Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at El Jen Skilled Care during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A resident with a history of smoking and cognitive decline was not re-assessed for smoking safety or had their care plan updated after a significant change in condition. After being found smoking in their room while on oxygen, staff did not complete a new smoking safety assessment or revise the care plan. The facility also failed to secure the resident's lighter and cigarettes, resulting in a fire that caused burns and smoke inhalation, requiring hospitalization.
Surveyors identified that the facility did not maintain its fire alarm system, as the main panel displayed a trouble alarm for a missing duct detector and showed an incorrect date and time after a power outage. The facility also lacked documentation of annual portable fire extinguisher inspections and had a fire safety plan that omitted protocols for extinguisher use and procedures for reviewing the fire alarm panel during alarms. These deficiencies affected 36 residents in one smoke compartment.
Staff removed the battery from a resident's motorized wheelchair without first obtaining the resident's permission or providing an explanation, following an incident where the resident accidentally ran over another individual's foot. The action was taken while the resident was out of the room, and both the Administrator and Maintenance Director later acknowledged that consent should have been obtained in accordance with resident rights.
A resident with multiple psychiatric and medical diagnoses was administered Seroquel, a psychotropic medication, without documented informed consent prior to the first dose. Facility staff, including an RN and the DON, confirmed that policy requires consent before administration, but the required documentation was missing from the resident's medical record.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not upheld, reflecting a failure to ensure resident autonomy in medical decision-making.
Two residents with complex medical conditions were not provided with education on the risks and benefits of pneumococcal, influenza, and COVID-19 vaccines, nor was there documentation of vaccine administration or declination. Staff interviews confirmed that required procedures for reviewing and documenting immunization status were not followed for these residents.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with cognitive impairment and a history of wandering was able to exit the facility undetected while wearing a wander guard bracelet that failed to activate an alert. The resident was not discovered missing until several hours later and was found outside the facility. Investigation revealed that the wander guard device's functionality had not been properly tested for this resident, leading to the deficiency.
A resident with multiple health conditions was physically abused by a CNA during a verbal altercation, resulting in the CNA's arrest. The incident was witnessed by another CNA, and the resident reported no physical or emotional harm. The facility documented the incident and implemented safety interventions.
A facility failed to report an alleged verbal abuse incident involving a resident with parkinsonism and other conditions to the State Agency within the required timeframe. The resident was documented as threatening another resident with a butter knife. The incident was reported five days late, contrary to the facility's policy requiring a two-hour reporting window for abuse allegations.
A facility failed to follow physician's orders for a resident requiring bilateral heel protectors at all times in bed. Observations showed the protectors were not applied, and staff interviews revealed inconsistencies in their application. The resident had a history of a healed wound and was at risk for skin breakdown, necessitating the use of heel protectors as ordered.
The facility failed to maintain an effective pest control program, as live cockroaches were found in the kitchen. During an inspection, two live and several dead baby cockroaches were observed behind the stove near the sink, with the area soiled by food debris and grease. The Maintenance Director confirmed the findings and provided a pest control report from two weeks prior, which did not document any live insect detection.
A facility failed to refer a resident for a PASRR Level 2 evaluation after a new diagnosis of bipolar disorder. The resident, admitted with various medical conditions, had no documented referral for evaluation following the new diagnosis. The ADON was unaware of the process, and the MDS Coordinator confirmed the oversight, citing new management and staff as contributing factors. The facility's policy required PASRR completion for all admissions, which was not followed.
The facility failed to develop and implement person-centered care plans for two residents, leading to potential health risks. One resident with end-stage renal disease exceeded fluid restrictions without a care plan addressing non-compliance, while another resident with dementia and high sodium levels lacked a hydration care plan despite refusal to drink fluids. Staff confirmed the absence of necessary care plans, highlighting a failure to adhere to facility policies.
A resident with Alzheimer's and other conditions, who was dependent on staff for oral care, did not receive consistent oral hygiene. The resident was observed with a dry mouth and white stringy material, indicating neglect in oral care. Despite the care plan requiring daily mouth care, records showed inconsistent provision of oral hygiene. The DON confirmed that oral care should have been provided at least twice daily.
A resident with dementia and anxiety disorder experienced two falls, but the facility failed to complete post-fall neurological checks as required by their protocol. The Director of Staff Development and the DON confirmed the absence of these checks in the medical records, which could delay necessary medical intervention.
