Trellis Centennial
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 8565 W Rome Blvd, Las Vegas, Nevada 89149
- CMS Provider Number
- 295106
- Inspections on file
- 20
- Latest survey
- May 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Trellis Centennial during CMS and state inspections, most recent first.
A resident with a hospital-diagnosed anxiety disorder was admitted and exhibited repeated care refusals, aggression, and behavioral symptoms, but the facility failed to document anxiety as an active diagnosis, did not develop a care plan or interventions for anxiety, and did not provide behavioral health services until after the resident expressed suicidal ideation. Staff recognized the behaviors but did not address them through the care planning process, resulting in psychosocial harm.
Staff failed to properly disinfect a shared glucometer with EPA-approved wipes, did not consistently perform hand hygiene or use PPE when entering rooms of residents on contact isolation for C. diff and wound infection, and did not document required education for visitors regarding isolation precautions. These lapses involved both staff and visitors and affected multiple residents with infectious conditions.
A resident with multiple medical conditions was administered Lovenox for deep vein thrombosis without a care plan or physician order for monitoring anticoagulant therapy. Staff did not perform or document routine assessments for bleeding or adverse reactions, and the MAR lacked evidence of monitoring, despite facility policy requiring these actions.
A resident with COPD and acute respiratory failure was administered oxygen via nasal cannula without a physician's order specifying flow rate or care instructions. Nursing staff and the DON confirmed the absence of required orders, and facility policy required such orders for oxygen administration.
A resident with multiple medical conditions did not receive pain management in accordance with physician orders. The MAR showed Hydrocodone-Acetaminophen was given for a pain rating of 4/10, despite orders specifying its use only for severe pain (7-10/10) and no orders covering pain rated 4-6/10. Nursing staff and the DON confirmed the medication was not administered as prescribed, and the physician was not contacted for clarification.
Two residents in the facility did not have documented evidence of receiving assistance with activities of daily living (ADLs) as required by their care plans. One resident, with muscle weakness and a fracture, lacked documentation of oral, toileting, and personal hygiene assistance over several shifts. Another resident, with muscle weakness and hemiplegia, reported being left in a soiled brief for hours, with no documentation of toileting hygiene during multiple shifts. The facility's policy requires documentation of ADL assistance, which was not adhered to, resulting in a deficiency.
A facility failed to record a resident's weight upon admission, which could have compromised their nutritional and medical well-being. The resident, admitted with conditions such as dysphasia and diabetes, had their weight recorded six days later. Staff interviews revealed that the facility's policy required weights to be taken upon admission, with the expectation of entry within 48 hours.
The facility failed to ensure accurate documentation of medications and treatment services for residents, including a Lidocaine patch, ACE wrap, TED hose, and Heparin injections. Errors included not removing a Lidocaine patch as scheduled, not applying an ACE wrap, inaccurately documenting TED hose application, and discrepancies in Heparin vial deliveries versus recorded administrations.
The facility failed to apply an ACE wrap and TED hose as ordered for two residents and did not administer Heparin as prescribed for another resident. The ACE wrap was not applied for over a week, and weekly skin assessments were not completed. TED hose was not provided due to size issues, yet nurses signed off as if it had been applied. Heparin administration records showed discrepancies, with more recorded doses than vials delivered.
The facility failed to ensure proper wound care for a resident with stage IV and stage III pressure ulcers, resulting in the wound being left uncovered and exposed to urine and feces. The CNA did not inform the licensed nurse or wound care treatment nurse about the soiled dressing, and the wound dressings on the resident's heels were undated, contrary to facility policy.
The facility failed to ensure a Lidocaine patch was applied and removed as ordered for a resident with muscle spasm, bacteremia, and a history of liver transplant. The patch was not removed or replaced as required, leading to the resident experiencing pain. The MAR inaccurately documented the removal and application of the patch, and staff confirmed the oversight.
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 10.34%. Errors included incorrect dosages of Sodium Bicarbonate and Zinc Sulfate, and improper administration of a Cyanocobalamin Injection Solution. The DON confirmed these errors and noted the potential for compromised absorption and adverse reactions.
The facility failed to document a narcotic administration in the Narcotics Logbook and found loose pills, personal food items, and an unlabeled white powdery substance in medication carts. The LPN and DON acknowledged these deficiencies and the need for proper medication storage and documentation.
