South Lyon Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Yerington, Nevada.
- Location
- 213 Whitacre St, Yerington, Nevada 89447
- CMS Provider Number
- 295011
- Inspections on file
- 19
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at South Lyon Medical Center during CMS and state inspections, most recent first.
The facility did not employ a qualified Infection Preventionist for several months, resulting in a lack of oversight for infection prevention, antibiotic stewardship, immunization, education, and infection control surveillance. Payroll records and staff interviews confirmed the absence of an IP, and other certified staff did not fulfill the IP role during this period.
A resident with intellectual disabilities and dementia, who was prone to scratching and picking at their skin, did not receive consistent care to address these behaviors. Although interventions such as hydroxyzine and geri sleeves were ordered, staff relied on observing the resident's actions to administer PRN medication, despite the resident's inability to request it. Ongoing skin injuries and bleeding were documented, and staff expressed uncertainty about the appropriateness of PRN orders for this resident.
A resident in need of pain management did not receive safe and appropriate pain management services as required.
A resident requiring hemodialysis did not have a documented physician's order for dialysis, and the facility lacked both a written contract with the dialysis provider and a dialysis care policy. Communication tools between the facility and the dialysis center were often incomplete, and staff interviews revealed uncertainty about responsibilities for monitoring and care, leading to uncoordinated dialysis services.
The facility did not have a full-time DON, as the interim DON split time between the hospital and LTC, dedicating only a small portion of hours to the LTC facility. This resulted in insufficient DON oversight for all residents during the period reviewed.
A resident with chronic respiratory failure and COPD was ordered to receive oxygen at three LPM as needed, but was repeatedly administered oxygen at two LPM according to documentation and direct observation. The resident reported ongoing shortness of breath and did not adjust the oxygen flow independently. An LPN and the DON confirmed the absence of an order for titration and acknowledged the importance of administering medications, including oxygen, at the prescribed dose.
Surveyors found that the Facility Assessment did not include nicotine dependence or addiction among the common diagnoses, despite five residents being current smokers and a designated smoking area in use. The Interim DON confirmed that the FA lacked documentation of residents with substance use disorders, contrary to facility policy and CDC guidance.
A resident with chronic respiratory failure and COPD received oxygen therapy as ordered, but staff failed to document its administration in the MAR over a three-month period. Observations and interviews confirmed the resident wore oxygen regularly, and both an LPN and the DON acknowledged that oxygen was administered but not recorded in the EHR, contrary to facility policy.
The QAPI committee did not identify or address a lapse in tracking and trending infections and antibiotic use within the Antibiotic Stewardship Program after the facility ceased infection prevention monitoring due to not having an Infection Preventionist on staff. This failure was contrary to facility policy, which required ongoing monitoring of medication management and infection prevention.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not maintain or document an Antibiotic Stewardship Program, including tracking and trending of infections and antibiotic use, for an extended period. The IP and interim DON confirmed that while some monitoring occurred, no records were kept as required by facility policy.
The facility did not effectively implement infection control protocols during a COVID-19 outbreak, resulting in 16 staff and 16 residents testing positive. Despite having the ability to isolate COVID-positive residents, leadership failed to enforce isolation, allowing infected residents to mingle with others, including in the dining room. Staff initially used surgical masks and later switched to N95s as the outbreak grew. Confusion among leadership regarding testing and quarantine policies further contributed to the spread, and at least one resident was hospitalized and died during the outbreak.
A COVID-19 outbreak occurred after the facility failed to follow CDC guidance and its own infection control policies, resulting in widespread transmission among staff and residents. Employees with symptoms continued to work, documentation of testing and return-to-work was incomplete, and isolation protocols were not enforced, allowing COVID-positive residents to intermingle with others. One resident with multiple comorbidities developed severe symptoms, was hospitalized, and died.
A resident with multiple chronic conditions was left uncovered and without a brief by a CNA, as observed and reported by an OA. The incident was not reported to the State Agency within the required timeframe, as facility staff delayed internal reporting and subsequent submission of the Facility Reported Incident.
The facility failed to properly administer its influenza and pneumonia vaccination programs, resulting in substandard care. Residents were not screened for vaccine eligibility, nor were they provided with education about the vaccines, preventing informed decision-making. Some residents received vaccines without proper consent, and one resident received a vaccine not approved for their age. The facility's policies were outdated and not followed, contributing to the deficiency.
The facility's Antibiotic Stewardship Program (ASP) was found lacking in essential components, including protocols for prescribing antibiotics and periodic review processes. Education on the ASP was not provided to staff or residents, and the Infection Preventionist (IP) did not effectively monitor or communicate antibiotic use. These deficiencies were confirmed by the Director of Nursing and the IP, highlighting significant gaps in the facility's antibiotic management practices.
The facility's Infection Preventionist (IP) did not complete the required training, failed to provide education on the Antibiotic Stewardship Program (ASP), and did not conduct antibiotic time outs. Additionally, the facility lacked processes for screening and educating residents on vaccines, and the IP did not communicate with prescribing providers, affecting 27 residents.
The facility failed to screen 26 residents for eligibility and provide education on influenza and pneumonia vaccinations, resulting in substandard care. Many residents either declined or received vaccines without proper documentation of screening, education, or consent. The facility's policies were outdated and not aligned with current CDC guidelines.
The facility failed to review its Infection Control and Prevention Plan annually and did not implement Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices. The IPCP was outdated and lacked essential elements, while EBP measures were not observed during an inspection, despite policy requirements for PPE and hand hygiene products.
