Royal Springs Healthcare And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 8501 Del Webb Blvd, Las Vegas, Nevada 89134
- CMS Provider Number
- 295073
- Inspections on file
- 22
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Royal Springs Healthcare And Rehab during CMS and state inspections, most recent first.
Failure to Complete Annual Dementia Training: The facility did not ensure annual dementia training was completed for an Administrator, DON, and IP. The Facility Assessment and facility policy required dementia training upon hire and annually, but personnel records showed each employee’s last dementia training was completed in early 2025, and the DSD confirmed the annual training had not been completed.
Surveyors found that the facility failed to update comprehensive care plans after significant changes in two residents’ conditions and treatments. One resident with hydronephrosis returned from the hospital with only one nephrostomy tube after the other was replaced with a stent, but the care plan continued to reference bilateral nephrostomy tubes and was not revised to reflect the new status. Another resident with lung cancer returned from a hospitalization under hospice care with a change in code status from full code to DNR, supported by a hospice DNR election form, yet the comprehensive care plan was not updated to include the hospice status or new code status. These omissions were confirmed by facility nursing leadership and were inconsistent with the facility’s policy requiring ongoing assessment and revision of care plans when residents’ conditions change.
A hospice resident with metastatic lung cancer, previously documented as full code, returned from a hospital stay under hospice care, but the facility did not obtain or maintain required hospice documents, including a DNR POLST, hospice election form, and physician certification of terminal illness, as required by policy and the hospice agreement. When the resident was later found unresponsive but with vital signs, an RN contacted hospice and the family, but only a DNR election form without a physician signature could be produced, and it took time to arrive. The family began compressions and called 911, and EMS requested hospice documents and a DNR POLST that the facility could not provide, leading to the resident’s transfer to the hospital. Surveyors found that the absence of a DNR POLST and complete hospice paperwork caused confusion among staff and emergency personnel and placed hospice residents at risk for their advance directives not being honored.
Failure to Care Plan for Camera Monitoring Device: A resident with acute respiratory failure with hypoxia, cognitive changes following CVA, and chronic pain syndrome had a camera installed in the room at family request, with the device actively recording audio and video and a roommate present. The DON confirmed the family continuously monitored the feed, but the resident's care plan did not include the electronic communication device, despite an earlier care conference about the monitoring device and a posted sign indicating recording was in use.
An LPN documented cleansing tasks for a resident’s nephrostomy, suprapubic catheter, and Foley catheter sites without actually performing the care, even though the resident did not have a Foley catheter. Observation found the suprapubic site unclean with buildup and no dressing, and the nephrostomy dressing old, loose, and stained. The DON stated the charting was mechanical and that the site care should have been done daily.
A resident with dementia, Alzheimer's disease, and CKD had conflicting code status documentation: a physician order listed DNR while the POLST listed Full Code and noted the resident lacked decisional capacity. The UM confirmed the mismatch and could not determine the correct code status, while the SSD found no documented family discussion about code status since admission and the DON stated the physician order should correspond with the POLST.
A resident with a suprapubic catheter and nephrostomy tube had inaccurate admission care orders and incomplete documentation. The LPN observed the suprapubic site was unclean with white buildup and no dressing, and the nephrostomy dressing was old, loose, and stained, while the resident said staff never cleaned the sites. The MAR showed staff signed off on cleansing the nephrostomy, suprapubic, and even a non-existent Foley catheter site, and the LPN and Unit Manager confirmed the documentation did not match the care actually provided.
Improper HOB Positioning During Tube Feedings: Two residents receiving enteral nutrition were observed with the HOB flat or below the ordered elevation while tube feeding pumps were running. One resident had a gastrostomy and impaired cognition, and the other had cerebral palsy, ventilator dependence, and dysphagia with orders and a care plan directing HOB elevation during and after feeding. Staff confirmed the HOB was not maintained at the required angle during the feedings.
Failure to monitor side effects of psychotropic and opioid medications for two residents. One resident receiving trazodone for insomnia was observed excessively sleepy and difficult to arouse, but the record lacked documented monitoring of side effects and sleep hours. Another resident receiving tramadol for pain had a care plan requiring monitoring for opioid adverse reactions, yet the chart lacked documented evidence that side effects were monitored.
An LPN crushed multiple routine meds together in a pill crusher and mixed them into applesauce for a resident who preferred crushed meds because there were too many. The resident took the meds without difficulty, but the LPN and DON acknowledged this was not consistent with policy, and one of the meds, divalproex sodium DR, had instructions not to crush; the resident also had an order for aspirin, with an alert noting a potential interaction with divalproex.
Unlabeled Food and Beverages in Nourishment Room Refrigerators: Open juice containers and a resident food item were found in nourishment room refrigerators without the required labels. Kitchen staff stated they were responsible for labeling resident beverages before placement, while nursing staff were responsible for labeling resident food items. A CNA stated she did not know labels were available for resident stored food items, and confirmed the items were not properly labeled.
The facility experienced significant staffing shortages on weekends from December 2024 to February 2025, resulting in delayed and inadequate care for residents. The facility's staffing levels were below the national average, with numerous instances of missing licensed nurses and CNAs. Staff and residents reported increased complaints, burnout, and dissatisfaction due to the low staffing levels, which affected the quality of care provided. The facility's failure to maintain sufficient nursing staff contributed to its one-star rating.
