Northern Nevada State Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sparks, Nevada.
- Location
- 36 Battleborn Way, Sparks, Nevada 89431
- CMS Provider Number
- 295105
- Inspections on file
- 28
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Northern Nevada State Veterans Home during CMS and state inspections, most recent first.
The facility failed to ensure timely completion of elder abuse prevention training for 10 employees, including the Executive Director, RNs, LPNs, CNAs, and other staff. Despite the facility's policy requiring training during orientation, several employees either lacked documentation of training or completed it late, yet were allowed to work with residents. This oversight potentially placed all residents at risk for abuse and neglect.
A resident with a documented allergy to animal hair and a care plan indicating a preference against pet therapy was approached by a therapy dog handler, leading to the resident feeling disrespected. The facility staff failed to communicate the resident's preference to the pet therapy organization, resulting in a breach of the resident's rights.
A long-term care facility failed to ensure proper medication administration, resulting in deficiencies. A resident with heart failure received Spironolactone despite a heart rate below the prescribed threshold due to an inaccurate transcription of the physician's order. Additionally, an LPN improperly administered eye drops to a resident with dementia, failing to follow the correct technique. The DON confirmed the expectations for medication administration were not met, and the facility's policies were not adhered to.
The facility failed to ensure that two direct care staff members, both RNs, maintained current CPR certification as required by their job descriptions. Employee #11 lacked documented evidence of CPR training, while Employee #12 had an expired CPR certification. The Human Resources Director confirmed the requirement for CPR certification for all direct care staff, as documented in the Facility Assessment.
A resident with PTSD and depression did not receive individualized activities to meet their needs and interests. The resident preferred staying in their room and needed help with electronic devices to alleviate depression. The facility's activities staff failed to engage with the resident or document interactions, despite the care plan acknowledging the resident's preferences. The last documented activity was a self-directed engagement with movies or television.
A medication cart was left unlocked in a unit with residents present, risking unauthorized access. Additionally, expired medications were found in a cart and storage room, including Docusate Sodium, Ondansetron, an IV solution, and Tuberculin Purified Protein Derivative. An RN confirmed the oversight, and the DON emphasized the need for immediate removal of expired medications.
The facility failed to ensure culinary staff checked holding temperatures for all hot foods before meal service in two dining rooms. In the [NAME]/Quail room, mechanical soft fish was served at 128°F, below the required 135°F. In the Aspen/Pinion room, minced vegetables were served at 132°F without rechecking. The facility's policy required hot foods to be held and served at a minimum of 135°F.
A facility failed to maintain accurate EMR and MAR records, leading to discrepancies in a resident's code status and medication orders. One resident's POLST indicated DNR, but the EMR showed full CPR, while another resident's Spironolactone order was incorrectly transcribed to include unnecessary heart rate monitoring. These errors could have compromised resident safety.
The facility failed to offer timely pneumonia vaccines to two residents, one of whom had serious respiratory and cardiac conditions, and another who had previously received a PPV23 vaccine but was not offered the subsequent PCV as recommended. The Infection Preventionist confirmed the lack of documentation and follow-up, indicating a lapse in the facility's immunization practices.
The facility failed to provide education on the risks and benefits of the COVID-19 vaccine and offer the vaccine to two residents. One resident's clinical record lacked documentation of being offered or receiving the vaccine, while another resident refused the vaccine without receiving the necessary education. The Infection Preventionist confirmed these deficiencies, which were not in compliance with the facility's vaccination policy.
A resident with a history of frequent falls and cognitive impairment experienced an unwitnessed fall resulting in head and body injuries. Despite consistently high BP readings and a visible head injury, the LPN did not review or act on the vital signs documented by the CNA, nor notify the physician. The resident was only sent to the hospital after the night shift nurse recognized the concerning findings and contacted the physician, constituting neglect as defined by facility policy and state regulations.
A resident with multiple medical conditions experienced an unwitnessed fall resulting in a subdural hematoma and was transferred for neurosurgical evaluation. Despite the serious injury and facility policy requiring immediate reporting of such incidents, the event and related allegations against the former DON were not reported to the State Agency or thoroughly investigated.
A resident with a history of frequent falls was found on the floor with multiple injuries and was later diagnosed with a subdural hematoma. Despite allegations that the former DON instructed staff not to send the resident to the hospital or provide care, facility leadership did not thoroughly investigate or report the allegations, contrary to facility policy.
The facility did not update nursing staff postings for all units, with the last update being on March 7, 2025. The Staffing Coordinator was responsible for weekday postings, while an RN was responsible for weekends. The RN admitted to not updating the postings for March 8 and 9, 2025, resulting in outdated information and a lack of awareness for residents and visitors about the nursing and direct care staff on duty.
A resident with PTSD and major depressive disorder was verbally abused by a CNA who used profane language during an interaction. The resident, feeling annoyed, yelled at the CNA to leave, prompting the CNA to respond with profanity. The facility's investigation confirmed the verbal abuse, which violated the facility's policies on resident rights and CNA professionalism.
A facility failed to submit an accurate and timely Facility Reported Incident (FRI) regarding verbal abuse towards a resident with major depressive disorder and vascular dementia. The initial report contained an incorrect incident date, and the final report was not submitted within the required timeframe. The Regional Director confirmed these discrepancies, which violated the facility's policy on reporting abuse allegations.