The facility did not ensure that contact information for State agencies and advocacy groups was posted in a language understandable to all residents. A resident who only spoke Spanish was unaware of where this information was located. The DON confirmed that the postings were not in a language understandable to this resident, despite the facility's policy stating that communication should be in a format and language the resident understands.
A resident with adjustment disorder and anxiety was verbally abused and harassed by another resident with dementia in an LTC facility. Despite complaints and staff witnessing the abuse, the facility failed to protect the resident, as the DON did not initially consider the behavior abusive due to the perpetrator's mental state. The facility's abuse prevention policy was not effectively enforced.
A resident with adjustment disorder and anxiety reported being verbally abused and harassed by another resident with dementia. The accused resident made derogatory comments and accusations of theft. Despite acknowledging the incident as verbal abuse, the DON did not report it to the State Agency, violating the facility's abuse prevention policy.
The facility failed to ensure timely physician visits for three residents, resulting in missed visits during required periods. A resident with traumatic subarachnoid hemorrhage and dementia missed a visit in June, another with diabetes and kidney disease missed a visit in April, and a third with COPD and diabetes missed a visit in March. The DON confirmed these lapses.
The facility did not complete an annual performance evaluation for a CNA hired over a year ago, as required by their policy. The CNA's personnel record lacked documentation of the evaluation, which was confirmed by the HR Supervisor.
A facility failed to ensure a Morphine oral suspension bottle had a measuring guide, hindering accurate reconciliation of controlled substances. The DON confirmed the absence of the guide during a medication cart inspection, and the pharmacist verified this deficiency. The resident involved had multiple diagnoses, including dementia and chronic pain syndrome, with a physician's order for Morphine. Discrepancies in the Controlled Drug Record and the actual bottle content were noted, suggesting potential issues with medication reconciliation.
A resident was administered Buspirone three times daily for anxiety-related behaviors without having a diagnosis of anxiety, contrary to the facility's policy. The DON confirmed the lack of a proper indication for the medication, which was prescribed for behaviors such as yelling and throwing items.
A resident's medication, Norco, was improperly repackaged by nursing staff into plastic envelopes with inadequate labeling, contrary to the facility's policy. The facility's policy lacked guidance on necessary label information, contributing to the deficiency.
A resident with specific dietary dislikes was not provided with a vegetable substitute of equal nutritional value during a meal. Despite the resident's documented dislike for Brussels sprouts, mashed potatoes were served instead, which were not nutritionally comparable. The RD confirmed the inadequacy of the substitution.
A resident with documented dislikes for certain vegetables was served carrots despite their preferences being noted. The facility's dietary staff, including the Dietary Manager and RD, acknowledged that disliked items should not be served, yet the resident received a meal containing carrots, which they refused to eat.
The QAPI committee failed to identify deficiencies in vaccination protocols and infection control. The facility lacked processes for screening and educating residents about pneumococcal and influenza vaccines, and consents were not obtained for new flu vaccines. The Infection Preventionist had not completed required training, and the facility's IPCP and ASP policies were outdated and incomplete. The QAPI committee was unaware of these issues until highlighted by the State Agency.
The facility failed to ensure a CNA and a resident were screened for COVID-19 booster vaccine eligibility, provided with education, and given the opportunity to make informed decisions about vaccination. The DON confirmed the facility was not tracking staff vaccination status and only provided education when new vaccines were available or during clinics.
The facility failed to ensure that a Registered Dietician completed required communication training. Despite a policy mandating annual training, the employee's record lacked documentation of such training. The Human Resources Supervisor confirmed the oversight, noting that all staff were required to complete the training within 30 days of hire and annually.
The facility did not ensure that a Registered Dietician completed the required resident rights training, as confirmed by the Human Resources Supervisor. The facility policy mandates this training within 30 days of hire and annually, but the employee's record lacked evidence of completion.
The facility failed to ensure timely elder abuse training for several employees, including a Registered Dietician, CNAs, an LPN, an RN, a Hospitality Aide, and a Housekeeper. The training was either not completed within 30 days of hire or was missing altogether, as confirmed by the Human Resources Supervisor. The facility's policy lacked a requirement for abuse training upon orientation.
The facility did not ensure that a Registered Dietician, hired in 2003, completed the required Quality Assurance Performance Improvement (QAPI) training. The Human Resources Supervisor confirmed the absence of documented QAPI training for this employee, despite the facility's policy requiring such training within 30 days of hire and annually thereafter.
A Registered Dietician at the facility, hired in 2003, lacked documented evidence of completing required infection control training. The facility's policy mandates annual training for all healthcare personnel, but the Human Resources Supervisor confirmed the dietician had not completed it, highlighting a lapse in the infection prevention and control program.
The facility failed to ensure timely completion of compliance and ethics training for an employee. A Registered Dietician, hired in 2003, lacked documented evidence of completing the required training. The HR Supervisor confirmed that all staff must complete this training within 30 days of hire and annually, but this was not done for the employee. The facility's policy mandates annual compliance and ethics education.
The facility did not ensure timely completion of behavioral health training for an employee hired as a Registered Dietician. The employee's record lacked evidence of the required training, which should have been completed within 30 days of hire and annually, as per facility policy.
