Silver State Pediatric Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 2496 W Charleston Blvd, Las Vegas, Nevada 89102
- CMS Provider Number
- 295108
- Inspections on file
- 12
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Silver State Pediatric Skilled Nursing Facility during CMS and state inspections, most recent first.
Food storage and sanitization deficiencies were identified when the Dietary Manager could not verify sanitizer ppm for the 3-compartment sink because test strips were unavailable, yet the sanitation log incorrectly showed verification had been completed. Staff also found expired food items in the refrigerator and nourishment room, and dented cans were not discarded as required. The Cook and Dietary Manager acknowledged that expired and damaged food items must be removed to prevent contamination and illness.
A resident with plagiocephaly and other complex diagnoses was observed wearing a cranial helmet, but the physician order for 23-hour wear with a daily one-hour removal and cleaning was not properly carried out or documented. The e-MAR remained blank, daily nursing assessments did not show the required removal and cleaning tasks, and the DON confirmed nursing was responsible for following the order while the POC record only reflected helmet cleaning.
Incomplete and Inaccurate Tube Feeding Bag Labeling: A resident with a G-tube and diagnoses including Trisomy nine mosaic syndrome had a TF bag observed with an inaccurate and incomplete label. The label listed the wrong preparer and time, and left blank the formula contents, hang time, and expiration information. An LPN explained the formula was actually poured into the bag that morning, and the DON confirmed the label was not completed correctly.
Undated Inhalation Bag Used With BIPAP Equipment: A resident with chronic respiratory failure, tracheostomy status, and BIPAP orders had a half-empty 2,000 ml inhalation solution bag hanging by a ventilator machine used for nighttime BIPAP. Surveyors observed the bag was not labeled or dated, and the RT, RT Director, and DON all confirmed it was undated.
Ice machine cleaning and maintenance were not properly performed. Kitchen staff said they only wiped the exterior and did not clean the interior components, while the Dietary Manager said staff cleaned only the bottom portion and an outside vendor was responsible for the upper section. The Dietary Manager could not provide documentation for the last deep cleaning or the schedule for internal cleanings, and brown buildup was observed inside the machine.
The facility failed to maintain cleanliness and proper labeling in the kitchen. Opened food items lacked open date labels, and the kitchen area had dried cooking oil and grime accumulation. The Kitchen Manager confirmed these issues, which violated the facility's policies on cleanliness and food storage.
The facility's outdated policies failed to provide appropriate guidance for pediatric care, particularly in the use of psychotropic medications, as confirmed by the DON. A resident with muscle spasms was prescribed Diazepam, but the policy was geared towards adults. Additionally, the facility's supervision policy did not reflect current practices, such as line-of-sight supervision and the use of walkie-talkies, which were acknowledged by the DON and Administrator as not being updated since an incident with injury.
Food Storage and Sanitization Deficiencies
Penalty
Summary
The facility failed to ensure sanitizer test strips were available to verify the concentration of the sanitizing solution in the three-compartment sink. On 02/24/2026 at 8:30 AM, the Dietary Manager was unable to complete the test strip verification because the facility had run out of test strips, and the manager stated the concentration in parts per million could not be verified without them. Although the sanitation log for that date documented that the test strip verification had been completed that morning, the Dietary Manager acknowledged the entry was incorrect and said it should have been dated 02/23/2026. The facility policy titled SSP SNF Sanitization, revised September 2025, stated that when chemical sanitizing solutions are used in the three-compartment sink, the sanitizer concentration shall be verified using manufacturer-appropriate test strips. The facility also failed to ensure expired food items were removed from the refrigerator and nourishment room, and failed to discard dented cans. On 02/25/2026, the Cook stated expired food could lead to cross-contamination and may cause harm, and said the expired food had been missed. The Dietary Manager stated any expired food must be thrown away upon discovery and that they did not want to risk making the children sick. On the same date, staff stated dented canned food may have been compromised or partially opened and must be removed from use and discarded to prevent illness. The Dietary Manager stated dented cans must be removed from the kitchen because they were considered damaged and could cause illness, and the facility policy titled SSP SNF food receiving and storage, revised September 2025, documented that food items must be inspected prior to acceptance and that dented cans and expired products must be rejected.
Helmet Order Not Followed or Documented
Penalty
Summary
The facility failed to follow a physician order for a resident with plagiocephaly who had diagnoses including respiratory failure of a newborn, laryngomalacia, chromosomal abnormality, and agenesis corpus callosum. The resident was observed asleep in a crib wearing a blue helmet device and later observed wearing the helmet while strapped in a bouncy chair. The RN explained the helmet was being used as a supportive device because the resident's skull did not form well, and that the helmet was removed for one hour each day so staff could assess the skin underneath. A physician order dated 01/08/2026 directed that the plagiocephaly helmet be worn 23 hours a day with a one-hour break daily, during shower time if applicable, and that if there was no shower the helmet still had to be removed and cleaned during the one-hour break. The order also directed that the helmet and hair be dried before reapplying the helmet, and that the helmet and head be cleaned every shift with CeraVe baby shampoo, with alcohol wipes permitted only for the helmet. The order was transcribed into the e-MAR, but the signature boxes were blank from 01/08/2026 through 02/26/2026, and the RN confirmed the order was entered under therapy orders and could not be seen by nursing who were responsible for carrying out the task. Review of the daily nursing assessments for three days showed no documentation that the helmet was removed for one hour or that the specific cleaning instructions were followed. The OT stated therapy initially applied the helmet and increased wear time until the resident tolerated 23 hours, after which therapy or nursing would obtain an order from the orthotist, and that therapy staff do not document services in the e-MAR. The NAC stated CNAs removed the helmet and documented cleaning in POC, but the POC report only showed the helmet was cleaned daily and did not show that the one-hour removal order was followed. The DON confirmed the e-MAR was blank or unsigned, that nursing was responsible for ensuring the helmet was removed and cleaned as ordered, and that the daily nursing assessments lacked evidence the physician order had been performed on the reviewed days.
