The Heights Of Summerlin, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 10550 Park Run Drive, Las Vegas, Nevada 89144
- CMS Provider Number
- 295083
- Inspections on file
- 26
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at The Heights Of Summerlin, Llc during CMS and state inspections, most recent first.
Unsanitary kitchen conditions were observed throughout food prep, storage, and dishwashing areas, including food debris, dirty carts, contaminated bulk food containers, and heavy buildup on equipment. Surveyors also found backed up water in the dishwasher and beverage areas from broken drain/sewer lines, and a nourishment room refrigerator at 60 degrees Fahrenheit with opened, undated foods and cold items stored above safe temperatures; the unit clerk’s temperature log showed 39 degrees Fahrenheit earlier that morning, which the DM said could not have changed that quickly.
Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident admitted with an indwelling Foley catheter did not have a baseline care plan that addressed catheter care. The resident was observed with a urine meter bag containing urine, reported the bag had not been emptied that morning, said the Foley had not been replaced since admission, and stated the insertion site was not being routinely cleansed. A family member reported they were personally providing cleaning care because staff were not doing so consistently; an RN and the DON later confirmed the baseline care plan did not include the catheter.
Failure to Implement Foley Catheter Care Plan: A resident with a Foley catheter, prostate cancer, BPH, and UTI had a care plan calling for catheter care twice daily, infection monitoring, and urine assessment, but staff did not implement the planned interventions. The resident reported the urinary bag had not been emptied that morning, the catheter had not been replaced since admission, and the insertion site was not being cleansed routinely; a family member said they were providing the resident’s cleaning needs because staff care was inconsistent. The medical record lacked evidence of physician care orders being entered or routine Foley care being documented, and the DON confirmed the care plan interventions were not implemented because the orders were not in the chart.
Care Plan for Skin Integrity Not Updated After Hospital Return. A resident with quadriplegia and multiple existing pressure ulcers was transferred to the hospital for fever, weakness, confusion, and drowsiness, then returned after treatment for acute sepsis and an infected right hip wound with purulent drainage concerning osteomyelitis and septic arthritis. The record lacked evidence that the skin integrity care plan was reviewed and updated on readmission, and the House Supervisor confirmed the wound care team had not updated it despite facility policy requiring care plan review when a resident's condition changes or after hospital readmission.
Missed Scheduled Shower for Resident Requiring Bathing Assistance: A resident with lymphedema and bilateral chronic venous stasis ulcers required max assist with bathing, but staff did not provide, offer, or re-offer a scheduled shower after admission. The CNA could not locate a shower sheet, and the RN confirmed the resident missed the scheduled shower, which was also noted as a missed opportunity for a skin check, removal of the compression device, and cleansing and moisturizing of the legs.
A resident with a G-tube and functional quadriplegia had repeated tube dislodgements that led to hospital transfers, and the physician order for tube care did not include instructions to prevent displacement; on observation, no abdominal binder was in place. Another resident with lymphedema and chronic venous stasis ulcers was observed wearing compression devices with severe leg pain, but the record lacked a physician order and wearing schedule for the compression device, and staff and the DON confirmed the management orders were not in place.
Failure to Complete Wound Care Skin Assessment on Readmission: A resident with quadriplegia, sepsis, and multiple existing pressure ulcers was readmitted with several dressings already in place, but the wound care team did not complete a comprehensive skin assessment on return. The admitting nurse documented wounds and dressings, yet staff confirmed no wound consult or admission skin assessment was completed, and old hospital dressings remained on the coccyx and both feet with loose edges and a foul odor noted during care.
Inadequate foot hygiene and delayed podiatry care were identified for a resident with scar condition fibrosis of the skin and CKD 3A. Staff observed thickened, dirty toenails with brown buildup and debris on both feet, and the resident reported the nails had not been addressed and that routine podiatry care had not occurred for several months. The resident relied on staff for personal skin care, yet feet were not washed with soap and water or moisturized during bed baths, and the RN confirmed there was no documentation of recent podiatry follow-up or listing for podiatry services.
Unsafe Mechanical Lift Transfer Due to Missing Harness Buckle: A resident with bilateral acute ischemic stroke and dependent transfer status was observed being moved from bed to wheelchair with a mechanical lift while the sling safety straps were not secured and one strap was missing its buckle. A CNA stated the strap was not used because the buckle clip was missing, and PT and the Administrator confirmed the resident required max assist/dependent transfers and that the harness should not have been used in that condition.
A resident with chronic pain syndrome received oxycodone HCl 10 mg and aspirin 81 mg during med pass, but the physician orders did not specify the oxycodone as immediate-release or the aspirin as enteric-coated. An RN later confirmed the mismatch between the orders and the meds given and acknowledged the orders should have been verified before administration.
