Coronado Ridge Skilled Nursing & Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Henderson, Nevada.
- Location
- 2855 W. Horizon Ridge Parkway, Henderson, Nevada 89052
- CMS Provider Number
- 295099
- Inspections on file
- 29
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Coronado Ridge Skilled Nursing & Rehabilitation Ce during CMS and state inspections, most recent first.
A resident who was discharged and later tested positive for Legionella at a hospital was not properly followed up by facility staff. The IP Nurse received notification from the hospital but did not document the call, gather key details, or initiate required infection surveillance actions such as water testing or resident tracking. The case was not reported to the Health District, and the Administrator was not informed, contrary to facility policy.
The facility failed to provide appropriate pain management for two residents by not administering pain medication as ordered for one resident and not performing a timely pain assessment for another. One resident with a history of severe pain and recent dosage increase continued to receive a lower dose, and staff did not clarify or document the change. Another resident was not assessed for pain upon admission, with the first assessment delayed until the next morning.
A facility failed to obtain informed consent before administering psychotropic medications to a resident with Alzheimer's disease. Despite having a process for informed consent, the facility did not document consent for Buspirone, Mirtazapine, and Depakote, which were prescribed for anxiety and agitation. Interviews with staff confirmed the oversight, and the facility's policy requiring informed consent for such medications was not followed.
A resident with a history of false allegations reported being hit by a CNA during care. Despite the facility's documentation indicating the need for a Cares in Pairs program, staff were unaware of this requirement, and no care plan was implemented. The DON acknowledged the lack of a care plan, which was against the facility's policy.
The facility failed to develop baseline care plans for two residents using medical devices. One resident, admitted with a soft collar after neck surgery, did not have a care plan for the collar's management. Another resident, with a leg fracture, lacked a care plan for an ACE wrap and CAM boot. An LPN confirmed these omissions, and the DON acknowledged the need for such plans. The facility's policy requires baseline care plans within 48 hours of admission, but these were not documented, leading to a deficiency.
A facility failed to document and apply TED stockings for a resident with heart failure and hypertension, as per their care plan and physician's orders. The resident was observed without the stockings, and the MAR showed missing documentation for several days. The ADON confirmed the lack of documentation and the absence of a specific policy for TED stockings, highlighting a deficiency in care plan execution.
The facility failed to manage medical devices and post-operative care for two residents, leading to potential risks for discomfort and skin issues. One resident's soft collar was not removed or assessed since admission, lacking physician orders for its management. Another resident's boot device was not assessed, and follow-up with the orthopedic surgeon was delayed due to missing documentation. The DON acknowledged these deficiencies, highlighting a lack of communication and documentation in care plans.
A facility failed to document psychoactive medication side effects monitoring for a resident with anxiety disorder and schizophrenia. Despite physician orders requiring monitoring every shift for medications like Trazodone and Risperdal, the MAR lacked documentation for specific dates. The ADON confirmed the oversight, and the facility's policy on psychotropic medication use was not followed, resulting in a deficiency.
A medication cart was left unlocked and unattended by a nurse, posing a risk of unauthorized access. Additionally, a resident with dementia had an unapproved bottle of hydrogen peroxide at their bedside, which was not part of their prescribed medications. Staff confirmed the oversight and acknowledged the need for secure medication storage.
Failure to Document and Respond to Legionella Notification
Penalty
Summary
The facility failed to provide documented evidence of actions taken and follow-up after being notified that a discharged resident tested positive for Legionella at a hospital. The resident, who had diagnoses including cerebral edema, urinary tract infection, E. Coli, and required supplemental oxygen, was transferred to the hospital due to altered mental status and shortness of breath. Hospital testing confirmed a positive Legionella PCR result from a nasopharyngeal swab. The Infection Preventionist (IP) Nurse received a phone call from the hospital informing them of the positive result but did not document the conversation or ask for critical details such as the date of the positive test or whether the resident was symptomatic. After receiving the notification, the IP Nurse relayed the information to the DON and ADON and inquired about the last time the facility's water system was tested for Legionella, which was in February with negative results. The IP Nurse was told by the Maintenance Director that further testing would not be conducted due to the previous negative result. No further investigation, water testing, or resident tracking was initiated. The IP Nurse acknowledged that the conversation with the hospital should have been documented and that additional information should have been gathered to determine if the infection was healthcare-associated. Other staff, including the ADON, Clinical Resource, and Maintenance Director, confirmed that the information about the positive Legionella case was shared verbally but not documented or acted upon according to infection surveillance protocols. The Administrator was not made aware of the hospital's notification, and the facility did not report the case to the Health District as required. The facility's policy required ongoing surveillance and appropriate interventions for significant infections, but these steps were not followed in this instance.