A resident with dementia and cognitive impairment was found shaving with multiple razors in their room, resulting in a small facial cut. The RN confirmed the resident should not have had access to razors due to confusion and accident risk. Facility policy required interventions to reduce environmental hazards, but this was not followed.
The facility failed to implement a fluid restriction for a dialysis-dependent resident and did not provide a one-on-one feeding assistant for another resident at risk for weight changes. Despite physician orders, the fluid restriction was not monitored, and the feeding assistance was not provided, leading to potential adverse health outcomes.
A resident with a midline IV line had the access left in place without therapeutic need, despite the initial treatment for hypotension being completed. The facility's policy required removal of unused IV lines, but there was no documentation or action taken to address the unnecessary IV access, posing a potential infection risk.
The facility failed to provide prescribed medications for two residents due to a lack of timely reordering. One resident did not receive Duloxetine for depression, and another did not receive Sertraline for major depressive disorder. The nursing staff did not follow the facility's policy to ensure medication availability, leading to a deficiency in pharmaceutical services.
The facility failed to discard expired medications, including compounded IV Vancomycin and Sodium Chloride tablets. An LPN confirmed that the medications, which were past their 'do not use' dates, should have been discarded or returned to the pharmacy as per facility policy.
The facility failed to follow guidelines for food storage, as eight packets of hamburger buns were found in the dry storage area beyond the recommended time. The cook confirmed the buns had been stored for more than two weeks, contrary to the facility's policy and storage chart, which indicated a storage time of four to five days.
A facility failed to ensure wound care contractors followed enhanced barrier precautions (EBP) during the treatment of a resident with a stage 4 decubitus ulcer. Despite a sign indicating the need for EBP, including PPE such as gloves and gowns, the wound care staff did not wear PPE during the procedure. This was confirmed by the charge nurse and the Director of Nursing, who noted the lack of training for the wound care team on EBP, as required by the facility's policy.
A facility failed to ensure abuse policies were implemented when a CNA reported hearing a noise suggestive of abuse but did not intervene to stop it. Despite being up to date on abuse training, the CNA did not follow protocol to ensure resident safety first.
The facility failed to ensure an incident where a resident with dementia and Alzheimer's disease was forced to take medications was promptly reported to the abuse coordinator and the agency. The incident, witnessed by multiple staff members, was not reported immediately, leading to a delay in investigation and reporting to the state agency. The deficiency highlights a failure in timely reporting and addressing suspected abuse, neglect, or theft.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Failure to Reassess Smoking Safety and Secure Smoking Materials Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff re-assessed a resident's smoking status and updated the care plan following a significant change in the resident's cognitive condition. The resident, who had a history of cigarette smoking and was at risk for injury and inappropriate behaviors, experienced a decline in cognition as documented by a lower BIMS score. Despite this significant change, the resident's smoking safety was not re-evaluated, and the Minimum Data Set (MDS) inaccurately reflected no tobacco use. The medical record lacked a corresponding Smoking Safety evaluation and care plan update after the change in condition. Additionally, after an incident where the resident was found smoking inside their room while using oxygen, staff did not complete a new smoking safety assessment or update the care plan as required by facility protocol. The Activity Director and DON confirmed that the event should have triggered a reassessment and care plan revision, but these actions were not taken. The resident's medical record did not reflect any follow-up or documentation of the incident in the smoking safety evaluation. Furthermore, the facility failed to secure the resident's lighter and cigarettes, contrary to the facility's protocol that prohibited residents from retaining smoking paraphernalia. Despite the implementation of a new smoking program protocol, the resident was able to access smoking materials and subsequently caused a fire in their room while using oxygen. This resulted in the resident sustaining burns and smoke inhalation, requiring hospitalization.
Failure to Maintain Fire Alarm System, Fire Extinguishers, and Fire Safety Plan
Penalty
Summary
The facility failed to maintain its fire alarm system, portable fire extinguishers, and fire safety plan in accordance with National Fire Protection Association (NFPA) standards. During a facility tour, the main fire alarm panel was observed to display a system trouble alarm, specifically indicating a missing duct detector in the water heater room. The fire alarm panel also showed an incorrect date and time, which the Maintenance Director attributed to a recent power outage and subsequent hard reset of the system. The facility was aware of the trouble alarm but had only scheduled future repairs with the vendor. Additionally, document review revealed that the facility could not provide evidence of annual inspections for portable fire extinguishers. Review of the facility's evacuation and fire safety plan showed that it lacked protocols for the use of portable fire extinguishers, such as the P.A.S.S. method, and did not include procedures for reviewing the fire alarm annunciator panel during an alarm condition. These deficiencies affected 36 residents in one of six smoke compartments, with the facility having a census of 137 residents at the time of the survey.