Improper Storage of Expired and Unsecured Medications: Surveyors found opened Latanoprost eye drops stored in a resident’s room refrigerator without an order for self-administration, and additional opened Visine eye drops in a med cart drawer past the expected discard timeframe. The DON confirmed the resident did not have an order to keep meds at bedside or in the room refrigerator, and the facility policy required medications to be stored in locked, secured locations and outdated products to be removed.
Insufficient kitchen staffing led to late meal delivery and food served at improper temperatures. The facility had three kitchen staff preparing breakfast trays, while residents on multiple halls complained that meals were late, cold, and often unpalatable. The DM reported the kitchen was short-staffed, with call-ins and high turnover, and stated the staffing pattern did not meet the needs of the census. The District Manager acknowledged the staffing shortage and difficulty meeting delivery times, and the Administrator stated adequate staffing would require more cooks and aides than were scheduled.
Late Meal Delivery and Improper Food Temperatures: Staff observed breakfast preparation and residents on multiple halls complained that meals were served late and were cold or unpalatable. Meal service records and temperature checks showed the last breakfast cart reached the 200-Hall after the scheduled window, with hot items below policy standards and cold items above the required temperature range. An LPN and three CNAs later reported they were used to lunch carts arriving late, and a resident stated the food was always late and cold.
Expired Food Left in Resident Refrigerators: Expired food items were found in the refrigerators of two residents. One resident with epilepsy, pneumonia, dysphagia, DM2, schizophrenia, and dementia had expired milk and yogurt, while another resident with spina bifida, chronic respiratory failure, paraplegia, DM2, and dysphagia had expired mustard, tartar sauce, ranch dressing, mayo, and pudding. A CNA and LPN confirmed the items remained, and the DON was unsure of the process for expired foods in resident rooms.
The facility failed to enforce its non-smoking policy and secure smoking materials for residents, leading to multiple residents retaining cigarettes and lighters. Despite being a non-smoking facility, residents were allowed to smoke outside under staff supervision, and smoking assessments were not conducted in a timely manner. This deficiency involved residents with a history of tobacco use, posing potential safety risks.
The facility failed to provide consistent snack availability for residents outside of scheduled mealtimes, leading to potential nutritional deficiencies. Observations showed empty snack trays and refrigerators, and residents reported difficulties in obtaining snacks. Staff confirmed the inconsistency, and the Administrator was unaware of the issue despite existing policies.
A facility failed to accurately assess a resident's use of a harness and straps, which were intended for safety due to the resident's spastic quadriplegic cerebral palsy and epileptic seizures. The MDS assessment incorrectly coded these as restraints, despite the care plan and physician's order indicating they were for safety. The DON and MDS Nurse confirmed the error, noting the harness and straps were not restraints due to the resident's involuntary movements.
A facility failed to develop a timely smoking care plan for a resident identified as a tobacco user upon admission. Despite the resident's diagnoses of anxiety disorder, muscle weakness, and nicotine dependence, a smoking care plan was not initiated until several months later, contrary to the facility's policy requiring a comprehensive care plan within 21 days. This delay had the potential to deprive the resident of necessary interventions.
A resident with multiple health conditions did not receive scheduled showers or baths on two occasions, as documented in their care plan. Despite the facility's policy and shower schedule, there was no evidence of the resident being offered or refusing these services, nor were alternative arrangements documented. Interviews with CNAs and the DON confirmed the oversight, highlighting a deficiency in the facility's care provision.
A facility failed to follow a resident's prescribed Foley catheter size and did not monitor or report signs of infection. The resident had a history of hydronephrosis and urinary retention, with a physician's order for a 16 French catheter, but an 18 French was used. The urine was dark, odorous, and contained sediments, yet there was no documentation of physician notification or monitoring. Staff interviews confirmed the lack of adherence to orders and documentation.
A facility failed to monitor and document a resident's anticoagulation therapy, missing PT-INR tests for a resident on Warfarin, risking adverse health outcomes. Additionally, pain medication was administered to another resident despite a documented pain level of zero, indicating a lack of proper pain assessment. These deficiencies highlight failures in medication administration and monitoring protocols.
A facility failed to secure medicated wound care cream, as observed with a resident who had a medication cup containing Triad Hydrophilic Wound Dressing left on their overbed tray table. An LPN and a Wound Care Nurse confirmed the cream was used by the wound care team and should not have been left unsecured. The DON acknowledged that the cream was a medication and should have been stored according to the facility's policy.
