Deficiencies (last 7 years)
Deficiencies (over 7 years)
28.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
296% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
163 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 163
Deficiencies: 7
Date: May 15, 2025
Visit Reason
Medicare Recertification Survey conducted from 2025-05-12 to 2025-05-15 including complaint and facility reported incidents investigation, focused on abuse, neglect, and wound care.
Complaint Details
One complaint investigated with allegations related to facility conditions and care; allegations were not substantiated due to lack of evidence.
Findings
The facility had multiple deficiencies including failure to integrate hospice care plans, delayed neurologist appointments, incomplete wound care, medication discrepancies with hospice orders, unsecured medication cart, and inadequate infection control practices.
Deficiencies (7)
Failed to ensure resident's hospice care plan was integrated with facility care plan and wound care was addressed for hospice resident.
Failed to ensure timely neurologist appointment and care plan updates for residents with neurological conditions.
Failed to provide wound care as ordered and monitor wound healing for resident with pressure ulcer.
Failed to check gastric residual volume prior to medication administration via gastrostomy tube.
Medication discrepancies between facility and hospice orders including missing orders and unmatched dosages.
Medication cart left unlocked and unattended with keys on top, accessible to unauthorized persons.
Failed to ensure hand hygiene was performed prior to entering room on enhanced barrier precautions.
Report Facts
Sample size: 32
Facility census: 163
Deficiency counts: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to findings on wound care, hospice coordination, and neurologist appointment delays | |
| Unit Manager | Named in relation to findings on neurologist appointment delays and hospice coordination | |
| Registered Nurse | Named in relation to medication discrepancies and wound care | |
| Licensed Practical Nurse | Named in relation to medication administration and wound care | |
| Certified Nursing Assistant | Named in relation to infection control and wound care |
Inspection Report
Routine
Deficiencies: 9
Date: May 15, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, wound care, referral coordination, infection control, and medication storage at Alta Skilled Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to integrate hospice wound care into the resident's care plan, delayed neurologist referral and appointment scheduling, inadequate wound care documentation and administration, medication discrepancies between facility and hospice orders, unsecured medication cart, failure to check gastric residuals before G-tube medication administration, and failure to perform hand hygiene prior to entering a resident's room on enhanced barrier precautions.
Deficiencies (9)
Failed to ensure a resident's Care Plan was integrated with the hospice plan of care and included wound care for a resident on hospice.
Failed to update care plans to include need for neurologist appointment and safety concerns related to smoking for two residents.
Failed to act timely on a physician order for neurologist referral and monitor for completeness, resulting in delayed care for a resident with Parkinson's disease.
Failed to ensure a resident's wound was monitored and treated per physician orders and facility policy, with multiple undocumented wound care treatments.
Failed to check gastric residual volume prior to administration of medication via gastrostomy tube for a resident.
Failed to ensure no discrepancies between a resident's available medications and medication orders, resulting in potential for missed symptom management.
Failed to ensure an unattended medication cart was not left unlocked with keys accessible, risking unauthorized access to medications.
Failed to coordinate care and services with a hospice agency providing care and medications to a resident, resulting in discrepancies in medication orders and care plans.
Failed to ensure staff performed hand hygiene prior to entering a room on enhanced barrier precautions for a resident with ESBL infection.
Report Facts
Residents sampled: 32
Medication cart: 1
Rooms on Enhanced Barrier Precautions: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Verbalized wound care and care plan integration deficiencies, referral coordination issues, medication discrepancies, and medication cart security |
| Unit Manager | Unit Manager | Confirmed lack of wound care plan, referral coordination, and medication cart security issues |
| Registered Nurse | Registered Nurse | Provided information on resident care, medication discrepancies, and wound care |
| Transportation Coordinator | Transportation Coordinator | Described referral process and communication issues for neurologist appointments |
| Licensed Practical Nurse | Licensed Practical Nurse | Admitted to not checking gastric residual prior to G-tube medication administration |
| Certified Nursing Assistant | Certified Nursing Assistant | Observed failing to perform hand hygiene prior to entering room on enhanced barrier precautions |
Inspection Report
Deficiencies: 2
Date: Feb 24, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations, specifically ensuring that drugs and biologicals are labeled and stored securely in locked compartments.
Findings
The facility failed to ensure that a wound cart and a medication cart containing resident medications were secured and locked, allowing potential unauthorized access. Observations and interviews confirmed that both carts were left unlocked and unattended in resident areas.
Deficiencies (2)
Wound cart left unlocked in the 200 hall entrance with residents nearby, allowing potential unauthorized access to medications.
Medication cart left unlocked in the 100 hall entrance and unattended, risking unauthorized access to medications.
Report Facts
Residents near unsecured wound cart: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Confirmed the wound cart was left unlocked and residents were near it. | |
| Director of Nursing (DON) | Verbalized that the floor nurse was responsible for ensuring carts were locked. | |
| Registered Nurse (RN) | Confirmed the medication cart was left unlocked and unattended. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jun 13, 2024
Visit Reason
The inspection was conducted in response to complaint #NV00071241, investigating allegations related to failure to notify a resident's representative and physician of a change in condition, failure to provide a comfortable environment, resident to resident abuse, failure to investigate missing resident money, incomplete care plans, incomplete medical records, medication availability and administration issues, infection control, and vaccination screening.
Complaint Details
Complaint #NV00071241 involved multiple issues including failure to notify family and physician of resident condition changes, failure to provide a comfortable environment, resident to resident abuse, failure to investigate missing resident money, incomplete care plans, incomplete medical records, medication availability and administration issues, infection control, and vaccination screening.
Findings
The facility was found deficient in multiple areas including failure to notify family and physician of resident condition changes, failure to provide a comfortable environment due to broken AC, failure to prevent resident to resident abuse, failure to investigate missing resident money, incomplete care plans for catheter care, incomplete medical records and weight monitoring, failure to ensure ordered medications were available and administered, failure to implement enhanced barrier precautions for infection control, and failure to properly screen and offer pneumococcal vaccinations.
Deficiencies (9)
Failed to notify a resident's representative and physician of a significant change in the resident's condition for Resident #305.
Failed to provide a comfortable, homelike environment when a broken air conditioning unit was not fixed or an accommodation offered for Resident #257.
Failed to protect residents from resident to resident abuse involving Resident #83 and Resident #122.
Failed to investigate a resident's report of missing money for Resident #149.
Failed to revise the care plan to include interventions to prevent Resident #98 from repeatedly pulling out the urinary catheter.
Failed to provide complete medical records including weight monitoring and G-tube care for Residents #143, #455, and #205.
Failed to ensure ordered medications were available and administered for Resident #18.
Failed to implement Enhanced Barrier Precautions when providing care to Resident #109's jejunostomy tube.
Failed to screen residents for pneumococcal vaccination eligibility and offer the vaccine appropriately for 28 residents including Resident #104.
Report Facts
Residents sampled: 33
Residents affected by pneumococcal vaccine screening deficiency: 28
Weight loss percentage: 35.5
Medication missed administrations: 10
Dates of survey completion: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources Manager | Interviewed regarding late CNA annual performance evaluation | |
| Regional Human Resources | Interviewed regarding late CNA annual performance evaluation | |
| Unit Manager | UM | Provided information on resident condition and care delays |
| Director of Nursing | DON | Provided multiple interviews regarding deficiencies and care issues |
| Licensed Practical Nurse | LPN | Provided information on catheter care and hospice medication |
| Registered Nurse | RN | Provided information on medication administration and resident care |
| Licensed Practical Nurse | LPN | Observed not wearing gown and gloves during J-tube care |
| Physician | Provided statements regarding resident care and notification | |
| Infection Control Preventionist | ICP | Interviewed regarding infection control policies and vaccine screening |
| Vice President of Clinical Services | VPCS | Interviewed regarding vaccine screening and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 13, 2024
Visit Reason
The inspection was conducted in response to complaints regarding failure to notify a resident's representative and physician of a significant change in condition, resident to resident abuse, and failure to provide adequate supervision to prevent elopement.