Failure to Obtain Resident Permission Before Removing Wheelchair Battery
Penalty
Summary
Staff failed to obtain permission from a resident prior to removing the battery from the resident's motorized wheelchair. The resident, who had diagnoses including multiple sclerosis, generalized anxiety disorder, and pain, was involved in an incident where the motorized wheelchair accidentally ran over another resident's foot. Following this incident, the resident was informed that they would be using a manual wheelchair for safety reasons. However, the battery of the motorized wheelchair was removed from the resident's room by the Maintenance Director, under the Administrator's instruction, without the resident's knowledge or consent while the resident was away at a doctor's appointment. The resident reported being upset that the battery was removed without their permission and confirmed that no one from the facility had asked for consent or explained the reason for the removal prior to the action. Both the Administrator and Maintenance Director acknowledged that the resident's permission should have been obtained and that the reason for the removal should have been communicated. The facility's own policy, as outlined in the Notice of Resident Rights, affirms the resident's right to a dignified existence, self-determination, and to be treated with respect and dignity.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering a psychotropic medication to a resident. The resident, who had diagnoses including type 2 diabetes mellitus, schizoaffective disorder bipolar type, major depressive disorder, and anxiety disorder, was prescribed Seroquel for paranoia, agitation, and irritability. Documentation showed that Seroquel was first administered on 07/17/2025, but there was no evidence in the medical record that informed consent had been obtained from the resident or their representative before the initial dose. Both a Registered Nurse and the Director of Nursing confirmed that facility policy requires informed consent prior to administering psychotropic medications, and that this was not documented for the resident in question.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulation. Specific actions or inactions leading to this deficiency are not detailed in the provided excerpt, but the deficiency centers on the lack of adherence to resident autonomy in medical decision-making.
Failure to Document and Educate on Vaccination Status
Penalty
Summary
The facility failed to ensure that education regarding the risks and benefits of pneumococcal, influenza, and COVID-19 vaccines was provided to residents, and did not ensure administration or obtain documented declinations for two of five residents reviewed for infection control. Specifically, two residents with significant medical histories, including infection of an amputation stump, cellulitis, depression, and chronic systolic heart failure, could not recall being offered immunizations or receiving explanations about the risks and benefits. There was no documented evidence that these residents had been educated about or offered the relevant immunizations. Interviews with facility staff revealed that the process for new admissions included reviewing immunization status, offering vaccines, and obtaining signed consent or declination, but this process was not documented for the two residents in question. The Infection Preventionist and Director of Nursing both acknowledged the absence of documentation regarding vaccination status for these residents, despite facility policy requiring immunization status to be determined and recorded upon admission or soon after.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Resident Elopement Due to Failure of Wander Guard System and Inadequate Supervision
Penalty
Summary
A resident with a history of Parkinsonism, major depressive disorder, and dementia with mood disturbance, who had demonstrated moderate to severe cognitive impairment, was able to elope from the facility without detection. The resident was last seen by staff in the evening and received medications and vital sign checks, but was later observed on security footage independently exiting the facility through a designated door in the early morning hours. The resident was not discovered missing until several hours later during a routine check, prompting a facility-wide search and eventual recovery of the resident outside the facility by a staff member. At the time of the elopement, the resident was wearing a wander guard bracelet, which failed to trigger an alert when the resident exited the building. The facility's investigation revealed that the functionality of the wander guard device had not been adequately tested for this resident, and the system did not activate as intended. Documentation showed that the maintenance department routinely checked the wander guard system at facility doors, but there was an oversight in ensuring the resident's individual device was operational, which contributed to the resident's ability to leave the facility undetected.
