIP would continue until improvement was maintained. Despite these guidelines, the facility lacked documentation of any PIP completed over the past year, indicating a failure to adhere to their own QAPI plan and regulatory requirements.
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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