Failure to Administer Pain Medication as Ordered and Timely Assess Pain
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for two residents by not administering pain medication as ordered and not performing timely pain assessments. For one resident with a history of lumbar fracture, long-term opiate use, and complex regional pain syndrome, the physician increased the Hydromorphone dosage from 4 mg to 6 mg every 4 hours due to ongoing pain that interfered with therapy and sleep. Despite the new order, the resident continued to receive the lower 4 mg dose until discharge, and there was no documentation that the increased dose was ever administered. Nursing staff did not discontinue the previous order or clarify the duplicate orders, and a pain assessment following the dosage increase was not completed as required by facility policy. Therapy staff documented that the resident experienced severe pain during therapy sessions and sometimes declined therapy due to ineffective pain management. Both the occupational and physical therapists confirmed that pain was a persistent issue and that the resident's participation in therapy was negatively affected by inadequate pain control. The Director of Nursing acknowledged that the physician's new order should have replaced the previous one and that staff should have followed the prescribed orders to manage the resident's pain effectively. For another resident admitted with a right femur fracture and multiple surgical incisions, the facility failed to perform a pain assessment upon admission as required by policy. The first documented pain assessment was not completed until the following morning, several hours after admission. The Director of Nursing and a registered nurse confirmed that the pain assessment was missing from the initial evaluation, which could have delayed identification and management of the resident's pain.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to a resident, identified as Resident 1 (R1). R1 was admitted with diagnoses including a puncture wound, a fracture of the fibula, and Alzheimer's disease. The medical record indicated that R1 had a legal representative appointed as a power of attorney. Despite this, the facility did not document informed consent for the administration of Buspirone, Mirtazapine, and Depakote, which were prescribed for anxiety, agitation, and aggressive behavior. The medications were administered without documented evidence of informed consent, which is a regulatory requirement. Interviews with the Director of Staff Development, a Registered Nurse, the Assistant Director of Nursing, and the Director of Nursing revealed that the facility had a process in place for obtaining informed consent, which included explaining the medication's purpose, risks, benefits, and potential side effects to the resident or their representative. However, this process was not followed for R1, as confirmed by the Director of Nursing upon reviewing R1's medical record. The Consultant Pharmacist also confirmed the necessity of informed consent for these medications due to their psychotropic nature. The facility's policy on the use of antipsychotic medications required informed consent, which was not adhered to in this case.
Failure to Implement Care Plan After Alleged Abuse
Penalty
Summary
The facility failed to initiate a care plan after a resident alleged physical abuse by a staff member. The resident, who had a history of making false allegations, reported that a female CNA was rough during peri care and hit the resident on the forearm/hand. This incident was reported to the direct care staff and subsequently to the administrator. Despite the facility's documentation indicating the need to revise care plans to include the Cares in Pairs program, there was no evidence that this was implemented by the survey date. Interviews with facility staff revealed a lack of awareness regarding the Cares in Pairs requirement for the resident. An LPN and a CNA both stated they were not aware of the need for two caregivers during the resident's care, except during transfers. The DON acknowledged the absence of a care plan related to the incident and agreed that it would have been beneficial to document interventions to prevent recurrence. The facility's policy mandates a comprehensive, person-centered care plan within 21 days of admission, but this was not adhered to in this case.
Failure to Develop Baseline Care Plans for Medical Devices
Penalty
Summary
The facility failed to develop a baseline care plan for two residents, which included necessary interventions for medical devices they were using. Resident 244 was admitted with a soft collar device following cervical spine surgery. Despite the requirement for the collar to be worn continuously, the facility did not include care and management interventions for the collar in the resident's baseline care plan. This omission was confirmed by an LPN who noted that the plan should have included details such as a referral to the surgeon, wearing schedule, skin assessments, and hygiene instructions. Resident 250 was admitted with a right leg fracture and required an ACE wrap dressing and a CAM boot device. The facility did not develop a care plan for these devices, which was confirmed by an LPN. The baseline care plan should have included management instructions for the ACE wrap and CAM boot, including a wearing schedule, skin assessments, and follow-up with the orthopedic surgeon. The lack of a care plan for these devices was acknowledged by the Director of Nursing, who confirmed that interventions should have been included. The facility's policy requires a baseline care plan to be developed within 48 hours of admission to address the resident's immediate health and safety needs. However, the medical records for both residents lacked documented evidence of such plans, leading to a deficiency in meeting professional standards of quality care. The absence of these care plans placed the residents at risk for discomfort and complications related to their medical conditions and devices.