Complaint Details
Complaint #NV00071241 involved failure to notify family and physician of resident's condition change, resident to resident abuse, and elopement due to alarm system failure.
Findings
The facility failed to notify the resident's representative and physician of a significant decline in a resident's condition, failed to prevent resident to resident abuse, and failed to provide adequate supervision to prevent a resident from eloping due to malfunctioning alarm systems.
Deficiencies (3)
Failed to ensure a resident's representative and physician were notified of a change in the resident's condition for 1 of 3 sampled residents.
Failed to protect residents from resident to resident abuse for 2 of 2 residents investigated.
Failed to provide protective supervision when a resident wearing a wander device followed an employee out of an alarmed exit door, and the alarm system failed to work, resulting in elopement.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Dates: Apr 30, 2024
Dates: May 7, 2024
Dates: Apr 9, 2024
Dates: Apr 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager (UM) | Advised nurses to call Physician if resident's leg condition worsened | |
| Director of Nursing (DON) | Verbalized lack of documentation of physician notification and confirmed elopement was preventable | |
| Physician | Verbalized that if notified of resident's decline and ultrasound unavailability, would have ordered hospital transfer without delay | |
| Administrator | Explained investigation of elopement and alarm system malfunction |
Inspection Report
Annual Inspection
Census: 163
Deficiencies: 5
Date: Jun 11, 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 (NAC) Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in several areas including failure to complete timely tuberculosis testing for an employee, failure to protect potable water supply due to a cross-connection, lack of updated non-discrimination and privacy policies, and failure to ensure timely and state-approved cultural competency training for employees.
Deficiencies (5)
Failure to complete tuberculosis testing for 1 of 20 sampled employees in accordance with state regulations.
Failure to comply with federal, state, and local regulations related to construction and maintenance, specifically failure to protect potable water supply due to a cross-connection in janitor room.
Failure to develop and post non-discrimination policies and statements as required by NRS 449.101, including lack of complaint log.
Failure to maintain confidentiality and privacy policies in compliance with NRS 449.102, including lack of documentation on sexual orientation, gender identity, and HIV status protections.
Failure to ensure cultural competency training was completed timely and using a state-approved program for 3 of 20 sampled employees.
Report Facts
Census: 163
Sample size: 20
Days late - Employee #17 cultural competency training: 153
Days late - Employee #19 cultural competency training: 135
Days late - Employee #20 cultural competency training: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christian Jason Magbitang | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Employee #9 | Named in deficiency for late tuberculosis testing | |
| Employee #17 | Certified Nursing Assistant | Named in deficiency for late and non-approved cultural competency training |
| Employee #19 | Dietary Aide | Named in deficiency for late cultural competency training |
| Employee #20 | Housekeeper | Named in deficiency for late and non-approved cultural competency training |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Apr 5, 2024
Visit Reason
The inspection was conducted following allegations of verbal abuse by staff members towards residents and failure to properly investigate and report abuse allegations, including physical abuse and verbal mistreatment.
Complaint Details
The complaint investigation involved allegations of verbal abuse by a Physical Therapist and a Registered Nurse, verbal and physical abuse allegations against staff including a CNA, failure to investigate and report abuse allegations, and medication administration errors. The investigation included interviews with residents, staff, family members, and review of facility policies and incident reports. Some allegations were not substantiated, but failures in investigation and reporting were noted.
Findings
The facility failed to ensure residents were free from verbal abuse by staff, failed to properly investigate and report abuse allegations, and failed to ensure medication administration was done safely and as ordered. Specific incidents involved verbal abuse by a Physical Therapist and a Registered Nurse, failure to investigate and report physical abuse allegations against a CNA, medication errors including leaving medications unattended and at bedside, and unlocked medication carts.
Deficiencies (8)
Failed to honor resident's right to dignity; verbal berating by Physical Therapist to Resident #9.
Failed to protect Resident #7 from verbal abuse by a Registered Nurse who was cursing and throwing medication bottles.
Failed to implement abuse investigation and reporting policies; abuse allegation by Resident #2 against a CNA was not investigated or reported.
Failed to timely report suspected abuse of Resident #2 within two hours as required.
Failed to respond appropriately to alleged verbal abuse by a Registered Nurse towards Resident #7 and Resident #19.
Licensed Practical Nurse lacked competency in medication administration; premixed medications left unattended on medication cart.
Medication error: Resident #1's medications were left at bedside without supervision, not administered as ordered, with a 100% medication error rate.
Unsecured medications: medication carts were left unlocked and medications were accessible to staff, residents, and visitors.
Report Facts
Medication error rate: 100
Days CNA worked after abuse allegation: 20
Days CNA worked after abuse allegation: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapist | Named in verbal abuse incident with Resident #9. | |
| Registered Nurse (RN) | Named in verbal abuse incidents with Resident #7 and Resident #19; terminated due to misconduct. | |
| Certified Nursing Assistant (CNA) | Named in physical abuse allegation by Resident #2; continued to work after allegation. | |
| Licensed Practical Nurse (LPN) | Observed leaving premixed medications unattended on medication cart. | |
| Director of Nursing (DON) | Involved in investigation and interviews; confirmed failures in investigation and medication administration. | |
| Administrator | Shared responsibility of Abuse Coordinator; involved in investigation and interviews. |
Inspection Report
Routine
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
An offsite visit was conducted on January 9, 2024, to review all previous deficiencies cited on December 6, 2023.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 3
Date: Dec 6, 2023
Visit Reason
This Statement of Deficiencies was generated as a result of a Complaint and Facility Reported Incident (FRI) investigation conducted at the facility on December 6, 2023, in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.
Complaint Details
The investigation was triggered by five complaints and 11 Facility Reported Incidents (FRI). Some FRIs were not investigated due to lack of trend or minimal harm potential. Specific complaints included allegations of fraudulent draining of a resident's bank account (substantiated with no regulatory deficiency), verbal abuse (unsubstantiated), neglect, physical abuse, and failure to provide necessary care to prevent injury (unsubstantiated due to lack of evidence).
Findings
The investigation included multiple allegations such as resident elopement, verbal abuse, neglect, physical abuse, improper care, and medication cart security. Some allegations were substantiated with deficiencies cited, while others were unsubstantiated due to lack of evidence. The facility failed to ensure timely reporting of incidents and proper securing of medication carts.
Deficiencies (3)
Resident-to-resident physical abuse involving punching and grabbing causing bruises and discoloration.
Failure to timely report alleged violations involving neglect, exploitation, or mistreatment to the State Survey Agency.
Medication carts were found unlocked and unattended in the hallway, allowing residents potential access to medications.
Report Facts
Complaints investigated: 5
Facility Reported Incidents (FRI) investigated: 11
Sample size: 18
Residents involved in physical abuse incident: 2
Residents involved in neglect and abuse allegations: 13
Date of compliance: Jan 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Named in relation to physical abuse incident and medication cart security. | |
| Licensed Practical Nurse (LPN) | Involved in observations and interviews related to resident abuse and medication cart security. | |
| Registered Nurse (RN) | Conducted observations and interviews related to resident abuse allegations. | |
| Certified Nursing Assistant (CNA) | Witnessed resident altercations and provided statements regarding abuse incidents. | |
| Administrator | Responsible for abuse prevention and reporting policies. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 6, 2023
Visit Reason
The inspection was conducted due to allegations of resident-to-resident physical abuse incidents and failure to timely report suspected abuse within the facility.
