Silver Ridge Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 1151 Torrey Pines Dr., Las Vegas, Nevada 89146
- CMS Provider Number
- 295072
- Inspections on file
- 30
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Silver Ridge Healthcare Center during CMS and state inspections, most recent first.
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.
The facility failed to maintain safe storage temperatures for perishable food items in the walk-in refrigerator, which consistently registered above the safe range of 35-41°F for several days. Despite being aware of the issue, the Dietary Manager and kitchen staff did not ensure maintenance was notified, leading to a delay in addressing the malfunction. This posed a risk of food-borne illness to residents.
A resident with multiple medical conditions was served meals inconsistent with their prescribed minced/moist diet and dietary preferences, leading to meal refusal and dissatisfaction. Despite a physician's order and documented dislikes, the resident received a pureed diet and meals containing pork, which they disliked. The kitchen manager confirmed the error, acknowledging a misunderstanding by the cook regarding meal consistencies.
A resident who had a fall and was sent to the hospital returned exhibiting confusion and combativeness, refusing care and vital checks. Despite these behaviors, the facility failed to notify the physician, as confirmed by staff interviews and a review of the medical record. This oversight was contrary to the facility's policy requiring communication of changes in condition to the primary care provider.
A resident with a stage 3 pressure ulcer did not have documented evidence of wound care treatments being administered as per physician's orders. The Treatment Administration Record lacked entries for the specified period, and interviews with the Wound Care Nurse and DON confirmed the absence of documentation. The facility's policy required documentation of skin condition and treatments, which was not followed.
The facility failed to properly date and time water bags and tubing systems for gastrostomy feeding hydration for two residents. Feeding formula bottles were dated but not timed, and tubing was undated, which was confirmed by an LPN. This oversight had the potential to compromise patient safety by increasing the risk of contamination and infections.
Expired medications were found in two medication rooms and one medication cart, including Vitamin C and Insulin Lispro. An LPN attempted to administer expired Vitamin C to a resident, and the facility's policy requires checking expiration dates and removing expired medications.
A facility failed to provide mandatory training, including abuse, fire, disaster, and dementia training, to a CNA hired in 2003. The CNA's file lacked documentation of these trainings, confirmed by the HR/Payroll Clerk. The Staff Development Assistant acknowledged the facility's obligation to comply with state and local laws for required training. The deficiency placed residents at risk for inappropriate care.
A facility failed to develop a baseline care plan for a resident admitted with an infected left foot and at risk for pressure ulcers. Despite a Braden scale assessment indicating risk factors, no care plan was initiated within the first 48 hours, leading to delayed interventions and the development of a pressure ulcer and other skin issues. The deficiency was confirmed by the treatment nurse and DON.
A resident at risk for pressure ulcers did not have a care plan developed or implemented, leading to multiple skin breakdowns. Despite assessments indicating risk factors such as limited mobility and moisture exposure, the facility failed to document a care plan for pressure ulcer prevention. The MDS Director and nursing staff did not ensure the inclusion of this critical care plan, contrary to facility policies.
A resident with cellulitis of the left foot was not properly assessed and monitored, leading to potential complications and hospitalization. Despite being admitted with a primary diagnosis of left foot cellulitis, the facility failed to document the condition of the foot or the presence of a CAM boot device in the admission skin assessments and subsequent weekly inspections. This oversight resulted in the development of an arterial wound with eschar and discoloration, which was only identified after a delay, causing severe pain and necessitating hospital transfer.
A resident at risk for pressure ulcers did not receive weekly skin assessments as required, leading to the development of a facility-acquired pressure ulcer. The resident, with limited mobility and other health conditions, was not included in the wound team's case load due to initial assessments showing no skin issues. Missed assessments delayed the identification and intervention for a deep tissue injury, which was eventually discovered by a CNA. Physician orders for wound management were obtained, but the resident was transferred to the hospital before implementation.