Resident Safety Compromised by CNA Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Certified Nurse Assistant (CNA) and a resident. The resident, who was admitted with acute respiratory failure, chronic obstructive pulmonary disease, and diabetes mellitus type 2, was involved in a verbal altercation with a CNA while being cared for in bed. This altercation escalated when the CNA struck the resident in the rib area with a closed fist. The incident was witnessed by another CNA, and the police were contacted, leading to the arrest of the offending CNA. The resident underwent a head-to-toe assessment following the incident, which revealed no bruising or discoloration, and the resident reported no pain or discomfort. Social Services and the facility's Administrator provided emotional support to the resident, who reported no psychosocial harm or emotional distress from the incident. The facility documented the incident in the resident's care plan, noting the altercation and implementing interventions to ensure the resident's safety and encourage communication of concerns.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident to the State Agency (SA) within the required timeframes. The incident involved a resident who was admitted with diagnoses including parkinsonism, dysphagia, cognitive communication deficit, and depression. On a specific date, the resident was documented in a behavior note as standing in the hallway with a butter knife in their sleeve, threatening to harm another resident. The Facility Reported Incident (FRI) was submitted to the SA five days after the incident, which was not within the required 24-hour timeframe for reporting abuse without serious bodily harm. The facility's policy, revised in 2022, mandates that allegations of verbal abuse, including threats, be reported to the appropriate agencies within two hours if the allegation involves abuse. The Administrator/Abuse Coordinator confirmed the delay in reporting.
Failure to Apply Heel Protectors as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders for the application of heel protectors for one resident, identified as Resident 5. The physician's orders, dated September 2, 2023, specified that bilateral heel protectors should be worn at all times when the resident is in bed to provide pressure relief and prevent skin breakdown. However, observations on December 18, 2024, revealed that the heel protectors were not applied while the resident was in bed at multiple times throughout the day. Instead, the heel protectors were found on top of a three-drawer organizer at the foot of the resident's bed. Interviews with facility staff, including a CNA, an LPN, and the Wound Treatment Nurse, indicated a lack of consistent application of the heel protectors. The CNA mentioned that the heel protectors were applied and removed at different times during the day, while the LPN incorrectly stated that the protectors were only needed at night if the resident had wounds. The Wound Treatment Nurse confirmed that the resident had a history of a healed wound and was at risk for skin breakdown, thus necessitating the use of heel protectors as ordered. The Director of Nursing also verified the need for heel protectors to be in place as per the physician's orders, highlighting a failure in following the prescribed care plan for the resident's condition and needs.
Deficient Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of live cockroaches in the kitchen. During a kitchen inspection, two live baby cockroaches and several dead ones were found in a corner behind the stove area near the triple compartment sink. The floor surface in this area was soiled with food debris and grease. The Maintenance Director confirmed the observation and provided proof of pest control performed two weeks prior, but the report did not document if live insects were detected during that visit. The facility's policy, last revised in May 2024, stated that an ongoing pest control program would be maintained to keep the facility free of insects.
Failure to Refer Resident for PASRR Level 2 Evaluation
Penalty
Summary
The facility failed to establish a process to identify residents with newly found changes or diagnoses that require a referral for a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation. This deficiency was identified for one of the 27 sampled residents, specifically Resident 98, who was admitted with diagnoses including orthopedic aftercare following surgical amputation, type 2 diabetes, and peripheral vascular disease. Despite a new diagnosis of bipolar disorder being documented on 08/13/2024, there was no evidence in the medical record that a referral for a PASRR Level 2 evaluation was made. The Assistant Director of Nursing (ADON) was unaware of the facility's process for requesting a PASRR Level 2 evaluation following a new mental illness diagnosis. The Minimum Data Set (MDS) Coordinator acknowledged that the medical record should have been reviewed after the new diagnosis, and a referral for evaluation should have been completed. The lack of a system to evaluate for PASRR Level 2 after a new diagnosis was attributed to new management and staff. The facility's policy, titled PASRR Completion Policy, indicated that all admissions should have the appropriate PASRR completed, but this was not adhered to in this case.
