Oasis Nursing & Rehab Of Green Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Henderson, Nevada.
- Location
- 100 Delmar Gardens Drive, Henderson, Nevada 89074
- CMS Provider Number
- 295041
- Inspections on file
- 21
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Oasis Nursing & Rehab Of Green Valley during CMS and state inspections, most recent first.
A resident with dementia and other medical conditions reported that a CNA was rude during care and intentionally hit them in the eye, later telling multiple staff, including an RN, LPN, and CNA, that they had been assaulted and that their eye hurt. Staff documentation noted a red mark and redness to the resident’s right eye, and the physician was contacted for redness around the eye. Although the facility’s policy required all abuse allegations to be reported to local, state, and federal agencies within specified timeframes, the RN did not notify the Administrator promptly, the Administrator was not aware of the allegation for several days, and the allegation was never reported to the State Agency. The Administrator chose to investigate first and, citing the resident’s history of making allegations and behavioral history, decided the unsubstantiated allegation was not reportable, while the Director of Social Services referenced prior informal guidance suggesting some allegations could be handled internally despite the written reporting policy.
The facility did not enforce or document its Legionella Water Management Program as required, with no evidence of regular monitoring or review prior to being notified of possible Legionella contamination. Two residents with complex respiratory and cardiac conditions tested positive for Legionella after being transferred to acute care, and the facility could not provide documentation of required water system inspections or control measures before the incident. The water management plan was found to be adequate but had not been periodically reviewed or tailored to the facility, and documentation of compliance only began after external notification.
A resident with intact cognition reported being inappropriately touched on the chest by another resident, who later admitted to the act. The incident was not immediately reported to staff, and the facility's investigation substantiated the abuse. Both residents had behavioral care plans addressing prior concerns, but the event was not prevented or promptly identified, resulting in a deficiency for failure to protect residents from abuse.
A resident with a kidney transplant was given Cialis tablets instead of the prescribed Tacrolimus capsules for several days due to a pharmacy mislabeling error. LPNs administered the medication based on the mislabeled bubble pack without recognizing the form discrepancy, and the error was only discovered after multiple doses when a nurse questioned the medication's appearance. The DON and Consultant Pharmacist confirmed the mislabeling and the failure to identify the error during medication administration.
A facility failed to monitor and document behaviors and side effects for residents on psychoactive medications, affecting six residents with conditions like dementia and psychosis. The issue arose during a transition to a new EHR system, where necessary orders did not migrate, leading to inconsistent documentation. Nurses were instructed to use progress notes instead of the MAR, but this resulted in inadequate monitoring, as acknowledged by the Clinical Care Coordinator.
The facility restricted residents from accessing the front porch area without a chaperone, despite no elopement risk and intact cognition for some. Residents were redirected to a courtyard gazebo, which is also a smoking area, causing dissatisfaction. The facility lacked a policy for this restriction, conflicting with residents' rights to self-determination.
A resident with chronic vision and hearing loss was inaccurately assessed, leading to inadequate care in a LTC facility. Despite being clinically blind and hard of hearing, the resident's MDS assessments documented adequate vision and hearing, resulting in insufficient meal assistance. The LPN and DON confirmed the inaccuracies, and the family reported a lack of accommodations for the resident's health status changes, contributing to weight loss and hospitalization.
The facility failed to conduct PASRR Level 2 evaluations for three residents with psychiatric diagnoses and behavioral issues. One resident exhibited combative behavior and delusions, another showed exit-seeking and inappropriate interactions, and a third displayed delusional behavior. The facility lacked a PASRR policy, and the Social Services Director was unaware of the requirement for PASRR Level 2 evaluations for residents with psychiatric diagnoses.
Two residents using CPAP and BiPAP machines lacked comprehensive care plans in a facility. One resident had no documented care plan for their CPAP machine, while the other had a care plan without interventions for their BiPAP machine. The DON confirmed the absence of necessary care plans and interventions, which are required for individualized care.
A high-risk resident developed a deep tissue injury (DTI) on the left heel due to the facility's failure to implement necessary interventions and conduct regular skin assessments. Despite a care plan outlining preventive measures, the DTI went untreated for weeks, with staff unaware of the condition until the resident complained of pain. The facility's policies for skin monitoring and pressure ulcer care were not followed, leading to a lack of documentation and communication among staff.
