Inspection Reports for Alpine Skilled Nursing and Rehabilitation Center
3101 PLUMAS STREET, RENO, NV 89509, RENO, NV
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 11, 2025 identified deficiencies related to resident rights, abuse investigations, care planning, and accident prevention following a complaint investigation. Earlier inspections showed a pattern of issues including resident-to-resident abuse, incomplete care plans, staff training deficiencies, and safety concerns such as fire hazards and medication management. Several complaint investigations substantiated allegations of verbal and physical abuse, neglect, and failure to prevent pressure ulcers, while others were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with resident care and safety, with no clear trend of sustained improvement or worsening.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
147 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 147
Deficiencies: 5
Date: Jun 11, 2025
Visit Reason
The inspection was conducted as a result of complaint (CPT) and facility reported incident (FRI) investigations at Alpine Skilled Nursing and Rehabilitation Center on 06/11/2025.
Complaint Details
The complaint investigation included multiple allegations such as failure to respond to discharge requests, unsafe discharge, failure to pay for hotel rooms, failure to provide financial statements, resident elopement, delayed call light response, lack of dignity and respect, unaddressed pain, resident-to-resident altercations including racial slurs, and smoking with oxygen leading to a fire. Several allegations were not substantiated due to lack of evidence.
Findings
The investigation included multiple allegations such as failure to respond to discharge requests, unsafe discharge, failure to pay for hotel rooms, failure to provide financial statements, resident elopement, delayed call light response, lack of dignity and respect, unaddressed pain, resident-to-resident altercations including racial slurs, and smoking with oxygen leading to a fire. Several allegations were not substantiated due to lack of evidence. Deficiencies were identified related to resident rights, abuse investigations, care planning, and accident prevention.
Deficiencies (5)
Failure to protect a resident's right to a dignified existence without discrimination when a resident-to-resident verbal altercation involved racial slurs.
Failure to investigate and report an allegation of verbal abuse to the State Agency.
Failure to develop and implement a comprehensive care plan for a resident with a history of nicotine dependence who continued to smoke while using oxygen.
Failure to update resident care plans after a resident-to-resident altercation involving racial slurs.
Failure to ensure a resident with a history of nicotine dependence was adequately supervised to prevent a preventable accident while smoking with oxygen in place.
Report Facts
Census: 147
Sample size: 11
Deficiency count: 5
Date of survey: Jun 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Signed the report on July 2, 2025 | |
| Director of Nursing (DON) | Interviewed and provided statements related to resident altercations, care planning, and abuse investigations | |
| Licensed Practical Nurse (LPN) | Interviewed regarding resident altercations and observations | |
| Certified Nursing Assistant (CNA) | Interviewed regarding resident care plans and altercations | |
| Licensed Master Social Worker | Interviewed residents and documented resident-to-resident interactions | |
| Abuse Coordinator/Director of Nursing (AC/DON) | Provided statements on abuse investigations and racial discrimination | |
| Registered Nurse (RN) | Interviewed regarding resident smoking behavior and care planning |
Inspection Report
Annual Inspection
Census: 140
Deficiencies: 3
Date: Jan 13, 2025
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey from January 5, 2025 through January 13, 2025, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in maintaining accurate personnel records, including timely fingerprinting for background checks and tuberculosis screening prior to employee start dates. Additionally, cultural competency training was not completed within the required timeframe for one employee. Corrective actions and monitoring plans were outlined to address these deficiencies.
Deficiencies (3)
Failure to ensure fingerprinting for Nevada Automated Background System clearance was completed within 10 days of hire for 5 of 22 sampled employees.
Failure to complete initial tuberculosis screening prior to start of work with residents for 1 of 22 sampled employees.
Failure to ensure cultural competency training was completed within 30 days of hire for 1 of 22 sampled employees.