During a tour of the secured memory care unit, various potentially harmful substances and items were found accessible to residents with severe cognitive impairments. Items such as alcohol-based hand rub, antibacterial hand soap, medications, sharp objects, and potentially toxic cleaning solutions were discovered in resident rooms and common areas. These residents, diagnosed with dementia and cognitive impairments, require a secure environment due to impaired safety awareness. The presence of these hazardous items poses a risk of ingestion or harm. The DON acknowledged that these items should not have been accessible, highlighting a lapse in adherence to the facility's policy on Memory Care Accident Hazards/Supervision.
A maintenance worker entered a resident's room without knocking or asking for permission, violating the resident's right to dignity and self-determination. The facility's policy requires staff to knock and ask for permission before entering a resident's room, but this was not followed in this instance.
A resident with Alzheimer's and severe dementia was found with a severe leg wound requiring emergency treatment. The facility failed to promptly investigate and report the injury to the State agency, as required by their abuse policy. The investigation was delayed, and the policy lacked specific timeframes for reporting.
A resident with Alzheimer's and severe dementia was found with a large, bleeding wound on their lower leg that required emergency treatment and sutures. The facility failed to report the injury of unknown origin to the State Agency immediately, as required by their policy, delaying the investigation into the cause of the injury.
A facility failed to include oxygen therapy in the baseline care plan for a resident with COPD, despite hospital discharge instructions and nursing notes indicating the need for chronic oxygen therapy. Observations confirmed the resident was using an oxygen concentrator, and both a Registered Nurse and the Director of Nursing acknowledged the omission in the care plan.
The facility failed to update a resident's care plan to match the physician's order for oxygen therapy and had inappropriate care plan interventions for three residents in the memory care unit. The care plans for these residents were not aligned with the facility's policy on comprehensive and person-centered care.
A resident with dementia and anxiety did not ingest their prescribed Metoprolol Succinate as required. A pill was found on the resident's side table, and it was confirmed that the nurse did not stay to ensure the medication was swallowed, violating the facility's medication administration policy.
The facility failed to ensure that an LPN was trained and certified to perform CPR, as required by facility policy. The Human Resources Director confirmed the lack of current CPR certification for the LPN, despite it being a requirement upon hire.
The facility failed to ensure a resident's medication orders were coordinated with the contracted hospice agency, resulting in discrepancies between the facility's orders and the hospice's Client Medication Report. Interviews revealed that medication reconciliation was not effectively implemented, and the designated Hospice Coordinator had limited interaction with hospice agencies after residents were admitted to hospice services.
The facility failed to follow physician's orders for respiratory care for two residents. One resident received oxygen at higher rates than prescribed, and another had an incomplete oxygen therapy order. Staff confirmed the discrepancies.
The facility failed to ensure MMRs were completed within the required timeframe for two residents. Both the Pharmacist and the DON confirmed that the MMRs for August 2023 were not completed within the stipulated 30 to 31 days as per the facility's policy.
The facility had a medication error rate of 8%, involving two residents. One resident's lidocaine patch was not removed as scheduled, and another resident's insulin pen was not prepared according to protocol. The DON confirmed the correct procedures were not followed.
The facility failed to ensure an employee wore appropriate hair restraints in the kitchen and did not perform hand hygiene before and after resident contact during a lunch service. A CNA was observed without a hair restraint covering their beard, and another CNA did not perform hand hygiene between delivering plates to residents.
The QAA Committee failed to identify the lack of timely training for staff. The Administrator confirmed that trainings were completed according to the online training company's standards, not regulatory standards, resulting in late completions.
The facility failed to ensure proper infection control practices during insulin administration and COVID-19 testing. An RN did not disinfect the rubber seal on an insulin pen before use, and a used COVID-19 test was found in a common area, used by a symptomatic staff member. These actions have the potential to spread communicable diseases.
The facility failed to ensure timely completion of elder abuse prevention training for three employees. A Registered Dietitian completed training one month past the anniversary date, while a CNA and an RN lacked documented evidence of annual training for 2024. The HR Director confirmed these deficiencies, noting that training is required upon hire and annually thereafter.
The facility failed to ensure annual behavioral health training for six employees, including the Administrator, DON, Recreation Director, a CNA, an RN, and the Infection Preventionist/LPN. Despite the policy requiring annual training, these employees only had dementia training documented for 2023, with no records for 2024.
The facility failed to update the Facility Assessment to reflect accurate staffing needs for the memory care unit. The FA documented a staffing plan of 1 staff member to 16 residents but did not include the memory care unit, which required a ratio of one staff member to eight residents. The Director of Nursing and the Administrator confirmed the discrepancy.
Delayed Elder Abuse Prevention Training for Staff
Penalty
Summary
The facility failed to ensure that initial elder abuse prevention training was completed in a timely manner for 10 out of 20 sampled employees. This deficiency was identified through personnel record review, interviews, and document review. Employees, including the Executive Director, Social Services Director, Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Culinary Staff, and Housekeepers, either lacked documented evidence of elder abuse prevention training or completed the training significantly late. The Human Resources Director confirmed that these employees had been working with residents prior to completing the required training. The facility's policy, revised in January 2023, mandates that all employees receive elder abuse prevention training during orientation and ongoing sessions, with training to be completed no less frequently than annually. Despite this policy, the facility did not adhere to its own guidelines, as evidenced by the delayed or missing training documentation for several employees. This oversight had the potential to place all residents at risk for abuse and neglect, as employees were not adequately trained before interacting with residents.