The facility failed to manage discontinued and expired medications in two medication rooms, risking medication errors. In 200 Hall, discontinued and expired medications like Cefepime and Teflaro were found mixed in the active supply. In 300 Hall, Lovenox injections, discontinued for a resident, were not removed. The facility's policy requires such medications to be destroyed or returned, but this was not followed.
The facility failed to complete PASARR level two referrals for five residents with newly identified psychiatric diagnoses, such as bipolar disorder and schizophrenia. Despite initial PASARR level one screenings indicating no mental illness, these residents were later diagnosed with psychiatric conditions during their stay. The Behavioral Coordinator and Director of Nursing acknowledged a knowledge deficit in the PASARR referral process, and the facility's policy identified the social worker as responsible for referrals, yet they were not trained or involved in the process.
The facility failed to update care plans for four residents, resulting in unaddressed weight loss and lack of restorative nursing services. Two residents with significant weight loss did not receive 1:1 feeding assistance as ordered, and two others with mobility issues were not provided RNA services despite therapy recommendations. The care plans were not revised to reflect these necessary interventions.
Two residents did not receive restorative nursing services due to staffing shortages and communication failures. One resident, with hemiplegia, expressed concerns about not receiving services after therapy coverage ended, while another resident with a traumatic brain injury was never placed on the restorative nursing case load. The facility's understaffing and lack of communication with attending physicians contributed to the deficiency.
Two residents with significant weight loss did not receive timely one-on-one feeding assistance as ordered, leading to improper food temperatures and inconsistent meal consumption. CNAs were overburdened with 15 residents each, including those needing feeding assistance, contributing to the delay. The facility's previous restorative dining program, which could have mitigated this issue, was discontinued during COVID and not reinstated.
A facility failed to deliver prescribed enteral feeding volumes for a resident with a gastrostomy, resulting in a significant deficit over three days. Additionally, another resident receiving tube feeding for dysphagia was observed with their head of the bed flat, contrary to orders requiring elevation to prevent aspiration. These deficiencies were confirmed by facility staff and were not in compliance with the facility's enteral feeding policy.
A facility failed to obtain and implement a physician's order for a resident's oxygen (O2) use, despite the resident's continuous O2 administration for shortness of breath and pulmonary disease. The resident's medical records lacked documentation of a physician's order or care plan, and the humidifier bottle was undated and empty. Staff confirmed the absence of necessary orders and care plans, contrary to the facility's oxygen therapy policy.
A facility failed to provide proper dialysis care for a resident with end-stage renal disease. The resident's medical records lacked documentation of a physician's order for dialysis, monitoring of the dialysis access, and pre- and post-dialysis vital signs. Staff confirmed that vital signs should have been taken before and after dialysis, but this was not done. The facility's policy required documentation of dialysis observations, but the necessary forms were incomplete.
The facility's FA was not updated to reflect current staffing needs and services, missing documentation on resident care requirements, services provided, and risk assessments. The AIT and DON confirmed the absence of leadership involvement and a staffing plan, despite a QAPI meeting to finalize the FA.
The facility's QAPI committee failed to effectively manage staffing issues, including a PIP for staffing shortages, high staff turnover, and low weekend staffing. The PIP was outdated, and no root cause analysis was conducted for the high turnover rate. Additionally, the facility did not maintain oversight over weekend staffing, leading to increased staff and resident complaints.
The facility failed to adhere to infection control practices in the nourishment room, where a staff member was observed drinking, ice was improperly placed in a handwashing sink, and the trash can was overflowing. Loose ice was also found in the freezer around food products. Interviews revealed a lack of awareness about proper procedures, and the Infection Preventionist confirmed these practices were against facility policies.
A resident with chronic heart failure experienced a decline in condition due to the facility's failure to adequately assess and monitor their symptoms. Despite reporting chest pain and shortness of breath, the resident did not receive timely or thorough assessments, leading to a lack of communication with the medical provider. The resident was eventually hospitalized and passed away from cardiogenic shock, highlighting deficiencies in the facility's care protocols and documentation practices.
A facility failed to assist a resident with hygiene needs, specifically facial shaving, despite the resident's scheduled shower days. The resident, with multiple medical conditions, was observed with a thick beard and expressed that shaving had not occurred as expected. Staff confirmed the resident's lack of personal clothing and the use of donated clothing, as well as the expectation for shaving on shower days. Facility logs lacked evidence of shaving, contrary to policy requirements for grooming assistance.
Failure to Complete Annual Dementia Training
Penalty
Summary
The facility failed to ensure annual dementia training was provided to 3 of 11 employees reviewed: Employee 1, the Administrator; Employee 2, the DON; and Employee 13, the IP. The Facility Assessment dated 02/2026 documented that training for care management for persons with dementia would occur upon hire and annually, and the facility policy titled Dementia Training, revised 03/2026, stated that all facility employees must complete at least three hours of continuing education in dementia care annually. During interviews on 03/13/2026, the DSD explained that annual trainings were scheduled and tracked to ensure completion and confirmed that the training was expected to be completed annually. Personnel record review showed Employee 1 completed dementia training on 01/27/2025, Employee 2 completed dementia training on 01/27/2025, and Employee 13 completed dementia training on 01/09/2025, but none had completed the required annual dementia training.