Report Facts
Employees sampled: 22
Deficiencies cited: 3
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Lawson | Administrator | Signed report as Laboratory Director's or Provider/Supplier Representative |
| Human Resources Manager | Responsible for ensuring plan of correction implementation and monitoring compliance with fingerprinting, TB screening, and cultural competency training | |
| Employee #1 | Administrator | Named in fingerprinting deficiency |
| Employee #10 | Licensed Social Worker | Named in fingerprinting deficiency |
| Employee #13 | Registered Nurse | Named in tuberculosis screening deficiency |
| Employee #14 | Licensed Practical Nurse | Named in cultural competency training deficiency |
| Employee #17 | Licensed Practical Nurse, Unit Manager | Named in fingerprinting deficiency |
| Employee #21 | Registered Nurse, Regional Minimum Data Set Nurse | Named in fingerprinting deficiency |
| Employee #22 | Registered Nurse, Vice President of Clinical Services | Named in fingerprinting deficiency |
Inspection Report
Annual Inspection
Census: 129
Deficiencies: 4
Date: Jan 31, 2024
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey to assess compliance with Nevada Administrative Code for skilled nursing facilities.
Findings
The facility was found deficient in several areas including incomplete tuberculosis (TB) testing for employees prior to employment, failure to ensure combustible materials were not stored in high hazard or equipment rooms, failure to protect potable water supply from cross-contamination, and failure to ensure cultural competency training was completed within 30 days of hire for certain employees.
Deficiencies (4)
Failed to ensure complete Tuberculosis (TB) testing for 5 of 13 sampled employees prior to employment.
Failed to ensure combustible items were not stored in high hazard or equipment rooms, including untreated plywood attached to fire-rated walls.
Failed to protect potable water supply from cross-connection and backflow issues in janitor room.
Failed to ensure cultural competency training was completed within 30 days of hire for 4 of 13 sampled employees.
Report Facts
Census: 129
Sample size: 13
Deficiency completion date: Apr 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #6 | Dietary Manager | Named in TB testing deficiency |
| Employee #10 | Cook | Named in TB testing deficiency |
| Employee #11 | Dietary Aide | Named in TB testing and cultural competency training deficiencies |
| Employee #12 | Housekeeping Aide | Named in TB testing and cultural competency training deficiencies; no longer employed |
| Employee #13 | Registered Nurse | Named in TB testing deficiency |
| Employee #5 | Social Services Assistant | Named in cultural competency training deficiency |
| Employee #8 | Certified Nursing Assistant | Named in cultural competency training deficiency |
Inspection Report
Annual Inspection
Census: 114
Capacity: 189
Deficiencies: 12
Date: Mar 21, 2023
Visit Reason
The inspection was conducted as a Medicare Life Safety Code recertification survey and Emergency Preparedness survey at Alpine Skilled Nursing and Rehabilitation Center.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness program but had deficiencies related to Life Safety Code including delayed egress doors requiring excessive force, self-closing doors held open improperly, cooking facility fire protection issues, electrical safety violations including extension cords and broken receptacles, lack of fire drill documentation, and improper storage of oxygen cylinders.
Deficiencies (12)
Delayed egress door at the end of the Wellington corridor required 25 pounds of pressure to open, exceeding the 15 pounds limit.
Self-closing door to the storage room in the Rehab dining room was held open with a cart full of decorations.
Fire protection extinguishment nozzles under the cooking hood were missing foil nozzle blowoff caps.
Extension cords were used as a substitute for fixed wiring in resident rooms 110, 61, and 302.
Broken or missing receptacle cover plates found in multiple locations including Activities Office, Room 57, Wellington Resident Lounge, Room 87, and Rehab Dining Room.
Electrical panel boards had items stored less than 36 inches in front of them, obstructing access.
Facility unable to produce documentation of staff training on Evacuation/Relocation plan and Fire Safety Plan Components.
Fire drills were not conducted at unexpected times under varying conditions at least once per shift per quarter, and staff were unfamiliar with fire drill procedures.
Facility failed to maintain smoke barrier doors with annual inspection reports missing.
Facility failed to install ground fault circuit interrupters (GFCI) in areas less than six feet from a sink edge.
Facility failed to inspect its essential electrical system weekly and provide documented evidence of monthly load testing.
Oxygen cylinders were not properly segregated into full and empty and combustible materials were stored less than five feet from oxygen cylinders.