A facility failed to provide necessary meal assistance to a blind resident, resulting in significant weight loss and hospitalization. Despite the resident's need for one-on-one feeding assistance due to blindness, this requirement was not communicated or documented, leading to inadequate care. The interdisciplinary team did not address the need for feeding assistance, and the resident's family was not involved in care planning, contributing to the resident's decline and eventual hospitalization for dehydration.
A facility failed to obtain physician orders for a resident's PEG tube care, including bolus feeding and water flushes. The resident, with a history of dementia and dysphagia, was observed with an outdated Glucerna bottle and lacked documented orders for tube care. The LPN and CCC confirmed the absence of necessary orders, despite the resident consuming more than 75% of meals. The facility had transitioned to a new EHR system, but the required orders were not ensured.
A resident with a urinary tract infection had a PICC line inserted for antibiotic therapy, but the facility failed to document care orders for site monitoring, flushes, and dressing changes. The last antibiotic dose was given without follow-up on the stop date or PICC line maintenance. Observations showed improper management, with a gauze pad covering the insertion site, preventing monitoring. The DON confirmed the absence of care orders, and the NP was unaware of the situation, highlighting a risk of infection due to inadequate PICC line care.
The facility failed to obtain physician orders for oxygen administration and monitoring for a resident with respiratory conditions, and for the use of a CPAP machine for another resident. The first resident received oxygen without documented orders or saturation monitoring, while the second resident used a CPAP machine without a physician's order or care plan. Staff confirmed the necessity of these orders to ensure proper respiratory care.
The facility failed to complete annual performance appraisals for four CNAs, risking substandard care. Employees hired between 2021 and 2022 lacked evaluations for multiple years. The HR Coordinator confirmed the absence, and the DON cited miscommunication with a former SDC as a reason. The Administrator was unaware of the issue, despite the appraisal form's importance for feedback and quality care.
The facility failed to ensure proper food storage and handling, with unlabeled and expired items found in storage, and improper meal service practices observed. A refrigerator was also operating above the recommended temperature, posing potential risks to resident safety.
Failure to Timely Report Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency within the required timeframe and in accordance with its own policy. A resident with osteomyelitis, cognitive communication deficit, and dementia without behavioral disturbance reported that a CNA became upset during care, was rude, and intentionally hit the resident in the right eye. The resident stated the eye hurt and that no one checked the eye that day, and also reported the incident to a nurse without receiving a response. The resident later stated they did not feel safe in the facility because the incident could happen again. Documentation shows that on 04/04/2026 the resident reported to an RN that, while being changed, a CNA moved them in a way they did not like, the resident raised their hands and pushed the CNA, and the CNA then hit the resident in the eye. The RN contacted the Acting DON, and a skin assessment documented a red mark under the right eye and redness to the eye. Additional staff statements dated 04/07/2026 from an LPN and a CNA recorded that the resident reported being hit in the face, having their hands held down, and being punched in the right eye, and that the resident’s eye was hurting and they reported being assaulted. Physician notes from the same date documented the physician was called for redness around the right eye and that the resident had been hit but could not recall the incident. The medical record showed the resident reported the alleged abuse to multiple staff members. Despite these reports and documented injuries, there was no documented evidence that the allegation of abuse was reported to the State Agency, and no documentation that the Administrator was notified until 04/07/2026. The Administrator stated the allegation, received on 04/04/2026, was not reported to them until 04/07/2026 and acknowledged that facility policy required all allegations of resident abuse to be reported to local, state, and federal agencies. The Administrator decided to investigate first and, based on the resident’s known behavior, difficulty with staff of certain races, and history of making allegations, determined the allegation was not reportable because it was unsubstantiated. The Acting DON acknowledged that the RN who received the allegation on 04/04/2026 did not notify the Administrator as required. The Director of Social Services reported prior guidance that allegations from residents with a documented history of false allegations could be handled internally and not reported, and was unable to identify any policy requiring all abuse allegations to be reported to the State Agency, despite the written policy specifying immediate reporting within 2 hours or 24 hours depending on the nature of the allegation.
