Torrey Pines Post Acute And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 1701 S. Torrey Pines Drive, Las Vegas, Nevada 89146
- CMS Provider Number
- 295045
- Inspections on file
- 23
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Torrey Pines Post Acute And Rehabilitation during CMS and state inspections, most recent first.
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.
The facility failed to timely report multiple confirmed resident-to-resident physical abuse incidents to the state agency as required. In four separate events, residents sustained injuries including a bleeding nose, skin tear, facial redness, eye discoloration, and forehead swelling after being pushed, kicked, punched, or hit by other residents. Reports for these incidents were either submitted late or not submitted at all, despite the facility policy requiring alleged abuse or incidents resulting in serious bodily injury to be reported to the state agency within two hours. Facility leadership, including the DON, DSD, and Assistant Administrator, acknowledged that these incidents met the criteria for timely reporting but were not reported within the required timeframe.
A resident with chronic medical conditions reported being slapped, cursed at, and nearly struck in the face with a lit cigarette by another resident with schizophrenia and a history of homicidal ideation, resulting in facial redness and involvement of law enforcement. Nursing documentation confirmed a physical altercation and the aggressor’s admission that the other resident "deserved it." Although the social services director reported the incident to the Administrator, facility leadership acknowledged that the event met criteria for abuse and should have been reported to the state agency and investigated under the facility’s abuse policy, but no such investigation or report was completed.
A resident with psychosis, schizophrenia, and major depressive disorder, initially assessed as not wandering and with moderately impaired cognition, later wandered into another resident’s room and was pushed to the floor, sustaining a bleeding nose, a skin tear, and forehead redness. Following this incident, the medical record did not contain a care plan addressing the new wandering behavior, despite the DON stating that the assigned nurse was responsible for initiating such a plan and describing typical wandering interventions, and despite facility policy requiring ongoing assessment and revision of person-centered care plans as resident conditions change.
A resident with severe cognitive impairment and significant behavioral issues, requiring one-on-one supervision and assistance with ADLs, was discharged to an independent living facility that could not meet these needs. The receiving facility did not provide ADL support or behavior monitoring, resulting in the resident becoming agitated and requiring emergency intervention shortly after arrival. Facility staff and the receiving facility owner confirmed the discharge was inappropriate and unsafe.
A resident with severe cognitive impairment and no available family or psychiatric support was discharged to an independent living facility without a competency assessment or legal representative in place. Despite staff acknowledging the resident's inability to make informed decisions, the facility failed to follow its policy requiring a psychiatric evaluation and did not secure guardianship or a POA.
A facility failed to protect residents from abuse, resulting in two incidents where one resident was physically aggressive towards another. In the first incident, a resident was struck by another, leading to the aggressor's transfer for psychiatric evaluation. In the second incident, a resident was hit, causing a fall and injury, with the aggressor also transferred to a hospital. Both incidents were verified, and the affected residents reported feeling safe afterward.
A medication cart was left unattended with 20 tablets of Divalproex Sodium DR 500 mg on top, posing a risk of unauthorized access. A RN acknowledged the oversight, and the DON confirmed that medications should be secured in the cart, as per facility policy.
A blood glucose monitor with a used test strip was left unattended on a medication cart in a hallway, posing an infection control risk. A RN acknowledged the glucometer had been used and should not have been left unattended. The DON and Infection Preventionist confirmed that monitors should be cleaned and stored after use, and test strips disposed of immediately.
A resident with hemiplegia and moderately impaired cognition did not receive scheduled showers on four occasions, as required by the facility's policy. Despite the requirement for CNAs to document showers in both shower sheets and the EHR, there was no evidence of showers being provided on these dates. The DON confirmed the showers were missed, highlighting a lapse in adherence to the facility's ADL policy.
