Tlc Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Henderson, Nevada.
- Location
- 1500 W Warm Springs Rd, Henderson, Nevada 89014
- CMS Provider Number
- 295071
- Inspections on file
- 32
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Tlc Care Center during CMS and state inspections, most recent first.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
The governing body failed to oversee a contracted behavioral health vendor’s documentation and interventions for two residents in a Medicaid behaviorally complex care program. Behavior tracking sheets contained multiple entries initialed by an unidentifiable individual, and one resident’s records listed numerous unapproved interventions such as detention, seclusion, suspension, and corporal punishment that were not part of the care plan and were not used by facility staff. Facility leadership reported that only contracted behavioral health staff completed these behavior sheets and submitted them to Medicaid, while a vendor supervisor later determined that a single employee had used an AI tool to generate interventions and had signed using other initials instead of obtaining real-time intervention information from facility staff as required.
A resident receiving Quetiapine for bipolar disorder with mood swings was given the antipsychotic for approximately two weeks without required monitoring of target behaviors or side effects. Although facility policy required evaluation and ongoing monitoring of antipsychotic use, the admitting nurse entered the medication order without corresponding behavior and side effect monitoring orders, so no EHR prompts appeared for floor nurses. An LPN, a charge nurse, and the DON all confirmed that behavior and side effect monitoring did not begin until later, when specific orders for monitoring mood swings, non‑pharmacological interventions, and side effects were finally entered.
A resident dependent on staff for bathing, with multiple medical conditions, did not receive scheduled showers or bed baths as required. The resident reported a rash and itching, and review of records confirmed that scheduled bathing was not consistently provided, contrary to facility policy.
A resident with multiple diagnoses did not have monthly weights documented for three consecutive months, despite physician orders and facility policy requiring this monitoring. Staff interviews confirmed that CNAs had not consistently obtained weights, leading to gaps in care planning and delayed interventions.
A resident with a left wrist fracture did not receive a timely orthopedic consult as ordered by the physician. Although the resident returned from the ER with a splint and an order for orthopedic follow-up, staff failed to initiate the insurance authorization process for over a month due to lack of communication and unclear delegation of responsibilities during a staff member's medical leave. The resident was not seen by an orthopedic specialist until nearly two months after the injury.
A resident with lower extremity impairment was improperly transferred without a Hoyer lift, resulting in a fall and injury. Additionally, an unsecured oxygen tank was found in another resident's room, posing a potential hazard. These incidents indicate lapses in staff training and adherence to safety protocols.
The facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program. The administrator, new to the position, could not locate electronic documents related to the QAPI program, despite evidence of meetings on specific dates. The facility's policy required maintaining documentation, but this was not adhered to, violating the State Operations Manual's requirements for a data-driven QAPI program.
The facility failed to maintain a QAPI Committee with the required members and did not document meetings at least quarterly. Key members were absent from meetings on multiple occasions, and the Administrator could not provide evidence of compliance with meeting frequency requirements, potentially affecting resident care quality.
A resident was self-administering Ketotifen Fumarate Ophthalmic Solution without a physician's order, assessment, or care plan in place. The resident kept the eye drops at the bedside, contrary to facility policy, which requires secure storage and an interdisciplinary team's assessment of the resident's ability to self-administer medications safely.
A resident with intact cognition expressed dissatisfaction with the frequency of showers provided, citing personal hygiene concerns. The facility failed to accommodate the resident's preference for more frequent showers due to the unavailability of a Hoyer sling necessary for transfers, resulting in missed showers. The facility's policy to honor resident preferences for type and frequency of baths was not adhered to.
The facility did not document responses to complaints from resident council meetings, where residents reported delays in call light responses and staff distractions. A resident waited up to 45 minutes for assistance, and another had not received a shower in three months. Despite these issues being documented, no written responses or corrective actions were provided.
A resident with severe cognitive impairment was found with both upper and lower bed rails raised, considered physical restraints, without proper physician orders or documented assessments. Staff acknowledged the use of restraints but lacked documentation or orders justifying their use. The facility's policies on physical restraints and fall protocol were not followed, leading to the deficiency.
A resident with severe cognitive deficit and Parkinson's disease was using side rails for bed mobility without a documented care plan or physician order. Despite a side rail assessment and consent being completed over a year prior, the facility failed to update the care plan and obtain a physician order, as confirmed by staff interviews. This oversight was contrary to the facility's policy requiring timely development of care plans.
A facility failed to obtain a physician's order for the removal or use of an IV access for a resident, including assessing and monitoring the site. The resident had an undated IV port, and inspections confirmed the absence of a date on the dressing. There were no current orders for the IV, and the facility's policies on IV removal and dressing changes were not followed, leading to a deficiency.
A facility failed to assess and document the use of bed rails for a resident with severe cognitive impairment and other health issues. The resident's medical record lacked evidence of physician orders, comprehensive assessments, and attempts of less restrictive alternatives. Staff confirmed the use of bed rails but could not provide documentation or recall installation details, placing the resident at risk of injury.
The facility failed to label and date pre-made sandwiches stored in the refrigerator, posing a potential risk to safety and health standards. During a kitchen tour, three sandwiches were found wrapped but not labeled or dated in the walk-in cooler. The Dietary Account Manager acknowledged the oversight, which violated the facility's policy requiring all foods to be labeled and dated to prevent cross-contamination.
