Highland Manor Of Mesquite Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mesquite, Nevada.
- Location
- 272 W Pioneer Blvd, Mesquite, Nevada 89027
- CMS Provider Number
- 295068
- Inspections on file
- 18
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Highland Manor Of Mesquite Rehabilitation Llc during CMS and state inspections, most recent first.
Failure to Provide Advance Directive Education: The facility did not provide written information or education about advance directives to four cognitively intact residents who had POLST forms and admission records noting DNR or comfort-focused treatment. Records for the residents showed diagnoses including CHF, COPD, respiratory failure, dementia, and CKD, but no documentation of advance directive education was found. Two residents stated the facility had not asked about or offered advance directive information, and the RVPO confirmed the facility could not locate any documentation of such education.
Dirty oxygen concentrator filters were observed for multiple residents receiving O2 therapy. Residents with diagnoses including COPD, hypoxemia, and respiratory failure were seen on nasal cannula while the concentrator filters had heavy dust or lint buildup. An LPN later removed one filter and confirmed it was very dirty, and an RN also acknowledged another filter was dirty and needed cleaning.
Laundry staff were not aware of the PPE available for sorting dirty laundry. During observation, no face shields or goggles were seen in the sorting area, and a laundry aide stated her apron was at home, the gloves were on the wall, and she used reading glasses instead of eye protection. The DON later stated the expectation was that aprons not be taken home and that face shields be available for eye protection, while the facility policy required laundry staff to handle linens to prevent spread of infection.
The facility did not maintain menu spreadsheets for weekly menus, including portion sizes and therapeutic diets, impacting residents' nutritional needs. Menus were neither updated nor reviewed by a dietitian, and were not followed as per facility policy. Observations revealed that serving utensils were used without reference to menu spreadsheets, leading to meals being served without consideration of specific dietary requirements. Residents with specific dietary needs, such as those with Alzheimer's, respiratory failure, dysphagia, diabetes mellitus, and vegetarian preferences, received meals that did not align with their prescribed diets. The Food Service Manager cited a transition to a new menu program and lack of training, while the Registered Dietitian noted the need for menu extensions and power foods for high calorie and protein diets.
The facility did not follow proper procedures for handwashing, cooling leftovers, and dating leftovers, affecting all residents receiving meals from the kitchen. Observations showed issues with food temperature maintenance, handwashing practices, and food item labeling. Cook1 held puree foods below the required temperature, and the FSM admitted to improper reheating procedures. Leftover Swedish meatballs and butternut squash were not cooled promptly, and undated omelets were found in the refrigerator. Both the FSM and Cook2 did not follow correct handwashing protocols, indicating a systemic issue in staff hygiene. The facility's policies lacked clear instructions on food temperature maintenance, handwashing, and food labeling. Staff showed a lack of awareness regarding proper food handling, such as cooling hot foods promptly and using soap during handwashing, posing a risk to resident health and safety.
The facility reported incidents involving six residents who experienced verbal and physical abuse. A CNA verbally abused two residents, calling one 'stupid,' which caused emotional distress. This behavior led to the CNA's termination. Additionally, two residents were involved in a physical altercation following aggressive comments, resulting in staff intervention. Another incident involved two residents where one displayed physical aggression, causing injuries. The aggressive resident was relocated and received 1:1 supervision until discharge. These events highlight the need for vigilance in preventing abuse among residents and staff.
The facility failed to complete a background check for a CNA before hire, allowing them to work multiple shifts with a provisional status. This was against the facility's policy and had the potential to negatively impact all residents.
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving two residents. The investigation lacked interviews with all potential witnesses and detailed documentation, placing the residents at risk of increased mental health issues and a diminished quality of life.
The facility failed to ensure that the Food Service Supervisor had completed a required course in food safety and management. The supervisor was hired with relevant experience but provided a certificate with an issue date after the hire date, indicating the course was retaken. This deficiency had the potential to affect all residents receiving meals from the facility's kitchen.
Failure to Provide Advance Directive Education
Penalty
Summary
The facility failed to ensure four of five residents reviewed were provided written information or education about advance directives and the right to formulate an advance directive. Resident 1 was admitted with diagnoses including transient cerebral ischemic attack, COPD, asthma, altered mental status, sleep disorder, and Alzheimer's dementia; the admission record listed a DNR/Allow Natural Death, comfort-focused treatment, no IV fluids, and no artificial nutrition or feeding tube. Resident 1's quarterly MDS showed a BIMS score indicating cognitive intactness, but the EMR contained a completed POLST form and the admission packet did not show any education regarding an advance directive. Resident 12 was admitted with diagnoses including CHF, COPD, type 2 diabetes, acute respiratory failure, and chronic kidney disease; the admission record listed DNR, selective treatment, and an artificial nutrition/feeding tube trial, and the admission MDS showed a BIMS score of 14. Resident 20 was admitted with acute and chronic respiratory failure, UTI, metabolic encephalopathy, hypertensive heart disease, dementia, and heart failure; the admission record listed DNR/Allow Natural Death, comfort-focused treatment, and no artificial nutrition or feeding tube, and the admission MDS showed a BIMS score of 14. Resident 79 was admitted with COPD exacerbation, acute respiratory failure with hypoxia and hypercapnia, pulmonary hypertension due to lung disease and hypoxia, and heart failure; the admission record listed DNR, comfort-focused treatment, no artificial nutrition or feeding tube, and no IV fluids, and the admission MDS showed a BIMS score of 15. For Residents 12, 20, and 79, the EMR showed POLST forms but no advance directives or documentation of education regarding advance directives. On interview, Resident 20 stated the facility had not asked about advance directives and had not provided education, and Resident 79 stated nobody had ever offered. The Regional Vice President of Operations stated the facility could not find anything regarding advance directive education for the four residents and confirmed there was no documentation of resident education regarding advance directives. The facility policy required the facility to determine on admission whether a resident had executed an advance directive and, if not, to determine whether the resident wanted to formulate one and provide information about the right to refuse treatment and formulate an advance directive.
