Inspection Reports for Life Care Center of Las Vegas
6151 Vegas Dr, Las Vegas, NV 89108, USA, NV, 89108
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related to medication administration, care planning, infection control, and resident safety, with several complaint investigations substantiated but often without regulatory deficiencies. The facility has faced recurring issues over the years including improper medication management, incomplete or inaccurate care plans, infection control lapses, and occasional environmental and safety concerns. The most recent report from July 30, 2024, was a complaint investigation that found no deficiencies, indicating some improvement in compliance. Earlier reports, such as the November 28, 2023 annual inspection, cited multiple deficiencies including medication errors, infection control breaches, and food safety violations. Several complaint investigations over time were unsubstantiated or substantiated without deficiencies, showing a mixed pattern without severe enforcement actions or fines listed in the available reports.
Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 0
Jul 30, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation completed from 07/26/2024 through 07/30/2024, involving three complaints at the facility.
Findings
Three complaints were investigated; two were substantiated without deficient practice and one was unsubstantiated with no regulatory deficiencies identified. The investigation included observations, interviews, clinical record reviews, and document reviews, resulting in no regulatory deficiencies.
Complaint Details
Three complaints were investigated: Complaint #NV00070875 and Complaint #NV00071489 were substantiated with no deficient practice; Complaint #NV00070517 was unsubstantiated with no regulatory deficiencies identified.
Report Facts
Complaints investigated: 3
Sample size: 5
Inspection Report
Annual Inspection
Census: 159
Deficiencies: 12
Nov 28, 2023
Visit Reason
Medicare Recertification Survey, Complaint and Facility Reported Incident investigations conducted from 11/28/2023 through 12/01/2023.
Findings
The survey identified multiple deficiencies including failure to ensure proper restraint assessments and orders, failure to coordinate PASARR evaluations, incomplete comprehensive care plans, inadequate personal hygiene assistance, improper medication administration and documentation, failure to follow oxygen therapy orders, food safety violations, and infection control breaches including improper PPE use.
Deficiencies (12)
| Description |
|---|
| Failure to ensure a resident with mitten restraints was assessed and physician order contained parameters for release. |
| Failure to refer a resident for PASARR level II evaluation as required. |
| Failure to develop and implement comprehensive person-centered care plans for residents with edema, contractures, and urinary incontinence devices. |
| Failure to provide showers or bed baths at least twice weekly for a resident. |
| Failure to ensure medication availability and timely administration, including Lidoderm patches and Flomax. |
| Failure to properly label and discard food items past use-by date and maintain kitchen equipment. |
| Failure to ensure oxygen therapy was administered as ordered and tubing changed as scheduled. |
| Failure to ensure proper infection prevention and control including PPE use for COVID-19 positive residents. |
| Failure to monitor psychotropic medication use and behavior monitoring as recommended by consultant pharmacist. |
| Failure to maintain medication error rate below 5%, with 3 errors identified resulting in 12% error rate. |
| Failure to ensure multidose vial was discarded after 28 days of opening. |
| Failure to maintain confidential and complete resident medical records. |
Report Facts
Census: 159
Sample size: 35
Medication error rate: 12
Use by date: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for monitoring compliance of corrective actions related to restraint assessments, PASARR referrals, care plans, medication administration, oxygen therapy, infection control, and other deficiencies. | |
| Unit Manager | Confirmed findings related to restraint assessments, care plans, medication availability, and oxygen therapy. | |
| Licensed Practical Nurse | Involved in medication administration and oxygen therapy; confirmed deficiencies in documentation and practice. | |
| Certified Nursing Assistant | Observed not wearing N95 respirator properly in COVID-19 positive resident room. | |
| Director of Staff Development | Confirmed lack of staff training on Purewick urinary collection device. | |
| Pharmacist | Confirmed medication delivery schedules and lack of refill requests for certain medications. | |
| Dietary Director | Confirmed food safety violations including expired food and unlabeled food containers. | |
| Infection Preventionist | Confirmed PPE use expectations and deficiencies. |
Inspection Report
Complaint Investigation
Census: 159
Deficiencies: 0
Aug 23, 2023
Visit Reason
The inspection was conducted as a result of complaint and Facility Reported Incident investigations at the facility on 08/23/2023.
Findings
The investigation included observations, interviews, clinical record reviews, and document reviews. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Two complaints and five Facility Reported Incidents were investigated, all were unverified with no regulatory deficiencies identified.
Report Facts
Sample size: 8
Inspection Report
Annual Inspection
Census: 150
Deficiencies: 1
Dec 6, 2022
Visit Reason
This inspection was conducted as a state licensure survey in conjunction with a Federal Recertification survey at the facility from 11/29/2022 through 12/06/2022, in accordance with Nevada Administrative Code (NAC) 449 for Skilled Nursing Facilities.
Findings
The facility failed to ensure that a state-approved cultural competency course was provided to 9 of 10 employees reviewed, which had the potential to result in discrimination against residents. The Director of Staff Development confirmed incomplete training and acknowledged the need for 100% staff completion.
Severity Breakdown
Severity 2 Scope 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide state-approved cultural competency training to 9 of 10 employees reviewed. | Severity 2 Scope 3 |
Report Facts
Employees reviewed: 10
Employees lacking cultural competency training: 9
Employees trained: 18
Census: 150
Sample size: 30
Employee files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clarissa DeWese | Executive Director | Signed the report |
| Director of Staff Development | Confirmed incomplete cultural competency training | |
| SDC, Director of Nursing, Executive Director | Responsible for ensuring plan of correction implementation |
Inspection Report
Annual Inspection
Census: 150
Deficiencies: 10
Dec 6, 2022
Visit Reason
This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey, Complaint Survey, and Facility Reported Incident investigation initiated on November 29, 2022, and completed on December 06, 2022.
Findings
The survey included complaint investigations and facility reported incidents. Several allegations were substantiated including medication administration errors, failure to provide timely medications, failure to implement a care plan for pressure ulcer prevention, failure to provide restorative nursing services, failure to monitor nutritional status and weight loss, medication errors, improper medication storage, and food preference issues. The facility also had issues with walk-in freezer temperature and expired food items.
Complaint Details
The survey included complaint #NV00067316 and others. Allegations substantiated included medication errors, failure to notify responsible parties of discharge, improper discharge practices, and failure to provide care as ordered. Some allegations were unsubstantiated.
Deficiencies (10)
| Description |
|---|
| Failure to implement a care plan for prevention of pressure ulcers for Resident #103. |
| Failure to provide restorative nursing program services for Residents #28, #48, and #53 due to lack of restorative aides. |
| Failure to assess and intervene for significant weight loss and failure to provide ordered nutritional supplements for Resident #78. |
| Medication administration errors including late administration, failure to clarify physician orders, and failure to document administration accurately for Resident #89 and others. |
| Failure to discard expired and discontinued medications and intravenous fluids for discharged residents and failure to properly store medications. |
| Failure to honor resident food preferences for Resident #3, resulting in serving disliked foods. |
| Failure to maintain food safety including discarding expired food, labeling and dating opened food items, maintaining cleanliness of kitchen equipment, and maintaining walk-in freezer temperature. |
| Failure to ensure medication error rate below 5% with observed medication errors for Resident #21. |
| Failure to maintain medical records accurately and timely including medication administration documentation for Resident #89. |
| Failure to maintain confidentiality and safeguard medical records. |
Report Facts
Census: 150
Sample size: 30
Medication error rate: 7.89
Weight loss: 20
Temperature: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to findings on medication administration, restorative nursing program, and medication storage. | |
| Director of Food and Nutrition Services | Named in relation to findings on food safety, expired food, and walk-in freezer maintenance. | |
| Registered Dietitian | Named in relation to findings on nutritional assessments and interventions. | |
| Director of Staff Development | Named in relation to restorative nursing program staffing issues. | |
| Licensed Practical Nurse | Named in relation to medication administration and storage observations. | |
| Dietary Director | Named in relation to food service and kitchen inspections. |
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 0
Sep 16, 2022
Visit Reason
The inspection was conducted as a result of a Complaint and Facility Reported Incident investigation initiated on 09/13/2022 and completed on 09/16/2022, involving seven complaints and five facility reported incidents.
Findings
The investigation substantiated some allegations with no regulatory deficiencies identified, including issues related to communication, medication refusal, wound care, and resident-to-resident altercations. Other allegations such as discharge assistance, harassment, medication errors, and abuse claims were not substantiated. No regulatory deficiencies were cited.
Complaint Details
Seven complaints and five facility reported incidents were investigated. Some allegations were substantiated without regulatory deficiencies, including medication refusal and wound care issues. Other allegations, including discharge assistance, harassment, medication errors, call light response, and abuse claims, were not substantiated. The facility was found to have no regulatory deficiencies.
Report Facts
Sample size: 14
Collectible amount: 363
Invoices: 1200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Provided invoices and account activity report related to resident rent and billing |
| Director of Nursing | Director of Nursing | Involved in investigation and provided information on medication and resident care |
| Nurse Case Manager | Nurse Case Manager | Provided explanations regarding resident discharge and care |
| Licensed Practical Nurse | Licensed Practical Nurse | Recalled conversations with family and resident care details |
| Unit Manager | Unit Manager | Recalled incidents related to resident care and family interactions |
| Abuse Coordinator | Abuse Coordinator | Managed investigation of alleged abuse incident |
| Wound Care Physician Assistant | Wound Care Physician Assistant | Provided wound care assessments and treatment details |
Inspection Report
Complaint Investigation
Census: 163
Deficiencies: 1
Mar 3, 2022
Visit Reason
The inspection was conducted as a result of a Focused Infection Control Survey, Complaint Investigation, and Facility Reported Incidents (FRIs) investigation from 03/01/2022 through 03/03/2022.
Findings
The facility investigated multiple resident-to-resident altercations and abuse allegations, with some substantiated but no regulatory deficiencies cited for those incidents. The facility was found to have failed to submit final investigation reports within five working days for four resident-to-resident altercations, violating reporting requirements.
Complaint Details
Three complaints and five FRIs were investigated. Complaint #NV00065297 was substantiated with no regulatory deficiency regarding a resident punching another resident. Complaint #NV00065432 was substantiated with no regulatory deficiency regarding pressure ulcers. Complaint #NV00065511 could not be substantiated regarding inappropriate discharge. Multiple FRIs related to resident-to-resident altercations and sexual abuse were substantiated with no regulatory deficiencies except for failure to submit timely final reports.
Deficiencies (1)
| Description |
|---|
| Failure to submit final investigation reports within five working days for resident-to-resident abuse incidents. |
Report Facts
Census: 163
Sample size: 14
Complaints investigated: 3
Facility Reported Incidents (FRIs) investigated: 5
Days for final report submission: 5
Residents involved in delayed reports: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for reporting investigations to the Administrator and completing investigation summaries |
| Director of Nursing | Director of Nursing | Provided information on reporting process changes and email confirmations |
| Administrator | Administrator | Responsible for awareness of incidents and final report submissions |
| Social Worker | Social Worker | Explained responsibilities of Assistant Director of Nursing regarding investigation reports |
Inspection Report
Complaint Investigation
Census: 155
Deficiencies: 0
Nov 3, 2021
Visit Reason
The inspection was initiated as a result of a CMS Focused Infection Control survey, Facility Reported Incident (FRI), and a Complaint investigation starting on 11/03/2021 and completed on 11/05/2021.
Findings
The investigation found no regulatory deficiencies related to the substantiated complaint and FRIs. The facility had adequate infection control policies, PPE supplies, and staff training. Multiple FRIs and complaints were investigated with no deficiencies identified.
Complaint Details
Complaint #NV00065159 was substantiated with no regulatory deficiency. Seven FRIs regarding resident-to-resident altercations and three FRIs regarding employee to resident abuse were investigated with no regulatory deficiencies identified. Two FRIs regarding resident elopement were substantiated with no deficiencies. Facility Reported Incident #NV00062292 regarding injury of unknown origin and Facility Reported Incident #NV00064140 regarding visitor to resident physical abuse were substantiated with no regulatory deficiencies.
Report Facts
Census: 155
Sample size: 18
Residents on 14-day observation: 27
Residents in Yellow Zone: 27
Residents in Green Zone: 128
Certified Nursing Assistants on secured unit: 2
Nurses on secured unit: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Identified a purple area under resident's eye and reported it to wound nurse, Assistant Director of Nursing, and Director of Nursing | |
| Assistant Director of Nursing | Informed about resident injury by CNA | |
| Director of Nursing | Informed about resident injury by CNA | |
| Charge Nurse | Recounted incident of visitor to resident physical abuse on 06/11/2021 | |
| Executive Director | Indicated use of Red Zone if COVID-19 positive residents identified | |
| Social Services Director | Explained resident visitation rights and restraining order details | |
| Activities Director | Explained resident visitation rights and restraining order details | |
| Abuse Coordinator | Explained resident visitation rights and restraining order details |
Inspection Report
Complaint Investigation
Census: 162
Deficiencies: 0
Jul 14, 2021
Visit Reason
This inspection was conducted as a Centers for Medicare and Medicaid Services (CMS) Focused Infection Control survey, Facility Reported Incident and Complaint investigation in accordance with 42 CFR Part 483 for Long Term Care Facilities.
Findings
The investigation included review of infection control practices, staff and visitor screening, PPE use, and multiple complaints alleging staff working sick, vaccination rates, visitation restrictions, resident care concerns, and abuse allegations. No regulatory deficiencies were identified and most complaints were not substantiated. One complaint was substantiated without regulatory deficiency.
Complaint Details
Five complaints and one facility reported incident were investigated. Allegations included staff working sick and infecting residents, inadequate staff vaccination, visitation restrictions, resident care concerns such as being left wet/soiled, refusal of discharge, verbal abuse and rough handling, broken bed remote controls, improper use of Hoyer lift, delayed CT scan for head injury, and failure to provide visitation or records. Most allegations were not substantiated except for visitation restrictions and delayed CT scan, both substantiated without regulatory deficiency.
Report Facts
COVID-19 positive cases: 7
Residents on 14-day observation: 25
Sample size: 6
Staff COVID-19 vaccination rate: 40
Inspection Report
Follow-Up
Deficiencies: 0
Apr 20, 2021
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 03/11/2021.
Findings
All deficiencies previously cited have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 162
Capacity: 78
Deficiencies: 1
Mar 18, 2021
Visit Reason
The inspection was conducted as a result of a Facility Reported Incident investigation regarding a resident fall with injury during a Hoyer transfer.
Findings
The investigation substantiated the incident without regulatory deficiencies. The facility failed to ensure one of five Hoyer lifts had a current service tag, indicating expired maintenance, which was corrected by removal and scheduling of service.
Complaint Details
Facility Reported Incident #NV00063397 was substantiated without regulatory deficiencies. The resident had a fall during a Hoyer transfer due to sling strap breakage, which was an isolated incident with proper technique followed.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure one of five Hoyer lifts had a current service tag; expired service tag observed on Hoyer lift model #9401395 and #9401438. |
Report Facts
Census: 162
Total Capacity: 78
Sample Size: 5
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interpreted service tag colors and maintenance schedule for Hoyer lifts |
| Director of Housekeeping and Laundry Services | Director of Housekeeping and Laundry Services | Handled freshly cleaned slings and explained sling maintenance |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Described sling condition and transfer technique |
| Director of Staff Development | Director of Staff Development (DSD) | Described sling condition and transfer technique |
| Maintenance Director | Maintenance Director | Removed Hoyer lift with expired tag, scheduled maintenance, and maintains equipment logs |
| Executive Director | Executive Director | Spoke to third party service technician and responsible for corrective actions |
| Unit Manager | Unit Manager | Indicated facility provided Hoyer transfer training and assessed equipment fit for use |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 10, 2021
Visit Reason
An offsite follow-up survey was completed on February 10, 2021 for all deficiencies cited on January 13, 2021.
Findings
All deficiencies cited on January 13, 2021 have been corrected. The facility was found to be in substantial compliance with regulations surveyed.
Inspection Report
Abbreviated Survey
Census: 131
Deficiencies: 1
Jan 13, 2021
Visit Reason
This inspection was conducted as a Centers for Medicare and Medicaid Services (CMS) Focused Infection Control survey in response to COVID-19 concerns, reviewing the facility's infection control and prevention program, including testing practices and compliance with COVID-19 regulations.
Findings
The facility was found to have deficiencies related to COVID-19 testing protocols, specifically failing to conduct confirmatory PCR testing following antigen test results as required by federal regulations and technical bulletins. Staff and residents were tested using Abbott Binax NOW antigen tests without appropriate PCR confirmation, and staff were unaware of the need for confirmatory testing in certain cases.
Deficiencies (1)
| Description |
|---|
| Failure to conduct confirmatory PCR testing following COVID-19 antigen test results as required by federal regulations and technical bulletins. |
Report Facts
Census: 131
Positive COVID-19 cases: 26
Presumptive COVID-19 cases: 38
Residents in Red Zone: 26
Residents in Yellow Zone: 38
Residents in Green Zone: 67
Testing frequency for residents: 2
Testing frequency for staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Verbalized facility had not sent COVID-19 specimens for PCR testing since November 2020 and was unaware of need for confirmatory PCR testing |
| Director of Nursing | Director of Nursing | Unaware that PCR testing was required in some instances when antigen test results were negative |
| Administrator | Administrator | Confirmed receipt of Technical Bulletin regarding COVID-19 testing requirements in December 2020 |
Inspection Report
Routine
Census: 154
Deficiencies: 1
Nov 20, 2020
Visit Reason
The inspection was conducted as a State licensure survey in conjunction with a Federal Focused Infection Control survey at the facility on 11/20/2020.
Findings
The facility failed to obtain a State Laboratory License prior to using the Quidel Sofia Antigen test machine and Abbott BinaxNOW COVID-19 Ag cards for COVID-19 testing on staff and residents.
Deficiencies (1)
| Description |
|---|
| Facility failed to obtain a State Laboratory License prior to use of Quidel Sofia Antigen test machine and Abbott BinaxNOW COVID-19 Ag cards. |
Report Facts
Census: 154
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clarissa Dewese | Executive Director | Named as Laboratory Director or Provider/Supplier Representative signing the report |
Inspection Report
Abbreviated Survey
Census: 154
Deficiencies: 2
Nov 20, 2020
Visit Reason
The inspection was a Centers for Medicare and Medicaid Services (CMS) Focused Infection Control survey conducted to evaluate the facility's infection control and prevention program, including COVID-19 related practices.
