Deficiencies (last 21 years)
Deficiencies (over 21 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
120 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 3
Date: Jul 1, 2025
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Re-Certification Survey at the facility from 06/22/2025 through 07/01/2025 to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The survey identified multiple regulatory deficiencies related to personnel records, including failure to ensure timely fingerprinting and background checks, incomplete dementia-specific training documentation, and lack of cultural competency training for some employees. Corrective actions and plans of correction were submitted to address these issues.
Deficiencies (3)
Failure to maintain current and accurate personnel records including fingerprinting and Nevada Automated Background System clearance within 10 days of hire for 1 of 21 sampled employees (Employee #21).
Failure to ensure 1 of 21 sampled employees (Employee #5) completed required dementia-specific training annually.
Failure to ensure 1 of 21 sampled employees (Employee #13) completed initial cultural competency training within required timeframe.
Report Facts
Census: 120
Employees reviewed: 21
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #21 | Medical Records Director | Named in deficiency for lack of fingerprinting and background check clearance |
| Employee #5 | Social Services Director | Named in deficiency for incomplete dementia-specific training documentation |
| Employee #13 | Registered Nurse | Named in deficiency for incomplete cultural competency training |
Inspection Report
Routine
Deficiencies: 18
Date: Jul 1, 2025
Visit Reason
The inspection was a routine survey of Life Care Center of Reno to assess compliance with healthcare regulations including resident care, medication management, infection control, and facility operations.
Findings
The facility had multiple deficiencies including failure to obtain psychotropic medication consents, lack of written notice for room changes for many residents, inaccurate Minimum Data Set (MDS) assessments, incomplete PASARR screening, incomplete baseline and comprehensive care plans, expired medications on medication carts, incomplete dialysis communication forms, inadequate infection control practices, and deficiencies in influenza and pneumococcal vaccination screening and education. The facility also failed to maintain required Quality Assurance and Performance Improvement (QAPI) committee attendance and documentation.
Deficiencies (18)
Failed to ensure consents for psychotropic medications were obtained for 1 of 24 sampled residents (Resident #421).
Failed to provide written notice including reason for room change to 37 of 49 residents relocated within the facility and 1 of 4 discharged residents.
Failed to ensure Minimum Data Set (MDS) assessments were accurate for 3 of 24 sampled residents (Resident #421, #2, and #171).
Failed to ensure an initial PASARR screening was completed prior to admission for 1 of 24 sampled residents (Resident #421).
Failed to ensure baseline care plans addressed mental health diagnoses and Foley catheter care for sampled residents.
Failed to develop and implement comprehensive care plans for Foley catheter care, bowel and bladder retraining, and pain management for sampled residents.
Failed to ensure an employee had current CPR training (Employee #9).
Failed to ensure all medications were signed and dated by the physician during visits for 1 of 24 sampled residents (Resident #421).
Failed to ensure the environment was free from accident hazards by not assessing and addressing risk of entrapment for 1 of 24 sampled residents (Resident #270).
Failed to adhere to infection control protocols by allowing a resident's catheter tubing to drag on the floor for 1 of 24 sampled residents (Resident #69).
Failed to ensure handwashing stations were in working order and stocked, dry food was sanitarily stored, griddle grease trap was clean, and refrigerator temperatures were monitored.
Failed to ensure expired medications were removed from medication carts and medication bottles were properly labeled.
Failed to ensure social services staff assessed the impact of room relocation on resident's psychosocial status for 1 of 24 sampled residents (Resident #171).
Failed to maintain compliance with State of Nevada Revised Statute (NRS) 449.174 related to fingerprinting and background check clearance for an employee accessing resident records (Resident #83).
Failed to ensure residents were appropriately screened, educated, and consented for influenza and pneumococcal vaccinations, and failed to administer vaccines as required for 38 residents reviewed.
Failed to maintain completed dialysis communication forms for 3 of 24 sampled residents (Resident #2, #85, and #61).
Failed to maintain required Quality Assurance and Performance Improvement (QAPI) committee members and meeting attendance.
Failed to ensure the facility's Quality Assurance and Performance Improvement (QAPI) committee implemented corrective action for systemic issues related to resident room changes and bowel and bladder program.
Report Facts
Residents affected by room change notification deficiency: 37
Residents reviewed for vaccination screening: 38
Residents with missing dialysis communication forms: 3
Residents with inaccurate MDS assessments: 3
Residents with incomplete PASARR screening: 1
Residents with incomplete baseline care plans: 2
Residents with incomplete comprehensive care plans: 3
Expired medication items found: 3
QAPI meetings missing required members: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Certified Nursing Assistant | Had expired CPR certification |
| Medical Records Director | Non-Nurse | Accessed resident records without fingerprinting and background check clearance |
| Director of Nursing | Named in multiple findings including psychotropic medication consent, room change notification, care plan deficiencies, expired medications, dialysis communication, infection control, and QAPI attendance | |
| Administrator | Named in findings related to room change notification, vaccination program, QAPI committee, and employee background check | |
| Regional Director of Clinical Services | Named in findings related to psychotropic medication consent, care plan deficiencies, dialysis communication, and vaccination program | |
| Registered Nurse | RN | Named in findings related to pain management, dialysis communication, and medication administration |
| Licensed Social Worker | LSW | Named in finding related to room change psychosocial assessment |
| Staff Development Coordinator | Registered Nurse | Named in finding related to expired CPR certification |
| Dietary Manager | Named in findings related to food safety and refrigerator monitoring | |
| Registered Dietician | Named in finding related to handwashing station and dry food storage | |
| Licensed Practical Nurse | LPN | Named in infection control finding |
| Regional Clinical Director | Named in dialysis communication finding | |
| Physician | Named in finding related to unsigned physician orders |
Inspection Report
Deficiencies: 1
Date: Apr 8, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with safeguarding resident-identifiable information and maintaining medical records in accordance with accepted professional standards.
Findings
The facility failed to ensure resident information was not visible on unattended computer screens and nursing station counters, potentially allowing unauthorized access to protected health information. Observations included exposed consultation reports and unlocked computer screens displaying resident information.
Deficiencies (1)
Failed to ensure resident information was not visible on unattended computer screens and nursing station counters, risking unauthorized access to protected health information.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Confirmed resident information was visible on consultation report and computer screen and explained the need to cover or lock screens. | |
| Staff Development Coordinator | Explained resident documentation should not be left visible and medication cart computers should be locked when unattended. |
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 3
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey at the facility from July 29, 2024 through August 1, 2024, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in personnel records related to fingerprinting and tuberculosis (TB) testing for employees, as well as in ensuring timely annual dementia training for staff. These deficiencies placed residents at risk due to incomplete employee eligibility requirements and training.
Deficiencies (3)
Failure to ensure fingerprinting and Nevada Automated Background System clearance was completed for 1 of 20 sampled employees (Employee #1).
Failure to complete tuberculosis testing timely for 1 of 20 sampled employees (Employee #13), with the 2024 annual TB test being two months late.
Failure to ensure annual dementia training was completed timely for 1 of 20 sampled employees (Employee #8).
Report Facts
Census: 118
Employee records reviewed: 20
Deficiencies cited: 3
Completion dates for corrective actions: Aug 10, 2024
Completion dates for corrective actions: Aug 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Executive Director | Named in deficiency for missing fingerprinting and background clearance |
| Employee #13 | Registered Nurse | Named in deficiency for late tuberculosis testing |
| Employee #8 | Certified Nursing Assistant | Named in deficiency for not completing annual dementia training timely |
| Carolyn Sprie | Administrator | Signed the report |
Inspection Report
Routine
Deficiencies: 11
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain working bed controls causing resident distress, inadequate documentation and communication during resident transfers, failure to complete bowel and bladder assessments and retraining programs, improper medication management including inaccurate controlled drug records and unsecured medications, failure to implement enhanced barrier precautions for wound care, and deficiencies in staff performance evaluations and environmental sanitation.
Deficiencies (11)
Failed to ensure the bed controls for Resident #94 were in working order, resulting in emotional distress and increased pain.
Failed to provide required documentation and communication during emergency transfer of Resident #76 to acute care hospital.
Failed to submit Pre-admission Screening and Resident Review (PASRR) Level II for Resident #76 with new diagnosis of schizophrenia.
Failed to complete bowel and bladder assessments upon admission and offer bowel and bladder retraining programs for multiple residents.
Failed to ensure oxygen was administered as ordered for Resident #442.
Failed to ensure controlled drug records were accurately completed for multiple residents, resulting in inaccurate medication reconciliation.
Failed to remove loose and unlabeled medications from medication carts and left medications unattended and unsecured in Resident #40's room.
Failed to ensure Certified Nursing Assistant had annual performance evaluation completed.
Failed to complete Treatment Administration Records for administration of skin protective ointment for Resident #2.
Failed to ensure the outside receptacle area was kept clean and free of trash, seepage, and flies.
Failed to implement Enhanced Barrier Precautions for Resident #26 with chronic wounds.
Report Facts
Controlled Drug Records discrepancies: 8
Medication counts discrepancies: 7
Resident candidates for bowel and bladder retraining: 10
Residents lacking bowel and bladder assessments: 12
Certified Nursing Assistant performance evaluation overdue: 1
Medication administration records incomplete: 1
Residents affected by Enhanced Barrier Precautions deficiency: 1
Residents affected by oxygen administration error: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #13 | Certified Nursing Assistant | Named in relation to missing annual performance evaluation |
| Director of Nursing | Director of Nursing (DON) | Provided multiple clarifications and confirmations regarding deficiencies |
| Staff Development Coordinator | Staff Development Coordinator (SDC) | Confirmed medication count discrepancies and unlabeled medications |
| Registered Nurse 1 | Registered Nurse (RN1) | Confirmed oxygen administration discrepancy and medication count issues |
| Registered Nurse 2 | Registered Nurse (RN2) | Confirmed medication administration documentation issues |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Confirmed wound care and lack of Enhanced Barrier Precautions |
| Infection Preventionist | Infection Preventionist (IP) | Explained Enhanced Barrier Precautions and confirmed deficiency |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Verbalized resident continence status |
| Maintenance Assistant | Maintenance Assistant | Explained source of thickened liquid in receptacle area |
| Regional President | Regional [NAME] President | Confirmed QAPI committee deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent a resident's roommate from urinating on the floor regularly and to ensure a clean, comfortable environment, as well as failure to coordinate care with the hospice provider for a resident.
Complaint Details
Complaint NV00070271 regarding Resident #2's behavior of urinating on the floor and the facility's failure to maintain a clean environment for Resident #1.
Findings
The facility failed to prevent Resident #2 from urinating on the floor regularly, impacting Resident #1's right to a clean environment. Additionally, the facility failed to coordinate care with the hospice provider for Resident #1, lacking hospice documentation and communication. The kitchen hand washing sink was also found not stocked with disposable hand towels.