Complaint Details
The complaint investigation focused on allegations of resident-to-resident physical abuse incidents involving Residents #5, #7, #8, and #9. The investigation found substantiated incidents of physical altercations and failure to timely report these incidents to the State Survey Agency within required timeframes.
Findings
The facility failed to protect residents from physical abuse by other residents in multiple incidents involving Residents #5, #7, #8, and #9. Additionally, the facility failed to submit timely Facility Reported Incidents (FRI) to the State Survey Agency within required timeframes. The facility also failed to ensure medication carts were secured when unattended.
Deficiencies (3)
Failed to protect residents from physical abuse by other residents in 2 of 13 Facility Reported Incidents involving Residents #5, #7, #8, and #9.
Failed to timely report suspected resident-to-resident physical abuse to the State Survey Agency for 1 of 18 sampled residents (Residents #5 and #7).
Failed to ensure medications were not left unsecured in a medication cart on the 300 hallway.
Report Facts
Facility Reported Incidents (FRI): 13
Facility Reported Incidents (FRI): 18
Time of incident: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Director of Nursing | Provided explanations regarding resident behaviors, abuse definitions, and expectations for staff reporting and intervention. |
| Administrator | Administrator | Verbalized role as abuse prevention coordinator and confirmed failure to report abuse allegations within required two-hour timeframe. |
| Registered Nurse (RN) | Registered Nurse | Witnessed resident altercations and provided statements regarding incidents. |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Provided statements regarding resident behaviors and abuse reporting procedures. |
| Certified Nursing Assistant (CNA) | Certified Nursing Assistant | Witnessed resident altercations and described intervention actions. |
Inspection Report
Follow-Up
Census: 153
Capacity: 180
Deficiencies: 6
Date: Oct 5, 2023
Visit Reason
Follow-up survey conducted on 10/05/2023 to verify correction of deficiencies cited in the July 12, 2023 Medicare recertification Life Safety Code revisit survey.
Findings
The facility failed to maintain delayed-egress doors within required pressure limits and smoke barrier doors had unsealed penetrations. Plans of correction were submitted and follow-up inspections found some improvements but some issues remained unresolved at the time of the revisit.
Deficiencies (6)
Delayed-egress doors required excessive pressure to open, exceeding 15 pounds, and some doors would not open or were painted shut.
Smoke barrier doors had unsealed penetrations including missing drywall and holes, compromising smoke barrier integrity.
Fire doors and door assemblies were not inspected and tested annually as required.
Electrical receptacles in patient care rooms were not tested or maintained per NFPA standards.
Fire safety plans and evacuation plans were incomplete or not available to staff.
Fire alarm system testing and maintenance records were incomplete or unavailable.
Report Facts
Residents present: 153
Licensed beds: 180
Delayed-egress door pressure: 35
Number of smoke barrier doors with unsealed penetrations: 3
Number of fire doors not inspected annually: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding fire plan knowledge and response during fire alarm |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding fire plan knowledge and response during fire alarm |
| Facility Maintenance Director | Interviewed about door inspections and maintenance; unable to produce documentation for door inspections | |
| Plant Operations Manager | Responsible party for corrective actions and monitoring compliance | |
| Plant Maintenance Supervisor | Verbalized awareness of plans of correction and door inspection requirements | |
| Nursing Home Administrator | Responsible party for corrective actions and monitoring compliance |
Inspection Report
Annual Inspection
Census: 153
Deficiencies: 3
Date: Jul 13, 2023
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey from July 10, 2023 through July 13, 2023, to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in multiple areas including failure to complete required tuberculosis (TB) testing for 12 of 20 sampled employees, untimely completion of dementia training for 2 employees, and failure to ensure timely cultural competency training for 12 of 20 sampled employees. Corrective actions and monitoring plans were outlined for each deficiency.
Deficiencies (3)
Failure to complete Tuberculosis (TB) testing for 12 of 20 sampled employees per Nevada Administrative Code (NAC) 441A.
Failure to ensure timely completion of dementia training for 2 of 20 sampled employees as required by NAC 449.74522.
Failure to ensure timely completion of cultural competency training for 12 of 20 sampled employees using a Division of Public and Behavioral Health approved training program.
Report Facts
Census: 153
Sample size: 20
Number of employees with incomplete TB testing: 12
Number of employees with untimely dementia training: 2
Number of employees with untimely cultural competency training: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christian Jason Magbitang | Administrator | Signed the report as Laboratory Director or Provider/Supplier Representative |
| Employee #1 | Administrator | Named in TB testing deficiency |
| Employee #5 | Social Services Coordinator | Named in TB testing and cultural competency training deficiencies |
| Employee #6 | Food Services Director | Named in TB testing and cultural competency training deficiencies |
| Employee #7 | Certified Nursing Assistant (CNA) | Named in TB testing deficiency |
| Employee #9 | Certified Nursing Assistant (CNA) | Named in TB testing and cultural competency training deficiencies |
| Employee #12 | Infection Preventionist | Named in TB testing deficiency |
| Employee #13 | Registered Nurse (RN) | Named in TB testing and cultural competency training deficiencies |
| Employee #14 | Licensed Practical Nurse (LPN) | Named in dementia training and cultural competency training deficiencies |
| Employee #15 | Licensed Practical Nurse (LPN) | Named in dementia training and cultural competency training deficiencies |
| Employee #16 | Certified Nursing Assistant (CNA) | Named in TB testing and cultural competency training deficiencies |
| Employee #17 | Certified Nursing Assistant (CNA) | Named in TB testing and cultural competency training deficiencies |
| Employee #18 | Named in cultural competency training deficiency | |
| Employee #19 | Dietary Aide | Named in TB testing deficiency |
Inspection Report
Routine
Deficiencies: 1
Date: Jul 12, 2023
Visit Reason
The inspection was conducted as an Emergency Preparedness survey in conjunction with a Medicare recertification survey to assess compliance with federal emergency preparedness regulations.
Findings
The facility failed to participate in a required second community-based or facility-based emergency preparedness exercise or drill during the past year, which could negatively impact the facility's readiness and staff skills in an emergency.
Deficiencies (1)
Failure to participate in a second community-based or facility-based full-scale exercise, mock disaster drill, or tabletop exercise to evaluate the effectiveness of the Emergency Preparedness Plan.
Report Facts
Residents: 153
Date of emergency preparedness exercise: Feb 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Verbalized that there had not been a second annual exercise of the Emergency Preparedness Plan |
Inspection Report
Routine
Census: 153
Capacity: 180
Deficiencies: 15
Date: Jul 11, 2023
Visit Reason
Routine Medicare Life Safety Code survey conducted at the facility to assess compliance with fire safety and other regulatory requirements.
Findings
The survey identified multiple deficiencies including delayed-egress doors requiring excessive force to open, fire protection equipment overdue for inspection, smoke detectors affected by airflow, kitchen fire protection system overdue for annual inspection, sprinkler system issues including foreign material and loose escutcheons, obstructed fire alarm system components, blocked fire extinguishers, fire doors failing to latch, electrical system issues including inaccurate panelboard schedules and use of residential power strips, and improper storage of oxygen cylinders.
Deficiencies (15)
Delayed-egress doors required more than 15 pounds of force to open or were painted shut.
Fire protection extinguishment system for the kitchen was overdue for annual inspection.
Smoke detector installed near fresh air vent possibly affecting operation.
Cooking facilities fire protection system overdue for inspection.
Sprinklers loaded with foreign material and escutcheons loose or missing.
Fire alarm system out of service without approved fire watch or staff training.
Sprinkler system maintenance and testing incomplete; sprinklers and escutcheons dirty or damaged.
Interior wall and ceiling finish documentation missing.