A resident in a facility experienced a breach in infection control practices when a CNA used a brief from another resident's room due to a shortage of bariatric-sized briefs. The Central Supply Clerk confirmed the shortage, and the facility's protocol was not followed, leading to potential cross-contamination risks. The Infection Preventionist and ADON confirmed that such actions were against infection control policies.
A resident with multiple diagnoses was involved in an altercation with a staff member, who blocked the resident's wheelchair and held their arms down, leading to the resident's agitation and kicking. The staff member threatened retaliation, and the incident was witnessed by another employee. The facility's records lacked documentation of social services involvement, and the resident's care plans were not updated following the incident. The facility substantiated the abuse allegation and terminated the staff member.
A facility failed to report an alleged physical abuse incident involving a resident to the State Agency within the required timeframes. The resident, with a history of aggressive behavior, was involved in an incident that was not reported until later in the day, and no final report was submitted. The facility's policy and state regulations require immediate reporting of such incidents, but the Administrator/Abuse Coordinator was unsure if the timelines were met.
The facility failed to provide adequate incontinent care for three residents, leading to potential skin integrity issues. One resident experienced a delay in receiving a brief change due to a supply shortage, while another resident's records showed a lack of documented toileting hygiene. Additionally, a third resident's medical records lacked documentation of toileting care during specific shifts, indicating care was not provided. The facility's policy required documentation of ADLs, which was not followed.
The facility failed to follow physician orders for medication administration, affecting several residents. A resident's insulin order lacked instructions for certain glucose levels, leading to unreported results. Another resident received an incorrect dosage of Calcium Carbonate due to supply issues. Staffing shortages caused missed medications for multiple residents, with no documentation of administration or refusal. The facility lacked a general medication administration policy.
A facility failed to maintain complete and accurate medical records for three residents, leading to potential care issues. One resident's refusal of a drug test was not documented, another resident's critical change in condition was not properly recorded or communicated, and a third resident's medication order was incorrectly transcribed, leading to unsupervised self-administration without proper assessment or care plan.
The facility failed to ensure the Infection Preventionist had specialized training and did not report a COVID-19 outbreak to the state agency. The outbreak involved 55 residents and 12 staff members. Additionally, N-95 respirator fit testing was not completed for staff, leading to improper PPE use.
A resident's grievance was not documented or investigated after a janitor massaged the resident's feet and legs, which was outside the janitor's job duties. Despite being reported to the Administrator and other staff, the incident was not logged in the facility's grievance log, violating the facility's policy on handling grievances.
A resident admitted with a serious infection did not receive Vancomycin as per hospital discharge instructions. The facility's process for ordering medications was not followed promptly, resulting in a delay in administering the antibiotic. Staff interviews revealed that the medication should have been available and administered sooner.
A facility failed to document discharge planning for a resident admitted for short-term rehabilitation after open heart surgery. The resident's medical record lacked evidence of a case manager's assessment for discharge needs, despite facility policy requiring such documentation. Interviews with staff confirmed the absence of a documented discharge plan, which should have been initiated early and updated throughout the resident's stay.
A facility failed to document assistance with activities of daily living (ADL) for a resident dependent on staff for toileting hygiene due to conditions like Parkinson's disease and acute respiratory failure. The resident's care plan required staff assistance for toileting and cleaning the peri-area with each incontinent episode. However, the Admission MDS and ADL Flowsheet showed missing documentation for toileting hygiene during the day shift on multiple dates, indicating a lack of recorded assistance. The MDS Coordinator and a CNA confirmed the resident's dependency and the need for proper documentation, which was not met according to the facility's ADL policy.
The facility failed to complete weekly wound evaluations for a resident with surgical wounds and did not implement a psychiatric consultation for another resident exhibiting aggressive behavior. The resident with wounds had inaccurate skin observations documented, and there was no evidence of weekly evaluations for three weeks. The resident with altered mental status showed combative behavior, but despite orders, no psychiatric consultation was documented or coordinated.
A facility failed to conduct weekly wound evaluations and accurately document skin observations for a resident with multiple skin conditions. Despite having a stage 1 pressure wound, a stage 3 pressure wound, and a deep tissue injury, the resident's medical record showed no weekly wound evaluations from admission to discharge. Interviews with staff confirmed the absence of evaluations and inaccuracies in documentation, contrary to facility policy.
The facility failed to manage sharps containers properly, with containers overfilled beyond the manufacturer's fill line, increasing the risk of needle stick injuries. Additionally, residents were observed smoking without supervision in an area with a propane grill improperly stored, posing a safety risk. The facility did not conduct regular assessments of smoking residents, as required by policy, compromising resident safety.