The facility failed to follow TBP and EBP for two residents, leading to multiple instances where staff and family members entered rooms without required PPE. Additionally, an LPN did not disinfect a medication vial topper before use, contrary to infection control protocols.
Failure to Develop and Implement Behavioral Health Care Plan for Resident with Anxiety
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's hospital-diagnosed anxiety, did not monitor behavioral symptoms, and did not provide necessary behavioral health services. Despite documentation from the hospital discharge summary, physician assessments, and therapy evaluations all identifying anxiety as an active medical condition, the facility did not code anxiety as an active diagnosis in the medical record until several days after admission. The baseline care plan created at admission did not include any focus, goals, or interventions related to anxiety, and there was no evidence of individualized behavioral health interventions being developed or implemented. Throughout the resident's stay, multiple instances of care refusal, verbal aggression, and behavioral symptoms such as yelling and use of abusive language were documented. Staff, including therapy and nursing, observed and reported these behaviors, but there was no documented evidence that these symptoms were addressed through the care planning process or that the interdisciplinary team (IDT) discussed or intervened regarding the resident's anxiety prior to the resident expressing suicidal ideation. The resident also reported to surveyors feelings of depression, hopelessness, and ongoing suicidal thoughts, and stated that requests for medication to address anxiety and sleep issues were denied by staff. Interviews with staff confirmed that the resident's behavioral symptoms and refusals were recognized but not addressed through a care plan or IDT intervention. The facility's own policy required assessment and individualized care planning for behavioral health symptoms, but this was not followed. The lack of timely recognition, documentation, and intervention for the resident's anxiety and behavioral health needs resulted in psychosocial harm, as evidenced by the resident's reported suicidal ideation.
Failure to Adhere to Infection Control Protocols and Contact Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances involving the use of shared medical equipment, adherence to contact isolation protocols, and education of staff and visitors regarding transmission-based precautions. In one case, a registered nurse disinfected a shared glucometer with an alcohol pad after use on a resident with diabetes and chronic kidney disease, despite the availability of EPA-approved disinfectant wipes and facility protocols requiring their use. The nurse believed alcohol pads were acceptable based on previous pharmacy guidance, but both the Director of Nursing and Infection Preventionist later confirmed that only EPA-approved wipes with a specified contact time were appropriate for disinfecting shared glucometers to prevent cross-contamination. In another instance, staff failed to follow contact isolation procedures for a resident on precautions for possible Clostridium difficile infection. Despite clear signage and the availability of personal protective equipment (PPE) at the room entrance, multiple staff members entered and exited the resident's room without donning the required PPE or performing hand hygiene with soap and water, as mandated for C. difficile precautions. Staff later acknowledged that they had not paid attention to the isolation signage and were aware that proper handwashing and PPE use were required but had not been performed. Additionally, the facility did not ensure that visitors and staff consistently adhered to contact precautions for a resident with a wound infection. A visitor entered and remained in the resident's room without wearing the required gown and gloves, stating they were unaware of the need for PPE. The facility's care plan and policies required education for visitors and documentation of such education, but there was no evidence in the medical record that the visitor had been informed about the precautions. Furthermore, a licensed practical nurse was observed entering the same resident's room without donning PPE, despite acknowledging the necessity of these measures to prevent infection spread.
Failure to Implement Care Plan and Monitoring for Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to formulate a care plan for anticoagulant use and did not obtain a physician order for monitoring a resident receiving anticoagulant therapy. The resident, who had diagnoses including dementia, Parkinson's disease, and gait abnormalities, was admitted and prescribed Lovenox for deep vein thrombosis. Although the medication was administered as ordered, there was no documented evidence of a care plan addressing anticoagulant use, nor was there a physician order in place for monitoring the resident for potential bleeding or adverse reactions during the course of therapy. Staff interviews confirmed that routine assessments for signs of bleeding, such as bruising, bleeding gums, hematuria, and black tarry stools, were not conducted or documented prior to or during the administration of Lovenox. The lack of a monitoring order meant that no prompts were generated for staff to implement necessary assessments, and the Medication Administration Record did not reflect any monitoring for bleeding or coagulation issues. The facility's own policy required such monitoring and documentation, but these steps were not followed for this resident.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen therapy for a resident with diagnoses including COPD with exacerbation, acute respiratory failure, and dementia. The resident was observed receiving oxygen via nasal cannula at varying flow rates without a humidifier, and there was no documented physician order specifying the use, flow rate, or care instructions for the oxygen therapy. Medical records did not contain evidence of an order for oxygen or for changing the nasal cannula, despite the resident's continuous dependence on supplemental oxygen. Interviews with nursing staff and the Director of Nursing confirmed that no physician order was in place for the oxygen therapy or related care, and that staff were expected to obtain such orders at the onset of oxygen use. The Physician Assistant also confirmed that a physician's order specifying flow rate, delivery method, and monitoring parameters was required for supplemental oxygen. Facility policies reviewed indicated that a physician's order was necessary for oxygen administration and for all medications and treatments.