During a facility survey, several deficiencies were noted in food storage and handling practices. Expired food items were found in the stand-alone refrigerator and freezer, including unlabeled and undated food stored in Ziploc bags. Juice containers for drink machines were stored inappropriately in the dry storage area, contrary to manufacturer guidelines requiring freezer storage and refrigeration prior to use. In the unit nourishment rooms, expired yogurt was found in the Northeast Unit, unmarked food items in the Northwest Unit used as a staff breakroom, and unlabeled or undated food items in the South Unit resident refrigerator.
The facility failed to complete PASARR level two referrals for two residents with new psychiatric diagnoses, despite the social services department being responsible for this process. The deficiency was confirmed by the Assistant Administrator and the Social Worker.
The facility failed to ensure the MAR was not signed off before medications were administered for two residents. An LPN signed the MAR before administering medications, leading to potential inaccuracies in documentation. The ADON and DON confirmed that the MAR should only be signed off after medication administration, as per facility policy.
The facility failed to ensure proper wound care for two residents, leading to potential risks of delayed healing, worsened wounds, and infection. One resident's wound was not cleansed or dressed as ordered, leaving it exposed to feces. Another resident received wound treatment without documented physician's orders. The facility's wound care policy was not followed, resulting in inadequate care.
The facility failed to ensure proper labeling and administration of tube feeding (TF) and gastrostomy tube (GT) site care for a resident. The TF bag was not labeled as required, and there was a discrepancy between the documented and actual TF rate. Additionally, the GT site dressing was not changed as scheduled, and care orders were not obtained or transcribed. These deficiencies were confirmed by the nursing staff and the Director of Nursing (DON).
The facility failed to manage IV access for two residents admitted with intravenous (IV) lines. One resident had a central venous catheter (CVC) that was not identified or managed, and another had a peripheral IV that was not identified or managed. Both oversights placed the residents at risk for infection.
The facility failed to properly assess and monitor a resident's arteriovenous fistula (AVF) for dialysis access. Despite the AVF being placed two months prior, there were no documented care orders or monitoring of the bruit/thrill. Staff interviews revealed inconsistencies and a lack of clarity in monitoring responsibilities, and the Director of Nursing acknowledged the oversight.
The facility had a medication error rate of 8%, with two errors identified. One resident did not receive Lactobacillus as ordered, and another resident's artificial tears were not spaced correctly. Both incidents involved failure to follow physician orders and facility policies.
The facility failed to update the facility assessment and involve department heads when staffing levels were reduced starting in October 2023. Despite a policy requiring annual and as-needed reviews, the assessment was not updated to reflect changes in staffing, particularly for nocturnal shifts. The reduction was a corporate decision due to budgetary reasons, and department heads were not consulted, potentially impacting resident care.
A facility failed to protect a resident from abuse when an RN pushed the resident, causing a fall. The resident, with multiple cognitive impairments, was assessed with no physical harm. The incident was witnessed by other staff, and the RN was terminated and reported to the board of nursing.
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 Timely Report Resident-to-Resident Physical Abuse Incidents
Penalty
Summary
The facility failed to ensure that allegations of physical abuse were reported to the state agency within the required timeframe for four residents. One incident involved a resident pushing another resident to the ground and kicking them, resulting in a bleeding nose, a skin tear on the arm, and redness to the left forehead; this event occurred on 12/18/2025 at 6:26 PM, but the report was not submitted to the state agency until 12/19/2025 at 5:04 PM. Another incident involved a resident being hit in the face by another resident in the smoking area, resulting in redness on the mandible; this incident occurred on 11/27/2025 during the day, and the report had not been submitted to the state agency at the time of the survey. A third incident occurred on 03/12/2026 at 4:00 AM, when a resident was punched by another resident and was observed to have discoloration around the left eye socket; this was reported to the state agency on 03/13/2026 at 3:05 PM. A fourth incident occurred on 03/11/2026 at approximately 9:00 PM, when a resident was hit on the head by another resident and was found to have swelling on the forehead; this was reported to the state agency on 03/13/2026 at 3:51 PM. During interviews on 04/22/2026 at 3:25 PM, the DON, DSD, and Assistant Administrator stated that these four incidents were confirmed physical abuse resulting in bodily injury and acknowledged they should have been reported to the state agency within two hours, in accordance with the facility’s Abuse Investigation and Reporting policy revised July 2017, which requires alleged violations of abuse or those resulting in serious bodily injury to be reported immediately but not later than two hours.