The facility failed to ensure staff used appropriate equipment for residents on transmission-based precautions, leading to potential cross-contamination. CNAs used personal blood pressure monitors for multiple residents, including those on precautions, and were unaware of the facility's disposable cuffs. Disinfection procedures were not properly followed, as staff did not adhere to the manufacturer's instructions for bleach wipes.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Oversee Contracted Behavioral Health Documentation and Interventions
Penalty
Summary
The governing body failed to oversee services performed by a contracted behavioral health vendor, including the accuracy of behavior documentation for two residents enrolled in the Medicaid Behaviorally Complex Care Program. The facility used a multi-page Behavior Frequency Documentation Data Sheet to track behaviors and interventions, but review of these sheets for two sampled residents showed entries with initials that could not be linked to any identifiable staff member. For one resident with schizophrenia, dementia, major depressive disorder, and generalized anxiety disorder, behavior sheets for two consecutive months contained multiple entries initialed as "AB" by an unverified staff member; a similar pattern of unverified initials appeared on another resident’s behavior sheets over two months. The behavior documentation for one of these residents included numerous interventions that were not part of the resident’s care plan and were not used by facility staff. These interventions were described as effective, successful, failed, or ineffective and included terms such as loss of privileges, time-out, detention, parent-teacher conferences, suspension, student-teacher conferences, expulsion, seclusion, calm-down corner, and corporal punishment. The Unit Manager stated that facility staff did not have access to the behavior data sheets, did not document on them, and had never used the listed interventions when addressing resident behaviors. The Administrator similarly reported that contracted behavioral health staff were solely responsible for completing the behavior documentation and submitting all related documents to Medicaid. Interviews with facility leadership and contracted vendor staff further showed that the contracted behavioral health staff, not facility staff, controlled the behavior documentation and submission process. The Assistant Administrator and Administrator confirmed that treatment and documentation for residents in the behaviorally complex care program were completed by the vendor’s behavioral health staff. A Lead Behavior Coordinator from the vendor acknowledged awareness that a Behavior Coordinator was using other initials to sign paperwork and that terms such as spanking and corporal punishment had appeared on the sheets. The vendor’s Chief Clinical Officer later determined that a single employee had documented interventions that were not actually implemented at the facility and that this employee had used an AI tool to generate interventions instead of obtaining real-time intervention information from facility staff, contrary to expectations and the consulting agreement that required accurate labeling and verification of patient data for claims submission.
Failure to Monitor Antipsychotic Target Behaviors and Side Effects
Penalty
Summary
The facility failed to ensure that a resident’s antipsychotic drug regimen was monitored for target behaviors and side effects as required. A cognitively intact resident admitted with diagnoses including metabolic encephalopathy, malignant neoplasm of the colon, and non‑traumatic subarachnoid hemorrhage was receiving Quetiapine 25 mg at bedtime for bipolar disorder manifested by mood swings. The admission MDS documented verbally aggressive behaviors and antipsychotic use. A physician order dated 04/15/2025 initiated Quetiapine, but the medical record lacked documented evidence that target behaviors or side effects were monitored from 04/15/2025 through 04/28/2025, despite facility policy that residents admitted on antipsychotics be evaluated for appropriateness and indication for use by the IDT and physician. On 04/29/2025, physician orders were entered to monitor mood swings as the target behavior and to use specified non‑pharmacological interventions with outcome codes every shift, as well as to monitor for specific side effects of Quetiapine (including dry mouth, constipation, blurred vision, confusion, hypotension, EPS, and others) every shift. Interviews with an LPN and a charge nurse confirmed that Quetiapine had been administered starting 04/15/2025 and that behavior and side effect monitoring did not begin until 04/29/2025, likely because the admitting nurse did not enter the monitoring orders at the time the medication was started. The charge nurse explained that if orders are not entered into the EHR, floor nurses are not prompted to complete related tasks. The DON confirmed that the resident was not monitored for target behaviors or potential side effects from the first dose of Quetiapine on 04/15/2025 until 04/29/2025 due to the late entry of monitoring orders, despite facility policy requiring monitoring to guide decisions about continued use, dosage, and GDR of antipsychotic medications.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for bathing due to medical conditions including dysphagia following cerebral infarction, type 2 diabetes mellitus, and essential hypertension, did not receive scheduled bathing as required. The resident reported experiencing a rash and itching, and stated that staff did not bathe or shower them regularly. Review of the facility's bathing schedule and medical records showed that the resident was assigned to receive showers or bed baths twice weekly, specifically on Wednesday and Saturday evenings, but these were not consistently provided as scheduled. A Certified Nurse Assistant confirmed the bathing schedule and that documentation was maintained in the medical record. The Director of Nursing also verified that the resident's scheduled showers were not provided as required. Facility policy stated that residents should be offered at least two full baths or showers per week, but this was not adhered to in the resident's case, as evidenced by gaps in the bathing documentation and the resident's own account of infrequent bathing.
Failure to Obtain and Document Monthly Weights as Ordered
Penalty
Summary
The facility failed to follow physician orders for obtaining monthly weights for a resident diagnosed with Parkinson's disease, dementia, and major depressive disorder. The physician had ordered monthly weights to be taken within the first week of each month for monitoring purposes. However, the medical record lacked documented weights for three consecutive months, specifically September, October, and November. This omission was identified through record review and confirmed by staff interviews, which revealed that Certified Nurse Assistants (CNAs) had not consistently obtained the required monthly weights. Multiple staff members, including the DON, Unit Manager, ADON, and Registered Dietitian, acknowledged ongoing challenges in obtaining accurate and consistent weight measurements. They indicated that missing or inaccurate weights had negatively impacted care planning and delayed timely interventions for residents experiencing weight loss or significant changes. The facility's policy required nursing staff to measure resident weights as ordered by the physician, but this was not consistently followed for the resident in question.
Failure to Timely Obtain Orthopedic Consult Following Physician Order
Penalty
Summary
The facility failed to obtain an orthopedic consult as ordered by the physician for a resident who had suffered a left wrist fracture following a fall. After the fall, the resident was sent to the emergency room, diagnosed with a left wrist fracture, and returned to the facility with a splint and ace wrap. A physician order for an orthopedic follow-up was placed, but the consult was not arranged in a timely manner. Staff interviews and documentation revealed that the process for obtaining insurance authorization for the consult was not initiated until over a month after the order was written. The case manager, who was responsible for obtaining insurance authorization, was unaware of the order and was on medical leave during a critical period, with no clear delegation of responsibility in their absence. The delay in obtaining the orthopedic consult resulted in the resident not being evaluated by an orthopedic specialist until nearly two months after the initial injury and order. Staff interviews indicated confusion and lack of communication regarding who was responsible for securing insurance authorization and scheduling the appointment. The unit manager and transportation coordinator both cited insurance approval as a reason for the delay, but the necessary steps to obtain approval were not taken promptly. Facility documentation confirmed that the insurance authorization request was not made until several weeks after the order, and the resident's nurse practitioner acknowledged that the delay was not acceptable.