Electrical panel schedules inaccurate or missing; damaged wall receptacles; use of residential power strips in patient care areas.
Smoke barrier walls had unsealed penetrations and patched walls with missing drywall.
Smoke barrier doors failed to latch properly.
Fire drills not conducted quarterly on each shift; staff unfamiliar with fire plan and response.
Emergency generator exercises and load tests not performed or documented as required.
Oxygen cylinders improperly stored with empty cylinders placed under 'Full Tanks' sign and not segregated.
Fire hydrant access obstructed by overgrown bushes.
Report Facts
Deficiencies cited: 15
Resident census: 153
Total licensed capacity: 180
Fire drill frequency: 4
Generator load test frequency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Maintenance Director | Named in relation to multiple findings including fire door repairs, electrical panel issues, sprinkler maintenance, fire watch training, and documentation deficiencies. | |
| Plant Operations Manager | Named in relation to oversight of fire safety, sprinkler maintenance, fire drills, generator testing, and oxygen cylinder storage. | |
| Corporate Maintenance Manager | Present at discovery of fire hydrant obstruction and smoke barrier penetrations. |
Inspection Report
Routine
Deficiencies: 15
Date: Jul 10, 2023
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, dignity, assisted feeding practices, knocking before entering rooms, resident treatment and safety, infection control, care planning, medication management, and other regulatory requirements.
Findings
The facility failed to honor resident rights and dignity, including privacy violations and improper assisted feeding practices. There were failures in care planning, infection control, medication storage and administration, dental care access, and staff training. Specific issues included exposed residents, lack of knocking before room entry, improper handling of bodily fluids, unsecured medications, failure to follow oxygen orders, and inadequate behavioral health and infection control training.
Deficiencies (15)
Failed to honor resident rights and dignity by not providing privacy for exposed residents, improper assisted feeding posture, and not knocking before entering rooms.
Failed to protect residents' rights regarding personal belongings, including unauthorized searches and improper handling of personal vehicles.
Failed to provide notice of rights, rules, services, and charges related to towing a resident's vehicle.
Failed to ensure residents were not exposed to bodily fluids from an overflowed commode and failed to properly clean and disinfect the area.
Failed to create a timely baseline care plan for alcohol dependency for a resident.
Failed to provide a complete care plan for bed rail use and failed to implement planned interventions related to resident activities.
Failed to provide individual activities to meet a resident's interests.
Failed to provide and implement appropriate treatment and care for a resident's self-treatment to prevent skin breakdown.
Failed to ensure medications requiring refrigeration were stored properly, expired medications were removed, medications were secured, and resident medications were not left unsecured at bedside.
Failed to ensure staff food was stored and labeled correctly, cans were undented, and staff washed hands appropriately.
Failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Failed to provide and implement an infection prevention and control program, including appropriate signage, staff education, and catheter bag management.
Failed to designate a qualified infection preventionist with appropriate education and competency.
Failed to ensure timely infection control training for all staff.
Failed to ensure behavioral health training was completed timely for staff.
Report Facts
Deficiencies cited: 15
Expired medications: 21
Medication count: 14
Dented cans: 2
Medication count: 14
Oxygen flow rate: 3
Oxygen flow rate: 2
Behavioral health training: 4
Resident rights training: 1
Infection control training: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Registered Dietician | Lacked documented evidence of resident rights and infection control training for 2023 |
| LPN #1 | Licensed Practical Nurse | Left computer screen unlocked exposing resident information |
| LPN #2 | Licensed Practical Nurse | Left computer screen unlocked exposing resident information |
| Administrator | Did not perform investigation of resident drinking hand sanitizer incident | |
| Administrator in Training | Did not perform full investigation of resident drinking hand sanitizer incident | |
| Director of Nursing | Confirmed multiple deficiencies including catheter bag on ground, medication storage issues, and care planning failures | |
| Unit Manager | Explained resident drinking hand sanitizer incident and lack of monitoring | |
| Social Worker | Failed to follow up on resident dental needs and appointments | |
| Licensed Practical Nurse | Verbalized need for care planning for side rails and alert charting for resident drinking hand sanitizer | |
| Certified Nursing Assistant | Observed improper cleaning of bodily fluid spill and catheter bag on ground | |
| Housekeeping/Laundry Director | Confirmed housekeeping was short staffed and spill was not properly cleaned | |
| Infection Preventionist | Lacked knowledge of neutropenic precautions and MDROs | |
| Licensed Social Worker | Did not follow up on behavioral health referrals and was unaware of some behavioral health notes | |
| Assistant Business Office Manager | Threatened resident to withhold assistance if rude |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 31, 2023
Visit Reason
The inspection was conducted due to complaints and incidents involving resident-to-resident abuse, failure to investigate alleged violations, incomplete care plans, and failure to provide scheduled care such as showers.
Complaint Details
The complaint investigation focused on incidents of resident-to-resident abuse involving Residents #8, #9, #10, and #11, including physical hitting and verbal aggression. The facility failed to investigate verbal abuse incidents and failed to implement appropriate interventions such as room changes. The investigation also included failure to update care plans and failure to provide scheduled care to Resident #12.
Findings
The facility failed to prevent resident-to-resident physical and verbal abuse, failed to investigate incidents of abuse per policy, did not develop or update care plans related to resident altercations and injury reporting, and failed to provide scheduled showers to a dependent resident.
Deficiencies (5)
Failed to protect residents from all types of abuse including physical and verbal abuse by other residents.
Failed to respond appropriately to all alleged violations by not investigating resident-to-resident verbal abuse incidents.
Failed to develop and implement a complete care plan related to resident-to-resident altercation.
Failed to update a resident's care plan to reflect history of not reporting severe injuries.
Failed to provide a dependent resident scheduled showers twice weekly as per care plan.
Report Facts
Residents sampled: 15
Days without shower: 8
Days without shower: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided explanations and confirmations regarding resident altercations, investigations, care plan deficiencies, and shower schedule issues. | |
| Licensed Practical Nurse (LPN) | Explained procedures for handling resident-to-resident altercations. | |
| Certified Nursing Assistant (CNA) | Reported incidents and explained shower schedules. | |
| Registered Nurse (RN) | Communicated about resident safety during altercations and care plan knowledge. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 14, 2023
Visit Reason
The inspection was conducted due to complaints and allegations involving resident abuse, including sexual abuse by a resident, verbal abuse by staff, misappropriation of resident funds, and failure to timely report and investigate abuse incidents.
Complaint Details
The complaint investigation involved allegations of sexual abuse by Resident #4 against Resident #2, verbal abuse by staff towards Resident #10, misappropriation of Resident #3's funds by a staff member, failure to submit required Facility Reported Incidents (FRI) for abuse allegations involving Residents #10, #11, and #12, and failure to investigate verbal abuse allegations involving Resident #10.
Findings
The facility failed to protect residents from sexual and verbal abuse, failed to prevent misappropriation of resident funds by staff, and failed to timely report and investigate allegations of abuse as required by policy and regulations.
Deficiencies (5)
Failed to ensure a cognitively impaired resident was not sexually abused by another resident.
Failed to ensure a resident was not verbally abused by a staff member.
Failed to ensure a resident's credit card was not used without permission by a staff member.
Failed to timely report suspected abuse and submit Facility Reported Incidents (FRI) to the state agency.
Failed to investigate an incident of verbal abuse per facility policy.
Report Facts
Residents sampled: 12
Days sexually inappropriate behavior documented: 6
Days wandering behavior documented: 12
Inspection Report
Complaint Investigation
Census: 160
Deficiencies: 6
Date: Feb 14, 2023
Visit Reason
The inspection was conducted as a result of complaint (CPT) and Facility Reported Incidents (FRI) investigations at the facility on 02/13/23 and completed on 02/14/23.