Failure to Investigate and Report Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to investigate and report an incident of alleged physical abuse involving one resident. One resident with fibromyalgia and an unspecified intracranial injury reported that another resident slapped and cursed at him in the smoking area, attempted to strike his face with a lit cigarette, and caused redness to his left mandible. A nurse’s progress note documented that the resident called law enforcement after being punched in the face, and law enforcement came to the facility and spoke with both residents. A change of condition evaluation noted the physical findings and that an X-ray was ordered and was negative for injury. The other resident involved had schizophrenia, paranoid personality disorder, and a documented history of schizophrenia, anxiety disorder, homicidal ideation, and a recent psychiatric hospitalization for chasing a person with a knife and threatening police. A nurse’s progress note documented that this resident admitted to being in a physical altercation and stated the other resident was being annoying and deserved it. The social services director reported informing the Administrator of the incident. However, the incident was not investigated or reported to the state agency as required by the facility’s Abuse Investigation and Reporting policy and regulatory time frames. Facility leadership, including the DON and Director of Staff Development, acknowledged that this was an abuse incident that should have been reported and investigated but was not.
Failure to Develop Care Plan for Newly Identified Wandering Behavior After Resident Altercation
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a newly identified wandering behavior for one resident following a resident-to-resident altercation. The resident was admitted with diagnoses including unspecified psychosis due to a substance or unknown physiological condition, schizophrenia, and major depressive disorder, and the admission MDS indicated moderately impaired cognition with no wandering behaviors at that time. A change of condition evaluation documented that the resident wandered into another resident’s room, where the other resident pushed the resident to the floor, resulting in a bleeding nose, a skin tear to the left forearm, and redness of the left forehead. Despite this incident, the medical record contained no documented evidence that a care plan addressing the new wandering behavior was developed, even though the DON stated that the assigned nurse was responsible for creating such a care plan and described typical interventions used for wandering. The facility’s own Comprehensive Person-Centered Care Plan policy indicated that assessments were ongoing and revised as information about residents and their conditions changed, but this was not reflected in the resident’s care plan documentation. The deficient practice was identified through interview, record review, and document review, which confirmed the absence of a care plan specific to the resident’s new wandering behavior after the documented incident.
Unsafe Discharge to Inappropriate Setting for Resident with High Care Needs
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident with severe cognitive impairment and significant behavioral issues. The resident, diagnosed with schizoaffective disorder bipolar type, psychosis, and manic episodes, required one-on-one supervision and substantial assistance with activities of daily living (ADLs) such as eating, toileting, and mobility. Despite these needs, the resident was discharged to an independent living facility that did not provide assistance with ADLs or behavior monitoring. The discharge summary and care plan documented the resident's need for close supervision and support due to behaviors including agitation, violence, and hallucinations. Upon arrival at the independent living facility, the resident became agitated and destructive, leading to a call to emergency services and subsequent transfer to a hospital. Interviews with facility staff and the independent living facility owner confirmed that the discharge was inappropriate, as the receiving facility was not equipped to meet the resident's care needs. The facility's own discharge policy required that all necessary information be provided to ensure a safe transition, but this was not followed, resulting in an unsafe discharge.
