Trellis Paradise
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 4375 S. Eastern Avenue, Las Vegas, Nevada 89119
- CMS Provider Number
- 295109
- Inspections on file
- 13
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Trellis Paradise during CMS and state inspections, most recent first.
Nursing staff did not document physician notification, change in condition, or nursing interventions for a resident who developed a high fever, despite facility policy requiring such actions. The resident, with a history of respiratory illness and pneumonia, had a temperature of 102.9°F recorded, but no further temperature checks or interventions were documented for over 15 hours. Interviews with LPNs, CNAs, an RN, and the DON confirmed that standard practice would have included prompt notification, interventions, and documentation, none of which occurred in this case.
A resident with chronic respiratory failure, COPD, and pneumonia experienced a significant fever, but the facility failed to ensure timely and complete documentation of nursing interventions, provider notification, and follow-up monitoring. Although a physician progress note acknowledged the fever and recommended monitoring, this note was not promptly transferred to the facility's software, and staff could not clarify the timing or provide documentation as required by policy.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended, which posed a risk of unauthorized access to medications and supplies. A treatment cart was left outside a nourishment room, and a medication cart was found unsecured in front of a resident's room. Staff acknowledged the carts should be locked, citing lost keys and potential lock issues.
A resident with multiple health conditions was discharged with a plan for follow-up care from a home health agency, but the agency never contacted the resident. The case manager failed to follow up with the agency or the resident, despite known issues with the agency's performance. The facility's policy required a post-discharge plan, which was not effectively executed.
A facility failed to protect a resident's PHI when a medication cart was left unattended with a laptop screen displaying sensitive information. The RN responsible was in training and did not lock the screen. Both an LPN and another RN confirmed that nurses are trained to secure laptops to protect PHI, as per the facility's confidentiality policy.
The facility failed to maintain proper linen handling procedures, risking patient exposure to infections. CNAs were observed carrying clean linen against their uniforms, contrary to facility policy requiring linen to be protected from contamination. The ADON confirmed the correct procedure was not followed.
A resident with malnutrition was not adequately monitored for hydration, leading to visible signs of dehydration such as dry, cracked lips and sunken eyes. Despite these symptoms, nursing staff failed to report the condition to the medical provider or document it, resulting in a significant fluid intake deficit. The Registered Dietician was unaware of the issue due to a lack of communication, and the Medical Director was not informed, preventing timely intervention.
A resident with severe malnutrition and other health issues received TPN through a midline IV catheter instead of a central line, contrary to manufacturer's recommendations. Despite the risks of complications due to high osmolarity, the facility proceeded with midline administration after consulting with a pharmacist and physician, leading to pain and edema in the resident's arm.
A resident with muscle weakness and recent back surgery was not repositioned as required, leading to discomfort and potential skin integrity issues. The resident also expressed a preference against using incontinence briefs, but this was not documented or communicated effectively by staff. The facility's policies did not adequately address these issues, resulting in a deficiency related to resident rights.
A resident's privacy was compromised when their body weight was posted on a board visible from the hallway. The resident, who was alert and oriented, expressed concern over this privacy issue. A nurse confirmed the visibility and removed the information. The DON mentioned a family request for the posting, but no documentation supported this. Facility policy prohibits posting clinical information without resident or family request.
A resident with severe malnutrition and other conditions received TPN administered by LPNs instead of RNs, contrary to state regulations. The facility's DON was unaware of this requirement, and LPNs documented administering TPN despite it not being in their job description.
A resident with multiple health issues was not discharged to a licensed group home as per physician's order. Despite the resident's agreement to move to a group home with hospice services, the discharge summary indicated a different address, which was not a licensed group home. The facility's case manager did not verify the home's licensing, leaving it to the insurance social worker, resulting in a deficiency.