Complaint Details
The complaint investigation included multiple allegations such as residents being left in urine-soaked beds, call lights not answered timely, pain medication delays, inadequate nursing staff, unsafe discharge planning, falls resulting in injuries, sexual abuse by a resident, verbal abuse by staff, misuse of resident's credit card by staff, and failure to maintain privacy. Some allegations were substantiated, others were not due to lack of evidence. Additional concerns were noted regarding lack of investigation and reporting of abuse allegations.
Findings
The investigation included multiple allegations related to resident care, abuse, neglect, and facility operations. Several allegations were not substantiated due to lack of evidence, but substantiated findings included sexual abuse by a resident, verbal abuse by staff, misuse of a resident's credit card by staff, and failure to maintain resident privacy. Additional concerns included lack of investigation and reporting of abuse allegations and failure to update care plans following resident-to-resident altercations.
Deficiencies (6)
Failure to ensure a resident's right to personal privacy was maintained when a privacy curtain was missing around a resident's bed.
Failure to ensure a cognitively impaired resident was not sexually abused by another resident and failure to prevent verbal abuse by staff.
Failure to prevent misappropriation of a resident's credit card by a staff member.
Failure to report alleged violations of abuse and neglect to the state agency and failure to complete required Facility Reported Incident (FRI) reports.
Failure to investigate allegations of verbal abuse per facility policy.
Failure to develop or update a care plan to include new interventions following resident-to-resident altercation allegations.
Report Facts
Sample size: 12
Number of CPTs investigated: 5
Number of FRIs investigated: 7
Resident census: 160
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 24, 2022
Visit Reason
An offsite revisit was conducted on October 24, 2022, to review all previous deficiencies cited on September 1, 2022.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 24, 2022
Visit Reason
An offsite revisit was conducted on October 24, 2022 for all previous deficiencies cited on August 31, 2022.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Deficiencies cited: 0
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 11
Date: Sep 1, 2022
Visit Reason
The inspection was conducted as a Medicare Recertification survey and a Facility Reported Incident (FRI) investigation from August 29, 2022 through September 1, 2022, in accordance with 42 CFR Chapter IV, Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to be 100% compliant with Healthcare Worker COVID-19 vaccination requirements. One FRI investigation regarding resident-to-resident abuse was unsubstantiated. Deficiencies were identified related to resident rights, privacy during wound care and urinary catheter care, shower provision, PASARR evaluations, care planning, medication administration, bed rail use, medication labeling and storage, infection control, and staff training on abuse prevention.
Deficiencies (11)
Failed to ensure resident privacy during wound care and urinary catheter care.
Failed to provide showers to a dependent resident as scheduled.
Failed to submit PASARR Level II determination for a resident with serious mental disorder.
Failed to implement comprehensive care plan for resident activities and failed to provide activities seven days a week.
Failed to administer pain medication as ordered for a resident.
Failed to obtain physician order and consent prior to bed rail use.
Failed to notify physician of unavailable medication and failed to ensure medication was administered as ordered.
Failed to ensure medications that cannot be crushed were not crushed.
Failed to ensure medications were not left unsecured at resident bedside without order.
Failed to perform hand hygiene between glove changes during wound care and failed to screen visitors for COVID-19 symptoms and temperature per policy.
Failed to ensure timely initial and annual elder abuse training for some employees.
Report Facts
Sample size: 27
Medication error rate: 7.14
Number of employees lacking timely elder abuse training: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #11 | Speech Therapist | Lacked timely elder abuse training. |
| Employee #15 | Licensed Practical Nurse | Lacked timely elder abuse training. |
| Employee #19 | Dietary Aide | Lacked timely elder abuse training. |
| Employee #10 | Registered Nurse | Lacked timely elder abuse training. |
| RN #1 | Registered Nurse | Observed not performing hand hygiene between glove changes during wound care. |
| DON | Director of Nursing | Provided multiple clarifications on facility policies and deficiencies. |
| LPN | Licensed Practical Nurse | Administered crushed lamotrigine which should not be crushed. |
| Consultant Pharmacist | Pharmacist | Confirmed lamotrigine should not be crushed. |
| Social Services Director | Social Services Director | Confirmed failure to submit PASARR Level II determination. |
Inspection Report
Routine
Census: 136
Capacity: 174
Deficiencies: 12
Date: Sep 1, 2022
Visit Reason
The inspection was a Medicare Life Safety Code survey conducted at the facility on 08/31/22 through 09/01/22 to assess compliance with health and safety regulations.
Findings
The facility had multiple deficiencies including delayed-egress doors requiring excessive force to open, smoke detectors placed near air vents, hazardous area doors lacking self-closing devices, sprinkler system maintenance issues, corridor doors blocked or damaged, unsealed smoke barrier penetrations, electrical system issues including inaccurate panel labeling, improper use of extension cords and power taps, missing signage on generator shut off, and incomplete fire drill documentation.
Deficiencies (12)
Delayed-egress doors required more than 15 pounds of force to open, violating NFPA 101 Life Safety Code.
Smoke detector installed too close to an air return vent, potentially affecting operation.
Hazardous area storage room doors larger than 50 square feet lacked self-closing devices.
Sprinkler system had dirt, paint, gaps, missing escutcheons, and wiring resting on sprinkler pipes.
Corridor doors were blocked by wheelchairs and walkers, had damaged or missing parts, preventing proper closure and smoke resistance.
Fire drills were not conducted on second and third shifts during multiple quarters.
Electrical panels had inaccurate circuit directories and were blocked by objects.
Ground fault circuit interrupter (GFCI) receptacles were missing or damaged near sinks and bathrooms.
Generator remote manual stop station lacked required signage.
Patient care related electrical equipment was plugged into non-medical grade residential style power taps.
Facility failed to provide evidence of weekly inspections of essential electrical system (generator).
Smoke barrier penetrations were unsealed in multiple locations.
Report Facts
Deficiencies cited: 12
Resident census: 136
Total licensed capacity: 174
Delayed-egress door force: 25
Fire drill frequency: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Manager | Present at discovery of multiple deficiencies including sprinkler issues, electrical issues, and fire drills. | |
| Interim Administrator | Present at discovery of multiple deficiencies including sprinkler issues, electrical issues, and fire drills. | |
| Administrator in Training | Present at discovery of multiple deficiencies including sprinkler issues, electrical issues, and fire drills. |
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 5
Date: Sep 1, 2022
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey from August 29, 2022 through September 1, 2022, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in several areas including incomplete pre-employment physical examinations for some employees, failure to ensure timely dementia training, failure to protect potable water from contamination due to plumbing issues, accumulation of dirt on exhaust fans, and incomplete cultural competency training for certain employees.
Deficiencies (5)
Failure to ensure pre-employment physical examinations were completed for 3 of 20 sampled employees.
Failure to ensure eight hours of initial and annual dementia training was completed for 3 of 20 sampled employees.
Failure to ensure potable water was protected due to plumbing issues including a hose laying in a mop sink and an invalid atmospheric vacuum breaker.
Failure to ensure exhaust openings were kept free from accumulation of dirt in bathrooms of rooms 401, 409, and 102.
Failure to ensure cultural competency training was completed for 3 of 20 sampled employees.
Report Facts
Census: 136
Sample size: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #10 | Physical Therapist | Named in findings for missing or late pre-employment physical and cultural competency training |
| Employee #11 | Speech Therapist | Named in findings for missing pre-employment physical, dementia training, and cultural competency training |
| Employee #12 | Infection Preventionist | Named in findings for missing pre-employment physical |
| Employee #13 | Registered Nurse | Named in findings for missing dementia training |
| Employee #14 | Licensed Practical Nurse | Named in findings for missing dementia training |
| Employee #4 | Registered Dietician | Named in findings for missing cultural competency training |
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 6
Date: Jun 7, 2022
Visit Reason
The inspection was conducted as a result of complaint and Facility Reported Incidents (FRI) investigation at Alta Skilled Nursing and Rehabilitation Center on June 6-7, 2022.