Failure to Implement Person-Centered Care Plans for Fluid Management
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to potential health risks. Resident 112, who was admitted with end-stage renal disease and a history of sudden cardiac arrest, was on a physician-ordered fluid restriction of 1000 ml per day. However, observations revealed that the resident had access to fluids exceeding this limit, including a yellow pitcher with ice water and additional drinks. Despite the resident's non-compliance with the fluid restriction, there was no documented care plan addressing this issue, and the staff failed to notify the physician or formulate a care plan to manage the resident's fluid intake. Resident 93, diagnosed with dementia, had consistently high sodium levels and was at risk of dehydration. The resident refused to consume fluids, and despite a physician's order to encourage fluid intake, the nursing staff did not actively promote hydration during meals. The resident's medical record lacked a care plan for hydration, even though the dietitian noted the resident's refusal to drink and the potential need for a feeding tube if hydration could not be maintained. The facility's policy on nutrition and hydration, which was outdated, indicated that a care plan should be documented for residents at risk of dehydration, but this was not done for Resident 93. The deficiencies in care planning for both residents were confirmed by various staff members, including an LPN, an RN Supervisor, and the Director of MDS. They acknowledged the absence of care plans for fluid restriction and hydration, which should have been developed upon receiving physician orders or identifying non-compliance. The lack of proper documentation and care planning for these residents' specific needs highlighted a failure to adhere to the facility's policies and procedures, potentially compromising the residents' health and safety.
Inadequate Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate oral care for a resident who was totally dependent on staff for assistance. The resident, who had diagnoses including Alzheimer's, hypothyroidism, hypertension, dysphagia, and schizoaffective disorder, was receiving hospice care and required assistance from two or more helpers for oral care. On a specific date, the resident was observed with a dry mouth and white stringy material, indicating a lack of proper oral hygiene. A Licensed Practical Nurse confirmed that oral care should have been provided by a Certified Nursing Assistant. The resident's care plan highlighted the need for daily mouth care due to the potential for oral health problems. However, a review of the Oral Care Record showed that oral care was provided inconsistently over a period of time. The Director of Nursing acknowledged that oral care should have been administered at least twice daily, regardless of the resident's hospice status.
Failure to Complete Post-Fall Neurological Checks
Penalty
Summary
The facility failed to complete post-fall neurological checks for a resident after two separate falls, which is a deficiency in following the established post-fall protocol. Resident 106, who has diagnoses including unspecified dementia, adult failure to thrive, and anxiety disorder, experienced falls on two occasions. On 06/09/2024, the resident was found on the floor with skin tears and bleeding, but the post-fall evaluation lacked documentation of fall details, vitals, contributing factors, and interventions. Similarly, on 08/16/2024, the resident reported a fall, but the medical record did not contain evidence of completed neurological checks. The Director of Staff Development and the Director of Nursing both confirmed the absence of documented neurological checks in the medical records for the falls on 06/09/2024 and 08/16/2024. The facility's protocol, as outlined in an undated document titled 'Fall Documentation Requirements,' mandates neurological checks and continued monitoring after a fall, which were not adhered to in these instances. This failure to follow protocol could potentially delay necessary medical intervention and care for residents.
Resident Access to Razors Despite Cognitive Impairment
Penalty
Summary
The facility failed to ensure a resident with dementia did not have access to razors in their room, leading to a deficiency in maintaining a safe environment free from accident hazards. Resident 8, who was admitted with diagnoses including dementia with behavioral disturbance, psychotic disorder, depressive disorder, and anxiety, was observed on August 20, 2024, at 10:00 AM shaving himself in the bathroom with a small cut on the left side of his face and five additional razors on the sink. A Registered Nurse confirmed the observation and noted that the resident had cognitive impairment, and it was unknown how the resident obtained the razors. The RN stated that Certified Nursing Assistants were responsible for assisting the resident with activities of daily living, including shaving, and indicated that the resident should not have had access to razors due to confusion and the risk of accidents. The facility's policy titled Safety and Supervision of Residents, dated July 2017, required the care team to implement interventions to reduce individual risks related to environmental hazards, including providing adequate supervision. However, the facility did not adhere to this policy, resulting in the resident's access to razors and the subsequent accident.