Failure to Employ Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was employed at least part time each month from late December 2024 to mid-May 2025. Payroll records confirmed that the previous IP's last day was 12/26/2024, and the next IP did not begin until 05/12/2025. During interviews, the Human Resource Manager verified that no other individual worked as an IP during this period. Although the CEO stated that two other employees held IP certification, it was confirmed that neither performed the duties of the IP, including oversight of the Antibiotic Stewardship Program, immunization, staff and resident education, or infection control surveillance. The interim Director of Nursing also confirmed that there was no IP in place during this time frame, resulting in a lack of oversight for the facility's Infection Prevention and Control Program and Antibiotic Stewardship Program. The absence of an IP was identified through document review and staff interviews, and the deficiency was cross-referenced with F881.
Failure to Provide Necessary Care for Resident with Intellectual Disabilities and Skin Picking
Penalty
Summary
A resident with a history of traumatic subarachnoid hemorrhage, mild intellectual disabilities, and unspecified dementia with agitation was not provided with adequate care and services to address persistent scratching and picking at their arms and legs. The resident's care plan acknowledged communication challenges and included interventions for skin picking, such as the use of hydroxyzine and physical barriers like geri sleeves. Physician orders specified washing and applying lotion to the arms, using geri sleeves or tubi grip, and administering hydroxyzine as needed for itching and skin picking. Despite these interventions, clinical records and observations documented ongoing open areas, scratch marks, and active bleeding on the resident's extremities. Staff interviews revealed that the resident lacked the cognitive ability to request PRN (as needed) medications, and nursing staff administered hydroxyzine only when they observed scratching behavior. Both the LPN and RN confirmed uncertainty about why the medication was ordered as PRN rather than scheduled, given the resident's inability to communicate their needs. The facility's policy required individualized care for residents with intellectual disabilities, but the care provided did not ensure consistent management of the resident's skin picking behavior, resulting in preventable discomfort and risk of skin breakdown.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Lack of Coordination and Policy for Dialysis Care
Penalty
Summary
The facility failed to ensure proper coordination of care for a resident requiring hemodialysis, as evidenced by the absence of a written contract or agreement with the dialysis provider, lack of a facility dialysis policy, and incomplete documentation of dialysis care. The resident, who had end stage renal disease and was dependent on renal dialysis, did not have a physician's order for hemodialysis documented in the clinical record. Additionally, the Dialysis and Nursing Home Handoff Communication Tool forms were found to be incomplete on multiple occasions, with missing documentation from the dialysis center. Interviews with facility staff, including an LPN, the DON, and the CEO, revealed uncertainty regarding staff responsibilities for dialysis care, monitoring of the fistula site, and review of communication forms from the dialysis center. The DON confirmed the absence of a contract with the dialysis center and a facility dialysis policy, while the CEO expressed uncertainty about what was expected of nursing staff in caring for residents on dialysis and acknowledged that staff may not be reviewing the handoff communication forms. These actions and inactions resulted in uncoordinated and unmonitored care for the resident receiving dialysis.
Failure to Maintain Full-Time Director of Nursing Coverage
Penalty
Summary
The facility failed to ensure the presence of a full-time Director of Nursing (DON) as required. During the survey, it was found that the current Chief Nursing Officer (CNO) was acting as the interim DON, but was only present in the facility for 32 hours per week according to the staffing schedule. Further, the DON confirmed working a total of 40 hours per week, but only 20% of that time, or approximately eight hours per week, was dedicated to the long-term care facility, with the remainder spent working for the hospital. The facility assessment indicated a DON was required, but the actual hours worked in the LTC facility did not meet the full-time requirement. This deficiency affected all 27 residents residing in the facility on the date in question.
Failure to Administer Oxygen at Prescribed Dose
Penalty
Summary
A resident with chronic respiratory failure and chronic obstructive pulmonary disease was admitted to the facility with a physician's order for oxygen via nasal cannula at three liters per minute (LPM) as needed for shortness of breath, with the option to remove if breathing was comfortable. Despite this order, multiple entries in the Oxygen Saturations Summary Report documented that the resident received oxygen at two LPM on several occasions. Observations confirmed that the resident's oxygen concentrator was set to two LPM during multiple checks, and the resident reported wearing oxygen continuously and experiencing difficulty breathing. The resident also stated that they did not adjust the oxygen flow themselves and relied on facility staff for administration. Interviews with an LPN and the Interim Director of Nursing (DON) confirmed that the clinical record did not include an order for oxygen titration and that the expectation was for medications, including oxygen, to be administered at the correct dose as prescribed. The DON acknowledged that administering oxygen at an incorrect dose constituted a medication error. Facility policy required nurses to ensure the right dose when administering medications. The deficiency was identified through observation, interview, and record review, showing that the resident did not consistently receive oxygen at the prescribed rate.
Facility Assessment Lacked Documentation of Nicotine Dependence and Substance Use Disorders
Penalty
Summary
The facility failed to ensure that its Facility Assessment (FA) accurately reflected the needs of its resident population, specifically by omitting nicotine dependence and addiction from the list of common diagnoses and conditions. During the survey, it was found that five residents were current cigarette smokers, and the designated smoking area was located off the outside patio accessed through the dining room. The FA, last reviewed in March 2025, did not include nicotine abuse or addiction, nor did it document the number of residents with active or current substance use disorders. This omission was confirmed by the Interim DON, who acknowledged that nicotine addiction was not identified as a diagnosis in the FA and that the number of residents with substance use disorders was not documented. The facility's policy required the FA to include the care required by the resident population, considering the types of diseases and other pertinent facts present within the population. However, the FA did not meet this requirement, as it lacked documentation of residents with nicotine dependence or other substance use disorders. The surveyors referenced CDC guidance that classifies tobacco (nicotine) use as a substance use disorder, further highlighting the deficiency in the facility's assessment process.