Deficiencies (3)
Failed to prevent Resident #2 from urinating on the floor regularly, affecting Resident #1's environment.
Failed to coordinate Resident #1's care with the hospice provider, lacking hospice documentation and communication.
Failed to ensure the kitchen hand washing sink was stocked with disposable hand towels.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Verbalized witnessing Resident #2 urinating on the floor and discussed room change request with Resident #1. |
| Executive Director | Executive Director | Verbalized Resident #1 wanted to move rooms due to Resident #2's behavior and confirmed lack of hospice documentation. |
| Licensed Social Worker | Licensed Social Worker | Confirmed being hospice coordinator and lack of hospice documentation review. |
| Medical Records Director | Medical Records Director | Verbalized not having Resident #1's hospice documentation on-site. |
| Licensed Practical Nurse | Licensed Practical Nurse | Confirmed no hospice plan of care or orders on-site for Resident #1. |
| Registered Nurse | Registered Nurse | Verbalized no log for hospice nurse visits and no documentation at nurse's station. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 3, 2023
Visit Reason
The inspection was conducted due to complaints involving resident-to-resident abuse and possible medication diversion at the facility.
Complaint Details
The complaint investigation involved allegations of resident-to-resident abuse documented in Facility Reported Incident (FRI) #NV00069244 and possible medication diversion documented in FRI #NV00069388. The abuse involved Resident #1 slapping Resident #2, resulting in bruising. The medication diversion involved missing Lorazepam concentrate for Resident #3, with an investigation into possible diversion by the Assistant Director of Nursing who was terminated.
Findings
The facility failed to prevent resident-to-resident abuse involving two residents, resulting in bruising and an X-ray order. Additionally, the facility failed to prevent diversion of a controlled substance medication for one resident, with approximately 7-8 mL of Lorazepam missing during an overnight shift.
Deficiencies (2)
Failed to prevent resident to resident abuse for 2 of 5 sampled residents.
Failed to prevent a controlled substance medication from being diverted for 1 of 5 sampled residents.
Report Facts
Residents sampled: 5
Residents affected by abuse: 2
Residents affected by medication diversion: 1
Lorazepam missing volume (mL): 7.5
Medication administered (mL): 0.25
Lorazepam remaining before discrepancy (mL): 29.75
Lorazepam remaining after discrepancy (mL): 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | RN who heard noises and observed resident-to-resident abuse | |
| Administrator | Administrator who verbalized findings and confirmed medication diversion | |
| Assistant Director of Nursing | Employee investigated for possible medication diversion and terminated |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements including informed consent for psychotropic medications, care planning, accident hazard prevention, staff performance reviews, medication administration, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, lack of timely and complete care plans for residents, unsafe bed placement creating entrapment and fire hazards, failure to conduct annual performance reviews for CNAs, inadequate monitoring of psychotropic medication side effects, unsecured medications on medication carts, failure to wear appropriate hair restraints in the kitchen, improper infection control practices including insulin pen disinfection and PPE use, and improper sterile technique during PICC line dressing changes.
Deficiencies (9)
Failure to ensure residents gave informed consent prior to administration of psychotropic medication (melatonin) for 2 of 22 sampled residents.
Failure to create and implement baseline care plans timely for melatonin and oxygen use for sampled residents.
Failure to develop and implement complete care plans addressing resident safety related to bed placement and use of IV antibiotics and transmission-based precautions for sampled residents.
Failure to ensure resident's bed was not pushed against a wall heater creating potential entrapment and fire hazard.
Failure to complete annual performance reviews timely for Certified Nursing Assistants employed greater than one year.
Failure to implement gradual dose reductions and monitor side effects and behaviors for psychotropic medications for sampled residents.
Failure to ensure medications were not left unsecured on top of medication cart.
Failure to ensure employees wore appropriate hair restraints in the kitchen.
Failure to implement infection prevention and control program including proper insulin pen disinfection, PPE use for contact isolation, and sterile technique during PICC line dressing changes.
Report Facts
Residents sampled: 22
Certified Nursing Assistants reviewed: 3
Medication doses: 3
Medication doses: 1
Medication doses: 0.5
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning, medication administration, respiratory care, and nursing staff competencies at Life Care Center of Reno.
Findings
The facility failed to timely create baseline care plans for melatonin and oxygen therapy, did not develop complete care plans addressing resident safety and antibiotic administration, failed to administer oxygen per physician orders, and nursing staff lacked proper knowledge on sanitizing insulin pens.
Deficiencies (4)
Failed to ensure a baseline care plan was created timely for melatonin medication and oxygen therapy for sampled residents.
Failed to develop and implement a complete care plan that meets all resident needs, including safety interventions for bed placement and care plans for IV antibiotics and transmission-based precautions.
Failed to provide safe and appropriate respiratory care by not administering oxygen per physician's order and lacking a care plan for oxygen therapy.
Failed to ensure nursing staff explained the correct procedure for sanitizing an insulin pen prior to administration.
Report Facts
Residents sampled: 22
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents observed for medication administration: 3
Residents affected: 1
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Confirmed Resident #81 lacked baseline care plan for melatonin and prepared insulin pen without proper sanitizing | |
| Director of Nursing (DON) | Verbalized lack of care plan for melatonin and oxygen therapy, confirmed Resident #538 was oxygen dependent | |
| Registered Nurse | Confirmed Resident #81 had been taking melatonin without baseline care plan | |
| Minimum Data Set (MDS) Coordinator | Confirmed baseline care plan development process and care plan requirements for antibiotics and melatonin | |
| Director of Clinical Services (DCS) | Verbalized bed placement safety concerns and correct insulin administration procedure | |
| Clinical Services Director (CSD) | Confirmed lack of care plan for antibiotics and transmission based precautions for Resident #486 | |
| Infection Preventionist (IP) | Confirmed correct procedure for sanitizing insulin pen rubber septum |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: May 8, 2023
Visit Reason
The inspection was conducted as a result of complaint and Facility Reported Incident (FRI) investigations from April 25, 2023, to May 8, 2023, to investigate multiple allegations regarding resident care and facility operations.
Complaint Details
Complaint #NV00068348 and others included allegations such as improper medication administration, failure to order CT scans after falls, inadequate use of side rails, use of portable heaters, inappropriate prescribing without lab tests, failure to inform family about therapy discontinuation, failure to communicate care, and resident abuse. None of these allegations were substantiated due to lack of evidence.
Findings
The investigation included observations, interviews, and document reviews related to medication administration, therapy services, resident care, and staff interactions. Multiple allegations were investigated but none were substantiated due to lack of evidence. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 11
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
An offsite revisit was conducted on December 8, 2022 for all previous deficiencies cited on September 22, 2022.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 110
Capacity: 198
Deficiencies: 8
Date: Sep 22, 2022
Visit Reason
The inspection was conducted as a Medicare recertification survey including an Emergency Preparedness survey and a Medicare Life Safety Code recertification survey.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness program but had multiple deficiencies related to Life Safety Code including issues with self-closing doors, exit signage, sprinkler system maintenance, portable fire extinguishers, electrical receptacles, and door inspections.
Deficiencies (8)
Doors with self-closing devices did not operate as designed; several doors did not latch when released from magnetic hold.
Exit doors that could be misconstrued as exits did not have required 'No Exit' signage.
Automatic sprinkler system had multiple issues including gaps in escutcheons, paint on sprinklers, lint and corrosion on sprinklers, and missing sprinkler lists in spare boxes.
Portable fire extinguishers were not installed at the appropriate height.
Extension cords and power strips were used improperly, including daisy chaining and use as substitutes for fixed wiring.
Broken electrical receptacles and missing ground-fault circuit interrupters (GFCI) in required locations.
Annual inspection and testing records for fire doors were not available; maintenance director recently hired and had not performed inspections.
Distribution panels had circuit breakers labeled as 'Spare' left in the 'On' position.
Report Facts
Deficiency count: 8
Resident census: 110
Total licensed capacity: 198
Inspection date: Sep 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to findings about sprinkler system deficiencies, door inspections, and electrical issues | |
| Maintenance Supervisor | Named in relation to confirmation of GFCI receptacle measurements |
Inspection Report
Annual Inspection
Census: 116
Deficiencies: 2
Date: Sep 15, 2022
Visit Reason
The inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in ensuring timely tuberculosis testing and background checks for employees, and in maintaining proper backflow prevention devices to protect potable water. No residents were affected by these deficiencies.
Deficiencies (2)
Failure to ensure 1 of 20 sampled employees met tuberculosis testing requirements and delayed submission of fingerprints for background checks for 2 employees.
Failure to comply with federal, state, and local regulations regarding backflow prevention devices, resulting in cross connections in janitor closets.
Report Facts
Employee records reviewed: 20
Employees with deficiencies: 3
Deficiency severity count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Rhodes | Administrator | Signed report and verbalized facility policies |
| Staffing Development Coordinator | Provided information on employee TB testing and background check delays | |
| Maintenance Director | Present at discovery of backflow prevention deficiency |
Inspection Report
Annual Inspection
Census: 116
Deficiencies: 18
Date: Sep 15, 2022
Visit Reason
This Statement of Deficiencies was generated as a result of an annual Medicare Recertification Survey and Facility Reported Incident (FRI) investigation conducted at the facility from September 12, 2022, through September 15, 2022.
Findings
The facility was found deficient in multiple areas including resident rights, privacy and confidentiality, freedom from abuse, comprehensive assessments, baseline and comprehensive care planning, medication administration, dietary services, and behavioral health services. Specific incidents included verbal abuse by a CNA, failure to complete timely and accurate assessments, incomplete care plans, medication errors, and failure to provide care consistent with resident preferences.
Deficiencies (18)
Resident Rights/Exercise of Rights - Facility failed to ensure signs with instructions were posted only with resident consent.
Personal Privacy/Confidentiality of Records - Facility failed to keep protected health information confidential for 2 residents.
Freedom from Abuse and Neglect - Resident was verbally abused and intimidated by a CNA.
Comprehensive Assessments & Timing - Facility failed to complete accurate and timely comprehensive assessments upon admission for 3 residents.
Quarterly Assessment at Least Every 3 Months - Facility failed to complete and submit quarterly MDS assessments timely for 3 residents.
Encoding/Transmitting Resident Assessments - Facility failed to transmit MDS assessments timely for 6 residents.
PASARR Screening for MD & ID - Facility failed to submit Level II PASARR referrals for 2 residents.
Baseline Care Plan - Facility failed to develop baseline care plans addressing ADLs and antipsychotic medication use for 3 residents.
Develop/Implement Comprehensive Care Plan - Facility failed to develop and implement comprehensive care plans including dialysis needs and feeding assistance for residents.
