Inspection Reports for College Park Rehabilitation Center

The inspection was conducted as a Medicare Recertification Survey, Complaint, and Facility Reported Incident investigations from 07/11/2023 through 07/13/2023.

The facility was found deficient in several areas including failure to notify a resident's representative of a urinary tract infection, failure to complete a discharge summary, medication administration errors, inadequate skin assessments, improper labeling of enteral feeding bags, oxygen administration without physician orders, and unlabeled medications in the medication cart.

Complaint #NV00068222 was verified with deficiencies related to tube feeding management and restoration of eating skills.

This document is a Medicare Life Safety Code (LSC) recertification survey conducted at the facility from 7/12/2023 through 7/14/2023 to assess compliance with fire safety and life safety codes.

The survey identified multiple deficiencies related to fire safety, including combustible vegetation around the facility, obstructions in means of egress, malfunctioning self-closing smoke barrier doors, inadequate emergency lighting testing, hazardous areas enclosure issues, and deficiencies in fire alarm system maintenance and testing. Corrective actions and preventive maintenance programs were planned to address these issues.

The inspection was conducted as a result of a Complaint and Facility Reported Incident investigation on 12/14/2022, involving two complaints and one facility reported incident.

The investigation found that none of the allegations in the complaints could be substantiated. However, two regulatory deficiencies unrelated to the allegations were identified, including failure to report an allegation of misappropriation in a timely manner and failure to ensure weekly skin checks for one sampled resident.

Two complaints and one facility reported incident were investigated. All allegations in complaints #NV00067268 and #NV00066979 were not substantiated. Facility Reported Incident #NV00067304 was also not substantiated. The facility failed to timely report an allegation of misappropriation involving Resident #3, placing residents at risk for exploitation or abuse.

The inspection was conducted as a result of a complaint investigation regarding an allegation that staff members did not recognize a resident needed to be evaluated by a doctor for a distended stomach and complaints of stomach pain.

The complaint was not substantiated. The resident was well known to staff, alert and oriented, and there was no documented evidence of a distended stomach or stomach pain prior to the resident being found unresponsive. Nurses and dietary staff monitored the resident closely, and no change in condition or complaints were reported. No regulatory deficiencies were identified.

Complaint #NV00066647 alleged staff failed to recognize a resident needed medical evaluation for a distended stomach and stomach pain. The allegation was not substantiated based on medical record review and staff interviews.

The inspection was conducted as a Medicare Recertification survey and a Complaint Survey initiated on March 15, 2022, and completed on March 18, 2022.

Two complaints were investigated. One complaint was substantiated with no regulatory deficiencies identified, and the other complaint was not substantiated. Several regulatory deficiencies were identified related to resident rights, bowel and bladder incontinence, medication error rates, food procurement and safety, and personal food policies.

Complaint #NV00064884 with four allegations was substantiated with no regulatory deficiencies identified. Complaint #NV00063818 with multiple allegations was not substantiated.

The inspection was conducted as a Medicare Recertification survey and a Complaint Survey initiated on March 15, 2022, and completed on March 18, 2022.

The survey included investigation of two complaints, both with some substantiated allegations but no regulatory deficiencies identified related to the complaints. Several regulatory deficiencies were identified including issues with resident dignity during feeding, failure to provide communal dining, improper catheter sizes used, medication errors exceeding 5%, multiple food safety violations in the kitchen, and improper handling and storage of personal food brought in by residents.

Two complaints were investigated. Complaint #NV00064884 with four allegations was substantiated with no regulatory deficiencies identified. Complaint #NV00063818 with multiple allegations could not be substantiated.

This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification health survey at the facility from 03/15/2022 through 03/18/2022.

The facility failed to ensure that 3 of 10 sampled employees who provided care to residents with dementia received the required eight hours of initial dementia training within the first 30 days of hire. The employees had incomplete or no dementia care training documented.

The inspection was conducted as a result of a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control Survey and Facility Reported Incident (FRI) investigations initiated on 09/30/2021 and finalized on 10/01/2021.

The facility had 18 COVID-19 positive residents and one resident on a 14-day observation period. The investigation included review of infection control policies, staff education, and facility practices. Three FRIs were substantiated with no regulatory deficiencies related to abuse, resident altercation, and a fall. Deficiencies were identified related to visitation rights and oxygen tank safety.

Three Facility Reported Incidents (FRIs) were investigated: employee to resident abuse substantiated with no regulatory deficiencies; resident-to-resident altercation substantiated with no regulatory deficiencies; and a fall substantiated with no regulatory deficiencies.

The inspection was conducted as an administrative review of nine Facility Reported Incidents (FRIs) related to resident-to-resident altercations, falls, wound care, employee to resident abuse, and misappropriation of resident funds.

All nine Facility Reported Incidents were substantiated with no regulatory deficiencies found. The facility conducted thorough investigations, updated care plans, followed policies, and took corrective actions including staff re-education and termination of a staff member involved in misappropriation.

The complaint investigation reviewed incidents of resident-to-resident altercations, falls, wound care, employee to resident abuse, and misappropriation of resident funds. Most incidents were substantiated with no regulatory deficiencies, except for one wound care incident where a nurse did not follow correct procedure but no negative outcome occurred. The employee involved in misappropriation was terminated and staff were re-educated on abuse and neglect policies.

The inspection was conducted as a result of a complaint investigation regarding an allegation that a resident was improperly discharged.

The allegation was not substantiated after review of physician discharge summary, nursing progress notes, and transfer forms. The transfer to a higher level of care was confirmed by multiple staff members, and the Public Guardian was notified. No regulatory deficiencies were identified.

Complaint # NV00062946 alleged improper discharge of a resident, which was not substantiated.

This inspection was a Centers for Medicare and Medicaid Services (CMS) Focused Infection Control survey conducted to evaluate the facility's compliance with infection control and prevention requirements, including COVID-19 related protocols.

The facility was found to have no regulatory deficiencies. The survey included review of infection control policies, PPE use, staff education, and COVID-19 unit management. PPE supplies were adequate and staff were observed following proper infection control practices.

The inspection was conducted as a result of a Focused Infection Control survey and a complaint investigation at the facility on 09/23/2020, in accordance with federal regulations for long term care facilities.

