Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Marquis Plaza Regency Post Acute Rehab during CMS and state inspections, most recent first.
A resident with a history of dementia, CVA, prior ICH, multiple falls, and impaired mobility experienced an unwitnessed fall while alone in a dark room after attempting to ambulate without required assistance. Staff found the resident on the floor with the call light on but did not initiate an SBAR or neuro assessment, despite facility policy requiring neuro checks after unwitnessed falls and changes in condition. Over the next day, the resident developed increasing confusion, lethargy, poor oral intake, and inability to hold a conversation. The NP changed pain medication but did not order a STAT CT or immediate transfer, instead planning delayed lab work, and no formal neuro assessment protocol was started or documented. The resident was eventually sent to the hospital at family request, where imaging showed a left subdural hematoma and subarachnoid hemorrhage, confirming a serious head injury that had not been promptly identified or evaluated in the facility.
Baseline Care Plan Not Developed for Residents With PICC Lines: Two residents admitted with PICC lines did not have complete baseline care plans addressing line care. One resident’s PICC dressing was outdated and soiled, and the care plan lacked flushing and site assessment interventions. The other resident’s PICC dressing was overdue, had reinforcement tape, and the record lacked evidence that the PICC line was included in the baseline care plan.
Failure to provide fingernail care for a resident who needed assistance with personal care and had a cognitive communication deficit. The resident’s fingernails were observed to be long with dark accumulations under the nails, and the resident reported receiving showers once to twice per week without nail trimming. The RN and RCMs stated CNAs or nurses should assess and trim nails during routine care, especially on shower days.
IV line orders and maintenance were not properly carried out for three residents. Two residents had PICC lines with overdue or missing dressing-change and maintenance documentation, and one resident had an undated peripheral IV with loose tape after IV fluids were completed. The DON confirmed staff did not clarify whether the PICC lines should remain in place and that required flushing, site assessment, and dressing-change tasks were missed.
Missing CPAP Settings and Care Plan: A resident with multiple diagnoses had a physician order for nightly CPAP use, but the record lacked the specific therapy settings and a CPAP care plan. Staff stated RT handled CPAP equipment and setup, the family brought the device from home after admission, and the DON confirmed the order did not include the required settings and the care plan was absent.
Personal Refrigerator Temperatures Not Monitored: Surveyors found two residents’ personal refrigerators contained undated food and no temperature log was maintained. Staff interviews showed CNAs checked for expired food but did not take actual temperatures, while maintenance monitored only facility refrigerators. The DON later checked the two personal refrigerators and found both at 50 degrees Fahrenheit, above the facility’s stated safe storage temperature, despite policy requiring daily temperature logs and monitoring of resident room refrigeration units.
PASRR Level II Not Completed for Resident With Psychotic Behaviors. A resident with bipolar disorder, hallucinations, and repeated psychotic and aggressive behaviors had a PASRR Level I only, despite psychiatry notes documenting bipolar disorder with psychotic features and ongoing delusions, yelling, cursing, hitting, kicking, and other disruptive behaviors. Staff and SW confirmed the resident did not have a PASRR Level II, even though the resident’s behaviors and mental health indicators had worsened.
A resident with cognitive impairment sustained a skin tear during an episode of agitation and combative behavior while being transferred to a wheelchair. Although a Physician's Assistant was notified and a dressing was applied, there was no documented evidence that the resident's representative was informed of the incident or injury, despite facility policy requiring such notification.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. A resident with constipation due to pain medication lacked a care plan for bowel management. Another resident receiving treatment for insomnia and edema did not have corresponding care plans. Additionally, a resident with PTSD did not have a care plan addressing their condition, despite exhibiting related behaviors. These oversights were confirmed by facility staff, highlighting a failure to adhere to care planning policies.
A resident was discharged without a complete discharge summary, lacking a recapitulation of their stay, treatments, and a physician's signature. The facility used the wrong template, and the resident and family did not receive necessary documentation, potentially affecting post-discharge care.
A resident with a pressure injury on the right knee did not receive wound care according to physician orders. The wound care nurse used silver alginate without a physician's order, contrary to the facility's policy requiring verification of orders before treatment. This oversight was confirmed by the DNS and had the potential to delay wound healing.
A resident with end-stage renal disease had blood pressures taken on their left arm, where a fistula was located, despite a care plan and physician's order prohibiting it. This oversight was confirmed by staff and led to complications with the resident's dialysis access, requiring surgical intervention.