Failure to Document Oxygen Administration in MAR
Penalty
Summary
The facility failed to document the administration of oxygen therapy for a resident with chronic respiratory failure and chronic obstructive pulmonary disease, as required by physician orders and facility policy. Although the resident had a physician's order for oxygen via nasal cannula at three liters per minute as needed for shortness of breath, the medication administration records (MARs) for May, June, and July did not contain any documentation of oxygen administration. Observations showed the resident wearing oxygen via nasal cannula on multiple occasions, with the oxygen concentrator set to two liters per minute. The resident reported wearing oxygen continuously and stated that all oxygen was administered by facility staff. Interviews with an LPN and the interim DON confirmed that oxygen was being administered but not documented in the electronic health record. The DON acknowledged that oxygen is considered a medication and should be documented on the MAR at the time of administration, in accordance with facility policy. The lack of documentation was confirmed by both the LPN and the DON, who stated that there was no record of oxygen administration for the resident during the three-month period reviewed.
Failure to Track Infections and Antibiotic Use in QAPI/ASP
Penalty
Summary
The facility's QAPI committee failed to identify and address a lapse in tracking and trending infections and antibiotic use as part of the Antibiotic Stewardship Program (ASP). According to interviews and document review, the facility stopped monitoring infection prevention and control from August 2024 through May 2025 due to the absence of an Infection Preventionist on staff. As a result, the QAPI committee did not recognize or act upon the lack of antibiotic stewardship tracking for resident antibiotics. Facility policy required the performance improvement plan to monitor systems of care, including medication management and infection prevention and control, but these measures were not followed during the specified period.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Document and Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an Antibiotic Stewardship Program (ASP) that included the tracking and trending of infections and antibiotic use from August 2024 through May 30, 2025. During a survey, the facility was unable to provide documented evidence of an ASP for this period. The Infection Preventionist (IP) confirmed that while infections and antibiotic use were monitored for trends, no documentation of these findings was maintained. The IP began employment at the facility on May 12, 2025, and only started documenting tracking and trending of infections and antibiotic use on May 30, 2025. The interim Director of Nursing (DON) also confirmed the absence of documented evidence for the ASP, including tracking and trending activities during the specified period. According to the facility's policy, the ASP should have included proactive monitoring of antimicrobial prescriptions, record-keeping of antibiotic use, and monthly documentation of all infections. However, these procedures were not followed or documented as required, resulting in the deficiency.
Failure to Implement Effective COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to ensure effective administration and implementation of infection control protocols in accordance with CDC guidance, resulting in a widespread COVID-19 outbreak among both staff and residents. Documentation showed that 16 employees and 16 out of 22 residents tested positive for COVID-19 during the outbreak period. The Chief Nursing Officer (CNO) confirmed that although the facility had designated isolation rooms that could be separated by fire doors, these were not utilized due to the interim Director of Nursing (DON) refusing to implement isolation measures. The CNO acknowledged having the authority to direct the DON but failed to enforce the isolation of COVID-positive residents, allowing them to intermingle with others, including in the dining room, which contributed to the spread of the virus. Staff initially used surgical masks for source control, but as the outbreak worsened, they switched to N95 respirators. The Infection Preventionist agreed with the initial use of surgical masks, but the decision to switch to N95s was made after further discussion. The Medical Director noted confusion and lack of clarity in the facility's COVID testing and quarantine policies, with ongoing debate among leadership about testing frequency and isolation procedures. Testing was conducted every 48 hours for a period, and at least one resident was hospitalized and subsequently died during the outbreak. The CNO stated that CDC guidance was followed, but the failure to isolate COVID-positive residents and unclear policies contributed to the outbreak.
Failure to Implement and Document COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to ensure that CDC guidance and its own Infection Prevention and Control Plan (IPCP) were followed in the management of a COVID-19 outbreak, resulting in 16 employees and 16 out of 22 residents becoming infected. Documentation revealed that employees who tested positive for COVID-19 were not consistently tracked regarding additional testing or return-to-work dates, and the facility's tracking spreadsheets lacked critical information. Staff with symptoms continued to work while symptomatic, and there was inconsistent use of appropriate source control, with surgical masks being used initially and N95 respirators only adopted as the outbreak worsened. The facility's leadership, including the Chief Nursing Officer (CNO) and interim Director of Nursing (DON), failed to enforce isolation protocols and did not utilize available isolation pods, allowing COVID-positive residents to intermingle with others, including in communal dining areas. Interviews with facility leadership confirmed that, despite available policies and CDC guidance, there was confusion and debate about testing frequency and quarantine procedures. The CNO acknowledged that the DON, who was a subordinate, refused to implement isolation measures, and the CNO did not override this decision, resulting in COVID-positive residents not being separated from others. The Medical Director also noted that the facility's policies were unclear regarding when to stop testing, contributing to inconsistent practices during the outbreak. Staff and residents were tested every other day, but the documentation did not always reflect adherence to recommended testing intervals or return-to-work criteria. Several residents with significant comorbidities, such as dementia, COPD, diabetes, and heart failure, contracted COVID-19 during the outbreak. One resident, who had multiple complex medical conditions including quadriplegia, hydrocephalus, and respiratory failure, developed severe COVID-19 symptoms, was transferred to an acute care hospital, and subsequently died. The facility's failure to implement and document appropriate infection prevention and control measures, including isolation, source control, and testing protocols, directly contributed to the widespread transmission of COVID-19 among both staff and residents.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of neglect and abuse involving a resident was reported to the State Agency (SA) within the required timeframe. The incident involved a resident with diagnoses including type two diabetes mellitus with diabetic polyneuropathy and chronic obstructive pulmonary disease. On the evening of the incident, an Observation Aide (OA) observed the resident uncovered from the waist down and without a brief after the resident had called for help and reported that a CNA had left the resident in that state. The OA was informed of the incident by the resident and subsequently reported it to the Director of Nursing Secretary (DON Secretary) three days later. According to facility policy, any person identifying signs of abuse or neglect must immediately report to the charge nurse, who then notifies the DON and Chief Risk Officer, with the DON or Chief Risk Officer responsible for reporting to the SA within 24 hours. In this case, the DON Secretary reported the allegation to the Chief Nursing Officer (CNO) on the same day it was received from the OA, as there was no DON at the time. However, the Facility Reported Incident (FRI) was not submitted to the SA until five days after the alleged incident occurred, resulting in a failure to meet the required reporting timeframe.