Failure to Enforce Legionella Water Management Program and Document Required Activities
Penalty
Summary
The facility failed to enforce its Legionella Water Management Program (LWMP) as required by its own policy. The LWMP included a checklist of inspection items, frequencies, and documentation requirements, but there was little to no evidence that these activities were performed or recorded prior to notification from the local health department. The Maintenance Director confirmed that while some activities may have been conducted, there was no documentation to support ongoing compliance with the LWMP until after the facility was alerted to possible Legionella contamination. The LWMP itself was found to be adequate for the facility type, but it had not been periodically reviewed, and some of its documentation was not specific to the facility. The deficiency came to light during a complaint investigation after two residents who had been admitted with complex respiratory and cardiac conditions tested positive for Legionella following their transfer to acute care facilities. One resident experienced a significant drop in oxygen saturation and required emergency transfer, while the other was treated for a persistent cough and tested positive for Legionella antigen. The source of the Legionella could not be conclusively determined, but the facility's lack of documented implementation of its water management plan was evident. Interviews with facility leadership, including the Administrator, Maintenance Director, and DON, revealed that the LWMP had not been reviewed or updated except in response to the notification of possible Legionella cases. Water testing and mitigation activities were only documented after the facility was informed of the potential contamination. Prior to this, there was no evidence of regular monitoring, system flushing, or other control measures as outlined in the LWMP.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident reported that another resident had touched their chest under their shirt without permission. The incident was reported to the Director of Social Services and the Administrator, and the accused resident admitted to the inappropriate contact. The facility's investigation substantiated the allegation of abuse. Prior to the incident, the resident who committed the abuse had a behavioral care plan addressing inappropriate sexual comments, while the resident who reported the abuse had a care plan for making false accusations and having physical altercations. The incident was not immediately reported to staff, as the affected resident only disclosed it to a relative, who also did not inform the facility. Skin assessments conducted during the relevant period noted a rash on the upper left chest of the affected resident, but no complaints of pain or discomfort were documented. The facility's policy requires maintaining an environment free from abuse, neglect, and exploitation. The failure to promptly identify and address the abuse, as well as the delay in reporting, contributed to the deficiency cited in the report.
Medication Administration Error Due to Pharmacy Mislabeling
Penalty
Summary
A resident with end stage renal disease and a history of kidney transplant was admitted and had a physician's order for Tacrolimus 0.5 mg capsule, an anti-rejection medication. However, due to a pharmacy error, a medication bubble pack containing Cialis 5 mg tablets was mislabeled as Tacrolimus and dispensed with the resident's name. Over a period of six days, the resident was administered Cialis instead of the prescribed Tacrolimus. The medical record did not show any order for Cialis for this resident. Licensed Practical Nurses confirmed administering the mislabeled medication, relying on the label and the five rights of medication administration, but failed to notice the discrepancy between the ordered capsule form and the tablet form present in the bubble pack. The error was only identified after several doses when another nurse questioned the form of the medication. The Director of Nursing and Consultant Pharmacist acknowledged the pharmacy's mislabeling and the failure of nursing staff to detect the error before administration, despite facility policies requiring verification of medication form and label against physician orders.
Deficient Monitoring of Psychoactive Medications
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of residents' behaviors and side effects for those receiving psychoactive medications. This deficiency was identified for six residents, each with various diagnoses such as dementia, depression, anxiety, and psychosis. The facility's policy required monitoring for significant negative changes from baseline and ruling out medications as the cause of these changes. However, the medical records for these residents lacked documented evidence of orders to monitor target behaviors and side effects related to the use of psychoactive medications. The deficiency was partly attributed to the facility's transition from one electronic health record (EHR) system to another. During this transition, the necessary orders for monitoring behaviors and side effects did not migrate successfully to the new system. As a result, licensed nurses were instructed to document observations in the progress notes rather than the medication administration record (MAR), leading to inconsistent monitoring and documentation practices. The Clinical Care Coordinator acknowledged the issue and took responsibility for auditing and ensuring the necessary orders were in place. The lack of consistent documentation and monitoring of psychoactive medication side effects was further complicated by the facility's reliance on paper MARs and progress notes during the EHR transition. Nurses were not keen on charting into paper MARs, and the facility was still pending training for entering order sets into the new EHR. This situation resulted in a lack of monitoring documentation essential for the physician and pharmacist during resident drug reviews, as highlighted by the facility's policies on medication monitoring and management.