Failure to Implement Fluid Restriction and Feeding Assistance
Penalty
Summary
The facility failed to adhere to a fluid restriction order for a dialysis-dependent resident, Resident 112, which was not properly implemented or monitored. Despite a physician's order for a 1000 ml fluid restriction, Resident 112 was observed with excess fluids at the bedside, including a large pitcher of ice water and additional drinks. The resident's medical records lacked documentation of the fluid restriction being followed, and there was no evidence of physician notification regarding the resident's non-compliance. Staff interviews revealed a lack of communication and documentation regarding the fluid restriction, contributing to the oversight. Additionally, the facility did not provide a one-on-one feeding assistant for Resident 22, who was at risk for weight changes. Despite a physician's order for one-on-one feeding assistance due to abnormal weight fluctuations, Resident 22 was observed eating meals without the required supervision. The resident's intake records showed inconsistent meal consumption, and staff interviews confirmed the absence of the mandated feeding assistance. The deficiencies in both cases highlight a failure in communication and adherence to physician orders, resulting in potential adverse health outcomes for the residents involved. The facility's policies and procedures for monitoring and implementing dietary restrictions and assistance were not effectively followed, as evidenced by the lack of documentation and staff awareness of the residents' specific needs.
Failure to Discontinue Unused IV Access
Penalty
Summary
The facility failed to ensure the discontinuation of an Intravenous (IV) access when it was no longer therapeutically needed for one resident. The resident, who was admitted with diagnoses including cerebral infarction and dysphagia, had a midline IV line in place with a dressing dated two days prior to the observation. Despite the IV access being present, there was no IV pump in the vicinity, and the resident, who was non-verbal, could not confirm its use. The physician's orders indicated that the IV was initially placed for a one-time hydration treatment due to hypotension, which was resolved after the administration of a saline bolus. However, there was no documented evidence in the physician or nursing progress notes justifying the continued presence of the midline IV. Interviews with nursing staff and the infection preventionist revealed that the unused IV line should have been addressed with the primary physician and discontinued if not needed. The facility's policy on IV catheter removal stated that the catheter should be removed if infusion therapy was discontinued, if not used within 24 hours, or if it was no longer part of the care plan. The failure to remove the IV line when it was no longer necessary posed a potential risk of infection due to the prolonged portal of entry for microorganisms.
Medication Unavailability for Two Residents
Penalty
Summary
The facility failed to ensure medications were acquired and available as prescribed for two residents, leading to a deficiency in pharmaceutical services. Resident 29, who was admitted with diagnoses including muscle wasting, atrophy, depression, and anxiety disorder, had a physician order for Duloxetine Hydrochloride 30 mg daily for depression. However, on August 22, 2024, the medication was not administered due to unavailability. The Licensed Practical Nurse (LPN) explained that the Duloxetine ran out of supply because the previous nurses did not reorder it when the supply was low. The Pharmacy Technician confirmed that the last order was placed on August 9, 2024, with 14 tablets delivered, and refills needed to be requested manually. Similarly, Resident 7, admitted with anxiety disorder and major depressive disorder, had a physician order for Sertraline Hydrochloride 50 mg daily. On the same day, the medication was unavailable for administration, and the LPN indicated it needed to be reordered. The Pharmacy Technician confirmed that a refill request was not placed until that day. The facility's policy required the nursing staff to ensure a sufficient supply of medications and contact the pharmacy if medications were unavailable, which was not adhered to in these cases.
Expired Medications Not Discarded
Penalty
Summary
The facility failed to ensure the proper disposal of expired medications, specifically compounded intravenous (IV) antibiotics and a bottle of tablet medications. During an observation on 08/22/2024, it was found that two bags of compounded IV Vancomycin, filled on 07/30/2024, and four bags filled on 08/01/2024, were still stored in the medication refrigerator of the 400 Hall medication room, despite having a 'do not use' date of 08/15/2024. A licensed practical nurse (LPN) confirmed that these IV medications should have been discarded as the resident had completed the antibiotic regimen, and the leftover bags should have been returned to the pharmacy. Additionally, an expired bottle of Sodium Chloride tablets, which expired in 07/2024, was found in the medication storage room. An LPN confirmed that the Sodium Chloride tablets were expired and should have been discarded to ensure resident safety. The facility's policy on Medication Labeling and Storage, revised in February 2023, states that discontinued, outdated, or deteriorated medications should be returned or destroyed as per the dispensing pharmacy's instructions.