Deficiency in Vaccination Program Administration
Penalty
Summary
The facility failed to effectively administer its influenza and pneumonia vaccination programs, resulting in substandard quality of care. The facility did not screen 23 out of 26 residents for eligibility to receive the influenza vaccine, nor did it provide education about the risks and benefits of the vaccine to the residents or their representatives. This lack of documentation and education prevented residents from making informed decisions about receiving the vaccine. Additionally, some residents were administered the flu vaccine without proper screening or consent, and one resident received a vaccine not approved for their age group. Similarly, the facility did not screen any of the 26 residents for eligibility to receive the pneumonia vaccine, nor did it provide education about the vaccine to the residents or their representatives. Thirteen residents declined the pneumonia vaccine without documented evidence of being screened or educated, and seven residents received the vaccine without proper screening or education. The facility's policy on pneumococcal vaccination was outdated, lacking current CDC guidance, which contributed to the deficiency. The facility's policies for both influenza and pneumonia vaccinations were not followed, as evidenced by the lack of documentation for screening, education, and consent. The influenza vaccination policy was revised in December 2023, but it was not effectively implemented. The pneumonia vaccination policy, last revised in 2017, was based on outdated CDC recommendations, further exacerbating the issue. These failures in policy implementation and adherence led to residents not being able to make informed decisions about their vaccinations, putting them at risk of adverse reactions.
Deficiencies in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to ensure the proper implementation and review of its Antibiotic Stewardship Program (ASP) policy. The policy, revised in October 2023, lacked essential components such as protocols for prescribing antibiotics, documentation of indication, dosage, and duration, and a process for periodic review of antibiotic use by prescribing practitioners. Additionally, there was no system for providing feedback reports on antibiotic use and resistance patterns. The Director of Nursing confirmed these deficiencies, highlighting the absence of a structured approach to antibiotic management. The facility also did not provide education related to the ASP to staff and residents. The Infection Preventionist (IP) confirmed that no education was provided because the IP was not clinical. Despite the policy stating that education should be provided, there was no documented evidence of such training. This lack of education contributed to the facility's inability to effectively manage antibiotic use and ensure compliance with the ASP. Furthermore, the facility's process for monitoring antibiotic use was inadequate. The IP did not review residents' antibiotic use upon admission, relying instead on a pharmacist who visited only once a month. The IP was not informed of new infections or cultures sent to the lab until results were returned, and an antibiotic time out was not performed. The IP also did not communicate with prescribing providers regarding antibiotic usage or prescribing habits, as the IP was not involved in clinical decision-making. These gaps in communication and monitoring processes further exacerbated the facility's failure to adhere to the ASP guidelines.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) completed the required specialized training course. The IP had not completed all the necessary modules of the Centers for Disease Control and Prevention (CDC) Infection Preventionist Training Course, lacking the full 19.75 Continuing Education Units (CEUs) required for course completion. Despite this, the IP had been working in the role without having completed an approved specialized training course, as confirmed by the Director of Nursing (DON). The facility also did not provide documented evidence of education related to the Antibiotic Stewardship Program (ASP) to the staff. The IP was responsible for providing such education but failed to do so. Additionally, the IP did not conduct or understand the process of an antibiotic time out, which is crucial for reassessing antimicrobial prescriptions. The IP relied on the pharmacist, who was only present once a month, for reviewing antibiotic use, and did not track isolation needs or changes in medications. Furthermore, the facility lacked a process for screening and educating residents about influenza and pneumonia vaccines. The DON confirmed that no residents had been screened for vaccine eligibility or provided with education on the risks and benefits of the vaccines. The IP was not involved in the vaccination process and did not communicate with prescribing providers, as the IP was not clinical. This lack of communication and process potentially affected the entire census of 27 residents.