Two residents at a facility were able to leave unsupervised due to ineffective elopement measures. One resident, with a history of wandering, was found at a homeless shelter after staff failed to respond to door alarms. Another resident, identified as an elopement risk, left the facility due to delayed implementation of interventions. The facility's surveillance system had dead spots, and staff did not adhere to the elopement policy, leading to potential harm.
During a survey, a facility was found to have several deficiencies including handwashing stations with water temperatures at 68°F, black tarry build-up under the stove shelf, food debris under the preparation table, expired thickened apple juice, undated ground beef, and a leaking sanitizer station. The maintenance director mentioned completing temperature adjustments and logs, while the dietitian emphasized the importance of labeling and dating perishable items. Further observations in nourishment rooms revealed expired and unlabeled items in refrigerators, a broken cabinet board with residue, and a lack of proper labeling and dating for food items. The Dietary Manager highlighted the shared responsibility between kitchen and nursing staff for monitoring and restocking nourishment rooms, in line with the facility's policy on food safety standards.
The facility failed to complete a PASARR level two referral for a resident with new diagnoses of schizophrenia, schizoaffective disorder, and unspecified dementia. Staff interviews revealed a lack of clarity and responsibility regarding the PASARR referral process, and the facility did not have a current process for identifying and referring residents for a new level of care.
The facility failed to develop a baseline care plan within 48 hours for a resident admitted with a knee brace. Despite hospital documentation indicating the need to maintain the knee brace in full extension, the facility did not assess or care plan for its use, as confirmed by staff interviews and record reviews.
The facility failed to update a care plan to include a physician's order for a cervical collar for a resident with Parkinson's disease and gastrostomy status. Despite a restorative note and a physician's order, the care plan lacked documentation of this update, which was confirmed as an oversight by the ADON.
A resident at very high risk for pressure ulcers was left in a Geri-chair without a cushion for over eight hours, contrary to the care plan and facility policy. Despite having healed sacral wounds, the resident was not turned, repositioned, or provided with continence care, leading to potential risks of reopening the wounds.
A facility failed to follow a physician's order for a cervical collar for a resident with Parkinson's disease, leading to discomfort and poor neck alignment. The collar remained in the therapy room due to a communication breakdown among staff.
The facility failed to identify, assess, and monitor a full-length knee brace for a resident with a high fall risk. Despite the resident's medical history and fall risk assessment, no care instructions were documented, leading to a fall when the brace's Velcro loosened and became stuck on the top sheet. Staff confirmed the lack of proper management contributed to the incident.
The facility failed to administer tube feeding as ordered for a resident and did not maintain proper bed elevation and timely replacement of the feeding bottle for another resident. The discrepancies in TF administration and bed positioning were confirmed by staff and attributed to communication and implementation failures.
The facility failed to administer oxygen (O2) as ordered for two residents, leading to potential health risks. One resident with acute respiratory distress had O2 flowing at 4 liters per minute (LPM) instead of the ordered 3 LPM. Another resident dependent on supplemental O2 had O2 flowing at 3 LPM and 4 LPM instead of the ordered 2 LPM. Staff confirmed the discrepancies and acknowledged the importance of following the physician's orders.
A facility failed to communicate a resident's Candida auris infection status to the dialysis provider, resulting in the resident receiving dialysis in the general area without necessary contact precautions. This oversight put both staff and other patients at risk for infection transmission.
The facility's pest control program was ineffective, as evidenced by a large quantity of ants discovered in the kitchen. The ants were observed moving from a small hole in the wall to the food preparation station. The presence of ants was confirmed by the dietitian and maintenance director. Despite monthly visits from a pest control company, the facility failed to prevent the infestation.