Failure to Revise Care Plans After Changes in Nephrostomy Status and Code Status
Penalty
Summary
The deficiency involves the facility’s failure to revise comprehensive care plans within 7 days of comprehensive assessments and when residents’ conditions or treatments changed. For one resident with hydronephrosis and bilateral nephrostomy tubes, the care plan initiated in mid-February 2025 identified bilateral nephrostomy tubes and included goals and interventions such as monitoring for infection, checking tubing for kinks, monitoring and recording output, and monitoring discomfort. A subsequent hospital discharge summary documented that the left nephrostomy tube was removed and replaced with a stent, and the resident returned with only a right-sided nephrostomy tube. The medical record contained no evidence that the care plan was updated to reflect the removal of the left nephrostomy tube, and the Unit Manager acknowledged that the care plan had not been revised and that this would have been an appropriate time to add interventions such as site cleansing and dressing changes per facility policy. The deficiency also includes a failure to update the comprehensive care plan for another resident who returned from the hospital under hospice care with a change in code status. This resident, admitted with malignant neoplasm of the bronchus or lung, initially had a POLST indicating no decisional capacity and a family election of full code/attempt resuscitation. After hospitalization for acute on chronic hypoxic respiratory failure, the resident returned under hospice care, and a hospice DNR election form documented the family’s agreement to allow natural death and not perform procedures to restart the heart. Despite these changes, the comprehensive care plan was not revised to reflect the resident’s hospice status or the change in code status from full code to DNR. The DON confirmed that the care plan did not reflect these changes, contrary to the facility’s policy stating that assessments are ongoing and care plans are revised as residents’ conditions change.
Failure to Maintain and Provide DNR POLST and Hospice Documentation
Penalty
Summary
The facility failed to ensure that a physician’s order for life-sustaining treatment (POLST) and required hospice documentation were obtained, maintained on-site, and made available to emergency personnel for a hospice resident with metastatic lung cancer. The resident was initially admitted as full code with a POLST indicating full resuscitation, later hospitalized for acute on chronic hypoxic respiratory failure, and then returned under hospice care. A hospice policy and hospice agreement required the facility to maintain the most recent care plan including advance directives, the hospice election form, physician certification of terminal illness, and other hospice orders. However, review of the hospice binder and medical record showed that the hospice election form, physician certification of terminal illness, and advanced directives including a DNR POLST reflecting the resident’s DNR status were missing. The DON confirmed that the hospice DNR election form alone was not an acceptable substitute in the state because it lacked a physician’s order. On the day of the incident, the RN found the hospice resident unresponsive but with vital signs during morning rounds and contacted hospice and the family. The RN reported that there was no DNR POLST in the hospice binder and hospice could only provide a DNR election form, which took time to be received and did not have a physician’s signature. During this period, the family panicked over the resident’s unresponsive state, began chest compressions, and another family member called 911. When emergency medical services arrived, they requested hospice documents and the DNR POLST, but the facility was unable to provide them, and the resident was transported to the hospital. Surveyors determined that the lack of a DNR POLST and other required hospice paperwork in the facility, contrary to facility policy and the hospice agreement, resulted in confusion among staff and emergency personnel and placed hospice residents at risk for advance directives not being honored at end of life.
Failure to Care Plan for Camera Monitoring Device
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for the use of an electronic communication device, a camera used for audio and video recording, for one resident. Resident 7 was admitted and readmitted with diagnoses including acute respiratory failure with hypoxia, other symptoms and signs involving cognitive functions following cerebral infarction, and chronic pain syndrome. On 03/10/2026, the resident was observed lying in bed with eyes open and the body in a contorted position while a camera was installed on the wall opposite the bed, above eye level, and a roommate was present in the room. A posted sign stated that an electronic communication device was in use and may record audio and/or video at all times. On 03/11/2026, the DON stated the resident's family was involved in care and had requested the camera be installed in the room, and that the family continuously monitored the audio and video from the camera. The DON confirmed the camera was actively recording audio and video. An interdisciplinary care plan conference dated 09/30/2024 documented that a care conference was held regarding installation of a monitoring device in the shared resident room in accordance with the law. However, the care plan dated 02/10/2026 lacked documented evidence that a care plan had been developed for the camera, and the DON confirmed the care plan did not include the electronic communication device. The DON acknowledged a care plan should have been developed to ensure staff awareness of recording, including goals and interventions such as signage.
Mechanical MAR Documentation for Catheter Site Care
Penalty
Summary
The facility failed to ensure documentation of care for one resident with a nephrostomy catheter, suprapubic catheter, and no Foley catheter was factual and matched the care actually provided. The resident was admitted and readmitted with diagnoses including hydronephrosis with renal and ureteral calculus obstruction and encounter to nephrostomy catheter and other artificial openings of the urinary tract. During observation, the resident’s suprapubic catheter site was found in the left lower quadrant with the insertion site not clean, white buildup present, and no dressing, and the resident stated that no one came to clean it. The right-sided nephrostomy site was covered with a dressing dated 03/03, appeared old and loose, and had a brown stain at the center; the resident stated no one came to care for it, and the LPN had difficulty removing the dressing and needed supplies to change it. Record review showed physician orders for cleansing the suprapubic catheter site, nephrostomy tube site, and Foley catheter site with soap and water every shift, and the MAR for March 2026 showed staff signed off on those cleansing tasks. The LPN confirmed signing off on nephrostomy, suprapubic, and Foley catheter cleansing without performing the tasks on multiple dates and stated not being aware of dressing change protocols for suprapubic catheters and nephrostomy tubes. The LPN also confirmed the resident did not have a Foley catheter. The CNA stated cleansing of the nephrostomy and suprapubic insertion sites was the nurse’s duty, while the Unit Manager stated the MAR appeared to have been signed mechanically. The DON stated nephrostomy site care should be done daily, suprapubic catheter sites should be assessed and cleaned daily, and nurses should not sign for cleansing tasks that were not performed.