Failure to Screen and Educate Residents on Vaccinations
Penalty
Summary
The facility failed to ensure that 26 out of 27 residents were screened for eligibility to receive influenza and pneumonia vaccinations, and did not provide education related to these vaccines. This resulted in substandard quality of care. The report highlights that the facility lacked documented evidence of screening and education for the influenza vaccine for 23 residents, and for the pneumonia vaccine for all 26 residents. The Director of Nursing confirmed the absence of a process for screening and educating residents about these vaccines. Several residents either declined or received the influenza vaccine without proper documentation of eligibility screening, education, or consent. For instance, eight residents declined the flu vaccine without documented evidence of being informed about the vaccine, while others received the vaccine without proper consent or education. One resident was administered a flu vaccine that was not approved for their age group, using a hospital consent form that was improperly filled out. Similarly, the facility failed to document eligibility screening, education, and consent for the pneumonia vaccine for all 26 residents. Some residents declined the vaccine without documented evidence of being informed, while others had signed consents but lacked documentation of screening and education. The facility's policies on vaccinations were outdated and did not align with current CDC guidelines, further contributing to the deficiency.
Infection Control and EBP Deficiencies
Penalty
Summary
The facility failed to ensure that its Infection Control and Prevention Plan (IPCP) was reviewed annually and appropriately tailored to the long-term care setting. The IPCP policy was last reviewed in October 2022, and the facility could not provide evidence of any subsequent review or revision. The policy incorrectly referred to the hospital's IPCP and included duties for hospital staff, lacking specific language for the long-term care facility. Additionally, the IPCP was missing critical elements such as a list of reportable communicable diseases, a process for reporting to state agencies, and guidelines for prohibiting employees with communicable diseases from direct contact with residents. It also lacked procedures for communication during resident transfers and receipt of pertinent notes upon return from other facilities. The facility also failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices. Both residents had medical conditions requiring such precautions, but the facility did not initiate or implement EBP for them. During an inspection, it was observed that Transmission-Based Precautions, including EBP, were not in place for any resident rooms. The facility's policy on EBP, revised in July 2024, required staff training on personal protective equipment (PPE) and the availability of PPE and hand hygiene products at the point of care, but these measures were not observed to be in practice.
Failure to Provide Multilingual Contact Information
Penalty
Summary
The facility failed to ensure that the contact information for pertinent State agencies and advocacy groups was posted in a language understandable to all residents. During a Resident Council Interview, a resident who only read and spoke Spanish expressed, through a translator device, that they were unaware of where this information was located. The Director of Nursing confirmed that none of the postings were understandable for residents who only read and spoke Spanish. The facility's policy on Resident Communication Rights, revised in July 2015, states that residents have the right to receive communication in a format and language they understand.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse and harassment by another resident. Resident #16, who was admitted with diagnoses including adjustment disorder with anxiety and chronic obstructive pulmonary disease, reported being harassed and called derogatory names by Resident #15. Resident #15, who has unspecified dementia and other mental health issues, accused Resident #16 of stealing a picture and used slurs against them, knowing it was offensive. Despite Resident #16's complaints to the Director of Nursing (DON), the issue persisted, and the DON advised Resident #16 to try to get along with Resident #15 due to their mental state. Multiple staff members, including an Observation Aide and Activity Aides, witnessed the verbal abuse and harassment. They reported incidents where Resident #15 accused Resident #16 of theft and used derogatory language, including slurs related to sexual orientation. Staff attempted to redirect Resident #15, but the behavior continued. The DON was aware of the situation but did not initially consider it abuse due to Resident #15's dementia. Documentation, including a Communication Note and a Patient Grievance Form, detailed incidents where Resident #15 entered Resident #16's room, made accusations, and used offensive language. The facility's policy on abuse prevention, revised in May 2023, states that residents should be free from abuse by other residents. However, the facility did not effectively address the ongoing harassment and verbal abuse experienced by Resident #16.
Failure to Report and Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report and investigate an allegation of resident-to-resident verbal abuse and harassment involving Resident #16. Resident #16, who was admitted with diagnoses including adjustment disorder with anxiety and chronic obstructive pulmonary disease, reported being harassed and called names by Resident #15. Resident #15, who has unspecified dementia and other conditions, accused Resident #16 of stealing a picture and made derogatory comments about Resident #16's sexual orientation. Despite these allegations, the Director of Nursing (DON) did not report the incident to the State Agency (SA) as required by the facility's abuse prevention policy. The DON acknowledged that the accusations and name-calling constituted verbal abuse and harassment, which should have been reported immediately. The facility's policy, revised in May 2023, mandates that all alleged, suspected, or observed abuse be reported immediately and investigated. However, the DON did not report the incident, citing Resident #15's dementia as a reason. This oversight allowed the allegations to go unreported and uninvestigated, contrary to the facility's policy and regulatory requirements.
Missed Physician Visits for Residents
Penalty
Summary
The facility failed to ensure timely physician visits for three residents, leading to deficiencies in their care. Resident #26, who was admitted with traumatic subarachnoid hemorrhage, fall, and unspecified dementia, did not have a documented physician visit in June 2024, despite the requirement for visits every 30 days during the first 90 days of admission. The Director of Nursing (DON) confirmed the absence of this visit, acknowledging the oversight in the resident's care schedule. Similarly, Resident #19, with diagnoses including type two diabetes mellitus, diabetic chronic kidney disease, and retinal edema, lacked a physician visit in April 2024. The DON confirmed this lapse. Additionally, Resident #7, diagnosed with chronic obstructive pulmonary disease, type II diabetes mellitus, and hypothyroidism, did not have a documented physician visit in March 2024, although visits were expected every 60 days after the initial 90 days. These omissions highlight a pattern of missed physician visits for residents, as confirmed by the DON.