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 Maintain Safe Food Storage Temperatures
Penalty
Summary
The facility failed to store perishable food items in a sanitary manner, as evidenced by the walk-in refrigerator maintaining temperatures above the safe range of 35-41 degrees Fahrenheit for several days. On multiple occasions, the internal thermometer of the walk-in refrigerator registered temperatures as high as 55 degrees Fahrenheit, with perishable items such as sliced ham and chicken salad also found at unsafe temperatures. This issue persisted from April 4, 2025, to April 8, 2025, without being adequately addressed, posing a risk of food-borne illness to all residents. The Dietary Manager (DM) acknowledged the temperature discrepancies and admitted to not checking the temperature log due to being busy. Despite the temperature log indicating a pattern of unsafe temperatures, the issue was not escalated to the Maintenance Director until April 8, 2025. The Assistant Dietary Manager and other kitchen staff were aware of the temperature issues but failed to ensure that maintenance was properly notified and that corrective actions were taken. The Maintenance Assistant did not recall being informed of the issue, and the Maintenance Director was only made aware on April 8, 2025, when a service company was called to address the problem. The facility's policy required that refrigerator temperatures be checked and recorded daily, with any deviations reported immediately to the Dietary Manager or maintenance. However, this protocol was not followed, leading to a delay in addressing the malfunctioning refrigerator. The Registered Dietician confirmed that storing food above 41 degrees Fahrenheit could allow harmful bacteria to grow, potentially causing nausea, vomiting, and diarrhea in residents consuming the spoiled food.
Failure to Honor Resident's Dietary Preferences and Consistency
Penalty
Summary
The facility failed to comply with the prescribed meal consistency and dietary preferences for a resident, leading to a deficiency in honoring the resident's right to self-determination and choice. The resident, who had a history of hypertension, chronic debility, hypothyroidism, atrial fibrillation, type 2 diabetes, and chronic obstructive pulmonary disease, was observed refusing meals due to incorrect consistency and unwanted food items. Despite a physician's order for a minced and moist texture diet, the resident was repeatedly served a pureed diet, which they had previously been removed from. Additionally, the resident's meal ticket indicated a dislike for pork, yet meals containing ham were served, further disregarding the resident's documented preferences. The kitchen manager confirmed the discrepancy between the prescribed minced/moist diet and the pureed diet being served, acknowledging the misunderstanding by the cook who considered both consistencies the same. The facility's policy on resident food preferences, which mandates awareness of resident preferences and allergies, was not adhered to, resulting in the resident's dissatisfaction and meal refusal. The resident's nutritional care plan highlighted the risk of altered nutrition and hydration due to their medical conditions, emphasizing the importance of adhering to dietary preferences to prevent significant weight changes and ensure adequate nutritional intake.
Failure to Notify Physician of Resident's Post-Fall Behavior
Penalty
Summary
The facility failed to notify the physician regarding a resident's post-fall behavior and refusal of care, which was a deficiency identified during the survey. The resident, who had been admitted with diagnoses including chronic obstructive pulmonary disease and chronic pulmonary edema, experienced a fall and was sent to the hospital for evaluation. Upon returning from the hospital, the resident exhibited confusion, combativeness, and refusal of care, including vital sign checks. Despite these significant changes in behavior, there was no documented evidence that the physician was notified of the resident's condition. Interviews with facility staff, including LPNs and the Supervising Nurse, confirmed that the resident's refusal of care and aggressive behavior were not communicated to the physician, contrary to the facility's policy. The facility's policy required that any change in condition, such as refusal of care, should be assessed, documented, and communicated to the primary care provider. The lack of notification to the physician about the resident's condition post-fall was a critical oversight, as confirmed by the Director of Nursing and other staff members.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to provide documented evidence that wound care treatments were administered according to the physician's orders for one resident. This resident, who was admitted with diagnoses including type 2 diabetes mellitus with circulatory complications, a stage 3 pressure ulcer in the sacral region, and atrial fibrillation, had a physician's order for specific wound care treatment. The order required cleansing the wound with normal saline, applying Medihoney and Triad cream, and covering it with gauze daily. However, the Treatment Administration Record (TAR) lacked documentation of these treatments being completed from March 25, 2025, through March 31, 2025. Interviews with the Wound Care Nurse and the Director of Nursing (DON) confirmed the absence of documentation for the wound care treatments during the specified period. The Wound Care Nurse explained that the Admission Nurse was responsible for the initial skin assessment, while the wound care staff was to perform further assessments and obtain treatment orders. The DON stated that staff were expected to document treatments on the TAR. The facility's policy on pressure ulcer prevention required licensed nurses to record the condition of the skin and the treatment provided, which was not adhered to in this case.