A resident with a right humerus fracture was not provided with the prescribed arm brace and sling, as per physician orders and the care plan. The resident reported significant pain and indicated that the brace helped alleviate discomfort. The Physical Therapy Director confirmed the necessity of the brace and sling, which should have been in place at all times. The facility's policy required the maintenance and supervision of assistive devices, but the resident was found without the prescribed equipment, potentially impacting their recovery.
The facility failed to maintain sanitary conditions in the kitchen, potentially exposing residents to foodborne illnesses. Observations included a cook without a beard cover, soiled kitchen equipment, undated and spilled milk, dented cans, and a dirty ice machine. A fan was improperly placed in the food prep area, and another cook was observed without a beard cover.
Failure to Document and Respond to Resident's High Temperature
Penalty
Summary
Nursing staff failed to document physician notification, a change in condition, nursing interventions, or attempts to obtain a physician order to manage a resident's high temperature, as required by facility policy. The resident, who had a history of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and pneumonia, was admitted with these diagnoses. On the evening of 08/14/2025, the resident's oral temperature was recorded at 102.9°F, but there was no further temperature documented until the following afternoon, over 15 hours later. During this period, there was no documentation of any interventions, physician or family notification, or a change in condition assessment in the medical record. Interviews with nursing staff, including LPNs, CNAs, an RN, and the DON, revealed that the facility's standard practice was to consider a temperature above 100.3°F as high and to implement interventions such as cooling measures, hydration, and notifying the physician for further orders, including medication like Tylenol. Staff also indicated that a change in condition assessment would be completed, the physician and family would be notified, and the temperature would be rechecked within an hour. However, in this case, none of these actions were documented for the resident with the high temperature. A review of the facility's policy on changes in a resident's condition confirmed that prompt notification of the physician, resident, and representative was required, along with detailed documentation of observations and interventions. The DON and physician both confirmed that the medical record lacked evidence of a change in condition, nursing interventions, or physician notification related to the resident's high temperature. The absence of documentation and follow-up actions was inconsistent with both facility policy and staff statements regarding standard procedures.
Incomplete and Delayed Medical Record Documentation Following Change in Condition
Penalty
Summary
The facility failed to ensure complete and accessible medical record documentation for one resident with multiple serious diagnoses, including chronic respiratory failure, COPD, and pneumonia. The resident experienced a significant change in condition, evidenced by an elevated oral temperature of 102.9°F, which was documented by an LPN. However, the medical record lacked evidence of timely and complete documentation of nursing interventions, follow-up monitoring, and provider notification related to this change in condition. Although a physician progress note acknowledged the fever and recommended monitoring and Tylenol as needed, this note was not transferred to the facility's software until several days later, and the Director of Nursing was unable to clarify the timing of the note's entry. Additionally, the DON refused to provide a copy of the note, citing HIPAA privacy, despite policy allowing surveyor access. Interviews with nursing staff and the physician confirmed that a temperature above 100.3°F should have triggered provider notification, interventions, and documentation, but the medical record did not contain evidence of these actions. The physician also expected documentation of interventions and rechecking of the temperature, but did not recall being updated by the covering physician. The facility's policies required documentation of changes in condition and provider notification, but there was no evidence in the record that these requirements were met. Furthermore, the physician services policy did not address accountability for timely electronic documentation or software transfers.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to secure medication and treatment carts, which were left unlocked and unattended, posing a risk of unauthorized access to medications and treatment supplies. On multiple occasions, a treatment cart was observed outside the nourishment room, unlocked and unattended, with contents such as scissors, ointments, creams, and dressings easily accessible to residents or visitors. A Certified Nursing Assistant confirmed the cart was unlocked and expressed concerns about resident safety due to the unsecured contents. A Registered Nurse acknowledged the cart was unsecured and mentioned that the key was lost, indicating the cart should be locked to prevent unauthorized access. Additionally, a medication cart was found unattended and unsecured in front of a resident's room, with an intravenous bag of Saline and Meropenem left on the counter. The Registered Nurse responsible for the cart was inside the room and not in view of the cart, and it was noted that the nurse was new and in training. Another medication cart was also found unlocked, with a Registered Nurse confirming the lock system might be broken and acknowledging the need for the cart to be locked to prevent residents from accessing medications. The Assistant Director of Nursing confirmed the medication cart should have been locked and was unaware of the inability to lock the carts in the south hallway. The facility's policy requires medication carts to be securely locked when out of the nurse's view.