Failure to Conduct Timely Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) received an annual performance evaluation in a timely manner. This deficiency was identified during a personnel record review, which revealed that one of the two CNAs employed for more than a year, specifically Employee #7, did not have documented evidence of a completed annual performance evaluation. Employee #7 was hired on April 1, 2023, and the facility's policy, revised in June 2019, mandates that employees be evaluated annually in the month of their hire date. The Human Resources Supervisor confirmed the absence of the evaluation documentation during an interview conducted on July 17, 2024.
Deficiency in Morphine Labeling and Reconciliation
Penalty
Summary
The facility failed to ensure that a bottle of Morphine oral suspension for a resident included a measuring guide on its label, which is necessary for accurate reconciliation of controlled substances. This deficiency was identified during an inspection of a medication cart by the Director of Nursing (DON), who confirmed that the bottle did not have the required measurement guide. The absence of this guide made it difficult for the facility to determine if the medication was correctly reconciled in the Narcotics Reconciliation log or if it had been diverted. The pharmacist also confirmed that the bottle lacked a measuring guide, which is a standard requirement for such medications. The resident involved had been admitted with multiple diagnoses, including unspecified dementia and chronic pain syndrome, for which Morphine Sulfate was prescribed. The physician's order specified a dosage of 0.1 ml every two hours as needed. However, discrepancies were noted in the Controlled Drug Record, which documented a different concentration of Morphine Sulfate than what was found in the bottle. The DON observed that the remaining quantity in the bottle was less than expected, suggesting a possible leak or other issue. The manufacturer's instructions emphasized the importance of careful record-keeping for controlled substances like Morphine, highlighting the facility's failure to adhere to these guidelines.
Psychotropic Medication Prescribed Without Proper Indication
Penalty
Summary
The facility failed to ensure that a psychotropic medication was prescribed to a resident with a diagnosed indication for use. Resident #9, who was admitted with diagnoses including vascular dementia with behavioral disturbances and unspecified depression, was administered Buspirone three times a day for behaviors such as yelling, banging fists, and throwing items. However, the resident did not have a diagnosis of anxiety, which was the indicated use for the medication as per the physician's order dated 10/19/2023. The Director of Nursing confirmed that Resident #9 received Buspirone for anxiety without having a diagnosis for it, which was against the facility's policy. The facility's policy on psychotropic medication use, revised in 08/2018, required that such medications be ordered by a physician when medically necessary and that attending physicians must certify the necessity of the medication to treat a specific condition or behavior. This oversight led to the administration of a psychotropic medication without a proper indication for use.
Improper Repackaging of Medications
Penalty
Summary
The facility failed to ensure that medications were not repackaged, as observed in the case of a resident who was admitted with multiple diagnoses including a fracture and osteoporosis. A physician's order had prescribed hydrocodone-acetaminophen (Norco) for chronic arthritic pain. During an inspection, it was found that the Norco tablets were improperly repackaged into plastic see-through envelopes, with only the resident's last name and the medication name and strength written on them. This repackaging was confirmed by the Director of Nursing (DON) to have been done by the nursing staff. The facility's policy on medication administration, dated January 2021, explicitly stated that medications should never be transferred from one container to another. However, the policy did not provide guidance on what information should be included on a medication label, such as the prescribed dose, strength, resident's name, route of administration, or any precautions. This lack of detailed labeling and adherence to policy led to the deficiency observed during the survey.
Inadequate Nutritional Substitution for Resident
Penalty
Summary
The facility failed to provide a vegetable substitute of equal nutritive value for a resident who had documented dislikes for Brussels sprouts. The resident, who was admitted with diagnoses including heart failure, chronic obstructive pulmonary disease, and gastro-esophageal reflux disease, was served a lunch menu that included roast turkey, Brussels sprouts, and corn pudding. Despite the resident's documented dislike for Brussels sprouts, mashed potatoes were substituted instead, which were not comparable in nutritional value. This was confirmed by the Registered Dietician, who stated that a substitute of equal nutritional value should have been offered.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to provide meals based on a resident's preferences, specifically for a resident with dislikes documented on their tray card. The resident, who was admitted with diagnoses including heart failure, chronic obstructive pulmonary disease, and gastro-esophageal reflux disease, had expressed a dislike for carrots and Brussels sprouts. Despite this, the lunch menu included carrots, and the resident was served a plate containing carrots. The Dietary Manager and Registered Dietician both acknowledged that items disliked by residents should not be served, and the facility's policy required screening residents for food preferences at admission. However, the resident was still served carrots, which they verbalized disliking and refused to eat.
Deficiencies in Vaccination Protocols and Infection Control
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify several deficiencies related to vaccination protocols and infection control. The Director of Nursing (DON) confirmed that the facility lacked a process for screening residents for eligibility to receive pneumococcal (PNA) and influenza vaccinations. Additionally, education related to these vaccines was not provided to residents, and consents were not obtained prior to administering new flu vaccines. The QAPI committee was unaware of these issues until they were highlighted by the State Agency. The Infection Preventionist (IP) had not completed the required specialized training course, as evidenced by the lack of a completion certificate. The transcript provided by the IP showed that the course was not fully completed, and the DON confirmed that the IP should have completed the course before assuming the role. The QAPI committee was also unaware of this training deficiency. The facility's Infection Control and Prevention Plan (IPCP) and Antibiotic Stewardship Program (ASP) policies were outdated and lacked essential components. The IPCP policy had not been reviewed or revised since October 2022 and contained references to hospital staff rather than long-term care facility staff. It also lacked a list of reportable communicable diseases and processes for reporting and communication during resident transfers. Similarly, the ASP policy lacked protocols for antibiotic use and feedback systems. The QAPI committee was not informed about these outdated policies.