Unsanitary kitchen conditions, plumbing-related water backup, and improper nourishment refrigerator storage
Penalty
Summary
The kitchen was observed to be maintained in an unsanitary condition during an initial tour with the Assistant Dietary Manager. Food prep areas had crumbs and other food debris, shelves under the steam table were dirty with dust, food crumbs, and stains, food transport carts were dirty, the back of the oven had heavy dust and old food debris, a second food prep table had old food debris and stains, the broiler behind the tray line had dirt buildup, a bulk sugar container was contaminated with oats, the oven doors had heavy buildup of food debris and grease stains, clean pitchers were inverted on a dirty surface near the two-compartment sink, the walk-in freezer and refrigerator floors were sticky and dirty, another food transport cart was dirty, an 18-quart salt container was dusty and dirty on the exterior, and the top of the commercial dishwasher had heavy buildup of food debris. The Dietary Manager stated forms had been created for kitchen cleaning tasks, but staff in-services had not yet been completed, and the facility policy required food preparation areas to be maintained in a clean and sanitary condition. The kitchen also had backed up water on the floor related to plumbing problems. Surveyors observed pooled water around a drain spout in the dishwasher area, and in the beverage area the flooring had black soot and accumulated dirt with heavy water backing up from a broken sewer line causing the floor on the left side of the beverage/coffee station to become wet. The Director of Maintenance stated he was aware of the broken sewer drain causing flooding in the beverage area, that water was being vacuumed manually until the sewer line or main drain line could be replaced, and that a work order had been submitted and estimates obtained, but he had not been informed of the broken drain line in the dishwashing area. In the nourishment room, a small refrigerator measured 60 degrees Fahrenheit and contained partially consumed butter and cream cheese with no open date, along with fruit cups, puddings, yogurt, and thickened apple juice; sampled yogurt measured 52.7 degrees Fahrenheit and apple juice 44.8 degrees Fahrenheit. The unit clerk had documented a refrigerator temperature of 39 degrees Fahrenheit earlier that morning, but could not explain the change, and the Dietary Manager stated the temperature could not have changed from 39 degrees Fahrenheit to 60 degrees Fahrenheit in 10 minutes. The facility policy required cold foods to be maintained at 41 degrees Fahrenheit or below and foods to be wrapped or stored in covered containers, labeled and dated.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Missing Baseline Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed for a resident admitted with an indwelling catheter. Resident 199 was admitted with diagnoses including prostate cancer, benign prostatic hyperplasia, and a urinary tract infection, and the admission MDS indicated intact cognition and an indwelling catheter. A nursing documentation evaluation also documented that the resident was admitted with a Foley catheter device. On 03/24/2026, the resident was observed awake in bed with family at bedside, with a urine meter bag hanging on the left side of the bed and containing 350 milliliters of clear yellow urine. The resident reported that no one had emptied the urinary bag that morning, that the Foley catheter had not been replaced since admission, and that no one routinely cleansed the insertion site. A family member stated they often visited and personally took care of the resident's cleaning needs because staff were not providing care consistently. The medical record lacked documented evidence of a baseline care plan for the resident's indwelling urinary catheter, and both an RN and the DON reviewed the record and confirmed the baseline care plan did not include the catheter.
Failure to Implement Foley Catheter Care Plan
Penalty
Summary
The facility failed to ensure care plan interventions for an indwelling catheter were implemented for one resident with diagnoses including prostate cancer, benign prostatic hyperplasia, and UTI. The resident was admitted with a Foley catheter, and the care plan initiated on 03/16/2026 identified the catheter as being in place due to obstructive uropathy with a goal of not having a UTI. Planned interventions included monitoring for signs and symptoms of infection, monitoring for skin irritation with daily care, monitoring urine for sediment, cloudy appearance, odor, blood, and amount, reporting abnormalities to the physician immediately, providing catheter care twice a day, and using a 16 French Foley catheter. On 03/24/2026 in the morning, the resident was observed awake in bed with family at bedside, with a urine meter bag hanging on the left side of the bed and containing 350 ml of clear yellow urine. The resident stated that no one had emptied the urinary bag that morning, the Foley catheter had not been replaced since admission, and no one routinely cleansed the insertion site. A family member stated they often visited and personally took care of the resident's cleaning needs because staff were not providing care consistently. The medical record lacked documented evidence that care and management orders were obtained from the attending physician, transcribed into the medical record, or that routine Foley catheter care was documented. The DON confirmed on 03/26/2026 that the catheter care plan included interventions that were not implemented because care orders were not entered into the medical record.