Failure to Administer Pain Medication per Physician Orders
Penalty
Summary
The facility failed to ensure that pain medication was administered according to physician orders for a resident with multiple diagnoses, including cellulitis of both lower limbs, muscle weakness, and acute and chronic respiratory failure with hypoxia. The resident had physician orders specifying Tylenol for mild pain rated 1-3/10 and Hydrocodone-Acetaminophen for severe pain rated 7-10/10, but there was no order for pain rated 4-6/10. Despite this, the Medication Administration Record (MAR) showed that Hydrocodone-Acetaminophen was administered for a pain rating of 4/10 on several occasions. Interviews with nursing staff and the Director of Nursing confirmed that the medication was not administered as per the physician's orders and that there was a lack of physician orders for pain rated 4-6/10. Staff did not contact the physician for clarification or new orders when the resident reported pain in this range, as required by facility policy. The facility's policy stated that medications should be administered safely, timely, and as prescribed, but this was not followed in the case of this resident.
Deficiency in Documenting ADL Assistance for Residents
Penalty
Summary
The facility failed to provide documented evidence of assistance with activities of daily living (ADLs) for two residents, leading to a deficiency in care. Resident 1, who was admitted with muscle weakness and a displaced intertrochanteric fracture of the left femur, required assistance with oral hygiene, toileting hygiene, and personal hygiene. Despite the care plan indicating the need for assistance, there was no documentation of these services being provided during several shifts in July, August, and September 2024. The Minimum Data Set (MDS) Director and the Director of Nursing (DON) confirmed the lack of documentation, which should have been recorded at least once per shift. Resident 2, admitted with muscle weakness, hemiplegia of the right dominant side, and respiratory failure, also required assistance with ADLs. The resident reported being left in a soiled brief for extended periods, particularly between 4:00 AM and 10:00 AM, and often while waiting for physical therapy. The ADL Documentation Survey Report for October and November 2024 showed no evidence of toileting hygiene being provided during several shifts. The MDS Director and DON confirmed the absence of documentation, which should have been recorded if the resident refused or was unavailable for care. The facility's policy on ADLs, revised in March 2018, mandates that residents unable to perform ADLs independently should receive appropriate support for hygiene, mobility, elimination, dining, and communication. However, the lack of documentation for the care provided to Residents 1 and 2 indicates a failure to adhere to this policy, resulting in a deficiency in the care provided to these residents.
Failure to Record Resident's Weight Upon Admission
Penalty
Summary
The facility failed to ensure that a resident's weight was taken and recorded upon admission, which could have compromised the nutritional and medical well-being of the resident. The resident, who was admitted with diagnoses including dysphasia, chronic kidney disease, and diabetes mellitus, had their weight recorded six days after admission. The medical record lacked evidence of the weight being obtained upon admission. Interviews with facility staff, including a CNA, a Charge Nurse, and the DON, revealed that the facility's policy required weights to be taken upon admission, with the expectation that this information be entered within 48 hours. The facility's Weight Assessment and Intervention policy specified that residents were to be weighed upon admission and weekly thereafter.