Services Provided Meet Professional Standards - Facility failed to administer medications according to policy and standards for 2 residents.
ADL Care Provided for Dependent Residents - Facility failed to provide showers to a dependent resident as scheduled.
Competent Nursing Staff - Facility failed to ensure DON had competency in care planning and documentation.
Behavioral Health Services - Facility failed to assess and care plan for psychosocial needs of a resident witnessing abuse.
Treatment/Service for Dementia - Facility failed to care plan non-pharmacological interventions for a resident with dementia exhibiting yelling behavior.
Free from Unnec Psychotropic Meds/PRN Use - Facility failed to ensure psychotropic medication was care planned and had clear consent/refusal documentation for a resident.
Label/Store Drugs and Biologicals - Facility failed to ensure medications were not left unsecured at resident bedside for 1 resident.
Food Procurement, Store/Prepare/Serve-Sanitary - Facility failed to discard expired thickened dairy drink stored in dry storage.
Resident Allergies, Preferences, Substitutes - Facility failed to provide meals consistent with resident's food preferences for 1 resident.
Report Facts
Sample size: 24
Residents affected: 116
Expired thickened dairy drink boxes: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Arthur Rhodes | Administrator | Signed initial comments on report |
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Date: Mar 15, 2022
Visit Reason
The inspection was conducted as a result of a Focused Infection Control Survey and Complaint Investigation triggered by one complaint regarding resident care and infection control practices.
Complaint Details
Complaint #NV00065898 was investigated with allegations of resident falls due to lack of supervision, delayed care for a fractured hip, and delayed reporting of blood in urine. The complaint was not substantiated due to lack of evidence.
Findings
The investigation found no substantiated abuse or neglect related to the complaint. However, a deficiency was identified in infection prevention and control where an unvaccinated healthcare worker (LPN) was not correctly wearing required Personal Protective Equipment (N95 mask). The facility was otherwise compliant with healthcare worker vaccination requirements.
Deficiencies (1)
An unvaccinated healthcare worker was not correctly wearing required Personal Protective Equipment (N95 mask worn below the nose).
Report Facts
Sample size: 5
Complaint count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew A. Rhodes | Administrator | Signed the Statement of Deficiencies |
| Licensed Practical Nurse (LPN) | Unvaccinated staff member not wearing N95 mask properly | |
| Infection Preventionist | Provided explanation about PPE requirements and vaccination exemptions | |
| Director of Nursing | Interviewed during complaint investigation | |
| Executive Director | Interviewed during complaint investigation | |
| Staff inB Development Coordinator | Responsible for monitoring corrective actions |
Inspection Report
Annual Inspection
Census: 106
Deficiencies: 2
Date: Sep 16, 2021
Visit Reason
The inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey at the facility from September 13 through September 16, 2021, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility failed to ensure that physical examinations were completed prior to employment for one employee and that background checks through the Nevada Automated Background Check System (NABS) were submitted timely for two employees. No residents were affected by these deficiencies.
Deficiencies (2)
Failure to ensure physical examinations were completed prior to employment for one employee.
Failure to ensure submission of fingerprints for clearance through NABS prior to start date for two employees.
Report Facts
Employee records reviewed: 20
Deficiency severity level: 2
Deficiency scope: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Rhodes | Administrator | Named as the person responsible for ensuring the plan of correction is implemented. |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Date: Mar 2, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation and a Focused Infection Control survey in accordance with 42 CFR Part 483 for Long Term Care Facilities.
Complaint Details
Complaint #NV00063150 was substantiated. The allegation that the facility failed to provide discharge planning to ensure a resident was discharged to a safe environment was substantiated.
Findings
The facility was found to have no COVID-19 positive residents or staff at the time of the survey and had implemented infection control measures including PPE use, testing, and cleaning protocols. However, the complaint investigation substantiated that the facility failed to provide a safe discharge plan for one resident, who was discharged to an unsafe environment without proper coordination or verification of the discharge location's safety and accessibility.
Deficiencies (1)
Failure to ensure a safe discharge plan was completed for one resident, including lack of verification of discharge location safety and failure to coordinate with Adult Protective Services.
Report Facts
Census: 102
Sample size: 5
COVID testing frequency: 2
COVID testing frequency: 1
Inspection Report
Routine
Census: 78
Deficiencies: 0
Date: Nov 16, 2020
Visit Reason
This inspection was a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey initiated at the facility on 11/16/20 to assess compliance with infection control regulations.
Findings
The investigation included review of the Infection Prevention and Control Program, policies, procedures, staff and resident testing, and hygiene practices. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
COVID-19 positive residents: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the investigation | |
| Regional Administrator | Interviewed during the investigation | |
| Licensed Practical Nurse | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Date: Oct 6, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 10/06/20 in accordance with federal regulations for long term care facilities.
Complaint Details
Three complaints were investigated: #NV00060597 regarding respiratory isolation signs; #NV00061805 regarding oral care assistance, staff yelling, skin infection care, and wound dressing; and #NV00061958 regarding family notification of discharge and condition changes. All allegations were found to be unsubstantiated.
Findings
Three complaints were investigated involving allegations related to respiratory isolation signs, resident care, staff behavior, and discharge procedures. None of the allegations were substantiated and no regulatory deficiencies were identified.
Report Facts
Sample size: 5
Complaints investigated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during investigation | |
| Certified Nursing Assistant | Interviewed during investigation and involved in allegation | |
| Licensed Practical Nurse | Wound care Licensed Practical Nurse | Interviewed during investigation |
| Registered Nurses | Interviewed during investigation | |
| Director of Social Services | Interviewed during investigation |
Inspection Report
Routine
Census: 97
Deficiencies: 0
Date: Jul 9, 2020
Visit Reason
The inspection was a COVID-19 Focused Infection Control survey initiated by CMS to assess compliance with infection prevention and control requirements for long term care facilities.
Findings
No regulatory deficiencies were identified during the survey. The investigation included review of infection prevention policies, staff and resident screening, testing practices, and facility procedures related to COVID-19.
Report Facts
Census at beginning of survey: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed during the infection control survey | |
| Director of Nursing | Interviewed during the infection control survey | |
| Central Supply Director | Interviewed during the infection control survey | |
| Assistant Business Office Manager | Interviewed during the infection control survey |
Inspection Report
Follow-Up
Census: 70
Deficiencies: 0
Date: May 12, 2020
Visit Reason
This visit was a COVID-19 Follow-up Focused Infection Control survey initiated by the Centers for Medicare and Medicaid Services (CMS) to assess regulatory compliance with infection control and prevention requirements.
Findings
The investigation included reviews of resident histories, facility maps, cleaning supplies, and interviews with key staff. No regulatory deficiencies were identified during this follow-up survey, and no further action was necessary.
Report Facts
COVID-19 positive residents: 4
COVID-19 presumptive positive residents: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding facility plans and COVID-19 status | |
| Director of Nursing | Interviewed regarding facility plans and COVID-19 status | |
| Medical Director | Interviewed regarding signs and symptoms of COVID-19 |
Inspection Report
Routine
Census: 86
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
This inspection was a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey initiated at the facility to assess compliance with infection control requirements during the COVID-19 pandemic.
Findings
No regulatory deficiencies were identified during the survey. The investigation included review of infection prevention policies, staff practices, and interviews with key facility personnel.
Report Facts
Census: 86
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 6
Date: Apr 17, 2019
Visit Reason
The inspection was conducted as a Medicare Life Safety Code (LSC) recertification survey and an Emergency Preparedness survey at the facility.
Findings
The facility had several deficiencies including incorrect directional exit signage, incomplete sprinkler system maintenance, corridor doors not resisting smoke for at least 20 minutes due to mail slots, inadequate staff knowledge during fire drills, unlabeled medical gas alarm panels, and an oxygen storage closet that was not properly protected or documented. Corrective actions were planned or implemented for each deficiency.
Deficiencies (6)
Exit sign in the Denton Building kitchen pointed right instead of left towards the designated exit.
Automatic fire sprinkler system was not properly maintained; sprinkler head missing in oxygen storage closet and sprinkler head less than required distance from wall in Clean Utility Room.
Corridor door (Business Office Manager's door) had a mail slot compromising its smoke resistance capability.
Fire drills failed to ensure staff familiarity with safety procedures; staff did not respond appropriately during fire drill.
Medical gases alarm panel was not properly labeled as 'Not In Use' while oxygen piping was not in use.
Oxygen storage closet was not adequately protected or documented as one-hour fire-rated construction; oxygen tanks exceeded allowed quantity.
Report Facts
Resident census: 105
Fire drill staff questioned: 3
Mail slot length: 13
Oxygen storage quantity limit: 120
Distance of sprinkler head from wall: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed directional exit sign error, sprinkler deficiencies, oxygen storage issues, and participated in exit conference | |
| Administrator | Provided fire drill policy and acknowledged mail slot deficiency during exit conference | |
| Employee #5 | Certified Nursing Assistant | Questioned about fire drill roles and demonstrated lack of knowledge |
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 0
Date: Apr 11, 2019
Visit Reason
This inspection was conducted as a State Licensure Survey completed in conjunction with a Federal Recertification survey at the facility from April 08, 2019 through April 11, 2019.
Findings
No regulatory deficiencies were identified during the survey. Employee records were reviewed as part of the inspection.
Report Facts
Employee records reviewed: 20
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 9
Date: Apr 11, 2019
Visit Reason
This Statement of Deficiencies was generated as a result of a Medicare Recertification survey conducted from April 8, 2019 through April 11, 2019, including one complaint investigation.
Complaint Details
One complaint investigated (Complaint #NV00056202) with allegations including catheter care, fecal matter presence, pain management, call light response, falls, bedpan use, and urinary tract infection. The allegations were not substantiated.
Findings
The survey identified multiple deficiencies including failure to develop baseline care plans for Foley catheter and oxygen, failure to update fall care plans, medication administration errors, improper catheter care, inadequate respiratory monitoring, food storage violations, and infection control issues including nebulizer storage and lack of antibiotic stewardship program.
Deficiencies (9)
Failed to provide a baseline care plan for Foley Catheter and Oxygen for 2 of 21 sampled residents.
Failed to update fall care plan with most recent fall and new intervention for 1 of 21 sampled residents.
Failed to administer Humalog insulin per physician order for 1 of 21 sampled residents.
Failed to ensure catheter bag was positioned below bladder level and failed to provide education on self-catheter care for 2 residents.
Failed to monitor oxygen saturation rates and clarify conflicting oxygen orders for 2 residents.
Failed to obtain pre-dialysis weight documentation for 1 resident receiving dialysis.
Failed to store uncooked dry lasagna noodles in a sealed container; pry bar stored on top of noodles.