Dirty oxygen concentrator filters observed for multiple residents
Penalty
Summary
The facility failed to ensure oxygen concentrator filters were kept free of dust and heavy lint buildup for three sampled residents receiving oxygen therapy. Residents R62, R5, and R79 were each observed using oxygen via nasal cannula while the exterior or cabinet filters on their oxygen concentrators were visibly dirty, with thick buildup of white lint or significant dust/lint noted during repeated observations by surveyors. R62 had diagnoses including bradycardia, hypoxemia, and atrial fibrillation, and had an order for oxygen at 2 L via nasal cannula to maintain oxygen saturation greater than 90% as needed for shortness of breath related to hypoxemia. On multiple observations, R62 was lying in bed wearing oxygen while the concentrator’s black side filter remained very dirty and full of white lint. R62 stated they had not seen staff change or clean the filter, and an LPN later removed the filter and confirmed it was very dirty with heavy lint buildup and said she was not aware of when it was last cleaned. R5 had diagnoses including COPD and chronic cough and had an order for oxygen at 2 L/min via nasal cannula, with titration to keep oxygen saturations above 92% as needed for shortness of breath related to COPD. The concentrator filter was observed repeatedly to be very dirty and full of white lint while R5 was on oxygen, and R5 stated they had not seen staff clean or change the filter. An LPN later removed the filter and found it clean after replacing it, stating she had just changed it because it needed cleaning. R79, who had diagnoses including COPD with exacerbation, acute respiratory failure with hypoxia and hypercapnia, pulmonary hypertension due to lung disease with hypoxia, and heart failure, was observed receiving oxygen at 3 LPM with a significant buildup of dust/lint on the concentrator’s exterior intake filter. An RN confirmed the filter was dirty and needed cleaning. The maintenance director and other facility staff described a monthly filter-cleaning process, but the observations showed the filters for these residents remained dirty during the survey period.
Laundry PPE Not Available or Known During Dirty Linen Sorting
Penalty
Summary
The facility failed to ensure that laundry staff were aware of the PPE available for use while sorting dirty laundry. During an observation of the laundry area on 04/10/2026 at 4:00 PM, no face shields or goggles were observed anywhere in the vicinity of the sorting area. A laundry aide stated that dirty clothes were brought in a barrel, removed, and placed into whites or colored for washing. When asked about aprons, gloves, and eye protection, the aide stated she had an apron but it was at home, said the gloves were on the wall, and stated she wore her reading glasses instead of eye protection. During an interview with the DON on 04/10/2026 at 4:15 PM, the laundry aide again stated the apron was at home because it had been taken home to wash and forgotten there. The aide did not know where the eye protection was and stated she had never had any. The DON stated the expectation was not to take aprons home and that face shields should be available for eye protection. The facility policy titled Infection Prevention and Control Program stated that laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection.
Menu Planning and Dietary Adherence Deficiencies
Penalty
Summary
The facility failed to have menu spreadsheets for the weekly menus that included portion sizes and regular and therapeutic diets for all residents, impacting the nutritional needs of residents. Menus were not updated, reviewed by a dietician, or followed as required by the facility's policy. The deficiency affected all residents who received meals prepared in the facility's kitchen. Observation of meal services on multiple occasions revealed that serving utensils were used without reference to menu spreadsheets, and residents were served meals without consideration of their specific dietary requirements. In the case of Resident 29 (R29), who was on a Regular High Calorie/High Protein diet with a mechanical soft texture, the resident was served meals that did not align with the prescribed diet. Despite the resident's specific dietary needs due to diagnoses of Alzheimer's disease, respiratory failure, and dysphagia, the facility failed to provide appropriate meals. Similarly, for Resident 16 (R16) on a Regular Puree diet due to dysphagia and dementia, the meals served did not match the prescribed diet, potentially compromising the resident's nutritional intake and well-being. Resident 34 (R34), with a diagnosis of diabetes mellitus and vegetarian preferences, did not receive appropriate vegetarian options and lacked protein in the meal served, highlighting a failure to meet the resident's dietary requirements. The Food Service Manager (FSM) and Registered Dietitian (RD) were unaware of the lack of menu spreadsheets and deviations from prescribed diets for residents. The FSM mentioned a transition to a new menu program and lack of training, while the RD highlighted the need for menu extensions and the utilization of power foods for high calorie and protein diets. The deficiency in menu planning and adherence to dietary requirements was evident through the observations of meal services and the discrepancies between prescribed diets and actual meals served to residents, indicating a systemic issue in ensuring residents' nutritional needs were met appropriately.