Conflicting Code Status Orders and POLST Documentation
Penalty
Summary
The facility failed to ensure physician orders matched the documented treatment preferences on the POLST form for one resident. The resident was admitted with diagnoses including unspecified dementia with psychotic disturbance, Alzheimer's disease, and chronic kidney disease. A physician order dated 03/27/2025 documented DNR, while the POLST dated 09/07/2025 documented Full Code and stated the resident lacked decisional capacity. The POLST was signed by the physician and the resident's family member. During interview, the Unit Manager reviewed the resident's POLST and physician orders and confirmed the documented treatment preferences did not match, and was unable to determine the resident's correct code status based on the conflicting orders. The Unit Manager explained that code status was determined by discussing Full Code versus DNR with the resident if alert, or with the resident's representative if not alert, and then entering a physician order and completing the POLST for physician signature. The Director of Social Services stated family was responsible for decisions and was unaware of any changes to the resident's code status, and review of the medical record found no documented evidence of any conversation with family regarding code status since admission. The DON stated the POLST was completed on admission and the physician's order was to correspond with the POLST.
Inaccurate catheter care orders and documentation
Penalty
Summary
The facility failed to ensure accurate and complete admission care orders and documentation for a resident with a suprapubic catheter and nephrostomy tube. The resident was admitted and readmitted with diagnoses including hydronephrosis with renal and ureteral calculus obstruction and encounter to nephrostomy catheter and other artificial openings of urinary tract. The admission MDS documented an indwelling catheter, including a suprapubic catheter and nephrostomy tube, and active diagnoses including renal insufficiency, obstructive uropathy, and a UTI in the last 30 days. During observation, the resident was alert in bed and allowed surveyor assessment of the catheter sites. The LPN identified that the resident did not have a Foley catheter, but instead had a suprapubic catheter in the left lower abdomen. The insertion site was described as not clean, with white buildup and no dressing, and the resident stated that no one comes to clean it. The urine in the drainage bag was yellow with sediment. The nephrostomy site on the right side had a dressing dated 03/03 that appeared old, was coming loose, and had a brown stain at the center. The resident stated that no one comes to care for it, and the LPN had difficulty removing the dressing because it was stuck to the site. Record review showed physician orders to cleanse the suprapubic catheter site, nephrostomy tube site, and Foley catheter site with soap and water every shift, but the record lacked documented evidence of dressing change orders for the nephrostomy tube and suprapubic catheter. The MAR showed staff signed off on cleansing the nephrostomy site, suprapubic catheter site, and a non-existent Foley catheter site every shift. The LPN confirmed signing off on care that was not performed on multiple days and acknowledged signing for Foley catheter care when the resident did not have a Foley catheter. The CNA stated catheter site cleansing was the nurse's duty, while the Unit Manager confirmed dressing change orders were not entered and that the MAR appeared to have been signed off mechanically. The DON stated nephrostomy site care should be done daily, suprapubic catheter site care should be assessed and cleaned daily, and nurses should not have signed off on care that was not performed.
Improper HOB Positioning During Tube Feedings
Penalty
Summary
The facility failed to ensure the head of bed (HOB) was elevated during tube feeding infusion for 2 of 40 sampled residents, placing residents receiving enteral nutrition at risk for aspiration as stated in the report. Resident 53 had diagnoses including nontraumatic intracranial hemorrhage and gastrostomy status, and the quarterly MDS documented moderately impaired cognition and receipt of nutrition by enteral means. During multiple observations, R53 was seen awake in bed while Jevity 1.2 was infusing at 80 mL/hr, with the HOB described as flat to approximately 10 degrees on one occasion and less than 30 degrees on another; a CNA also described the HOB as flat while the feeding was running. Resident 176 had diagnoses including cerebral palsy, ventilator dependence, and oropharyngeal dysphagia, and the care plan and physician order directed that the HOB be elevated 30 to 45 degrees during enteral feeding and after feeding. On observation, R176 was lying in bed with the torso and face turned to the right in a contorted position while the enteral feeding pump was running at 65 mL/hr and the HOB was flat. An RN confirmed the HOB was flat while the feeding was running and stated it had been lowered to help the resident sleep, while the DON later confirmed the HOB should have remained elevated during feeding and afterward per the order and care plan.