Failed to store nebulizer tubing in a sanitary condition and lacked a complete infection control surveillance plan.
Failed to establish an antibiotic stewardship program including antibiotic use protocols and monitoring system.
Report Facts
Sample size: 21
Deficiencies cited: 9
Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple findings including failure to develop care plans, oxygen monitoring, and infection control. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plan updates, oxygen orders, and catheter care education. |
| Medical Director | Medical Director | Interviewed regarding resident catheter care education. |
| Infection Control Nurse | Infection Control Nurse | Named in infection control findings and antibiotic stewardship program. |
| Food Service Manager | Food Service Manager | Interviewed regarding improper storage of dry lasagna noodles. |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed regarding oxygen orders and catheter care. |
| Certified Nursing Assistant | Certified Nursing Assistant | Interviewed regarding nebulizer mask storage. |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: Jan 28, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 01/28/19 regarding allegations about improper medical treatment at the facility.
Complaint Details
Complaint #NV00055660 included allegations that a physician scraped out ear wax with a paperclip and that the facility treated a resident's sore with ointment and a band-aid. Both allegations were not substantiated.
Findings
The complaint allegations were investigated through facility tour, interviews, and medical record review, and were found to be unsubstantiated. No regulatory deficiencies were identified.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Date: Oct 4, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints with multiple allegations regarding quality of care, physician services, resident rights, staffing, neglect, falsification of records, and dietary services.
Complaint Details
Two complaints were investigated with multiple allegations including over sedation, rude physician behavior, denial of visitation, call light accessibility and response, abuse/neglect, resident rights violations, insufficient staffing, malnutrition/dehydration, medication errors, inaccurate records, and insufficient food/meals skipped. None of the allegations were substantiated.
Findings
The investigation included observations, interviews with staff and residents, and document reviews. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 6
Complaints investigated: 2
Inspection Report
Renewal
Census: 106
Deficiencies: 5
Date: May 10, 2018
Visit Reason
This report was generated as a result of the Medicare recertification survey conducted from 05/07/18 to 05/10/18, including investigation of two complaints during the survey.
Complaint Details
Two complaints were investigated during the survey. Complaint #NV00051884 was substantiated related to failure to provide a 30-day notice of discharge to residents. Complaint #NV00050996 was not substantiated.
Findings
The survey identified deficiencies related to required notices and contact information, notice requirements before transfer/discharge, comprehensive assessments and timing, psychotropic medication use, and food safety requirements. One complaint was substantiated regarding failure to provide a 30-day notice of discharge to residents.
Deficiencies (5)
Required Notices and Contact Information - Resident rights to receive notices and contact information were not fully met.
Notice Requirements Before Transfer/Discharge - Facility failed to provide timely and complete discharge notices to residents.
Comprehensive Assessments & Timing - Facility failed to conduct timely comprehensive assessments for residents.
Free from Unnecessary Psychotropic Medications/PRN Use - Facility failed to ensure proper use and documentation of psychotropic medications.
Food Procurement, Store, Prepare, Serve - Facility failed to properly label chemical spray bottles and maintain food temperatures.
Report Facts
Census: 106
Sample size: 22
Complaints investigated: 2
Residents with discharge notice deficiencies: 6
Residents with wandering care plan deficiency: 1
Residents with psychotropic medication deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Signed the statement of deficiencies on 05/22/2018 | |
| Assistant Business Office Manager and Social Services Director | Confirmed sending 30-day discharge notices and Medicare Non-Coverage letters | |
| Assistant Director of Nursing (ADON) | Confirmed behavioral care plan initiation for Resident #79 | |
| MDS Coordinator | Confirmed behavioral care plan initiation for Resident #79 | |
| Food Service Director | Provided information on chemical spray bottles and food safety practices | |
| Cook | Observed food preparation and serving temperatures |
Inspection Report
Renewal
Deficiencies: 0
Date: May 8, 2018
Visit Reason
The survey was conducted as an Emergency Preparedness survey in conjunction with a Medicare recertification survey at the facility on 2018-05-08.
Findings
No deficiencies were cited during this survey.
Inspection Report
Life Safety
Capacity: 198
Deficiencies: 0
Date: May 8, 2018
Visit Reason
The survey was conducted as a Medicare Life Safety Code (LSC) and Emergency Preparedness recertification survey.
Findings
The facility was found to be fully equipped with an automatic fire sprinkler system and no deficiencies were cited during this survey.
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
Date: Oct 9, 2017
Visit Reason
The inspection was conducted as a complaint investigation following two complaints received on October 9, 2017, regarding discharge procedures, physician orders, and care concerns at the facility.
Complaint Details
Complaint #NV00049636 was unsubstantiated but noted failure to obtain physician orders and signatures on discharge summaries. Complaint #NV00050166 was unsubstantiated but noted failure to obtain physician's signature on discharge summary and no alarm on bed.
Findings
The investigation found that the facility failed to obtain physician orders for discharge and physician signatures on discharge summaries for sampled residents. Multiple allegations related to resident care, including bruising, grooming, staffing, and falsified paperwork, were reviewed but found unsubstantiated.
Deficiencies (1)
Facility failed to obtain a physician's order for discharge for 1 of 5 sampled residents and failed to obtain physician's signature on the discharge summary for 2 of 5 sampled residents.
Report Facts
Census: 110
Sample size: 5
Inspection Report
Annual Inspection
Census: 134
Deficiencies: 8
Date: Apr 13, 2017
Visit Reason
The inspection was conducted as a Medicare recertification survey on April 13, 2017, including investigation of two complaints during the survey period.
Complaint Details
Two complaints were investigated during the survey period: Complaint #NV00048887 and Complaint #NV00048329. Both complaints could not be substantiated.
Findings
The survey identified multiple deficiencies related to quality of care, treatment, pressure sore management, catheter care, accident prevention, medication storage, special needs treatment, and infection control. Several residents were found to have unmet care needs or safety risks, and corrective actions were planned.
Deficiencies (8)
Failed to follow a physician's order for padded side rails for Resident #9.
Failed to follow physician's order related to pressure sore management and failed to document physician notification for Resident #11.
Failed to change Foley catheter per physician's order for Resident #8.
Failed to ensure resident rooms were free from potential safety hazards including improper storage of gait belt and insulin syringe.
Failed to ensure medication supplies were locked and secure.
Failed to provide proper foot care and treatment for residents with special needs.
Failed to ensure physician orders were followed for oxygen administration for multiple residents.
Failed to establish an infection prevention and control program meeting regulatory requirements.
Report Facts
Sample size: 29
Residents sampled: 28
Residents sampled: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named as individual responsible for corrective actions related to multiple deficiencies. | |
| Staff Development Coordinator | Named as individual responsible for corrective actions related to multiple deficiencies. | |
| Registered Nurse | RN | Acknowledged side rails did not have pads and confirmed medication storage issues. |
| Licensed Practical Nurse | LPN | Verified heels were not floated and confirmed oxygen tubing observations. |
| Assistant Director of Nursing | ADON | Verified resident lying in bed without anti-contracture boot and confirmed catheter order was not followed. |
| Director of Rehabilitation Services | Confirmed gait therapy belt was a safety issue. |
Inspection Report
Life Safety
Capacity: 198
Deficiencies: 6
Date: Apr 4, 2017
Visit Reason
This document is a Medicare Life Safety Code (LSC) recertification survey conducted to assess the facility's compliance with fire safety standards, specifically the NFPA 101 Life Safety Code, 2012 edition.
Findings
The facility was found deficient in maintaining the automatic fire sprinkler system, portable fire extinguishers, corridor doors, fire drills, electrical equipment, and gas equipment storage. Multiple sprinkler system issues were observed in two smoke compartments affecting residents, staff, and guests. Corrective actions were planned and assigned to the Director of Environmental Services.
Deficiencies (6)
NFPA 101 Sprinkler System - Installation: Sprinkler escutcheons were hanging loose, missing, or obstructed; fire department connection was obstructed and lacked signage.
Portable Fire Extinguishers: Facility failed to install portable fire extinguishers in designated smoking areas.
NFPA 101 Corridor - Doors: Doors protecting corridor openings did not close properly due to tape over door jam.
NFPA 101 Fire Drills: Facility failed to conduct fire drills at unexpected times and staff were unfamiliar with fire response procedures.
NFPA 101 Electrical Equipment - Power Cords and Extension Cords: Facility failed to maintain electrical wiring and equipment in compliance with NFPA 70.
NFPA 101 Gas Equipment - Cylinder and Container Storage: Facility failed to display required precautionary signs on storage room doors.
Report Facts
Licensed capacity: 198
Dates of survey: Survey conducted on 04/04/17 and 04/05/17
Date of completion for corrective actions: May 20, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Environmental Services | Named as individual responsible for corrective actions and acknowledged deficiencies at time of discovery | |
| Director of Environmental Dietary Services | Acknowledged deficiencies related to fire extinguishers and corridor doors |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Date: Jan 18, 2017
Visit Reason
The inspection was conducted as a result of a complaint investigation involving three complaints with multiple allegations including resident abuse, medication errors, falsified records, insufficient supplies, injury of unknown origin, resident neglect, and quality of care concerns.
Complaint Details
Three complaints were investigated: Complaint #NV00047754 with four allegations, Complaint #NV00047552 with one allegation, and Complaint #NV00047473 with four allegations. All allegations were unsubstantiated.
Findings
The investigation included review of three resident records, interviews with key facility staff, and policy review. All allegations were found to be unsubstantiated and no regulatory deficiencies were identified. No further action was necessary.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 0
Date: Sep 22, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations about a resident's air mattress not being implemented until discharge and wound care documentation issues.
Complaint Details
Complaint # NV00046846 included two allegations: 1) a resident's air mattress was not implemented until discharge, and 2) a resident's wound care was not documented. Both allegations were not substantiated after interviews and record reviews.
Findings
The complaint investigation found that the allegations could not be substantiated and no regulatory deficiencies were identified. No further action was necessary.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Date: Jul 6, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding an allegation of resident client neglect and injury of unknown origin.
Complaint Details
Complaint #NV00046059 involved an allegation of resident client neglect and injury of unknown origin, which was not substantiated.
Findings
The complaint was investigated through record review and interviews with the Director of Nursing and acting Administrator. The allegation was not substantiated and no deficiencies were identified.
Report Facts
Complaint count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the complaint investigation | |
| acting Administrator | Interviewed during the complaint investigation |
Inspection Report
Life Safety
Deficiencies: 0
Date: May 2, 2016
Visit Reason
The survey was conducted as a Medicare Life Safety Code (LSC) survey to assess compliance with Chapter 19, EXISTING Health Care Occupancies, of the 2000 Edition of the National Fire Protection Association's (NFPA) 101, Life Safety Code.
Findings
No deficiencies were cited during this survey.