Documentation Failures in Medication and Treatment Services
Penalty
Summary
The facility failed to ensure documentation accurately reflected medications and treatment services provided to residents. For Resident 166, a Lidocaine patch was not removed as scheduled, and the Medication Administration Record (MAR) inaccurately documented its application and removal. The patch was left on for more than 12 hours, contrary to the physician's order, and the MAR indicated it was removed when it was still in place. This discrepancy was confirmed by both the resident and the Licensed Practical Nurse (LPN), who acknowledged the error in documentation and the failure to follow the physician's order for timely removal of the patch. Resident 9 had an active physician's order for an ACE wrap to be applied to the left foot amputation surgical site every shift. However, the resident reported that the ACE wrap had not been applied for more than a week, despite the MAR indicating otherwise. The Wound Care Treatment Nurse (WCTN) and the Director of Nursing (DON) confirmed that the ACE wrap was not applied as ordered and that the MAR was inaccurately documented. The WCTN was unsure of the indication for the ACE wrap, and the DON emphasized the importance of accurate documentation and adherence to physician's orders. Resident 43 had orders for TED hose to be applied for edema management and Heparin injections for deep vein thrombosis (DVT) prophylaxis. The TED hose was not applied as ordered, and the MAR inaccurately documented its application. The charge Registered Nurse (RN) admitted to signing off on the TED hose application despite the hose being too small for the resident. Additionally, there was a significant discrepancy in the number of Heparin vials delivered versus the number of recorded administrations, indicating missed doses. The DON and the Consultant Pharmacist confirmed the discrepancy and the failure to follow the facility's medication administration and documentation policies.
Failure to Apply ACE Wrap, TED Hose, and Administer Heparin as Ordered
Penalty
Summary
The facility failed to ensure proper application and clarification of an ACE wrap for a resident who had undergone a surgical amputation. Despite a physician's order for the ACE wrap to be applied every shift, the resident reported that the wrap had not been applied for more than a week. The wound care treatment nurse and the director of nursing confirmed that the ACE wrap was an active order but had not been applied as required. Additionally, the facility did not complete weekly head-to-toe skin assessments as ordered, which led to unmonitored swelling in the resident's left foot. The wound care treatment nurse acknowledged the lack of assessment and indicated that the physician would be notified for new orders to treat the edema. Another resident was not provided with TED hose as ordered for edema management. The resident had a physician's order for TED hose to be applied twice a day, but the resident reported not having used compression stockings since admission. The certified nursing assistant and licensed practical nurse assigned to the resident were unaware of the TED hose order, and the charge nurse admitted that the facility did not have appropriately sized TED hose for the resident. Despite this, multiple nurses had been signing off on the medication administration record as if the TED hose had been applied. The facility also failed to administer Heparin as ordered for a resident. The resident was supposed to receive Heparin injections twice a day, but the medication administration records showed discrepancies between the number of recorded administrations and the number of Heparin vials delivered. The director of nursing and the consultant pharmacist confirmed that there were 57 more recorded administrations than the number of vials delivered, indicating missed doses. The facility's policies on medication administration and documentation were not followed, leading to inaccurate records and potential harm to the resident.
Failure to Ensure Proper Wound Care and Communication
Penalty
Summary
The facility failed to ensure proper wound care for a resident with stage IV pressure ulcers on the sacral region and stage III pressure ulcers on the right and left buttocks. The resident's wound was found uncovered and soaked with urine and feces during incontinent care. The CNA responsible for the resident's care did not inform the licensed nurse or wound care treatment nurse about the soiled dressing, leading to the wound being left exposed. The WCTN confirmed that the wound should not be left open to prevent contamination and potential worsening of the wound or infection. Additionally, the facility's policy required wound dressings to be dated, which was not followed in this case, as the dressings on the resident's heels were undated. The facility's failure to follow wound care protocols and ensure proper communication among staff members resulted in the resident's wound being left exposed to contaminants. The WCTN and the wound physician emphasized the importance of following wound care orders to promote healing and prevent complications. The Director of Nursing also confirmed that staff members were expected to cover wounds to prevent exposure to feces and urine. The facility's policies on wound care and prevention of pressure injuries were not adhered to, leading to the identified deficiencies.