Deficiencies in Resident Transfer and Oxygen Tank Safety
Penalty
Summary
The facility failed to ensure that the plan of care was followed regarding transfers for a resident, leading to a fall with injury. The resident, who had a history of lower extremity impairment and required a Hoyer lift for transfers, was improperly transferred by a CNA without the necessary equipment. The CNA attempted to transfer the resident independently, resulting in the resident's knee buckling and a fall to the floor, causing a nondisplaced fracture of the proximal tibia. The CNA did not check the resident's care plan or consult with the assigned nurse, leading to the improper transfer method being used. Additionally, the facility failed to secure an oxygen tank for another resident, creating a potential hazard. The oxygen cylinder was observed unsecured beside the resident's bed, contrary to the facility's policy requiring oxygen tanks to be stored in sturdy portable carts or approved stands. The CNA confirmed the tank was not secured and acknowledged the need for a holder to prevent it from falling. The facility's policies on fall protocols and oxygen safety were not adhered to, as evidenced by the lack of a comprehensive investigation and documentation following the fall incident, and the unsecured oxygen tank. The deficiencies highlight lapses in staff training and adherence to established safety protocols, which could lead to resident injuries.
Failure to Maintain QAPI Documentation
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program. During an interview and document review, the administrator acknowledged the inability to produce documentation showing the development, implementation, and maintenance of an effective, comprehensive QAPI program. Although evidence of QAPI meetings on specific dates was provided, the administrator, who had been in the position for a short time, could not locate where the electronic documents were filed or if they were filed at all. The facility's policy on QAPI Committee, which was undated, stated that the facility would maintain documentation and demonstrate evidence of its ongoing QAPI program. The State Operations Manual requires facilities to develop, implement, and maintain a data-driven QAPI program, with documentation to demonstrate its ongoing implementation, which was not adhered to in this case.
QAPI Committee Composition and Meeting Frequency Deficiency
Penalty
Summary
The facility failed to maintain documented evidence of a Quality Assurance and Performance Improvement (QAPI) Committee that meets the required composition and frequency. Specifically, the QAPI Committee was missing key members during its meetings on several occasions. On 02/27/2025, the meeting lacked the presence of the Director of Nursing and an Administrator, Owner, or Board Member. On 09/24/2024, the meeting was missing the Medical Director or his/her designee and an Administrator, Owner, or Board Member. Additionally, the meeting on 07/30/2024 did not include the Medical Director or his/her designee. These omissions indicate a failure to comply with the regulatory requirements for the composition of the QAPI Committee. Furthermore, the facility did not maintain documentation of the QAPI Committee meeting at least quarterly, as required. The Administrator acknowledged the absence of documented evidence for meetings on the specified dates and admitted to being unable to locate electronic documents or confirm if they were filed. This lack of documentation and adherence to meeting frequency requirements has the potential to negatively impact the quality of resident care and life. The facility's policy and the state operations manual both stipulate the necessity of maintaining a QAPI Committee with specific members and meeting at least quarterly, which the facility failed to uphold.
Failure to Obtain Physician's Order and Assessment for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a physician's order was obtained, an assessment was completed, and a care plan was developed for the self-administration of medication for one resident. The resident, who was admitted with diagnoses including peripheral vascular disease and age-related physical debility, was self-administering Ketotifen Fumarate Ophthalmic Solution for eye itching without the necessary physician's order or assessment. During a medication administration pass observation, it was noted that the resident kept and self-administered the eye drops, which were stored in a purse at the bedside, contrary to the facility's policy. The Licensed Practical Nurse (LPN) and the Regional Director of Clinical Services confirmed that there were no physician's orders, assessments, or care plans in place for the resident's self-administration of the eye drops. The facility's policy required that an interdisciplinary team determine the clinical appropriateness and safety of self-administration, including a specific skill assessment of the resident's abilities. The policy also mandated that self-administered medications be stored securely, which was not adhered to in this case.
Failure to Accommodate Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that residents have the right to make choices about significant aspects of their life, as evidenced by the case of a resident with intact cognition who expressed dissatisfaction with the frequency of showers provided. The resident, who was admitted with diagnoses of nontraumatic intracerebral hemorrhage and hemiplegia and hemiparesis following cerebral infarction, reported that two showers per week were insufficient and expressed concerns about personal hygiene issues such as sweating, greasy hair, and body odor due to the infrequent showers. The facility's failure to accommodate the resident's preference for more frequent showers was compounded by the unavailability of a Hoyer sling necessary for shower transfers, resulting in missed showers. The Administrator-In-Training and the Assistant Director of Nursing confirmed that the resident's shower days were scheduled for Tuesday, Thursday, and an additional day on Sunday, but acknowledged the lack of a Hoyer sling on a scheduled shower day and the absence of documentation for another scheduled shower. The facility's policy stated that residents should be offered at least two full baths per week, with preferences for type and frequency honored, which was not adhered to in this case.