Failure in Coordination of Care for Discharged Resident
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Summary
The facility failed to ensure proper coordination of care for a resident discharged to a home health agency, leading to a potential risk for an unsafe discharge. The resident, who had multiple health conditions including chronic obstructive pulmonary disease, muscle weakness, and multiple sclerosis, was discharged with a plan for follow-up care involving physical therapy, occupational therapy, and nursing services from a specified home health agency. However, the resident reported not being contacted by the agency within the expected 24 to 48 hours post-discharge, and the agency confirmed that the resident was never under their care. The case manager admitted to not following up with the home health agency or the resident to ensure services were provided, despite acknowledging previous issues with the agency's performance. The Director of Nursing confirmed the importance of follow-up calls to maintain continuity of care. The facility's policy required the care planning team to develop a post-discharge plan with arrangements for follow-up care, which was not effectively executed in this case.
Failure to Protect Resident's Protected Health Information
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Summary
The facility failed to protect a resident's protected health information (PHI) when a medication cart was left unattended and unsecured in front of a resident's room. On the cart, a laptop computer screen was left open, displaying the resident's name, medication profile, and diagnoses, which were visible to the public or other residents passing by. The Registered Nurse (RN) responsible for the cart was in the resident's room and had not locked the computer screen to safeguard the resident's medical information. The RN explained that this was only the employee's fourth day and they were still in training. Both a Licensed Practical Nurse (LPN) and another RN confirmed that nurses are trained to lock or close laptops to protect PHI. The facility's policy on confidentiality, revised in October 2017, mandates the protection and safeguarding of residents' personal and medical records.
Improper Linen Handling Procedures
Penalty
Summary
The facility failed to maintain proper linen handling procedures, which placed patients at risk for exposure to infections. On March 26, 2025, a Certified Nursing Assistant (CNA1) was observed carrying clean linen beneath their left arm and against their uniform while entering a resident's room. Later that morning, two CNAs were seen exiting the linen room with clean linen held against their chests and uniforms, confirming they were transporting it to resident rooms. CNA2 acknowledged that staff should hold clean linen away from their bodies or use a plastic bag during transport to prevent contamination. The Assistant Director of Nursing (ADON) observed the incident and indicated that the CNAs should have transported the clean linen away from their bodies to prevent contamination from potentially unclean uniforms. The facility's policy on Soiled Laundry and Bedding, revised in September 2022, requires that clean linen be protected from dust and soiling during transport and storage to ensure cleanliness.
Failure to Monitor and Maintain Resident Hydration
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Summary
The facility failed to adequately monitor and maintain the hydration status of Resident 255, who was admitted with diagnoses including malnutrition. Observations on multiple occasions revealed the resident exhibited signs of dehydration, such as dry, cracked lips, sunken eyeballs, and dry flaking skin on the lower extremities. Despite these visible symptoms, the nursing staff, including a CNA and an LPN, did not report the resident's condition to the medical provider or document the symptoms in the resident's records. The Registered Dietician (RD) had not completed a full dietary evaluation for Resident 255, and the resident was receiving 700ml less fluid per day than the recommended intake of 1975ml. The RD was unaware of the resident's dehydration symptoms as the nursing staff had not communicated this information. The facility's Medical Director confirmed that they were not informed of the resident's condition, which prevented timely medical intervention such as intravenous hydration. The resident's care plan identified a risk for dehydration and included interventions like encouraging increased oral fluids and monitoring for signs of dehydration. However, these interventions were not effectively implemented, as evidenced by the lack of documentation and communication regarding the resident's fluid intake deficits and dehydration symptoms. The facility's policies on change in condition and hydration were not followed, as there was no notification to the physician or the resident's representative about the significant change in the resident's condition.
