Inspection Reports for Chimney Rock Villa

The complaint alleged the facility failed to investigate causative factors in falls. The allegation was substantiated based on record reviews and interviews.

The investigation confirmed that the facility failed to identify potential causal factors related to a fall for one sampled resident, resulting in deficiencies cited under F 689 and 175 NAC 12-006.09D7b (1). The resident fell on 4/23/18, and although initially denying pain, was later found to have a rib fracture. The Director of Nursing confirmed that causal factors were not identified to implement changes to reduce recurrent falls.

The complaint investigation was triggered by allegations of abuse, disrespectful treatment, failure to follow advanced directives, failure to notify responsible parties of changes, failure to provide appropriate activities, and failure to address grievances. The investigation included resident record reviews, observations, and interviews with residents, family members, and staff. Several allegations were substantiated with cited deficiencies.

The investigation confirmed multiple deficiencies including failure to protect a resident from staff abuse, failure to treat a resident with respect and dignity, failure to notify a responsible party of changes in condition, failure to provide requested activities, and failure to follow up on grievances. The facility was compliant with following advanced directives. Deficiencies were cited under various regulatory codes.

The visit was complaint-related investigating allegations that the facility failed to protect residents from abuse, failed to report allegations of abuse, and failed to ensure residents are free from misappropriation. The investigation found the facility followed policies and regulatory requirements with no violations.

The facility was found to be following policies regarding allegations of abuse with no violations cited. Deficiencies were found related to life safety code violations including lack of self-closing doors on hazardous area storage rooms and inadequate clearance around electrical panels. Additional deficiencies included worn toilet seats, incomplete care plans, unlabeled towel bars, kitchen ceiling damage, non-functioning bathroom ventilation systems, and an incomplete emergency preparedness plan.

The facility was found deficient in multiple areas including staff CPR certification, privacy of medical records, maintenance of equipment, accurate resident assessments, care planning, medication monitoring, resident call system functionality, fire safety including fire door inspections, exit discharge clearance, fire drills, and electrical safety regarding multi-plug adapters.

The complaint investigation addressed allegations of misappropriation, insufficient staffing, and failure to assist residents with personal hygiene. The misappropriation and staffing allegations were unsubstantiated with no violations noted. The personal hygiene allegation was substantiated with a cited violation.

No violations were found related to misappropriation or staffing sufficiency. However, a violation was cited for failure to ensure residents received personal hygiene care according to their preferences, specifically for three sampled residents who did not receive baths twice weekly as planned.

The facility was found deficient in multiple areas including failure to notify physicians of pressure ulcers, inadequate care planning and treatment for pressure ulcers, failure to monitor medication effectiveness, improper infection control practices, housekeeping and maintenance deficiencies, food safety violations, and life safety code violations such as incomplete fire drills and sprinkler system obstructions.

The complaint investigation included allegations of insufficient staffing, failure to appoint a facility administrator, failure to assist residents with bathing, and failure to ensure the administrator has required credentials. The allegations were substantiated with some previously corrected issues not cited again.

The investigation substantiated several complaints including insufficient staffing for resident bathing in September and October 2015, failure to employ a qualified Director of Food Service, failure to follow background check policies, dignity issues related to mechanical lift slings, inadequate accommodation for a resident with spinal curvature, failure to notify residents of room changes, ongoing urine odors in a resident's room, untimely MDS assessments, incomplete care plan updates, failure to transmit discharge MDS, inadequate pain monitoring, failure to restore bladder function, unsanitary food service conditions, medication order errors, incomplete pharmacist recommendations, infection control issues with wheelchair arm rests and washbasin storage, pest control issues with dead insects in light fixtures, and fire safety code violations including blocked exits and missing smoke detectors.

The complaint investigation was triggered by allegations that the facility failed to ensure safe resident transfers, secure resident mail, licensed staff administering medications, sufficient staffing, and proper reporting of abuse. The investigation substantiated these allegations with multiple deficiencies cited.