Findings
The facility had six positive COVID-19 cases at the time of inspection. Deficiencies were found related to failure to provide timely intervention for a resident with COVID-19 symptoms and inadequate documentation and medical clearance for N95 respirator fit testing for staff. The facility lacked complete records of respirator fit tests including make/model/size of masks and medical clearance prior to use.
Deficiencies (2)
| Description |
|---|
| Failure to provide timely intervention to a resident with COVID-19 symptoms, including delayed physician notification and treatment. |
| Failure to provide medical clearance prior to N95 respirator fit testing and incomplete documentation of fit test results including make/model/size of respirators for staff. |
Report Facts
COVID-19 positive cases: 6
Resident census: 154
Residents in Red Zone: 6
Residents in Yellow Zone: 40
Residents in Green Zone: 108
Number of staff fit tested: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist Nurse | Provided education on infection control and confirmed deficiencies related to respirator fit testing and medical clearance | |
| Licensed Practical Nurse (LPN) | Explained nursing procedures and was observed wearing N95 respirator | |
| Activities Director | Observed wearing N95 respirator not fit tested and reported facility ran out of fit tested masks | |
| Certified Nursing Assistant (CNA) | Observed wearing N95 respirator | |
| Registered Nurse (RN) | Observed wearing N95 respirator | |
| Wound Care Nurse | Observed wearing N95 respirator | |
| Physical Therapist (PT) | Observed wearing N95 respirator |
Inspection Report
Complaint Investigation
Census: 146
Deficiencies: 1
Sep 24, 2020
Visit Reason
The inspection was conducted as a result of a CMS Focused Infection Control survey and complaint investigation triggered by three complaints regarding infection control, resident care, and discharge processes.
Findings
The facility was found to be generally compliant with infection control policies including PPE use and COVID-19 precautions. However, one complaint was substantiated regarding improper discharge procedures for Resident #9, who was discharged without proper written notice, reason for discharge, or contact information for physician and social worker, resulting in inadequate post-discharge support.
Complaint Details
Three complaints were investigated. Complaint #NV0060990 was substantiated regarding improper discharge of Resident #9 to an independent living home without following discharge process requirements. Other complaints related to fall risk, oxygen saturation reporting, and COVID-19 status were not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide written notice of discharge reason and contact information for physician and social worker for Resident #9 at time of discharge. | SS=D |
Report Facts
Census: 146
Sample size: 17
COVID-19 positive residents: 6
PPE inventory: 20150
PPE inventory: 4000
PPE inventory: 8380
PPE inventory: 36000
PPE inventory: 1500
PPE inventory: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Director of Social Services | Verbalized Resident #9 was not assessed by social services and explained discharge information |
| Case Manager | Case Manager | Assisted with Resident #9 discharge but was not aware of psychiatric history or discharge discussion details |
| Assistant Director of Nursing | Assistant Director of Nursing | Verbalized that families were called with COVID-19 test results |
| Two Licensed Practical Nurses | Licensed Practical Nurses | Reviewed medical records verifying oxygen levels and COVID-19 test result notifications |
Inspection Report
Routine
Census: 120
Deficiencies: 0
Jun 11, 2020
Visit Reason
This inspection was a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey conducted to evaluate the facility's compliance with infection prevention and control requirements during the COVID-19 pandemic.
Findings
The facility implemented infection control measures including isolation and quarantine units, staff and resident COVID-19 testing, use of personal protective equipment (PPE), and disinfection protocols. No regulatory deficiencies were identified during the survey.
Report Facts
PPE inventory: 14050
PPE inventory: 1448
PPE inventory: 2000
PPE inventory: 38000
PPE inventory: 1503
PPE inventory: 208
COVID-19 positive residents: 13
COVID-19 positive residents: 7
Residents in quarantine: 9
Residents in quarantine: 49
Residents receiving outpatient dialysis: 7
COVID-19 testing round dates: 3
COVID-19 positive staff: 8
COVID-19 positive staff: 2
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 0
May 14, 2020
Visit Reason
This inspection was conducted as a result of a complaint investigation regarding allegations of unauthorized visitors exposing residents to COVID-19, insufficient personal protective equipment, inadequate isolation and care of COVID-positive residents, lack of respiratory outbreak system, and improper reporting to health authorities.
Findings
The investigation found no substantiated deficiencies. Staff screening and visitor restrictions were in place, adequate PPE supplies were available, COVID-positive residents were isolated with designated staff, respiratory outbreak protocols were followed, and the facility reported appropriately to health authorities.
Complaint Details
One complaint (#NV00060747) was investigated with five sampled cases. All five allegations related to COVID-19 precautions and care were not substantiated.
Report Facts
PPE supplies: 2255
PPE supplies: 40000
PPE supplies: 1290
PPE supplies: 2316
Complaint sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Eight CNAs interviewed and observed regarding COVID-19 precautions and care | |
| Licensed Practical Nurse (LPN) | Two LPNs interviewed regarding COVID-19 precautions and care | |
| Registered Nurse (RN) | One RN interviewed regarding COVID-19 precautions and care | |
| Administrator | Administrator explained staff assignments and visitor restrictions | |
| Director of Nursing (DON) | DON explained staff assignments and COVID-19 unit operations | |
| Infection Control Preventionist (IP) | IP explained screening procedures | |
| Central Supply Director | Indicated sufficient PPE supplies |
Inspection Report
Follow-Up
Census: 124
Deficiencies: 0
May 14, 2020
Visit Reason
This was a Covid-19 focused Infection Control follow-up survey conducted by Centers for Medicare and Medicaid Services (CMS) to assess regulatory compliance with infection prevention and control requirements.
Findings
The facility was found to be following their infection control policies with no regulatory deficiencies identified. The survey included review of infection prevention program effectiveness, resident care practices, visitor screening, and staff education. Dedicated nursing staff and separation of Covid-19 positive residents were observed.
Report Facts
Covid-19 positive residents: 32
Covid-19 positive residents in secured unit: 13
Covid-19 positive residents in rooms 226 to 233: 4
Covid-19 positive residents in 300 hall: 15
Residents not affected by Covid-19: 12
Inspection Report
Routine
Census: 173
Deficiencies: 3
Apr 15, 2020
Visit Reason
The inspection was a COVID-19 Focused Infection Control survey initiated by Centers for Medicare and Medicaid Services to assess the facility's infection prevention and control program and compliance with COVID-19 related regulations.
Findings
The facility failed to ensure all staff were fit tested for N95 masks, a kitchen staff member was not ServSafe certified, and screening questions for signs and symptoms of COVID-19 were inconsistently asked at the facility entrance. The facility had no positive COVID-19 residents at the time but had residents on isolation and staff who tested positive.
Deficiencies (3)
| Description |
|---|
| Failure to ensure all staff were fit tested for N95 masks. |
| Kitchen staff member was not ServSafe certified. |
| Inconsistent screening for signs and symptoms of COVID-19 at facility entrance. |
Report Facts
Census: 173
N95 masks in supply: 4000
Date of survey: Apr 15, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Reported resident sent to hospital tested positive for COVID-19 and staff not fit tested for N95 masks |
| Infection Control Preventionist | Infection Control Preventionist | Confirmed staff had not been fit tested for N95 masks and confirmed screening procedures |
| Cook | Cook | Reported not having ServSafe certification |
| Assistant Dietary Manager | Assistant Dietary Manager | Indicated staff on duty were not ServSafe certified |
| Dietary Manager | Dietary Manager | Confirmed each shift should have a ServSafe certified employee |
| Receptionist | Receptionist | Verified visitor screening procedures including signs and symptoms questions |
Inspection Report
Annual Inspection
Census: 169
Deficiencies: 13
Oct 11, 2019
Visit Reason
Annual Medicare Recertification survey conducted from 2019-10-08 to 2019-10-11 with an extended survey on 2019-10-11, including investigation of two complaints.
Findings
The survey identified multiple deficiencies including failure to provide dignity catheter covers, incomplete restorative care plans, failure to ensure discharge planning and home health services, medication administration errors, incomplete dialysis communication, improper medication storage and labeling, failure to follow dietary orders, oxygen administration errors, pain management issues, infection control concerns including catheter bags on the floor, and failure to maintain proper documentation and physician orders for catheter and PICC line care.
Complaint Details
Two complaints were investigated. Complaint #NV00058946 was substantiated regarding failure to facilitate home health services and durable medical equipment for a discharged resident. Complaint #NV00058938 regarding staff exposure to a resident was not substantiated.
Severity Breakdown
SS=D: 4
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to provide dignity catheter covers for residents #65, #101, and #130. | SS=D |
| Failure to develop and implement a comprehensive care plan for restorative care for resident #84. | SS=D |
| Failure to ensure discharge planning and home health services were provided for resident #100. | — |
| Failure to ensure catheter care and maintenance orders were followed for resident #129. | — |
| Failure to follow restorative care orders for resident #84. | — |
| Failure to change catheter per physician orders for resident #116. | — |
| Failure to obtain physician orders and document central line dressing changes and PICC line flushes for residents #129 and #581. | — |
| Failure to follow dietary orders for resident #81 resulting in provision of thick liquids despite order to discontinue. | — |
| Failure to follow physician order for oxygen administration for resident #91. | SS=D |
| Failure to follow physician order for PRN pain medication administration for resident #71. | SS=D |
| Failure to complete Pre/Post Dialysis Communication forms for residents #81, #162, and #580 and failure to clarify dialysis days for resident #162. | — |
| Medication cart left unlocked and accessible to residents; failure to date opened medication vials; failure to complete temperature logs for medication refrigerator. | — |
| Failure to keep urinary catheter bags off the floor for residents #101, #89, #37, and #157, posing infection control risks. | — |
Report Facts
Sample size: 44
Deficiency count: 12
Medication cart unlocked incident: 1
Missed refrigerator temperature checks: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for correction and continued monitoring of catheter care, dialysis communication, medication storage, and infection control. | |
| Unit Manager | Responsible for monitoring catheter care, medication cart security, and dialysis communication. | |
| Registered Nurse | Confirmed oxygen administration error and PICC line dressing change issues. | |
| Licensed Practical Nurse | Acknowledged medication cart unlocked and PICC line dressing change procedures. | |
| Infection Control Coordinator | Reported catheter bags should not be on the floor. | |
| Nutritional Coordinator/Dietary Manager | Reported dietary order errors and audit procedures. |
Inspection Report
Annual Inspection
Deficiencies: 11
Oct 11, 2019
Visit Reason
The 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.
Findings
The facility failed to develop and maintain a comprehensive emergency preparedness program including a facility-based and community-based risk assessment, strategies for emerging infectious diseases, delegation of authority and succession plans, cooperation with emergency officials, safe evacuation policies, sheltering in place procedures, communication plans including contact information for staff and emergency officials, and means to provide occupancy and needs information to authorities.
Severity Breakdown
SS=D: 10
SS=O: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to develop and maintain a comprehensive emergency preparedness program based on facility and community risk assessments including strategies for emerging infectious diseases. | SS=D |
| Failed to include a current and documented community-based risk assessment in the emergency preparedness plan. | SS=D |
| Failed to include strategies for addressing emergency events identified by the facility-based risk assessment. | SS=D |
| Failed to identify all business functions essential to the facility's operations during an emergency. | SS=O |
| Failed to include delegation of authority and succession plans to ensure continuity of operations during an emergency. | SS=O |
| Failed to include a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials. | SS=D |
| Failed to develop and implement emergency preparedness policies and procedures for safe evacuation including identification of evacuation locations. | SS=D |
| Failed to develop and implement emergency preparedness policies and procedures that addressed a means to shelter in place for staff and volunteers. | SS=D |
| Failed to develop and maintain an emergency preparedness communication plan including names and contact information for staff, entities providing services, patients' physicians, volunteers, and emergency preparedness officials. | SS=D |
| Failed to develop and maintain an emergency preparedness communication plan that included contact information for federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance. | SS=D |
| Failed to develop and maintain an emergency preparedness communication plan that included a means of providing information about the facility's occupancy, needs, and ability to provide assistance to authorities. | SS=D |
Report Facts
Staff missing contact info: 2
Date of survey: Oct 11, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Named in relation to corrective actions and re-education on emergency preparedness plan updates and monitoring. | |
| Executive Director | Named in relation to corrective actions and responsibility for emergency preparedness plan compliance and monitoring. | |
| Director of Maintenance | Named in relation to corrective actions and responsibility for emergency preparedness plan compliance and monitoring. |
Inspection Report
Life Safety
Census: 165
Capacity: 178
Deficiencies: 7
Oct 11, 2019
Visit Reason
Medicare Life Safety Code (LSC) recertification survey conducted at the facility on 10/10/19 and 10/11/19.
Findings
The facility was surveyed for compliance with NFPA Life Safety Code and Health Care Facilities Code. Deficiencies were found related to fire safety systems including cooking extinguishment system nozzle caps missing, fire alarm system sensitivity testing overdue, sprinkler system maintenance issues including dusty sprinkler heads and missing spare parts, fire extinguisher accessibility, fire door inspections incomplete, and electrical receptacle testing not documented.
Severity Breakdown
SS=D: 2
SS=E: 1
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Cooking extinguishment system nozzle blowoff caps were missing or damaged. | SS=D |
| Fire alarm system smoke detectors in 100 and 200 units were not sensitivity tested every two years as required. | SS=D |
| Sprinkler heads were dusty, spare sprinkler parts missing, obstructions within 18 inches of sprinkler heads, and overdue five-year internal inspection of sprinkler piping. | SS=E |
| Fire extinguisher cabinet in west courtyard was locked and not readily accessible. | — |
| Not all smoke and fire door assemblies were inspected and repaired as required; some repairs were pending. | — |
| Electrical receptacle testing in resident care rooms was not documented as completed. | SS=F |
| Facility failed to develop and maintain a testing and maintenance program for fixed and portable patient-care related electrical equipment; some equipment lacked inspection tags or had expired tags. | SS=F |
Report Facts
Deficiencies cited: 7
Resident census: 165
Total licensed capacity: 178
Date of survey: Oct 11, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Acknowledged deficiencies related to fire safety and electrical equipment testing | |
| Executive Director | Named as responsible individual for corrective actions and monitoring |
Inspection Report
Complaint Investigation
Census: 170
Deficiencies: 4
Jul 31, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation completed at the facility on 07/31/19, involving three complaints.
Findings
The investigation substantiated two complaints related to failure to assess a resident for pressure sore development and wound care supplies being left open, and failure to provide timely medication administration. Several other allegations were unsubstantiated. Deficiencies were identified in quality of care, treatment and services to prevent pressure ulcers, pharmacy services, and labeling/storage of drugs and biologicals.
Complaint Details
Three complaints were investigated. Complaint #NV00057874 was unsubstantiated. Complaint #NV00057426 was substantiated regarding failure to assess a resident for pressure sore development. Complaint #NV00057888 was substantiated regarding wound care supplies left open and residents not receiving medications on time, and lack of emergency medications (D50 and Narcan).
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to provide medications per physician order for 2 of 9 sampled residents and failed to administer medications in a timely manner for 1 of 9 sampled residents. | SS=D |
| Facility failed to ensure a weekly skin assessment was provided and completed prior to discharge for 1 sampled resident. | SS=D |
| Facility failed to have Naloxone (Narcan) and Dextrose 50% (D50) available for emergency use. | SS=D |
| Facility failed to properly label and store drugs and biologicals, including open wound care supplies without dates and lack of proper storage security. | SS=D |
Report Facts
Census: 170
Sample size: 9
Complaints investigated: 3
Residents with medication issues: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during investigation | |
| Director of Maintenance | Interviewed during investigation | |
| Unit Charge Nurses | Interviewed during investigation | |
| Licensed Practical Nurse (LPN) | Confirmed medication documentation issues and skin assessment process | |
| Registered Nurse (RN) | Provided medication administration information and inventory list | |
| Advance Practice Registered Nurse (APRN) | Verbalized expectations for reporting missing antibiotic doses and opioid availability | |
| Certified Nurse Assistant (CNA) | Interviewed regarding resident care | |
| Treatment Nurse | Confirmed resident skin risk and assessment issues | |
| Physician's Assistant (PA) | Confirmed facility follow-up skin assessment | |
| Social Worker | Interviewed about resident discharge | |
| Nurse Practitioner (NP) | Confirmed wound care and skin status |
Inspection Report
Complaint Investigation
Census: 165
Deficiencies: 0
Apr 12, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation completed in the facility on 04/12/19, related to allegations about resident bathing practices, staffing ratios, staff respectfulness, and threats to Certified Nursing Assistants regarding staffing complaints.
Findings
The investigation included observations, interviews with residents, staff, and family members, and review of policies and medical records. The complaint was found to be unsubstantiated and no deficiencies were identified.
Complaint Details
Complaint #NV00056696 was unsubstantiated. Allegations included residents not being bathed regularly due to staff shortages, insufficient Certified Nursing Assistants per resident ratio, forced assistance by male CNAs to female residents, disrespectful nursing staff, threats to CNAs about staffing complaints, and overall understaffing.
Report Facts
Sample size: 5
Number of residents: 165
Number of complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 166
Deficiencies: 2
Jan 31, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation completed on 01/31/19, involving two complaints regarding resident care and facility actions.
Findings
Two complaints were substantiated: one involving a resident who suffered a stroke and experienced a delay in transfer for medical treatment, and another regarding failure to take action after a resident's hearing aid was broken. Several other allegations were not substantiated. The facility failed to ensure timely assessment and transfer of a resident with stroke symptoms and failed to ensure proper treatment and maintenance of residents' hearing aids.
Complaint Details
Two complaints were investigated. Complaint #NV00055904 was substantiated regarding a resident suffering a stroke and delay in transfer. Complaint #NV00055846 was substantiated regarding failure to take action after a resident's hearing aid was broken.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident was assessed and transferred to an acute care facility in a timely manner after exhibiting stroke symptoms. | SS=D |
| Facility failed to take action after being made aware a resident's hearing aid was broken. | SS=D |
Report Facts
Census: 166
Sample size: 5
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the investigation and named as individual responsible for corrective actions | |
| Certified Nurse Assistant #1 | CNA | Provided key observations regarding Resident #2's condition and care |
| Licensed Practical Nurse | LPN | Explained nursing expectations related to resident condition changes |
| Certified Nurse Assistant #2 | CNA | Reported observations about Resident #2's condition |
| Certified Nurse Assistant #3 | CNA | Indicated reporting procedures for emergent situations |
| Unit Manager | Involved in assessment and communication with family regarding Resident #2 | |
| Medical Director | Provided rapid response protocol and guidance on corrective actions | |
| Executive Director | Named as individual responsible for corrective actions and follow-up | |
| Social Worker | SW | Notified about hearing aid issues and family communications |
Inspection Report
Complaint Investigation
Census: 165
Deficiencies: 3
Dec 14, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding wound care nurses keeping medications from discharged residents and reusing them on other residents.