Failure to Respect Resident's Refusal of Pet Therapy
Penalty
Summary
The facility failed to honor a resident's right to refuse pet therapy, despite the resident having a documented allergy to animal hair and a care plan specifying the resident's preference not to be approached for pet therapy. On a specific occasion, a therapy dog handler approached the resident's room and asked if the resident would like a visit from the dog. The resident, who had previously communicated their allergy and preference to avoid pet therapy, expressed frustration and felt disrespected by the repeated inquiries. The handler was unaware of the resident's preference due to a lack of communication among the facility staff and the pet therapy organization. The resident's electronic health record documented an allergy to animal hair/dander, and the care plan was revised to reflect the resident's preference against pet therapy. However, the LPN and CNA responsible for the resident were not informed about the pet therapy schedule or the need to avoid certain residents. The Volunteer Services Director/Interim Activities Director acknowledged that the pet therapy organization should have been informed about residents who did not wish to participate, and the DON confirmed that the resident should not have been approached, indicating a breakdown in communication and adherence to the facility's policies on resident rights and pet therapy.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that nurses adhered to professional standards of medication administration, as outlined in the State Board of Nursing Nurse Practice Act. Specifically, there was a failure to verify the appropriateness of a medication order for a resident diagnosed with heart failure. The resident's medication administration record (MAR) documented the administration of Spironolactone, which was supposed to be held if the resident's heart rate was below 60 beats per minute. However, the medication was administered on multiple occasions when the resident's heart rate was below this threshold. This discrepancy was due to an inaccurate transcription of the physician's order during a change of ownership, which led to the incorrect documentation in the electronic health record (EMR). Another deficiency was observed in the administration of eye drops to a resident with a diagnosis of unspecified moderate dementia. An LPN administered Artificial Tears without following the correct technique, resulting in a portion of the medication falling below the resident's eye. The LPN failed to draw the resident's lower eyelid down before administration, which is a necessary step to ensure the medication is properly instilled. This improper technique could potentially lead to reduced effectiveness of the medication or an increased risk of infection. The Director of Nursing (DON) confirmed the expectations for medication administration, which include verifying the right person, time, route, dosage, medication, and documentation. The DON also acknowledged the transcription error during the change of ownership and the lack of documentation for physician clarification regarding the Spironolactone order. The facility's policies on medication administration and eye medication instillation were not adhered to, leading to these deficiencies.
Deficiency in CPR Certification for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff maintained current Cardio-Pulmonary Resuscitation (CPR) certification for two of eleven sampled direct care employees. Employee #11, a Registered Nurse (RN), was hired without documented evidence of CPR training and certification in their personnel record. Employee #12, an RN/Infection Preventionist, had an expired CPR certification documented in their personnel record. Both employees' job descriptions required CPR certification as a minimum job requirement. The Human Resources Director confirmed that CPR certification was required for all direct care staff and acknowledged that Employees #11 and #12 did not have current CPR certifications. The Facility Assessment also documented that licensed nurses and certified nursing assistants were expected to maintain CPR certification.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities to meet the needs and interests of a resident diagnosed with post-traumatic stress disorder and chronic and major depressive disorder. The resident expressed a preference for staying in their room rather than participating in group activities and desired assistance with using electronic devices, such as a smartphone and a tablet, to alleviate feelings of depression. Despite these expressed needs, the facility's activities staff did not consistently engage with the resident or document individualized interactions, as evidenced by the lack of activity documentation in the electronic health record for a 14-day period. The Activities/Life Enrichment care plan for the resident acknowledged the resident's preference for solitary activities and included goals to engage the resident in activities of interest. However, the facility's activities staff did not follow through with daily check-ins or provide the necessary assistance with electronic devices, which could have helped the resident pursue personalized interests and reduce feelings of isolation. The Director of Volunteer Services/Interim Activities Director confirmed that the activities program could have supported the resident's needs but failed to do so, as the last documented activity was a self-directed engagement with movies or television.
Medication Security and Expiration Management Deficiency
Penalty
Summary
The facility failed to ensure the security and proper management of medications in one of its units. On March 11, 2025, a medication cart was observed left unlocked in the Tahoe/Truckee unit with five residents present in the area, posing a risk of unauthorized access to medications. A Registered Nurse (RN) confirmed the cart was unsecured and acknowledged the potential for residents to access the medications. The facility's policy mandates that all drugs and biologicals must be stored in locked compartments, which was not adhered to in this instance. Additionally, on March 13, 2025, expired medications were found in a medication cart and storage room on the Pinion/Aspen unit. The expired items included Docusate Sodium capsules, Ondansetron tablets, an IV solution bag, and a vial of Tuberculin Purified Protein Derivative. The RN confirmed these items had expired and should have been removed and destroyed. The Director of Nursing (DON) stated that expired medications should be immediately removed to prevent administration to residents, as they could be ineffective or harmful.