Deficiencies in Handwashing, Food Cooling, and Labeling Procedures
Penalty
Summary
The facility failed to adhere to proper procedures for handwashing, cooling leftovers, and dating leftovers, potentially impacting all residents who received meals prepared in the facility's kitchen. Observations revealed discrepancies in food temperature maintenance, handwashing practices, and labeling of food items. Cook1 was found holding puree foods below the required temperature, while the FSM acknowledged the lack of proper reheating procedures. Leftover Swedish meatballs and butternut squash were not cooled promptly as per guidelines, and omelets were left undated in the refrigerator. Additionally, both the FSM and Cook2 were observed not following correct handwashing protocols, highlighting a systemic issue in staff hygiene practices. The deficiency in food safety protocols was further compounded by inadequate staff training and non-compliance with established policies. The facility's policies lacked clear instructions on food temperature maintenance, handwashing procedures, and food labeling requirements. Staff members demonstrated a lack of awareness regarding proper food handling practices, such as cooling hot foods promptly and using soap during handwashing. These deficiencies in training and adherence to policies posed a significant risk to the health and safety of residents who relied on the facility for their meals.
Incidents of Verbal and Physical Abuse Among Residents and Staff
Penalty
Summary
The facility failed to ensure that six residents (R40, R60, R5, R57, R19, and R130) were free from verbal and physical abuse. Resident 40 (R40) and Resident 60 (R60) were subjected to verbal abuse by a Certified Nurse Assistant (CNA) who called R40 "stupid," leading to emotional distress for the residents. The investigation revealed that CNA1's behavior escalated, resulting in the termination of their employment. Resident 5 (R5) and Resident 57 (R57) were involved in a physical altercation where R5 made aggressive comments towards R57, leading to physical violence between the two residents. Both residents were separated and redirected by staff following the incident. Additionally, Resident 19 (R19) and Resident 130 (R130) were involved in a physical altercation where R130 threw punches at R19, resulting in injuries to both residents. R130 displayed physical aggression towards R19, leading to scratches and abrasions on R130's body. The investigation documented that R130 was relocated to another hall and received 1:1 supervision until discharge. The report highlighted the need for the facility to ensure the safety and well-being of all residents by preventing verbal and physical abuse among residents and staff.
Failure to Complete Background Check for CNA Before Hire
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA3) had a completed background check prior to hire, as required by their policy on Abuse Prohibition and Reporting. CNA3 was hired on January 15, 2024, but their fingerprints were not completed and re-mailed until February 20, 2024. Despite the incomplete background check, CNA3 worked multiple shifts from January 28, 2024, to April 22, 2024. The facility's records showed that the background check was still in process, and CNA3's employment status was provisional. The Human Resources Manager confirmed that the fingerprints had to be re-sent due to an error, and the results had not yet been received. The Administrator acknowledged that the state was behind on processing fingerprints and that staff must be let go if their background check cannot be appealed. The facility's failure to complete the background check for CNA3 before allowing them to work had the potential to negatively impact all residents. The facility's policy required screening of potential employees, including healthcare workers' background checks and screening through the Office of Inspector General (OIG) Exclusion database. However, CNA3 was allowed to work without a completed background check, which was against the facility's policy and could have put residents at risk. The deficiency was identified through a review of CNA3's employee file, facility policies, and interviews with the Human Resources Manager and Administrator.
Incomplete Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving two residents. Resident 40, who has a history of stroke with left-sided paralysis, bipolar disorder, and affective mood disorder, reported that a Certified Nurse Aide (CNA) called them 'stupid' while assisting them in the bathroom. Resident 60, who has Parkinson's disease, bipolar disorder, and PTSD, overheard the incident and reported it to a Registered Nurse. The facility's investigation was incomplete, as it did not include interviews with all potential witnesses or detailed documentation of the interviews that were conducted. The Facility Investigation report only included written statements from two staff members and lacked documentation of interviews with other staff or residents who may have witnessed the incident. The Social Services Director (SSD) admitted to speaking with two other residents but failed to document their names or responses. The Administrator acknowledged that the investigation was not complete after reviewing the report. This failure to conduct a thorough investigation placed the residents at risk of increased mental health issues and a diminished quality of life.
Failure to Ensure Food Service Supervisor Completed Required Course
Penalty
Summary
The facility failed to ensure that the Food Service Supervisor had completed a course in food safety and management, as required by the job description. The Food Service Supervisor was hired on 12/12/23 and had two or more years of experience as a kitchen supervisor in a healthcare setting. However, the certificate of completion for the Certified Food Protection Manager course had an issue date of 04/24/24, which was after the hire date. During interviews, the Food Service Supervisor confirmed that they had retaken the course because they could not find the certificate for the previously taken course. This deficiency had the potential to affect all residents who received meals prepared in the facility's kitchen.
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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