Failure to Monitor Side Effects of Psychotropic and Opioid Medications
Penalty
Summary
The facility failed to ensure that psychotropic and opioid medications were monitored for side effects for 2 of 40 sampled residents. One resident with diagnoses including cerebral infarction, atherosclerotic heart disease of native coronary artery, and COPD was ordered trazodone 50 mg at bedtime for insomnia. The care plan directed staff to monitor for side effects such as daytime drowsiness, dizziness, and orthostatic hypotension, but the medical record lacked documentation of side effect monitoring and hours of sleep. During observations, the resident was found lying in bed, difficult to awaken, with eyes fluttering or closed, and staff stated the resident slept most of the day and was sometimes confused with day and night when awakened for morning medications. A second resident with diagnoses including acute respiratory failure with hypoxia, cognitive changes following cerebral infarction, and chronic pain syndrome had an order for tramadol via PEG tube every 6 hours as needed for severe pain. The care plan identified tramadol as an opioid and directed staff to monitor for adverse reactions including altered mental status, constipation, dizziness, nausea, sedation, respiratory distress, and urinary retention, but the record lacked documented evidence that tramadol side effects were monitored. The resident was observed restless, with uncoordinated arm movements and facial grimacing, and the DON confirmed the record lacked documented side effect monitoring for the medication.
Crushed medications together and crushed a do-not-crush DR medication
Penalty
Summary
The facility failed to ensure medications were not crushed together and failed to ensure a medication with instructions not to crush was not crushed for one resident with end stage renal disease and hemiplegia and hemiparesis following cerebral infarction. During a medication pass observation, an LPN prepared the resident’s routine medications, including buspirone, hydralazine, amlodipine, vitamin C, aspirin, vitamin D, divalproex sodium delayed release, Colace, labetalol, multivitamins with minerals, and zinc sulfate, and then crushed the medications together in a pill crusher before placing them into applesauce for administration. The resident stated a preference for crushed medications mixed into applesauce because there were too many, and the resident took the medications without difficulty while eating breakfast. The LPN later acknowledged that crushing the pills together was not in accordance with facility policy, which required medications to be crushed individually in separate pouches so refused medications could be documented accurately and medications that should not be crushed would not be altered. The DON and consultant pharmacist confirmed that divalproex sodium DR must not be crushed, that delayed-release and enteric-coated medications should not be crushed, and that the manufacturer’s guide instructed the medication be swallowed whole. The resident had an order for divalproex sodium DR 125 mg twice daily for agitation and restlessness associated with dementia, and the record also noted an alert that aspirin may increase the pharmacologic effects of divalproex.
Unlabeled Food and Beverages in Nourishment Room Refrigerators
Penalty
Summary
The facility failed to ensure that open juice containers stored in the nourishment room refrigerators were labeled with an open date and that a resident food item stored in the nourishment room was labeled with the resident's name and use-by date. During observations on 03/10/2026, the 100 Hall nourishment room refrigerator contained an open one-gallon apple juice container and an opened 3-liter cranberry juice container with no labeling. The 200 Hall nourishment room refrigerator contained an open one-gallon apple juice container, a 3-liter cranberry juice container, and a resident food item with no labeling. The 300 Hall nourishment room refrigerator contained an open one-gallon apple juice container and an opened 3-liter cranberry juice container with no labeling. During interviews, the kitchen team leader stated kitchen staff were responsible for labeling resident beverages stored in resident refrigerators and should have labeled both containers before placement, and clarified that resident personal food items were to be labeled by nursing staff before being placed in the refrigerator. A Unit Manager stated all resident food items were to be labeled before being placed into the resident refrigerator for proper identification. Another Unit Manager later stated nursing staff were responsible for labeling resident food items and that labels were available in each nourishment room. A CNA stated not knowing that labels were available for residents' stored food items, and confirmed the resident food items were not properly labeled with the resident's name, room number, date stored, and expiration date. The facility policy stated food brought by family or visitors left with the resident to consume later would be labeled and stored in a manner clearly distinguishable from facility prepared food, and the food receiving and storage policy stated beverages must be dated when opened and discarded after 24 hours, and all resident food items must be labeled with the resident's name, the item, and the use-by date.
Inadequate Weekend Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate nursing staff coverage during weekends from December 2024 through February 2025, leading to inappropriate and delayed care for residents. The Payroll-Based Journal (PBJ) Staffing Data Report indicated excessively low weekend staffing, with the facility utilizing 2.1 total nursing hours per resident per day, significantly below the national average of 3.355 hours. The facility's staffing schedules and timesheets confirmed numerous instances of missing licensed nurses and CNAs on both day and night shifts across multiple weekends, resulting in increased staff complaints, burnout, and resident dissatisfaction. Interviews with staff and residents highlighted the impact of staffing shortages on care quality. A CNA reported being assigned up to 20 residents when working short-staffed, which compromised the quality of care provided. During a resident council meeting, a resident reported waiting over six hours for a call light response due to low weekend staffing. Another resident noted consistent understaffing on night shifts, with only two nurses present instead of the scheduled five, leading to overworked CNAs who eventually quit. The Director of Nursing (DON) and the Scheduler acknowledged the staffing deficiencies and verified the accuracy of the schedules. They noted increased staff complaints and burnout, with staff transferring to weekday positions when available. The facility's failure to maintain sufficient nursing staff with the necessary competencies and skills resulted in unmet resident needs, as evidenced by the challenges reported by CNAs in providing essential care such as showering, turning, repositioning, and feeding. The facility's staffing issues contributed to its one-star rating as of January 2025, down from a two-star rating previously.