Complaint Details
The complaint investigation included six complaints and seven Facility Reported Incidents (FRIs). Substantiated complaints included resident to resident abuse, failure to provide showering assistance, failure to provide ordered care to cholecystostomy, failure to assess prior to dialysis, and failure to schedule hearing exam. Several other allegations were not substantiated due to lack of evidence.
Findings
The investigation included review of clinical records, interviews with staff and residents, and observation of care. Several allegations were substantiated including resident to resident abuse, failure to provide showering assistance, failure to provide care to a cholecystostomy, failure to assess prior to dialysis, and failure to schedule a hearing exam. Other allegations were not substantiated due to lack of evidence. Deficiencies were identified related to care planning, ADL care, quality of care, dialysis monitoring, medication storage, and transportation for hearing exams.
Deficiencies (6)
Failure to develop and implement comprehensive care plans reflecting resident behaviors and abuse incidents for residents #6 and #7.
Failure to provide showering assistance as ordered for residents #1 and #2.
Failure to provide care to cholecystostomy drain site as ordered for resident #1.
Failure to schedule and ensure hearing exam for resident #2 as ordered.
Failure to monitor dialysis complications and document assessments for resident #1.
Medication carts were left unlocked and unattended, allowing unauthorized access.
Report Facts
Census: 139
Sample size: 13
Complaints investigated: 6
Facility Reported Incidents (FRIs) investigated: 7
Days without shower: 17
Days without shower: 9
Days without shower: 13
Days without shower: 6
Days without shower: 8
Days without shower: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding investigations, care plans, abuse checklist, and monitoring of dialysis and hearing appointments. | |
| Registered Nurse (RN) | Interviewed regarding investigations and medication cart security. | |
| Licensed Practical Nurse (LPN) | Interviewed regarding investigations and medication cart security. | |
| Administrator | Interviewed regarding investigations and medication cart security. | |
| Unit Manager | Interviewed regarding hearing appointment scheduling and dialysis monitoring. | |
| Certified Nursing Assistant (CNA) | Interviewed regarding investigations and shower documentation. | |
| Transportation service worker/scheduler | Interviewed regarding scheduling of hearing appointments. |
Inspection Report
Renewal
Deficiencies: 1
Date: Dec 28, 2021
Visit Reason
This inspection was conducted as a State Re-licensure Survey desk review for the facility in accordance with Nevada Administrative Code (NAC), Chapter 449, Skilled Nursing Facilities.
Findings
The facility failed to ensure that 1 of 10 sampled employees met the requirements for pre-employment physicals, specifically Employee #3 had a physical completed after the date of hire.
Deficiencies (1)
Employee #3's pre-employment physical was completed after the date of hire.
Report Facts
Sample size of employee records reviewed: 10
Severity level: 2
Scope: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Registered Nurse | Named in deficiency for pre-employment physical completed after date of hire |
| Kaitlin Modina | Administrator | Signed the report and mentioned as VP of clinical services providing inservice |
Inspection Report
Renewal
Capacity: 180
Deficiencies: 0
Date: Sep 10, 2021
Visit Reason
The inspection was conducted as a state licensure construction standards bed increase survey to approve two additional skilled nursing beds and verify renovations converting private rooms to shared rooms.
Findings
The facility was found to be in substantial compliance with the regulations, with no further action necessary concerning this Statement of Deficiencies/Plan of Correction.
Report Facts
Licensed skilled nursing beds: 180
Survey date: Sep 10, 2021
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 0
Date: Aug 24, 2021
Visit Reason
The inspection was conducted as a result of a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey and complaint investigation at Alta Skilled Nursing and Rehabilitation Center on 08/24/2021.
Complaint Details
Seven complaints were investigated with allegations including lack of foot and toenail care, failure to assess change in condition, unclean resident rooms, missing personal items, phone system issues, inadequate physical therapy, medication administration concerns, and visitation difficulties. All allegations were found unsubstantiated due to lack of evidence after thorough investigation including observations, interviews, and record reviews.
Findings
The investigation included review of infection control practices, staff and resident hygiene, and multiple complaints alleging various deficiencies in resident care and facility operations. None of the seven complaints investigated were substantiated due to lack of evidence. The facility's policies, clinical records, and staff practices were reviewed and observed during the survey.
Report Facts
Sample size: 7
COVID-19 positive staff: 1
Inspection Report
Complaint Investigation
Census: 152
Deficiencies: 0
Date: Mar 25, 2021
Visit Reason
The inspection was conducted as a result of complaint investigations at the facility on 03/25/21, triggered by two complaints with multiple allegations regarding resident care, facility policies, and COVID-19 related concerns.
Complaint Details
Two complaints were investigated: Complaint #NV00063344 with 10 allegations related to facility security, visitation, COVID-19 vaccine administration, resident neglect, missing clothing, untreated scabs, phone answering, cable TV, resident activities, and staff conduct on social media; and Complaint #NV00063273 with 15 allegations related to call bell response, phone answering, physical therapy, follow-up after discharge, medication administration, resident hygiene, rash treatment, weight loss, allergy management, guardianship communication, paramedic communication, and CPAP machine use. None of the allegations were substantiated.
Findings
All allegations from the two complaints were investigated and found to be not substantiated based on interviews, observations, clinical record reviews, and policy reviews. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 6
Weight measurements: 220.2
Weight measurements: 221
Weight measurements: 222
Weight measurements: 220
Weight measurements: 225
Weight measurements: 230
Weight measurements: 231
Weight loss percentage: 4.7
Weight loss: 11
Calorie intake: 2300
Protein intake: 95
Medication dosage: 50
Medication dosage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding COVID-19 vaccine administration, missing clothing, call bell and phone answering allegations, and CPAP machine delivery |
| Administrator | Administrator | Interviewed regarding facility security and visitation policies |
Inspection Report
Abbreviated Survey
Census: 137
Deficiencies: 0
Date: Dec 7, 2020
Visit Reason
The inspection was a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey initiated to assess compliance with infection prevention and control requirements related to COVID-19.
Findings
The survey included review of infection prevention policies, surveillance plans, PPE stock, staff and resident testing, and facility practices. No regulatory deficiencies were identified during the survey.
Report Facts
COVID-19 positive residents: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed during the inspection | |
| Vice President of Operations | Interviewed during the inspection | |
| Director of Housekeeping and Laundry | Interviewed during the inspection | |
| Occupational Therapy Assistant assigned to the COVID unit | Interviewed during the inspection | |
| Administrator in Training | Interviewed during the inspection | |
| Telehealth Coordinator | Interviewed during the inspection |
Inspection Report
Abbreviated Survey
Census: 152
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
The inspection was conducted as a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey to assess compliance with infection prevention and control requirements related to COVID-19.
Findings
No regulatory deficiencies were identified during the survey. The investigation included review of infection prevention and control policies, staff and resident hygiene practices, and interviews with facility leadership and staff.
Report Facts
Census at time of survey: 152
Inspection Report
Complaint Investigation
Census: 152
Deficiencies: 0
Date: Oct 27, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation at Alta Skilled Nursing and Rehabilitation Center on 10/27/2020, involving multiple complaints alleging various resident care issues.