Failure to Ensure Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that culinary staff checked the holding temperatures for all hot foods before beginning meal service in the [NAME]/Quail dining room. During a lunch service, a culinary staff member did not check the temperature of all hot food items, including mashed potatoes and mechanical soft fish, before plating them for residents. The Dietary Manager later found that the mechanical soft fish was at 128 degrees Fahrenheit, below the required holding temperature of at least 135 degrees Fahrenheit. This oversight had the potential to result in foodborne illness due to improper food temperature management. In the Aspen/Pinion dining room, a similar issue occurred where a culinary staff member recorded the temperature of minced and moist texture vegetables at 132 degrees Fahrenheit, which was out of the safe range. Despite recognizing the temperature was too low, the staff member did not recheck the temperature before serving the food to residents. The Dietary Manager later confirmed that the food should have been reheated to 165 degrees Fahrenheit for at least 15 seconds before serving. The facility's policy required all hot food items to be held and served at a temperature of at least 135 degrees Fahrenheit, which was not adhered to in these instances.
Inaccurate EMR and MAR Transcription Errors
Penalty
Summary
The facility failed to ensure that the electronic medical record (EMR) accurately reflected a resident's code status, leading to a discrepancy between the EMR and the Physician's Order for Life-Sustaining Treatment (POLST) for one resident. This resident, diagnosed with unspecified dementia and anxiety, had a POLST indicating a do not resuscitate (DNR) status, while the EMR incorrectly documented full treatment cardiopulmonary resuscitation (CPR). The Director of Nursing (DON) confirmed that the EMR was not updated in a timely manner, which could have led to staff not honoring the resident's wishes in an emergency. Another deficiency was identified in the transcription of physician orders into the Medication Administration Record (MAR) and EMR for a resident with heart failure. The resident's MARs and EMR included an incorrect order to hold Spironolactone if the heart rate was less than 60 beats per minute. The DON later clarified that the original order did not require monitoring of the pulse rate for Spironolactone, indicating a transcription error during a change of ownership when orders were transferred between EMR systems. These deficiencies highlight the facility's failure to maintain accurate medical records and ensure that physician orders are correctly transcribed and reflected in the EMR. The discrepancies in the residents' records could have led to significant medication errors and compromised resident safety, as staff relied on inaccurate information to make clinical decisions.
Failure to Offer Timely Pneumonia Vaccines
Penalty
Summary
The facility failed to ensure that residents were offered timely pneumonia vaccines, which is a deficiency in their immunization practices. Specifically, Resident #21, who was admitted with serious respiratory and cardiac conditions, did not have documentation in their clinical record of being offered or receiving a pneumonia vaccine. The Infection Preventionist (IP) confirmed that there was no documentation of the vaccine being offered or administered, and acknowledged that the consent for vaccinations was not completed. This oversight indicates a lapse in following up with the resident or their representative to provide necessary education and offer the vaccine. Similarly, Resident #22, who had a history of heart disease and had previously received the 23-valent pneumococcal polysaccharide (PPV23) vaccine, was not offered the subsequent pneumococcal conjugate vaccines (PCV) as recommended by the CDC. The clinical record lacked documentation of the resident being educated on or offered the next PCV in the series, which should have occurred at least one year after the PPV23 vaccine. The IP confirmed that the resident should have been offered one of the PCV vaccines to complete the pneumococcal vaccine series, as per the facility's policy and CDC guidelines.
Failure to Educate and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that two residents were provided with education on the risks and benefits of the COVID-19 vaccination and were offered the vaccine. Resident #21, who was admitted with diagnoses including acute respiratory failure and heart failure, did not have documentation in their clinical record indicating that they were offered or received a COVID-19 vaccine. The Infection Preventionist (IP) confirmed that the consent for vaccinations was not completed, and there was no follow-up with the resident or their representative to provide education and offer the vaccine. Resident #22, who was admitted and later readmitted with diagnoses such as atherosclerotic heart disease and ischemic cardiomyopathy, refused a COVID-19 vaccination. However, there was no documentation that education on the vaccine was provided to the resident or their representative at the time of refusal. The IP confirmed that the resident should have been given education on the risks and benefits of the vaccination when it was offered. The facility's policy on vaccination requirements, revised in June 2022, mandates compliance with federal mandates, which was not adhered to in these cases.
Failure to Monitor and Respond to Resident's Condition After Fall
Penalty
Summary
A deficiency occurred when a resident with a history of frequent falls, chronic subdural hemorrhage, hepatic encephalopathy, and alcohol-induced persisting dementia experienced an unwitnessed fall in their room. The resident was found face down on the floor with their head touching the ground, exhibiting a red spot on the forehead, a large red scrape to the right chest, a skin tear on the lower right arm, and purple, swollen fingers. The resident was confused at baseline and unable to accurately recall recent events. After the fall, the resident was assisted to the shower and a skin assessment was performed. Neurological checks and vital signs were initiated, with blood pressure readings consistently elevated, reaching as high as 195/79. The LPN responsible for the resident did not review or act upon the vital signs documented by the CNA, despite the CNA notifying the LPN of the resident's high blood pressure. The LPN focused on other aspects of the neuro check, such as eyes and handgrips, and did not follow up with the CNA regarding the vital signs or review the documentation before initialing the neuro assessment flowsheet. The LPN did not notify the physician of the elevated blood pressure or the head injury, and the resident was not sent to the hospital until the night shift nurse identified the concerning findings and contacted the physician, who then ordered the resident's transfer for further evaluation. Interviews with staff and review of facility policies confirmed that the nurse was expected to assess the resident, obtain and review vital signs, perform neuro checks, and notify the physician based on assessment findings. The failure to review and act on the resident's vital signs, as well as the lack of timely physician notification and intervention, constituted neglect. This neglect was further supported by the facility's own policies and state regulations, which require nurses to supervise delegated tasks, monitor outcomes, and intervene appropriately when a resident's condition changes.