Improper Administration of TPN via Midline IV
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Summary
The facility failed to ensure the safe administration of total parenteral nutrition (TPN) for a resident, leading to complications. The resident, who had severe protein-calorie malnutrition, dementia, dysphagia, and a history of venous thrombosis and embolism, was initially admitted with a recommendation for TPN through a central line. However, due to unsuccessful attempts to insert a central line, the TPN was administered through a midline IV catheter, which is not recommended for solutions with high osmolarity like TPN. Despite the manufacturer's recommendation for central line administration due to the high osmolarity of the TPN solution, the facility proceeded with midline administration after consulting with a pharmacist and the attending physician. The resident experienced pain and edema in the arm where the midline was inserted, indicating potential complications. The decision to use a midline was made after the resident returned from the hospital with a midline instead of a central line, and the family requested TPN administration before hospice care. The facility's actions were based on the inability to place a central line and the family's wishes, but this led to the administration of TPN in a manner contrary to the manufacturer's guidelines. The pharmacist and physician acknowledged the risks associated with midline administration of high osmolarity solutions, yet the TPN was continued temporarily. This practice resulted in the resident experiencing pain and potential complications, highlighting a deficiency in adhering to safe administration protocols for TPN.
Failure to Honor Resident Rights in Repositioning and Incontinence Care
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Summary
The facility failed to honor resident rights related to repositioning and the use of incontinence briefs for one resident, identified as R252. The resident was admitted with diagnoses including muscle weakness and was at risk for pain following recent back surgery. The care plan for R252 included goals for comfort using non-pharmaceutical methods and interventions such as repositioning every two hours to prevent skin integrity impairment. However, observations and interviews revealed that R252 was not repositioned as required, with the resident expressing discomfort from lying on their back continuously. The Turn and Reposition daily log showed multiple instances where R252 was not repositioned during various shifts. Additionally, the facility did not adequately address the resident's preferences regarding the use of incontinence briefs. R252, who was alert and able to communicate, stated a preference for not using the briefs, although they were willing to do so for the convenience of the staff. The CNA caring for R252 was unaware of the resident's preferences and did not know how to check them on the computer. The care plan lacked documentation regarding the use of incontinence briefs, and the facility's policy on urinary incontinence did not address resident preferences for using such briefs.
Privacy Breach: Resident's Weight Information Publicly Displayed
Penalty
Summary
The facility failed to safeguard the privacy of a resident by posting their body weight on a room's board that was visible from the hallway. This incident involved a resident who was alert, oriented, and capable of making their own decisions. The resident, who had been admitted with diagnoses including COPD, acute hypoxic respiratory failure, prediabetes with steroid-induced hyperglycemia, and sleep apnea, expressed concern that their weight information should not be visible to everyone due to privacy issues. A Registered Nurse confirmed the visibility of the weight information and removed it from the board. The Director of Nursing later indicated that a family member had requested the weight to be documented on the board, but there was no documented evidence of such a request in the medical record. The facility's policy on dignity stated that signs indicating a resident's clinical status or care needs should not be openly posted unless requested by the resident or family member.
Improper Administration of TPN by LPNs
Penalty
Summary
The facility failed to ensure that total parenteral nutrition (TPN) was administered by qualified Registered Nurses (RNs) for one of the sampled residents. The resident, who was admitted with severe protein-calorie malnutrition, dementia, dysphagia, and a history of venous thrombosis and embolism, had a physician's order for TPN to be administered intravenously. However, the medication administration record (MAR) for August and September revealed that TPN was documented as administered by Licensed Practical Nurses (LPNs) on multiple occasions, despite the Nevada Nursing Practice Act specifying that LPNs are not authorized to administer TPN. Interviews with LPNs and the Director of Nursing (DON) confirmed that LPNs had documented administering TPN, although they were only supposed to monitor the infusion. The DON was unaware that LPNs could not administer TPN according to state regulations. A review of personnel records showed that TPN administration was not included in the LPNs' job descriptions. This oversight in ensuring compliance with professional standards of quality had the potential to expose the resident to medication errors and health complications.