Complaint Details
Five complaints were investigated: #NV00060838, #NV00060336, #NV00061315, #NV00060124, and #NV00060406. Allegations ranged from residents being left soiled, missing personal items, improper medication and oxygen administration, inadequate discharge procedures, to falls and neglect. All allegations were unsubstantiated based on thorough investigation including interviews with residents, staff, and review of medical records and facility policies.
Findings
The investigation reviewed five complaints with multiple allegations including resident care, communication, supplies, and discharge procedures. All allegations were found to be unsubstantiated based on observations, interviews, and record reviews. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 5
Complaints investigated: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the complaint investigation | |
| Food Service Director | Interviewed regarding food preferences complaint | |
| Social Worker | Interviewed during the complaint investigation | |
| Assistant Administrator | Interviewed during the complaint investigation | |
| Licensed Practical Nurse | Interviewed during the complaint investigation |
Inspection Report
Follow-Up
Census: 151
Deficiencies: 0
Date: May 21, 2020
Visit Reason
This visit was a COVID-19 focused infection control follow-up revisit survey initiated by CMS to assess compliance with infection prevention and control requirements.
Findings
The investigation included review of infection prevention and control program policies, resident care practices, screening, and staffing policies. No regulatory deficiencies were identified during this follow-up survey.
Report Facts
Positive COVID-19 residents: 1
Inspection Report
Routine
Census: 159
Deficiencies: 0
Date: Apr 10, 2020
Visit Reason
This inspection was a COVID-19 Focused Infection Control survey conducted by Centers for Medicare and Medicaid Services (CMS) to assess compliance with infection prevention and control requirements.
Findings
The investigation included review of the Infection Prevention and Control Program, policies, resident care practices, surveillance, visitor screening, staff education and monitoring, and staffing policies during emergencies. No regulatory deficiencies were identified.
Report Facts
Sample size: 5
COVID-19 positive residents: 0
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 0
Date: Nov 21, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by allegations regarding resident care at the facility.
Complaint Details
One complaint (NV00059277) was investigated with allegations that a resident appeared overmedicated and groggy, dehydrated, and had uncombed hair placed in a ponytail. These allegations were not substantiated.
Findings
The investigation included observations, interviews, and record reviews, and found that the allegations could not be substantiated. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the investigation | |
| Licensed Practical Nurse | Interviewed during the investigation; responsible for Clinical Set Up at admission |
Inspection Report
Routine
Census: 117
Capacity: 174
Deficiencies: 16
Date: May 29, 2019
Visit Reason
The inspection was a Medicare Life Safety Code (LSC) recertification survey conducted at the facility on 05/28/19 and 05/29/19.
Findings
The survey identified multiple deficiencies including obstructed egress corridors, blocked emergency exit signage, failure to conduct required emergency lighting tests, lack of flame spread rating documentation for interior finishes, sprinkler system maintenance issues, missing portable fire extinguishers and signage, doors with self-closing devices held open, unsealed smoke barrier penetrations, electrical panel obstructions and inaccurate labeling, incomplete fire drill documentation, incomplete smoking policy and unsafe smoking area, and failure to test hospital-grade electrical receptacles annually.
Deficiencies (16)
Eight foot corridors were obstructed by linen carts reducing clearance below required minimum.
Emergency exit signs were blocked by curtains and not visible.
Facility failed to conduct required 1.5 hour annual functional testing of emergency lighting systems.
Facility failed to provide evidence of flame spread rating for Fiberglass Reinforced Plastic (FRP) in kitchen.
Automatic sprinkler system had sprinklers loaded with dust, lint, paint overspray, physical damage, missing escutcheons, and lacked documentation of sprinkler types.
Smoking area lacked portable fire extinguisher and/or fire blanket and cigarette butts were found on ground.
Corridor doors with self-closing devices were held open with objects preventing proper closure.
Smoke barrier construction penetrations were not properly sealed to prevent passage of smoke.
Fire doors in smoke barriers failed to latch closed when released from magnetic holding devices.
Electrical panels were blocked by furniture, had inaccurate or missing circuit directories, and relocatable power taps and extension cords were used as fixed wiring in resident rooms.
Fire drills were not conducted at unexpected times on all shifts, including night and evening shifts, and staff were unfamiliar with fire drill procedures.
Facility smoking policy was incomplete and failed to provide safe disposal of cigarette butts.
Curtains in storage room and medical records bathroom exceeded allowable size and lacked documentation of meeting NFPA 701 flame retardant standards.
Non-hospital grade electrical receptacles were not tested annually as required.
Essential electrical system (EES) weekly inspections and monthly tests were not conducted or documented as required, including failure to document transfer times and testing intervals.
Patient care-related electrical equipment was improperly used with relocatable power taps and multipliers (daisy chaining) in resident rooms.
Report Facts
Licensed skilled nursing beds: 174
Resident census: 117
Deficiencies cited: 15
Emergency lighting test duration: 1.5
Fire sprinkler heads measured height: 8.5
Fire sprinkler system test duration: 30
Water storage capacity: 600
Water storage capacity: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed multiple deficiencies including blocked signage, fire drill issues, smoking policy gaps, and electrical testing lapses | |
| Plant Operations Manager | Confirmed multiple deficiencies including obstructed corridors, sprinkler issues, emergency lighting testing, fire door issues, electrical panel obstructions, and essential electrical system testing lapses | |
| Director of Housekeeping | Confirmed smoking area lacked portable fire extinguisher | |
| Certified Nursing Assistant | Observed confused during fire drill scenario |
Inspection Report
Routine
Census: 117
Capacity: 174
Deficiencies: 11
Date: May 29, 2019
Visit Reason
The inspection was a Medicare Life Safety Code recertification survey conducted at the facility on 05/28/19 and 05/29/19.
Findings
The survey identified multiple deficiencies related to life safety code compliance including missing exit signage, emergency lighting testing deficiencies, fire sprinkler system maintenance issues, smoke barrier penetrations, malfunctioning smoke barrier doors, incomplete fire drill procedures, incomplete smoking policy, and electrical system maintenance lapses.
Deficiencies (11)
Missing readily visible signage on emergency exit door in the 600 wing.
Failure to conduct required 1.5 hour annual functional testing of emergency lighting systems.
Failure to maintain automatic fire sprinkler system; sprinklers were dirty, damaged, painted, or physically bent.
Fire sprinkler spare box lacked a list of sprinkler types and quantities; missing NFPA 25 documentation; sprinkler escutcheon missing; items resting on sprinkler pipes.
Portable fire extinguishers lacked required signage for visibility.
Smoke barrier wall penetrations were not properly sealed to prevent smoke passage.
Smoke barrier doors in the 600 wing had malfunctioning latching devices and did not latch closed properly.
Fire drills were not conducted at unexpected times on all shifts quarterly; night shift fire drills missing; staff unfamiliar with fire drill procedures; delayed Code Red announcement during drill.
Smoking policy incomplete; missing provisions for ashtrays and metal containers with self-closing covers in smoking areas.
Non-hospital grade electrical receptacles in resident rooms were not tested annually as required.
Essential electrical system (EES) weekly inspections and monthly load tests were not consistently performed or documented; transfer times not documented or outside required intervals.
Report Facts
Deficiencies cited: 11
Resident census: 117
Total licensed capacity: 174
Fire drill missing night shift quarters: 3
EES load test interval: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Manager | Confirmed multiple deficiencies including missing signage, emergency lighting testing, sprinkler system issues, smoke barrier penetrations, fire drill concerns, and electrical system testing lapses. | |
| Administrator | Confirmed missing exit signage, fire drill procedure issues, and smoking policy deficiencies. | |
| Certified Nursing Assistant | Observed during fire drill simulation and was confused about fire alarm procedures. |
Inspection Report
Annual Inspection
Census: 117
Deficiencies: 12
Date: May 23, 2019
Visit Reason
Medicare Recertification survey conducted from May 20, 2019 through May 23, 2019.