Failure to Report Suspected Neglect and Serious Injury to State Agency
Penalty
Summary
The facility failed to report an allegation of neglect and a fall resulting in serious bodily injury to the State Agency as required. A resident with a history of nontraumatic chronic subdural hemorrhage, hepatic encephalopathy, and alcohol-induced persisting dementia was found on the floor of their room, face down, with injuries including a large red scrape to the chest, a skin tear on the arm, and purple, swollen fingers. The fall was unwitnessed, and neurological checks were initiated. The resident's blood pressure remained high, and redness was noted on the forehead. The resident was later sent to the emergency room, where a subdural hematoma was diagnosed, and subsequently transferred for neurosurgical evaluation due to a new acute hemorrhage. Despite the serious nature of the injuries and the requirement to report such incidents, the facility did not notify the State Agency about the fall or the resulting injury. Interviews with facility leadership confirmed that the incident was not reported. Additionally, allegations were made against the former DON regarding instructions not to send the resident to the hospital or provide care, but these allegations were not thoroughly investigated or reported to the State Agency either. Facility policy required immediate reporting of alleged violations involving abuse, neglect, or injuries of unknown source, especially those resulting in serious bodily injury. However, the facility did not follow this policy in the case of the resident's fall and subsequent injury, nor in response to the allegations against the former DON. The lack of reporting and investigation was confirmed by both the Executive Director and the Regional Director of Quality and Clinical Services.
Failure to Investigate Alleged Neglect Following Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was found on the floor in their room with injuries, including a large red scrape to the chest, a skin tear on the lower right arm, and purple, swollen fingers. The resident had a history of frequent falls and was found face down, with no initial signs of head injury, but later developed redness to the forehead and elevated blood pressure. The resident was eventually sent to the emergency room, where a subdural hematoma was diagnosed, and subsequently transferred for neurosurgical evaluation. Despite the incident and the resulting injury, the facility did not initiate a thorough investigation into allegations that the former DON instructed staff not to send the resident to the hospital or provide care. The Regional Director of Quality and Clinical Services (RDQCS) acknowledged being informed of these allegations but did not consider them to be neglect and did not report or investigate them further. The RDQCS reviewed the resident's record and determined the allegations lacked merit, leading to no formal investigation or reporting to the State Agency (SA). Facility policy required that all allegations of abuse, neglect, or exploitation be thoroughly investigated and reported to the Administrator and SA within five working days. However, in this case, the facility did not follow its own policy or regulatory guidelines, as the allegations against the former DON were neither investigated nor reported, despite being communicated to facility leadership.
Failure to Post Current Nursing Hours
Penalty
Summary
The facility failed to ensure that current nursing hours were posted daily for all six units, as required. On March 10, 2025, it was observed that the nursing staff postings were outdated, showing the date of March 7, 2025. Interviews with the Staffing Coordinator and a Registered Nurse (RN) revealed that the Staffing Coordinator was responsible for posting the direct care staff information from Monday through Friday, while the RN was responsible for posting on Saturdays and Sundays. However, the RN confirmed that the postings for March 8 and March 9, 2025, were not updated. Both the Staffing Coordinator and the RN acknowledged that the nursing staff postings had not been updated since March 7, 2025, leading to a lack of awareness for residents and visitors regarding the number of nursing and direct care staff on duty.
Verbal Abuse by CNA Towards Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who had been admitted with diagnoses including post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. On the evening of the incident, the resident reported being called a profanity by the CNA while in their room. The resident expressed annoyance with the CNA and yelled for them to leave, which led to the CNA responding with profane language. This interaction was confirmed by the resident and the CNA admitted to using the profanity out of frustration. The facility's investigation substantiated the verbal abuse claim. The Regional Director of Quality and Clinical Services confirmed that the CNA had verbally abused the resident. The facility's policies on abuse and resident rights, which were revised in January 2023, clearly state that residents have the right to be free from verbal abuse and should be treated with dignity and respect. The CNA's actions were in direct violation of these policies, as well as the job description that emphasizes maintaining professionalism and composure when interacting with residents.
Failure to Submit Accurate and Timely Abuse Report
Penalty
Summary
The facility failed to submit a Facility Reported Incident (FRI) with accurate and complete information and did not provide a final report to the State Agency (SA) within the required five-day timeframe for a resident. The resident, who was admitted with diagnoses including major depressive disorder, vascular dementia, and anxiety disorder, was involved in an incident of employee to resident verbal abuse during medication administration. The initial FRI, submitted by the Administrator, inaccurately documented the incident date as occurring on a different date than reported. The Regional Director of Quality and Clinical Services confirmed the discrepancy and acknowledged that the final FRI was not submitted within the required timeframe. The facility's policy mandates that allegations of abuse, neglect, or exploitation be thoroughly investigated and reported to the appropriate State Agency within five working days of the alleged violation.