Findings
The complaint was substantiated for the allegation that wound care nurses kept medications from discharged residents and reused them. Other allegations related to treatment ointments, pressure wound reporting, medication sign-out, and physician visits were not substantiated. Deficiencies were found in medication labeling, storage, and disposal practices.
Complaint Details
Complaint #N00055127 was substantiated regarding wound care nurses keeping medications from discharged residents and reusing them. Other allegations were not substantiated.
Deficiencies (3)
| Description |
|---|
| Treatment medications were not discarded after residents were discharged for 3 of 6 sampled residents. |
| A treatment medication was labeled in accordance with regulatory requirements. |
| Individual Normal Saline (NS) packs were not discarded after use. |
Report Facts
Census: 165
Sample size: 6
Complaint count: 1
Medication labeling units: 100000
Medication labeling units: 250
Medication labeling milligrams: 87
Medication labeling milligrams: 788
Medication labeling percentage: 0.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed medications should have been discarded after resident discharge and responsible for corrective actions |
| Nursing Unit Managers | Nursing Unit Managers | Responsible for conducting random medication cart checks and ensuring compliance |
Inspection Report
Life Safety
Census: 167
Capacity: 178
Deficiencies: 4
Nov 6, 2018
Visit Reason
Medicare Recertification Life Safety Code survey conducted to assess compliance with NFPA 101 Life Safety Code and related fire safety standards.
Findings
The facility failed to appropriately identify fire alarm circuits on electrical panelboards, maintain the automatic fire sprinkler system, and maintain accurate circuit directories for electrical panels. Additional deficiencies included corroded fire sprinklers and improper use of electrical equipment.
Severity Breakdown
SS=E: 2
SS=F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Fire alarm circuits on electrical panelboards 'EA' and 'EB' were not appropriately marked in red. | SS=E |
| Facility failed to maintain the automatic fire sprinkler system, including missing list of sprinklers in the spare box and corroded sprinklers. | SS=E |
| Circuit directories in multiple electrical panels were inaccurate and lacked adequate detail. | SS=F |
| Use of a relocatable power tap to power a mini refrigerator in the business office was not permitted. | SS=F |
Report Facts
Licensed beds: 178
Census: 167
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Interviewed regarding fire alarm circuit markings, sprinkler system maintenance, and electrical panel issues | |
| Maintenance Director | Responsible for conducting rounds to ensure electrical panels are identified and involved in corrective actions | |
| Executive Director and Director of Maintenance | Executive Director and Director of Maintenance | Named as individual responsible for corrective actions and completion dates |
Inspection Report
Deficiencies: 0
Nov 6, 2018
Visit Reason
The inspection was conducted as an Emergency Preparedness survey in conjunction with a Medicare recertification survey on 11/06/18 - 11/07/18, in accordance with federal and state regulations.
Findings
The facility was found to be in substantial compliance with the regulations regarding the Emergency Preparedness program. No deficiencies requiring further action were cited.
Inspection Report
Annual Inspection
Census: 171
Deficiencies: 14
Oct 30, 2018
Visit Reason
This inspection was a Medicare Recertification survey conducted from October 30, 2018 through November 2, 2018, including investigation of two complaints.
Findings
The survey found multiple deficiencies related to transfer and discharge requirements, comprehensive care plans, quality of care, medication administration, infection control, nutrition and hydration, pharmacy services, and other regulatory requirements. Two complaints were investigated and not substantiated. The facility failed to obtain physician orders for transfers, implement comprehensive care plans, ensure medication administration accuracy, and maintain infection control and food safety standards.
Complaint Details
Two complaints were investigated and both were not substantiated. Complaint #NV00054554 alleged staff went through a resident's personal belongings without permission; complaint #NV00054662 alleged the facility was not facilitating a resident's transfer to another acute rehabilitation facility for therapy.
Severity Breakdown
SS=D: 14
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to obtain a physician order to transfer a resident to a hospital. | SS=D |
| Failed to develop and implement comprehensive care plans for residents. | SS=D |
| Failed to ensure medication administration was performed according to physician orders and nursing standards. | SS=D |
| Failed to ensure quality of care including physician orders for discontinuation of central lines and pacemaker management. | SS=D |
| Failed to maintain nutrition and hydration status for residents with significant weight loss. | SS=D |
| Failed to ensure proper tube feeding management and enteral nutrition. | SS=D |
| Failed to ensure parenteral/IV fluids were administered consistent with professional standards and physician orders. | SS=D |
| Failed to ensure proper storage and labeling of drugs and biologicals. | SS=D |
| Failed to ensure medication error rates were below 5 percent. | SS=D |
| Failed to ensure infection prevention and control program was effective including hand hygiene and linen handling. | SS=D |
| Failed to ensure food safety including discarding expired milk and cleaning ice machines. | SS=D |
| Failed to ensure dialysis communication and care was properly documented and orders followed. | SS=D |
| Failed to ensure psychotropic drug regimens were free from unnecessary drugs and properly monitored. | SS=D |
| Failed to ensure short peripheral catheter insertion, labeling, and removal policies were followed. | SS=D |
Report Facts
Sample size: 34
Deficiencies cited: 14
Resident count at start of survey: 171
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to findings on medication administration and monitoring. |
| Unit Manager | Unit Manager | Named in relation to findings on transfer orders, care plans, and medication administration. |
| Licensed Practical Nurse | Licensed Practical Nurse | Named in relation to medication administration and care plan findings. |
| Registered Nurse | Registered Nurse | Named in relation to catheter care and medication administration findings. |
| Pharmacist | Pharmacist | Named in relation to medication order and delivery findings. |
| Dietary Director | Dietary Director | Named in relation to food safety and nutrition monitoring findings. |
| Executive Director | Executive Director | Named in relation to oversight of corrective actions. |
Inspection Report
Complaint Investigation
Census: 170
Deficiencies: 2
Sep 5, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation completed on 09/05/18, involving two complaints related to resident care and staff conduct.
Findings
Two complaints were substantiated involving misappropriation/exploitation and failure to ensure a safe environment leading to accidents. The facility failed to protect a resident from misappropriation by a staff member who was also the resident's beneficiary and failed to provide adequate supervision to prevent a resident from falling.
Complaint Details
Two complaints were investigated and both were substantiated. Complaint #NV00053920 involved failure to prevent accidents and supervision issues. Complaint #NV00054212 involved a staff member who was a resident's beneficiary and misappropriation of resident property.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to protect a resident from misappropriation and report the violation when discovered, involving a staff member listed as Medical Durable Power of Attorney and beneficiary. | SS=D |
| Facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision to prevent falls for one resident. | SS=D |
Report Facts
Sample size: 5
Complaints investigated: 2
Fall Risk Evaluation score: 18
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 1
Jul 20, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation completed on 07/20/18, involving two complaints regarding resident altercation and medication administration.
Findings
Two complaints were substantiated: a resident push-down altercation with no regulatory deficiencies cited, and improper administration of thyroid medication with a cited deficiency. The facility failed to accurately transcribe medication orders for one resident, leading to incorrect medication timing.
Complaint Details
Two complaints were investigated. Complaint #NV00053725 regarding a resident altercation was substantiated with no deficiencies cited. Complaint #NV00053515 regarding improper thyroid medication administration was substantiated with a deficiency cited under Tag F755.
Deficiencies (1)
| Description |
|---|
| Failure to accurately transcribe a medication from admission orders for one resident, resulting in incorrect medication timing. |
Report Facts
Sample size: 5
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed and acknowledged medication transcription errors |
| Unit Manager | Unit Manager | Confirmed medication transcription error on MAR |
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 1
Jul 20, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation completed on 07/20/18, triggered by two complaints regarding resident altercation and improper administration of thyroid medication.
Findings
The investigation substantiated two complaints: a resident was pushed down in an altercation with no regulatory deficiencies cited, and improper administration of thyroid medication with a deficiency identified related to pharmacy services and medication transcription errors.
Complaint Details
Two complaints were investigated. Complaint #NV00053725 was substantiated with no regulatory deficiencies cited regarding a resident altercation. Complaint #NV00053515 was substantiated regarding improper administration of thyroid medication, with a deficiency cited under tag F755.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to accurately transcribe medication orders for one resident, resulting in incorrect medication administration. | SS=D |
Report Facts
Census: 167
Sample size: 5
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during investigation | |
| Unit Manager | Interviewed during investigation and confirmed medication transcription error | |
| Desk Nurse | Interviewed during investigation | |
| Licensed Practical Nurse | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 166
Deficiencies: 4
Mar 29, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #NV00052229 regarding a resident who was alert and oriented but unable to self-administer medications and lacked endurance to stand and complete meal preparation, resulting in discharge to an independent living facility.
Findings
The facility was found deficient in ensuring residents' delegation of rights, discharge planning process, and specialized rehabilitative services. Specifically, the facility failed to ensure proper delegation of rights for one resident, failed to evaluate and implement an effective discharge planning process including self-administration of medications and meal preparation, and failed to provide occupational therapy services per physician's order. The complaint was substantiated.
Complaint Details
Complaint #NV00052229 was substantiated. The allegation involved a resident who was alert and oriented but unable to self-administer medications and lacked endurance to stand and complete meal preparation, resulting in discharge to an independent living facility.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure a resident's delegation of rights was followed for 1 of 3 sampled residents (Resident #3). | SS=D |
| Failure to develop and implement an effective discharge planning process including evaluation of resident's capacity for self-administration of medications, meal preparation, and self-care needs for 1 of 3 sampled residents (Resident #3). | SS=D |
| Failure to provide specialized rehabilitative services, specifically occupational therapy, per physician's order for 1 of 3 sampled residents (Resident #3). | SS=D |
| Failure to ensure medication reconciliation and education on discharge medications for 1 of 3 sampled residents (Resident #3). | SS=D |
Report Facts
Census: 166
Sample size: 3
Medicare days: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Interviewed and explained resident's competency and decision-making capacity | |
| Director of Nursing | DON | Explained nursing expectations for medication administration teaching and confirmed findings regarding medication education and supervision |
| Director of Rehabilitation | Confirmed resident required minimal assist for transfers and acknowledged need for assistance with ambulation | |
| Admissions Director | Explained verification of resident's insurance and Medicare coverage | |
| Business Office Manager | Revealed resident was on private pay with Medicare Part B |
Inspection Report
Complaint Investigation
Census: 173
Deficiencies: 0
Jan 30, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints alleging issues related to discharge letters, notice for discharge, inadequate staffing, and failure to break up a fight between residents.
Findings
The investigation found that the allegations regarding failure to submit appropriate discharge letters and 30-day notice for discharge were not substantiated. Allegations of inadequate staffing and failure to break up a fight were also not substantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Two complaints were investigated: Complaint #NV00051881 alleging failure to submit appropriate discharge letters and 30-day notice for discharge, which was not substantiated; and Complaint #NV00051695 alleging inadequate staffing and failure to break up a fight between residents, which was also not substantiated.
Report Facts
Sample size: 7
Residents per Certified Nursing Assistant: 24
Inspection Report
Life Safety
Capacity: 178
Deficiencies: 3
Oct 12, 2017
Visit Reason
This document is a Medicare Life Safety Code (LSC) re-certification survey conducted on 10/12/17 and 10/13/17 to assess compliance with fire safety regulations for a healthcare facility licensed for 178 beds.
Findings
The facility was found deficient in maintaining appropriate informational signage for delayed egress doors, inspection and maintenance of the kitchen hood system, and installation of a manual stop button for the emergency generator. Corrective actions were planned and assigned to the Environmental Services Director and others with completion dates set for November 20, 2017.
Severity Breakdown
F: 1
E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Egress doors had faded or unrecognizable signs noting 15 second delayed egress, failing to meet NFPA 101 Life Safety Code requirements. | F |
| Facility failed to ensure inspection and maintenance of the kitchen hood system as required by NFPA 96. | E |
| Facility failed to install a manual stop button for the emergency generator as required by NFPA 110. | E |
Report Facts
Licensed bed capacity: 178
Inspection dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Named in corrective actions for deficiencies related to signage, kitchen hood inspection, and emergency generator | |
| Administrator | Acknowledged deficiencies at time of discovery and during exit interview |
Inspection Report
Plan of Correction
Census: 172
Deficiencies: 6
Oct 3, 2017
Visit Reason
This Plan of Correction was generated as a result of a Medicare Recertification survey conducted from October 3, 2017 through October 6, 2017, including one complaint investigation which was not substantiated.
Findings
The facility was found deficient in several areas including comprehensive assessments, medication administration, catheter care, food safety, resident call system, and treatment for special needs. Corrective actions and monitoring plans were outlined for each deficiency to ensure compliance and prevent recurrence.
Complaint Details
One complaint (#NV00050595) was investigated with allegations including staff rudeness, delayed assistance, medication errors, and inappropriate staff instructions. The complaint was not substantiated.
Deficiencies (6)
| Description |
|---|
| 483.20(b)(1) Comprehensive Assessments - The facility failed to ensure the functional status for eating was coded correctly for 1 of 26 sampled residents. |
| 483.25(e)(1)-(3) No Catheter, Prevent UTI, Restore Bladder - The facility failed to follow a physician's order to change a Foley catheter for 1 of 26 sampled residents. |
| 483.25(e)(1)-(3) No Catheter, Prevent UTI, Restore Bladder - The facility failed to follow a physician's order for discontinuing a PICC line for 1 of 26 sampled residents. |
| 483.25(b)(2)(f)(g)(5)(h)(i)(j) Treatment/Care for Special Needs - The facility failed to ensure proper foot care, respiratory care, prostheses care, and parenteral fluids consistent with professional standards. |
| 483.60(i)(1)-(3) Food Procure, Store/Prepare/Serve - The facility failed to ensure proper food storage, cooling, and staff attire compliance. |
| 483.90(g)(2) Resident Call System - The facility failed to ensure call lights were within reach for 2 of 26 sampled residents. |
Report Facts
Census: 172
Sample size: 26
Deficiency count: 6
Complaint number: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named as individual responsible for corrective actions and involved in findings related to medication administration and assessments |
| MDS Coordinator | MDS Coordinator | Involved in assessment findings and corrective action plans |
| Unit Manager | Unit Manager | Named in medication administration deficiency and corrective actions |
| Licensed Practical Nurse | Licensed Practical Nurse | Involved in medication administration incident and findings |
| Certified Nursing Assistant | Certified Nursing Assistant | Involved in resident feeding and call light findings |
| Dietary Director | Dietary Director | Responsible for corrective actions related to food safety and staff attire |
| Executive Director | Executive Director | Responsible for monitoring corrective actions related to food safety and call light use |
Inspection Report
Complaint Investigation
Census: 173
Deficiencies: 0
Aug 2, 2017
Visit Reason
The inspection was conducted as a result of a complaint investigation involving two complaints alleging inappropriate discharge and unexplained injury to a resident.
Findings
The investigation included observations, interviews with staff and residents, and medical record reviews. Both complaints were found to be unsubstantiated, and no regulatory deficiencies were identified.
Complaint Details
Complaint #NV00049438 alleged a resident was discharged to an inappropriate facility and was not substantiated. Complaint #NV00049407 alleged a resident was found with bruising and an acute fracture of the left arm with unknown cause; this was also not substantiated.
Report Facts
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the complaint investigation | |
| Administrator | Interviewed during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 0
May 11, 2017
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding an allegation that a staff member struck a resident in the back while toileting.
Findings
The complaint was investigated through observations, interviews, and record reviews, and the allegation was not substantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00047662 alleged that a staff member struck a resident in the back while toileting; this allegation was not substantiated after investigation.
Report Facts
Sample size: 6
Number of residents interviewed: 8
Number of employee files reviewed: 3
Inspection Report
Life Safety
Census: 168
Capacity: 178
Deficiencies: 5
Nov 3, 2016
Visit Reason
The inspection was a Medicare Life Safety Code (LSC) re-certification survey conducted to assess compliance with fire safety standards at the facility.
Findings
The facility failed to maintain means of egress free of obstructions, had issues with fire department connection couplings and swivels, corridor doors that did not resist smoke passage, and deficiencies in the essential electrical system including a low battery indicator and lack of evidence of monthly generator load testing. Corrective actions were planned and assigned to the Environmental Services Director and others.
Severity Breakdown
D: 3
E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Means of egress was partially obstructed by unattended trash containers reducing egress to five feet. | D |
| Fire department connection couplings and swivels were damaged and could not rotate smoothly. | E |
| Corridor doors failed to resist passage of smoke due to gaps between doors and frames. | E |
| Essential electrical system alarm annunciator showed a 'Low Battery' light indicating a problem with the battery. | D |
| Lack of evidence that the emergency generator had been exercised under load for 30 minutes each month. | D |
Report Facts
Licensed beds: 178
Census: 168
Trash container capacity: 64
Number of smoke compartments affected: 2
Number of smoke compartments affected: 6
Number of rooms with door gaps: 19
Generator exercise frequency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| W.W. Williams | Maintenance Director/Safety Officer | Connected generator and corrected deficient practice |
| E.S.D | Environmental Services Director | Acknowledged deficiencies, corrected practices, and responsible for monitoring corrective actions |
| E.D. | Named as individual responsible for corrective actions along with E.S.D. |
Inspection Report
Annual Inspection
Census: 168
Deficiencies: 8
Nov 1, 2016
Visit Reason
The inspection was a recertification survey conducted from 11/1/16 through 11/4/16, including investigation of three complaints and review of facility policies and medical records.
Findings
The facility was found deficient in multiple areas including medication administration, care for residents with limited range of motion, accident hazard prevention, treatment and care for special needs, nutrition, pharmaceutical services, and infection control. Some complaints were substantiated, particularly regarding medication administration.