A resident with cerebrovascular disease and hypertension received seven medications late, resulting in a medication error rate of 25.93%. The medications were administered beyond the allowed timeframe, contrary to the facility's policy. The LPN and DON confirmed the late administration did not adhere to the policy, which requires timely medication administration.
A resident with multiple health conditions was not screened for pneumococcal vaccine eligibility, nor provided with education or the opportunity to receive the vaccine, as required by the facility's policy. The Infection Preventionist confirmed the lack of documentation and adherence to the vaccination protocol.
Failure to Perform Neuro Checks and Timely Evaluation After Unwitnessed Fall Resulting in Head Bleed
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and appropriate post-fall assessment for a resident at high risk for falls following an unwitnessed fall. The resident had a history of dementia, CVA, intracerebral hemorrhage, osteoarthritis, CHF, hypertension, diabetes, bilateral knee replacement, and multiple prior falls, including a fall with fracture within the six months prior to admission. On admission, the resident was care planned as at risk for falls due to decreased mobility from infected knee hardware, pain requiring narcotics, and a history of falls, and required assistance with positioning, transfers, and ambulation. Prior to the fall, nursing documentation described the resident’s baseline mentation as alert and oriented to person, place, and time, pleasant, cooperative, and without neurological concerns. On the date of the incident, a night-shift RN found the resident on the floor in their room at approximately 6:05 AM after an unwitnessed fall. The room was dark, the door was closed, the call-light indicator was on, and the call-light button was on the floor. The resident was lying on their back, slightly to the side, with their head near the dresser, and it was believed the resident had attempted to ambulate to the bathroom without assistance despite requiring assistance for transfers and ambulation. A fall/post-fall assessment was completed, and the NP and family were notified. The resident denied hitting their head, and no SBAR or neurological assessment was initiated at that time, despite facility protocol requiring neuro assessments after an unwitnessed fall and the resident’s known fall risk and mobility limitations. Following the fall, the resident developed increasing confusion, lethargy, and poor oral intake. An SBAR later documented that after receiving Oxycodone 10 mg, the resident became confused and disoriented, with continued confusion later that evening; the physician was notified, Oxycodone was discontinued, and Tramadol was ordered. Nursing notes documented that overnight the resident continued to exhibit delirium and confusion. The next day, the resident was described as confused, lethargic, forgetful, with decreased awareness of surroundings and refusal to eat, and later as alert but disoriented, lethargic, non-responsive at times, unable to hold a conversation, exhibiting hallucination-like behaviors, with poor oral intake and decreased participation in therapy. The NP evaluated the resident, attributed confusion to multiple factors including diagnoses and medications, did not order a STAT CT scan, and instead ordered labs for a later date, with no immediate imaging or transfer planned. Despite facility policy requiring neurological assessments following a fall involving head trauma or a change in condition, the RCM, ADON, and NP confirmed that no neurological assessment protocol was initiated or documented after the unwitnessed fall, even as the resident’s confusion and lethargy progressed. The resident was ultimately transferred to the hospital at the family’s request due to worsening condition, including ongoing confusion, lethargy, inability to hold a conversation, and decreased oral intake. Emergency Department records documented that the resident presented after an unwitnessed fall with subsequent confusion and altered mental status, with sudden worsening of mental status and bruising to the left cheek concerning for head strike. A CT scan of the head revealed a 4 mm left subdural hematoma and a posterior left temporal subarachnoid hemorrhage with no significant mass effect. Prior imaging from before admission had shown only a chronic infarct with no acute intracranial bleeding, and facility leadership confirmed there was no intracranial bleeding at baseline. The PA interviewed during the survey stated that increased confusion and altered mental status after an unwitnessed fall represented a significant change in condition and an emergency, and that standard clinical practice would be to obtain an immediate CT scan to rule out intracranial injury. The facility’s failure to recognize and respond in a timely manner to the resident’s significant change in condition, to initiate required frequent and systematic neurological assessments, and to ensure timely medical evaluation after the unwitnessed fall led to a delay in identification and treatment of the resident’s serious head injury. The facility’s own policies required staff to monitor and document the resident’s response following a fall, reassess and revise interventions when a fall occurred or condition changed, and perform neurological assessments upon physician order, following a fall involving head trauma, or with a change in condition. These neurological assessments were to include frequent neuro checks and vital signs, monitoring for lethargy, decreased level of consciousness, and weakness, and immediate reporting of any change in neurological status to the physician. The RCM and ADON confirmed that neuro assessments were separate from routine vital signs and required specific documentation, and that no such assessments were initiated or documented for this resident after the unwitnessed fall, despite ongoing confusion and lethargy. The PTA also confirmed that the resident required supervision for ambulation and was not safe to ambulate independently, and that unsupervised ambulation in a dark environment increased fall risk. The survey findings concluded that the facility failed to ensure adequate supervision and appropriate post-fall assessment, failed to recognize and respond to a significant change in condition, and failed to initiate required neurological assessments and timely medical evaluation, resulting in actual harm as evidenced by the resident’s subdural hematoma and subarachnoid hemorrhage.