Deficiency in COVID-19 Vaccination Protocol for Staff and Residents
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was screened for eligibility to receive a COVID-19 booster vaccine, provided with education regarding the vaccine, and given the opportunity to make an informed decision to receive or decline the vaccination. The CNA, hired on 10/25/2020, had received previous doses of the COVID vaccine on 10/13/2021 and 02/03/2021. However, there was no documented evidence that the CNA was informed about updated COVID vaccines, screened for eligibility, or had completed a declination for the vaccine. The Director of Nursing (DON) confirmed that the facility was no longer tracking COVID vaccination status for staff and that education related to COVID vaccines was only provided when new vaccines were available or during vaccination clinics. Additionally, the facility failed to ensure that one of six residents reviewed for immunization with a COVID booster vaccine was screened for eligibility, provided with education regarding the vaccine, and given the opportunity to make an informed decision to receive or decline the vaccine. The DON acknowledged that education related to COVID vaccines was not being provided to residents or staff outside of specific circumstances, such as the availability of new vaccines or vaccination clinics. This lack of documentation and education represents a deficiency in the facility's vaccination protocol.
Failure to Ensure Communication Training for Staff
Penalty
Summary
The facility failed to ensure that communication training was completed by a staff member, specifically Employee #4, who was hired as a Registered Dietician on September 11, 2003. A review of Employee #4's personnel record revealed a lack of documented evidence of communication training. On July 23, 2024, the Human Resources Supervisor confirmed that all staff were required to complete communication training within 30 days of hire and annually thereafter, but Employee #4 did not have this training documented. The facility's policy, effective April 2022, mandated that employees complete communication training at least annually.
Failure to Ensure Resident Rights Training for Staff
Penalty
Summary
The facility failed to ensure that all staff members completed the required resident rights training, as evidenced by the personnel record review of a Registered Dietician, hired on 09/11/2003, who did not have documented evidence of completing this training. The Human Resources Supervisor confirmed that all staff were required to complete Resident Rights training within 30 days of hire and annually thereafter, but Employee #4 did not meet this requirement. The facility's policy, effective 08/2022, mandates that employees complete Resident Rights education at least annually.
Failure to Ensure Timely Elder Abuse Training
Penalty
Summary
The facility failed to ensure timely completion of elder abuse training for seven out of twenty sampled employees. Employee #4, a Registered Dietician, had completed elder abuse training in 2022 but lacked documentation for 2023. Employee #7, a CNA, completed the training more than 30 days after being hired. Employee #10, an LPN, and Employee #17, a CNA, both lacked initial elder abuse training before starting work on the floor. Employee #11, an RN, completed the training more than 30 days after hire. Employee #19, a Hospitality Aide, and Employee #20, a Housekeeper, also lacked timely completion of the training, with Employee #20 completing it more than 30 days after hire. The Human Resources Supervisor confirmed that all staff were required to complete elder abuse training within 30 days of hire and annually thereafter. However, the facility's abuse prevention policy, revised in May 2023, did not include a requirement for abuse training upon orientation. This oversight contributed to the delay in training for the identified employees, as confirmed by the Human Resources Supervisor during the survey.
Failure to Complete QAPI Training for Registered Dietician
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) training was completed for all staff, specifically for one of the sampled employees, a Registered Dietician hired on September 11, 2003. The personnel record for this employee lacked documented evidence of QAPI training. On July 23, 2024, the Human Resources Supervisor confirmed that all staff were required to complete QAPI training within 30 days of hire and annually thereafter, but acknowledged that the Registered Dietician did not have the required training. The facility's policy, revised in November 2017, mandates annual training on the QAPI program for all staff.
Infection Control Training Lapse for Registered Dietician
Penalty
Summary
The facility failed to provide timely infection control training to all staff, as evidenced by the case of a Registered Dietician, hired on September 11, 2003, who did not have documented evidence of completing the required infection control training. According to the facility's policy, effective January 2021, all healthcare personnel are required to receive infection control training annually. During an interview on July 23, 2024, the Human Resources Supervisor confirmed that all staff must complete this training within 30 days of hire and annually thereafter. However, it was confirmed that the Registered Dietician had not completed the necessary infection control training, indicating a lapse in adherence to the facility's infection prevention and control program.
Failure to Complete Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that compliance and ethics training was completed in a timely manner for one of the sampled employees. Employee #4, who was hired as a Registered Dietician on September 11, 2003, did not have documented evidence of having completed the required compliance and ethics training. According to the Human Resources Supervisor, all staff are required to complete this training within 30 days of hire and annually thereafter. However, it was confirmed that Employee #4 did not have the necessary training documented in their personnel record. The facility's policy, effective October 2022, mandates that all employees complete compliance and ethics continuing education annually.
Failure to Complete Behavioral Health Training
Penalty
Summary
The facility failed to ensure that behavioral health training was completed in a timely manner for one of the sampled employees, specifically Employee #4, who was hired as a Registered Dietician. Employee #4's personnel record did not contain documented evidence of having completed the required behavioral health training. According to the Human Resources Supervisor, all staff were mandated to complete this training within 30 days of hire and annually thereafter. However, it was confirmed that Employee #4 had not completed the training as required by the facility's policy, which was effective from July 2022.
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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