The investigation found deficiencies including unsafe wheelchair transport without footrests, unsecured resident mail accessible to other residents, medication administration by an unlicensed person, insufficient staffing leading to missed baths and restorative exercises, failure to report verbal abuse, and inadequate supervision leading to resident injury.

The complaint investigation was triggered by allegations that the facility failed to report allegations within 24 hours, failed to provide care for hearing devices, failed to protect residents from misappropriation, failed to submit investigations within 5 working days, failed to provide appropriate housekeeping, failed to ensure services meet residents' needs, and failed to report concerns of neglect per regulations. The investigation confirmed failures in timely reporting and investigation submission, and incomplete registry checks for staff.

The facility was found to have failed to submit a completed investigation related to misappropriation of resident property to the State Agency, failed to report allegations of neglect and a fall-related injury to the State Agency within required timeframes, and failed to complete required nurse registry checks for staff. Other allegations such as care for hearing devices, protection from misappropriation, housekeeping, and meeting residents' needs were found to be adequately addressed with no deficiencies cited.

The complaint investigation addressed allegations that the facility failed to treat residents with dignity and respect, failed to report allegations of abuse, failed to have sufficient staff to meet residents' needs, failed to provide medications according to the Five Rights, and failed to identify when medication had changed in color/shape/consistency. All allegations except the medication administration policy violation were found to have no violations.

The facility was found to have no violations regarding dignity and respect, abuse reporting, staffing sufficiency, and medication changes. However, a deficiency was cited for failure to ensure medication was administered according to facility policy, specifically for a Registered Nurse setting up medications ahead of time, which was against policy and led to dismissal of the nurse.

The complaint alleged the facility fails to provide change of position in a safe manner. The investigation included interviews with residents, staff, and the administrator, observations of transfers, and record reviews. The facility was cited for failure to use a gait belt during transfer, resulting in a fall and injury to Resident 1.

The facility failed to provide a safe transfer to one sampled resident, resulting in a fall and injury. Observations and interviews confirmed that a gait belt was not used during the transfer, and documentation of the fall was delayed. The resident sustained a non-displaced fracture to the left knee and required use of a total lift for transfers.

The complaint investigation included allegations of failure to revise care plans, maintain essential equipment, ensure resident resuscitation status, provide care to prevent skin breakdown, supervise residents during meals, train staff to meet resident needs, provide bowel elimination care, ensure clean clothing, and maintain bathing schedules. Some allegations were substantiated with deficiencies cited, others were not.

The facility was found deficient in multiple areas including failure to complete required discharge summary components, delayed notification of pressure ulcers, incomplete care plans for contractures, catheter care, swallowing issues, dialysis, failure to update care plans after incidents, inadequate staff knowledge of care plans, insufficient monitoring of wandering and exit seeking behaviors, failure to provide scheduled bathing, inadequate pressure ulcer treatment and documentation, lack of restorative programs for contractures, unsafe wheelchair transport without footrests, improper medication self-administration monitoring, food service sanitation violations, infection control issues with soiled call light strings and unlabeled equipment, and nonfunctional resident call light systems. Life safety code deficiencies included malfunctioning fire alarm communicator, obstructed sprinkler heads, and lack of fire alarm out-of-service policy.

The facility was found deficient in multiple areas including failure to provide private telephone access for residents, inadequate promotion of dignity and respect during dining, incomplete care plans for medication use and psychosocial needs, failure to revise care plans timely, inadequate infection control practices including employee illness tracking and improper storage of resident care equipment, and lack of complete automatic sprinkler system coverage.

The facility was found deficient in multiple areas including failure to notify physician timely of resident medical changes, incomplete care plans especially related to dialysis and wheelchair use, expired medical supplies, inadequate hand hygiene by staff, incomplete treatment documentation, and life safety code violations such as insufficient exit lighting, missing fire drills documentation, and lack of cleaning documentation for kitchen hood and ducts.