Failure to Assess Competency and Secure Guardianship for Severely Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, diagnosed with schizoaffective disorder bipolar type, psychosis, and a manic episode, was admitted and later readmitted to the facility. The resident's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment, and the psycho-social assessment noted severely impaired decision-making skills and no available family or psychiatric facility support. Despite these findings, the resident was listed as their own responsible party, and there was no documentation of a Power of Attorney (POA) or guardianship in the medical record. The facility's policy required referral to a psychiatrist for capacity assessment in such cases, but this was not done. Staff interviews confirmed that the resident could not make their own decisions and required a legal representative, yet no competency assessment was completed to determine the need for guardianship or a representative. The resident was ultimately discharged to an independent living facility based on their own verbal consent, despite staff acknowledging the resident's inability to make informed decisions. The facility failed to follow its own policy and state-specific laws regarding guardianship and consent for residents with impaired cognition.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect Resident 2 from physical abuse by Resident 3, who was observed being physically aggressive and striking Resident 2's body. This incident occurred despite the presence of staff, as a Certified Nurse Assistant had to intervene to separate the residents. Resident 3 was subsequently placed on one-to-one supervision and transferred to an acute care hospital for psychiatric evaluation. The incident was verified, and Resident 2 expressed feeling more comfortable after Resident 3 was removed from the facility. In another incident, Resident 4 was not protected from physical abuse by Resident 5, who struck Resident 4's face, causing a fall and a bleeding nose. The residents were immediately separated, and Resident 5 was placed on one-to-one monitoring and transferred to an acute hospital. The incident was verified, and Resident 4 was sent to the hospital for evaluation. Despite the incident, Resident 4 reported feeling safe upon returning to the facility. Both incidents highlight the facility's failure to prevent resident-to-resident altercations, which had the potential to cause emotional and physical harm.
Unsecured Medication on Cart
Penalty
Summary
The facility failed to ensure the security of medications, as observed on 03/12/2025. A medication cart was left unattended at the entrance of the northeast hallway, with a medication card containing 20 tablets of Divalproex Sodium DR 500 mg on top. This occurred while staff, visitors, and residents were present in the hallway. A Registered Nurse later acknowledged the oversight, stating that the pills should not have been left unattended, as it posed a risk of unauthorized access. The Director of Nursing confirmed that medications should be secured in the cart when not being administered, aligning with the facility's policy on the storage of medication, which mandates that all drugs and biologicals be stored safely and securely.
Infection Control Breach with Unattended Glucometer
Penalty
Summary
The facility failed to ensure proper infection control practices were followed when a blood glucose monitor with a used test strip was left unattended on top of a medication cart. On March 12, 2025, at 12:24 PM, the medication cart was parked unattended at the entrance of the northeast hallway in front of a resident room, with staff, visitors, and residents present in the hallway. The blood glucose monitor had a test strip inserted, which had a dark red substance visible, indicating it had been used. At 12:27 PM, a Registered Nurse (RN) acknowledged that the glucometer had been used to obtain a resident's blood sugar and that the test strip needed to be discarded, and the monitor disinfected. The RN admitted that the glucometer should not have been left unattended. Later, at 2:15 PM, the Director of Nursing (DON) confirmed that for infection control, blood glucose monitors should be cleaned and stored away after use and not left unattended on top of the medication cart. At 3:12 PM, the Director of Staff Development/Infection Preventionist stated that blood glucose monitor testing strips should be disposed of immediately after use to prevent the spread of infection.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that showers were provided as scheduled for one resident, identified as Resident 1 (R1), who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction. R1 had moderately impaired cognition and required partial to moderate assistance with bathing. The facility's shower schedule indicated that R1 was to receive two showers a week on Tuesdays and Fridays. However, there was no documented evidence that R1 received showers on four specific dates: 07/02/2024, 07/09/2024, 07/16/2024, and 07/19/2024. Interviews and document reviews revealed that the facility's process required CNAs to document showers on shower sheets and in the electronic health record (EHR). Despite this, the Director of Staff Development and the corporate EHR specialist confirmed the absence of documentation for the specified dates. The Director of Nursing acknowledged that the showers were missed or not provided on those dates, emphasizing that showers must be provided as scheduled, with any changes or refusals documented. The facility's Supporting ADL policy stated that residents unable to perform ADLs independently should receive necessary services to maintain personal hygiene.