Baseline Care Plan Not Developed for Residents With PICC Lines
Penalty
Summary
The facility failed to ensure a baseline care plan was developed and implemented for two residents admitted with PICC lines. Resident 159 was admitted with diagnoses including congestive heart failure and diabetes mellitus and had a right upper arm PICC line placed in the hospital for insulin infusion to treat diabetic ketoacidosis. On 09/09/2025, the PICC dressing was dated 08/29/2025 and a RN observed black matter that appeared to be dried blood around the insertion site. The RN stated the facility protocol was to change PICC dressings every seven days or sooner if soiled or loose, and noted that the nurses administering IV Lasix should have identified the outdated and soiled dressing and changed it. The resident’s baseline care plan, initiated 09/03/2025, identified the PICC line and a goal to prevent complications with an intervention to follow physician orders for dressing changes, but the record lacked documented evidence that dressing changes were followed and did not include flushing or site assessment interventions. Resident 164 was admitted with diagnoses including cellulitis of the left lower limb and had a single lumen IV access in the left upper arm placed in the hospital for antibiotics. On 09/09/2025, the dressing was dated 08/17/2025 and had reinforcement tape on the top and bottom edges. The resident stated the line had not been used since admission, staff did not routinely flush it, and no one changed the dressing. The RCM confirmed the PICC line was not in use, the dressing was overdue, and that if the physician ordered the line to remain, maintenance orders including flushing, site assessment every shift, and weekly dressing changes should have been entered and carried out. The medical record lacked documented evidence that the PICC line was included in the baseline care plan, and the DON stated the baseline care plan failed to include care and management for the resident’s PICC line.
Failure to Provide Fingernail Care
Penalty
Summary
The facility failed to ensure fingernail care was provided for one sampled resident who was unable to perform the task independently. Resident 146 was admitted with diagnoses including need for assistance with personal care and cognitive communication deficit. On observation, the resident’s fingernails on both hands were more than a quarter of an inch long and had dark brown to black accumulations of dry substances embedded between the tip of the hand and nailbed. The resident was awake and conversive during interview and stated not being sure why the fingernails were not trimmed, reporting showers from staff once to twice per week and no fingernail trimming provided. During interviews, the RN caring for the resident agreed the fingernails should have been trimmed and stated CNAs should inspect and trim fingernails during shower days, with refusals reported to the assigned nurse. Another RN stated nurses and CNAs could trim fingernails and that nails should be assessed routinely during care, especially on shower days. Two RCMs stated finger and toenails should be looked at during every care of a resident and confirmed fingernails should be trimmed by CNAs or nurses. The facility policy on assisting the nurse in examining and assessing the resident included grooming and dressing assistance with bathing, hair, and nail care.