Hazardous Substances Found Accessible in Memory Care Unit
Penalty
Summary
The facility failed to ensure the secured memory care unit was free from potentially harmful and hazardous substances for vulnerable, cognitively impaired residents. During a tour of the memory care unit, various substances and items were found in resident rooms and accessible areas, including alcohol-based hand rub, antibacterial hand soap, medications, sharp objects, and potentially toxic items like cleaning solutions and personal care products. These items were accessible to residents with severe cognitive impairments, posing a risk of ingestion or harm. Residents in the memory care unit, such as Resident #88, Resident #31, and Resident #43, had documented diagnoses of dementia and cognitive impairments, requiring the safety of a secure unit due to impaired safety awareness and decision-making abilities. Despite these known vulnerabilities, hazardous items like alcohol-based hand rub, sharp objects, and medications were found in their living areas. The presence of these substances could lead to adverse health outcomes, including ingestion and potential hospitalization for these residents with severe cognitive impairments. The Director of Nursing acknowledged that residents in the memory care unit should not have had access to certain hazardous items, such as an Automated External Defibrillator and potentially dangerous personal care products. The facility's policy on Memory Care Accident Hazards/Supervision emphasized the importance of providing an environment free from accident hazards and ensuring supervision to prevent avoidable accidents for the high-risk population in the memory care unit. However, the findings from the survey indicated a lack of adherence to these policies, putting residents at risk of harm due to the presence of hazardous substances and materials in their living areas.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain a resident's dignity when a maintenance worker entered a resident's room without knocking or asking for permission. Resident #60, who has diagnoses including cerebral infarction, bipolar disorder, and chronic post-traumatic stress disorder, reported that staff did not always wait for a reply when knocking on the door. On one occasion, a maintenance worker entered the resident's room without knocking and proceeded to check a light fixture in the bathroom. The resident questioned the maintenance worker, who admitted to forgetting to knock and ask for permission. The facility's policy on Resident Rights-Respect and Dignity, last reviewed in December 2023, emphasizes the importance of treating residents with respect and dignity. Both the Administrator and a Registered Nurse confirmed that the expectation is for all staff to knock and ask for permission before entering a resident's room. Despite this policy, the maintenance worker failed to adhere to these guidelines, resulting in a breach of the resident's right to a dignified existence and self-determination.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy to investigate and report a resident's injury of unknown origin. Resident #4, who has Alzheimer's disease and severe dementia with agitation, was found with a large wound on their lower leg that required emergency treatment and stitches. Despite the severity of the injury, the facility did not conduct a thorough investigation immediately, nor did it report the incident to the State agency within the required timeframes. The injury was first documented by nursing staff in the early morning, and the resident was sent to the emergency department later that morning due to profuse bleeding. The investigation into the root cause of the injury was not documented until two days later. The Director of Nursing confirmed that such an injury should have prompted a thorough investigation, including interviews and written statements from staff. The Administrator acknowledged that the incident was reported as an injury of unknown origin but was not reported to the State agency as required. The facility's policy on abuse did not include specific timeframes for investigation and reporting, which contributed to the delay in addressing the incident. The failure to follow the policy and report the incident promptly could result in continued resident harm.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report a resident's injury of unknown origin to the State Agency in a timely manner. Resident #4, who had diagnoses including Alzheimer's disease and severe dementia with agitation, was found with a large wound on their lower leg. The wound, which was profusely bleeding, required emergency department treatment and 12 sutures to close. Despite the severity and unknown origin of the injury, the facility did not report the incident to the State Agency immediately as required by their policy. The investigation into the root cause of the injury was not concluded until two days later, on 02/28/2024. The facility's policy on preventing and prohibiting abuse mandates that any suspicious injury be reported immediately to the Administrator, State Agency, and other required agencies. However, the Administrator confirmed that the injury was not reported to the State Agency at the time it was discovered. This failure to report in a timely manner could potentially allow injuries of unknown origin to go uninvestigated for potential abuse. The facility's inaction in this case represents a significant lapse in adhering to their own policies and regulatory requirements.
Failure to Include Oxygen Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan was developed to address the care and interventions for oxygen therapy for a resident with chronic obstructive pulmonary disease (COPD). The resident was admitted with diagnoses including COPD, heart-valve replacement, and aortic stenosis. Despite the hospital discharge plan and nursing notes indicating the resident required chronic oxygen therapy at 3 liters per minute (lpm) via nasal cannula, the baseline care plan dated 04/12/2024 did not include any care plan for oxygen therapy. This omission was confirmed by both a Registered Nurse and the Director of Nursing, who acknowledged that the baseline care plan should have included oxygen therapy interventions. Observations on 04/15/2024 and 04/16/2024 confirmed the resident was using an oxygen concentrator at 2.0 lpm and verbalized the need for continuous oxygen due to COPD. The facility's policy on respiratory care required a practitioner's order for oxygen therapy and a care plan identifying interventions based on the resident's assessment and orders. However, the resident's baseline care plan lacked these essential details, which could result in staff being unaware of the resident's chronic oxygen needs.
Inaccurate and Inappropriate Care Plans
Penalty
Summary
The facility failed to ensure the Comprehensive Care Plan was updated to include the care and interventions for oxygen therapy for one resident and that the care plan interventions were appropriate for three residents residing in the specialized care unit. Specifically, Resident #145's care plan did not match the physician's order for oxygen therapy, which indicated a range of 1-3 liters per minute (lpm) to maintain oxygen saturation levels above 90%. The care plan only documented oxygen therapy at two lpm. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged that the care plan should have been updated to reflect the current physician's order. Additionally, the care plans for three residents in the memory care unit (Residents #9, #56, and #67) were found to be inappropriate. These residents were documented as being able to leave the locked unit independently and were instructed not to open the doors for other residents. However, the DON and the Administrator confirmed that it was not the intention for these residents to be responsible for the oversight of other residents. The care plans lacked dates, and the facility's policy on comprehensive care plans emphasized that care plans should be person-centered and drive the type of care and services a resident receives.