Inspection Report
Annual Inspection
Census: 134
Deficiencies: 4
Date: Apr 25, 2016
Visit Reason
The inspection was conducted as an annual Medicare Recertification Survey from April 25, 2016 through April 28, 2016, in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.
Findings
The survey identified multiple deficiencies related to resident care including failure to prevent decrease in range of motion, failure to ensure drug regimens were free from unnecessary drugs, failure to ensure proper medication dose reductions, and failure to maintain proper drug records and infection control practices. Corrective actions and plans of correction were outlined for affected residents and systemic changes to prevent recurrence were described.
Deficiencies (4)
Facility failed to identify and ensure a resident with a contracture was assessed properly and treated to prevent decrease in range of motion.
Facility failed to ensure residents' drug regimens were free from unnecessary drugs, including failure to ensure gradual dose reductions of antipsychotic medications.
Facility failed to maintain drug records, label/store drugs and biologicals properly, and failed to remove expired medications from access.
Facility failed to establish and maintain an infection control program and failed to ensure staff and family members followed infection control policies.
Report Facts
Census: 134
Sample size: 25
Date range: 4
Date of completion for corrective actions: 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marvelle Harris | Administrator | Signed the statement of deficiencies on 5/11/16 |
| Director of Nursing | Named as individual responsible for corrective actions related to contracture management and medication issues | |
| Director of Therapy | Named as individual responsible for corrective actions related to contracture management | |
| Staff Development Coordinator | Named as individual responsible for corrective actions related to contracture management and medication issues | |
| Director of Social Services | Named as individual responsible for corrective actions related to medication issues | |
| Infection Control Nurse | Named as individual responsible for corrective actions related to infection control |
Inspection Report
Annual Inspection
Census: 129
Deficiencies: 5
Date: May 7, 2015
Visit Reason
This Statement of Deficiencies was generated as a result of an annual Medicare Recertification Survey conducted from May 4, 2015 through May 7, 2015, in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.
Complaint Details
Three complaints were investigated during the survey period. Complaint #NV000042036 contained one allegation which was not substantiated. Complaint #NV000042054 contained four allegations which were not substantiated. Complaint #NV000040736 contained one allegation which was not substantiated.
Findings
The survey investigated three complaints, none of which were substantiated. Multiple deficiencies were identified related to resident care, medication administration, drug regimen, infection control, and drug storage and labeling.
Deficiencies (5)
Facility failed to ensure a swallow evaluation was completed in a timely manner for Resident #9.
Facility failed to ensure residents who have not used antipsychotic drugs are not given these drugs unless clinically necessary, affecting Residents #17 and #8.
Facility failed to ensure a physician addressed pharmacist recommendations for Resident #8.
Facility failed to properly secure medications for 4 of 15 resident rooms observed and proper labeling of drugs and biologicals.
Facility failed to ensure infection control practices were followed for hand washing and use of gloves.
Report Facts
Residents sampled: 28
Residents affected: 24
Deficiency completion dates: Multiple corrective action completion dates ranged from June 14, 2015 to June 26, 2015.
Inspection Report
Annual Inspection
Census: 129
Deficiencies: 5
Date: May 7, 2015
Visit Reason
The inspection was conducted as an annual Medicare Recertification Survey from May 4, 2015 through May 7, 2015, including investigation of three complaints during the survey period.
Complaint Details
Three complaints were investigated during the survey period. Complaint #NV000042036 with one allegation of failure to protect resident with safe discharge was not substantiated. Complaint #NV000042054 with four allegations including improper infection control, failure to assess and monitor resident condition, failure to provide adequate personal care, and nursing services professional standards not met were all not substantiated. Complaint #NV000040736 with one allegation that resident was not informed of discharge to another facility was not substantiated.
Findings
The facility was found to have multiple deficiencies including failure to complete timely swallow evaluations, improper use and monitoring of psychotropic medications, failure to act on pharmacist recommendations, improper medication storage and labeling, and lapses in infection control practices such as inadequate hand hygiene.
Deficiencies (5)
Failure to ensure a swallow evaluation was completed in a timely manner for 1 of 24 residents (Resident #9).
Failure to ensure residents received comprehensive assessment and documentation prior to administration of psychotropic medications for 2 of 24 residents (Resident #17 and #8).
Failure to ensure physician addressed pharmacist recommendations for 1 of 24 residents (Resident #8).
Failure to ensure medications were properly secured and labeled in 4 of 15 resident rooms observed (Residents #9, #26, #27, and #28).
Failure to ensure infection control practices were followed for hand washing during resident care.
Report Facts
Residents sampled: 28
Psychotropic medication refusals: 3
Xanax administrations: 21
Xanax medication interventions: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Rehabilitation Services | Confirmed swallow evaluation order and delay for Resident #9 | |
| Nurse Manager | Interviewed regarding psychotropic medication use and complaint investigations | |
| Licensed Practical Nurse (LPN) | Interviewed regarding nervousness signs and medication administration for Resident #8 | |
| Registered Nurse (RN) | Confirmed medication storage issues and pharmacist recommendation not addressed | |
| Licensed Nurse (LN) | Observed failing to follow hand hygiene protocols during gastrostomy tube dressing change | |
| Director of Nursing | Confirmed physician did not address pharmacist recommendation and psychotropic medication meeting procedures | |
| Licensed Social Worker (LSW) | Interviewed regarding complaint investigations and psychotropic medication meeting |
Inspection Report
Routine
Deficiencies: 1
Date: May 7, 2015
Visit Reason
The inspection was conducted to assess compliance with clinical record-keeping requirements, specifically regarding documentation of daily catheter care for residents.
Findings
The facility failed to ensure accurate documentation of daily catheter care for one sampled resident with a supra-pubic catheter, despite orders requiring daily care. Licensed nursing staff confirmed catheter care was performed daily, but documentation was incomplete.
Deficiencies (1)
Failure to ensure accuracy of clinical records for documenting daily catheter care for one resident.
Report Facts
Sampled residents: 24
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | Confirmed physician orders for daily catheter care | |
| Licensed nurse | Confirmed catheter care was being done daily |
Inspection Report
Life Safety
Deficiencies: 0
Date: May 13, 2014
Visit Reason
This survey was conducted as a Medicare Life Safety Code (LSC) survey to assess compliance with Chapter 19, EXISTING Health Care Occupancies, of the 2000 Edition of the National Fire Protection Association's (NFPA) 101, Life Safety Code.
Findings
No deficiencies were cited during this Life Safety Code survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 25, 2014
Visit Reason
This survey was conducted as a Medicare Life Safety Code (LSC) survey to assess compliance with Chapter 19, EXISTING Health Care Occupancies, of the 2000 Edition of the NFPA 101 Life Safety Code.
Findings
There were no deficiencies cited during this Life Safety Code survey.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Feb 19, 2014
Visit Reason
The inspection was conducted as a State Licensure Survey in conjunction with a federal recertification survey at the facility from 2/19/2014 through 2/24/2014 to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility failed to ensure proper infection control practices, including inadequate use of barriers and cleaning during medication administration for a resident with C-diff, improper handling of food items dropped on the floor, and failure to keep catheter bags off the floor. Observations and interviews confirmed these lapses in infection control and policy adherence.
Deficiencies (4)
Failure to ensure staff followed infection control practices regarding contact infection precautions for one resident, including improper handling of medication containers and lack of cleaning before returning items to common areas.
Failure to discard food items dropped on the floor, as observed with cereal boxes being placed back on resident trays after falling.
Failure to keep catheter collection bags off the floor as required by facility policy.
Failure to consistently follow hand hygiene protocols during glucometer blood testing.
Report Facts
Survey duration days: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #5 | Licensed Practical Nurse (LPN) | Observed and interviewed regarding glucometer blood testing and hand hygiene practices |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 1
Date: Aug 28, 2013
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 8/28/13 regarding allegations of medications not being given timely.
Complaint Details
Complaint #NV00036369 was substantiated regarding medications not being given timely.
Findings
The facility failed to ensure timely administration of pain medication for 2 of 6 residents reviewed, specifically Resident #2 and Resident #4, resulting in substantiated medication timing deficiencies.
Deficiencies (1)
Facility failed to ensure residents were given pain medication in a timely manner for 2 of 6 residents.
Report Facts
Census: 131
Residents reviewed for pain medication: 6
Residents with untimely pain medication: 2
Date of Completion: Jan 17, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed on 8/28/13 regarding authorization process for narcotic medications |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 1
Date: Aug 28, 2013
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegation #NV00036369 regarding medications not being given in a timely manner.
Complaint Details
Complaint #NV00036369 was substantiated regarding medications not being given timely.
Findings
The facility failed to ensure timely administration of pain medication for 2 of 6 residents reviewed. Specifically, delays in pain medication delivery and authorization from the pharmacy caused residents to experience unmanaged pain, leading one resident to leave the facility against medical advice.
Deficiencies (1)
Failure to provide pain medication in a timely manner for 2 of 6 residents.
Report Facts
Census: 131
Residents reviewed for pain medication timeliness: 6
Residents with delayed pain medication: 2
Pain rating: 8
Pain rating: 9
Time delay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed on 8/28/13 regarding medication authorization delays |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Date: Apr 2, 2013
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations that the facility failed to properly care for a resident's pressure sores.
Complaint Details
Complaint #NV000 35017 involved allegations that the facility failed to properly care for Resident #1's pressure sores. The allegation was unsubstantiated.
Findings
The allegation was found to be unsubstantiated based on observation, interview, and record review. The resident was admitted with several pressure sores and appropriate individualized interventions were only partially effective due to the resident's numerous co-morbidities and fragile condition. No violations of regulations were found.
Report Facts
Resident files reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed during the investigation | |
| Director of Nurses | Interviewed during the investigation | |
| Wound Care Nurses | Two wound care nurses interviewed during the investigation | |
| Staff Nurse | Interviewed during the investigation | |
| Certified Nursing Assistant | Interviewed during the investigation |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 3, 2013
Visit Reason
This survey was conducted as a Medicare Life Safety Code (LSC) survey to assess compliance with the National Fire Protection Association's (NFPA) 101, Life Safety Code.
Findings
No deficiencies were cited during this Life Safety Code survey conducted on 1/3/13 and 1/4/13.
Inspection Report
Annual Inspection
Census: 113
Deficiencies: 6
Date: Jan 2, 2013
Visit Reason
The inspection was conducted as the annual Medicare recertification survey from January 2, 2013 through January 8, 2013, including one complaint investigation during the survey period.
Complaint Details
Complaint #NV 00034242 alleged failure to obtain consent and orders for a physical restraint. The complaint was substantiated after medical record review, policy review, and staff interview.