Failure to Date and Time Feeding Tubes and Water Bags
Penalty
Summary
The facility failed to ensure proper dating and timing of water bags and tubing systems used for gastrostomy feeding hydration for two residents. For one resident, the feeding formula bottle was dated but not timed, and the tubing was undated and disconnected from the gastrostomy tube. Additionally, a water bag was present but undated and untimed. A Licensed Practical Nurse confirmed that the feeding tubing and water bag should have been dated upon initiation to ensure they were changed every 48 hours, as per the physician's order. For the second resident, the feeding formula bottle was dated but not timed, and the tubing was undated. The resident was observed receiving feeding formula at a specified rate, but the water bag and tubing were undated and untimed. The facility's policy indicated that prefilled formula containers and tubing should be changed every 48 hours or per manufacturer guidelines. The failure to date and time these items had the potential to compromise patient safety by increasing the risk of contamination and infections.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to remove expired medications from two of three medication rooms and one of five medication carts, which could potentially compromise patient safety. During an inspection on April 10, 2025, a Licensed Practical Nurse (LPN) was observed attempting to administer a 250-milligram tablet of Vitamin C to a resident. The Vitamin C had expired in December 2024, and the LPN acknowledged that the expiration date should have been checked before administration. This incident occurred on the 200 Hall medication cart. Further inspection of the medication rooms revealed additional expired medications. In one medication room, a bottle of Vitamin C 250 mg was found to have expired in December 2024. In another medication room, an opened vial of Insulin Lispro, dated February 14, 2025, was found. According to the label, this medication should have been discarded within 28 days of opening, but it had not been. The facility's policy, dated November 2011, requires that nurses check expiration dates before administering medications and that expired medications be removed and destroyed. The policy also specifies that vials should be discarded 30 days after being opened.
Failure to Provide Mandatory Training to CNA
Penalty
Summary
The facility failed to ensure that mandatory training, including abuse, fire, disaster, and dementia training, was provided to a Certified Nursing Assistant (CNA), identified as Employee 10 (E10). E10 was hired on March 4, 2003, and a review of their employee file revealed a lack of documentation for the required training. On April 11, 2025, the Human Resource/Payroll Clerk confirmed that E10 had no record of completing these mandatory trainings. The Staff Development Assistant acknowledged that the facility was expected to comply with state and local laws, which included providing state-required training such as care of dementia residents, abuse, fire, and disaster training. The Covenant Care Employee Training Requirements, updated in December 2022, outlined the necessity for new hires and annual compliance-related training for all employees, including abuse and neglect, safety-related training, and training required by federal and state requirements specific to Nevada. The State Operations Manual for Long Term Care Facilities mandates in-service training for nurse aides, including dementia management and resident abuse prevention training. The deficiency placed residents at risk for inappropriate care.
Failure to Develop Baseline Care Plan for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was admitted with an infected left foot and assessed to be at risk for developing pressure ulcers. The resident, who had a history of left toe cellulitis, peripheral vascular disease, and diabetes mellitus, was admitted without a care plan addressing pressure ulcer prevention and skin integrity maintenance. A Braden scale assessment indicated the resident was at risk due to factors such as limited mobility and skin exposure to moisture. Despite this assessment, the medical record lacked evidence of a baseline care plan being developed within the first 48 hours of admission. The deficiency was confirmed by the treatment nurse and the Director of Nursing, who acknowledged that a care plan should have been initiated. The absence of a care plan potentially delayed necessary interventions, leading to the development of a pressure ulcer, groin rash, and complications to the resident's left foot and toes. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not adhered to, resulting in the identified issues.