Medication Administration Deficiency
Penalty
Summary
The facility failed to meet professional standards of medication administration for one resident diagnosed with unspecified dementia and anxiety. A physician's order required the resident to take Metoprolol Succinate Extended Release 25 mg, 1.5 tablets by mouth once a day. On the morning of 04/15/2024, a pill was found on the resident's side table, indicating that the medication had not been ingested as required. The Assistant Director of Nursing (ADON) confirmed that the medication was Metoprolol and that it had been administered the previous night according to the Medication Administration Record (MAR). The ADON acknowledged that the nurse administering the medication did not stay with the resident to ensure the medication was swallowed, which is against the facility's policy and professional standards of practice. The Director of Nursing (DON) also confirmed that medications should not be left unsecured at a resident's bedside and that nurses are expected to stay with the resident until the medication is effectively administered. The facility's policy on medication administration, reviewed in December 2023, mandates that medications be administered following the six rights of medication administration and in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards. The incident was documented as a medication error, highlighting a lapse in adherence to these standards and policies.
Failure to Ensure CPR Certification for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest. Specifically, one of the four sampled licensed nurses, Employee #15, who was hired as a Licensed Practical Nurse (LPN), did not have documented evidence of CPR training and certification in their personnel record. The Human Resources Director confirmed that CPR certification was required for all licensed nurses upon hire and acknowledged that Employee #15 did not have current CPR certification. The facility's policy on Cardiopulmonary Resuscitation, last reviewed on a specified date, stated that all licensed nursing staff would maintain current CPR certification.
Failure to Coordinate Medication Orders with Hospice Agency
Penalty
Summary
The facility failed to ensure a resident's medication orders were coordinated with the contracted hospice agency providing end-of-life care. This deficiency was identified for one resident who had diagnoses including Alzheimer's disease, unspecified cirrhosis of the liver, and other chronic pain. Discrepancies were found between the facility's Order Summary Report and the hospice agency's Client Medication Report. These discrepancies included differences in orders for medications such as Famotidine, Omeprazole, Lorazepam, and oxygen administration, as well as the presence of an order for Venelex ointment in the facility orders but not in the hospice orders. Interviews with facility staff and the hospice agency's RN Case Manager revealed that medication reconciliation was supposed to occur weekly, but the discrepancies indicated this process was not effectively implemented. The Director of Social Services, who was identified as a Hospice Coordinator, was not familiar with the term and had limited interaction with hospice agencies after residents were admitted to hospice services. The Director of Nursing confirmed that medication changes should be reconciled in real time to ensure consistency between facility and hospice orders. The facility's contract with the hospice agency and its policy on hospice care both emphasized the need for coordination and communication to resolve any inconsistencies in physician orders.
Failure to Follow Physician's Orders for Respiratory Care
Penalty
Summary
The facility failed to obtain and/or follow a physician's order for respiratory care for two residents. Resident #145 was observed receiving oxygen at 4.0 and 4.5 liters per minute (lpm) on different occasions, despite a physician's order specifying oxygen administration at 1-3 lpm. The Registered Nurse (RN) and Director of Nursing (DON) confirmed that the oxygen should not exceed 3.0 lpm without a change in the physician's order, and the physician should be notified if the resident's oxygen saturation was not above 90 percent at 3.0 lpm. Resident #295 was observed receiving oxygen at 2.0 lpm, although the hospital discharge plan indicated the resident required 3.0 lpm. The physician's order for Resident #295 lacked a specified flow rate and a range to maintain the resident's oxygen saturation. The RN and DON confirmed the deficiency in the oxygen therapy order. The facility's policy required a practitioner's order for oxygen therapy, including specific flow rates and monitoring instructions, which was not followed in this case.
Failure to Complete Monthly Medication Reviews on Time
Penalty
Summary
The facility failed to ensure Monthly Medication Reviews (MMR) were completed within the required timeframe for two residents. Resident #66, diagnosed with dementia and other conditions, did not have an MMR completed within thirty days for August 2023, as the review was done on 09/01/2023 instead of within the month. Similarly, Resident #51, with diagnoses including adjustment disorder and insomnia, also lacked an MMR within the required timeframe for August 2023, with the review completed on 09/01/2023. Both the Pharmacist and the Director of Nursing confirmed that the MMRs were not completed within the stipulated 30 to 31 days as per the facility's policy, which mandates monthly reviews by a licensed pharmacist.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medication was administered with an error rate of less than 5%. There were 25 opportunities and two medication errors, resulting in a medication error rate of 8%. One incident involved a resident with dementia and other conditions, where a Registered Nurse (RN) failed to remove a lidocaine patch as scheduled, leading to the application of a new patch without removing the old one. The RN confirmed the error, and the Director of Nursing (DON) acknowledged that the patch should have been removed to prevent skin irritation. Another incident involved a resident with type two diabetes mellitus, where an RN did not follow proper protocol for preparing an Insulin Glargine (Lantus) pen. The RN did not swab the pen tip with alcohol before attaching the needle, contrary to the manufacturer's instructions and facility policy. The DON confirmed the correct procedure, which includes swabbing the pen tip with alcohol before attaching the needle. The facility's policy on medication administration emphasizes following the six rights of medication administration and adhering to accepted professional standards and practices.