Failure to Document and Apply TED Stockings
Penalty
Summary
The facility failed to ensure proper documentation and application of Thrombo-Embolus Deterrent (TED) stockings for a resident with heart failure and essential hypertension. The resident was observed without TED stockings, despite having a care plan and physician's orders specifying their use to manage dependent edema. The resident's medical records, including the Medication Administration Record (MAR), showed multiple instances where the application of the stockings was not documented or signed off by nursing staff. The Assistant Director of Nursing (ADON) confirmed the lack of documentation and was unable to provide justification for the missing entries. The facility did not have a specific policy for TED stockings, although there was a policy for heart failure management. The expectation was for nursing staff to document the completion of tasks as per physician's orders, which was not adhered to in this case, leading to a deficiency in the resident's care plan execution.
Deficiencies in Post-Operative Care and Device Management
Penalty
Summary
The facility failed to ensure proper care and management orders for medical devices and post-operative appointments for two residents, leading to potential risks for discomfort and skin integrity issues. Resident 244, who was admitted with a cervical disc disorder and post-surgical soft collar device, did not have the collar removed or the skin underneath assessed since admission. The medical record lacked documented evidence of physician orders for the collar's management, and the admitting nurse failed to transcribe necessary care orders, resulting in a delay in appropriate monitoring and care. Resident 250, admitted with a right tibia fracture and post-surgical boot device, also experienced deficiencies in care. The resident's boot device had not been removed for assessment since a week prior, and there was no communication regarding the ACE wrap, boot device, or post-operative appointment. The medical record lacked evidence of a scheduled follow-up with the orthopedic surgeon, and clarification orders for the ACE wrap and boot device were not obtained. Weekly skin checks were missed, and the facility did not know the resident's surgeon, leading to a significant delay in post-operative care. The Director of Nursing acknowledged the deficiencies, including the delay in post-operative appointments and missed skin checks. The facility's policies required immediate entry of care orders upon admission and regular skin assessments, which were not followed. The lack of communication and documentation regarding the residents' care plans and follow-up appointments contributed to the deficiencies observed by the surveyors.
Failure to Document Psychoactive Medication Side Effects Monitoring
Penalty
Summary
The facility failed to ensure that psychoactive medication side effects monitoring was documented for one of the sampled residents, Resident 3 (R3). R3 was admitted with diagnoses of anxiety disorder and schizophrenia and had multiple physician orders for monitoring the side effects of various psychoactive medications, including Trazodone, Venlafaxine, Risperdal, Seroquel, and Vistaril. These orders required monitoring for a range of side effects every shift, and the results were to be documented in the medication administration record (MAR). However, the MAR for R3 revealed that the monitoring of side effects for the listed psychoactive medications was not completed or signed off on specific dates in August 2024. There was no documented evidence in the MAR or progress notes explaining why the monitoring was not signed off. The comprehensive care plan for R3 included interventions to monitor and document side effects and effectiveness of the medications every shift, but this was not adhered to. The assistant director of nursing (ADON) confirmed the lack of documentation during a review of the medical record and was unable to provide additional evidence or justification for the unsigned monitoring orders. The facility's policy on psychotropic medication use, revised in July 2022, required monitoring for adverse consequences, but this was not followed in R3's case, leading to the deficiency.
Medication Security and Storage Deficiency
Penalty
Summary
The facility failed to ensure the security of medications, as observed with one of the six medication carts. A nurse left the medication cart unlocked and unattended while stepping away to the nursing station, leaving it vulnerable to unauthorized access. During this time, other staff members, including a Unit Manager, were present but did not secure the cart. The Unit Manager acknowledged the oversight and reminded the nurse of the importance of keeping the cart locked when unattended. Additionally, a resident was found with a bottle of hydrogen peroxide on their bedside table, which was not prescribed or included in their self-administration medication safety screen. The resident, diagnosed with senile degeneration of the brain and unspecified dementia, was unable to recall the origin of the hydrogen peroxide. Facility staff, including an LPN and the Assistant Director of Nursing, confirmed that the hydrogen peroxide should not have been at the resident's bedside, as it was not part of the resident's approved self-administered medications.
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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