Facility Restricts Resident Access to Front Porch
Penalty
Summary
The facility failed to honor the residents' right to self-determination by not allowing them to make choices about significant aspects of their lives, specifically regarding their ability to sit outside on the front porch area. This deficiency was observed in one sampled resident and three unsampled residents. Despite having no elopement risk, these residents were restricted from accessing the front porch area without a chaperone, which was not a documented policy of the facility. The residents expressed dissatisfaction with this restriction, comparing the facility to a prison due to the lack of freedom to sit outside without supervision. The report highlights that the facility is located near a minor street with a large, covered portico and a wrap-around porch area with park benches for residents to enjoy. However, residents were instructed to use the gazebo area in the courtyard, which is also the designated smoking area, instead of the front porch. This restriction was enforced by the receptionist, who would redirect residents to the courtyard unless a staff or family member was available to accompany them. The facility's administrator and social services director justified this practice by citing protective oversight and safety concerns, despite the residents' cognitive abilities and low elopement risk. The facility lacked a formal policy requiring residents to have a chaperone to access the front porch area, and the residents' rights document in the admissions packet emphasized their right to self-determination and a dignified existence. The residents' inability to make independent choices about their outdoor activities, despite their cognitive status and elopement assessments, was a significant oversight in respecting their rights and preferences, leading to potential psychosocial distress.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for a resident, specifically regarding vision, hearing, and functional status impacting activities of daily living. The resident, who was admitted with chronic vision and hearing loss, Parkinson's disease, and weakness, was observed struggling with meal assistance due to these impairments. Despite being clinically blind and hard of hearing, the resident's meal ticket did not indicate the need for assistance, and the staff was not informed of the resident's requirements for one-on-one feeding assistance. The resident's Minimum Data Set (MDS) assessments inaccurately documented adequate vision and hearing, and only required setup or cleanup assistance with eating. However, the resident was clinically blind and required full assistance with meals. The Licensed Practical Nurse (LPN) assigned to the resident confirmed these inaccuracies, noting that the resident had been blind and hard of hearing for some time and was dependent on staff for activities of daily living since the death of their spouse. The MDS Coordinator, responsible for the assessments, admitted to not being aware of the resident's true condition and acknowledged the oversight in the assessments. The Director of Nursing (DON) and a family member corroborated the resident's condition, confirming the resident's blindness and hearing difficulties. The family member expressed concerns about the facility's failure to accommodate the resident's health status changes, which contributed to a significant weight loss and hospitalization. The report highlights the importance of accurate assessments to ensure appropriate care plans and assistance levels for residents.
Failure to Complete PASRR Level 2 Evaluations for Residents with Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation for three residents who displayed behavioral activity or had a psychiatric diagnosis. Resident 99 was admitted with diagnoses including psychosis and bipolar disorder, but the PASRR Level 1 used for admission did not reflect these diagnoses. Observations and nursing progress notes documented Resident 99's combative and aggressive behavior, refusal of medications, and episodes of delusions and confusion, indicating a need for a PASRR Level 2 evaluation. Resident 135 was admitted with diagnoses including bipolar disorder and schizophrenia, but the PASRR Level 1 used for admission only documented dementia and Alzheimer's. The resident exhibited behaviors such as exit-seeking and inappropriate interactions with other residents. The Director of Social Services was unaware that a PASRR Level 2 was required for residents with psychiatric diagnoses and behavioral issues, and the facility lacked a PASRR policy. Resident 72 was readmitted with multiple psychiatric diagnoses, including schizophrenia and dementia with psychotic disturbance. Despite displaying delusional behavior and expressing concerns about an impersonator, there was no documented evidence of a PASRR Level 2 screening. The Social Services Director acknowledged that the PASRR Level 2 process should have been initiated. The facility's policy stated that new or changed behaviors indicating a serious mental disorder should be referred for a PASRR Level 2 evaluation, but this was not done for Resident 72.