Failure to Implement Pressure Ulcer Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who was at risk for developing pressure ulcers. The resident, who was admitted with conditions including cellulitis, peripheral vascular disease, and diabetes mellitus, was assessed using the Braden scale and found to be at risk due to factors such as limited mobility and exposure to moisture. Despite these assessments, the medical record did not contain evidence of a care plan for pressure ulcer prevention or skin integrity maintenance. The deficiency was identified when a change of condition document revealed multiple areas of skin breakdown, including excoriation and skin tears. The MDS Director confirmed that the pressure ulcer care area was triggered but not addressed in the care plan. The Director of Nursing clarified that the responsibility for initiating the care plan lay with the admission nurse or any assigned nurse, and the MDS Director should have ensured its inclusion in the comprehensive care plan. The facility's policies required a baseline care plan to be used until a comprehensive care plan was developed, but this was not followed in this case.
Failure to Monitor and Document Resident's Foot Condition
Penalty
Summary
The facility failed to adequately assess and monitor a resident's left foot, which was being treated for cellulitis, leading to potential complications and hospitalization. The resident was admitted with a primary diagnosis of left foot cellulitis, along with other conditions such as diabetes mellitus, peripheral vascular disease, and a history of above-the-knee amputation. Despite these conditions, the admission skin assessments and subsequent weekly skin inspections did not document the condition of the resident's left foot or the presence of a CAM boot device. This lack of documentation and monitoring resulted in the resident's left foot developing an arterial wound with eschar and discoloration, which was only identified after a significant delay. The treatment nurse and the Director of Nursing confirmed that weekly skin checks were missed or completed late, which could have identified issues with the resident's left foot earlier. The facility's policy required documentation of skin integrity issues post-admission, including wound location, size, and signs of infection, but these were not followed. The deficiency in monitoring and documentation led to the resident experiencing severe pain and discoloration in the left leg, prompting a transfer to the hospital for further evaluation and management.
Failure to Conduct Weekly Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to ensure that weekly skin assessments were conducted for a resident at risk for developing pressure ulcers. The resident, who was admitted with a right above-the-knee amputation and other conditions such as peripheral vascular disease and diabetes mellitus, was identified as being at risk for pressure ulcers due to limited mobility and chairfast status. Despite this, the medical record lacked documented evidence of weekly skin checks on three occasions, which were confirmed by the treatment nurse and the Director of Nursing (DON). This oversight potentially contributed to the development of a facility-acquired pressure ulcer on the resident's left hip, which was identified by a CNA and assessed by a nurse. The deficiency was further highlighted when the treatment nurse confirmed that the resident was not included in the wound team's case load due to the initial assessment showing no skin issues. The missed weekly skin checks delayed the identification and intervention for the resident's skin breakdown, which was eventually noted to be a deep tissue injury. Physician orders for wound management were obtained, but the resident was transferred to the hospital before they could be implemented. The facility's policy required weekly skin assessments to identify new skin impairments and ensure timely interventions, which were not adhered to in this case.
Failure to Implement Effective Elopement Measures
Penalty
Summary
The facility failed to effectively execute elopement measures for two residents, leading to incidents where both residents were able to leave the facility unsupervised. Resident 1, who had a history of wandering and was equipped with a Wanderguard, was last seen by staff at 6:15 PM near the front entry. Despite being on frequent monitoring and having a comprehensive care plan in place, Resident 1 was discovered missing at 7:10 PM and was later found at a local homeless shelter. Staff members reported not hearing or responding to any door alarms around the time of the incident, indicating a lapse in the facility's monitoring and response protocols. Resident 2, who was admitted with altered mental status and homelessness, was identified as a potential elopement risk but did not have the necessary interventions implemented in a timely manner. On one occasion, Resident 2 was found outside the facility after being reported missing by a CNA. The elopement risk assessment tool had flagged Resident 2 as at risk, but the care plan and interventions were not completed until after the elopement incident occurred. This delay in implementing the necessary measures contributed to the resident's ability to leave the facility unsupervised. The facility's elopement and missing resident policy, dated December 2017, required ongoing evaluation and adequate planning for residents identified at risk of elopement. However, the facility's failure to adhere to these protocols, including the lack of effective monitoring and response to door alarms, as well as the incomplete implementation of care plans for at-risk residents, resulted in the potential for harm to the residents involved. The facility's surveillance system also had limitations, with several dead spots not covered by cameras, further complicating the ability to monitor and prevent elopements.