The facility had no COVID-19 positive residents at the time of inspection but three staff members were positive. Four complaints were investigated, none of which were substantiated. The facility maintained adequate PPE inventory and followed infection control policies related to COVID-19. One deficiency related to discharge planning process was identified.

Four complaints were investigated: 1) Staff not being provided PPE - not substantiated. 2) Residents under observation status residing with COVID-19 positive residents - not substantiated. 3) Staff going in and out of COVID unit without PPE - not substantiated. 4) Residents not getting re-tested for COVID-19 when symptomatic - not substantiated. Additional complaints included allegations of disrespectful social worker behavior (not substantiated) and failure to timely conduct preventive services and screenings (not substantiated).

The inspection was conducted as a complaint investigation initiated on 06/03/2020, combined with a Focused COVID-19 survey in accordance with federal regulations for Long Term Care Facilities.

The facility had four COVID-19 positive residents and three presumptive COVID-19 residents at the time of the survey. Multiple infection prevention and control practices were reviewed, including staff screening, PPE use, and resident isolation. One complaint was investigated with all allegations found not substantiated. A deficiency was cited related to failure to obtain and record food temperatures prior to meal service.

Complaint #NV00061200 was investigated with five allegations regarding mask use by residents and staff, staff working across COVID and non-COVID units, and infection control practices. None of the allegations were substantiated.

This document is a COVID-19 focused infection control survey initiated at the facility on 04/30/2020 to assess compliance with infection prevention and control requirements.

The survey found deficiencies related to the facility's failure to ensure employees were trained and fit tested for N95 masks prior to working in the COVID-19 unit. Corrective actions included fit testing all staff working on the COVID positive unit and implementing monitoring procedures to prevent recurrence.

The inspection was conducted as a State Licensure survey in conjunction with a Federal recertification survey from February 4, 2020 through February 7, 2020, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.

The facility was found deficient in multiple areas including failure to provide fire and disaster training to one employee, lack of documented physical examinations prior to employment for one employee, failure to complete annual performance evaluations for two Certified Nursing Assistants, and failure to ensure initial and annual dementia training for all employees providing care to residents with dementia. Severity levels were mostly at Level 2 with one Level F deficiency noted.

This inspection was conducted as an Emergency Preparedness survey in conjunction with a Medicare recertification survey to assess compliance with Federal and State emergency preparedness regulations.

The facility failed to develop and maintain a comprehensive emergency preparedness program addressing emerging infectious diseases, cyber attacks, collaboration with emergency officials, subsistence needs, tracking of staff and patients, evacuation policies, sheltering in place, communication plans, occupancy information, and emergency power systems. Multiple deficiencies were cited related to these failures.

The inspection was conducted as a state licensure survey in conjunction with a federal recertification survey to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.

The facility failed to ensure the environment was free of hazards that could cause accidents, specifically due to combustible and non-combustible garbage, including pine needles, being stored on the roof, which posed a fire risk. Previous surveys had cited similar deficiencies related to roof debris and fire hazards.

This document is a Plan of Correction generated as a result of a Medicare Life Safety Code recertification survey conducted at the facility on 02/04/2020 and 02/05/2020.

The facility was found deficient in multiple areas related to Life Safety Code compliance including means of egress obstructions, emergency lighting testing, fire alarm system maintenance, sprinkler system maintenance, corridor door functionality, evacuation and relocation planning, fire drills, smoking regulations, maintenance inspections, electrical systems, and power cords. Corrective actions and monitoring plans were outlined for each deficiency.

This inspection was conducted as a Medicare Recertification survey from February 4, 2020 through February 7, 2020, in accordance with 42 CFR Chapter IV, Part 483, Requirements for Long Term Care Facilities.

The survey identified multiple deficiencies related to resident rights, treatment decisions, Medicaid/Medicare coverage, ADL care, parental IV fluids, respiratory care, competent staff, posting nursing staffing, drug regimen, labeling and storage of drugs, food procurement, and infection control. The facility submitted a plan of correction addressing these deficiencies.

The inspection was conducted as a result of an onsite investigation of Facility Reported Incidents related to resident care and compliance with federal regulations.

Two facility reported incidents were investigated with no regulatory deficiencies identified for one incident and no deficiencies for the other. However, a regulatory deficiency was identified related to failure to revise pressure ulcer care plans for two sampled residents.

The investigation involved two facility reported incidents (#NV00059511 and #NV00059569). No regulatory deficiencies were identified for these incidents, but a deficiency was found related to care plan revisions during the investigation.

The inspection was conducted as a result of a complaint investigation completed on 09/10/19, involving two complaints related to resident care and notification practices.

One complaint was substantiated regarding failure to notify the resident's responsible party upon hospital transfer, resulting in a deficiency. Another complaint was substantiated without deficiencies related to wrong medication information. Several other allegations were not substantiated.

Two complaints were investigated. Complaint #NV00058445 was substantiated without deficiencies related to wrong medication information. Complaint #NV00058461 was substantiated with a deficiency for failure to notify the resident's responsible party of hospital transfer.

The inspection was conducted as a complaint investigation based on complaint #NV00057052, which included allegations regarding delayed response to call lights and improper administration of a resident's pain medication.

The investigation included observations, interviews, and record reviews, and found no regulatory deficiencies. The complaint allegations were not substantiated, and no further action was necessary.

Complaint #NV00057052 alleged that the facility was not responding to call lights in a timely manner and that a resident's pain medication was not given according to physician orders. These allegations were not substantiated after investigation.

The inspection was conducted as a complaint investigation in response to allegations regarding resident care and treatment at the facility.

The investigation included observations, interviews, and record reviews, and concluded that no regulatory deficiencies were identified. The complaint allegations were not substantiated and no further action was necessary.

Complaint #NV00056753 involved allegations of delayed wound care treatment, improper cleaning of a resident, failure to reposition a resident, and inadequate response to elevated vital signs. None of these allegations were substantiated after investigation.

This plan of correction was prepared following an Emergency Preparedness survey conducted on 03/07/19 and 03/08/19, in conjunction with a Medicare recertification survey, to address deficiencies identified related to emergency preparedness policies and procedures.

The facility failed to fully develop and implement emergency preparedness policies and procedures addressing subsistence needs for staff and patients, and failed to provide policies and procedures for the facility's role under a waiver declared by the Secretary for provision of care at an alternate care site.

This report documents the Medicare Life Safety Code recertification survey conducted at the facility on 03/07/19 and 03/08/19 to assess compliance with fire safety regulations and facility licensing requirements.