Failure to Address Resident Council Complaints
Penalty
Summary
The facility failed to document a written response to complaints raised during resident council meetings, which had the potential to leave resident concerns unresolved. During meetings held in February and March 2025, residents expressed dissatisfaction with the timeliness of call light responses and reported that staff were often distracted by their phones. One resident mentioned waiting up to 45 minutes for assistance, while another reported not having received a shower in three months. Despite these complaints being documented in the meeting minutes, no written responses or corrective actions were provided by the facility. Resident 57, who served as the Resident Council President, confirmed that the facility did not consistently respond to concerns raised in the meetings. The Activities Assistant noted that while meeting notes were shared with department heads, responses were not consistently returned to the activities department. The Administrator, who had recently commenced employment, acknowledged the absence of written responses and was unable to locate any documentation addressing the complaints. The Regional Director of Clinical Services confirmed that concerns should have been investigated and documented, as per the facility's policy on grievances and complaints.
Failure to Ensure Resident is Free from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that Resident 168 was free from the use of physical restraints not needed for medical treatment. The resident, who had severe cognitive impairment and was at risk for falls, was found with both upper and lower bed rails raised, which were considered physical restraints. The facility did not have physician orders or documented assessments justifying the use of these restraints, and the resident's care plan lacked documentation of alternatives considered before implementing the restraints. Observations and interviews revealed that the staff, including a CNA and an LPN, were aware of the use of bed rails and floor mats for safety but did not have proper documentation or orders for their use. The LPN acknowledged that the lower bed rails were considered restraints and could not recall how long they had been in place. The facility's Assistant Director of Nursing and Regional Director of Clinical Services confirmed the lack of physician orders and care plan documentation for the use of the rails, and the Director of Maintenance was unaware of the installation of lower rails until identified by the survey team. The facility's policies on physical restraints and fall protocol were not followed, as there was no documented evidence of a comprehensive investigation or root cause analysis for the use of restraints or past falls involving the resident. The facility's failure to conduct proper assessments, obtain necessary orders, and document the use of restraints led to the deficiency, which could have resulted in harm to the resident.
Failure to Revise Care Plan and Obtain Physician Order for Side Rails
Penalty
Summary
The facility failed to ensure a resident-centered care plan was revised and a physician order obtained for the use of side rails for one resident. The resident, who was admitted with diagnoses including Parkinson's disease and required assistance with personal care, had a severe cognitive deficit as indicated by a BIMS score of 5/15. Observations revealed that the resident was using side rails for bed mobility and transfers, but there was no documented care plan or physician order for the use of these side rails prior to specific dates. The resident's medical record showed a side rail assessment and consent were completed over a year before the deficiency was noted, but the care plan and physician order were not updated accordingly. Interviews with facility staff, including an LPN and the Unit Manager, confirmed that side rails were being used as an enabler for the resident's transfers and bed mobility. However, the staff acknowledged that the necessary care plan and physician order were not in place. The facility's policy required a baseline care plan to be developed within 48 hours of admission and a comprehensive care plan within seven days of the comprehensive assessment, but these protocols were not followed in this case, leading to a lack of communication and potential risk for the resident.
Failure to Obtain Physician's Order for IV Access Management
Penalty
Summary
The facility failed to obtain a physician's order for the removal or use of an intravenous (IV) access for a resident, including assessing and monitoring the site. This deficiency was identified for one resident who was initially admitted with diagnoses including anoxic brain damage, seizures, and a carrier of carbapenem-resistant Enterobacter. During an observation, the resident was found with an undated IV port on the right arm, and subsequent inspections by the Director of Nursing (DON) and an Assistant Director of Nursing (ADON) confirmed the absence of a date on the dressing. The ADON noted that the dressing appeared to need changing and that there were no current orders for an IV. A review of the resident's physician orders revealed an order to insert the IV on a previous date for IV antibiotics, but there were no orders to flush the IV line or monitor the dressing. The DON acknowledged that there should have been orders to flush the IV line, change and monitor the dressing weekly, and remove the IV line after the completion of the antibiotics. The facility's policies on IV removal and dressing changes were not followed, as there was no documentation of the dressing change or monitoring, which is essential to prevent catheter-related infections.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that Resident 168 was properly assessed and reviewed for risks and benefits before the installation of bed rails. The resident, who was admitted with diagnoses including muscle weakness, lack of coordination, and severe cognitive impairment, was observed with full bed rails raised without documented evidence of physician orders or a comprehensive assessment. The facility's policy requires a Side Rail and Entrapment Risk Assessment, which was not completed after the resident's readmission, and there was no documentation of less restrictive alternatives being attempted prior to the use of bed rails. The medical record for Resident 168 lacked evidence of a physician's order for the use of bed rails and floor mats, and the care plan did not document the use of these interventions. Additionally, the Side Rail Consent form was incomplete, missing the resident's name and signature, as well as the signature of a resident representative. The facility's staff, including a CNA, LPN, and ADON, confirmed the use of bed rails but were unable to provide documentation or recall when the rails were installed. The facility's policy on bed rails requires an interdisciplinary assessment, consultation with the attending physician, and input from the resident or legal representative, none of which were documented in this case. The facility also failed to conduct in-service training on bed rail guidelines, and the Director of Maintenance confirmed that the facility did not track when bed rails were installed. This lack of documentation and adherence to policy placed Resident 168 at risk of injury from falls, entrapment, and other potential harm.