Food Storage and Handling Deficiencies Identified
Penalty
Summary
During a facility survey conducted on [DATE], several deficiencies were identified related to food storage and handling practices at the long-term care facility. Observations revealed expired food items in the stand-alone refrigerator and freezer, including unlabeled and undated food items stored in Ziploc bags. Additionally, juice containers for drink machines were found stored inappropriately in the dry storage area, contrary to manufacturer guidelines which specified freezer storage and refrigeration prior to use. The report also highlighted issues in the unit nourishment rooms, such as expired yogurt in the Northeast Unit, unmarked food items in the Northwest Unit used as a staff breakroom, and unlabeled or undated food items in the South Unit resident refrigerator.
Failure to Complete PASARR Level Two Referrals
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for two residents. Resident 22 was admitted with diagnoses including major depressive disorder, bipolar disorder, and psychotic disorder. Despite these diagnoses, the medical record lacked evidence of a PASARR level two referral. The social worker confirmed that the resident was diagnosed with bipolar disorder after admission and should have been referred for a PASARR level two review, which was not done. Resident 28 was readmitted with primary diagnoses including anxiety disorder, depression, bipolar disorder, schizophrenia, and a psychotic disorder. The resident's medical record also lacked evidence of a PASARR level two referral despite new diagnoses of brief psychotic disorder, manic episode, and paranoid personality disorder. The Assistant Administrator and the Social Worker confirmed that the resident had new psychiatric diagnoses that met the criteria for a PASARR level two referral, which was not completed. The report highlights that the admissions department deferred to the social services department for PASARR level two referrals, but the social worker was not aware of their responsibility in this process. The Assistant Administrator confirmed that social services were responsible for identifying and referring residents for PASARR level two reviews, but this was not effectively communicated or executed, leading to the deficiency.
Premature Signing of MAR Before Medication Administration
Penalty
Summary
The facility failed to ensure the medication administration record (MAR) was not signed off before the medications were administered for two residents. For Resident 246, an LPN prepared eight medications and signed the MAR before administering them. The resident refused two medications, but the MAR had already been signed off. The LPN explained that the MAR was signed off early to avoid forgetting later. The Assistant Director of Nursing (ADON) confirmed that the MAR should not be signed off until after the medications are administered, as residents might refuse or not successfully receive the medications. For Resident 75, an LPN prepared four medications and signed the MAR before administering them, explaining that this practice was customary in their previous job out of state. The Director of Nursing (DON) indicated that staff members are expected to sign off on the MAR only after completing the medication administration to ensure accurate documentation. The facility's policy on administering medications states that medications should be administered safely, timely, and as prescribed, with the MAR being signed off only after each medication is given.
Inadequate Wound Care Management
Penalty
Summary
The facility failed to ensure proper wound care for two residents, leading to potential risks of delayed healing, worsened wounds, and infection. For one resident, the facility did not cleanse the wound or replace the dressing as ordered, resulting in the wound being soaked with urine and feces. The resident, who was blind, confused, and dependent on staff for daily activities, had a wound on the right buttock that was not properly managed. The family reported that the staff failed to turn and reposition the resident on schedule, and observations confirmed that the wound dressing was not applied, leaving the wound exposed to feces. The CNA and RN both confirmed that they were not informed when the wound dressing needed to be changed, leading to the wound being soaked in feces for an extended period of time. The WCTN also confirmed that they were not notified about the soiled dressing and emphasized the importance of keeping the wound covered to promote healing and prevent infection. For another resident, the facility did not obtain and transcribe wound treatment orders before providing the treatment. This resident had a surgical amputation and stage 3 pressure ulcers on the right and left buttocks. During a wound observation, it was found that the old dressings on the right leg stump and left foot were undated. The WNP confirmed that the dressings were undated and that the wounds had been treated the previous day. However, the medical records lacked documented evidence of the physician's orders for wound treatments until several days later. The DON and wound physician both indicated that the wound treatment required an order and that the staff were expected to ensure orders were in place before providing the treatment. The facility's policy on wound care, revised in 2010, indicated that the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. The policy required verification of a physician's order for the procedure and providing wound care treatment as ordered. The failure to follow these guidelines resulted in inadequate wound care for the residents, potentially leading to further complications.