The facility was found deficient in several areas related to fire safety including improper labeling of fire alarm circuits, insufficient testing and maintenance of smoke detectors, sprinkler system deficiencies, inadequate inspection of portable fire extinguishers, inaccurate electrical panelboard directories, failure to conduct timely fire drills, and incomplete smoking policy enforcement. Corrective actions and staff reeducation were planned and documented.

This report is a Statement of Deficiencies generated as a result of a Medicare Recertification survey conducted from February 26, 2019 through March 1, 2019, to assess compliance with federal regulations for long term care facilities.

The facility was found deficient in multiple areas including baseline care plans, comprehensive care plans, quality of care, medication administration, wound care, infection control, and physician visits. Specific deficiencies involved failure to develop appropriate care plans for residents, inadequate wound assessments and management, medication errors, and lapses in infection prevention protocols.

The inspection was conducted as a complaint investigation related to allegations that Environmental Service staff did not perform hand hygiene after changing gloves between multiple patient rooms and during cleaning tasks.

The complaint was substantiated with findings that Environmental Services staff failed to perform hand hygiene between glove changes and when moving between dirty and clean areas during cleaning of resident rooms. The facility failed to ensure proper infection control practices, specifically hand hygiene and cleaning sequence.

Complaint #NV00055600 was substantiated. The allegation that Environmental Service staff did not perform hand hygiene after changing gloves between multiple patient rooms and in between tasks of cleaning high touch surfaces and bathroom surfaces in patient rooms was substantiated. Other allegations related to glove use during blood glucose testing, glove use for bleach wipes, and gown stocking were not substantiated.

The inspection was conducted as a State Licensure Administrative Review including investigation of one complaint alleging inadequate insurance coverage by the facility.

The complaint alleging inadequate insurance coverage was not substantiated after offsite review and verification of insurance documentation and an electronic interview with the insurance company's Senior Account Manager. No regulatory deficiencies were identified.

Complaint #NV00052988 alleging the facility did not have adequate insurance to cover claims was investigated and found to be unsubstantiated.

The inspection was conducted as a complaint investigation triggered by allegations regarding resident care and staff practices at the facility.

The investigation included observations of staff hand washing, isolation precautions, use of personal protective equipment, housekeeping cleaning processes, and interviews with residents and staff. No regulatory deficiencies were identified and the complaint allegations were not substantiated.

Complaint #NV00052657 included allegations that nurses ignored a resident's rash, a staff member with scabies was told to return to work, and housekeeping was instructed to use only water for cleaning contaminated rooms. These allegations were not substantiated.

The inspection was conducted as a result of a complaint investigation regarding the facility's failure to provide written notification of transfer/discharges as required by federal regulations.

The facility was found to have failed to provide the required notice of discharge to the Nevada State Ombudsman Office for 5 out of 5 sampled residents. The complaint was substantiated, and the facility was unaware that hospital transfers/discharges were considered facility-initiated.

Complaint #NV00051905 was substantiated. The allegation that the facility failed to provide written notification of transfer/discharges was substantiated.

The inspection was conducted as a result of a complaint investigation regarding the facility's failure to provide written notification of transfer/discharges as required by federal regulations.

The facility was found to have failed to notify the Nevada State Ombudsman Office of the transfer or discharge of 5 sampled residents to the hospital, violating notice requirements before transfer/discharge.

Complaint #NV00051905 was substantiated. The allegation that the facility failed to provide written notification of transfer/discharges per the Federal requirement was substantiated.

This inspection was conducted as a Medicare Emergency Preparedness survey and a Medicare Life Safety Code (LSC) recertification survey at the facility on 1/26/18.

The facility was found deficient in emergency preparedness policies and procedures, including lack of written transfer agreements and communication plans, and failed to maintain means of egress and fire safety equipment in accordance with NFPA standards. Several deficiencies related to emergency preparedness and life safety code were identified.

This inspection was conducted as a Medicare Recertification survey from January 23, 2018 through January 26, 2018, to assess compliance with federal regulations for long term care facilities.

The facility was found deficient in several areas including resident rights related to staff knocking before entering rooms, notice requirements before transfer or discharge, comprehensive care plans, activities, sufficient nursing staff, labeling and storage of drugs, and physical environment safety. Corrective actions and re-education plans were outlined for each deficiency.

The inspection was conducted as a result of a complaint investigation involving three allegations: improper restraint of a resident, failure to turn a resident resulting in a pressure ulcer, and staff ignoring call bells.

The investigation included observations, interviews with facility staff, and medical record reviews for five residents. The complaint allegations were not substantiated and no regulatory deficiencies were identified.

Complaint #NV00049671 contained 3 allegations which could not be substantiated: #1 a resident was improperly restrained, #2 a resident was not turned resulting in a pressure ulcer, and #3 staff ignored call bells.

The inspection was conducted as a result of a complaint investigation regarding two allegations: a fire started at the facility and the alarm did not activate automatically, and a resident fell during evacuation and required hospitalization.

The investigation found that the fire alarm system was functional and no fire occurred inside the building; the small fire on the roof caused smoke but did not trigger the alarm. The resident fall was unrelated to the alleged fire. No regulatory deficiencies were identified.

Complaint #NV00050451 contained 2 allegations which could not be substantiated: Allegation #1 about the fire and alarm malfunction, and Allegation #2 about a resident fall during evacuation.

This inspection was conducted as a Medicare Life Safety Code (LSC) recertification survey to assess compliance with fire safety regulations.

The facility was found to have multiple deficiencies related to fire safety, including exit doors requiring excessive force to open, failure to maintain fire alarm system testing documentation, automatic fire sprinkler system issues, corridor doors not resisting smoke passage, and non-hospital grade electrical receptacles in resident rooms.

This plan of correction was prepared following a Medicare Recertification survey conducted from January 10, 2017 through January 13, 2017, to address identified deficiencies in resident care and facility compliance.

The facility was found deficient in multiple areas including dignity and respect of individuality, care and services for highest well-being, treatment to prevent and heal pressure sores, drug regimen free from unnecessary drugs, therapeutic diets prescribed by physician, food procurement and sanitation, physician visits, pharmaceutical services, safe and comfortable environment, and emergency procedures. Specific resident cases highlighted failures in communication, oxygen therapy, wound care, medication administration, diet consistency, and sanitation.