Incomplete and Inaccurate Tube Feeding Bag Labeling
Penalty
Summary
The facility failed to ensure that Resident 3’s tube feeding bag was labeled with complete and accurate information. Resident 3 was admitted with diagnoses including Trisomy nine mosaic syndrome, tracheostomy status, and gastrostomy status, and received nutrition through a G-tube. A physician order dated 12/11/2025 directed Complete pediatric formula original 1.0, 250 milliliters at 250 milliliters per hour four times a day. During observation on 02/24/2026, the resident’s tube feeding bag was connected to tubing threaded through a pump and had a sticker label with the resident’s name, room number, and the name of a staff member listed as the preparer, but the label stated the bag was prepared at 12:00 AM and left blank the formula contents, the date and time the formula was hung, and the expiration date and time. The LPN explained that the night shift nurse had hung an empty bag and that the LPN had actually poured the formula into the bag at 7:30 AM that morning. The DON confirmed the label was inaccurate and incomplete and stated the LPN should have completed the label with the resident’s name, room number, formula contents, staff who prepared it, and the date and time it was initiated.
Undated Inhalation Bag Used With BIPAP Equipment
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 3, who was admitted with diagnoses including Trisomy nine mosaic syndrome, chronic respiratory failure, tracheostomy status, and gastrostomy status. The resident had a physician order for BIPAP/Bilevel 23/+14 with a back-up rate of 14 every night shift by respiratory therapy. On the morning of the observation, the resident was in the dining area on a stander with a white gauze observed on the neck area. Later that morning, surveyors observed a ventilator machine labeled RT management only on the left side of the resident's crib. The machine was off, and a 2,000 ml bag of inhalation solution that was half empty was hanging by the ventilator machine. The bag was not labeled or dated. The RT stated the resident had been decannulated and used the ventilator machine for BIPAP treatment at night, and confirmed the inhalation bag was not dated. The RT Director stated the bag should have been dated with initials and that the bags were good for 30 days once opened per manufacturer. The DON also confirmed the inhalation bag was not labeled and dated.
Ice Machine Not Properly Cleaned or Maintained
Penalty
Summary
The facility failed to ensure the ice machine was kept clean and maintained safely. During observation and interview, kitchen staff stated they only cleaned and wiped the exterior surfaces of the ice machine and did not clean the interior components, and the Dietary Manager stated staff cleaned only the bottom portion of the machine while an outside service provider was responsible for cleaning the upper section. The Dietary Manager could not provide documentation showing when the last deep cleaning of the interior components was completed and was unaware of the schedule or frequency of internal cleanings. A sticker on the machine showed a date of 09/16/2025, and the Dietary Manager acknowledged the brown buildup observed inside the machine appeared to come from the upper internal section. The facility policy for cleaning fixed equipment required removable parts to be washed and sanitized and non-removable parts to be cleaned with detergent and hot water, rinsed, air-dried, and sanitized.
Kitchen Cleanliness and Food Labeling Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the kitchen area, as observed during a kitchen tour. Several food items, including Truvani plant-based protein powder and a jar of sundried tomatoes, were found opened and partially consumed without an open date label. Additionally, the four drawer-base refrigerators used as the base for cook top stoves had splatters of dried cooking oil, and the handles were tacky to touch. The gap between the cook top base, the oven rack, and the backsplash down to the floor had dried residues of cooking oil and gray materials settled on the floor. The Kitchen Manager confirmed these findings and acknowledged the need for further cleaning and proper labeling. The facility's policies on cleanliness and food storage require all equipment and surfaces to be kept clean and all food items to be labeled and dated, which were not adhered to in this instance.
Outdated Policies and Inadequate Supervision Practices
Penalty
Summary
The facility failed to ensure that its policies were reviewed, updated, and suited to the resident population, which led to a deficiency in care. The policy for the use of psychotropic medications was outdated and did not provide guidance for pediatric usage, which was confirmed by the Director of Nursing (DON). This was particularly relevant for a resident admitted with muscle spasms and congenital hypertonia, who was prescribed Diazepam for muscle spasms. The facility's policy was geared towards an adult population, which could potentially lead to inappropriate care for pediatric residents. Additionally, the facility's policy on resident supervision was not updated to reflect current practices. Although staff were observed to maintain line-of-sight supervision and use walkie-talkies for communication, the written policy did not include these practices. The DON acknowledged that the policy had not been amended to reflect changes implemented after an incident with injury. The Administrator admitted that a systematic review of facility policies had not been conducted, and many policies were outdated and not reflective of actual practices, which could impede staff training and care delivery.
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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