Care Plan for Skin Integrity Not Updated After Hospital Return
Penalty
Summary
The facility failed to ensure a comprehensive care plan for skin integrity was reviewed and updated when Resident 15 returned from the hospital after treatment for an infected wound. Resident 15 was admitted and later readmitted with diagnoses including quadriplegia, acute sepsis, and pressure ulcers. A quarterly MDS documented intact cognition, quadriplegia, risk for pressure ulcers, and multiple existing wounds, including two stage 3 pressure ulcers and four unstageable pressure ulcers. A change of condition note dated 03/04/2026 stated the resident was transferred to the hospital for fever, weakness, confusion, and drowsiness. The hospital discharge summary stated the resident was admitted for acute sepsis and altered mental status and was found to have a right hip wound with significant purulent discharge and secretions concerning osteomyelitis and septic arthritis. The resident was discharged back to the skilled nursing facility, but the medical record lacked documented evidence that the comprehensive skin breakdown care plan was reviewed and updated upon readmission. On 03/25/2026, the House Supervisor reviewed the record and confirmed the wound care team had not updated the skin integrity care plan on readmission, despite the facility policy stating care plans are reviewed and revised when a resident's condition changes and when a resident is readmitted from a hospital stay.
Missed Scheduled Shower for Resident Requiring Bathing Assistance
Penalty
Summary
The facility failed to ensure a scheduled shower was provided for a resident who required assistance with bathing. Resident 231 was admitted with diagnoses including lymphedema and bilateral chronic venous stasis ulcers, and the admission MDS indicated the resident required maximal assistance with bathing. On 03/26/2026 in the morning, the resident stated that since admission no one had provided or offered a shower and expressed concern about chronic wounds on both legs that had been infected in the past. During the survey, a CNA reviewed the shower book for the resident's unit and reported the resident's showers were scheduled for Monday and Thursday afternoons, but no shower sheet could be located for the resident. The wound PA stated it was unfortunate the resident missed the scheduled shower because it would have been an opportunity to do a skin check, relieve the resident from the compression device, and cleanse and moisturize the resident's legs. The RN assigned to the resident reviewed the shower book and interviewed CNAs and confirmed the resident had not been provided, offered, or re-offered a shower since admission, including a scheduled shower on 03/23/2026, and could not explain why the assigned CNA did not offer or provide one.
Failure to Manage Recurrent G-Tube Dislodgement and Compression Device Orders
Penalty
Summary
The facility failed to ensure appropriate care and services were provided to prevent recurrent gastrostomy tube dislodgement for a resident with functional quadriplegia and dysphagia who had a G-tube. The resident had repeated episodes of G-tube displacement that resulted in hospital transfers for replacement on multiple occasions, including events documented on 05/05/2025, 06/16/2025, 10/03/2025, and 02/20/2026. A physician order dated 10/09/2025 included routine G-tube care such as flushing, residual checks, head-of-bed elevation, and site cleansing, but it did not include instructions to prevent tube displacement. When the tube was found displaced on 02/20/2026, staff reported it was not trauma related and could not explain how it became dislodged. On observation, the resident did not have an abdominal binder in place to prevent further dislodgement. The facility also failed to obtain care and management orders for a compression device for a resident with lymphedema and bilateral chronic venous stasis ulcers. The resident had been hospitalized for progressive lower extremity edema, pain, weeping stasis, and superimposed cellulitis, and was admitted after completing antibiotics. On the unit, the resident was observed wearing compression devices on both lower legs and reported severe pain rated 10/10, along with concern that the compression devices had not been removed since they were applied by wound care. The resident stated wound care had removed hospital dressings and applied compression stockings without explaining their purpose. Record review showed no documented physician order for the compression device or for its management, including a wearing schedule. Staff interviews showed uncertainty about whether a physician order and care plan were required, and the wound PA stated the Tubi-grips were used for edema and venous insufficiency management and should be changed daily or every other day due to loss of elasticity. The DON confirmed there was no order for the compression device with proper interventions for management, and the facility policy stated treatment orders should clearly describe the treatment, site, frequency, duration, and diagnosis.
Failure to Complete Wound Care Skin Assessment on Readmission
Penalty
Summary
The facility failed to ensure a comprehensive skin assessment was completed by the wound care team when a resident with quadriplegia, acute sepsis, and multiple existing pressure ulcers was readmitted. The resident’s quarterly MDS documented intact cognition, quadriplegia, high risk for pressure ulcers, and multiple unhealed wounds, including two stage 3 pressure ulcers and four unstageable pressure ulcers. The facility’s policy required a comprehensive skin evaluation upon admission or readmission, with physician notification for orders. After the resident returned from the hospital following treatment for acute sepsis and altered mental status, the admitting nurse documented a body check that identified moisture-associated skin damage on the coccyx, a right hip wound, a left hip wound, a dressing on the left side of the neck, and dressings on both outer ankles. The medical record did not contain evidence that the wound care team completed a comprehensive skin assessment on readmission. During survey observation, the resident had a foam dressing over the coccyx and protective dressings on both feet and heels, with the bilateral foot dressings coming loose at the edges and a foul odor present during care. Staff interviews confirmed the wound care team was not alerted to the resident’s return through a new admission report or a wound consult report in the EHR. The RN stated the resident’s wounds were not well known to the floor nurse because wound care followed the resident, and the treatment nurse confirmed the wound team did not complete an admission skin assessment. The treatment nurse and wound physician assistant stated hospital dressings should have been removed to visualize the skin underneath, and the PA noted dressings used for protection should not remain on longer than seven to 10 days. The DON acknowledged the admitting nurse completed a head-to-toe assessment but stated a wound consult was not necessary because the resident was already on the wound care caseload.