IV Line Orders and Maintenance Not Properly Carried Out
Penalty
Summary
The facility failed to ensure safe, appropriate administration of IV fluids by not transcribing and carrying out care orders for PICC lines for two residents and by not properly dating and maintaining a short peripheral IV line for a third resident. Resident 159 was admitted with diagnoses including congestive heart failure and diabetes mellitus and had a right upper arm PICC line placed in the hospital for insulin infusion related to diabetic ketoacidosis. On observation, the PICC dressing was dated 08/29/2025 and appeared to have black dried blood around the insertion site. The resident stated the line was not used during the first few days in the facility and nearly became occluded before staff flushed it when IV Lasix was ordered. For Resident 159, the medical record did not show maintenance orders for flushing, site assessment, or dressing changes were entered on admission, and the MAR showed the PICC dressing had not been changed since admission. A physician order later documented PICC dressing changes every seven days, but the record lacked evidence that flushing and site assessment orders were transcribed and carried out in accordance with facility policy. Resident 164 was admitted with cellulitis of the left lower limb and had a left upper arm PICC line inserted in the hospital for antibiotics. On observation, the dressing was dated 08/17/2025 with reinforcement tape at the edges, and the resident stated the line had not been routinely flushed and the dressing had not been changed. The record showed a physician order for weekly PICC dressing changes and another order for normal saline flushes every shift, but the dressing had not been changed since admission and the chart also contained an order to remove the PICC line because the resident had no IV medications, while a nurse signed off on removal without the line being removed. Resident 162 was admitted with diagnoses including abnormality in blood chemistry and myopathy and had a left-hand peripheral IV line used for hydration. On observation, the peripheral IV was undated and the tape was loose at the ends, and the resident stated the line had not been used since lab results improved. An RN confirmed the line should have been signed and dated at insertion and that the line was no longer needed because dehydration had resolved. The record showed orders for a hep lock and IV fluids for two days, but there was no documented order to remove the peripheral line after the fluids were completed and no evidence that maintenance orders for flushing and site assessments were transcribed and carried out.
Missing CPAP Settings and Care Plan
Penalty
Summary
The facility failed to ensure physician orders with therapy settings were obtained and a comprehensive care plan was developed for a resident receiving CPAP therapy. The resident was admitted with diagnoses including displaced comminuted fracture of the shaft of the right femur, type 2 diabetes mellitus, and gastro-esophageal reflux disease. A physician order dated 08/28/2025 documented use of CPAP every night, but the medical record lacked a care plan for CPAP use. During interviews, the RN stated the RT managed CPAPs for residents, and the RT Director stated the RT department was responsible for equipment changes and initial setup of CPAP equipment. The RT Director was unaware the resident had a CPAP and explained that if a resident brought a CPAP from home, the settings would be preset in the device and the physician order would denote the needed settings. The RCM stated the family brought the CPAP machine to the facility after admission, the charge nurse entered the physician order when the device was delivered, and the resident lacked a CPAP care plan. The DON confirmed the physician order did not include the specific CPAP settings required for use and the resident's medical record lacked a care plan for CPAP. Facility policy required review of physician orders to determine settings and set CPAP accordingly, and required care plans to be revised as resident information and condition changed.
Personal Refrigerator Temperatures Not Monitored
Penalty
Summary
The facility failed to ensure that the temperature in two residents’ personal refrigerators was monitored. On 09/09/2025, surveyors observed the personal refrigerators for Residents 63 and 94 contained undated food items and there was no temperature log. Resident 63 was admitted with diagnoses including hyperlipidemia, atherosclerotic heart disease, and heart failure. Resident 94 was admitted and readmitted with diagnoses including major depressive disorder, hyperlipidemia, and gastro-esophageal reflux disease. During interviews on 09/12/2025, both residents stated that family members or staff checked food dates and helped with the refrigerator, but the temperature was not being recorded. A housekeeper said the inside of residents’ personal refrigerators was cleaned only upon request and expired food was thrown away at those times. A maintenance staff member stated temperatures were monitored for facility refrigerators, not residents’ personal refrigerators, unless there was a reported issue. CNAs reported checking personal refrigerators for leftover or expired food, but not taking the actual temperature. The DON stated CNAs were responsible for checking residents’ personal refrigerators daily and that the medical task documentation system allowed staff to mark whether temperature was checked, but no temperature log was available. The DON checked both refrigerators and found they were 50 degrees Fahrenheit, and acknowledged they were too warm and needed to be cooler than 40 degrees Fahrenheit. The facility policy required staff to monitor resident room refrigeration units, discard unlabeled or expired food, and record refrigerator and freezer temperatures daily on a temperature log.