Failure to Label and Date Pre-Made Foods in Refrigerator
Penalty
Summary
The facility failed to ensure that pre-made foods were stored, labeled, dated, and used within seven days in the refrigerator, which posed a potential risk to safety and health standards. During a follow-up tour of the kitchen and dietary areas, three sandwiches were found in a plastic tub in the walk-in cooler. These sandwiches were wrapped but not labeled or dated. The Dietary Account Manager acknowledged that the sandwiches should have been labeled and dated to inform the kitchen staff of how long the items had been stored in the cooler. A Healthcare Services Group Policy, revised in February 2023, stated that all foods should be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross-contamination.
Infection Control Breach Due to Supply Shortage
Penalty
Summary
The facility failed to maintain proper infection control practices for one resident, identified as Resident 25, who was admitted with a displaced bicondylar fracture of the right tibia. On a specific date, Resident 25 requested assistance with a brief change and was informed by staff that the facility was out of the required bariatric-sized briefs. The Central Supply Clerk confirmed the shortage, attributing it to a lack of ordering by the backup supply clerk during their absence. The facility placed an order for the briefs, but they were not expected to arrive until two days later. In the interim, the facility's transportation driver was tasked with purchasing the necessary briefs. In an attempt to address the immediate need, a CNA obtained a brief from another resident's room to use for Resident 25, which was confirmed by both the CNA and Resident 25. This action was against the facility's infection control policy, as confirmed by the Infection Preventionist and the Assistant Director of Nursing (ADON), who stated that taking items from one resident's room to another could lead to cross-contamination and the spread of infections. The ADON explained that the proper protocol when out of supplies was to notify the charge nurse and central supply, and if necessary, the Administrator would be informed to purchase the required items.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a staff member and a resident. The resident, who was admitted with diagnoses including encephalopathy, urinary tract infection, hypothyroidism, and hypertension, was involved in an altercation with a staff member. The incident occurred when the resident, in a wheelchair, was arguing with a staff member and attempting to return to a previous room. The staff member blocked the resident's movement and held the resident's arms down against the wheelchair, leading to the resident becoming agitated and kicking at the staff member. The staff member threatened to retaliate if kicked by the resident. The incident was witnessed by another employee, who observed the staff member repeatedly holding the resident's hands down against the wheelchair while the resident yelled to be released. The facility's records lacked documentation of social services involvement in the situation, aside from a referral to psychiatric services for the resident's agitation. Additionally, the resident's care plans were not updated or revised following the incident. The facility substantiated the allegation of physical abuse, suspended the staff member involved, and subsequently terminated their employment.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical abuse involving a resident to the State Agency (SA) within the required timeframes. The incident involved a resident who was admitted with diagnoses including encephalopathy, urinary tract infection, hypothyroidism, and hypertension. On a specific date, the resident exhibited aggressive behavior, including kicking at staff and verbal aggression. The Director of Social Services notified the Administrator-In-Training of the potential abuse allegation via email, and the Administrator acknowledged receipt shortly after. However, the initial Facility Reported Incident was not submitted to the SA until later that evening, and no final report was received by the SA. The facility's policy and the State Operations Manual for Long Term Care require that alleged abuse incidents be reported immediately, but not later than two hours if they involve abuse or result in serious bodily injury, or within 24 hours if they do not. Additionally, the results of all investigations must be reported to the State Survey Agency within five working days. The Administrator/Abuse Coordinator, who was not working at the facility at the time of the event, was unsure if the incident was reported within the required timeframes. This deficiency had the potential to place residents at risk for incidents of physical abuse not being adequately protected.
Inadequate Incontinent Care and Documentation Issues
Penalty
Summary
The facility failed to provide adequate incontinent care for three residents, leading to potential compromise of their skin integrity. Resident 25 experienced a delay in receiving a brief change from 6:00 AM until approximately 10:30 AM due to the facility running out of the specific bariatric-sized briefs required. The Central Supply Clerk confirmed the shortage was due to an oversight in ordering supplies, and a substitute was not available until later that day. The CNA eventually found a brief from another resident's room to address the immediate need. Resident 468's records indicated a lack of documented evidence of toileting hygiene being provided consistently. The Admission Minimum Data Set (MDS) and care plan documented the resident's incontinence and need for maximal assistance, yet the ADL documentation showed 'not applicable' for several days, suggesting that care was not provided. The MDS Director and Assistant Director of Nursing confirmed the documentation errors and acknowledged that the 'not applicable' entries indicated the task was not completed. Resident 417's medical records also lacked documentation of toileting hygiene during specific day shifts, as confirmed by the MDS Nurse and Regional Director of Clinical Services. The absence of documentation suggested that care was not provided during these times. The facility's policy required that activities of daily living and personal care be documented in the clinical record, which was not adhered to in these cases.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure physician orders were followed in medication administration for several residents, leading to potential therapeutic inefficacy. Resident 469 was admitted with diagnoses including metabolic encephalopathy and type 2 diabetes. The physician's order for Humalog insulin lacked instructions for blood glucose levels between 71-149 mg/dL. On two occasions, the resident's blood glucose levels fell within this range, but there was no documentation of physician notification, as required by the facility's policy. Resident 219 received an incorrect dosage of Calcium Carbonate due to a lack of supply of the prescribed 600 mg tablets. The LPN administered a 500 mg tablet instead, acknowledging the error and the need to clarify the order with the physician. The facility's policy mandates verification of medication orders prior to administration, which was not adhered to in this instance. Additionally, several residents did not receive their medications in a timely manner due to staffing issues. Employee 28 was tasked with covering two separate halls, leading to missed medication administrations for multiple residents. The facility lacked a general medication administration policy, and the Director of Nursing stated that medications should be administered within an hour of the scheduled time unless documented otherwise. This oversight resulted in numerous medications being marked as missed, with no documentation of administration or refusal by the residents.