Inadequate Foot Hygiene and Delayed Podiatry Care
Penalty
Summary
Provide appropriate foot care was deficient for one resident with diagnoses including scar condition fibrosis of the skin and chronic kidney disease stage 3A. On 03/24/2026 and 03/25/2026, observations of the resident’s bilateral feet showed brown buildup underneath the toenails on both feet, thickened toenails, and great toenails extending approximately 1.5 inches beyond the nail bed. A significant amount of brown debris was also observed on the plantar forefoot areas. The resident stated the toenails were long and dirty, had not been addressed, and attributed the condition to not receiving routine podiatry care. The resident also reported being unable to perform personal skin care and relying on staff for assistance. The resident received bed baths on Wednesdays and Saturdays, but staff had not washed the legs and feet with soap and water or applied lotion. The resident had not been seen by podiatry services for approximately four to five months, and record review showed the last podiatry visit was on 12/17/2025. A CNA acknowledged the nails were thickened, discolored, and very long, and an RN confirmed there was no documentation showing when the resident was last seen by podiatry and that the resident was not listed for podiatry services. The Unit Clerk stated nursing staff notified when residents needed podiatry services and entered requests into the podiatry log, while Social Services scheduled appointments; the Social Services Director confirmed the resident was due for podiatry care.
Unsafe Mechanical Lift Transfer Due to Missing Harness Buckle
Penalty
Summary
The facility failed to ensure a resident with non-weight-bearing status was safely transferred from bed to wheelchair using a mechanical lift harness in good repair. Resident #132 was admitted with diagnoses including bilateral acute ischemic stroke, and the MDS assessment showed the resident was dependent for chair-to-bed transfers. During observation, two CNAs transferred the resident from the bed to a wheelchair using a mechanical lift to assist the resident to stand, but the safety straps of the grip sling were not secured and one strap was missing its buckle. The resident used arm strength to self-support by holding onto the sling loops while the transfer was being completed. One CNA stated the safety strap was not used because the buckle clip was missing, and inspection of the mechanical lift confirmed the buckle clip for the safety strap was absent. A PT stated the resident’s last PT evaluation was in 2024, the resident had been discharged from PT on 03/25/2024 after reaching maximal potential, and the resident was totally assisted with transfers. The PT also stated the resident needed maximum assistance and was dependent for bed-chair-bed transfer, and that the harness safety strap should have been used. The Administrator later confirmed the buckle clip for the harness safety strap was missing and acknowledged the harness should not have been used in that condition.
Medication Orders Not Fully Verified Before Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration observations and record review. On 03/25/2026 in the morning, a Registered Nurse administered oxycodone HCl 10 mg and aspirin 81 mg orally to Resident #191, who had been admitted and re-admitted with diagnoses including chronic pain syndrome. Review of the physician’s orders showed the oxycodone order did not specify that the medication was the immediate-release formulation that was given, and the aspirin order did not specify that it was to be enteric-coated. At 11:00 AM, an RN verified that the oxycodone order did not specify immediate-release and that the aspirin administered was enteric-coated rather than regular aspirin, and acknowledged the orders should have been confirmed before administration. The facility policy stated medications are to be administered in accordance with the prescriber’s order and checked three times to ensure the correct medication before administration.
Improper Storage of Expired and Unsecured Medications
Penalty
Summary
The facility failed to ensure medications were secured and stored in accordance with accepted professional principles when expired and improperly stored eye drops were found during survey observations. Resident 175 was admitted with diagnoses including spina bifida with hydrocephalus, chronic respiratory failure with hypoxia, paraplegia, type 2 diabetes mellitus, and dysphagia. In the resident’s room refrigerator, surveyors observed one opened bottle of Latanoprost Solution 0.005% eye drops dated 09/06/2025 and another opened bottle dated 02/11/2026. An LPN confirmed the bottles were in the resident’s refrigerator and stated they should have been kept securely in the medicine room refrigerator. The DON later stated the expectation was for medications to be safely stored on the medication cart for staff administration unless the resident had an order for self-administration, and confirmed Resident 175 did not have such an order. The DON stated the eye drops should have been in the medication cart or in the medication room refrigerator if refrigeration was needed. During inspection of the third floor 300 high medication cart, surveyors also found two bottles of Visine eye drops labeled open 02/22/2026 in the top drawer; the ADON stated the eye drops should have been disposed of one month after opening. The facility policy stated drugs and biologicals were to be stored in locked compartments, medications requiring refrigeration were to be stored in the drug room refrigerator or other secured locations, and discontinued, outdated, or deteriorated drugs or biologicals were to be returned to the dispensing pharmacy or destroyed.