Deficiencies in Handwashing Stations, Food Labeling, and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper handwashing stations with hot water, labeled and dated food items, and a clean kitchen environment, as observed during a survey. The initial tour of the kitchen revealed handwashing stations with a temperature of 68 degrees Fahrenheit, black tarry build-up under the stove shelf, food debris under the preparation table, expired thickened apple juice, undated ground beef, and a leaking sanitizer station. The maintenance director mentioned completing temperature adjustments and logs, while the dietitian emphasized the importance of labeling and dating perishable items in storage areas. Further observations in the nourishment rooms on different units identified expired and unlabeled items in refrigerators, a lack of proper labeling and dating for food items, and maintenance issues such as a broken cabinet board with residue. The Dietary Manager stressed the necessity of labeling and dating food items to prevent foodborne illness and spoilage, with responsibilities shared between kitchen and nursing staff for monitoring and restocking nourishment rooms. The facility's policy outlined procedures for checking expiration and use-by dates, repackaging food, and labeling containers to maintain food safety standards.
Failure to Complete PASARR Level Two Referral
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for one resident. The resident was admitted with primary diagnoses including bipolar disorder, new schizophrenia, schizoaffective disorder, and a secondary diagnosis of unspecified dementia. Despite these diagnoses, the resident's PASARR level one document indicated no mental illness, intellectual disability, or related condition, and the resident was deemed appropriate for nursing facility placement. Subsequent assessments and psychiatry notes revealed new diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia, but there was no documented evidence of a PASARR level two referral being made. Interviews with facility staff, including the MDS Director, Admissions Director, and Social Services Director (SSD), revealed a lack of clarity and responsibility regarding the PASARR referral process. The MDS Director confirmed the resident's new diagnoses but indicated that MDS nurses were not involved in the referral process. The Admissions Director stated responsibility for initial PASARR assessments but not for ongoing referrals. The SSD, who had been employed for three months, was unaware of the need to identify and refer residents for PASARR level two. The Director of Nursing (DON) and Assistant DON, along with a charge nurse, confirmed that the facility did not have a current process for identifying and referring residents for a new level of care or PASARR level two, as the former SSD who handled this task was no longer employed at the facility.
Failure to Develop Baseline Care Plan for Knee Brace
Penalty
Summary
The facility failed to ensure a baseline care plan was developed within 48 hours for the use of a leg brace following the admission of Resident 189. Resident 189 was admitted with diagnoses including the presence of a left artificial knee joint, cellulitis of the left lower limb, left knee pain, and unsteadiness of feet. Despite the hospital's Transfer/Discharge Summary and the History and Physical documentation indicating the need to maintain the knee brace in full extension at all times, the facility did not assess the knee brace or develop a care plan for its use following the resident's admission. This oversight was confirmed through observations, interviews, and record reviews, revealing that the knee brace was not identified in the admission assessment and was not care planned accordingly. Interviews with the Registered Nurse, Charge Nurse, Director of Rehabilitation Services, and Assistant Director of Nursing confirmed that the knee brace should have been assessed and care planned upon admission. The facility's policy on Baseline Care Plan, dated 10/2022, mandates the development and implementation of a baseline care plan within 48 hours of a resident's admission, including the necessary instructions to provide effective and person-centered care. However, this policy was not followed, resulting in a lack of documented evidence and care planning for Resident 189's knee brace, which was essential for the resident's post-surgery care and safety.