Report Facts
Deficiencies cited: 12
Resident census: 114
Total licensed capacity: 189
Force required to open delayed egress door: 25
Distance from sink to receptacle: 5.5
Frequency of generator testing: 12
Generator test interval: 20
Generator test interval: 40
Fire drill frequency: 4
Minimum clearance for panel boards: 36
Minimum distance between oxygen and combustibles: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator-in-Training | Present at discovery of multiple deficiencies and confirmed missing documentation. | |
| Maintenance Director | Present at discovery of multiple deficiencies and confirmed missing documentation. | |
| Plant Operations Manager | Present at discovery of multiple deficiencies and involved in corrective actions. |
Inspection Report
Annual Inspection
Census: 115
Deficiencies: 14
Date: Mar 20, 2023
Visit Reason
Annual Medicare Recertification Survey and Facility Reported Incident (FRI) investigation conducted from March 12, 2023 through March 16, 2023, and an extended survey on March 20, 2023.
Findings
Substandard quality of care was identified including failure to provide scheduled showers to a dependent resident, failure to obtain informed consent for psychotropic medications, failure to protect resident property, failure to update care plans for psychotropic medication use and toileting programs, failure to prevent pressure ulcers, failure to maintain nutrition and hydration, failure to follow oxygen therapy orders, failure to secure medications, failure to properly store food, and failure to protect resident health information.
Deficiencies (14)
Failed to provide care for a resident to promote personal hygiene to ensure a dignified existence for 1 of 23 sampled residents (Resident #20) by not providing scheduled showers twice weekly.
Failed to obtain informed consent for psychotropic medications for 1 of 23 sampled residents (Resident #63).
Failed to protect resident property when food purchased by Resident #8 was lost and not reimbursed timely.
Failed to develop and implement a comprehensive care plan for psychotropic medication use for 1 of 23 sampled residents (Resident #63).
Failed to update care plan to include interventions for a scheduled toileting program for 1 of 23 sampled residents (Resident #78).
Failed to provide necessary treatment and services to prevent pressure ulcers and promote healing for 1 of 23 sampled residents (Resident #207) as a deep tissue injury progressed to a stage III pressure ulcer.
Failed to implement bowel and bladder program including scheduled toileting and voiding diaries for 109 of 115 sampled residents with potential to participate in the program.
Failed to document administration of insulin for 1 of 23 sampled residents (Resident #12) and failed to secure personal health information for 2 of 23 sampled residents (Residents #1 and #71).
Failed to follow physician's order for oxygen therapy for 1 of 23 sampled residents (Resident #16) including failure to document refusals and physician notification.
Failed to secure medication cart and resident medications for 1 of 23 sampled residents (Resident #32) and left medications unsecured in unlocked rooms accessible to residents.
Failed to discard expired mushrooms from refrigerator posing risk of foodborne illness.
Failed to protect resident personal health information on medication cart computer screens for 2 of 23 sampled residents (Residents #1 and #71).
Failed to maintain nutritional status and monitor significant weight loss for 2 of 23 sampled residents (Residents #41 and #63).
Failed to administer medications within prescribed time frames resulting in medication errors for 2 of 23 sampled residents (Residents #51 and #54).
Report Facts
Deficiencies cited: 33
Census: 115
Sample size: 23
Weight loss: 10.67
Weight loss: 12.67
Weight loss: 13.72
Medication error rate: 6.06
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in findings related to shower schedule, oxygen therapy, medication administration, and resident hygiene. | |
| Nurse Supervisor | Named in findings related to shower schedule and resident hygiene. | |
| Licensed Practical Nurse | Named in medication administration and oxygen therapy findings. | |
| Registered Nurse | Named in medication administration and medication cart security findings. | |
| Unit Manager | Named in findings related to bowel and bladder program and medication security. | |
| Dietary Assistant Manager | Named in findings related to food storage and expiration. | |
| Administrator | Named in findings related to food storage and reimbursement for lost food. | |
| Registered Dietitian | Named in findings related to weight loss monitoring. |
Inspection Report
Annual Inspection
Census: 115
Deficiencies: 2
Date: Mar 15, 2023
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in ensuring timely dementia training and cultural competency training for employees. Specifically, 8 of 18 sampled employees lacked timely dementia training and 11 of 18 sampled employees lacked documented evidence of cultural competency training using an approved program.
Deficiencies (2)
Failure to ensure dementia training was completed within 30 days of hire and annually by the employee's anniversary date for 8 of 18 sampled employees.
Failure to ensure cultural competency training was completed using a Division of Public and Behavioral Health approved training program for 11 of 18 sampled employees.