Insufficient Kitchen Staffing Affected Meal Timeliness and Temperature
Penalty
Summary
The facility failed to ensure there was a sufficient number of kitchen personnel to safely and effectively carry out food and nutrition services. The facility assessment, updated 08/29/2025 and reviewed by the quality assurance committee on 12/30/2025, showed the facility was licensed for 190 beds with an average daily census of 160 residents and that staffing was to be adjusted based on census and center needs. On 03/24/2026, the facility census was 170, and at 7:40 AM there were three kitchen staff members preparing breakfast trays, including the Assistant Dietary Manager and two dietary aides. During the morning of 03/24/2026, five residents on the 100-Hall, four residents on the 200-Hall, and six residents on the 300-Hall complained that meals were served late, cold, and often not good. A tray line observation on 03/27/2026 during breakfast meal service showed meals were served late based on the facility’s delivery schedule and were not at appropriate temperatures per facility policy, which required hot foods at 135 degrees Fahrenheit and cold foods below 41 degrees Fahrenheit. The Dietary Manager stated the average daily census ranged from 170 to 175 residents per day and that the kitchen was staffed with one Dietary Manager, one Assistant Dietary Manager who doubled as a cook, and two dietary aides who also served as transporters. The Dietary Manager’s job description stated the role included managing food and kitchen supply budgets, hiring and orienting staff, and performing essential duties of dietary aides, cooks, and dishwashers as needed. The Assistant Dietary Manager’s job description described responsibilities for assisting with staffing, supervising dining services staff, and supporting planning, budgeting, purchasing, inventory, and recordkeeping. The Dietary Manager stated the facility needed one full-time Dietary Manager, an Assistant Dietary Manager who did not double as a cook, one full-time cook, an assistant cook or food preparer, and three dietary aides not counting transporters. The Dietary Manager also reported two call-ins that day and high turnover, with 12 kitchen staff quitting since December 2025. The District Manager acknowledged the kitchen was short-staffed and that delivery times were hard to meet, impacting the quality of food served. The Administrator stated kitchen staffing concerns had not been brought to their attention and indicated that, for an average daily census of 170, adequate staffing would include one Dietary Manager, four cooks, five aides/servers/transporters, and an Assistant Dietary Manager who would not double as a cook.
Late Meal Delivery and Improper Food Temperatures
Penalty
Summary
The facility failed to ensure food was served on time and at appropriate temperatures in accordance with its Food Preparation policy. On 03/24/2026, the facility census was 170, and during the morning meal service, three kitchen staff members were observed preparing breakfast trays, including the Assistant Dietary Manager and two dietary aides. That same morning, residents in the 100-Hall, 200-Hall, and 300-Hall complained that meals were being served late and that the food was cold and often not good. On 03/27/2026, temperatures taken on the service line showed oatmeal at 197 degrees Fahrenheit, regular ham at 186 degrees Fahrenheit, pureed ham at 183 degrees Fahrenheit, and pancakes at 101 degrees Fahrenheit. The Meal Delivery Times document showed the 200-Hall was the last unit scheduled for breakfast, with service planned from 8:10 AM to 8:35 AM, but the last cart did not arrive until 8:45 AM and the last resident was not served until 9:02 AM. After service, test tray temperatures were recorded at 109.9 degrees Fahrenheit for regular ham, 120.5 degrees Fahrenheit for pureed ham, 101 degrees Fahrenheit for pancakes, 52.0 degrees Fahrenheit for fresh milk, and 39.7 degrees Fahrenheit for apple juice. The DM and District Manager confirmed breakfast was delivered late and that food was served not at appropriate temperatures per facility policy. Later that day, an LPN and three CNAs were waiting for the lunch cart on the 200-Hall and stated they were used to it being delivered late, and a resident stated the food was always late and cold.