Deficiency in Comprehensive Care Plans for Sleep Apnea Devices
Penalty
Summary
The facility failed to ensure comprehensive care plans were created for the management of sleep apnea devices for two residents. Resident 64, who was admitted with diagnoses including an open wound on the lower back and hemiplegia after a cerebral infarction, used a CPAP machine at night to aid breathing. However, there was no documented evidence in the physician and nursing progress notes that the resident was using the CPAP machine, nor was there a comprehensive care plan for its use, care, and maintenance. Similarly, Resident 390, admitted with obstructive sleep apnea and amyotrophic lateral sclerosis, used a BiPAP machine at night. Although the care plan documented the medical diagnosis and the use of the BiPAP machine, it lacked any care interventions, leaving the space allotted for them blank. The Director of Nursing confirmed the absence of care interventions in Resident 390's care plan and the lack of a care plan for Resident 64's CPAP machine, acknowledging that care plans are required to ensure individualized care provisions.
Failure to Provide Adequate Pressure Ulcer Care for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care for a high-risk resident, identified as R52, who developed a deep tissue injury (DTI) on the left heel. R52 was admitted with multiple diagnoses, including diabetes mellitus and dysphagia, and was assessed as high risk for pressure sores with a Braden Scale score of 10. Despite the care plan outlining necessary interventions such as turning, repositioning, and using pressure-reducing devices, these measures were not consistently implemented. The resident's medical records lacked evidence of regular skin assessments and appropriate treatment for the DTI. On a specific date, R52 complained of heel pain, and an LPN confirmed the presence of a DTI, which appeared to be several weeks old. The wound care treatment nurse noted that the injury had not been previously addressed, and the necessary offloading techniques were not applied. The CNA responsible for R52's care reported observing skin discoloration weeks earlier but did not ensure the information was properly documented or acted upon. The facility's policy required skin assessments twice a week, but records showed only one assessment was completed in September. The facility's failure to adhere to its policies and procedures for skin monitoring and pressure ulcer care resulted in the DTI going untreated for an extended period. The lack of documentation and communication among staff members contributed to the oversight, as the LPN and clinical care coordinator were unaware of the resident's condition until it was too late. This deficiency highlights a breakdown in the facility's processes for identifying and managing pressure injuries in high-risk residents.
Failure to Assist Blind Resident with Meals Leads to Weight Loss and Hospitalization
Penalty
Summary
The facility failed to provide adequate assistance with food and fluids to a resident who was clinically blind, leading to significant weight loss and hospitalization. The resident, who had chronic vision and hearing loss, was observed with an untouched breakfast tray and expressed the need for help with meals due to blindness. Despite the resident's condition, the meal ticket did not reflect the need for full assistance, and the CNA assigned was not informed of the requirement for one-on-one feeding assistance. The interdisciplinary team had discussed the resident's weight loss and added supplements to the diet, but the need for feeding assistance was not addressed. The resident's medical records inaccurately documented adequate vision and hearing, which contributed to the lack of appropriate care. The speech therapy evaluation recommended feeding assistance due to the risk of aspiration and malnutrition, but this was not communicated to the team or reflected in the resident's care plan. The Director of Nursing acknowledged the oversight and confirmed that the resident's significant weight loss was not adequately addressed. The dietary team failed to communicate the resident's needs during weekly meetings, and the resident's family was not involved in care plan discussions. The resident was eventually sent to the hospital for dehydration and weakness, highlighting the facility's failure to provide necessary assistance and hydration.
Failure to Obtain Physician Orders for PEG Tube Care
Penalty
Summary
The facility failed to ensure that physician orders for bolus tube feeding, water flushes, and gastrostomy tube care were obtained for a resident with a PEG tube. The resident, who was admitted with diagnoses including dementia, diabetes mellitus, urinary tract infection, dysphagia, and gastrostomy, was observed with an unopened Glucerna tube feeding bottle labeled with an outdated date. The resident's medical records lacked documented evidence of physician orders for bolus feeding, water flushing, placement verification, and PEG tube site care or monitoring. The LPN and Clinical Care Coordinator confirmed that the bolus feeding was intended only if the resident's meal intake was less than 75%, and the resident was on a soft mechanical diet, consuming more than 75% of meals. However, the necessary physician orders for administering the bolus feeding and managing the PEG tube were not obtained. The facility had transitioned to a new electronic health record system, and the Clinical Care Coordinator was responsible for ensuring the necessary orders were in place, but this was not done. The facility's policy required checking the tube's position before each feeding and medication administration, which was not adhered to in this case.