The inspection was conducted as a complaint investigation initiated on November 16, 2016, to investigate two complaints regarding wound care and intravenous antibiotics at the facility.

The investigation substantiated one complaint regarding failure to provide written bed hold information at discharge, while other allegations related to wound care and antibiotic administration were not substantiated. The facility failed to follow policy ensuring written bed hold notice was provided to residents and their representatives at discharge.

Two complaints were investigated. Complaint #NV00047328 was substantiated regarding failure to provide written bed hold information. Other allegations about wound care and intravenous antibiotics were not substantiated.

The inspection was conducted as a complaint investigation survey triggered by two complaints regarding resident care and conditions at the facility.

The investigation substantiated one complaint that the resident's legal representative was not notified about a change in the resident's skin condition, specifically a pressure ulcer. The other complaint alleging a resident acquired a pressure ulcer and neglect resulting in health deterioration was not substantiated. Deficiencies were identified related to failure to notify the attending physician and family about the resident's skin condition and lack of physician orders for wound care.

Two complaints were investigated: Complaint #NV00045619 was substantiated regarding failure to notify the resident's legal representative about a change in skin condition. Complaint #NV00045748 alleging pressure sores and neglect was not substantiated.

The inspection was conducted as a complaint investigation survey triggered by two complaints alleging failure to notify a resident's legal representative about changes in skin conditions and allegations of pressure ulcers and neglect.

The investigation substantiated that the facility failed to notify the attending physician and the resident's legal representative about a change in skin condition for one resident. The facility did not have physician orders for wound care treatment and lacked documentation of notification and discharge instructions related to the resident's skin condition.

Two complaints were investigated. Complaint #NV00045619 was substantiated regarding failure to notify the resident's legal representative about changes in skin conditions. Complaint #NV00045748 alleging pressure sores and neglect was not substantiated.

This inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety standards at the skilled nursing facility.

The facility was found deficient in several Life Safety Code standards including failure to conduct fire drills at unexpected times, failure to maintain automatic sprinkler system gauges, corroded sprinkler heads, improperly maintained commercial cooking fire suppression system, and electrical wiring and equipment issues including unsafe use of extension cords and power taps.

This plan of correction was generated as a result of the Medicare recertification survey conducted from 2/9/16 through 2/12/16 to address identified deficiencies.

Deficiencies were identified related to resident care and services, including failure to perform and document dialysis communication forms, neurological assessments, medication administration errors, and provision of adaptive feeding equipment. Corrective actions and audits were planned to ensure compliance and prevent recurrence.

The re-visit survey was conducted in response to findings from an annual re-certification survey completed on 2015-03-27, to verify correction of previous deficiencies and investigate two complaints.

Two complaints were investigated but not substantiated. The investigation included observations, interviews, and record reviews. No regulatory deficiencies were identified and no further action was necessary.

Complaint #NV00042824 included allegations of a resident's matted hair and dirty face, pressure sores, and an unclean wound dressing; Complaint #NV00042590 alleged unsafe discharge without oxygen and appropriate hospital bed. Both complaints were not substantiated after investigation.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted from March 24, 2015 through March 27, 2015, including two complaint investigations.

The survey identified multiple deficiencies including failure to obtain informed consent for psychotropic medication, failure to clarify advanced directives, incomplete grievance investigations, failure to inform residents of bed-hold policies, inappropriate catheter use, infection control lapses, unsafe storage of chemicals and medications, food safety violations, and inadequate staff training.

Two complaint investigations were conducted. Complaint #NV00042191 with two allegations regarding cashing a resident's Social Security check after discharge and failure to provide appropriate rehabilitation services; both allegations were not substantiated. Complaint #NV00041515 alleged failure to hold a bed for a transferred resident; this was not substantiated.

The survey was a Medicare Recertification Survey conducted from March 24, 2015 through March 27, 2015, including two complaint investigations.

The facility had multiple deficiencies including failure to administer oxygen and IV fluids per physician orders, failure to ensure informed consent and monitoring for psychotropic medications, incomplete investigations of resident grievances, unsafe food handling practices, unsecured medications, and inadequate infection control practices.

Two complaint investigations were conducted. Complaint #NV00042191 regarding cashing a resident's Social Security check and provision of rehabilitation services was not substantiated. Complaint #NV00041515 regarding bed hold policy was not substantiated.

This Statement of Deficiencies was generated as the result of a State Licensure Survey completed in conjunction with a federal survey at College Park Rehabilitation Center from March 24, 2015 through March 27, 2015, to investigate compliance with Nevada Administrative Code (NAC) Chapter 449, Skilled Nursing Facilities.

The facility failed to ensure oxygen and intravenous fluids were administered in accordance with physician's orders for Resident #1, including failure to monitor oxygen tank levels and properly label IV fluids, which could lead to increased respiratory distress and dehydration.

The investigation was complaint-related, focusing on Resident #1's care involving oxygen therapy and IV fluids. The complaint was substantiated as deficiencies were found in monitoring and administration of treatments.

The inspection was conducted as a State Licensure Survey in conjunction with a federal survey to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Skilled Nursing Facilities.

The facility failed to ensure oxygen and intravenous fluids were administered according to physician's orders for one resident. Specifically, Resident #1 was found with an empty oxygen tank and an IV saline solution not labeled or dated, resulting in inadequate oxygenation and fluid administration.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted from March 24, 2015 through March 27, 2015, including two complaint investigations during the survey.

The survey found multiple deficiencies related to informed consent for psychotropic medications, right to refuse treatment, bed-hold policy, investigation of allegations of misappropriation of resident funds, housekeeping and maintenance, infection control, medication administration, and other care and safety issues. Corrective actions and monitoring plans were outlined for each deficiency.

Two complaint investigations were conducted during the survey. Complaint #NV00042191 contained two allegations which could not be substantiated. Complaint #NV00041515 contained one allegation which could not be substantiated.

This inspection was conducted as a Medicare Life Safety Code survey at College Park Rehabilitation Center from 3/24/15 through 3/27/15 to assess compliance with the NFPA 101 Life Safety Code standards.

The facility was found deficient in several Life Safety Code standards including inadequate exit signage, improperly installed fire extinguishers, and improper use of flexible cords near electrical equipment. Corrective actions were planned to address these deficiencies with specific completion dates.