Care Plan Update Failure for Cervical Collar
Penalty
Summary
The facility failed to ensure a care plan for range of motion was updated to include a physician's order for a cervical collar for one resident. The resident was admitted with diagnoses including Parkinson's disease and gastrostomy status. A restorative note indicated the resident would benefit from a soft collar for neck repositioning, and a physician's order was later documented for the use of the collar. However, the care plan initiated earlier lacked documented evidence of this update. The Assistant Director of Nursing confirmed the oversight during a review of the care plan.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident identified as having a very high risk of developing pressure ulcers was turned and repositioned per policy and provided with a cushion while seated in the Geri-chair. Resident 191, who had diagnoses including stages two and three pressure ulcers in the sacral region, hemiplegia, and hemiparesis, was observed in the Geri-chair without a cushion for extended periods. Despite the care plan indicating the need for a Roho cushion and repositioning every two hours, the resident was left in the Geri-chair from 7:00 AM to 3:00 PM without being turned, repositioned, or provided with continence care. This neglect was confirmed by both a Registered Nurse and a Certified Nursing Assistant, who admitted that the resident had not been attended to for over eight hours. The wound coordinator and the Wound Care Treatment Nurse confirmed that the resident's sacral wound had healed but emphasized the importance of using a Roho cushion to prevent reopening the wound. The facility's policy on skin integrity, which mandates turning and repositioning residents at least every two hours, was not followed. The interdisciplinary team was unaware that the resident had been placed in the Geri-chair for such an extended period, highlighting a communication breakdown within the care team. The primary physician also stressed the importance of turning, repositioning, and offloading pressure to prevent wound development and promote healing.
Failure to Follow Physician's Order for Cervical Collar
Penalty
Summary
The facility failed to ensure a physician's order for a cervical collar was followed for a resident diagnosed with Parkinson's disease and gastrostomy status. The resident had a tendency to lean to one side, and a soft cervical collar was recommended and ordered to maintain proper neck alignment and increase comfort. Despite the order being placed and the collar being delivered, the resident was observed on multiple occasions without the cervical collar, leading to discomfort and poor alignment of the head and neck. The cervical collar was found to have remained in the therapy room due to a communication breakdown among therapy staff and restorative nurse aide services. On two separate observations, the resident was seen with their head leaning to the left side without the cervical collar. The Director of Staff Development confirmed the absence of the collar in the resident's room, and the Certified Nursing Assistant assigned to the resident was unaware of the order for the cervical collar. The Director of Rehabilitation later confirmed that the collar had been delivered but not provided to the resident due to miscommunication. The facility's policy on cervical collars indicated they should be used as directed by a physician's order, which was not followed in this case.
Failure to Identify and Manage Knee Brace for Resident
Penalty
Summary
The facility failed to ensure the use of a full-length knee brace or immobilizer was identified, assessed, monitored, and care orders were obtained for Resident 189. Resident 189 was admitted with diagnoses including the presence of a left artificial knee joint, cellulitis of the left lower limb, left knee pain, and unsteadiness of the feet. Despite being at high risk for falls, the facility did not document the knee brace in the medical records, nor were there any care instructions for its management. The resident experienced a fall when the brace's Velcro loosened and became stuck on the top sheet, contributing to the fall. The resident's fall risk assessment indicated a high risk for falls, but no interventions were implemented to manage the knee brace properly. On multiple occasions, staff confirmed that the knee brace was not identified, assessed, or monitored following the resident's admission. The Charge Nurse and the Director of Rehabilitation Services acknowledged that the lack of identification and management of the knee brace contributed to the fall incident. The Assistant Director of Nursing also confirmed that the fall was avoidable and that the resident needed assistance with mobility and transfer. The facility's policy on Fall Prevention and Response was not followed, as the resident did not receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.