Complaint Details
Three complaints were investigated. Complaint #NV00047431 was not substantiated. Complaint #NV00046530 was not substantiated. Complaint #NV00047115 was substantiated regarding a resident not receiving medications until 9/20/16.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure medications were administered per physician's orders for 2 of 26 residents; physician's orders were unclear or missing for topical medication, blood sugar testing, dialysis, and wound dressing. | SS=D |
| Facility failed to ensure preventative measures for further decrease of range of motion for 2 of 26 residents. | SS=D |
| Facility failed to ensure medication was safely stored during 1 of 4 medication pass observations. | SS=D |
| Facility failed to ensure residents received proper treatment and care for special needs including injections, parenteral and enteral fluids, colostomy care, tracheostomy care, respiratory care, foot care, and prostheses. | SS=E |
| Facility failed to ensure unused medication tablets were properly destroyed during 1 of 4 medication pass observations. | SS=D |
| Facility failed to ensure vegetables were palatable and appealing in appearance. | SS=D |
| Facility failed to provide routine and emergency pharmaceutical services to meet residents' needs. | SS=D |
| Facility failed to establish and maintain an infection control program ensuring gloves were used and hand hygiene performed during intravenous medication administration for 1 of 26 residents. | SS=D |
Report Facts
Sample size: 26
Complaints investigated: 3
Residents affected by medication administration deficiency: 2
Residents affected by range of motion deficiency: 2
Medication pass observations: 4
Medication pass observations with unsafe storage: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to medication administration findings and interviews |
| Registered Nurse | Registered Nurse | Interviewed during complaint investigations and medication administration findings |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed during complaint investigations and medication administration findings |
| Pharmacy Technician | Pharmacy Technician | Interviewed during complaint investigations and medication administration findings |
| Unit Manager | Unit Manager | Responsible for corrective actions and monitoring deficiencies |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding range of motion deficiencies |
| Dietary Manager | Dietary Manager | Responsible for corrective actions related to nutrition deficiencies |
| Executive Director | Executive Director | Responsible for corrective actions related to nutrition deficiencies |
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 0
Jun 29, 2016
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that a Certified Nursing Assistant slapped a resident on the face.
Findings
The complaint could not be substantiated after observations, interviews, and record reviews. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00046074 alleged that a Certified Nursing Assistant slapped a resident on the face; this allegation was not substantiated.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 0
Jun 29, 2016
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that a Certified Nursing Assistant slapped a resident on the face.
Findings
The complaint was not substantiated after observation of care, interviews with residents and staff, review of medical records, and facility policies. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00046074 alleged a Certified Nursing Assistant slapped a resident on the face; the allegation was not substantiated.
Report Facts
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 173
Deficiencies: 1
Apr 7, 2016
Visit Reason
The inspection was conducted as a complaint investigation following two complaints alleging staff misconduct and resident discharge delays, as well as failure to provide antibiotic medication for a urinary tract infection.
Findings
Two complaints were investigated; one was substantiated regarding failure to provide antibiotic medication for a urinary tract infection, while the other complaint allegations could not be substantiated. The facility failed to provide appropriate treatment to restore normal bladder function for one resident, resulting in a deficiency.
Complaint Details
Complaint #NV00045367 with allegations of nurse misconduct and delayed resident discharge was not substantiated. Complaint #NV00045495 regarding failure to provide antibiotic medication for a urinary tract infection was substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide antibiotic medication for a urinary tract infection to Resident #2 in a timely manner. | SS=D |
Report Facts
Census: 173
Sample size: 5
Deficiencies cited: 1
Date of completion: May 23, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed failure to clarify medication orders for Resident #2 |
Inspection Report
Complaint Investigation
Census: 173
Deficiencies: 1
Apr 7, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints alleging staff misconduct and failure to provide appropriate care, including failure to provide antibiotic medication for a urinary tract infection.
Findings
Two complaints were investigated; one was substantiated regarding failure to provide antibiotic treatment for a urinary tract infection, while other allegations were not substantiated. The facility failed to provide timely antibiotic treatment for one resident, starting treatment 14 days after admission.
Complaint Details
Complaint #NV00045367 was not substantiated regarding nurse misconduct and delayed discharge. Complaint #NV00045495 was substantiated for failure to provide antibiotic medication for a urinary tract infection. Another allegation of resident neglect was not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide services to restore normal bladder function and timely antibiotic treatment for a urinary tract infection for one resident. | SS=D |
Report Facts
Sample size: 5
Days delay: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed failure to clarify medication orders and acknowledged delay in antibiotic treatment |
Inspection Report
Annual Inspection
Census: 170
Deficiencies: 6
Jan 29, 2016
Visit Reason
This Statement of Deficiencies was generated as a result of a Medicare recertification survey conducted at the facility from 1/26/16 through 1/29/16, in accordance with 42 CFR Part 483 - Requirements for Long Term Care Facilities.
Findings
The survey identified multiple regulatory deficiencies including inconsistent documentation of cardiopulmonary resuscitation (CPR) code status, inadequate assessment and documentation for physical restraints, failure to maintain nutrition status and follow dietitian recommendations for severe weight gain, medication regimen issues including unnecessary drugs and incomplete consents, and a medication administration error rate exceeding 5%.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to show consistency related to cardiopulmonary resuscitation (CPR) code status for 2 of 26 sampled residents. | SS=D |
| Failed to ensure an assessment and documentation for the use of a lap buddy and geri-chair with lap tray were completed for 2 of 26 sampled residents. | SS=D |
| Failed to ensure that the resident environment remains as free of accident hazards as possible; failed to ensure anti-tip devices were appropriately secured to a wheelchair for 1 of 26 residents. | SS=D |
| Failed to ensure acceptable parameters of nutritional status were maintained and dietitian recommendations for medication regimen review were followed to address severe weight gain for 1 of 26 sampled residents. | SS=D |
| Failed to ensure each resident's drug regimen was free from unnecessary drugs and consents for psychotropic medications were complete for sampled residents. | SS=D |
| Failed to maintain a medication administration error rate of five percent or less; calculated error rate was 7.69 percent. | SS=D |
Report Facts
census: 170
sample size: 26
medication administration error rate: 7.69
weight gain percentage: 15.86
weight gain in pounds: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed medication and restraint findings, and clarified medication administration issues | |
| Licensed Nurse (LN) | Involved in medication administration and chart reviews related to deficiencies | |
| Licensed Practical Nurse (LPN) | Participated in resident assessments and documentation reviews | |
| Registered Dietitian (RD) | Provided nutritional assessments and recommendations related to weight gain | |
| Pharmacist | Reviewed medication regimens and provided consultation | |
| Physician Assistant (PA) | Discussed resident weight gain and medication review |
Inspection Report
Annual Inspection
Census: 170
Capacity: 178
Deficiencies: 3
Jan 28, 2016
Visit Reason
The inspection was conducted as a Medicare re-certification and Life Safety Code survey to assess compliance with fire safety and electrical standards at the facility.
Findings
The survey identified multiple deficiencies including improper use of extension cords and daisy chaining of power taps, missing electrical panel schedules, an open junction box with exposed wiring, and incomplete fire watch policies for both sprinkler and fire alarm systems.
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to maintain electrical wiring and equipment according to National Electric Code standards, including use of extension cords as substitutes for fixed wiring and daisy chaining power taps. | SS=E |
| Failure to produce a complete fire watch policy for the sprinkler system, lacking language that fire watch personnel have the sole function of conducting the fire watch. | SS=D |
| Failure to produce a complete fire watch policy for the fire alarm system, lacking language that fire watch personnel have the sole function of conducting the fire watch. | SS=D |
Report Facts
Licensed bed capacity: 178
Resident census: 170
Smoke compartments affected: 4
Inspection Report
Life Safety
Census: 170
Capacity: 178
Deficiencies: 4
Jan 27, 2016
Visit Reason
This inspection was conducted as a Medicare re-certification Life Safety Code (LSC) survey to assess compliance with fire safety standards and electrical wiring requirements at the facility.
Findings
The survey identified multiple deficiencies related to electrical wiring and equipment not meeting National Electrical Code standards, including improper use of extension cords and lack of panel schedules. Additionally, deficiencies were found in the fire watch and fire alarm system policies and procedures, including incomplete fire watch policy and failure to produce a complete fire watch policy for the fire sprinkler system.
Severity Breakdown
Level 1: 1
Level 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Electrical wiring and equipment not maintained according to National Electrical Code standards, including use of daisy chained power taps and missing panel schedules. | Level 1 |
| Failure to maintain a required automatic sprinkler system with proper fire watch policy when out of service for more than 4 hours. | Level 2 |
| Incomplete fire watch policy lacking language that fire watch personnel have the sole function of conducting the fire watch. | Level 2 |
| Failure to produce a complete fire watch policy for the fire alarm system when out of service for more than 4 hours. | Level 2 |
Report Facts
Licensed beds: 178
Census: 170
Deficient smoke compartments: 4
Dates of survey: 2016-01-27 and 2016-01-28
Inspection Report
Annual Inspection
Census: 170
Deficiencies: 1
Jan 26, 2016
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a federal recertification survey at the facility on 1/26/16, to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in maintaining acceptable parameters of nutritional health and medication review related to severe weight gain in one resident. The facility failed to ensure proper nutritional status and dietitian recommendations were followed, resulting in a deficiency related to nutritional health and hydration.
Severity Breakdown
Severity 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure acceptable parameters of nutritional status were maintained and dietitian recommendations for medication regimen review were followed to address severe weight gain for 1 of 26 sampled residents (Resident #25). | Severity 2 |
Report Facts
Census: 170
Sample size: 26
Weight gain percentage: 22.44
Weight gain in pounds: 63
Inspection Report
Annual Inspection
Census: 170
Deficiencies: 1
Jan 26, 2016
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 Chapter 449 for Skilled Nursing Facilities.
Findings
The facility failed to ensure acceptable nutritional health parameters were maintained for Resident #25, who experienced severe weight gain without appropriate interdisciplinary care plan adjustments or adequate physician notification. The clinical record lacked evidence that recommendations from the Registered Dietitian and Pharmacist were reviewed and addressed by the attending physician and psychiatrist, and that nationally recognized standards of practice for Type II Diabetes Mellitus and facility policies were followed.
Severity Breakdown
Scope 1 Severity 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain acceptable nutritional health parameters and follow Dietitian recommendations for medication regimen review to address severe weight gain in Resident #25. | Scope 1 Severity 2 |
Report Facts
Census: 170
Sample size: 26
Weight gain: 63
Weight gain percentage: 15.86
Weight gain percentage: 21.56
A1C laboratory result: 8.9
Fasting glucose: 147
Fasting glucose: 207
Fasting glucose: 277
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant | Physician Assistant | Discussed weight gain issue with nurses and resident; recommended psychiatric and endocrinologist consults |
| Pharmacist | Pharmacist | Explained medication regimen review process and lack of documentation for medication review due to weight gain |
| Pharmacy Manager | Pharmacy Manager | Indicated no request for medication review from the Dietitian was documented |
| Registered Dietitian | Registered Dietitian | Provided nutritional assessments and recommendations for medication review due to weight gain |
Inspection Report
Renewal
Census: 170
Deficiencies: 5
Jan 26, 2016
Visit Reason
This document is a Statement of Deficiencies generated as a result of a Medicare recertification survey conducted from 1/26/16 through 1/29/16 to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found deficient in multiple areas including failure to consistently document cardiopulmonary resuscitation (CPR) code status for sampled residents, failure to ensure assessments and documentation for physical restraints, failure to maintain a safe environment free of accident hazards, failure to maintain acceptable nutritional status for residents, and failure to maintain medication administration error rates below five percent.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to show consistency related to cardiopulmonary resuscitation (CPR) code status for 2 of 26 sampled residents. | SS=D |
| Failure to ensure assessment and documentation for the use of a lap buddy and geri-chair with lap tray for 2 of 26 sampled residents. | SS=D |
| Failure to ensure anti-tip devices were appropriately secured to a wheelchair for 1 of 26 residents. | SS=D |
| Failure to maintain acceptable parameters of nutritional status and follow dietitian recommendations for medication regimen review for 1 of 26 sampled residents. | SS=D |
| Failure to maintain medication administration error rate of five percent or less; calculated error rate was 7.69 percent. | SS=D |
Report Facts
Census: 170
Sample size: 26
Medication administration error rate: 7.69
Medication administration error rate threshold: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged consent did not identify side effects for medication Zoloft and confirmed aspirin medication issues |
| Licensed Nurse | Licensed Nurse | Administered medication and confirmed aspirin medication issues |
| Unit Manager | Unit Manager | Responsible for monitoring corrective actions related to restraints and medication administration |
| Executive Director | Executive Director | Responsible for corrective actions related to medication administration error rates |
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 0
Dec 3, 2015
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegation #NV00044409 regarding a resident neglect claim related to failure to provide supervision while the resident was outside on the patio.
Findings
The complaint was investigated through observations, interviews with staff and residents, medical record reviews, and policy reviews. The allegation of neglect was not substantiated.
Complaint Details
Complaint #NV00044409 alleged neglect due to failure to provide supervision while a resident was outside on the patio. The allegation was not substantiated after investigation.
Report Facts
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed during complaint investigation | |
| Director of Nursing | Interviewed during complaint investigation | |
| Licensed Practical Nurses | Three interviewed during complaint investigation | |
| Certified Nursing Assistants | Two interviewed during complaint investigation | |
| Director of Therapy | Interviewed during complaint investigation | |
| Director of Maintenance | Interviewed during complaint investigation |
Inspection Report
Capacity: 178
Deficiencies: 0
Nov 6, 2015
Visit Reason
This was a State Licensure construction standards survey conducted in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing, focusing on the third phase of a three phase remodeling project.
Findings
The facility was found to be in substantial compliance with all Code requirements following the remodeling project which reduced licensed beds to 178 and included renovations to resident rooms and various facility areas. No further action was required.
Report Facts
Licensed beds: 178
Private resident rooms remodeled: 15
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 0
Apr 29, 2015
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations of a resident sustaining fractures during transfer in the facility van and delayed notification to the resident's spouse.
Findings
The investigation included observations, interviews, and record reviews, and concluded that the allegations could not be substantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00042668 involved two allegations: a resident sustained a shoulder and hip fracture during transfer in the facility van, and the resident's spouse was not notified of the incident for two days. Both allegations were not substantiated.
Report Facts
Number of complaints investigated: 1
Census: 171
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed during the investigation | |
| Director of Activities | Interviewed during the investigation | |
| Director of Nursing | Interviewed during the investigation | |
| Executive Director | Interviewed during the investigation |
Inspection Report
Deficiencies: 4
Feb 20, 2015
Visit Reason
This inspection was conducted as a State Licensure construction standards survey to evaluate compliance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing, focusing on remodeling and construction work in the 400 Wing and Rehabilitation Gym areas.
Findings
The survey identified deficiencies including failure to comply with the 2006 edition of the AIA Guidelines for Design and Construction of Health Care Facilities, inadequate HVAC filtration system with only one filter instead of two per air handling unit, incomplete and untested plumbed-in medical gas and vacuum systems, and lack of approval from the Nevada State Fire Marshal's Office as evidenced by the absence of a Certificate of Compliance.
Deficiencies (4)
| Description |
|---|
| Failure to comply with the 2006 edition of the American Institute of Architects Guidelines for Design and Construction of Health Care Facilities. |
| HVAC filtration system lacked the required two filters per air handling unit; only one MERV 13 filter was installed without pre-filters. |
| Plumbed-in oxygen and vacuum medical gas systems were not completed, tested, or certified prior to final inspection. |
| Facility failed to obtain approval from the Nevada State Fire Marshal's Office; no Certificate of Compliance was issued. |
Report Facts
Number of air handling units inspected: 7
Number of resident rooms with plumbed-in oxygen and suction outlets: 25
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Senior Project Manager | Interviewed regarding HVAC filtration system and medical gas certification |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 7
Dec 4, 2014
Visit Reason
The inspection was conducted as a result of a Medicare recertification survey and complaint investigation, including investigation of two complaints with multiple allegations.
Findings
The investigation found that none of the complaint allegations were substantiated. Several regulatory deficiencies were identified related to residents' rights, self-administration of drugs, dignity and respect, care and services, drug regimen, infection control, and medication records.
Complaint Details
Two complaints were investigated: Complaint NV#00041325 with three allegations (resident dislocated shoulder without treatment, falsified pressure ulcer information, inappropriate level of care) and Complaint NV00041293 with one allegation (inappropriate record keeping). None of the allegations were substantiated.
Severity Breakdown
SS=D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility did not ensure the legal representative for 1 of 25 residents was allowed to exercise rights. | SS=D |
| Facility failed to develop a plan of care and assessment for self-administration of medications for 1 of 25 residents. | SS=D |
| Facility failed to promote care in a manner that maintains dignity and respect for 1 resident. | SS=D |
| Facility failed to provide care/services to attain or maintain highest practicable physical, mental, and psychosocial well-being for multiple residents. | SS=D |
| Facility failed to ensure drug regimen was free from unnecessary drugs for multiple residents. | SS=D |
| Facility failed to secure medications and label/store drugs and biologicals appropriately for multiple residents. | SS=D |
| Facility failed to establish and maintain an infection control program to prevent spread of infection during residents' meal time. | SS=D |
Report Facts
Residents present: 145
Sample size: 25
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during investigation of complaint allegations and named in findings related to consent signatures and corrective actions | |
| Admissions Director | Interviewed during investigation of complaint allegations | |
| Patient Care Manager | Interviewed during investigation of complaint allegations | |
| Unit Manager | Named in findings related to hospice documentation, medication administration errors, and audits | |
| Licensed Practical Nurse | Observed feeding resident and named in findings related to care | |
| Certified Nursing Assistant | Observed feeding resident and named in findings related to care and medication administration | |
| Executive Director | Named as individual responsible for corrective actions | |
| Director of Staff Development | Conducted in-service on food handling practices | |
| Treatment Nurse | Explained wound care ointment use | |
| Physician Assistant | Acknowledged wound care ointment use |
Inspection Report
Annual Inspection
Census: 145
Deficiencies: 7
Dec 4, 2014
Visit Reason
The inspection was conducted as a Medicare recertification survey and complaint investigation at the facility on 12/4/2014.
Findings
The survey included investigation of two complaints which were not substantiated. Multiple deficiencies were identified including failure to ensure legal representatives exercised resident rights, lack of self-administration medication plans, inadequate feeding practices, poor coordination of hospice care, failure to follow physician orders, incomplete neurological assessments after falls, improper medication administration, failure to monitor psychotropic and hypnotic drug effects, medication storage and labeling issues, and infection control lapses during meal times.