The inspection was conducted as a Medicare Life Safety Code survey in accordance with NFPA 101, Chapter 19, Existing Health Occupancies, to assess compliance with life safety code standards.

The facility was found deficient in marking exits properly, specifically failing to label two courtyards with 'NO EXIT' signs. Additionally, fire extinguishers were installed above the maximum allowed height, and electrical wiring violations were noted including improper use of extension cords and blocked electrical panels.

The inspection was conducted as a complaint investigation triggered by Complaint #NV00041249, which contained two allegations regarding resident abuse and neglect.

The investigation substantiated that facility staff had been closing a resident's door in response to yelling and that the resident had not been physically abused, but the facility failed to conduct comprehensive assessments and develop appropriate care plans for the resident. Additionally, deficiencies were found related to drug records and medication cart security.

Complaint #NV00041249 contained two allegations: 1) Facility staff closing resident's door in response to yelling was substantiated. 2) Allegation that resident had been rough handled, hit, and fondled by staff was not substantiated.

The inspection was conducted as a result of a complaint investigation regarding allegations of staff closing a resident's door in response to yelling and allegations of abuse.

The facility substantiated the allegation that staff had been closing a resident's door in response to yelling but did not substantiate allegations of physical abuse. The facility failed to complete a comprehensive assessment and develop an interim care plan for one resident with behavioral issues. Additionally, medication carts were found unlocked, violating facility policy.

Complaint #NV00041249 contained two allegations: 1) staff closing the resident's door in response to yelling, which was substantiated; 2) resident being rough handled, hit, and fondled by staff, which was not substantiated. The investigation included resident observations, interviews, and review of facility policies.

The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health on 11/4/14, based on complaint #NV00040887 which contained two allegations regarding facility cleanliness and food temperature.

The complaint was substantiated for the allegation that the facility was not clean, with multiple unsanitary conditions observed in resident bathrooms and shower rooms. The allegation that food was cold was not substantiated after observations and interviews. Corrective actions included deep cleaning of bathrooms and showers and re-education of housekeeping staff.

Complaint #NV00040887 contained two allegations: 1) Facility not clean - substantiated; 2) Food is cold - not substantiated. The complaint investigation was initiated by the Division of Public and Behavioral Health on 11/4/14.

The inspection was conducted as a complaint investigation triggered by complaint #NV00040887, which contained two allegations: the facility was not clean and that food was cold.

The complaint investigation substantiated the allegation that the facility was not clean, identifying multiple unsanitary conditions in resident bathrooms and community shower rooms. The allegation regarding cold food was not substantiated after observations, interviews, and temperature reviews.

Complaint #NV00040887 contained two allegations: #1 Facility not clean (substantiated), #2 Food is cold (not substantiated). The complaint investigation was initiated by the Division of Public and Behavioral Health on 11/4/14.

This report was generated as a result of a Medicare recertification survey conducted from June 2, 2014 through June 6, 2014, including investigation of one complaint.

The survey identified multiple deficiencies including failure to notify family of care planning meetings, failure to obtain informed consent for psychotropic medications, failure to notify legal representatives of significant changes, failure to facilitate medically-related social services, failure to assist with hearing aids, inadequate supervision leading to a fall, failure to monitor oxygen saturation, incomplete antibiotic therapy, unsanitary food storage and preparation conditions, improper garbage disposal, and failure to perform hand hygiene prior to treatment.

Complaint #NV00038528 contained three allegations: 1) Resident left unattended in bathroom resulting in a fall (substantiated), 2) Facility staff continued to leave resident unattended despite family concerns (substantiated), 3) Facility staff failed to provide soda to resident (not substantiated). Investigation initiated on 2014-06-03.

This plan of correction was generated as a result of a Medicare recertification survey conducted from June 2, 2014 through June 6, 2014, including investigation of one complaint with three allegations.

The survey found deficiencies related to failure to notify and include family in care planning, failure to obtain informed consent for psychotropic medications, failure to inform legal representatives of changes, failure to provide medically related social services, failure to ensure proper treatment and assistive devices for vision and hearing, failure to ensure residents are free from unnecessary drugs and medication errors, failure to maintain sanitary food storage and preparation, failure to dispose of garbage properly, and failure to maintain infection control and hand washing practices.

Complaint #NV00038528 contained three allegations: 1) Resident left unattended in bathroom resulting in a fall (substantiated), 2) Facility staff continued to leave resident unattended despite family concerns (substantiated), 3) Facility staff failed to provide soda to resident (not substantiated).

The inspection was conducted as a complaint investigation triggered by Complaint #NV00038394 regarding an allegation that the Medical Power of Attorney was denied access to healthcare information and not recognized as the Medical POA.

The complaint was not substantiated after review of medical records and interviews with the Director of Nursing, a Charge Nurse, two Social Workers, and the Medical POAs of two residents. The paperwork for the Medical POA was received after the resident was admitted and verified by legal.

Complaint #NV00038394 was investigated and found not substantiated regarding denial of access to healthcare information by the Medical Power of Attorney.

The inspection was conducted as a state licensure construction standards survey to evaluate compliance with Nevada Administrative Code (NAC) 449, Hospitals, focusing on the facility's proposed upgrades to the medical gas system and essential electrical system for future ventilator dependent residents.

The facility failed to maintain their Level 1 Medical Gas Systems and did not install the emergency electrical system according to submitted plans, resulting in commingled circuits and insufficient separation of Life Safety Branch and Critical Branch circuits. Additionally, corridor widths were reduced by stored items, failing to maintain required clear widths.

Annual Medicare Recertification survey conducted in conjunction with a State Licensure survey.

The facility had multiple deficiencies including failure to maintain accurate advance directives, incomplete discharge documentation, failure to report and investigate abuse allegations, unsanitary conditions, medication errors, infection control issues, and life safety code violations.

This document is a Statement of Deficiencies generated as a result of an annual Medicare Recertification survey conducted in conjunction with a State Licensure survey at the facility from 7/9/13 through 7/16/13.

The survey identified multiple regulatory deficiencies related to residents' rights, documentation, infection control, medication administration, life safety code compliance, and other areas. The facility failed to ensure proper advance directive processes, documentation of transfers and discharges, investigation of abuse allegations, maintenance of clinical records, infection control measures, and medication error rates among others.