Failure to Ensure Hair Restraints and Hand Hygiene
Penalty
Summary
The facility failed to ensure an employee wore the appropriate hair restraints when working in the kitchen and did not perform hand hygiene before and after resident contact during a lunch service. On 04/17/2024, a Certified Nursing Assistant (CNA) was observed entering the kitchen area without a hair restraint covering their full beard. The Dietary Services Director (DSD) confirmed that the facility's policy required hair restraints to cover all hair on the head, but the policy did not address facial hair. The DSD expected employees to cover all hair on the head and face while working in the kitchen to maintain sanitary conditions. Additionally, on 04/15/2024, during a lunch service, a CNA was observed delivering multiple plates to residents without performing hand hygiene between each interaction. The CNA confirmed that they had not performed hand hygiene between passing plates to residents, despite the facility's policy requiring hand hygiene before and after contact with residents. The Infection Preventionist (IP) also confirmed that hand hygiene should be performed after delivering a tray or plate to a resident and before picking up the next one to reduce the risk of spreading pathogens.
QAA Committee Failed to Identify Timely Training Deficiency
Penalty
Summary
The Quality Assessment and Assurance (QAA) Committee failed to identify the lack of timely training for staff. During an interview, the Administrator acknowledged that the QAA Committee had not recognized concerns regarding the timeliness of training. The Administrator explained that the online training system allowed for trainings to be completed by the end of the month they were due, which resulted in trainings being completed late. The Administrator confirmed that trainings were being completed according to the online training company's standards rather than regulatory standards. The facility's QAPI Plan emphasized systemic improvement and education but did not address the specific issue of timely training compliance.
Infection Control Deficiencies in Insulin Administration and COVID-19 Testing
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the administration of insulin and COVID-19 testing. Specifically, a Registered Nurse (RN) did not disinfect the rubber seal on an insulin pen with alcohol before attaching a needle and administering insulin to a resident with type two diabetes mellitus. The RN explained that the pen tip was not swabbed because it had been covered by the cap. The Director of Nursing (DON) confirmed the correct procedure was to swab the pen tip with alcohol before attaching the needle, as documented in the facility's policy and the manufacturer's instructions. Additionally, a used COVID-19 test was found in a common area near the nursing desk, which had been used by a symptomatic staff member. The Infection Preventionist (IP) confirmed that the test should have been performed in a designated testing room and not in a resident area. The facility's policy stated that symptomatic staff should be restricted from the facility pending COVID-19 test results. These deficiencies have the potential to cause the spread of communicable diseases within the facility.
Failure to Ensure Timely Elder Abuse Prevention Training
Penalty
Summary
The facility failed to ensure timely completion of elder abuse prevention training for three employees. Employee #4, a Registered Dietitian, was hired on 04/21/2022, but did not complete the required abuse prevention training until 05/22/2023, one month past the employee's anniversary date. Employee #7, a Certified Nursing Assistant, was hired on 04/10/2023, and while initial training was documented on the hire date, there was no evidence of annual abuse prevention training for 2024. Similarly, Employee #9, a Registered Nurse hired on 05/06/2019, had documented abuse prevention training on 03/27/2023, but lacked evidence of annual training for 2024. The Human Resources Director confirmed these deficiencies, noting that training is required upon hire and annually thereafter. The facility's policy, last reviewed on 12/18/2023, mandates training upon hire, annually, and as needed.
Failure to Ensure Annual Behavioral Health Training
Penalty
Summary
The facility failed to ensure annual behavioral health training was completed for six of twenty sampled employees. The employees in question included the Administrator, Director of Nursing, Recreation Director, a Certified Nursing Assistant, a Registered Nurse, and the Infection Preventionist/Licensed Practical Nurse. Despite the facility's policy requiring all staff to undergo behavioral health training upon hire and annually, these employees did not have documented evidence of completing the required training for 2024. The personnel files for these employees only showed dementia training completed in 2023, with no records for 2024 training. On April 17, 2024, the Human Resources Director confirmed that the six employees had not received the required behavioral health training for 2024 by their respective anniversary dates. The facility's policy, last reviewed in December 2023, mandates that staff members who have direct contact with and provide care to persons with dementia must complete continuing education specifically related to dementia. The lack of compliance with this policy was identified through personnel record reviews, interviews, and document reviews.
Failure to Update Facility Assessment for Memory Care Unit
Penalty
Summary
The facility failed to ensure the Facility Assessment (FA) was updated to reflect accurate and current staffing needs of the facility's special care unit (memory care). The FA dated [DATE] documented a staffing plan for direct care staff as 1 staff member to 16 residents, but did not include staffing levels required for the memory care unit. On 04/17/2024, the Director of Nursing verbalized that the staffing ratio in the memory care unit was one staff member to eight residents. On 04/18/2024, the Administrator confirmed that the FA staffing plans did not address the staffing needs of the memory care unit. The facility policy titled Facility Assessment, revised on 02/2024, documented that the Pyramid/[NAME] household was designated as a special care unit specific to memory care.
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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