Failure to Remove Discontinued and Expired Medications
Penalty
Summary
The facility failed to properly manage discontinued and expired medications in two of its three medication rooms, which could lead to medication errors. During an inspection of the medication room in 200 Hall, accompanied by an LPN, it was found that several medications, including Cefepime, Teflaro, Meropenem, and Sodium Chloride solutions, had been discontinued for discharged residents and some had expired. The LPN and the Unit Manager confirmed these medications should have been removed from the active supply for destruction or return but were instead mixed back in. Additionally, expired supplies such as BD SurePath collection containers and BinaxNOW boxes were also found in the active supply. In the medication room in 300 Hall, another LPN confirmed that Lovenox injections, discontinued for a resident upon discharge, had not been removed from the active supply. The Unit Manager acknowledged the oversight in checking the medication room and missing the separation of these medications. The facility's policy on the storage of medications, revised in September 2019, clearly states that discontinued or expired drugs and biologicals should not be used and must be returned to the dispensing pharmacy or destroyed, highlighting a failure to adhere to this policy.
Failure to Complete PASARR Level Two Referrals for Residents with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete Preadmission Screening and Resident Review (PASARR) level two referrals for five residents with newly identified psychiatric diagnoses. These residents were initially admitted with PASARR level one screenings that did not indicate mental illness, intellectual disability, or related conditions, and were deemed appropriate for nursing facility placement. However, during their stay, these residents were diagnosed with various psychiatric conditions such as bipolar disorder, depression, anxiety disorder, and schizophrenia, which were not followed by the necessary PASARR level two referrals. The Behavioral Coordinator, responsible for PASARR for the past two years, admitted to a lack of knowledge regarding the criteria for referring residents for a new level of care or PASARR level two. This knowledge deficit resulted in the failure to refer residents with newly identified psychiatric conditions for further evaluation and determination. The Director of Nursing also acknowledged the facility's knowledge deficit in the PASARR referral process, noting that the interdisciplinary team was not well-versed in identifying residents who met the criteria for a new level of care or PASARR level two referral. The facility's PASARR policy, revised in December 2006, stated that residents with level one screenings who meet criteria for mental illness, intellectual disability, or related disorders should be referred to the state PASARR representative for level two screening. However, the policy identified the social worker as responsible for the referral process, yet the social worker was neither trained nor involved in the PASARR process. This lack of training and involvement contributed to the facility's failure to ensure appropriate referrals for residents with newly identified psychiatric diagnoses.
Failure to Revise Care Plans for Nutrition and Mobility
Penalty
Summary
The facility failed to revise comprehensive care plans to reflect new interventions for nutrition and mobility for four residents. Two residents, one with hemiplegia and hemiparesis and another with mild neurocognitive disorder and protein calorie malnutrition, experienced significant weight loss over a three-month period. Despite physician orders for 1:1 feeding assistance, both residents were observed without staff assistance during meals, and their care plans were not updated to include these new interventions. Additionally, two other residents with mobility issues were not provided with restorative nursing services as recommended by therapy discharge summaries. One resident, with hemiplegia and hemiparesis, expressed concerns about not receiving RNA services due to staff shortages, which were supposed to be provided three times a week. The other resident, with a traumatic brain injury and epilepsy, was also not receiving RNA services despite recommendations to maintain their current level of performance and prevent decline. The Director of Nursing and Unit Manager confirmed that the care plans for these residents were not revised to include the necessary interventions, which should have been done according to the facility's Comprehensive Care Plan policy. This policy requires care plans to be updated when a resident's condition changes or when new interventions are added.
Failure to Provide Restorative Nursing Services Due to Staffing and Communication Issues
Penalty
Summary
The facility failed to provide restorative nursing services to two residents, leading to potential declines in their functional abilities. Resident 156, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, expressed concerns about not receiving restorative nursing services due to staffing shortages. The resident had previously received physical and occupational therapy, but after insurance coverage ended, was placed on restorative nursing services, which were not consistently provided due to the departure of two restorative nurse aides. The Director of Rehabilitation and the 100-Hall Unit Manager confirmed that the therapy recommendations for restorative nursing services were not communicated to the resident's attending physician, which contributed to the lack of service provision. Resident 67, admitted with diagnoses including traumatic brain injury and epilepsy, also did not receive restorative nursing services after being discharged from physical and occupational therapy. The Director of Rehabilitation was unaware if the therapy recommendations were communicated to the appropriate staff, and the medical record lacked evidence of such communication. The Unit Manager and the restorative nurse aide confirmed that Resident 67 was never placed on the restorative nursing case load due to a breakdown in communication, resulting in the resident not receiving the necessary services. The Director of Nursing acknowledged that the facility was understaffed, with only one restorative nurse aide responsible for multiple tasks, making it impossible to provide adequate restorative nursing services to all residents in need. The facility's policy stated that residents should receive nursing care to promote safety and independence, but the lack of communication and staffing issues led to a failure in providing these services, potentially impacting the residents' quality of life.