Deficient PICC Line Management in Resident Care
Penalty
Summary
The facility failed to ensure proper care and management of a peripherally inserted central catheter (PICC) line for a resident, leading to a risk of infection. The resident was admitted with a urinary tract infection and had a PICC line inserted for antibiotic therapy. However, the medical record lacked documented evidence of care orders for the PICC line, such as site monitoring, flushes, and dressing changes, since its insertion. The last dose of the prescribed antibiotic was administered, but there was no follow-up with the physician regarding the stop date for the antibiotic therapy or instructions on whether to maintain or discontinue the PICC line. Observations revealed that the PICC line was not properly managed, with a gauze pad covering the insertion site, which should not have been there, as it prevented nurses from monitoring the site every shift. The Director of Nursing confirmed the absence of care orders and acknowledged that the lack of routine PICC line care placed the resident at risk for another infection. The Nurse Practitioner was unaware of the absence of care orders and indicated that they had not been contacted by the facility regarding the resident's antibiotic therapy, which could have led to further testing and appropriate management of the PICC line.
Failure to Obtain Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to obtain physician orders for the administration and monitoring of oxygen (O2) for Resident 155, who was admitted with diagnoses including pneumonia, respiratory tuberculosis, and dependence on supplemental O2. Observations revealed that Resident 155 was receiving O2 at 5 liters per minute via nasal cannula without documented physician orders or O2 saturation monitoring. A Licensed Practical Nurse confirmed the absence of necessary orders and monitoring, and the Clinical Care Coordinator acknowledged the requirement for such orders to prevent potential risks associated with improper O2 administration. Additionally, the facility did not secure a physician's order for the use of a CPAP machine for Resident 64, who was admitted with conditions including an open wound and hemiplegia after cerebral infarction. Resident 64 self-managed the CPAP machine brought from home, but there was no documented evidence of a physician's order or care plan for its use. The Director of Nursing confirmed that a physician's order was necessary for CPAP use, which would generate a care and maintenance order set in the electronic healthcare records.
Failure to Complete Annual Performance Appraisals for CNAs
Penalty
Summary
The facility failed to complete annual performance appraisals for four certified nursing assistants (CNAs), identified as Employees 6, 7, 9, and 10, which placed residents at risk for receiving substandard quality of care. Employee 6, hired in June 2022, and Employee 7, hired in July 2022, did not have performance evaluations for 2023 and 2024. Employee 9, hired in August 2021, lacked evaluations for 2022, 2023, and 2024, while Employee 10, hired in November 2021, was missing evaluations for 2022 and 2023. The Human Resources (HR) Coordinator confirmed the absence of these evaluations and explained the process involved the Director of Nursing (DON) completing the forms, which were then to be returned to HR. The DON acknowledged responsibility for completing the appraisals, a task previously shared with a former Staff Development Coordinator (SDC). The DON indicated that the forms might not have been completed due to an assumption that the other party had done so. The Administrator was unaware of the missing appraisals and emphasized their importance for discussing areas of improvement and ensuring quality care. The facility's appraisal form, dated 2007, highlighted the significance of these evaluations as feedback tools, with a process in place for managers to gather information and discuss performance with staff prior to filing the completed forms.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, which posed a potential risk to resident safety and health standards. Observations revealed that scrambled egg patties in the walk-in cooler were not labeled or dated, and corn muffin mixes in the dry storage area had expired. Additionally, previously baked pies and scooped ice cream in the freezer were unlabeled and undated. These lapses in labeling and dating could lead to contamination and inadequate storage of food items. During meal service, an uncovered plate of food was mistakenly served to a resident with the incorrect food texture. The plate was returned to the steam table and later served to another resident, contrary to safe food handling practices. The unit one refrigerator was also found to be operating at temperatures above the recommended range, potentially compromising the safety of stored items such as milk, juice, yogurt, and salads. These deficiencies highlight the facility's failure to adhere to professional standards for food storage and handling.
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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