Findings
Multiple deficiencies were identified including failure to obtain informed consent and physician orders for physical restraints and psychotropic medications, inadequate housekeeping and maintenance services, failure to meet professional standards in medication administration, unsecured medication carts, inadequate infection control practices, and incomplete clinical records documentation.
Deficiencies (6)
Failure to obtain consent and physician's order for physical restraint and psychotropic medication for residents.
Failure to maintain housekeeping and maintenance services for resident dining tables.
Failure to ensure licensed nursing staff provided care at professional standards regarding medication administration and physician notification.
Failure to secure medication and treatment carts and ensure proper medication storage and security.
Failure to maintain an effective infection control program including cleaning and disinfection of reusable equipment and isolation rooms.
Failure to maintain complete, accurate, and accessible clinical records for residents.
Report Facts
Census: 113
Sample size: 28
Medical records reviewed: 23
Date of completion: Feb 22, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #6 | Licensed Practical Nurse (LPN) | Involved in medication administration deficiencies and education. |
| Employee #8 | Licensed Practical Nurse (LPN) | Observed administering medications incorrectly and involved in medication administration deficiencies. |
| Employee #9 | Licensed Practical Nurse (LPN) | Interviewed regarding medication cart security and medication administration. |
| Employee #10 | Infection Control Nurse | Interviewed regarding infection control practices and cleaning procedures. |
| Employee #11 | Housekeeper | Interviewed regarding cleaning procedures for isolation and non-isolation rooms. |
| Employee #12 | Housekeeper | Interviewed regarding cleaning procedures and use of toilet bowl brushes. |
| Employee #13 | Director of Housekeeping | Interviewed regarding storage of cleaning equipment and infection control. |
| Director of Nursing | Director of Nursing | Interviewed regarding restraint procedures and medication cart security; responsible party for corrective actions. |
| Executive Director | Executive Director | Interviewed regarding findings and responsible party for corrective actions. |
Inspection Report
Annual Inspection
Census: 113
Deficiencies: 6
Date: Jan 2, 2013
Visit Reason
The inspection was conducted as an annual Medicare recertification survey from January 2 through January 8, 2013, including investigation of one complaint regarding failure to obtain consent and orders for physical restraint.
Complaint Details
Complaint #NV 00034242 alleged failure to obtain consent and orders for a physical restraint. The complaint was substantiated based on medical record review, policy review, and staff interviews.
Findings
The facility was found deficient in obtaining informed consent and physician orders for physical restraints and psychotropic medications for certain residents. Additional deficiencies included housekeeping and maintenance issues, failure to meet professional standards in medication administration, failure to secure drugs properly, and inadequate infection control practices.
Deficiencies (6)
Failure to obtain consent and a physician's order for a physical restraint and psychotropic medication for residents.
Failure to provide housekeeping and maintenance services to maintain sanitary, orderly, and comfortable interior.
Failure to ensure licensed nursing staff provided care at professional standards regarding medication administration through feeding tubes and physician notification.
Failure to secure drugs in a locked compartment; medication carts found unlocked and unattended.
Failure to establish and maintain an infection control program to prevent spread of infection and maintain sanitary environment.
Failure to maintain clinical records accurately and completely for residents.
Report Facts
Residents in sample size: 28
Residents reviewed for complaint investigation: 23
Residents with consent/order deficiencies: 2
Residents affected by infection control deficiencies: 3
Inspection Report
Complaint Investigation
Census: 117
Capacity: 138
Deficiencies: 0
Date: Oct 31, 2012
Visit Reason
The inspection was conducted as a result of complaint investigations regarding allegations of linens not being changed, handwashing/sanitizing not done, and physician neglect for Resident #1.
Complaint Details
Complaint #NV000 33163 included allegations that linens were not changed, handwashing/sanitizing was not done, and the physician did not act for Resident #1. Additional allegation was that staff delayed contacting emergency services for Resident #2. All allegations were found unsubstantiated based on observations, interviews, and record reviews.
Findings
The investigation found that linens were changed as needed and the facility was clean. Staff were sanitizing their hands between patient contacts, though housekeeping noted a need to replenish sanitizer dispensers more often. Resident #1 was seen multiple times by medical staff with new orders carried out. Allegations related to Resident #1 were unsubstantiated. For Resident #2, who had respiratory failure and was declining, the physician was notified immediately upon condition change and emergency services were called promptly. Allegations of delay in emergency contact were unsubstantiated.
Report Facts
Licensed capacity: 138
Census: 117
Patient stay duration: 17
Number of resident files reviewed: 12
Number of times Resident #1 seen by physician: 2
Number of times Resident #1 seen by nurse practitioner: 3
Number of days new orders given for Resident #1: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Interviewed during investigation | |
| Assistant Director of Nurses | Interviewed during investigation | |
| Housekeeper | Interviewed during investigation | |
| Staff Nurse | Interviewed during investigation and involved in emergency services call | |
| Staff Development Coordinator | Interviewed during investigation | |
| Physician | Interviewed during investigation and involved in Resident #1 and #2 care |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 138
Deficiencies: 0
Date: May 23, 2012
Visit Reason
The inspection was conducted as a result of a complaint investigation (Complaint #30921) regarding allegations of infection control issues, delayed physician notification, feeding tube problems, insufficient fluids, and low antibiotic dosage for Resident #1.
Complaint Details
Complaint #30921 involved allegations of C-diff infection, delayed physician notification, feeding tube clogging requiring ER visits, insufficient fluids, and low antibiotic dosage. The complaint was not substantiated as no violations were found.
Findings
The investigation found that the resident left the facility multiple times, making infection source unclear. The facility was under a plan of correction for infection control from a prior annual survey and could not be cited again. Physician notification and orders were timely after symptoms appeared. Appropriate actions were taken for feeding tube issues and hydration. No violations of regulations were found.
Report Facts
Licensed capacity: 138
Census: 119
Resident facility exits: 3
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 3
Date: Mar 8, 2012
Visit Reason
This inspection was conducted as an annual Medicare Recertification survey in accordance with 42 CFR Chapter IV Part 483 for States and Long Term Care Facilities, covering the period from March 5, 2012 to March 8, 2012.
Findings
The facility was found to have multiple deficiencies including failure to prevent administration of an antibiotic to a resident with a documented allergy, unsanitary food procurement and preparation conditions, and inadequate infection control practices related to cleaning agents and procedures. Corrective actions and education plans were outlined for dietary, nursing, and housekeeping staff to address these issues.
Deficiencies (3)
Failure to prevent administration of an antibiotic to a resident with a documented allergy.
Failure to maintain clean and sanitary conditions in the dietary department, nourishment storage areas, and main dining room.
Failure to establish and maintain an effective Infection Control Program, including improper use of disinfectants and inadequate cleaning procedures.
Report Facts
Census: 120
Sample size: 24
Date range: Survey conducted from March 5, 2012 to March 8, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Machelle Harris | Executive Director | Signed the Statement of Deficiencies on 3/22/12 |
| Employee #3 | Dietary Manager/Food Service Manager | Involved in dietary observations and education |
| Employee #7 | Licensed Practical Nurse (LPN) | Observed during medication administration and cleaning process |
| Employee #8 | Housekeeper | Observed cleaning patient rooms and interviewed about cleaning agents |
| Employee #5 | Housekeeping Supervisor | Interviewed regarding cleaning products and procedures |
| Employee #4 | Infection Control Coordinator/Nurse | Interviewed regarding infection control practices and cleaning agents |
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 3
Date: Mar 8, 2012
Visit Reason
This inspection was conducted as an annual Medicare Recertification survey in accordance with 42 CFR Chapter IV Part 483 for States and Long Term Care Facilities.
Findings
The facility was found deficient in multiple areas including failure to prevent administration of an antibiotic to a resident with a known allergy, unsanitary conditions in the dietary department and nourishment storage areas, inadequate infection control practices including improper cleaning agents used against C. difficile, and improper handling of ice and medical equipment.
Deficiencies (3)
Failed to prevent administration of an antibiotic listed as an allergen to a resident.
Failed to maintain clean and sanitary conditions in the dietary department, nourishment storage areas, and main dining room.
Failed to establish and maintain an Infection Control Program to prevent spread of infection, including improper cleaning agents used against C. difficile and inadequate infection control practices.
Report Facts
Sample size: 24
Antibiotic dosage: 500
Completion date for plan of correction: 2012
Percentage of glycolic acid in toilet brush: 11.185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Dietary Manager | Acknowledged findings related to dietary sanitation and ice handling |
| Employee #4 | Infection Control Coordinator/Nurse | Responsible for infection control program, unaware of ineffective cleaning agents used |
| Employee #5 | Housekeeping Supervisor | Unaware that cleaning product did not contain bleach |
| Employee #7 | Licensed Practical Nurse (LPN) | Observed not cleaning blood pressure cuff and stethoscope between uses |
| Employee #8 | Housekeeper | Observed cleaning patient rooms including isolation rooms with ineffective disinfectants |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 6, 2012
Visit Reason
The inspection was conducted as a Medicare Life Safety Code (LSC) survey to assess compliance with NFPA 101 Life Safety Code standards for existing health care occupancies.
Findings
The facility failed to maintain fire extinguishers in working condition for 3 of 13 extinguishers in the Landa building and 1 of 10 extinguishers in the Denton building. The Maintenance Director confirmed annual service was performed on 2/9/12, but the units in question were re-serviced on 3/6/12 due to faulty O-rings.
Deficiencies (1)
Failed to maintain fire extinguishers in working condition for 3 of 13 extinguishers in the Landa building and 1 of 10 extinguishers in the Denton building.
Report Facts
Fire extinguishers needing service: 4
Total fire extinguishers in Landa building: 13
Total fire extinguishers in Denton building: 10
Date of annual fire extinguisher service: Feb 9, 2012
Date of re-service for deficient extinguishers: Mar 6, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding fire extinguisher service and deficiencies |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 5, 2012
Visit Reason
The inspection was conducted as a Medicare Life Safety Code (LSC) survey to assess compliance with fire safety standards at the Life Care Center of Reno.
Findings
The facility failed to maintain fire extinguishers in working condition in multiple locations, including the Landa and Denton buildings. The Maintenance Director arranged for re-servicing of the extinguishers during the survey.
Deficiencies (1)
Portable fire extinguishers were not maintained in working condition in several locations, including the corridor across from the private dining room, activities room on the back wall, corridor outside the conference room, and corridor across from the occupational therapy room.
Report Facts
Fire extinguishers failed: 4
Date of service: Mar 6, 2012
Date of annual service: Feb 9, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Machelle Stanie | Signed as Laboratory Director or Provider/Supplier Representative | |
| Maintenance Director | Interviewed regarding fire extinguisher service and responsible for monitoring compliance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 18, 2012
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 01/18/2012, focusing on allegations including unanswered call bells, pain medication not given as requested, poor quality of colostomy care, falls due to poor quality of care, and facility-acquired infections.