Failure to Ensure Proper Labeling and Administration of Tube Feeding and GT Site Care
Penalty
Summary
The facility failed to ensure proper labeling and administration of tube feeding (TF) for a resident, identified as Resident 55 (R55). On multiple occasions, the TF bag or container and water bag were not labeled with the resident's name, TF rate, date/time, and nurse's initials as ordered by the physician. This was confirmed by a Registered Nurse (RN) who acknowledged the risk of misidentification due to the lack of labeling. Additionally, there was a discrepancy between the TF rate documented in the Medication Administration Record (MAR) and the actual rate being administered, which was not updated in the electronic record as per the new physician's order. The Director of Nursing (DON) confirmed that the staff failed to verify, transcribe, and update the MAR to match the actual TF rate delivered by the pump, leading to confusion and improper administration of the TF rate for R55. The Registered Dietitian (RD) also confirmed that the new order was not transcribed and the MAR was not updated accordingly. The facility policy required that all aspects of the resident's care be provided in accordance with physician orders, which was not followed in this case. Furthermore, the facility failed to obtain, transcribe, and implement care orders for the gastrostomy tube (GT) site and dressing change for R55. The GT site dressing was observed to be dated 04/30, indicating that it had not been changed as scheduled. The RN confirmed that the GT site should have been cleansed and the dressing changed daily at night, but this was not done. The wound nurse practitioner (WNP) and the Assistant Director of Nursing (ADON) indicated that both the Licensed Nurses and the Wound Care Team were responsible for the GT site care and management. However, the medical record lacked documented evidence of care orders for the GT site, and the dressing change was not implemented as required. The facility's policies on Physician Orders and Enteral Feeding Tube Care were not adhered to, resulting in the failure to provide adequate care and services to R55. The policies required that physician orders be documented and transcribed accurately, and that the GT site be monitored and the dressing changed to prevent infection. The DON acknowledged that the staff skipped the process, leading to confusion and non-compliance with the facility's policies. The failure to follow these policies could have jeopardized the resident's health and well-being.
Failure to Manage IV Access for Admitted Residents
Penalty
Summary
The facility failed to ensure care and management orders were obtained, transcribed, and carried out for residents admitted with intravenous (IV) access. Resident 65 was admitted with a double-lumen central venous catheter (CVC) in the left upper chest, which was not identified during the admission assessment. The CVC dressing was observed to be half off, exposing the insertion site, and there were no documented care orders for the CVC. The Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON) confirmed the oversight, acknowledging that the CVC had not been properly managed, placing the resident at risk for infection. The Director of Nursing (DON) indicated that the admission nurse should have performed a full head-to-toe assessment and obtained appropriate care orders from a physician. Resident 245 was admitted with a peripheral intravenous (IV) access in the left forearm, which was also not identified during the admission assessment. The IV line had a transparent dressing that was coming loose, and the resident indicated that the IV had not been used, flushed, or dressed since admission. The Infection Preventionist (IP) confirmed the resident's account and indicated that the admission nurse should have obtained a removal order from the physician. The Assistant Director of Nursing (ADON) reviewed the medical record and confirmed that the peripheral IV was not identified, and care orders were not obtained, placing the resident at risk for infection. The Director of Nursing (DON) reiterated that the admission nurse should have identified the IV and clarified its management with the physician. The facility's policies on Nursing Admission Assessment and Maintaining Patency of Peripheral Lines were not followed, as the licensed nurses failed to assess the residents' IV therapy needs and obtain necessary care orders. The Dressing Change for Vascular Access Devices policy was also not adhered to, as the CVC and peripheral IV dressings were not changed as required. These oversights in the admission process and failure to follow established protocols resulted in the residents being placed at risk for infection.