This follow-up (revisit) survey was conducted to assess compliance with federal and state regulations for long term care facilities, including a federal recertification revisit and complaint revisit.

The facility was found to be in substantial compliance with regulations regarding this survey, and no further action was necessary.

The inspection was conducted as the annual Medicare re-certification survey from July 23, 2012 through July 31, 2012, including investigation of one substantiated complaint.

The survey identified multiple deficiencies related to informed consent for medications, privacy and confidentiality of records, dignity and respect of residents, safe and clean environment, adequate lighting, comprehensive assessments, care planning, medication administration, infection control, and other regulatory requirements. One complaint regarding over-medication and failure to timely transfer a resident was substantiated.

Complaint #NV00032497 was initiated by the Bureau of Health Care Quality and Compliance on 7/23/12 and finalized on 7/31/12. The complaint was substantiated, involving over-medication of a resident and failure to timely transfer the resident with a significant change of condition to an acute care facility.

This report documents the annual Medicare re-certification survey conducted from July 23, 2012 through July 31, 2012, including a complaint investigation initiated by the Bureau of Health Care Quality and Compliance.

The survey identified multiple deficiencies including failure to obtain complete informed consent for medications, failure to ensure residents' privacy and dignity, inadequate safe and clean environment, incomplete comprehensive assessments, failure to develop comprehensive care plans, medication administration errors, and failure to promptly notify physicians of lab results. One complaint regarding over-medication and failure to transfer a resident timely was substantiated.

Complaint #NV00032497 was initiated by the Bureau of Health Care Quality and Compliance on 7/23/12 and finalized on 7/31/12. The complaint was substantiated regarding over-medication of a resident and failure to transfer the resident with a significant change of condition to an acute care facility timely.

This document is a Statement of Deficiencies generated as a result of a Life Safety Code (LSC) survey conducted at the facility to assess compliance with NFPA 101 Life Safety Code standards.

The facility failed to maintain means of egress free of obstructions, had issues with the medical gas alarm panels not accurately displaying system status, and failed to ensure electrical wiring and equipment met National Electrical Code standards, including uncovered junction boxes in the attic.

The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with NFPA 101 standards for existing health care occupancies, focusing on fire safety and emergency egress.

The facility was found to have multiple deficiencies including obstructed exit corridors due to furnishings reducing egress width, inaccurate medical gas alarm panel sensor readings, and open electrical junction boxes without covers in attic areas.

This document is a Statement of Deficiencies generated as a result of a revisit conducted from December 12, 2011 through December 14, 2011 for the Medicare recertification survey originally conducted from July 6, 2011 through July 8, 2011, and includes a complaint survey completed on October 24 through October 25, 2011.

No regulatory deficiencies were identified at the time of the revisit. One complaint was investigated and found not substantiated based on medical record review and interviews.

One complaint (CPT #NV00028930) alleging the facility falsified records/reports was investigated and was not substantiated through medical record review and interviews.

This inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 10/13/11, finalized during a Medicare recertification revisit on 10/24-25/11. The complaint involved allegations regarding improper discharge to an unlicensed group home, failure to provide adequate oxygen, and failure to provide discharge medications/prescriptions.

The facility was found to have substantiated deficiencies including failure to ensure safe and orderly transfer/discharge of Resident #1 to a licensed home, failure to provide adequate oxygen delivery, and failure to maintain complete and accurate clinical records. The complaint was substantiated with multiple documentation and procedural failures identified.

Complaint #NV00029635 was investigated and substantiated. Allegation #1: Facility discharged a resident to an unlicensed group home. Allegation #2: Facility failed to provide enough oxygen and ensure delivery. Allegation #3: Facility failed to provide discharge medications/prescriptions, which was not substantiated.

This inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 10/13/11, related to allegations about discharge practices, oxygen provision, and medication prescriptions at the facility.

The investigation substantiated that the facility discharged a resident to an unlicensed group home, failed to provide adequate oxygen and ensure its delivery, and did not provide discharge medications/prescriptions. Additionally, the facility failed to maintain complete and accurate clinical records for the resident and did not ensure a safe discharge process.

Complaint #NV00029635 was investigated and substantiated. Allegation #1: Facility discharged a resident to an unlicensed group home (substantiated). Allegation #2: Facility failed to provide enough oxygen and ensure delivery (substantiated). Allegation #3: Facility failed to provide discharge medications/prescriptions (not substantiated).

The inspection was conducted as a Medicare recertification survey from July 6, 2011 through July 8, 2011, including investigation of three substantiated complaints regarding pressure ulcers and inappropriate discharges.

The facility was found deficient in ensuring safe discharge for residents and in preventing and treating pressure ulcers. Specifically, failures were noted in discharge planning and transfer procedures for Residents #14 and #15, and in assessment, monitoring, and treatment of pressure ulcers for Residents #3 and #11.

Three complaints were investigated and substantiated: 1) Resident developed a pressure ulcer (Complaint #NV00028930), 2) Allegation of inappropriate discharge (Complaint #NV00029075), 3) Allegation of inappropriate discharge (Complaint #NV00028755).

This report was generated as a result of a revisit on August 31, 2011 through September 1, 2011 for the Medicare recertification survey conducted from July 6, 2011 through July 8, 2011. Three complaints were investigated during this revisit.

The facility was found to have deficiencies related to safe and orderly transfer/discharge of residents and treatment/prevention of pressure sores. Two residents were identified as not having safe discharge arrangements, and two residents developed pressure sores due to inadequate assessment, monitoring, and treatment.

Three complaints were investigated: 1) Allegation of a resident developing a pressure ulcer was substantiated. 2) Allegation of an inappropriate discharge was substantiated. 3) Another allegation of inappropriate discharge was substantiated.

The inspection was conducted as an annual Medicare re-certification survey from July 6 through July 8, 2011, including investigation of one complaint regarding an unsafe discharge of a resident.

The facility was found to have multiple deficiencies including failure to maintain dignity and respect for residents, reasonable accommodation of needs, proper notification before room changes, clean and safe environment, comprehensive care plans, medication administration errors, maintenance issues, and failure to maintain accurate clinical records. Several residents required assistance with eating, positioning, and hydration, and the facility failed to provide adequate supervision and training to staff.

Complaint #NV28755 regarding an unsafe discharge of one resident was investigated and substantiated based on staff interviews, record review, and policy review.