Report Facts
Employees sampled: 18
Employees lacking timely dementia training: 8
Employees lacking cultural competency training: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Bellaty | Administrator | Signed the report and confirmed training deficiencies |
| Human Resources Director | Acknowledged training requirements and confirmed deficiencies in dementia and cultural competency training | |
| Employee 3 | Activity Director | Lacked timely dementia training |
| Employee 4 | Registered Dietician | Lacked timely dementia and cultural competency training |
| Employee 5 | Social Services Director | Lacked timely dementia training |
| Employee 7 | Certified Nursing Assistant (CNA) | Lacked timely dementia and cultural competency training |
| Employee 8 | Certified Nursing Assistant (CNA) | Lacked timely dementia and cultural competency training |
| Employee 9 | Certified Nursing Assistant (CNA) | Lacked timely dementia and cultural competency training |
| Employee 10 | Infection Preventionist | Lacked timely dementia training |
| Employee 11 | Registered Nurse (RN) | Lacked timely dementia and cultural competency training |
| Employee 12 | Licensed Practical Nurse (LPN) | Lacked cultural competency training |
| Employee 13 | Licensed Practical Nurse (LPN) | Lacked cultural competency training |
| Employee 14 | Certified Nursing Assistant (CNA) | Lacked cultural competency training |
| Employee 15 | Certified Nursing Assistant (CNA) | Lacked cultural competency training |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 9
Date: Jan 18, 2023
Visit Reason
This Statement of Deficiencies was generated as a result of a Complaint (CPT) and Facility Reported Incident (FRI) investigations conducted at the facility on January 18, 2023, in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.
Complaint Details
The complaint investigation included allegations of abuse, neglect, exploitation, and mistreatment involving multiple residents. Some allegations were substantiated, including a deep tissue injury caused by a deflated air mattress during a power outage, verbal and physical abuse among residents, and failure to maintain proper care and monitoring. Other allegations could not be substantiated due to lack of evidence.
Findings
The investigation included allegations of abuse, neglect, and mistreatment involving multiple residents. Several allegations were substantiated including a resident left on a deflated air mattress resulting in a deep tissue injury, verbal abuse, and physical altercation between residents. Other allegations could not be substantiated due to lack of evidence. The facility failed to ensure proper care and monitoring of residents, including failure to maintain air mattress inflation during a power outage.
Deficiencies (9)
Resident #3 developed a deep tissue injury due to being left on a deflated air mattress during a power outage.
Resident #6 was verbally abusive to other residents and attempted to hit them with a cane.
Resident #7 had a physical altercation with another resident.
Facility failed to maintain air mattress inflation and did not plug the mattress into an emergency power outlet during a power outage.
Resident #4 was verbally abusive and threatened other residents.
Resident #10 was verbally abusive and aggressive towards a roommate.
Resident #17 was verbally abusive and physically aggressive, throwing punches at other residents.
Facility failed to report and investigate verbal abuse incidents timely and appropriately.
Facility failed to ensure appropriate care to prevent pressure ulcers and deep tissue injuries.
Report Facts
Census: 111
Sample size: 10
Number of CPT investigations: 1
Number of FRI investigations: 6
Pressure ulcer measurement: 8
Pressure ulcer measurement: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named as abuse coordinator and responsible for checking air mattress during power outage | |
| Administrator | Confirmed power outage and failure to plug air mattress into emergency power outlet | |
| Wound Care Registered Nurse | Noted deep tissue injury on resident #3 after power outage | |
| Wound Care Specialist Nurse Practitioner | Documented wounds on resident #3 |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: Dec 14, 2022
Visit Reason
The inspection was conducted as a result of a Facility Reported Incident (FRI) and complaint (CPT) investigation at Alpine Skilled Nursing and Rehabilitation Center on 12/13/22 and completed on 12/14/22.
Complaint Details
The investigation covered five complaints (CPTs) and five facility reported incidents (FRIs) with allegations including lack of hot water, telehealth use for evaluations, refusal to turn residents, broken beds, withheld insulin, opened mail, delayed discharge, undisclosed wounds, lack of showers, missed therapies, physical abuse, untreated scabies, unsafe discharge environment, rough handling, lack of supervision, verbal abuse, locking residents in rooms, and failure to prevent elopement. None were substantiated due to lack of evidence.