Incomplete and Inaccurate Medical Records for Three Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for three residents, leading to potential care issues. Resident 98 was admitted with chronic obstructive pulmonary disease, Type 2 diabetes mellitus, and dependence on supplemental oxygen. A physician ordered a drug test for the resident, but the facility could not produce the test results. The Regional Director of Clinical Services stated that the resident refused the test, but there was no documentation of this refusal in the medical record. The Assistant Director of Nursing confirmed the lack of documentation regarding the resident's refusal. Resident 467, who had diagnoses including venous insufficiency and Down Syndrome, experienced a significant change in condition with an oxygen saturation level dropping to the 60s. A Nurse Practitioner ordered the resident to be sent to the emergency room, but the transfer did not occur, and there was no documentation of the low oxygen saturation or the provider being notified of the resident not being sent to the hospital. The Assistant Director of Nursing confirmed the absence of documentation regarding the change in condition and the lack of communication with the Nurse Practitioner. Resident 469 had a physician order for Metformin self-administration, but the Medication Administration Record indicated unsupervised self-administration, which was not allowed. The Director of Nursing acknowledged that there was no assessment or care plan for self-administration, and the order was incorrectly transcribed. The Director confirmed that the order needed clarification with the physician and proper documentation was required.
Inadequate Infection Control and Reporting in COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that the appointed Infection Preventionist (IP) had the necessary specialized training in infection control prior to assuming the role. The IP, who was appointed at the end of September 2024, did not have the required training and was not aware of the need to report a COVID-19 outbreak to the state agency. The outbreak involved 55 COVID-19 positive residents and 12 positive staff members. The IP was also unable to work full-time due to health issues and there was no designated backup to oversee the infection control program during their absence. The facility did not report a significant COVID-19 outbreak to the appropriate state agency, despite being aware of the outbreak's progression. The outbreak began with two residents testing positive, followed by additional cases over a two-week period. Although the facility reported the outbreak to the National Healthcare Safety Network (NHSN), it failed to notify the state agency as required. Additionally, the facility did not complete N-95 respirator fit testing for staff, as observed in several instances where staff members were either improperly using or not using the required personal protective equipment (PPE). Staff members, including a Housekeeping Aide, a CNA, and an RN, were either not fit-tested or were unaware of where to find N-95 respirators in the facility. The Infection Preventionist confirmed that fit testing had not been conducted, which was a critical responsibility outlined in their job description.
Failure to Document and Investigate Resident Grievance
Penalty
Summary
The facility failed to ensure a grievance report was initiated and followed through for a resident who was involved in an incident where a nonclinical staff member performed a task outside their scope of duties. The resident, who had been admitted with acute post-traumatic pain and fractures, had their feet and legs massaged by a janitor, as reported by the resident's significant other. This incident was not documented in the facility's grievance log, despite being reported to the Administrator and other staff members. Interviews with various staff members, including a CNA, Case Manager, and the alleged housekeeper, confirmed the occurrence of the incident. The housekeeper admitted to applying medicated ointment and socks to the resident, which was outside their job duties. The facility's policy required all grievances to be documented and investigated, but this was not done in this case, leading to a deficiency in handling resident grievances appropriately.
Failure to Administer Vancomycin Upon Admission
Penalty
Summary
The facility failed to initiate Vancomycin medication upon admission for a resident with a serious infection, as per the hospital discharge instructions. The resident was admitted with diagnoses including infection following a procedure and enterocolitis due to Clostridium difficile. The hospital discharge instructions specified the continuation of Vancomycin IV 750 mg once daily. However, the medication administration record showed that the first dose of Vancomycin was not given until several days after admission. Interviews with facility staff revealed that the process for ordering medications involved using hospital discharge instructions to electronically send orders to the pharmacy. The Unit Manager and Nurse Supervisor indicated that the process should take less than a day, and emergency medications, including Vancomycin, were available on hand. Despite this, the resident did not receive the medication at the next required dose, which was due shortly after admission. The delay in administering the antibiotic was acknowledged by the consultant pharmacist, who emphasized the importance of maintaining dosing levels to ensure effective treatment.
Lack of Documented Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide documented evidence of discharge planning for one resident, identified as Resident 10, who was admitted for short-term rehabilitation following open heart surgery. The resident's medical record did not contain documentation of a case manager's assessment for discharge needs during their stay. Interviews with the Licensed Social Worker and the Case Manager revealed that discharge assessments should be documented within twenty-four hours of admission and continually updated, but no such documentation was found for Resident 10. The Director of Nursing confirmed the absence of a documented discharge plan in the resident's medical record, which was contrary to the facility's policy requiring early initiation and documentation of discharge planning.
Failure to Document ADL Assistance for Resident
Penalty
Summary
The facility failed to provide documented evidence of assistance with activities of daily living (ADL) for one resident, identified as Resident 3 (R3), who was dependent on staff for toileting hygiene. R3 was admitted with diagnoses including abnormalities of gait and mobility, and osteomyelitis of the vertebra, sacral, and sacrococcygeal region. The resident's care plan indicated a self-care performance deficit due to Parkinson's disease and acute respiratory failure, requiring staff assistance for toileting and cleaning the peri-area with each incontinent episode. However, the Admission Minimum Data Set (MDS) and ADL Flowsheet for February and March 2024 showed that documentation for toileting hygiene during the day shift was marked as Not Applicable (NA) on multiple dates, indicating a lack of recorded assistance. The MDS Coordinator confirmed that R3 was dependent on ADLs and required help from staff with toileting hygiene, including changing adult briefs. A Certified Nursing Assistant (CNA) acknowledged that the documentation should have reflected the resident's dependency and the assistance provided. The Director of Nursing (DON) stated that CNAs were expected to document ADL assistance every shift. The facility's policy on ADLs emphasized that residents unable to perform activities of daily living should receive necessary services to maintain good nutrition, grooming, and personal hygiene. The lack of documentation for R3's toileting hygiene assistance during the specified periods constituted a deficiency in care.