Failure to Administer Tube Feeding as Ordered and Maintain Proper Bed Elevation
Penalty
Summary
The facility failed to ensure that tube feeding (TF) was administered as ordered for Resident 191 and that the head of the bed was elevated during TF administration for Resident 54. For Resident 191, the TF was ordered to be administered at 65 ml/hr but was observed to be infusing at 60 ml/hr, resulting in a total volume delivered of 1200 ml instead of the prescribed 1300 ml. This discrepancy was confirmed by a Registered Nurse (RN) and attributed to a failure in communication and implementation of the updated order. The resident was non-verbal and dependent on TF due to dysphagia and post-stroke status, with the TF increase intended to address weight loss and promote wound healing. The failure to adjust the TF rate as ordered was acknowledged by the Charge Nurse and the Assistant Director of Nursing (ADON), who indicated that the Licensed Nurses were expected to verify and deliver the ordered dose accurately. For Resident 54, the facility did not ensure that the head of the bed was elevated above 30 degrees during TF administration, and the TF bottle was used beyond the 24-hour limit. The resident, diagnosed with protein-calorie malnutrition and muscle weakness, was observed with the bed in a low position and the TF bottle labeled with a date indicating it had been in use for more than 24 hours. A Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) confirmed these observations. The ADON and LPN both stated that the head of the bed should be raised at least 30 degrees to prevent aspiration and that the TF bottle should be discarded after 24 hours. The facility's policy also documented that feeding containers, tubing, and syringes should be changed every 24 hours, which was not adhered to in this case.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen (O2) was administered as ordered for two residents, leading to potential health risks. Resident 44 was admitted with acute respiratory distress and chronic obstructive pulmonary disease, with a physician's order for O2 at 3 liters per minute (LPM) via nasal cannula. However, observations on 04/23/2024 revealed that the O2 was flowing at 4 LPM. The registered nurse confirmed the discrepancy and acknowledged that the incorrect flow rate could cause hypoxemia or carbon dioxide retention. The charge nurse indicated that licensed nurses were expected to check the ordered O2 flow rate during shift changes and rounds to ensure residents' safety. Similarly, Resident 131, who was admitted with shortness of breath and dependence on supplemental O2, had a physician's order for O2 at 2 LPM. Observations on 04/23/2024 and 04/24/2024 showed that the O2 was flowing at 3 LPM and 4 LPM, respectively. The registered nurse confirmed the incorrect flow rate and noted that the resident's O2 saturation was 99% with no signs of respiratory distress. The assistant director of nursing indicated that licensed nurses were expected to verify and follow the O2 flow rate as ordered. The facility's policy on medication administration emphasized that medications, including O2, should be administered as ordered by the physician and in accordance with professional standards of practice.
Failure to Communicate Infection Status to Dialysis Provider
Penalty
Summary
The facility failed to ensure that a resident's infection status was communicated with the dialysis provider, leading to a significant deficiency. Resident 99, who was admitted with end-stage renal disease and required dialysis, tested positive for Candida auris, a highly contagious fungal infection. Despite the positive test result, there was no documented evidence that the facility communicated this critical information to the dialysis provider. As a result, the resident continued to receive dialysis treatments in the general area without the necessary contact precautions, putting both staff and other patients at risk for transmission of the infection. On multiple occasions, staff at the dialysis facility, including the primary nurse, charge nurse, and facility administrator, confirmed that they were unaware of Resident 99's C. auris status. The dialysis facility had specific protocols for managing patients with C. auris, including cohorting infected patients and employing full personal protective equipment (PPE). The lack of communication from the skilled nursing facility meant that these protocols were not followed, further increasing the risk of infection spread. The Infection Preventionist and Director of Nursing at the skilled nursing facility acknowledged the oversight and confirmed that the resident's infection status should have been communicated to the dialysis provider. The facility's policies and agreements with the dialysis provider explicitly required the exchange of information regarding significant changes in a resident's health status, including infections. The failure to adhere to these policies resulted in a serious lapse in infection control measures, endangering both dialysis staff and patients.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to ensure the pest control program was effective, as evidenced by the discovery of a large quantity of ants in the kitchen. During an initial tour, ants were observed on the side wall next to the dishwasher, moving in a line from a small hole in the wall to the food preparation station. The presence of ants was confirmed by the dietitian and maintenance director. The Dietary Manager indicated that pest control concerns were reported verbally to the maintenance department, which was responsible for the pest control program. The Maintenance Director explained that the pest control company visited monthly and would address concerns the same day or the next day if identified. Despite these measures, the facility's pest control program was not effective in preventing the ant infestation in the kitchen. The facility's policy on pest control documented a program for controlling insects and rodents, but it was not adequately implemented in this instance.
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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