Failure to Provide Timely Feeding Assistance
Penalty
Summary
The facility failed to provide timely feeding assistance to two residents, Resident 110 and Resident 84, who had physician's orders for one-on-one feeding assistance. Resident 110, diagnosed with hemiplegia and hemiparesis following a cerebral infarction, experienced significant weight loss over a three-month period. Despite having a physician's order for one-on-one assistance with meals, staff often left Resident 110's meal tray unattended, resulting in food being served at improper temperatures, which affected the resident's appetite and meal consumption. Resident 84, diagnosed with mild neurocognitive disorder and protein-calorie malnutrition, also experienced significant weight loss. The resident had orders for one-on-one feeding assistance due to fluctuating meal consumptions related to cognitive issues. However, staff served Resident 84's meal tray without immediate assistance, leading to inconsistent meal consumption. Both residents were part of a larger issue where CNAs were assigned to care for 15 residents each, including multiple residents requiring feeding assistance, which contributed to the delay in providing necessary one-on-one feeding support. The Unit Manager and Registered Dietitian confirmed the significant weight loss and the need for one-on-one feeding assistance for both residents. They acknowledged that the facility's previous restorative dining program, which allowed staff to assist multiple residents simultaneously, had been discontinued during COVID and had not been reinstated. The Director of Nursing emphasized the importance of following physician's orders for one-on-one feeding assistance and acknowledged that the facility had not discussed reinstating the restorative dining program in their Quality Assurance Performance Improvement meetings.
Deficiencies in Enteral Feeding Administration and Positioning
Penalty
Summary
The facility failed to ensure that enteral feeding was completely delivered as ordered for one resident, identified as Resident 105. The resident was admitted with diagnoses including bed confinement and gastrostomy, requiring tube feeding due to Pelizaeus-Merzbacher disease. The physician's order specified a continuous infusion of Jevity 1.2 at a rate of 70 ml per hour for 20 hours daily. However, observations revealed that the feeding was frequently paused or not infusing, and the total volume delivered over three days was significantly less than ordered, resulting in a deficit of 1,221 ml. The Registered Nurse and Unit Manager confirmed the feeding was not completed as prescribed, and the Registered Dietitian noted the deficit could contribute to malnutrition. Another deficiency was identified for Resident 136, who required tube feeding due to dysphagia and had a physician's order to keep the head of the bed elevated during and after feeding to prevent aspiration. Observations showed that the resident's head of the bed was flat while the tube feeding was running, contrary to the care plan and physician's order. The RN Unit Manager confirmed the head of the bed was not elevated as required, acknowledging that staff might have failed to reposition the resident after providing care. The facility's policy on enteral tube feeding required verification of physician orders and adherence to procedures, including labeling the formula and maintaining the head of the bed at a semi-Fowler's position during feeding. These deficiencies in following prescribed orders and facility policies could lead to inadequate nutrition and increased risk of complications for the residents involved.
Failure to Obtain and Implement Physician's Orders for Oxygen Use
Penalty
Summary
The facility failed to ensure a physician's order for oxygen (O2) use and care orders were obtained and implemented for a resident with diagnoses including shortness of breath and pulmonary disease. The resident was observed receiving O2 at 2 liters per minute (LPM) via nasal cannula, with an undated and empty humidifier bottle, indicating a lack of proper documentation and care planning. Despite the resident's continuous O2 use, there was no documented evidence of a physician's order or care plan until several days after the resident's admission. Interviews with facility staff, including a registered nurse and the unit manager, confirmed the absence of necessary O2 orders and care plans. The staff acknowledged that O2 use required a physician's order, transcription into the medication administration record, and inclusion in the care plan, none of which were completed in a timely manner. The facility's policy on oxygen therapy, which mandates administration based on physician's orders and proper labeling and dating of equipment, was not adhered to, resulting in a deficiency in the resident's care.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to ensure proper dialysis care for a resident with end-stage renal disease, who was dependent on renal dialysis. The resident's medical records lacked documentation of a physician's order for dialysis, monitoring of the dialysis access, and pre- and post-dialysis vital signs. Observations and interviews revealed that the resident's dialysis port was not assessed at the facility, and vital signs were not taken immediately before leaving for dialysis or upon return, as required. Licensed staff confirmed that vital signs should have been taken shortly before the resident left for dialysis and upon return to monitor for potential hypotension. The facility's policy required shunt sites to be checked every shift and evaluated after each dialysis treatment for complications, with documentation of pre- and post-dialysis observations, including vital signs and the condition of the shunt site. However, the Unit Manager and Director of Nursing confirmed that the dialysis orders were not fully transcribed into the Medication Administration Record, and the dialysis communication forms were incomplete. This lack of documentation and monitoring could compromise the resident's health and safety.
Facility Assessment Lacks Critical Updates and Documentation
Penalty
Summary
The facility failed to ensure that the Facility Assessment (FA) was updated to accurately reflect the current staffing needs and services provided, as well as to include all required components. The FA, last updated on January 2, 2025, was missing critical documentation such as the care required by the resident population, services provided, and a facility-based and community-based risk assessment using an all-hazards approach. Additionally, the FA lacked active involvement from nursing home leadership and management, and did not include information on staffing levels needed for specific shifts. The Administrator-in-Training (AIT) and the Director of Nurses (DON) confirmed these deficiencies during interviews. The AIT was unable to find documentation of the types of services provided by the facility, such as respiratory therapy and wound care, and acknowledged the absence of a qualitative tool for risk assessment. Furthermore, the FA did not evaluate the resident population's acuity or include a staffing plan. The DON indicated that the Quality Assurance and Performance Improvement (QAPI) committee had convened to finalize the FA, but the staffing plan was not reviewed or included at that time.