Expired Food Left in Resident Refrigerators
Penalty
Summary
The facility failed to ensure expired food items were discarded from 2 of 38 sampled resident refrigerators, including those of Resident 151 and Resident 175. Resident 151 was admitted with diagnoses including epilepsy, pneumonia, dysphagia, type 2 diabetes mellitus, schizophrenia, and dementia. On 03/24/2026, R151’s refrigerator contained an opened 1.89-liter bottle of Lucerne reduced fat milk expired 03/19/26 and an unopened six-ounce container of Yoplait original strawberry cheesecake yogurt expired 02/25/26. A CNA confirmed the expired items and stated expired food would be discarded because it was inedible and could make the resident ill. An LPN confirmed the items remained in the refrigerator and stated staff on light duty were responsible for checking expiration dates and removing expired food items from resident refrigerators. Resident 175 was admitted with diagnoses including spina bifida with hydrocephalus, chronic respiratory failure with hypoxia, paraplegia, type 2 diabetes mellitus, and dysphagia. On 03/24/2026, R175’s refrigerator contained an opened bottle of French’s yellow mustard expired 02/10/2026, two opened bottles of tartar sauce expired 10/16/2024 and 10/18/2024, an opened bottle of ranch dressing expired 09/23/2025, an opened bottle of real mayo expired 02/27/2026, and two butterscotch pudding containers expired 03/16/2026. A CNA confirmed the expired items and stated CNAs were responsible for discarding expired items from resident refrigerators, but also said expired items were kept if they had no odor and would not be thrown out unless a nurse was notified. An LPN confirmed the expired items and stated they must be discarded. The DON later stated she was unsure of the expectation and process for expired foods in resident rooms. The facility policy stated foods brought by family or visitors were to be labeled with the resident’s name, current date, and use-by date, and items would be thrown out after 48 hours; unopened items followed the manufacturer’s use-by date.
Failure to Enforce Non-Smoking Policy and Secure Smoking Materials
Penalty
Summary
The facility failed to appropriately assess and manage residents who smoked, despite being a non-smoking facility. Resident 66 was admitted with a history of tobacco use and expressed an unwillingness to use nicotine patches, intending to continue smoking. The facility was aware of this but did not conduct a timely smoking assessment or secure smoking materials. Resident 66 and another resident were found with cigarettes and lighters in their possession, and they were allowed to smoke outside under staff supervision, contrary to the facility's non-smoking policy. Resident 104, who had signed a Smoke-Free Center Acknowledgement Form, was also found to have cigarettes and a lighter in their possession. Despite the facility's policy, Resident 104 reported smoking outside unaccompanied until recently. The facility's documentation indicated that Resident 104 was not allowed to smoke, yet the resident continued to possess smoking materials, which were only confiscated after surveyors' intervention. Resident 65, admitted with nicotine dependence, was similarly affected by the facility's inconsistent enforcement of its non-smoking policy. Although the facility claimed to be non-smoking, Resident 65 was allowed to smoke outside with staff supervision until the policy was enforced more strictly. The facility's lack of a formal policy for securing smoking paraphernalia and inconsistent enforcement of the non-smoking policy led to residents retaining smoking materials, posing potential safety risks.
Inconsistent Snack Availability for Residents
Penalty
Summary
The facility failed to ensure that snacks were consistently available to residents outside of scheduled mealtimes, which had the potential to leave residents hungry between meals and not meet their nutritional needs. Observations on multiple occasions revealed empty snack trays and refrigerators at various nursing stations across different floors. Interviews with residents indicated a lack of knowledge on how to request food alternatives or snacks, and some residents reported having to order food from outside the facility or visit the kitchen themselves to obtain snacks. Staff members, including a Registered Nurse and a Licensed Practical Nurse, confirmed the inconsistency in snack availability and the challenges faced in obtaining snacks from the kitchen. The Dietary Director and District Kitchen Manager stated that the expectation was for snacks to be replenished twice daily, in the morning and afternoon. However, this expectation was not met, as evidenced by the empty snack trays and refrigerators observed during the survey. The facility's policy on snacks aimed to provide residents with adequate nutrition, but the lack of consistent snack availability indicated a failure to adhere to this policy. The Administrator was unaware of the concerns regarding snack availability, despite the expectation that snacks be available as requested by residents.
Inaccurate Assessment of Harness and Straps Use
Penalty
Summary
The facility failed to ensure the accuracy of the assessment for a resident, identified as R60, regarding the use of a harness and straps. R60, who has spastic quadriplegic cerebral palsy and epileptic seizures, was observed in a tilted wheelchair with a harness and straps in place. The physician's order indicated that these were for safety purposes. However, the Quarterly Minimum Data Set (MDS) assessment inaccurately coded the harness and straps as restraints used daily. The care plan noted the risk of complications from seatbelt use and included interventions for safety and mobility, but did not classify the harness and straps as restraints. The Director of Nursing (DON) and the MDS Nurse confirmed that the harness and straps were not considered restraints due to R60's involuntary movements, and thus, no restraint assessment or reduction was required. The facility's policy on comprehensive care planning emphasized the need for ongoing assessments and updates to care plans as resident information changed. Despite this, the MDS assessment was not updated to reflect the correct use of the harness and straps, leading to the deficiency.