PASRR Level II Not Completed for Resident With Psychotic Behaviors
Penalty
Summary
The facility failed to ensure a PASRR Level II was completed for one sampled resident who had diagnoses including bipolar disorder and hallucinations and who later exhibited repeated behavioral symptoms. The resident was admitted with a PASRR Level I screening dated 07/05/2023 that documented no mental illness, mental retardation, related condition, or dementia and deemed the resident appropriate for nursing facility placement. However, the resident’s record showed numerous psychiatry evaluations from 05/30/2024 through 04/25/2025 documenting bipolar disorder with psychotic features and generalized anxiety disorder, with medications continued to address delusions, depression, anxiety, and restlessness. The resident’s behavior notes from 03/09/2025 through 05/12/2025 documented multiple incidents consistent with significant mental illness, including delusions that people were trying to kidnap or kill the resident, blocking a room door out of fear, rummaging through a roommate’s belongings, claiming ownership of the facility, pulling a fire alarm, trying to induce vomiting, spitting out medications, refusing care, yelling, screaming, cursing, disrupting others, entering a roommate’s personal space, stealing property, hitting a glass window with a folded walker, splashing water at care providers, throwing objects, grabbing others, and hitting and kicking staff and residents. The resident was also reported to have kicked a roommate twice in the lower leg and kicked a dietary person in the leg, and continued to exhibit behavioral issues by trying to hit staff members and residents. Despite these documented behaviors and psychiatric findings, there was no evidence that a PASRR Level II assessment was completed. The resident was later transferred to a geriatric-psychiatric facility where the patient was admitted. Interviews with RNs, RCMs, and the SW confirmed that behaviors were reported and discussed in IDT meetings, that the resident did not have a PASRR Level II, and that the purpose of PASRR was to determine whether the current facility was appropriate for the resident’s level of care or whether additional recommendations were needed for behavioral needs. The facility policy stated that a PASRR Level II request should be completed when a resident is determined to have SMI or when there is an exacerbation of behaviors or worsening mental health indicators.
Failure to Notify Resident Representative of Incident and Injury
Penalty
Summary
The facility failed to notify a resident's representative of an incident and a newly identified skin tear. The resident in question was admitted with multiple diagnoses, including cognitive impairment, and was documented as confused, with communication deficits that made it difficult to conduct a mental status assessment. The care plan indicated significant cognitive deficits, and the admissions record listed a family member as the resident's representative and emergency contact. On the date of the incident, the resident became agitated and combative, resulting in a skin tear on the left lower leg during a transfer to a wheelchair. A dressing was applied, and a Physician's Assistant was notified. However, there was no documented evidence in the medical record that the resident's representative was notified of either the incident or the resulting skin tear. Interviews with facility staff, including the Resident Case Manager and the Administrator, confirmed the lack of documentation and acknowledged that the family should have been notified, especially given the resident's cognitive status. Facility policy required notification of the resident's representative in such situations, but this was not followed in this case.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and implemented for several residents, leading to deficiencies in addressing their medical needs. Resident #24, who was admitted with diagnoses including pain in the left hip and an artificial hip, experienced constipation due to pain medications. Despite receiving various medications for bowel care, the resident's comprehensive care plan lacked a specific plan for managing constipation. This oversight was confirmed by the Director of Nursing, who acknowledged the absence of a care plan for constipation. Resident #134, admitted with a fracture and hematoma, was prescribed Melatonin for insomnia and Lasix for edema. However, the comprehensive care plan did not include plans for managing these conditions. The Director of Nursing confirmed that the resident should have had care plans for insomnia and edema, as they were receiving medications for these issues. The lack of care plans for these conditions was a significant oversight in the resident's care management. Resident #28, diagnosed with PTSD and metabolic syndrome, did not have a care plan addressing PTSD, despite having a history of related behaviors and being prescribed Prazosin. An incident where the resident became upset and exhibited aggressive behavior highlighted the need for a care plan. The Resident Care Manager and Assistant Director of Nursing confirmed the absence of a care plan for PTSD, which should have included specific behaviors and interventions. The facility's policies emphasized the importance of interdisciplinary and person-centered care plans, which were not adhered to in these cases.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, which is a necessary component of ensuring continuity of care post-discharge. The resident, who had been admitted with conditions including hemiplegia, hypertension, type 2 diabetes with neuropathy, and fibromyalgia, was discharged without a comprehensive discharge summary. This summary should have included a recapitulation of the resident's stay, the treatments and services provided, and a physician's signature. The absence of this documentation was confirmed by the Social Services Director, Medical Records Clerk, and Medical Records Director. The deficiency was further highlighted when the Administrator acknowledged that the wrong template was used for the discharge, resulting in the lack of a proper discharge summary. Consequently, the resident and their family did not receive the necessary documentation regarding the resident's admission, treatments, and services provided during their stay. This oversight has the potential to impact the resident's ability to receive appropriate post-discharge care, medications, or treatments.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a wound care nurse followed physician orders for a resident with a pressure injury. The resident, who was admitted with a fracture of the right femur, developed an unstageable pressure injury on the right knee. A physician's order was in place to cleanse the wound with normal saline, apply barrier cream, and cover it with foam dressing three times a week. However, during a wound care observation, the wound care nurse used silver alginate on the wound without obtaining a physician's order, which was not documented in the resident's clinical record. The wound care nurse admitted to using silver alginate for approximately one week without a physician's order, and the Director of Nursing Services confirmed that a physician's order was required for wound care. The facility's policy mandates verifying a physician's order before providing wound care, and the clinical record lacked evidence of such an order for the use of silver alginate. This oversight had the potential to delay the healing of the resident's wound.