Inadequate QAPI Oversight on Staffing Issues
Penalty
Summary
The facility failed to ensure the effective implementation and oversight of its Quality Assurance Performance Improvement Plan (QAPI) concerning staffing issues. The QAPI committee did not adequately follow through on the Performance Improvement Project (PIP) for staffing shortages, which was initiated in December 2021. Although the PIP identified pay rate and benefits as root causes and outlined action plans such as offering competitive pay, bonuses, and utilizing agency staff, there was no documentation to confirm whether these measures were still effective or if new interventions were needed. The Director of Nursing (DON) acknowledged that the PIP was not current, as the facility had stopped using agency nurses since 2022, and staffing issues had not been discussed in recent QAPI meetings. The facility also failed to conduct a root cause analysis on its high staff turnover rate. The CMS Provider Rating Report indicated a significant turnover rate for registered nurses and all nursing staff, with 51 licensed nurses leaving the facility over a one-year period. The DON and staff scheduler confirmed the turnover but admitted that the facility lacked a formal process for identifying reasons for staff departures, such as conducting exit interviews. The Human Resources Director corroborated this, noting that exit interviews were not routinely conducted, and reasons for staff leaving were informally gathered and not systematically analyzed. Additionally, the facility did not maintain adequate oversight over low weekend staffing patterns. The CMS Payroll-Based Journal Staffing Data Report highlighted excessively low weekend staffing, which was confirmed by the DON and staff scheduler upon reviewing staffing schedules. The DON reported increased staff complaints about weekend staffing and burnout, as well as resident complaints regarding call light response times. Despite these issues, the QAPI process was not fully utilized to address the staffing shortage, high turnover, and weekend staffing problems, as acknowledged by the DON.
Infection Control Lapses in Nourishment Room
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in the nourishment room, as observed on February 11, 2025. A staff member was seen consuming a drink while seated next to a handwashing sink, which is against facility policy. Additionally, a clear bag filled with cubed ice was improperly placed inside the handwashing sink, and the trash can was overflowing onto the floor. Loose cubed ice was also found at the bottom of the freezer and around food products, which could lead to contamination. Interviews with the Food Service Director and a Registered Nurse revealed a lack of awareness regarding the improper use of the handwashing sink for melting ice and the necessity of maintaining cleanliness in the nourishment room. The Infection Preventionist confirmed that these practices were not in line with infection control standards, as outlined in the facility's policies on employee hygiene, sanitary practices, and housekeeping. These deficiencies in maintaining a clean and safe environment in the nourishment room had the potential to cause the spread of bacteria.
Failure to Monitor Resident with Change in Condition
Penalty
Summary
The facility failed to adequately assess, re-assess, and monitor a resident, identified as Resident 3 (R3), who experienced a change in condition. R3 was admitted with chronic heart failure and was capable of communicating needs. The resident reported chest pain and shortness of breath to a family member, which led to a chest x-ray revealing pleural effusions. Despite these symptoms, there was a significant lack of documentation and follow-up assessments by the nursing staff over several days, which contributed to the resident's acute physical decline. The clinical notes for R3 showed gaps in documentation and monitoring, with no focused or complete assessments conducted to establish a baseline or identify potential causes of the symptoms. The notes indicated that R3's condition was not adequately monitored, with long intervals between progress notes and insufficient reassessment of the resident's respiratory and cardiac status. The facility's failure to perform regular and thorough assessments, as well as to document these assessments, meant that critical changes in R3's condition were not communicated effectively to the medical provider. Interviews with facility staff, including LPNs and the Director of Nurses (DON), revealed a lack of awareness and adherence to protocols for managing residents with chest pain and congestive heart failure. The DON acknowledged that the nurses did not perform necessary assessments and that the medical provider relied on detailed clinical information from the nursing staff to make informed decisions. The absence of a facility policy for nursing standards of practice and the reliance on the Nevada Nurse Practice Act further highlighted the deficiencies in the facility's approach to resident care. Ultimately, R3 was transported to the hospital, where they passed away due to cardiogenic shock, a condition that might have been mitigated with timely and appropriate interventions by the facility staff.
Failure to Assist Resident with Hygiene Needs
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect by not assisting with the resident's hygiene needs. The resident, who was admitted with diagnoses including traumatic hemorrhage of the cerebrum, type 2 diabetes mellitus, chronic obstructive pulmonary disease, muscle wasting and atrophy, and dysphagia, was observed in bed wearing a clean medical gown but had not been shaved, resulting in a thick beard. The resident expressed that they were admitted with very few clothes and preferred to wear the facility-provided gowns. The resident also mentioned that they had been shaved about three weeks ago during a shower but not during the most recent shower, despite the expectation that shaving occurs on shower days. Interviews with facility staff, including a CNA and an LPN, confirmed that the resident did not have personal clothing upon admission and was provided with donated clothing. The staff also confirmed that the resident's shower days were scheduled for Tuesdays and Fridays, and that shaving should occur on these days. However, the facility's daily shower monitoring logs did not provide evidence that the resident was being shaved on these scheduled shower days. The facility's policy and procedure manuals emphasize the importance of assisting residents with grooming and dressing after showers, as well as treating residents with respect, kindness, and dignity.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