Failure to Develop Timely Smoking Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was identified as a tobacco user upon admission. The resident, who was admitted with diagnoses including anxiety disorder, muscle weakness, and nicotine dependence, had an Admission Minimum Data Set (MDS) assessment indicating current tobacco use. Despite this, a smoking care plan was not initiated until several months later, which was contrary to the facility's policy that required a comprehensive care plan to be developed within 21 days of admission. The MDS Nurse acknowledged that the resident's tobacco use should have triggered a smoking assessment and care plan upon admission. The Director of Nursing confirmed that the facility's policy required a comprehensive care plan to be developed for residents marked as tobacco users in the MDS assessment. The delay in developing the smoking care plan for the resident had the potential to deprive the resident of necessary interventions to maintain overall well-being.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that showers or baths were provided as scheduled for a resident, identified as Resident 471, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, anemia, left foot cellulitis, gastritis, and stroke. The resident's Minimum Data Set indicated a need for partial/moderate assistance with showering and bathing. The care plan initiated for the resident specified dependency on staff for Activities of Daily Living (ADL) care. However, a review of the resident's medical records for December 2024 and January 2025 revealed a lack of documented evidence that the resident received a shower or bath on two specific dates, December 21, 2024, and January 1, 2025. There was also no documentation indicating that the resident refused a shower or bath on these dates or that alternative arrangements were made to provide these services on other days. Interviews with Certified Nursing Assistants (CNAs) confirmed that showers were scheduled twice a week, and documentation was expected to be recorded either on a weekly bath and skin report sheet or in the electronic medical record. The Director of Nursing (DON) verified that the shower schedule had not changed and confirmed the absence of documentation for the missed showers. The facility's policy on Activities of Daily Living, revised in March 2018, required appropriate care and services to be provided for residents unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. The lack of documentation and failure to provide scheduled showers or baths constituted a deficiency in care, with potential implications for the resident's hygiene and health.
Failure to Follow Foley Catheter Orders and Monitor for Infection
Penalty
Summary
The facility failed to adhere to the prescribed Foley catheter size and did not monitor or report signs of infection for a resident with a history of hydronephrosis and urinary retention. The resident was admitted with a physician's order for a 16 French Foley catheter, but an 18 French catheter was in place. The resident's urine was noted to be dark, brownish, and odorous with sediments, yet there was no documentation of physician notification or appropriate monitoring for infection symptoms. Staff interviews revealed that the facility's licensed nurses did not follow the prescribed Foley catheter size and failed to document or implement care orders for the catheter's maintenance and management. The resident's medical record lacked evidence of care orders, and the administration record did not reflect the necessary monitoring tasks. The Director of Nursing and a Nurse Practitioner confirmed the importance of following the prescribed catheter size and monitoring for infection, but these actions were not documented or executed as required.
Deficiencies in Anticoagulation Monitoring and Pain Medication Administration
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of a resident's anticoagulation therapy. Resident 12, who was on Warfarin for conditions including pulmonary embolism and venous thrombosis, did not have PT-INR tests conducted as ordered on specific dates. The last recorded PT-INR was on 03/04/2025, despite orders for tests on 03/10/2025, 03/13/2025, and 03/17/2025. The Director of Nursing confirmed the oversight, and the Licensed Practical Nurse admitted the test requisition was not prepared due to an assumption it was completed by the night shift. This lack of monitoring and documentation could have led to adverse health outcomes for the resident. Another deficiency involved the administration of pain medication to Resident 13, who was documented to have a pain level of zero at the time of administration. Despite having a care plan for chronic pain syndrome and being on a high dose of Oxycodone, the medication was administered on multiple occasions without proper assessment of pain levels. The Director of Nursing acknowledged the documentation error and emphasized the need for pain level assessment prior to medication administration. The Registered Nurse confirmed that pain medication should not have been given when the pain level was zero, as it could lead to unnecessary medication and potential harm. These deficiencies highlight the facility's failure to adhere to protocols for medication administration and monitoring, which are crucial for resident safety. The lack of proper documentation and communication with physicians regarding PT-INR levels and pain assessments contributed to these issues. The facility's policies on anticoagulant monitoring and physician orders were not followed, leading to potential risks for the residents involved.
Failure to Secure Medicated Wound Care Cream
Penalty
Summary
The facility failed to ensure that medicated wound care barrier cream was secured, as observed in the case of one resident. The resident, who was admitted with diagnoses including atherosclerotic heart disease, chronic diastolic heart failure, and a fracture around the right hip joint, was found with a clear medication cup containing an iridescent white cream on their overbed tray table. A Licensed Practical Nurse confirmed that the cream was a medicated product used by the wound care team and acknowledged that it should not have been left in the resident's room. Further confirmation from a Wound Care Nurse identified the cream as Triad Hydrophilic Wound Dressing, which was sometimes left by the wound care team for other nurses to apply during resident care. The Director of Nursing confirmed that the cream was considered medication and should have been secured according to the facility's policy on medication labeling and storage.
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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