Failure to Monitor Dialysis Access
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident's arteriovenous fistula (AVF) for dialysis access. The resident, who had chronic kidney disease and was dependent on renal dialysis, had an AVF placed in the left upper arm approximately two months prior. Despite this, the facility did not have documented evidence of assessment or care orders for the AVF, nor was the bruit/thrill monitored as required. The resident's medical records lacked documentation of the AVF assessment, and the facility staff confirmed that there were no care and monitoring orders in place until a later date. Interviews with facility staff, including registered nurses and licensed practical nurses, revealed a lack of clarity and consistency in monitoring the AVF. The staff indicated that while the dialysis center was responsible for dressing changes on dialysis days, the facility nursing staff were responsible for monitoring the bruit/thrill. However, due to the absence of proper orders and prompts, the AVF was not consistently monitored. The Director of Nursing acknowledged the oversight and confirmed that there should have been an assessment and care orders in place for the AVF. The facility's policy on dialysis care, which required licensed nurses to monitor and document pre- and post-dialysis observations, was not followed in this case.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure their medication error rate was below five percent, with two errors identified out of 25 opportunities, resulting in an error rate of 8%. One deficiency involved a resident who was admitted with diagnoses including osteomyelitis and anemia. On the specified date, an LPN in the Northeast unit failed to administer Lactobacillus as ordered by the physician. The LPN acknowledged the error and was uncertain about the next steps. The Director of Nursing confirmed that the missed medication was an error and should have been administered within one hour of the prescribed time, as per facility policy. Another deficiency involved a resident with diagnoses including cataract and dry eye syndrome. An RN in the Southeast unit failed to follow the physician's order to space the administration of artificial tears by five minutes. The RN administered the eye drops to both eyes without the required spacing. The Director of Nursing indicated that the nurses were expected to follow the medication instructions or clarify the order, and the eye drops should have been instilled with the specified interval to ensure proper absorption. Both incidents highlight a failure to follow physician orders and facility policies, leading to medication administration errors.
Failure to Update Facility Assessment and Involve Department Heads in Staffing Changes
Penalty
Summary
The facility failed to ensure the facility assessment was reviewed and updated when staffing levels were reduced starting in October 2023. The facility's policy required a designated team to conduct a facility-wide assessment annually and as needed to ensure resources were available to meet the specific needs of the residents. The assessment included a detailed review of the resident population, including resident acuity and available resources such as staff type and staffing plan. Despite a reduction in staffing levels, particularly licensed nurses on the nocturnal shift, the facility assessment was not updated to reflect these changes. The Assistant Administrator confirmed that the reduction in staffing levels was a corporate decision due to budgetary reasons, and the Administrator acknowledged that the staffing plan, a substantial component of the facility assessment, should have been reviewed and updated accordingly. Additionally, the facility assessment policy required input from all department heads during the review of resident needs and facility resources. However, the department heads were neither involved nor consulted on the changes in the staffing plan. The Administrator confirmed that the input of staff and department heads should have been taken into consideration in line with the facility assessment policy. This failure to update the facility assessment and involve department heads had the potential to impact the facility's ability to meet residents' care needs effectively.
Failure to Protect Resident from Abuse by Staff Member
Penalty
Summary
The facility failed to ensure that a resident was free from abuse by a staff member. Specifically, an incident occurred where a Registered Nurse (RN) was witnessed pushing a resident, resulting in the resident falling to the ground. The resident, who had a diagnosis including bipolar disorder, unspecified psychosis, anxiety disorder, unspecified dementia, and altered mental status, was assessed and found to have no signs of physical harm or mental anguish following the incident. The resident was unable to remember the details of the incident due to their cognitive condition. The incident was observed by a Certified Nursing Assistant (CNA) and a Housekeeper/Floor Technician, who reported that the RN engaged in a verbal dispute with the resident and then pushed the resident, causing the fall. The RN did not follow the facility's training on how to handle potential situations with residents and was subsequently suspended, terminated, and reported to the board of nursing. The facility's policy on abuse prevention was not adhered to by the RN, leading to the deficiency in protecting the resident from abuse.
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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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