Complaint Details
Complaint #NV00029871 alleging call bells not being answered and pain medication not given as requested were not substantiated. Complaint #NV000300445 alleging falls due to poor quality of care and facility-acquired infection were not substantiated. The allegation of poor quality of colostomy care was substantiated.
Findings
The investigation found that the allegations regarding call bells and pain medication were not substantiated due to lack of evidence, while the allegation of poor quality of colostomy care was substantiated. The facility failed to have a system in place to ensure colostomys were assessed and care was routinely performed for residents with colostomys.
Deficiencies (1)
Facility failed to have a system in place that insured colostomys were assessed and failed to ensure colostomy care was routinely performed for 2 of 2 sampled residents with colostomys.
Report Facts
Sample size: 8
Resident age: 71
Date of admission: Sep 6, 2011
Plan of Correction completion date: Feb 29, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Macarena G. Harris | Executive Director | Signed the Statement of Deficiencies |
| RN #1 | Interviewed regarding colostomy care and scheduling | |
| CNA #1 | Interviewed about colostomy care practices | |
| CNA #2 | Interviewed about colostomy care practices and resident transfer | |
| LPN #1 | Interviewed about nursing care during resident's ER visit | |
| Director of Nursing | Director of Nursing | Responsible individual for corrective actions in Plan of Correction |
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 1
Date: Jan 18, 2012
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by allegations including call bells not being answered, pain medication not given as requested, poor quality of colostomy care, falls due to poor quality of care, and facility acquired infections.
Complaint Details
Complaint #NV00029871 included allegations of call bells not being answered, pain medication not given as requested, and poor quality of colostomy care; only the colostomy care allegation was substantiated. Complaint #NV00030445 included allegations of falls due to poor care and facility acquired infections; these were not substantiated.
Findings
The investigation found that allegations regarding call bells, pain medication, falls, and facility acquired infections were not substantiated due to lack of evidence. However, poor quality of colostomy care was substantiated due to failure to have a system ensuring routine assessment and care of colostomies for 2 sampled residents.
Deficiencies (1)
Facility failed to have a system in place to ensure colostomies were assessed and colostomy care was routinely performed for 2 of 2 sampled residents with colostomies.
Report Facts
Sample size: 8
Clinical records reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding colostomy care practices |
| CNA #1 | Certified Nursing Assistant | Interviewed about colostomy care frequency and procedures |
| CNA #2 | Certified Nursing Assistant | Interviewed about colostomy care frequency and procedures |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding knowledge of resident's colostomy condition at discharge |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 14, 2011
Visit Reason
The inspection was conducted as a Medicare complaint investigation regarding allegations of dirty dishes at the facility.
Complaint Details
Complaint NV00029222: The allegation regarding dirty dishes was not substantiated.
Findings
The allegation regarding dirty dishes was not substantiated based on observations of two kitchens, staff and resident interviews, and document review. No violations of regulations were found.
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 0
Date: Oct 3, 2011
Visit Reason
The inspection was conducted as a result of a Medicare complaint investigation at the facility on 2011-10-03, completed on 2011-10-18, to investigate allegations of lack of quality care regarding medication administration, assessment and treatment of a urinary tract infection, and provision of nutrition and hydration.
Complaint Details
Three complaints were investigated: 1) failure to administer medications as ordered and failure to notify family when resident failed to take medications; 2) failure to properly assess and treat a urinary tract infection; 3) failure to provide nutrition and hydration to a resident. All complaints were unsubstantiated.
Findings
The investigation included interviews and review of clinical and hospital records. All complaints were found to be unsubstantiated, and no regulatory deficiencies were identified.
Report Facts
Census: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed during complaint investigations | |
| Director of Nursing | Interviewed during complaint investigations | |
| Unit Manager | Interviewed during complaint investigations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 21, 2011
Visit Reason
The inspection was conducted as a Medicare complaint investigation regarding quality of care and discharge planning at the facility.
Complaint Details
Complaint NV 0028102: The complaint allegation regarding quality of care was unsubstantiated. The complaint allegation regarding discharge planning and rights was unsubstantiated.
Findings
The complaint allegations regarding quality of care and discharge planning were unsubstantiated through record review and interviews. No regulatory deficiencies were identified.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 24, 2010
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 3/24/2010, in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing.
Complaint Details
Complaint #NV00024719 was unsubstantiated.
Findings
Complaint #NV00024719 was unsubstantiated and no regulatory deficiencies were identified during the investigation.
Inspection Report
Annual Inspection
Census: 179
Deficiencies: 14
Date: Jan 29, 2010
Visit Reason
Annual Medicare recertification survey conducted from 1/25/10 through 1/29/10 to assess compliance with 42 CFR Chapter IV Part 483 Requirements for long Term Care Facilities.
Findings
The facility was found deficient in multiple areas including informed consent for psychotropic medications, personal privacy breaches, physical restraint consent, dignity and respect, reasonable accommodation of needs, activities programming, provision of medically-related social services, comprehensive care planning, medication administration errors, food safety and sanitation, infection control practices, and medication error rates exceeding 5%.
Deficiencies (14)
Failed to ensure 3 of 27 residents or their legal representatives were informed of the risks and benefits of psychotropic medications.
Failed to ensure resident information was consistently maintained in a confidential manner.
Failed to obtain proper consent before implementing a physical restraint for 1 of 32 residents.
Failed to ensure staff consistently knocked on doors before entering resident rooms and served meals in a way to promote resident dignity.
Failed to provide needed transportation for 1 of 5 unsampled residents.
Failed to provide activities meeting interests and needs for 2 of 27 residents who spent most of the day in their rooms.
Failed to provide medically-related social services to meet psychosocial well-being for 4 of 27 residents.
Failed to develop a comprehensive care plan for communication for 2 of 27 residents.
Failed to develop a comprehensive care plan for hospice for 1 of 27 residents.
Failed to ensure services provided met professional standards of quality including following physician orders, medication administration, recaps, and special diet needs for 4 of 27 residents.
Failed to ensure food was palatable, attractive, and at the proper temperature during one of two main dining observations.
Failed to ensure food was prepared under sanitary conditions including sanitizer levels, storage of cups, cracked bin covers, and ice handling.
Failed to ensure proper infection control practices including hand hygiene during meal service, proper handling of blood specimens, cohorting policies, and reporting of communicable diseases.
Failed to ensure medication error rates were below 5%, with a 10% error rate observed during medication passes.
Report Facts
Census: 179
Sample size: 27
Medication error rate: 10
Medication errors: 5
Medication administration opportunities: 48
Temperature: 100
Temperature: 102
Temperature: 108
Temperature: 140
Temperature: 68.1
Freezer temperature: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Agreed informed consent for Effexor should have been obtained | |
| Licensed Practical Nurse (LPN) Employee #5 | Confirmed offsetting MAR pages exposed resident information | |
| Dietary Manager Employee #11 | Interviewed about meal service and food temperatures | |
| Social Worker Employee #2 | Interviewed regarding psychosocial services and family contact | |
| Activities Director Employee #7 | Interviewed about activities programming | |
| Resident Care Manager Employee #3 | Confirmed sliding scale insulin coverage should have been followed | |
| Med pass nurse Employee #1 | Interviewed about medication refusals and administration | |
| Speech Therapist Employee #19 | Interviewed about swallowing and thickened liquids | |
| Dietary Aide Employee #20 | Interviewed about preparation of thickened liquids | |
| Licensed Practical Nurse Employee #22 | Observed placing blood specimens on counter | |
| Infection Control Nurse Employee #21 | Observed wound care and infection control practices | |
| Certified Nursing Assistant Employee #10 | Observed handling water pitchers without hand hygiene |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 27, 2010
Visit Reason
The inspection was conducted as a Medicare Life Safety Code (LSC) survey using Chapter 19, EXISTING Health Care Occupancies, of the 2000 Edition of the NFPA 101 Life Safety Code.
Findings
No deficiencies were cited during this Life Safety Code survey conducted on 1/26/10 and 1/27/10.
Inspection Report
Annual Inspection
Census: 179
Deficiencies: 11
Date: Jan 25, 2010
Visit Reason
This report documents the annual Medicare recertification survey conducted at the facility from January 25, 2010 through January 29, 2010, to assess compliance with federal regulations for long term care facilities.
Findings
The survey identified multiple deficiencies related to informed consent for psychotropic medications, personal privacy and confidentiality of records, physical restraints, dignity and respect of individuality, reasonable accommodation of needs, provision of medically related social services, medication error rates, food procurement and sanitation, infection control, and comprehensive care planning. The facility failed to meet several regulatory requirements as evidenced by observations, record reviews, and interviews.
Deficiencies (11)
Facility failed to ensure 3 of 27 residents or their legal representatives were informed of the risks and benefits of psychotropic medications.
Facility failed to ensure resident information was consistently maintained in a confidential manner.
Facility failed to obtain proper consent before implementing a physical restraint for 1 of 32 residents.
Facility failed to ensure staff consistently knocked on doors before entering resident rooms and served meals in a manner promoting dignity.
Facility failed to provide needed transportation for 1 of 5 unsampled residents.
Facility failed to provide activities meeting interests and needs for 2 of 27 residents.
Facility failed to provide medically-related social services to meet psychosocial well-being for 4 of 27 residents.
Facility failed to develop comprehensive care plans for 2 of 27 residents.
Facility failed to ensure medication error rates were below 5%, with a 10% error rate observed during medication passes.
Facility failed to ensure food was prepared and stored under sanitary conditions.
Facility failed to maintain infection control practices to prevent spread of disease and contamination.
Report Facts
Residents present: 179
Sample size: 27
Medication error rate: 10
Residents with deficiencies: 3
Residents with deficiencies: 1
Residents with deficiencies: 4
Residents with deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #13 | Nurse on duty | Confirmed Resident #2 had been receiving Effexor without signed consent |
| Employee #5 | Licensed Practical Nurse (LPN) | Confirmed offsetting MAR pages revealed resident medical information |
| Employee #2 | Social Worker | Interviewed regarding social services and resident family contacts |
| Employee #1 | Med pass nurse | Interviewed about medication refusals and administration |
| Employee #21 | Infection Care Nurse | Observed wound care and infection control practices |
| Employee #22 | Infection Control Nurse | Educated staff on infection control and observed specimen handling |
| Employee #3 | Resident Care Manager | Interviewed about infection control and resident care |
| Employee #9 | Director of Nursing | Discussed Resident #11's condition and care plan |
| Employee #7 | Activities Director | Acknowledged Resident #2 did not receive planned room visits |
| Employee #6 | Nurse Unit Manager | Interviewed about missing dentures and complaint follow-up |
| Employee #15 | Medication Nurse | Prepared medications and educated on medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 18, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 12/18/09.