Annual Medicare re-certification survey conducted from July 6, 2011 through July 8, 2011 to assess compliance with 42 CFR Chapter IV Part 483 Requirements for States and Long Term Care Facilities.

The facility was found deficient in multiple areas including dignity and respect of residents, reasonable accommodation of needs, right to notice before room change, safe and clean environment, comprehensive care plans, professional standards in services provided, maintenance of resident assessments, provision of necessary care and services, catheter use, accident hazards, nutrition status, hydration, medication error rates, diet meeting resident needs, pharmaceutical services, clinical record maintenance, and emergency procedures training.

This document is a Statement of Deficiencies generated as a result of a State licensure survey conducted at the facility from July 6, 2011 through July 8, 2011.

The facility failed to properly assess the medical justification for continued urinary catheter use for residents admitted with catheters, and failed to maintain nutritional health for one resident who experienced severe weight loss. Deficiencies were noted in catheter use assessment and nutritional care planning.

This Life Safety Code (LSC) survey was conducted to assess compliance with fire safety and life safety standards in the facility.

The survey identified multiple deficiencies related to fire safety and life safety code compliance, including issues with corridor door latching mechanisms, smoke compartment protection, exit signage, smoke barrier penetrations, door closings during fire alarm, corridor width obstructions, sprinkler system maintenance and clearance, smoking policy enforcement, HVAC smoke damper maintenance, and electrical system compliance.

The inspection was conducted as a Life Safety Code (LSC) survey at College Park Rehabilitation Center on July 6-7, 2011, to assess compliance with NFPA 101 Life Safety Code standards related to fire safety and emergency preparedness.

The facility was found deficient in multiple Life Safety Code standards including door latching mechanisms, smoke compartment protections, exit signage, smoke barriers, fire alarm system operation, sprinkler system maintenance, and smoking regulations enforcement. Corrective actions and monitoring plans were outlined for each deficiency.

This report documents a State licensure survey conducted at the facility from July 6, 2011 through July 8, 2011 to assess compliance with regulatory requirements.

The survey identified deficiencies related to urinary catheter use and nutritional health, including failure to assess medical necessity for continued catheter use and failure to maintain acceptable nutritional status for sampled residents.

This Statement of Deficiencies was generated as a result of a Medicare complaint survey initiated on June 10, 2011 and completed on June 14-15, 2011, in accordance with 42 Chapter IV Part 483 Requirements for Long Term Care Facilities.

Two complaints were investigated: Complaint #28512 was unsubstantiated with nine allegations all unsubstantiated. Complaint #28534 was substantiated with one allegation substantiated and one allegation substantiated with a deficiency related to failure to provide documented evidence of a criminal background check for a contracted housekeeper.

Complaint #28512 was unsubstantiated with nine allegations unsubstantiated. Complaint #28534 was substantiated. Allegation #1 of complaint #28534 alleging a male housekeeper assaulted and/or raped a resident was unsubstantiated. Allegation #2 of complaint #28534 involved failure to show documented evidence of a criminal background check on an employee and was substantiated with a deficiency.

The inspection was conducted as a complaint investigation from 10/12/10 through 10/14/10 regarding allegations that the facility did not ensure proper protective supervision for residents and improperly discharged residents to unlicensed group homes.

The complaint was substantiated with three deficiencies cited related to protective supervision and care planning for residents, including failure to ensure social services follow-up, development of comprehensive care plans, and provision of necessary care and services to residents. One resident was not evaluated by a mental health care provider and subsequently attempted suicide.

Complaint #NV00026572 was substantiated regarding improper protective supervision. Complaint #NV00026585 regarding improper discharge to unlicensed group homes was not substantiated.

The inspection was conducted as a complaint investigation from 10/12/10 through 10/14/10 regarding allegations that the facility did not ensure proper protective supervision for residents and improperly discharged residents to unlicensed group homes.

The complaint alleging improper protective supervision was substantiated with three deficiencies cited related to failure to provide medically-related social services, develop comprehensive care plans, and provide necessary care/services for highest well-being. The complaint about improper discharge to unlicensed group homes was not substantiated.

Complaint #NV00026572 alleging failure to ensure proper protective supervision was substantiated with three deficiencies cited. Complaint #NV00026585 alleging improper discharge to unlicensed group homes was not substantiated.

The inspection was conducted due to concerns about potential exploitation and improper discharge planning for residents, specifically related to Residents #1 and #2, including allegations of possible abuse, neglect, and misappropriation of property.

The facility failed to provide adequate medically-related social services for 2 of 3 sampled residents. Resident #1 was discharged with a Power of Attorney (POA) who was suspected of exploitation, and Resident #2's discharge planning and safety concerns were not properly addressed, including threats made by Resident #2 and concerns about exploitation and unsafe discharge.

The complaint involved concerns that Resident #1's POA may exploit him and whether Resident #1 should be discharged home with her. Employee #4 reported filing concerns with Aging and Disability Services Division (ADSD). For Resident #2, concerns included threats made by Resident #2, potential exploitation, and unsafe discharge. Employee #4 filed a complaint with ADSD but did not report concerns to the Survey and Certification Agency.

This Statement of Deficiencies was generated as a result of a complaint investigation conducted at the facility on June 8, 2010, and finalized on June 23, 2010, in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.

The complaint #NV00025199 was substantiated, finding that the facility did not ensure timely notification of the physician or interested family member regarding a significant change in condition for Resident 1. Documentation and interviews revealed failures in communication and monitoring related to Resident 1's critical condition and medication levels.

Complaint #NV00025199 was substantiated. Complaint #NV00025617 was unsubstantiated. The substantiated complaint involved failure to timely notify the physician when Resident 1's condition changed.

This Statement of Deficiencies was generated as a result of the complaint investigation conducted at the facility on June 8, 2010, and finalized on June 23, 2010. The investigation was triggered by complaints #NV00025199 and #NV00025617.

The investigation substantiated that the facility did not timely notify the physician or the resident's legal representative of a significant change in Resident 1's condition. Documentation and interviews revealed failures in communication regarding Resident 1's deteriorating health and changes in treatment.

Complaint #NV00025199 was substantiated. Complaint #NV00025617 was unsubstantiated.

The inspection was conducted as a result of a complaint investigation at the facility on 2010-04-15, in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing.