Failure to Adhere to Dialysis Care Plan
Penalty
Summary
The facility failed to ensure that licensed staff adhered to a physician's order and care plan for a resident requiring dialysis, which prohibited taking blood pressure on the resident's left arm where a fistula was located. Despite the care plan and physician's order clearly stating no blood pressure should be taken on the left arm, multiple instances were documented where blood pressures were taken on the resident's left arm over a period of time. This oversight was confirmed by several staff members, including two Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), who acknowledged the presence of the order and the potential harm of taking blood pressure on the arm with a fistula. The resident, who had chronic kidney disease and was dependent on renal dialysis, experienced complications with their dialysis access. An outpatient dialysis record indicated that the resident's left upper arm graft was clotted, preventing dialysis on a scheduled date, and necessitating referral to a surgery center. Subsequent surgical interventions were required to address stenosis in the graft and vein, which were treated with angioplasty. The DON confirmed that the thrombosis in the fistula led to a missed dialysis session and required surgical intervention. Despite a sign at the resident's bedside indicating no blood pressure should be taken on the left arm, the facility's failure to adhere to this directive resulted in the documented deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 25.93% due to seven medication errors out of 27 opportunities. This deficiency was identified through observation, interview, clinical record review, and document review. The specific incident involved a resident who was administered seven medications late, contrary to the facility's policy. The medications were supposed to be given at 8:00 AM, with a permissible window of one hour before or after this time. However, the medications were administered at 9:13 AM, which was beyond the allowed timeframe. The resident involved had a medical history that included cerebrovascular disease, essential hypertension, and hyperlipidemia. The medications administered late included Aspirin, Lisinopril, Protein Gel/Liquid, Cholecalciferol, Plavix, PreserVision AREDS 2+ Multivitamin, and Vitamin C. The LPN confirmed the late administration and acknowledged it did not adhere to the facility's policy. The Director of Nursing also confirmed that medication administration after 9:00 AM was considered late and did not comply with the policy, which emphasized the importance of administering medications at the right time as part of the five rights of medication administration.
Failure to Screen and Educate Resident on Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident was properly screened for eligibility to receive a pneumococcal vaccine, provided with education regarding the vaccine, and offered the vaccine for administration or declination. This deficiency was identified during a review of the clinical records and confirmed by the Infection Preventionist. The resident in question was admitted and readmitted with diagnoses including iron deficiency anemia, shortness of breath, chronic obstructive pulmonary disease, and unspecified asthma. Despite these conditions, there was no documented evidence in the resident's clinical record that the necessary steps for pneumococcal vaccination were followed. The facility's policy, dated October 20, 2020, required that all residents be assessed for vaccine eligibility upon admission and offered the vaccine within 30 days if indicated. Additionally, a review of prior vaccination status was to be conducted within five working days of admission, and education regarding the vaccine's risks and benefits was to be provided. The policy also mandated documentation of the vaccination details in the resident's clinical record. However, these procedures were not adhered to for the resident, as confirmed by the Infection Preventionist, indicating a lapse in following the established vaccination protocol.
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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.
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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) |
|---|---|---|---|---|
| El Jen Skilled Care | 1 mi | ★★★★★ | 3 | 0 |
| Advanced Health Care Of Summerlin | 1.2 mi | ★★★★★ | 1 | 0 |
| Neurorestorative | 1.7 mi | ★★★★★ | 3 | 0 |
| Silver Hills Health Care Center | 1.7 mi | ★★★★★ | 42 | 0 |
| Life Care Center Of Las Vegas | 2 mi | ★★★★★ | 13 | 0 |
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