Findings
The investigation included multiple allegations related to resident care, abuse, medication administration, and facility operations. None of the allegations were substantiated due to lack of evidence. Observations, interviews, clinical record reviews, and document reviews were conducted. No regulatory deficiencies were identified.
Report Facts
Sample size: 11
Number of CPTs investigated: 5
Number of FRIs investigated: 5
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 4
Date: Aug 30, 2022
Visit Reason
This inspection was conducted as a result of a Facility Reported Incident (FRI) investigation triggered by allegations of resident abuse and neglect, including bruises and fractures of unknown origin, and other injury concerns.
Complaint Details
The complaint investigation involved 10 Facility Reported Incidents (FRIs) alleging bruises, fractures, and physical altercations among residents. Some allegations were substantiated, such as resident-to-resident altercations involving physical and verbal abuse, while others could not be substantiated due to lack of evidence.
Findings
The investigation included observations, interviews with residents and staff, and clinical record reviews. Multiple allegations of abuse and neglect were investigated, with some substantiated and others not due to lack of evidence. Deficiencies related to resident rights, abuse, neglect, care planning, and failure to update care plans after incidents were identified.
Deficiencies (4)
Failure to protect residents from abuse, neglect, and exploitation including physical and verbal abuse.
Failure to develop and update comprehensive care plans reflecting resident needs and incidents.
Failure to ensure residents were free from physical abuse and neglect.
Failure to investigate and document resident-to-resident altercations and implement appropriate interventions.
Report Facts
Sample size: 13
Number of FRIs investigated: 10
Census: 88
Audit duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed during investigation and confirmed lack of care plans related to resident injuries and altercations. | |
| Licensed Practical Nurse (LPN) | Interviewed and verbalized being unaware of resident altercations and interventions. | |
| Certified Nursing Assistants (CNAs) | Interviewed regarding resident care and interactions. |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 14
Date: May 16, 2022
Visit Reason
The inspection was conducted as an annual Medicare Recertification Survey including complaint and facility reported incident investigations, and an extended survey to assess compliance with federal regulations.
Findings
The facility was found to have multiple deficiencies including substandard quality of care related to medication administration, resident rights violations, infection control issues, incomplete care planning, failure to implement bowel and bladder programs, medication errors, and inadequate infection prevention and control practices. The facility also failed to maintain accurate records, conduct proper staff vaccination tracking, and ensure proper PPE use and fit testing.
Deficiencies (14)
Resident rights violations including failure to protect residents from medication errors and failure to assist with toileting upon request.
Failure to develop baseline care plans within required timeframes for new admissions.
Failure to develop comprehensive care plans addressing resident needs including bowel and bladder continence.
Failure to administer medications timely and document administration accurately, including controlled substances.
Failure to ensure proper catheter care and tracheostomy care per physician orders.
Failure to provide showers as scheduled and maintain hygiene for dependent residents.
Failure to implement bowel and bladder toileting programs for incontinent residents.
Failure to maintain accurate narcotic medication counts and reconcile controlled substances.
Failure to administer medications via gastrostomy tube per manufacturer instructions and physician orders.
Failure to maintain accurate facility assessment including resident population, staffing, and resources.
Failure of the Quality Assurance and Performance Improvement (QAPI) committee to meet regularly, address systemic concerns, and document meeting minutes and attendance.
Failure to follow infection prevention and control policies including proper PPE use, hand hygiene, fit testing for N95 masks, and COVID-19 staff screening.
Failure to accurately track and report COVID-19 vaccination status for all staff including contractors, licensed practitioners, and volunteers.
Failure to offer and document influenza and pneumococcal vaccinations and education for residents.
Report Facts
Medication error rate: 11.11
Resident census: 82
Sample size: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Not provided | Director of Nursing | Named in multiple findings related to medication administration, infection control, and facility assessment |
| Not provided | Administrator | Named in multiple findings related to infection control, facility assessment, and QAPI oversight |
| Not provided | Licensed Practical Nurse | Named in medication administration and infection control findings |
| Not provided | Certified Nursing Assistant | Named in infection control and resident care findings |
| Not provided | Licensed Social Worker | Named in grievance and resident council findings |
| Not provided | Vice President of Clinical Services | Named in grievance and facility assessment findings |
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 3
Date: Mar 21, 2022
Visit Reason
This Statement of Deficiencies was generated as a result of a Focused Infection Control Survey and Complaint Investigation conducted at the facility on 03/21/22. The investigation included one complaint and three Facility Reported Incidents (FRI).