Complaint Details
The survey included investigation of two complaints (NV#00041325 and NV00041293) with multiple allegations including untreated dislocated shoulder, falsified pressure ulcer information, inappropriate level of care, and insufficient documentation of assistance to bed. None of the allegations were substantiated.
Severity Breakdown
SS=D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility did not ensure the legal representative for 1 of 25 residents was allowed to exercise the rights for the resident. | SS=D |
| Facility failed to develop a plan of care and assessment for self administration of medications for 1 of 25 residents. | SS=D |
| Facility failed to ensure a resident was fed slowly to allow adequate time for chewing and swallowing for 1 resident. | SS=D |
| Facility failed to ensure care was coordinated between nursing facility and hospice services for 3 residents; failed to follow physician orders for 2 residents; and failed to ensure neurological assessments were completed following falls for 1 resident. | SS=D |
| Facility failed to ensure residents receiving hypnotic and psychotropic medications were properly monitored and failed to administer medication in accordance with physician's order for 1 resident. | SS=D |
| Facility failed to secure medications for 1 resident and failed to label a prescribed medication appropriately for 1 resident while out on pass. | SS=D |
| Facility failed to ensure proper infection control procedures were followed during residents' meal time. | SS=D |
Report Facts
Sample size: 25
Closed records reviewed: 3
Medication error: 200
Residents with deficiencies: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding complaint investigations and acknowledged consent forms should have been signed by guardian | |
| Admissions Director | Interviewed during complaint investigations | |
| Patient Care Manager | Interviewed during complaint investigations | |
| Social Services Director | Interviewed regarding consent forms and guardianship | |
| Unit Manager | Responsible for hospice care coordination and medication error reporting | |
| Registered Nurse | Observed medication administration and acknowledged medication labeling error | |
| Licensed Practical Nurse | Observed feeding practices and medication administration | |
| Certified Nursing Assistant | Observed feeding practices and infection control lapses during meal service | |
| Wound Care Consultant/Physician Assistant | Acknowledged inappropriate use of A&D ointment | |
| Treatment Nurse | Explained use of A&D ointment packets |
Inspection Report
Life Safety
Census: 148
Capacity: 239
Deficiencies: 3
Dec 2, 2014
Visit Reason
The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety standards at the facility.
Findings
The facility was found deficient in maintaining automatic sprinkler systems, protecting fire department connections, sealing penetrations in smoke barriers, and ensuring electrical wiring compliance with NFPA standards. These deficiencies posed risks to residents, staff, and visitors.
Severity Breakdown
SS=F: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to protect openings on the Fire Department's Connection, increasing risk of obstruction to emergency water and pressure. | SS=F |
| Penetrations of smoke barriers by ducts were not properly sealed, affecting occupants of two smoke compartments. | SS=D |
| Flexible wiring was plugged into additional flexible wiring creating a 'mixed daisy chain' violating UL listing and potentially overloading circuits. | SS=D |
Report Facts
Licensed beds: 239
Census: 148
Deficiency observation time: 1405
Deficiency observation time: 1450
Deficiency observation time: 1510
Plan of correction completion date: Jan 12, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named as individual responsible for corrective actions | |
| Environmental Services Director | Named as individual responsible for corrective actions | |
| Administrator | Informed of findings during exit interview | |
| Director of Environmental Services | Informed of findings during exit interview | |
| Director of Nursing | Informed of findings during exit interview | |
| Regional Representative for Clinical Services | Informed of findings during exit interview | |
| Maintenance Director | Responsible for corrective actions such as caulking and removing extension cords | |
| Maintenance Team | Conducted facility safety sweeps and environmental rounds |
Inspection Report
Life Safety
Census: 148
Capacity: 239
Deficiencies: 3
Dec 2, 2014
Visit Reason
The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety standards at the facility.
Findings
The survey identified multiple deficiencies related to fire safety, including a damaged cap on the Fire Department's Connection, unsealed penetrations in smoke barrier walls, and improper use of flexible wiring creating a daisy chain, all of which could affect residents, staff, and visitors.
Severity Breakdown
SS=F: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to protect openings on the Fire Department's Connection, increasing risk of obstruction to emergency water supply. | SS=F |
| Penetrations in fire/smoke barrier walls were not properly sealed to resist smoke passage, affecting two of four smoke compartments. | SS=D |
| Flexible wiring was plugged into additional flexible wiring, creating a 'mixed daisy chain' and potentially overloading circuits. | SS=D |
Report Facts
Licensed beds: 239
Census: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Environmental Services | Named in relation to findings shared during exit interview | |
| Director of Nursing | Named in relation to findings shared during exit interview | |
| Administrator | Named in relation to findings shared during exit interview | |
| Regional Representative for Clinical Services | Named in relation to findings shared during exit interview | |
| Director of Maintenance | Provided information about the fire/smoke barrier penetration |
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 2
Sep 30, 2014
Visit Reason
The inspection was conducted as a complaint investigation following two complaints (#40527 and #40291) regarding medication administration issues at the facility.
Findings
The facility was found to have failed to ensure medications were administered as prescribed for 3 of 5 residents reviewed, with substantiated complaints related to missed medications and improper medication administration practices. Infection control deficiencies were also identified related to medication cart hygiene and hand hygiene practices.
Complaint Details
Complaint #40527 contained 2 allegations: 1) A resident did not receive prescribed eye drops or vitamin C on 4/14/14 (substantiated), 2) A resident did not receive Comtan and Sinemet medications as prescribed (not substantiated). Complaint #40291 contained 1 allegation: A resident did not receive medications on 8/18/14 and 8/19/14 as ordered by the physician (substantiated).
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure medications were administered as ordered by the physician for 3 of 5 residents. | SS=D |
| Failure to follow infection control policies related to cleaning blood pressure cuffs and stethoscopes and proper hand hygiene during medication administration. | SS=D |
Report Facts
Census: 156
Sample size: 5
Residents with medication administration issues: 3
Residents sampled for infection control deficiencies: 5
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 2
Sep 30, 2014
Visit Reason
The inspection was conducted as a result of complaint investigations related to medication administration and infection control at the facility.
Findings
The facility failed to ensure medications were administered as ordered for 3 of 5 residents, failed to document missed medications properly, and did not follow infection control policies regarding handling of medications and cleaning reusable equipment.
Complaint Details
Complaint #40527 contained 2 allegations: one substantiated regarding missed eye drops or vitamin C on 4/14/14, and one unsubstantiated regarding missed Comtan and Sinemet medications. Complaint #40291 contained one substantiated allegation that a resident did not receive medications on 8/18/14 and 8/19/14 as ordered.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure medications were given to residents as ordered by the physician for 3 of 5 residents. | SS=D |
| Failed to establish and maintain an infection control program to prevent spread of infection, including failure to discard medications that fell from dispensing containers and failure to clean reusable equipment. | SS=D |
Report Facts
Census: 156
Sample size: 5
Medication doses missed: 3
Inspection Report
Complaint Investigation
Census: 155
Deficiencies: 1
Jul 29, 2014
Visit Reason
This inspection was conducted as a result of a Medicare complaint survey triggered by complaint #NV00039724 alleging that medication was not administered as ordered, resulting in a resident having seizures and being admitted to an acute care facility.
Findings
The facility failed to ensure medications were administered as per physician orders for 3 of 5 sampled residents, including residents #2, #3, and #5. Deficiencies were related to medication administration errors, missing documentation, and failure to follow facility policies and procedures.
Complaint Details
Complaint #NV00039724 alleged medication was not administered as ordered and resulted in a resident having seizures and being admitted to acute care. The allegation was substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to provide care/services for highest well being as evidenced by medication administration errors for 3 of 5 sampled residents. |
Report Facts
Census: 155
Sample size: 5
Deficient residents: 3
Date survey completed: Aug 12, 2014
Date survey conducted: Jul 29, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication administration and corrective actions |
| Director of Nurses | Director of Nurses | Interviewed regarding medication administration and corrective actions |
Inspection Report
Complaint Investigation
Census: 155
Deficiencies: 3
Jul 29, 2014
Visit Reason
The inspection was conducted as a Medicare complaint survey triggered by complaint #NV00039724 alleging medication was not administered as ordered, resulting in a resident having seizures and being admitted to an acute care facility.
Findings
The facility failed to ensure medications were administered as per physician orders for 3 of 5 sampled residents, including missed seizure medications and delayed administration, which was substantiated by medical record reviews, interviews, and policy reviews.
Complaint Details
Complaint #NV00039724 was substantiated; the allegation that medication was not administered as ordered resulting in seizures and hospital admission was confirmed.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to administer medications as ordered for Resident #2, including seizure medications, resulting in seizures and hospital transfer. | SS=D |
| Failure to administer seizure medications as ordered for Resident #3, with multiple missed doses documented. | SS=D |
| Failure to administer Klonopin as ordered for Resident #5, with documented medication holds and no administration until several days later. | SS=D |
Report Facts
Sample size: 5
Census: 155
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses | Interviewed regarding medication administration failures |
| Assistant Director of Nurses | Assistant Director of Nurses | Interviewed regarding medication administration failures |
Inspection Report
Life Safety
Census: 176
Capacity: 239
Deficiencies: 4
Feb 27, 2014
Visit Reason
The inspection was conducted as a Life Safety Code (LSC) survey to evaluate compliance with NFPA 101 standards for existing health care occupancies.
Findings
The facility was found to have multiple deficiencies related to life safety code standards, including obstructed access to a fire alarm pull station, improperly located and corroded sprinkler heads, and a non-functioning remote Emergency Power Supply (EPS) annunciator.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| One fire alarm pull station had obstructed access due to a table and chair placed in front of it in the Rehabilitation Gym. | SS=D |
| One sprinkler head in the Rehabilitation Gym storeroom was located just five and one-half inches above a light fixture, violating positioning requirements. | SS=D |
| Two sprinkler escutcheons near the dishwashing machine in the Dietary Department were heavily corroded. | SS=D |
| The remote EPS annunciator at the 200 Hall Nurses Station was not functioning due to a disconnected ground wire. | SS=D |
Report Facts
Licensed bed capacity: 239
Resident census: 176
Inspection dates: 2
Generator exercise time: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Environmental Services | Removed the annunciator's face plate and discovered the disconnected ground wire causing the remote EPS annunciator malfunction |
Inspection Report
Complaint Investigation
Census: 175
Deficiencies: 15
Feb 26, 2014
Visit Reason
The inspection was conducted as a Medicare recertification survey combined with a complaint investigation initiated due to allegations regarding family notification of change of condition, resident falls, and anti-psychotic use.
Findings
The facility was found to have multiple deficiencies including failure to notify family of changes in condition, inadequate documentation for transfers and discharges, improper use and monitoring of physical restraints, failure to ensure resident dignity and privacy, inadequate care and services for residents, and unsafe environmental conditions such as unsafe water temperatures.
Complaint Details
Complaint NV#00038064 was investigated. The complaint regarding family notification of change of condition, resident falls, and anti-psychotic use were substantiated. The allegation regarding call lights not being answered was not substantiated.
Severity Breakdown
Severity: 2: 1
Severity: 3: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Facility failed to provide notification to the resident's family of community medical appointments for 1 of 42 sampled residents. | — |
| Facility failed to obtain a physician order for discharge for 1 of 3 discharged sampled residents. | — |
| Facility failed to ensure consent was received before a physical restraint was used for 1 of 42 sampled residents; failed to ensure a tab alarm was used as ordered for 1 of 42 sampled residents; and failed to ensure reassessment was completed for the appropriateness of a physical restraint for 1 of 42 sampled residents. | — |
| Facility failed to ensure staff knocked prior to entering occupied resident rooms, failed to provide privacy during treatment and medication administration for two unsampled residents, and failed to ensure privacy for 1 of 42 sampled residents. | — |
| Facility failed to ensure dietary supplements were administered according to physician orders for 1 of 42 sampled residents. | — |
| Facility failed to ensure appropriate treatment to prevent further decrease in range of motion for 1 of 42 sampled residents. | — |
| Facility failed to provide psychological services for 2 of 42 sampled residents. | — |
| Facility failed to ensure adequate supervision to prevent accidents for 1 of 42 sampled residents; failed to initiate a care plan for 2 of 42 residents after falls; failed to ensure medication cart was secured; and failed to ensure sharps containers were emptied when full. | — |
| Facility failed to maintain acceptable nutritional status for 1 of 42 sampled residents and failed to follow physician orders for dietary consults. | — |
| Facility failed to ensure residents received oxygen in accordance with physician orders for 3 of 42 sampled residents. | — |
| Facility failed to ensure residents' drug regimens were free from unnecessary drugs and failed to monitor side effects and behaviors related to psychotropic medications for multiple residents. | — |
| Facility failed to maintain sanitary conditions in nourishment room and kitchen, including improper food storage and unsanitary equipment. | Severity: 2 |
| Facility failed to maintain safe hot water temperatures in resident bathrooms, with temperatures exceeding safe limits. | Severity: 3 |
| Facility failed to ensure timely notification of abnormal laboratory results to the physician for 1 of 42 sampled residents. | — |
| Facility failed to ensure medication error rates were less than five percent. | — |
Report Facts
Census: 175
Sample size: 42
Closed records reviewed: 3
Severity 2 deficiencies: 1
Severity 3 deficiencies: 1
Inspection Report
Life Safety
Census: 176
Capacity: 239
Deficiencies: 4
Feb 26, 2014
Visit Reason
This Life Safety Code survey was conducted to assess compliance with fire safety standards, including fire alarm systems, sprinkler systems, and emergency power supply annunciators.
Findings
The facility was found to have multiple deficiencies related to fire safety, including obstructed fire alarm pull stations, improperly located and corroded sprinkler heads, and a non-functioning remote EPS annunciator. Corrective actions were planned and initiated immediately.
Deficiencies (4)
| Description |
|---|
| Fire alarm pull station was obstructed by a table and chair in the Rehabilitation Gym. |
| One sprinkler head in the Rehabilitation Gym storeroom was improperly located just above a light fixture. |
| Two sprinkler escutcheons near the dishwashing machine were heavily corroded. |
| Remote EPS annunciator at the 200 Hall Nurses Station had a loose horn and was not functioning due to disconnected ground wire. |
Report Facts
Licensed beds: 239
Census: 176
Date of Completion: Apr 25, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| W. W. Williams | Outside contractor | Responsible for quarterly inspection of EPS annunciators |
| Executive Director | Individual responsible for corrective actions and monitoring | |
| Maintenance Director | Responsible for implementing corrective actions related to fire safety deficiencies | |
| Director of Environmental Services | Removed annuciator's face plate and discovered disconnected ground wire |
Inspection Report
Complaint Investigation
Census: 175
Deficiencies: 11
Feb 25, 2014
Visit Reason
The inspection was conducted as a result of a Medicare recertification survey and a complaint investigation initiated on 2/25/2014, focusing on issues including unsafe water temperatures and investigation of one complaint.
Findings
The survey identified multiple deficiencies including failure to notify family of changes in health status, inadequate documentation for transfers and discharges, improper use of physical restraints, failure to ensure privacy and dignity, medication administration errors, failure to prevent weight loss, and unsafe environmental conditions such as unsafe water temperatures.
Complaint Details
Complaint #NV00038064 was investigated. The complaint allegations regarding family notification of change of condition, resident falls, and anti-psychotic were substantiated. The allegation regarding call lights was not substantiated.
Severity Breakdown
F 154: 1
F 202: 1
F 221: 1
F 241: 1
F 318: 1
F 319: 1
F 323: 1
F 325: 1
F 328: 1
F 332: 1
F 465: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to provide notification to resident's family of community medical appointments for 1 of 42 sampled residents (Resident #17). | F 154 |
| Failure to obtain a physician order for discharge for 1 of 3 discharged sampled residents (Resident #19). | F 202 |
| Failure to ensure consent was received before a physical restraint was used for 1 of 42 sampled residents (Resident #13). | F 221 |
| Failure to ensure staff knocked prior to entering an occupied resident room and failed to ensure privacy while providing treatment and medication for two unsampled residents (Residents #45, #46) and failed to ensure privacy for 1 of 42 sampled residents (Resident #7). | F 241 |
| Failure to ensure dietary supplements were administered as ordered and to prevent decrease in range of motion for 1 of 42 sampled residents (Resident #2). | F 318 |
| Failure to provide psychological services for 2 of 42 sampled residents (Residents #21 and #22). | F 319 |
| Failure to ensure adequate supervision to prevent accidents and failure to update care plans for 2 of 42 sampled residents (Residents #17 and #19). | F 323 |
| Failure to maintain nutrition status and prevent weight loss for Resident #11. | F 325 |
| Failure to provide proper treatment and care for residents receiving oxygen and respiratory care for 3 of 42 sampled residents (Residents #13, #20, #43). | F 328 |
| Failure to ensure medication error rate was less than 5% for Resident #26. | F 332 |
| Failure to maintain safe, functional, sanitary, and comfortable environment including unsafe water temperatures in resident rooms and public bathrooms. | F 465 |
Report Facts
Census: 175
Sample size: 42
Deficiency count: 11
Medication error rate: 24.3
Water temperature: 125.9
Water temperature: 120
Inspection Report
Complaint Investigation
Census: 182
Deficiencies: 0
Sep 25, 2013
Visit Reason
The inspection was conducted as a Medicare complaint survey initiated by the Nevada State Health Division on 9/24/13 to investigate two complaints regarding discharge planning and allegations of neglect.
Findings
Both complaints were found to be unsubstantiated after review of clinical records, policies, and interviews with facility staff and other involved parties.
Complaint Details
Complaint # NV00036720 alleging poor discharge planning and a resident being "kicked out in the street" was unsubstantiated. Complaint # NV00036699 alleging neglect related to dehydration, malnourishment, and inadequate monitoring was also unsubstantiated.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 211
Deficiencies: 1
Jul 1, 2013
Visit Reason
The inspection was conducted as a result of complaint investigations on June 17, 2013 and July 1, 2013, regarding allegations including improper medication administration, dirty environment, poor quality linen, lack of care equipment, incorrect discharge, and refusal to readmit a resident.
Findings
The complaint investigations were largely unsubstantiated except for a deficiency cited at F 281 related to improper administration and documentation of medications, specifically failure to clarify physician orders regarding medication routes and improper alteration of medication administration records for residents with enteral feeding tubes.