Failure to Complete Wound Evaluations and Psychiatric Consultations
Penalty
Summary
The facility failed to ensure weekly wound evaluations were completed and documented accurately for a resident with multiple surgical wounds. The resident was admitted with acute post-traumatic pain and fractures, and initial evaluations noted several surgical incisions with staples. However, subsequent weekly skin observations inaccurately documented no skin conditions, and there was a lack of documented weekly wound evaluations for three consecutive weeks. The Director of Nursing confirmed the absence of these evaluations and acknowledged the inaccuracies in the resident's skin observations. Additionally, the facility did not implement a physician's order for a psychiatric consultation for another resident exhibiting aggressive and inappropriate behaviors. The resident, diagnosed with altered mental status due to metabolic encephalopathy, displayed combative and sexually inappropriate behavior towards staff. Despite two orders for a psychiatric evaluation, there was no documentation of the consultation being completed or coordinated by the nursing staff. The Unit Manager and Director of Nursing confirmed the lack of documentation and coordination for the psychiatric consultation. These deficiencies highlight the facility's failure to adhere to its policies regarding wound care and psychiatric evaluations, potentially delaying necessary assessments and interventions for the residents involved.
Failure to Conduct Weekly Wound Evaluations and Accurate Skin Observations
Penalty
Summary
The facility failed to ensure that weekly wound evaluations were completed and weekly skin observations were documented accurately for one resident. This deficiency was identified for a resident who was admitted with multiple skin conditions, including a stage 1 pressure wound on the right heel, a stage 3 pressure wound on the right buttock, and a deep tissue injury on the left iliac crest. Despite these conditions, the resident's medical record lacked documented evidence of weekly wound evaluations from admission to discharge. The weekly skin observations documented in the resident's medical record inaccurately reported no skin conditions, which contradicted the initial wound care consultation notes. Interviews with the Wound Care Nurse, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed the absence of weekly wound evaluations and the inaccuracies in the weekly skin observations. The facility's policy required nursing staff to complete weekly wound evaluations and skin observations to monitor residents' skin conditions. However, the wound care team did not fulfill this responsibility, and the charting did not accurately reflect the resident's skin conditions, as acknowledged by the DON.
Failure to Manage Sharps Containers and Supervise Smoking Area
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by not properly managing sharps containers. On multiple occasions, sharps containers were observed to be overfilled beyond the manufacturer's recommended fill line, with sharp objects such as used razors protruding from the containers. This was confirmed by various staff members, including an LPN and the Assistant Director of Nursing, who acknowledged that the containers should have been replaced when they reached three-quarters of their capacity. Despite having an adequate supply of empty sharps containers, the facility did not adhere to its policy of replacing them in a timely manner, thereby increasing the risk of needle stick injuries. Additionally, the facility did not ensure adequate supervision in the designated smoking area, which posed a safety risk to residents. Several residents were observed smoking without staff supervision in an area where a propane-fueled gas grill was improperly stored with its controls set to a low position, which could potentially start a flame. The Administrator acknowledged that the grill should have been removed after a barbeque event and that the area should have been cleaned of cigarette butts. Furthermore, residents were not consistently assessed for their ability to smoke independently, with many not having received a quarterly assessment as required by the facility's policy. The lack of supervision and failure to conduct regular assessments of smoking residents were confirmed by various staff members, including a Nursing Supervisor and the Director of Nursing. The facility's policy required that all smoking residents be evaluated for their ability to smoke independently and that these evaluations be reviewed monthly by the interdisciplinary team. However, the facility did not comply with these requirements, as evidenced by the outdated assessments and unsupervised smoking sessions, compromising the safety and well-being of the residents.
Improper Use of Personal Blood Pressure Monitors for Residents on Transmission-Based Precautions
Penalty
Summary
The facility failed to ensure that staff used appropriate equipment for residents on transmission-based precautions, leading to a potential risk of cross-contamination. On December 4, 2024, a CNA was observed using a personal electronic blood pressure monitor to take vital signs for residents, including those on transmission-based precautions. The CNA confirmed using the same equipment for multiple residents and was unaware of the facility's disposable blood pressure cuffs. The CNA attempted to disinfect the equipment with bleach wipes but was not familiar with the required contact time for effective disinfection, and the equipment was wiped dry with a tissue after cleaning. Another CNA also used a personal blood pressure monitor for residents and disinfected it with bleach wipes, allowing it to air dry or wiping it with a tissue. The Director of Nursing confirmed that residents on transmission-based precautions should have dedicated equipment, and staff were expected to follow the manufacturer's instructions for disinfecting wipes. The facility's policy stated that non-critical resident-care equipment should be dedicated to a single resident when possible, and if reuse was necessary, it should be cleaned and disinfected according to guidelines. The manufacturer's instructions for the disinfecting wipes specified different kill times for various pathogens, which were not followed by the staff.
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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