Failure to Discharge Resident to Licensed Group Home
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 161, was discharged to a licensed group home as per the physician's order. Resident 161 had multiple diagnoses, including restless leg syndrome, generalized muscle weakness, diabetes mellitus, unspecified protein-calorie malnutrition, legal blindness, and adult failure to thrive. The resident was admitted to the facility after being discharged from the emergency department due to uncontrolled muscle spasms and reported not having food at home. The resident required assistance with placement and expressed a desire to be discharged to a group home in a specific area of town. Throughout the resident's stay, various notes documented the resident's condition and discharge planning. The interdisciplinary team and case management were involved in discussing discharge options with the resident, who was agreeable to moving into a group home with hospice services. The resident's family was willing to assist with group home expenses, and the resident was evaluated and accepted to a group home. However, the discharge summary indicated that the resident was discharged to a home, and a review of the Bureau of Health Care Quality and Compliance Health Facility Locator website revealed that there was no licensed group home at the address provided. The facility's case manager indicated that the resident was alert and oriented and chose the discharge address. However, the case manager did not verify if the home was a licensed group home, leaving it to the insurance social worker to ensure compliance with the physician's order. The medical record lacked documented evidence that the resident was discharged to a licensed group home, as required, or that the discharge plan was altered based on the resident's preference to go to a private residence with hospice services.
Failure to Provide Prescribed Arm Brace and Sling
Penalty
Summary
The facility failed to ensure that a resident with a right humerus fracture was provided with the necessary arm brace and sling as per the physician's orders and care plan. The resident, identified as Resident #98, was admitted with a diagnosis of a right humerus fracture and had a physician's order dated 09/05/2024, which specified the use of a [NAME] brace and a sling with an abduction pillow at all times. On 09/17/2024, it was observed that the resident was not wearing the prescribed brace and sling, which had been removed by a staff member the previous night and could not be located. The resident reported significant pain and indicated that the brace helped alleviate the discomfort caused by the fracture. The care plan dated 08/30/2024, and a physician progress note from 09/12/2024, confirmed the necessity of the brace and sling for the resident's condition. The Physical Therapy Director also confirmed that the brace and sling should have been in place at all times until 10/14/2024. The facility's policy on Assistive Devices and Equipment required the maintenance and supervision of assistive devices as dictated by the resident's care plan. The failure to adhere to these orders and policies resulted in the resident not receiving the appropriate treatment and care, as evidenced by the absence of the prescribed brace and sling, potentially leading to complications in the resident's recovery process.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially expose residents to foodborne illnesses. During an inspection, it was observed that a cook was preparing meals without wearing a beard cover, despite having facial hair. The top surfaces of both the oven and the dishwasher were visibly soiled with greasy matter, dust, and yellowish debris. Additionally, an open bottle of milk was found undated in the walk-in refrigerator, and a milk carton was found spilled on the floor under a rack with dairy products. In the dry storage area, a 4-pound can of tuna and two 6-pound cans of pineapple chunks were visibly dented. The ice machine lid had white stains, and the inside rim was dirty and stained, despite the kitchen manager's claim that it was cleaned two weeks prior. Further observations during a tray line inspection revealed a fan placed on the floor blowing air into the food preparation area, which the kitchen manager acknowledged could lead to potential food contamination with dust. Additionally, another cook with a beard was observed setting up meal trays without wearing a beard cover. The kitchen manager confirmed these observations and acknowledged that the beard cover should have been worn, and the fan should not have been placed in the preparation area.
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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