The complaint #NV00024539 was substantiated with deficiencies cited related to failure to notify the family of a change in condition, transfer to an acute care facility, and subsequent death of Resident #1. The facility also failed to maintain updated contact information for family or legal representatives of Resident #1.

Complaint #NV00024539 was substantiated with deficiencies cited related to notification failures and record maintenance concerning Resident #1.

The inspection was conducted as a result of a complaint investigation (Complaint #NV00024539) regarding the facility's compliance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing.

The facility was found to have failed to notify the family of a change in condition, transfer to an acute care facility, and subsequent death of Resident #1. Additionally, the facility failed to maintain updated contact information for the resident's family or legal representatives.

Complaint #NV00024539 was substantiated with deficiencies cited related to failure to notify family and maintain contact information for Resident #1.

The inspection was conducted as a Medicare Life Safety Code (LSC) recertification survey to assess compliance with the NFPA 101 Life Safety Code standards.

The facility failed to ensure that all doors protecting corridor openings resisted the passage of smoke, and failed to maintain required corridor widths due to obstructions such as trash cans, medication carts, and ice carts. Additionally, fire drills were not conducted properly and staff were not knowledgeable about fire safety procedures.

The inspection was conducted as a Medicare Life Safety Code (LSC) recertification survey to assess compliance with NFPA 101 Life Safety Code standards for existing health care occupancies.

The facility failed to ensure corridor doors resisted smoke passage due to impediments preventing door closure, failed to maintain required corridor widths due to obstructions such as medication and ice carts, and staff lacked adequate knowledge of fire safety plan procedures during fire drills.

Annual Medicare re-certification survey conducted from April 6, 2010 through April 9, 2010 to assess compliance with 42 CFR Chapter IV Part 483 Requirements for States and Long Term Care Facilities.

The facility was found deficient in multiple areas including failure to follow employee screening policies, failure to ensure resident privacy, inadequate social services follow-up, improper medication administration practices, inappropriate use of antipsychotic drugs, inconsistent influenza vaccine policies, and lapses in infection control practices including hand hygiene and isolation precautions.

This report was generated as a result of the annual Medicare re-certification survey conducted at the facility from April 6, 2010 through April 9, 2010, to assess compliance with federal regulations for long term care facilities.

The survey identified multiple deficiencies including failure to implement policies prohibiting abuse and neglect, failure to ensure dignity and respect of residents, inadequate provision of medically related social services, failure to meet professional standards in medication administration, and deficiencies in infection control practices.

The inspection was conducted as a result of a complaint investigation at the facility on December 4, 2009, in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing.

The complaint #NV00023297 was found to be unsubstantiated. No deficiencies were cited and no further action was necessary.

Complaint #NV00023297 was unsubstantiated.

The inspection was conducted as a result of a complaint investigation triggered by complaint #NV00023106.

No regulatory deficiencies were identified and the complaint was found to be unsubstantiated.

Complaint #NV00023106 was unsubstantiated.

This document is a Statement of Deficiencies generated as a result of a re-licensure survey of the facility conducted from March 24, 2009 through March 27, 2009.

The survey identified regulatory deficiencies related to personnel records, including missing documentation of physical examinations and tuberculosis testing for some employees, and failure to ensure required dementia training within the first 30 days of employment for several employees.

The inspection was conducted as a result of the annual Medicare re-certification and complaint survey from March 24, 2009 through March 27, 2009, including investigation of two substantiated complaints.

The facility was found deficient in multiple areas including failure to update comprehensive care plans for residents, improper medication administration, failure to maintain sanitary conditions, expired medications not properly disposed, incomplete clinical records, and medication errors.

Two complaints were investigated during the survey: CPT #21052 and CPT #21163, both substantiated with deficiencies.

This document is a Statement of Deficiencies generated as a result of a re-licensure survey of the facility conducted from March 24, 2009 through March 27, 2009.

The survey identified deficiencies related to personnel records, specifically missing documentation of physical examinations and tuberculosis testing for some employees, and failure to ensure required dementia training for employees within the first 30 days of employment.

The inspection was conducted as a result of the annual Medicare re-certification and complaint survey at the facility from March 24, 2009 through March 27, 2009, including investigation of two substantiated complaints.

The facility was found deficient in several areas including comprehensive care plans, quality of care, medication errors, sanitary conditions, pharmacy services, and clinical records. Deficiencies were substantiated through observation, interviews, and record reviews involving multiple residents.

Two complaints were investigated during the survey: CPT #21052 and CPT #21163, both substantiated with deficiencies.

This inspection was conducted as a Medicare Complaint Investigation triggered by a complaint regarding the treatment and care of a resident who sustained an injury of unknown origin.

The facility failed to conduct a thorough investigation of an injury of unknown origin for one resident, resulting in a delay of treatment for a fracture. The investigation lacked documented interviews, timelines, and preventive measures. The resident sustained a complex fracture that was ultimately determined not to be caused by abuse or neglect, but the facility delayed assessment and treatment for approximately 12 hours.

The complaint investigation was substantiated (CPT# 19510) with findings related to staff treatment of residents and quality of care deficiencies concerning a resident who sustained a fracture of unknown origin. The investigation concluded no abuse or neglect was indicated.

The inspection was conducted as a result of a complaint investigation involving two complaints, one substantiated and one unsubstantiated, related to resident care and facility supervision.

The facility was found deficient in ensuring adequate supervision and timely search for a resident who eloped, and in providing proper respiratory care for a resident using a non-rebreather mask. The facility failed to follow its elopement policy and did not provide the required oxygen flow rate for the non-rebreather mask.

Two complaints were investigated: Complaint #18347 was substantiated and Complaint #19007 was unsubstantiated. The substantiated complaint involved failure to supervise a resident who eloped and failure to provide proper respiratory care.

The inspection was conducted as a complaint survey investigating multiple complaints regarding the facility's care and procedures, including substantiated and unsubstantiated complaints.

The facility failed to ensure Resident #1 was transferred safely, resulting in a fall and broken fibula, and failed to follow policy and procedures for the transfer and handling of Resident #2 after her death. Staff were unaware of proper protocols for deceased residents and did not use available equipment appropriately.

The complaint investigation included multiple complaints (NV#18367, NV#17724, NV#18248, NV#18438, NV#18776, NV#18347, NV#17871) with some substantiated (NV#18367, NV#18776) and others unsubstantiated. The findings related to Resident #1 and Resident #2 were substantiated.

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