Findings
The facility had multiple deficiencies including failure to ensure meal trays were delivered simultaneously to roommates, lack of informed consent for psychotropic medications and restraints, failure to ensure call light accessibility, inadequate infection control practices, medication errors, and food service deficiencies.
Deficiencies (12)
Failed to ensure meal trays were delivered to rooms with roommates served at the same time for 1 resident.
Failed to obtain informed consent prior to administration of psychotropic medications and use of restraints for 2 residents.
Failed to ensure a resident had access to a call light when needed.
Failed to develop and implement comprehensive care plans addressing pain management, wound care, and use of scoop mattress for 3 residents.
Failed to remove unsecured oxygen tanks from resident room and secure cigarette lighter for a resident.
Failed to obtain dialysis communication forms for 1 resident.
Medication error rate was 7.14%, exceeding 5%.
Failed to administer eye drops within prescribed time window.
Failed to properly label multi-dose vials, discard expired medications, and secure medications.
Failed to prepare enough menu items in advance, follow recipes, and serve full entree portions according to menu for multiple residents.
Failed to properly store food items, label and date food in refrigerators, and maintain proper hand hygiene practices.
Failed to ensure aseptic technique during suprapubic catheter irrigation, conduct annual review of infection prevention and control program, and maintain washing machine in good repair.
Report Facts
Census: 117
Sample size: 24
Medication error rate: 7.14
Deficiency count: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in pain management and medication administration findings |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Named in meal tray delivery timing deficiency |
| Director of Nursing | Director of Nursing | Named in multiple findings including meal tray delivery, call light accessibility, pain management, and infection control |
| Dietary Manager | Dietary Manager | Named in food service and menu preparation deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in meal tray delivery and dialysis communication findings |
| Registered Nurse #11 | Registered Nurse | Named in suprapubic catheter irrigation infection control finding |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Named in medication administration timing deficiency |
| Food Service Director | Food Service Director | Named in food service deficiencies and corrective actions |
| Housekeeping Laundry Supervisor | Housekeeping Laundry Supervisor | Named in washing machine maintenance deficiency |
Inspection Report
Annual Inspection
Census: 117
Deficiencies: 16
Date: May 23, 2019
Visit Reason
The inspection was a Medicare Recertification survey conducted from May 20, 2019 through May 23, 2019 to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found deficient in multiple areas including resident rights, informed consent for psychotropic medications and restraints, meal delivery timing for roommates, pain management, infection control, medication administration, food safety, and equipment maintenance. Specific issues included delayed meal tray delivery to roommates, lack of informed consent for psychotropic medications and restraints, failure to ensure call light accessibility, soiled linens, medication errors, improper food preparation and serving, and failure to maintain equipment in safe operating condition.
Deficiencies (16)
Resident Rights/Exercise of Rights - failure to ensure meal trays were delivered to roommates simultaneously.
Right to be Informed/Make Treatment Decisions - failure to obtain informed consent prior to administration of psychotropic medications and use of restraints.
Reasonable Accommodations - failure to ensure call light was accessible to resident.
Safe Environment - failure to maintain clean linens and resident room floor.
Right to be Free from Physical Restraints - failure to assess and monitor use of lap buddy restraint.
Reporting of Alleged Violations - failure to submit final investigation report within required timeframe.
Develop/Implement Comprehensive Care Plans - failure to develop care plans addressing pain management, wound care, and use of scoop mattress.
Quality of Life - failure to ensure resident was not left unattended with food tray and needed assistance to eat.
Free of Accident Hazards/Supervision/Devices - failure to secure oxygen tanks and cigarette lighter.
Dialysis - failure to obtain dialysis communication forms.
Competent Nursing Staff - failure to demonstrate competency in assisting resident with eating, serving roommates simultaneously, and changing soiled linens.
Label/Store Drugs and Biologicals - failure to label multi-dose vials with open date, discard expired medications, and secure medications.
Menus Meet Resident Needs/Prep in Advance/Followed - failure to prepare enough menu items, follow recipes, and serve full entree portions.
Nutritive Value/Appearance, Palatable/Preferred Temperature - failure to serve food palatable and at safe temperature.
Food Procurement, Store/Prepare/Serve-Sanitary - failure to remove dented cans, label food items, and maintain hand hygiene.
Infection Prevention & Control - failure to maintain aseptic technique during suprapubic catheter irrigation, conduct annual IPCP review, and maintain laundry machine in good repair.
Report Facts
Census: 117
Sample size: 24
Medication error rate: 7.14
Deficiencies cited: 16
Meal tray delay: 54
Meal tray delay: 32
Pain level: 10
Flu vaccine vial expiration: Jun 5, 2019
Tuberculin vial expiration: Apr 8, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in meal tray delivery timing deficiency and roommate meal serving |
| Director of Nursing | Named in multiple findings including meal delivery timing, pain management, infection control, medication administration | |
| Licensed Practical Nurse #1 | LPN | Named in pain management deficiency |
| Licensed Practical Nurse #2 | LPN | Named in pain management deficiency |
| Registered Nurse #11 | RN | Named in medication error and catheter flushing deficiencies |
| Dietary Manager | Named in food preparation and serving deficiencies | |
| Cook #17 | Named in food preparation and serving deficiencies | |
| Housekeeping Supervisor | Named in laundry machine maintenance deficiency | |
| Maintenance Director | Named in laundry machine maintenance deficiency |
Inspection Report
Annual Inspection
Census: 117
Deficiencies: 1
Date: May 23, 2019
Visit Reason
The inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey at the facility from May 20, 2019 through May 23, 2019, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility failed to ensure pre-employment physicals were completed prior to initial employment for 11 of 18 sampled employees and a background check had been completed for only 1 of 18 sampled employees. Several employee personnel records lacked documented evidence of pre-employment physicals and background checks despite employees having worked with residents since their hire dates.
Deficiencies (1)
Failure to ensure pre-employment physicals were completed prior to initial employment for 11 of 18 sampled employees and background checks were incomplete.
Report Facts
Census: 117
Employees reviewed: 18
Deficiency severity scope: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zachary S. Gray | Administrator | Signed the report as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Date: Jan 9, 2019
Visit Reason
The inspection was conducted as a complaint investigation initiated on 01/09/19 and completed on 01/11/19, triggered by two complaints regarding facility conditions and resident care.
Complaint Details
Two complaints were investigated. Complaint #NV00055601 regarding failure to maintain smoke detectors was substantiated. Complaint #NV00055188 regarding failure to ensure protective supervision to prevent resident elopement was not substantiated. Several other allegations related to call light alternatives, resident weighing, food temperature, resident hygiene, physical therapy, and use of CPAP machine were not substantiated.
Findings
The investigation substantiated one complaint regarding failure to maintain smoke detectors in resident rooms, identifying deficiencies with smoke detectors being loose or missing. Other allegations were not substantiated. Corrective actions included tightening and replacing smoke detectors and implementing monthly audits to ensure compliance.
Deficiencies (1)
Failure to keep the resident environment free of accident hazards by not maintaining the fire alarm system, specifically smoke detectors that were loose or missing in resident rooms.
Report Facts
Census: 101
Sample size: 5
Date of completion: Apr 5, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the investigation | |
| Unit Manager | Interviewed during the investigation | |
| Registered Nurse | Interviewed during the investigation | |
| Certified Nursing Assistants | Two CNAs interviewed during the investigation | |
| Physical Therapist | Interviewed during the investigation | |
| Maintenance Supervisor | Involved in smoke detector testing and maintenance | |
| Administrator | Interviewed regarding smoke detector issues | |
| Plant Operations Director | Responsible for compliance and corrective actions related to smoke detectors |
Report
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