Improper Food Storage Practices
Penalty
Summary
The facility failed to adhere to guidelines for food storage and use, which could potentially expose residents to foodborne illnesses. During an inspection of the kitchen, eight packets of hamburger buns dated 07/27/2024 were found in the dry storage area on 08/20/2024. The cook confirmed that each packet had a sticker indicating the date they were received and acknowledged that the buns had been stored for more than two weeks, exceeding the recommended storage time. According to the facility's policy titled 'Food Receiving and Storage,' food should be stored in compliance with safe handling practices. Additionally, the facility's 'Dry Storage Chart' indicated that unopened packets of bread, including hamburger buns, should be stored for four to five days in the dry storage area.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure that wound care contractors adhered to enhanced barrier precautions (EBP) during the treatment of a resident with a stage 4 decubitus ulcer. The resident, who was admitted with chronic obstructive pulmonary disease, schizoaffective disorder, and anemia, required wound care for a severe pressure ulcer in the sacral area. Despite a sign posted at the entrance of the resident's room indicating the need for EBP, including the use of personal protective equipment (PPE) such as gloves and gowns, the wound care staff did not wear PPE during the procedure. This observation was confirmed by the charge nurse, who acknowledged that the wound care team should have followed the EBP guidance to prevent cross-contamination. The deficiency was further supported by a physician order and a care plan, both of which documented the necessity of EBP for the resident's pressure injury. The Director of Nursing (DON) confirmed that the contractor wound care team lacked training related to EBP, which was a requirement according to the facility's policy. The policy, last revised in March 2024, stipulated that EBP, including the use of gloves and gowns, should be implemented during high-contact activities like wound care to reduce the transmission of multidrug-resistant organism (MDRO) infections. The policy also indicated that staff should be trained on EBP before caring for residents.
Failure to Implement Abuse Policies and Procedures
Penalty
Summary
The facility failed to ensure abuse policies and procedures were implemented for one of the sampled residents. A Certified Nursing Assistant (CNA1) reported hearing a noise that sounded like a hand slapping against skin while another CNA (CNA2) was providing care to a resident. Despite having concerns about potential physical abuse, CNA1 did not intervene to stop the alleged abuse and instead walked directly to the charge nurse to report the incident. The facility's investigation confirmed that CNA1 did not see any physical abuse but heard sounds that raised concern. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) both indicated that the facility protocol required staff to first ensure resident safety by intervening and then contact the abuse coordinator, which CNA1 failed to do. The Licensed Social Worker (LSW) familiar with the incident explained that a reenactment showed it would be nearly impossible to see the interaction between the staff member and the resident without entering the room. The LSW and DON both confirmed that CNA1's actions did not meet the facility's expectations. Despite being up to date on abuse training, CNA1 did not follow the protocol of intervening to stop suspected abuse. The facility's policy on Resident Rights documented that all residents would be free from abuse, neglect, misappropriation of property, and exploitation.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to ensure an incident involving an elderly resident with dementia and Alzheimer's disease, who was forced to take medications, was promptly reported to the abuse coordinator and the agency within the mandated timeframes. The incident occurred when a Certified Nursing Assistant (CNA) witnessed another CNA holding the resident's head while a Licensed Practical Nurse (LPN) forced the resident to take medication. The incident was not reported immediately, and the investigation and reporting to the state agency were delayed, compromising the resident's health and well-being. The resident's care plan documented episodes of resistance to care during medication administration, with interventions including re-approaching calmly and re-offering medication. Despite this, the incident where the resident was forced to take medication was witnessed by multiple staff members and reported to the family, but not to the supervisor or abuse coordinator. The family had previously witnessed similar incidents and had advised the LPN to stop forcing the medication. The facility's investigation confirmed the incident, but there was a significant delay in reporting it to the state agency. Interviews with staff and the Director of Nursing (DON) confirmed the delay in reporting and investigating the incident. The involved staff members received abuse training, and the facility reported the incident to the nursing board. The facility's policies on resident rights and abuse investigation and reporting were not followed, as the incident should have been reported immediately and within 24 hours to the state agency. The deficiency highlights a failure in timely reporting and addressing suspected abuse, neglect, or theft, which could lead to unaddressed abuse and compromise the resident's health and well-being.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 524 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Las Vegas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Plaza Regency Post Acute Rehab | 1 mi | ★★★★★ | 23 | 0 |
| Advanced Health Care Of Summerlin | 2.1 mi | ★★★★★ | 1 | 0 |
| Silver Hills Health Care Center | 2.3 mi | ★★★★★ | 42 | 0 |
| Neurorestorative | 2.3 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Las Vegas | 2.8 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.