Complaint Details
Complaint #NV00035672 involved review of medical records and enteral administration of food and medications; complaint was unsubstantiated but deficiency cited. Complaint #NV35815 involved allegations of dirty environment and lack of care; unsubstantiated. Complaint #NV00034212 involved refusal to readmit a resident from acute care; unsubstantiated.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure clinical care staff performed standards of practice for clarification of physician orders regarding proper medications to be crushed, appropriate medications to be administered by enteral routes, and proper alteration of medication administration records for 11 of 19 residents with enteral feeding tubes. | SS=E |
Report Facts
Active census: 211
Sample size: 31
Residents with enteral feeding tubes: 18
Residents with medication deficiencies: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed during complaint investigations | |
| Director of Nursing | Interviewed and confirmed facility had 18 residents with enteral feeding tubes; acknowledged lack of policy for crushing medications without physician order | |
| Assistant Director of Nursing | Interviewed during complaint investigations | |
| Speech Therapist | Interviewed during complaint investigations | |
| Physician of record | Interviewed during complaint investigations | |
| Employee #6 | Nurse Manager | Confirmed nursing staff responsibility to clarify medication orders |
| Employee #8 | Licensed or Registered Nurse | Administered medications for Resident #2 per enterostomy tube |
| Employee #9 | Licensed or Registered Nurse | Administered medications for Resident #2 per enterostomy tube |
| Employee #10 | Licensed or Registered Nurse | Administered medications for Resident #2 per enterostomy tube |
| Employee #11 | Licensed or Registered Nurse | Administered medications for Resident #2 per enterostomy tube |
| Employee #18 | Nurse | Confirmed nurses should have clarified medication route for Resident #13 |
Inspection Report
Complaint Investigation
Census: 205
Deficiencies: 0
Mar 27, 2013
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by allegations including misappropriation and damage of a resident's property by a Certified Nursing Assistant, improper resident transfer without appropriate infection control measures and durable medical equipment, and lack of family involvement in resident care.
Findings
The investigation found that none of the allegations could be substantiated based on interviews with facility staff, clinical record reviews, and policy reviews. No deficiencies were identified during the investigation.
Complaint Details
Three complaints were investigated: 1) Allegation of misappropriation and damage of resident property by a Certified Nursing Assistant, which was not substantiated. 2) Allegation of improper resident transfer and lack of infection control and durable medical equipment, which was not substantiated. 3) Allegation that the facility did not actively involve a resident's family member in care, which was not substantiated.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 207
Deficiencies: 4
Feb 13, 2013
Visit Reason
This complaint survey was conducted as a result of a Medicare complaint investigation initiated by the Nevada State Health Division on 2/13/13, related to complaint #NV 00034326 containing 5 allegations.
Findings
The investigation found multiple deficiencies including failure to ensure call lights were answered timely for 10 of 23 residents, incomplete and inaccurate clinical records, failure to develop and follow comprehensive care plans for sampled residents, and failure to provide care meeting professional standards such as Foley catheter care and medication administration documentation. The complaint was substantiated.
Complaint Details
Complaint #NV 00034326 contained 5 allegations. The complaint was substantiated. Allegations included failure to attend to resident needs timely, failure to ensure dignity and respect, failure to develop and follow care plans, and failure to maintain accurate clinical records.
Severity Breakdown
SS=E: 2
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure call lights were answered timely for 10 of 23 residents and staff failed to knock and announce themselves prior to entering resident rooms. | SS=E |
| Facility failed to develop comprehensive care plans for residents and failed to follow care plans for 4 of 5 sampled residents. | SS=E |
| Facility failed to provide services meeting professional standards including Foley catheter care and medication administration documentation for sampled residents. | SS=D |
| Facility failed to maintain complete, accurate, and accessible clinical records for 2 of 5 sampled residents. | SS=D |
Report Facts
Census: 207
Sample size: 5
Residents with call light issues: 10
Residents with care plan issues: 4
Residents with clinical record issues: 2
Allegations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to inability to verify care plan adherence and medication administration documentation |
| Certified Nursing Assistant | CNA | Mentioned in relation to call light response and resident assistance |
| Licensed Nurse | Licensed Nurse (LN) | Mentioned in relation to call light response and clinical record documentation |
Inspection Report
Complaint Investigation
Census: 207
Deficiencies: 4
Feb 13, 2013
Visit Reason
The inspection was conducted as a Medicare complaint survey initiated by the Nevada State Health Division on 2/13/13 to investigate complaint #NV 00034326 containing 5 allegations regarding resident care and facility practices.
Findings
The facility was found to have substantiated deficiencies including failure to timely answer call lights for multiple residents, failure to follow care plans for repositioning and catheter care, incomplete and inaccurate clinical records, and failure to provide care in accordance with physician orders.
Complaint Details
Complaint # NV 00034326 was substantiated. The complaint contained 5 allegations including failure to attend to resident needs timely, worsening pressure sores, failure to provide water, and failure to turn and reposition residents. The investigation included review of clinical records, interviews, and observations.
Severity Breakdown
SS=E: 2
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure call lights were answered timely for 10 of 23 residents and failure to ensure staff knocked and announced themselves prior to entering occupied resident rooms. | SS=E |
| Failure to develop and follow comprehensive care plans for residents, including repositioning and catheter care for 4 of 5 sampled residents. | SS=E |
| Failure to provide services that meet professional standards, including failure to follow physician's orders for repositioning and catheter care. | SS=D |
| Failure to maintain complete, accurate, and accessible clinical records for 2 of 5 sampled residents, including missing documentation of vital signs prior to medication administration and incomplete medication administration records. | SS=D |
Report Facts
Residents with call light issues: 10
Sample size: 5
Resident census: 207
Medication administration missing documentation: 7
Repositioning documentation missing: 4
Inspection Report
Re-Inspection
Census: 185
Deficiencies: 0
Sep 7, 2012
Visit Reason
This document is a Medicare re-visit survey conducted as a follow-up to a Medicare Complaint Investigation survey completed on 2012-07-12.
Findings
No deficiencies were identified during this re-visit survey.
Complaint Details
The re-visit survey was conducted following a Medicare Complaint Investigation survey.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Census: 202
Deficiencies: 1
Aug 30, 2012
Visit Reason
The inspection was conducted as a complaint investigation survey initiated on 2012-08-07 and finalized on 2012-08-30, triggered by four complaints regarding resident care and facility practices.
Findings
The investigation substantiated several allegations including failure to identify and monitor a resident who became unresponsive, dietary assessment issues, lack of notification to hospice upon resident transfer, and pain medication management deficiencies. Other allegations such as lack of fluids, pest infestation, dignity and respect issues, and incontinence care were not substantiated.
Complaint Details
Four complaints were investigated: #NV00032505, #NV00032751, #NV00032465, and #NV00032399. Complaints #NV00032505, #NV00032751, and #NV00032465 were substantiated, while #NV00032399 was not substantiated.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING - Facility failed to ensure hospice was notified upon resident transfer, provide accurate and thorough pain assessments, and ensure continuous monitoring and assessment of residents with changes in condition. | SS=B |
Report Facts
Resident census: 202
Sample size: 7
Complaint count: 4
Pain assessment sample: 3
Weight records dates: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to identify and monitor resident, dietary assessment, hospice notification, and pain medication management |
| Administrator | Administrator | Interviewed regarding pest infestation allegation and hospice notification policy |
Inspection Report
Complaint Investigation
Census: 202
Deficiencies: 4
Aug 30, 2012
Visit Reason
The inspection was conducted as a complaint investigation survey initiated on 2012-08-07 and finalized on 2012-08-30, triggered by four complaints regarding resident care and facility conditions.
Findings
The facility was found to have substantiated deficiencies including failure to notify hospice upon resident transfer, inadequate pain assessments for multiple residents, inaccurate dietary assessments related to significant weight gain, and failure to continuously monitor and assess a resident with a change in condition. Several allegations such as lack of fluids, pest infestation, and dignity issues were not substantiated.
Complaint Details
Four complaints were investigated: #NV00032505 substantiated failure to identify, assess, and monitor a resident who became unresponsive; #NV00032751 substantiated dietary assessment issues; #NV00032465 substantiated lack of notification to hospice and pain medication issues; #NV00032399 not substantiated regarding dignity and respect concerns.
Severity Breakdown
SS=B: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure hospice representative was contacted upon resident transfer to acute care for blood transfusion. | SS=B |
| Failure to provide accurate and thorough pain assessments for multiple residents. | SS=B |
| Failure to provide accurate dietary assessment information for a resident with significant weight gain. | SS=B |
| Failure to continuously monitor and assess a resident with a change in condition. | SS=B |
Report Facts
Census: 202
Sample size: 7
Complaints investigated: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding multiple substantiated complaints and deficiencies | |
| Administrator | Interviewed regarding hospice notification and complaint substantiation | |
| Director of Central Supplies | Interviewed regarding incontinence care and supply availability |
Inspection Report
Complaint Investigation
Census: 218
Deficiencies: 2
Jul 5, 2012
Visit Reason
This complaint investigation was conducted as a result of a Medicare complaint survey initiated by the Bureau of Health Care Quality and Compliance on July 5, 2012, regarding allegations of improper fall prevention procedures and a patient receiving the wrong diet.
Findings
The investigation substantiated the complaint that the facility failed to follow proper fall prevention procedures for three sampled residents, including inadequate documentation and implementation of fall risk assessments and interventions. The allegation regarding a patient receiving the wrong diet was not substantiated.
Complaint Details
The complaint was substantiated. CPT # NV 00031961 contained two allegations: 1) The facility did not follow proper fall prevention procedures (substantiated). 2) A patient had received the wrong diet (not substantiated).
Severity Breakdown
Severity 3: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 3 of 3 sampled residents were provided fall prevention measures in accordance with the facility's policy. | Severity 3 |
| Facility failed to ensure clinical records for 2 of 3 sampled residents were accurate and complete. | — |
Report Facts
Residents present: 218
Fall risk scores: 18
Fall risk scores: 19
Fall risk scores: 20
Fall risk score: 22
Dates: Jul 23, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named as individual responsible for corrective actions and fall prevention program oversight |
| Executive Director | Executive Director | Named as individual responsible for corrective actions and fall prevention program oversight |
Inspection Report
Complaint Investigation
Census: 218
Deficiencies: 2
Jul 5, 2012
Visit Reason
The inspection was conducted as a result of a Medicare complaint survey initiated by the Bureau of Health Care Quality and Compliance on July 5, 2012, to investigate two allegations regarding fall prevention procedures and diet orders.
Findings
The complaint was substantiated with findings that the facility failed to follow proper fall prevention procedures for three sampled residents and failed to ensure clinical records were accurate and complete. The allegation that a patient received the wrong diet was not substantiated.
Complaint Details
The complaint was substantiated. CPT # NV 00031961 contained two allegations: 1) failure to follow proper fall prevention procedures (substantiated), and 2) a patient received the wrong diet (not substantiated).
Severity Breakdown
Severity 3: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility did not follow proper fall prevention procedures as evidenced by failure to ensure 3 of 3 sampled residents were provided fall prevention measures according to facility policy. | Severity 3 |
| The facility failed to ensure clinical records were accurate and complete for 2 of 3 sampled residents. | — |
Report Facts
Census: 218
Fall Risk Scores: 18
Fall Risk Scores: 19
Fall Risk Scores: 20
Fall Risk Scores: 20
Fall Risk Scores: 22
Deficiency Count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed and confirmed lack of documentation and failure to follow fall prevention policy |
| Employee #3 | Unit Manager | Responsible for ensuring the Falling Star Program was followed and fall risk measures were in place |
| Licensed Nurse | Licensed Nurse (LN) | Interviewed regarding fall risk assessments and tab alarm orders |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Provided care to residents and verbalized fall risk program details |
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 1
Jun 13, 2012
Visit Reason
The inspection was conducted as a complaint investigation survey from 2012-03-02 through 2012-06-13, triggered by six complaints regarding wound care, weight loss, grooming, medication reimbursement, unsafe discharge, medication administration, referral to endocrinologist, open flame in room, involuntary discharge, and discharge and re-admission rights.
Findings
Most allegations were not substantiated except for one complaint regarding an unsafe discharge of a resident to a second story home without adequate caregiver support, which was substantiated based on clinical record review, interviews, and policy review. The facility failed to ensure a safe discharge for one resident who required 24-hour care but was discharged to an elderly frail caregiver unable to provide adequate assistance.
Complaint Details
Six complaints were investigated. Five complaints regarding improper wound care, lack of appropriate wound care, lack of care related to weight loss, lack of grooming, failure to reimburse for lost/stolen medications, unsafe discharge to a second story home, inappropriate medication administration, lack of referral to endocrinologist, patient's right to have open flame, involuntary discharge, and inappropriate discharge and re-admission rights were not substantiated. One complaint (#NV00030469) regarding unsafe discharge was substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure a safe and orderly discharge for one resident who required total assistance and 24-hour care but was discharged to an elderly frail caregiver unable to provide adequate support. | SS=D |
Report Facts
Sample size: 8
Number of complaints investigated: 6
Resident age: 98
Discharge date: Jan 6, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Licensed Social Worker | LSW who did not follow up to ensure 24-hour care was in place for discharged resident |
| Employee #2 | Licensed Social Worker | Interviewed regarding Resident #1's discharge and care needs |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 2, 2012
Visit Reason
The inspection was conducted as a complaint investigation survey initiated by the Bureau of Health Care Quality and Compliance on multiple complaints received on 3/2/12 and 5/2/12 regarding various allegations including wound care, medication administration, discharge safety, and reimbursement issues.
Findings
The investigation found that most allegations, such as improper wound care, lack of appropriate wound care, lack of care related to weight loss, grooming, medication administration, referral to specialists, open flame rights, involuntary discharge, and inappropriate discharge and re-admission rights, could not be substantiated. However, the allegation regarding an unsafe discharge was substantiated due to failure to ensure safe discharge for one resident.
Complaint Details
Six complaints were investigated, all initiated by the Bureau of Health Care Quality and Compliance between 3/2/12 and 5/2/12. Most allegations were not substantiated except for one complaint (#NV00030469) regarding unsafe discharge which was substantiated based on clinical record review, interviews, and policy review.
Severity Breakdown
F 204 SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide sufficient preparation and orientation to ensure safe and orderly transfer or discharge for one resident (Resident #1). | F 204 SS=D |
Report Facts
Sample size: 8
Complaints investigated: 6
Resident age: 98
Date of discharge: Jan 6, 2012
Date of completion: Jul 27, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Social Worker | Interviewed during complaint investigations and involved in assessment and follow-up related to discharge planning and resident care | |
| Director of Nursing | Interviewed during complaint investigations and involved in review of clinical records and policies | |
| Administrator | Interviewed during complaint investigations and involved in review of policies and procedures | |
| Social Services Director | Responsible for auditing discharged residents' charts and ensuring corrective actions are implemented | |
| Executive Director | Executive Director | Named as individual responsible for corrective action completion |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 20, 2012
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on January 20, 2012, based on complaint #NV00030213 which contained four allegations regarding nurse behavior, Foley catheter care, call light response, and resident supervision.
Findings
The complaint was substantiated for the allegation that the facility failed to obtain physicians' orders for Foley catheter care and failed to document catheter care properly for multiple residents. Other allegations regarding nurse verbal abuse, call light response, and resident wandering were unsubstantiated. The facility was cited for deficiencies related to not following policies on physician orders and documentation of care.
Complaint Details
Complaint #NV00030213 contained four allegations: (1) nurse verbal abuse during Foley catheter change (unsubstantiated), (2) wrong Foley catheter size and delayed catheter change (substantiated), (3) call lights not answered timely (unsubstantiated), and (4) residents wandering unsupervised (unsubstantiated). The complaint was substantiated based on allegation #2.
Severity Breakdown
SS=C: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility nurses failed to obtain physicians' orders for Foley catheter care for multiple residents and failed to document catheter care properly. | SS=C |
| Facility failed to maintain complete, accurate, and accessible clinical records for residents, including documentation of catheter care. | SS=C |
Report Facts
Residents affected: 19
Residents with missing physician orders: 13
Residents with undocumented catheter care: 12
Residents with amended medical records: 1
Date of completion: March 26, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Confirmed catheter care documentation and physician orders during investigation | |
| Employee #5 | Signed off catheter care records and admitted signing off catheter care before leaving facility during investigation | |
| Director of Nursing | Director of Nursing | Indicated physicians ordered Foley catheters and catheter care should be documented |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 20, 2012
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on January 20, 2012, based on Complaint #NV00030213 which contained four allegations regarding resident care and supervision.
Findings
The complaint investigation substantiated that the facility failed to obtain physicians' orders for Foley catheters and catheter care for multiple residents, failed to document catheter care performed, and improperly amended a medical record. Other allegations regarding verbal abuse, call light response, and resident supervision were unsubstantiated.
Complaint Details
Complaint #NV00030213 contained four allegations: verbal abuse by nurses (unsubstantiated), wrong Foley catheter size and delayed catheter change (substantiated), untimely call light response (unsubstantiated), and unsupervised wandering residents (unsubstantiated).
Severity Breakdown
SS=C: 2
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility nurses failed to obtain physicians' orders for Foley catheters and catheter care for multiple residents, failed to document catheter care performed, and improperly amended a medical record. | SS=C |
Report Facts
Residents with Foley catheter care issues: 19
Residents lacking physician orders for Foley catheter care: 13
Residents lacking documentation of catheter care performed: 12
Residents with amended medical record not following policy: 1
Allegations in complaint: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Confirmed necessity of physician orders for Foley catheters and catheter care; called Employee #5 regarding documentation issues | |
| Employee #5 | Signed off catheter care documentation before care was completed and admitted to signing off early during on-site investigation | |
| Director of Nursing | Director of Nursing | Indicated physicians ordered Foley catheters and catheter care should be documented |
Inspection Report
Annual Inspection
Census: 201
Deficiencies: 15
Dec 6, 2011
Visit Reason
This report is a Statement of Deficiencies generated as a result of the annual Medicare recertification survey conducted at the facility from November 29, 2011 through December 6, 2011. One complaint was investigated during this survey.
Findings
The survey identified multiple deficiencies related to preparation for safe transfer and discharge, investigation and reporting of adverse events, dignity and respect of residents, professional standards of care, maintenance of resident assessments, provision of care and services, infection control, medication error rates, emergency procedures, and other regulatory requirements. Corrective actions and plans of correction were detailed for each deficiency.
Complaint Details
Complaint #NV00029844 regarding Admission, Transfer & Discharge Rights was substantiated. The complaint investigation was initiated by the Bureau of Health Care Quality and Compliance on 11/29/11.