Failure to Apply and Remove Lidocaine Patch as Ordered
Penalty
Summary
The facility failed to ensure the Lidocaine patch was applied and removed as ordered for Resident 166, who was admitted with diagnoses including muscle spasm, bacteremia, and a history of liver transplant. The physician's order specified the application of a Lidocaine patch, 5% topically, daily to the affected area at 9:00 AM and removal at 8:59 PM. However, on 06/04/2024, it was observed that the patch applied on 06/02/2024 was still in place, and no new patch had been applied on 06/03/2024. The Medication Administration Record (MAR) inaccurately documented the removal and application of the patch on 06/02/2024 and 06/03/2024, respectively. The Licensed Practical Nurse (LPN) confirmed the patch had not been removed or replaced as required, and the resident reported experiencing pain due to this oversight. Interviews with the Physician Assistant (PA), Director of Nursing (DON), and Pain Specialist highlighted the importance of timely application and removal of the Lidocaine patch for effective pain management. The PA and DON acknowledged that the staff were expected to follow the orders for the effectiveness of the pain medication. The Pain Specialist emphasized that the patch should be removed after 12 hours to prevent skin irritation and mentioned a previous incident where a resident's skin was burned due to untimely removal. The facility's pain management policy, dated 10/2022, indicated a commitment to appropriate assessment and treatment of pain based on professional standards of practice, which was not adhered to in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was below five percent, resulting in an error rate of 10.34%. This was based on three errors identified out of 29 opportunities observed. The first error involved an LPN administering 650 mg of Sodium Bicarbonate to a resident instead of the prescribed 325 mg. The LPN acknowledged the mistake and confirmed that the correct procedure would have been to cut the 650 mg tablet in half. The Director of Nursing (DON) confirmed the error and noted that the resident should have been monitored for adverse reactions. The second error involved the same LPN administering a Cyanocobalamin Injection Solution subcutaneously instead of intramuscularly as ordered. The LPN admitted to the mistake and acknowledged that medications should be administered per physician orders. The DON confirmed the error and explained that incorrect administration could compromise absorption. The third error involved the LPN administering 200 mg of Zinc Sulfate to another resident instead of the prescribed 220 mg. The LPN acknowledged the mistake and reported that the ordering provider should have been contacted for clarification. The DON confirmed the error and noted that the resident received a lower dose than prescribed.
Medication Documentation and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and storage of medications, as observed during an inspection of two medication carts. At Station 1, loose pills, including half of a white pill, half of a yellow pill, and a full pink pill, were found under medication packets. The LPN present admitted to not checking under the medication packets while cleaning the cart at the start of the shift and acknowledged that the cart should have been free of loose pills. At Station 2, a narcotic medication administration was not logged in the Narcotics Logbook. Additionally, personal food items such as a bag of cheese crackers and multiple small chocolate bars were found in a drawer next to clean supplies. An unlabeled and uncovered white powdery substance, identified as thickener for fluids, was found in a clear plastic cup on top of clean supplies. The LPN confirmed the narcotic was administered but not documented, acknowledged the personal food items were theirs, and admitted awareness of the policy against storing food in medication carts. The DON confirmed the need for proper logging of narcotics and adherence to storage policies.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to ensure that transmission-based precautions (TBP) and Enhanced Barrier Precautions (EBP) were followed for two residents. For Resident 166, who was on contact precautions due to a Methicillin-resistant Staphylococcus aureus (MRSA) infection, multiple instances were observed where staff, family members, and a housekeeper entered the room without wearing the required personal protective equipment (PPE). The Certified Nursing Assistant (CNA) and family members were not informed about the need for PPE, and the housekeeper admitted to not paying attention to the precaution signage. The Infection Preventionist (IP) confirmed that the failure to follow precautions posed a risk of cross-contamination and exposure to other residents and staff members. Similarly, for Resident 33, who was on contact precautions due to a Clostridium difficile (C. diff) infection, a family member and the admissions director were observed entering the room without donning the required gown and gloves. The family member was not educated about the need for PPE, and the admissions director ignored the contact isolation signage. Both individuals failed to perform hand hygiene upon leaving the room, which the IP confirmed increased the risk of cross-contamination. Additionally, the facility failed to follow proper infection control procedures during medication administration for Resident 34. A Licensed Practical Nurse (LPN) accessed a medication vial without disinfecting the vial topper, believing it was unnecessary for new sterile vials. The Director of Nursing (DON) confirmed that all medication vials, regardless of their condition, needed to be wiped with alcohol to disinfect the vial topper. This failure to adhere to infection control protocols could potentially lead to contamination and infection.
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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