Complaint Details
Complaint #NV00065750 alleging a resident was left in bed all day was substantiated. Other allegations related to falls, neglect, medication administration, misappropriation of funds, resident altercation, and injury of unknown origin were not substantiated due to lack of evidence.
Findings
The complaint alleging a resident was left in bed all day was substantiated. Other allegations related to falls, medication administration, misappropriation of funds, resident altercation, and injury of unknown origin were not substantiated due to lack of evidence. The facility was 100% compliant with Healthcare Worker vaccination requirements. Deficiencies unrelated to the complaint were also identified. Additionally, isolated deficiencies causing no harm were found, including failure to assist a resident out of bed, failure to provide discharge notice to the resident and Ombudsman, and failure to update a care plan after a resident fall.
Deficiencies (3)
Resident was left in bed all day and was not assisted out of bed as required.
Failure to provide written discharge notification to resident and State Long Term Care Ombudsman for one resident.
Failure to update care plan with new interventions after an unwitnessed resident fall.
Report Facts
Sample size: 5
Complaint count: 1
Facility Reported Incidents (FRI): 3
Resident census: 121
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during complaint investigation | |
| Administrator | Interviewed during complaint investigation and provided explanations regarding resident care expectations and discharge notification | |
| Social Worker | Interviewed during complaint investigation and documented resident complaints | |
| Director of Nursing (DON) | Acknowledged failure to update care plan after resident fall |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Jan 20, 2022
Visit Reason
This Statement of Deficiencies was generated as a result of a complaint and Facility Reported Incident (FRI) investigation conducted in the facility on 01/19/22 and concluded on 01/20/22.
Complaint Details
The investigation was complaint-driven, involving six complaints and 36 Facility Reported Incidents (FRIs). Some allegations were substantiated such as resident-to-resident abuse and falls, while others were not substantiated due to lack of evidence.
Findings
The investigation included multiple complaints and FRIs, with some allegations substantiated such as resident-to-resident abuse and falls. Several allegations could not be substantiated due to lack of evidence. Deficiencies were found related to resident rights, abuse, neglect, fall risk assessments, and safety.
Deficiencies (3)
Facility failed to protect and promote a resident's right to retain and use a razor for personal hygiene for 1 of 44 residents (Resident #17).
Resident #6 was physically abused by Resident #7 who punched Resident #6 in the face causing an abrasion.
Facility failed to ensure fall risk assessments were completed upon admission and after falls for 4 of 8 sampled residents (Residents #11, 12, 13, and 14).
Report Facts
Complaints investigated: 6
Facility Reported Incidents (FRI) investigated: 36
Sample size: 44
Residents with fall risk assessment deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to findings about resident safety and care planning |
| Clinical Services Director | Clinical Services Director (CSD) | Named in relation to findings about resident safety and care planning |
| Registered Nurse | Registered Nurse (RN) | Named in relation to findings about resident safety and care planning |
Inspection Report
Follow-Up
Census: 78
Deficiencies: 1
Date: Jan 4, 2021
Visit Reason
This Statement of Deficiencies was generated as a result of complaint investigations and a Medicare Follow-up (Re-visit) survey conducted at the facility on 01/04/21 in response to findings from a complaint investigation initiated on 09/02/20 and concluded on 10/21/20.
Complaint Details
Complaint #NV00062773 with the allegation a resident's teeth were unbrushed was substantiated. Other allegations including a cut on a resident's chin, body odor, unshaven legs, soiled brief, tube feeding stopped without consent, incorrect admission date, failure to review allergies, verbal and physical abuse allegations were unsubstantiated.
Findings
The revisit survey found the facility came into compliance for F686. One complaint regarding a resident's teeth being unbrushed was substantiated. Several other allegations including physical and verbal abuse, body odor, and medication issues were not substantiated. The facility lacked documented evidence of routine oral care, including tooth brushing, for one resident.
Deficiencies (1)
Failed to provide documented evidence of routine oral care, including brushing, to 1 of 7 sampled residents (Resident #2).
Report Facts
Census: 78
Sample size: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the investigation; confirmed lack of documented oral care and policy | |
| Licensed Practical Nurse | Interviewed during the investigation as employee of concern |
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