Severity Breakdown
D: 8
C: 1
B: 1
E: 1
F: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| 483.12(a)(7) PREPARATION FOR SAFE/ORDERLY TRANSFER/DISCHRG - Facility failed to ensure sufficient communication, preparation and coordination for safe discharge of Resident #29. | — |
| 483.13(c)(1)(ii)-(iii), (c)(2)-(4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS - Facility failed to investigate and report adverse events including unwitnessed falls and injuries of unknown origin timely for Residents #20, #21, and #38. | D |
| 483.15(a) DIGNITY AND RESPECT OF INDIVIDUALITY - Facility failed to ensure dignity was maintained for Residents #25, #1, and #33. | D |
| 483.20(k)(3)(i) SERVICES PROVIDED MEET PROFESSIONAL STANDARDS - Facility failed to ensure staff provided care meeting professional standards for Residents #4, #9, and #34. | D |
| 483.25(d) MAINTAIN 15 MONTHS OF RESIDENT ASSESSMENTS - Facility failed to maintain resident assessments for 30 sampled residents. | C |
| 483.25(b) SUFFICIENT DIETARY SUPPORT PERSONNEL - Facility failed to ensure sufficient dietary support personnel to carry out dietary functions. | B |
| 483.35(f) FREQUENCY OF MEALS/SNACKS AT BEDTIME - Facility failed to offer snacks in the evening to residents. | — |
| 483.35(i) FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY - Facility failed to maintain kitchen in sanitary condition. | D |
| 483.60(b), (d), (e) DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS - Facility failed to ensure proper medication administration and storage, and medication error rate was 27.1%. | D |
| 483.25(m)(1) FREE OF MEDICATION ERROR RATES OF 5% OR MORE - Facility failed to maintain medication error rate below 5%. | D |
| 483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS - Facility failed to ensure residents free of significant medication errors. | D |
| 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES - Facility failed to provide a safe environment free of accident hazards for Residents #35 and #36. | D |
| 483.25(e)(2) INCREASE/PREVENT DECREASE IN RANGE OF MOTION - Facility failed to ensure use of assistive devices to prevent decline in range of motion for Resident #22. | D |
| 483.65 INFECTION CONTROL, PREVENT SPREAD, LINENS - Facility failed to maintain an effective infection control program. | E |
| 483.75(m)(2) TRAIN ALL STAFF-EMERGENCY PROCEDURES/DRILLS - Facility failed to ensure staff were fully familiar with fire drill procedures. | F |
Report Facts
Census at beginning of survey: 201
Sample size: 30
Medication error rate: 27.1
Medication passes observed: 59
Residents sampled: 30
Falls investigated: 2
Incidents audit frequency: 5
Medication pass observation frequency: 5
Fire drill frequency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #30 | Unspecified | Interviewed regarding discharge communication and complaint investigation |
| Employee #4 | Unspecified | Interviewed regarding discharge planning and communication |
| Employee #7 | Risk Manager | Interviewed regarding reporting of incidents and investigations |
| Employee #16 | Certified Nursing Assistant (CNA) | Observed providing care and medication pass, involved in medication error findings |
| Employee #21 | Treatment Nurse | Educated on wound care and infection control, involved in wound care findings |
| Employee #23 | Physician Assistant | Educated on hand hygiene and infection control |
| Employee #9 | Certified Nursing Assistant (CNA) | Educated on fire drill procedures and medication administration |
| Employee #24 | Unspecified | Educated on sanitation of blood pressure cuff and fire drill procedures |
| Employee #12 | Social Worker | Interviewed regarding resident dentures and dental care |
| Employee #29 | Unspecified | Involved in resident care and medication administration |
| Employee #8 | Dietary Hostess | Observed during meal service and dietary support findings |
| Employee #14 | MDS Coordinator | Interviewed regarding electronic medical records and documentation |
| Employee #15 | Consultant Dietician | Interviewed regarding nutritional interventions and medication administration |
| Employee #17 | Unspecified | Involved in blood pressure cuff sanitation |
| Employee #18 | Unspecified | Interviewed regarding staff assistance to residents |
| Employee #19 | Unspecified | Interviewed regarding resident care and medication administration |
| Employee #20 | Unspecified | Interviewed regarding resident care and staff assistance |
| Employee #27 | Charge Nurse | Interviewed regarding fire drill and resident care |
| Employee #4 | Unspecified | Interviewed regarding discharge planning |
Inspection Report
Annual Inspection
Census: 201
Deficiencies: 14
Dec 6, 2011
Visit Reason
Annual Medicare recertification survey conducted from November 29, 2011 through December 6, 2011, including investigation of one complaint regarding Admission, Transfer & Discharge Rights.
Findings
The facility was found deficient in multiple areas including discharge planning, investigation and reporting of adverse events, dignity and respect of residents, professional standards of care, maintenance of resident assessments, provision of care to maintain highest well-being, range of motion support, accident hazards, medication error rates, infection control, dietary support personnel, dental services, drug storage security, and emergency procedures training.
Complaint Details
Complaint #NV00029844 regarding Admission, Transfer & Discharge Rights was substantiated. The complaint investigation was initiated by the Bureau of Health Care Quality and Compliance on 2011-11-29.
Severity Breakdown
SS=D: 9
SS=C: 1
SS=E: 2
SS=F: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure sufficient communication, preparation and coordination for safe and appropriate discharge for Resident #29. | SS=D |
| Failed to investigate and report adverse events including unwitnessed falls and injuries of unknown origin in a timely manner for Residents #20, #21, and #38. | SS=D |
| Failed to ensure dignity was maintained for Residents #25, #1, and #33. | SS=D |
| Failed to ensure staff provided care meeting professional standards for Residents #4, #9, and #34. | SS=D |
| Failed to maintain all resident assessments completed within the previous 15 months in the resident's active record for all 30 sampled residents. | SS=C |
| Failed to provide necessary care and services to maintain highest practicable physical, mental, and psychosocial well-being for 9 sampled residents. | SS=E |
| Failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion (Resident #22). | SS=D |
| Failed to ensure resident environment was free of accident hazards and provide adequate supervision and assistance devices for Residents #35 and #36. | SS=D |
| Failed to ensure medication error rate was below 5%, with a 27.1% error rate observed. | SS=E |
| Failed to ensure drugs and biologicals were securely stored; medication cart left unlocked with medications unattended; controlled drug storage box unsecured. | SS=D |
| Failed to maintain a comprehensive infection control program to prevent disease transmission, including improper wound care glove use, unclean blood pressure cuffs, unlabeled personal items, and blocked handwashing sink. | SS=D |
| Failed to train all staff in emergency procedures and conduct effective fire drills; staff unaware of fire extinguisher use and proper fire response. | SS=F |
| Failed to ensure residents were offered snacks in the evening. | — |
| Failed to provide appropriate dental services for Resident #31; dentures lost and improperly identified. | — |
Report Facts
Census: 201
Sample size: 30
Medication error rate: 27.1
Medication passes observed: 59
Medication errors observed: 16
Weight loss: 33
Weight loss percent: 27
Blood pressure: 100
Blood pressure: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #30 | Interviewed regarding discharge communication failure for Resident #29 | |
| Employee #4 | Interviewed regarding discharge planning and chart availability for Resident #29 | |
| Employee #7 | Risk Manager | Interviewed regarding failure to report and investigate falls and injuries for Residents #20, #21, and #38 |
| Employee #18 | Interviewed regarding staff assistance to residents to use bathroom | |
| Employee #19 | Interviewed regarding staff assistance to residents to use bathroom and holding blood pressure medications for Resident #25 | |
| Employee #20 | Interviewed regarding staff assistance to residents to use bathroom | |
| Employee #21 | Observed providing wound care with improper hand hygiene | |
| Employee #23 | Physician Assistant | Observed providing wound care with improper hand hygiene |
| Employee #14 | MDS Coordinator | Interviewed regarding lack of training and access to computerized MDS system |
| Employee #15 | Consultant Dietician | Interviewed regarding failure to communicate medication discontinuation for Resident #3 |
| Employee #16 | Interviewed regarding medication errors and pain medication administration | |
| Employee #24 | Observed and interviewed regarding blood pressure cuff cleaning | |
| Employee #27 | Interviewed regarding fire drill response and failure to announce fire location | |
| Employee #29 | Interviewed regarding missing Jewett Brace and restorative aide services for Resident #19 | |
| Employee #8 | Dietary Hostess | Interviewed regarding insufficient dietary support personnel |
| Employee #12 | Social Worker | Interviewed regarding lost dentures and dental appointment for Resident #31 |
| Unit Manager | Interviewed regarding medication administration and drug storage security | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including medication administration, MDS access, infection control, and fire drill |
| Director of PT/OT | Interviewed regarding splint provision for Resident #22 |
Inspection Report
Life Safety
Deficiencies: 3
Dec 2, 2011
Visit Reason
The inspection was conducted as a Life Safety Code (LSC) survey to evaluate compliance with fire safety standards under NFPA 101, Chapter 19, Existing Health Care Occupancies.
Findings
The facility was found deficient in staff familiarity with fire drill procedures, improper storage of soiled linen and trash receptacles exceeding 32 gallons outside of hazardous areas, and failure to segregate full and empty oxygen cylinders in storage rooms.
Severity Breakdown
E: 1
D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Staff were not fully familiar with procedures during fire drills; staff did not carry fire extinguishers and did not respond appropriately to simulated fires. | E |
| Soiled linen and trash receptacles exceeding 32 gallons were stored in a common shower room not protected as a hazardous area. | D |
| Full and empty oxygen cylinders were stored together in the same room without segregation, despite signage indicating proper storage locations. | D |
Report Facts
Deficiencies cited: 3
Capacity of soiled linen/trash receptacles: 100
Date of fire drill observation: Nov 30, 2011
Date of oxygen cylinder observation: Nov 29, 2011
Inspection Report
Life Safety
Deficiencies: 3
Dec 2, 2011
Visit Reason
The inspection was conducted as a Life Safety Code (LSC) survey at the Life Care Center of Las Vegas on November 29, 30, and December 2, 2011, to assess compliance with fire safety and related health care occupancy standards.
Findings
The facility was found deficient in several Life Safety Code standards including fire drill procedures, storage of soiled linen and trash receptacles, and proper storage and segregation of oxygen cylinders. Corrective actions and monitoring plans were outlined to address these deficiencies.
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Fire drills were held at unexpected times under varying conditions but staff were not fully familiar with procedures to take during a fire drill. | SS=E |
| Soiled linen or trash collection receptacles exceeded 32 gallons capacity and were not located in a room protected as a hazardous area when unattended. | SS=D |
| Full and empty oxygen cylinders were stored together in the same room without proper segregation and signage. | SS=D |
Report Facts
Date of Completion: 2012
Fire drill time: 14
Oxygen storage room capacity: 3000
Trash receptacle capacity: 32
Trash receptacle capacity in gallons: 100
Inspection Report
Complaint Investigation
Census: 206
Deficiencies: 0
Sep 30, 2011
Visit Reason
The inspection was conducted as a Medicare complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 9/30/11 regarding allegations of the facility not giving medication and attempting to discharge an unstable resident.
Findings
The investigation found no substantiation for the allegations after review of clinical records, policies, and staff interviews. Medication administration and discharge procedures were found to be in compliance with facility policies. No regulatory deficiencies were identified.
Complaint Details
Complaint NV00029318 was investigated. The allegations regarding failure to give medication and improper discharge were not substantiated based on clinical record review, policy review, and staff interviews.
Report Facts
Resident records reviewed: 10
Open resident records reviewed: 5
Closed resident records reviewed: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 7, 2011
Visit Reason
The inspection was conducted as a Medicare complaint investigation based on allegations that a resident was not being fed orally, did not participate in activities, was over sedated, and developed worsening bed sores.
Findings
The complaint was unsubstantiated. The resident was fed via gastric tube due to aspiration risk, participated in activities, was not over medicated, and the pressure sores were healing. No regulatory deficiencies were identified.
Complaint Details
Complaint NV00028656 alleged the resident was not fed orally, left in room without activities, over sedated, and had worsening bed sores. Investigation found these allegations unsubstantiated.
Inspection Report
Complaint Investigation
Census: 212
Deficiencies: 4
Jun 2, 2011
Visit Reason
The inspection was conducted as a Medicare complaint survey initiated by the Bureau of Health Care Quality and Compliance on June 2, 2011, due to six allegations related to resident care and facility practices.
Findings
The investigation substantiated several deficiencies including failure to ensure privacy and dignity of residents, timely administration of pain medication, proper food temperature, adherence to physician orders for pain medication and dressing changes, and infection control practices related to sharps containers and isolation precautions.
Complaint Details
The complaint contained six allegations including improper discharge planning, food temperature issues, delayed pain medication, staff yelling at residents, and weight loss. Some allegations were substantiated through clinical record review, resident interviews, and observations; others were not substantiated.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure privacy with care, staff not knocking or announcing themselves before entering resident rooms, and call lights not answered timely. | SS=D |
| Failure to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, including failure to follow physician's orders for oral pain medication and dressing changes to PICC line. | SS=D |
| Failure to ensure food was served at appropriate temperature to meet residents' needs. | SS=D |
| Failure to establish and maintain an infection control program, including failure to ensure sharps containers and contact isolation policies were followed. | SS=D |
Report Facts
Census: 212
Weight loss: 15
Medication doses missed: 3
Temperature readings: 128
Temperature readings: 160
Temperature readings: 162
Temperature readings: 152
Temperature readings: 100
Inspection Report
Complaint Investigation
Census: 212
Deficiencies: 4
Jun 2, 2011
Visit Reason
The inspection was conducted as a Medicare complaint survey initiated by the Bureau of Health Care Quality and Compliance on June 2, 2011, to investigate six allegations related to resident care and facility practices.
Findings
The investigation substantiated several allegations including improper discharge procedures, delayed pain medication administration, cold food service, and failure to follow physician orders for medication and dressing changes. Additional deficiencies were noted in infection control practices, privacy violations, and sharps container management.
Complaint Details
The complaint contained six allegations including improper discharge by a non-primary physician, discharge due to refusal to vacate a private room, cold food service, delayed pain medication, staff yelling at resident about pain medication, and unexplained resident weight loss. Several allegations were substantiated, others were not.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure privacy with care, staff not knocking before entering resident rooms, and delayed response to call lights. | SS=D |
| Failure to ensure physician's orders were followed for oral pain medication and dressing changes to a PICC line. | SS=D |
| Failure to provide food at appropriate temperature for residents. | SS=D |
| Failure to maintain infection control practices including improper use of contact isolation and overfilled sharps containers. | SS=D |
Report Facts
Allegations: 6
Census: 212
Medication doses missed: 9
Call light wait time: 45
Sharps containers overfilled: 4
Food temperature: 128
Inspection Report
Complaint Investigation
Census: 212
Deficiencies: 1
Apr 5, 2011
Visit Reason
This report was generated as a result of a Medicare complaint survey conducted from 2011-02-03 through 2011-04-05 to investigate complaint NV00027274 containing four allegations.
Findings
The investigation found that three of the four allegations could not be substantiated, while one allegation regarding unnecessary hospital transfers was substantiated. The facility failed to fully inform Resident #1 about transfers to acute care hospitals, violating residents' rights to be informed of their health status and treatment.
Complaint Details
Complaint NV00027274 contained four allegations: 1) Two Certified Nursing Assistants blocked a resident from the courtyard (unsubstantiated). 2) Facility used resident's roommate to harass him (unsubstantiated). 3) Unnecessary hospital transfers using government money (substantiated). 4) Loss of citizenship papers and cash (unsubstantiated).
Severity Breakdown
F 154 SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to fully inform Resident #1 about transfers to acute care hospitals, violating residents' rights to be informed of health status, care, and treatments. | F 154 SS=D |
Report Facts
Census: 212
Complaint Allegations: 4
Inspection Report
Complaint Investigation
Census: 212
Deficiencies: 1
Apr 5, 2011
Visit Reason
The inspection was conducted as a result of a Medicare complaint survey from 2/3/11 through 4/5/11, investigating Complaint NV00027274 which contained four allegations regarding resident and staff interactions and facility practices.
Findings
The investigation found that three of the four allegations were unsubstantiated, while one allegation regarding unnecessary hospital transfers was substantiated. The facility failed to fully inform a resident about his hospital transfers, violating residents' rights to be informed of their health status and treatments.
Complaint Details
Complaint NV00027274 contained four allegations. Allegations #1, #2, and #4 were not substantiated. Allegation #3 regarding unnecessary hospital transfers was substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 483.10(b)(3), 483.10(d)(2) INFORMED OF HEALTH STATUS, CARE, & TREATMENTS - Facility failed to fully inform Resident #1 why he had been sent to the acute care hospital twice in one day. | SS=D |
Report Facts
Census: 212
Complaint Allegations: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 2, 2010
Visit Reason
This Statement of Deficiencies was generated as a result of a Complaint Investigation conducted at the facility on 12/2/10 in accordance with 42 CFR, Chapter IV, Section 482.1 to 482.57.
Findings
The complaint #NV26938 was investigated and found to be not substantiated. No deficiencies were identified and no further action is necessary.
Complaint Details
Complaint #NV26938 was investigated on 12/2/10 and was not substantiated. Allegations regarding violation of resident rights, neglect, lack of quality of care in timely answering call bells, and inappropriate medication administration were all found not substantiated based on observations, interviews, record and clinical reviews.
Inspection Report
Annual Inspection
Census: 216
Deficiencies: 9
Oct 22, 2010
Visit Reason
The inspection was conducted as the annual Medicare recertification survey from October 18 through October 22, 2010, in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.
Findings
The survey identified regulatory deficiencies related to dignity and respect of individuality, development of comprehensive care plans, provision of care and services for highest well-being, treatment/services to improve or maintain ADLs, free of accident hazards, food procurement and preparation, pharmaceutical services, infection control, and other care-related issues. Two complaints were investigated but not substantiated.
Complaint Details
Two complaints were investigated during the survey: Complaint #NV00026623 alleging failure to prevent a fall and improper assessment was not substantiated; Complaint #NV00026689 alleging lack of sufficient staffing was not substantiated.
Severity Breakdown
E: 1
D: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Dignity and respect of individuality not maintained; residents treated like children and privacy not assured. | E |
| Failure to develop comprehensive care plans for residents. | D |
| Failure to provide care and services to attain or maintain highest practicable well-being. | D |
| Failure to provide treatment/services to improve or maintain ADLs for resident. | D |
| Failure to ensure resident environment free of accident hazards and adequate supervision. | D |
| Failure to procure, store, prepare, and serve food under sanitary conditions and proper temperatures. | D |
| Failure to provide pharmaceutical services to meet resident needs and ensure expired medications removed. | D |
| Failure to establish and maintain infection control program and ensure staff follow universal precautions. | D |
| Failure to ensure supervision to prevent accidents related to resident smoking implements. | D |
Report Facts
Census: 216
Sample size: 30
Completion date for corrective actions: 2010
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Fed Resident #26 and educated on feeding and sitting down while feeding | |
| Employee #7 | Registered Nurse | Worked on 100 Hall, took Resident #23's blood pressure, educated on resident rights |
| Employee #5 | Unable to show coordination of care plans, hospice plan of care, and care plan implementation | |
| Employee #6 | Observed administering medications via GT and infection control violations | |
| Employee #3 | Interviewed regarding feeding times on Resident #17's MAR | |
| Employee #12 | Registered Nurse | Documented assessments for Resident #31 |
| Director of Nursing | DON | Interviewed regarding holding hands policy and medication storage |
| Assistant Dietary Director | Observed food preparation and temperature control | |
| Administrator | Interviewed regarding Resident #31's cigarettes and lighters |
Inspection Report
Annual Inspection
Census: 216
Deficiencies: 8
Oct 22, 2010
Visit Reason
Annual Medicare recertification survey conducted from October 18, 2010 through October 22, 2010, including investigation of two complaints regarding fall prevention and staffing.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' dignity and respect, inadequate development and implementation of comprehensive care plans, improper diet order coordination, failure to follow infection control practices during gastrostomy tube medication administration, expired medications in the Pyxis system, unsafe food temperature maintenance, and inadequate supervision related to resident smoking materials.
Complaint Details
Two complaints were investigated during the recertification survey: Complaint #NV00026623 regarding fall prevention and assessment after falls, and Complaint #NV00026689 regarding staffing sufficiency. Both complaints were not substantiated.
Severity Breakdown
SS=E: 1
SS=D: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure staff provided care in a manner that enhanced residents' dignity and assured privacy. | SS=E |
| Failure to develop, review, revise, and consistently implement comprehensive care plans for residents, including coordination with hospice services. | SS=D |
| Failure to provide services according to the plan of care to maintain eating skills for a resident. | SS=D |
| Failure to ensure staff followed universal precautions and clean technique when administering medications through a gastrostomy tube. | SS=D |
| Failure to ensure resident environment remained free of accident hazards and provide adequate supervision to prevent accidents. | SS=D |
| Failure to ensure food was maintained at proper temperatures before meal service. | SS=D |
| Failure to have a system in place to ensure expired medications were not available for use in the Pyxis medication dispensing system. | SS=D |
| Failure to establish and maintain an infection control program to prevent infection spread, including proper hand hygiene and glove use during gastrostomy tube medication administration. | SS=D |
Report Facts
Sample size: 30
Closed records: 3
Unsampled residents: 1
Expired medication date: 2010
Temperature: 129.8
Temperature: 98.1
Temperature: 127.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #6 | Observed administering medications through gastrostomy tube without proper hand hygiene and glove use; dropped syringe left on counter. | |
| Employee #4 | Observed feeding Resident #26 and noted inconsistent implementation of care plan to maintain resident's independence in self-feeding. | |
| Employee #5 | Unable to show coordinated care plans between facility and hospice for Resident #9; found hospice plan of care misplaced. | |
| Employee #12 | Registered Nurse | Documented smoking safety assessments for Resident #31. |
| Director of Nursing | Director of Nursing | Interviewed regarding resident care and medication system issues. |
| Infection Control Coordinator | Infection Control Coordinator | Provided information on infection control practices and policies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 3, 2010
Visit Reason
The inspection was conducted as a complaint investigation at the Life Care Center of Las Vegas from 09/02/10 through 09/03/10 in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.
Findings
The complaint #NV00025838 could not be substantiated based on the investigation findings.
Complaint Details
Complaint #NV00025838 was investigated and found to be not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 3
Apr 26, 2010
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 4/26/10, finalized on 4/27/10, in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing.
Findings
The facility was found to have deficiencies related to failure to update and revise the care plan to meet changing hygiene needs, failure to ensure the medical record was organized and complete, and failure to reassess and provide additional hygiene interventions to prevent body odors for Resident #1. The complaint was substantiated with deficiencies cited under Tags Z112, Z121, and Z130.
Complaint Details
Complaint #NV00024418 was substantiated with deficiencies cited under Tags Z112, Z121, and Z130.
Severity Breakdown
Severity 1: 1
Severity 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure the care plan was updated and revised to meet the changing hygiene needs since 7/10/09 for Resident #1, who was unable to wash and dry underneath his abdominal folds and developed body odors. | Severity: 2 |
| Failed to ensure the medical record was organized and complete to determine care and services provided to Resident #1. | Severity: 1 |
| Failed to reassess and provide additional hygiene interventions to prevent body odors for Resident #1; care plan dated 7/10/09 addressed odor but was not changed despite continued odor due to resident's inability to reach area under abdomen. | Severity: 2 |
Report Facts
Deficiencies cited: 3
Dates: Apr 26, 2010
Dates: Apr 27, 2010
Completion date: Jun 18, 2010
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named as responsible party for accomplishing and monitoring compliance with corrective action |
| Executive Director | Executive Director | Named as responsible party for accomplishing and monitoring compliance with corrective action |
| MDS Coordinator | MDS Coordinator | Named as responsible party for accomplishing and monitoring compliance with corrective action |
| Health Information Director | Health Information Director | Named as responsible party for accomplishing and monitoring compliance with corrective action |
| Unit Managers | Unit Managers | Named as responsible party for accomplishing and monitoring compliance with corrective action |
Inspection Report
Complaint Investigation
Deficiencies: 3
Apr 26, 2010
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NV00024418, which was substantiated with deficiencies cited related to care planning and medical record maintenance.
Findings
The facility failed to update and revise the comprehensive care plan to meet the changing hygiene needs of Resident #1, who developed body odors due to inadequate hygiene care. Additionally, the medical record was found to be incomplete and disorganized, preventing proper determination of care and services provided. The facility also failed to reassess and provide additional hygiene interventions to prevent body odors.
Complaint Details
Complaint #NV00024418 was substantiated with deficiencies cited related to care planning and medical record maintenance.
Severity Breakdown
Severity: 2: 2
Severity: 1: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure the care plan was updated and revised to meet changing hygiene needs for Resident #1, who developed body odors. | Severity: 2 |
| Failed to ensure the medical record was organized and complete to determine care and services provided to Resident #1. | Severity: 1 |
| Failed to reassess and provide additional hygiene interventions to prevent body odors for Resident #1. | Severity: 2 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 12, 2010
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on January 12, 2010.
Findings
The complaint #NV00023235 was found to be unsubstantiated and no regulatory deficiencies were identified during the investigation.
Complaint Details
Complaint #NV00023235 was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 3, 2009
Visit Reason
This Statement of Deficiencies was generated as a result of a complaint investigation conducted in the facility on November 3, 2009, in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing. The investigation involved complaints #NV00022947, #NV00023128, and #NV00023493, all of which were found to be unsubstantiated.
Findings
The facility failed to provide a physician-ordered special diet and nutrition program for 1 of 9 residents (Resident #6), violating NAC 449.74487 Nutritional Health; Hydration. The deficiency was related to the nutritional health of the patient not being maintained as required.
Complaint Details
Complaint #NV00022947 was unsubstantiated. Complaint #NV00023128 was unsubstantiated with an unrelated deficiency (see TAG Z290). Complaint #NV00023493 was unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Failed to provide a physician ordered special diet and nutrition program for 1 of 9 residents (Resident #6) as required by NAC 449.74487 Nutritional Health; Hydration. |
Report Facts
Residents affected: 1
Residents reviewed: 9
Plan of Correction completion date: Dec 30, 2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E.D | Dietary Manager | Named as individual responsible for corrective actions related to dietary deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 3, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation involving three complaints, all of which were found to be unsubstantiated.
Findings
The facility failed to provide a physician-ordered special diet and nutrition program for 1 of 9 residents (Resident #6), violating nutritional health and hydration regulations.
Complaint Details
Complaint #NV00022947 was unsubstantiated. Complaint #NV00023128 was unsubstantiated with an unrelated deficiency. Complaint #NV00023493 was unsubstantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide a physician ordered special diet and nutrition program for 1 of 9 residents (Resident #6). | SS=D |
Report Facts
Residents affected: 1
Residents reviewed: 9
Inspection Report
Annual Inspection
Census: 223
Deficiencies: 7
Oct 26, 2009
Visit Reason
The inspection was conducted as the annual Medicare recertification survey at the facility from October 20, 2009 through October 26, 2009.
Findings
The facility was found deficient in multiple areas including failure to implement and maintain policies regarding abuse of residents, failure to maintain residents' dignity and respect, failure to follow comprehensive care plans, inadequate infection control practices, improper medication storage and handling, and failure to maintain a quality assessment and assurance program.
Severity Breakdown
SS=D: 5
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to implement and maintain written policies and procedures regarding abuse of residents, including failure to intervene and protect residents from sexual abuse incidents. | SS=D |
| Failure to ensure an environment that maintained residents' dignity and respect, including feeding practices and privacy violations. | SS=D |
| Failure to initiate and/or follow written comprehensive care plans for residents, including lack of care plans for foot drop and infection precautions. | SS=D |
| Failure to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. | SS=D |
| Failure to properly store and secure drugs and biologicals and maintain them at proper cooling temperatures. | SS=D |
| Failure to establish and maintain an infection control program to prevent transmission of disease and infection, including failure to maintain contact isolation precautions and educate residents and staff. | SS=F |
| Failure to maintain a quality assessment and assurance committee that identifies quality deficiencies and implements appropriate corrective actions, including infection control and abuse policy deficiencies. | SS=F |
Report Facts
Residents sampled: 31
Closed records reviewed: 3
Medication pills found loose: 16
Refrigerator temperature: 51
Refrigerator temperature: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #17 | Observed feeding multiple residents simultaneously, contributing to dignity deficiency | |
| Employee #16 | Entered resident room without permission, contributing to dignity deficiency | |
| Employee #20 | Medication Nurse | Observed leaving medication cart unlocked and found loose pills in medication drawer |
| Employee #21 | Revealed unawareness of resident's hand splint use | |
| Employee #23 | Admitted to not putting hand splint on resident as scheduled |
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 15, 2009
Visit Reason
This inspection was conducted as a result of a complaint investigation in the facility on 10/15/09, in accordance with Nevada Administrative Code for Skilled Nursing Facilities.
Findings
The facility was found to have deficiencies related to incomplete and inaccurate medical records and failure to ensure proper administration of narcotic medications according to physician orders for one resident. Three specific regulatory violations were cited involving maintenance of medical records, administration of drugs, and pharmaceutical services.
Complaint Details
Complaint #NV000022750 was substantiated with deficiencies cited; Complaint #NV000022838 was unsubstantiated.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| A medical record must be complete, accurate, organized, and readily accessible to authorized persons; the facility failed to ensure a patient's medical record was complete and contained narcotic medication administration records for August 2009 for Resident #1. | Severity: 2 |
| The facility failed to ensure staff administered narcotic pain medication on a consistent basis according to physician's orders for Resident #1. | Severity: 2 |
| The facility failed to meet the needs of a resident by failing to acquire prescribed narcotic pain medication from the pharmacy in a timely manner and to administer narcotic pain medication according to physician's orders for Resident #1. | Severity: 2 |
Report Facts
Severity level: 2
Scope: 1
Correction submission timeframe: 10
Correction anticipated date: Dec 14, 2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unknown Executive Director | Executive Director | Responsible party for accomplishing and monitoring compliance with corrective action |
| Unknown Director of Nursing | Director of Nursing | Responsible party for accomplishing and monitoring compliance with corrective action |
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 15, 2009
Visit Reason
The inspection was conducted as a result of complaint investigation for two complaints, NV00022838 which was unsubstantiated, and NV00022750 which was substantiated with deficiencies cited.
Findings
The facility failed to ensure a patient's medical record was complete and contained narcotic medication administration records, failed to administer narcotic pain medication consistently according to physician's orders, and failed to acquire prescribed narcotic pain medication in a timely manner for one resident. These deficiencies were substantiated under complaint NV00022750.
Complaint Details
Complaint #NV00022838 was unsubstantiated. Complaint #NV00022750 was substantiated with deficiencies cited.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a patient's medical record was complete and contained narcotic medication administration records for August 2009 for 1 of 2 residents (Resident #1). | Severity: 2 |
| Failed to ensure staff administered narcotic pain medication on a consistent basis according to physician's orders for 1 of 2 residents (Resident #1). | Severity: 2 |
| Failed to acquire prescribed narcotic pain medication from the pharmacy in a timely manner and to administer narcotic pain medication according to physician's orders for 1 resident (Resident #1). | Severity: 2 |
Report Facts
Residents involved: 1
Complaints investigated: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 26, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing.
Findings
The complaint #NV00022915 was partially substantiated with no deficiencies cited. No regulatory deficiencies were identified during the investigation.
Complaint Details
Complaint #NV00022915 was partially substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 11, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on August 11, 2009, in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing. Several complaints were investigated, with some substantiated and deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to accurately document skin conditions for 5 of 10 residents, failure to change a Huber needle every seven days for 1 resident, and failure to prevent the development of a mid back pressure sore for 1 resident. Deficiencies were substantiated in relation to these complaints.
Complaint Details
Complaint #NV00021922 was substantiated with deficiencies cited. Complaint #NV00022643 and #NV00022721 were unsubstantiated. Complaints #NV00022725 and #NV00022739 were substantiated with deficiencies cited.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure that admission assessments, nurse's notes, treatment Kardexes, and the Minimum Data Set accurately and consistently documented the skin condition for 5 of 10 residents. | 2 |
| Failed to ensure a Huber needle was changed every seven days in accordance with professional nursing standards for 1 of 10 residents. | 2 |
| Failed to prevent the development of a mid back pressure sore for 1 of 10 residents. | 2 |
Report Facts
Residents with inaccurate skin condition documentation: 5
Residents with Huber needle issue: 1
Residents with pressure sore development: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 14, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by complaint #NV00021836, which was substantiated, and complaint #NV00022288, which was unsubstantiated.
Findings
The facility failed to ensure Calamine lotion was applied as ordered by the physician on 4/18/09 and failed to clarify the continued use of an abdominal pad following the 4/18/09 order for one of two residents (Resident #1).
Complaint Details
Complaint #NV00021836 was substantiated with deficiencies cited. Complaint #NV00022288 was unsubstantiated.
Severity Breakdown
Severity 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure Calamine lotion was applied as ordered by the physician on 4/18/09 and failed to clarify the continued use of an abdominal pad following the 4/18/09 order for Resident #1. | Severity 2 |
Report Facts
Complaint number substantiated: 1
Complaint number unsubstantiated: 1
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 9, 2009
Visit Reason
The inspection was conducted as a complaint investigation under State licensure at the Life Care Center of Las Vegas on March 9, 2009, following multiple complaints received by the facility.
Findings
The investigation substantiated several complaints, identifying deficiencies including failure to ensure a registered nurse assessed a resident after a fall, and failure to obtain ordered laboratory testing for two residents. Some complaints were unsubstantiated or did not result in cited deficiencies.
Complaint Details
Multiple complaints were investigated: Complaint #NV00020682 was unsubstantiated with an unrelated deficiency cited; #NV00021195 was substantiated with deficiencies cited; #NV00020769 and #NV00020765 were unsubstantiated; #NV00020240 was substantiated with no deficiency cited; #NV00019904 was substantiated (resident to resident altercation) with no deficiency cited; #NV00019731 and #NV00019586 were unsubstantiated; #NV00020246 was substantiated with no deficiency cited.
Severity Breakdown
Severity 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure that a registered nurse assessed residents for injury following a fall in accordance with Nevada Administrative Code (NAC) 632 of the Nurse Practice Act for 1 of 14 residents. | Severity 2 |
| Failure to obtain laboratory testing as ordered by the physician for 2 of 14 residents. | Severity 2 |
Report Facts
Residents reviewed: 14
Complaints investigated: 9
Inspection Report
Annual Inspection
Census: 226
Deficiencies: 5
Nov 7, 2008
Visit Reason
This inspection was conducted as the annual Medicare recertification survey from November 4, 2008 through November 7, 2008, including investigation of one complaint.
Findings
The facility was found deficient in multiple areas including failure to prevent neglect of a resident who self-inflicted injury, failure to follow physician's orders for medication administration, unsafe environmental hazards in resident rooms, inadequate tracheostomy care, and lack of competency in communication skills by a nurse aide.
Complaint Details
Complaint #NV00019600 was substantiated with no deficiencies. Complaint #NV00018292 was substantiated with deficiencies related to neglect and quality of care.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to implement procedures that prohibit neglect for 1 of 31 sampled residents (#31) who shot himself in the facility parking lot. | SS=D |
| Failed to follow a physician's orders for medication administration for 1 of 31 sampled residents (#30). | SS=D |
| Failed to maintain the environment free of accident hazards in multiple units; unsecured personal care items accessible to residents in locked unit rooms and electrical outlets accessible near resident beds. | SS=E |
| Failed to ensure appropriate care of a resident's tracheostomy as per physician's orders for 1 of 31 residents (#8). | SS=D |
| Failed to ensure one Certified Nurse's Assistant was competent to meet residents' needs in communication due to language barrier. | SS=D |
Report Facts
Residents sampled: 31
Closed records reviewed: 3
Medication dosage: 10
Medication dosage: 5
Medication dosage: 5
Date of incident: 2008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #11 | Certified Nurse's Assistant (CNA) | Identified as lacking competency in English communication, impacting resident care. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding Resident #31 incident and medication error for Resident #30. |
| Nurse Manager | Nurse Manager for 200 Hall | Reported communication issues with Employee #11. |
| Unit Manager | Unit Manager | Reported lack of policy regarding access to personal care items in locked unit. |
| Employee #14 | Nurse | Reported Resident #8 generally changed her own tracheostomy dressing. |
Document
Deficiencies: 0
TSPN11 sod
Visit Reason
The document does not contain any information regarding an inspection or regulatory visit.
Findings
No findings or content related to facility inspection or compliance are present in the document.
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