Complaint Details
Complaint #NV00023899 was substantiated with no deficiencies cited.
Findings
The complaint #NV00023899 was substantiated but no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 9, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 12/9/09, finalized on 12/23/09, in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing.
Complaint Details
Complaint #NV00023819 was investigated and found to be unsubstantiated.
Findings
The complaint #NV00023819 was unsubstantiated. No deficiencies were cited in this report.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 1, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 12/1/09.
Complaint Details
Complaint #NV00023608 was investigated and determined to be unsubstantiated.
Findings
The complaint #NV00023608 was found to be unsubstantiated. No deficiencies are explicitly cited in the report.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 31, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 08/31/2009.
Complaint Details
Complaint #NV00022864 was investigated and found to be unsubstantiated.
Findings
The complaint #NV00022864 was unsubstantiated and no regulatory deficiencies were identified during the investigation.
Notice
Deficiencies: 1
Date: Jun 3, 2009
Visit Reason
The document serves as a notice to the facility administrator that the Health Division intends to impose sanctions due to regulatory deficiencies identified in a prior survey.
Findings
The Health Division is imposing monetary penalties based on the severity and scope of deficiencies found during a survey, with a total penalty of $400. The Plan of Correction submitted by the facility was reviewed and deemed acceptable.
Deficiencies (1)
Deficiency at TAG Z230 with a severity level of three and a scope level of two or less
Report Facts
Monetary penalty amount: 400
Penalty reduction percentage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Cavanagh | Health Facilities Surveyor III | Signed the notice imposing sanctions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 8, 2009
Visit Reason
The inspection was conducted as a complaint investigation under State licensure following Complaint #NV00021344, which was substantiated. The investigation focused on the facility's compliance with Nevada Administrative Code (NAC) 449, Skilled Nursing Facilities Regulations.
Complaint Details
Complaint #NV00021344 was substantiated. The investigation revealed inadequate monitoring and assessment of a resident's nutritional and fluid intake, leading to hospitalization.
Findings
The facility failed to monitor and assess the food and fluid intake of one resident, resulting in hospitalization for hypotension associated dehydration. The resident had poor nutrition, low oral intake, and fluid intake, leading to severe health decline and transfer to a hospital. Documentation and nursing interventions were inadequate to prevent this outcome.
Deficiencies (1)
Failure to monitor and assess the food and fluid intake of one resident resulting in hospitalization for hypotension associated dehydration.
Report Facts
Meal refusals: 10
Average meal intake percentage: 32
Average fluid intake: 476
White blood count on admission: 17.7
Hemoglobin on admission: 11.3
Creatinine on admission: 1.7
Bicarbonate on admission: 17
White blood count on discharge: 8.2
Hemoglobin on discharge: 10.2
Creatinine on discharge: 0.9
Bicarbonate on discharge: 21
Inspection Report
Annual Inspection
Census: 172
Deficiencies: 10
Date: Jan 29, 2009
Visit Reason
Annual Medicare recertification survey conducted from 1/26/09 through 1/29/09, including investigation of complaint #NV00020738.
Complaint Details
Complaint #NV00020738 was investigated and substantiated with a deficiency cited (F309) related to failure to provide necessary rehabilitation equipment in a timely manner for resident #26.
Findings
The facility was found deficient in multiple areas including failure to post state agency contact information, failure to provide timely rehabilitation equipment, failure to check gastrostomy tube placement before medication administration, failure to maintain acceptable nutritional parameters, unnecessary drug use, improper food temperature and sanitary conditions, inadequate infection control program, and failure to promptly notify physicians of lab results.
Deficiencies (10)
Failed to post state agency contact information for all residents, specifically for 1 of 28 residents (#26).
Failed to ensure services were provided in accordance with professional standards for 2 of 28 residents (#3, #27).
Failed to provide necessary rehabilitation equipment in a timely manner for 1 of 28 residents (#26).
Failed to ensure nursing checked placement of gastrostomy tube prior to administering medications for 1 of 28 residents (#3).
Failed to ensure 1 of 28 residents (#11) maintained acceptable weight parameters.
Failed to ensure residents' drug regimens were free from unnecessary drugs for 2 of 28 residents (#27, #16).
Did not ensure food was served at proper temperature.
Did not ensure food was stored and prepared under sanitary conditions.
Failed to establish and maintain an infection control program that investigated, controlled, and prevented infections for 5 of 28 residents (#16, #20, #21, #22, #28).
Failed to promptly notify the attending physician of a laboratory report for 1 of 28 residents (#16).
Report Facts
Census: 172
Sample size: 28
Temperature: 110
Temperature: 90
Temperature: 52
Temperature: 50
Temperature: 122
Temperature: 120
Temperature: 130
Temperature: 110
Temperature: 50
Weight loss: 14.4
Weight: 156
Weight: 135.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 14 | Registered Nurse | Named in medication administration and documentation deficiencies for Resident #27 |
| Resident Care Manager #4 | Resident Care Manager | Named in failure to notify physician of lab report for Resident #16 |
| Employee #8 | Named in infection control deficiency related to Resident #22 |
Inspection Report
Annual Inspection
Census: 172
Deficiencies: 9
Date: Jan 26, 2009
Visit Reason
This inspection was conducted as an annual Medicare recertification survey from January 26, 2009 through January 29, 2009. A complaint (#NV00020738) was also investigated during this survey.
Complaint Details
Complaint #NV00020738 was investigated and substantiated with a deficiency cited (F309) related to failure to provide necessary rehabilitation equipment in a timely manner for Resident #26.
Findings
The facility was found deficient in multiple areas including failure to post state agency contact information, failure to provide necessary rehabilitation equipment in a timely manner, failure to ensure proper placement checks of gastrostomy tubes prior to medication administration, failure to maintain acceptable nutritional parameters for residents, failure to ensure medication regimens were free from unnecessary drugs, failure to maintain proper food temperatures and sanitary conditions, and failure to establish an effective infection control program.
Deficiencies (9)
Failure to post state agency contact information for residents, specifically for Resident #26.
Failure to provide necessary rehabilitation equipment in a timely manner for Resident #26.
Failure to ensure nursing staff checked placement of gastrostomy tube prior to administering medications for Resident #3.
Failure to maintain acceptable weight parameters for Resident #11.
Failure to ensure residents' medication regimens were free from unnecessary drugs for Residents #27 and #16.
Failure to ensure food was served at proper temperatures.
Failure to ensure food was stored and prepared under sanitary conditions.
Failure to establish and maintain an infection control program to prevent infections for residents #16, #20, #21, #22, and #28.
Failure to promptly notify attending physician of laboratory findings for Resident #16.
Report Facts
Residents present: 172
Sample size: 28
Residents with deficiencies: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Thomas | Executive Director | Named in relation to validation of state agency information posting |
| Director of Nurses | Interviewed regarding gastrostomy tube placement and medication administration policies | |
| Dietician | Interviewed regarding nutritional assessments and interventions | |
| Infection Control Nurse | Interviewed regarding infection control program and infection tracking | |
| Resident Care Manager #4 | Interviewed regarding lab report communication and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 29, 2008
Visit Reason
The inspection was conducted as a complaint survey based on complaint #NV00018821 alleging the facility failed to provide services and properly maintain equipment. The complaint was substantiated.
Complaint Details
Complaint #NV00018821 was substantiated. The complaint alleged failure to provide services and properly maintain equipment.
Findings
The facility failed to notify the physician of abnormal bladder scan results for one resident, failed to obtain a physician's order for a bladder scan, failed to assess and intervene on bladder scan results, and failed to maintain test equipment per manufacturer recommendations. The resident was discharged to an acute care facility after complications.
Deficiencies (2)
Facility failed to notify the physician of abnormal bladder scan results for one resident.
Facility failed to obtain a physician's order for a bladder scan, failed to assess and intervene on bladder scan results, and failed to maintain test equipment per manufacturer's recommendations for one resident.
Report Facts
Bladder scan results: 999
Bladder scan result: 269
Urine catheterization result: 95
Urine return: 1000
Bladder scan threshold: 400
Bladder scan normal capacity range: 400
Bladder scan normal capacity range: 600
Bladder scan normal urine volume range: 250
Bladder scan normal urine volume range: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Harris | Executive Director | Signed the Statement of Deficiencies |
| Director of Nursing | Named in findings regarding family concerns and bladder scan procedures | |
| Director of Nurses | Named in Plan of Correction to audit bladder scan results and ensure proper procedures |
Inspection Report
Plan of Correction
Census: 174
Deficiencies: 6
Date: Feb 25, 2008
Visit Reason
This document is a Plan of Correction submitted following a Medicare recertification survey conducted from 02/25/08 through 02/29/08. The plan addresses deficiencies identified during the survey.
Findings
The facility was found deficient in multiple areas including staff treatment of residents, social services, urinary incontinence care, sanitary conditions in food preparation and service, pharmacy services, and infection control. Specific issues included failure to report abuse allegations, lack of timely social service care plans, inadequate urinary incontinence treatment, improper food transport, improper labeling and disposal of drugs, and failure to maintain infection control tracking.
Deficiencies (6)
Failure to ensure allegations involving mistreatment and abuse were reported to appropriate state agencies as required.
Failure to provide medically related social services timely and to initiate social service care plans.
Failure to ensure appropriate treatment and services for urinary incontinence to restore normal bladder function.
Failure to store, prepare, distribute, and serve food under sanitary conditions.
Failure to employ or obtain services of a licensed pharmacist to maintain accurate drug records and ensure proper labeling and disposal of drugs.
Failure to maintain an infection control program that identifies, tracks, and records residents placed in isolation for infection.
Report Facts
Census: 174
Sample size: 28
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Harris | Executive Director | Signed the Plan of Correction document dated 3/2/08 |
| Director of Nursing | Director of Nursing | Named in relation to abuse reporting and audit responsibilities |
| Social Services Director | Social Services Director | Named in relation to social services deficiencies and corrective actions |
| Restorative Nurse | Restorative Nurse | Named in relation to urinary incontinence program and audits |
| Dietary Manager | Dietary Manager | Named in relation to food transport and sanitary conditions |
| Resident Care Managers | Resident Care Managers | Named in relation to medication room audits and compliance |
| Pharmacy Consultant | Pharmacy Consultant | Named in relation to conducting random audits of medication |
| Infection Control Nurse | Infection Control Nurse | Named in relation to infection control program and audits |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 12, 2007
Visit Reason
This complaint investigation was conducted due to a facility-reported incident where a resident had a fall with injury, substantiated with deficiencies cited related to notification of changes and quality of care.
Complaint Details
Complaint #NV00015925 was a facility reported incident that a resident had a fall with injury. The incident was substantiated with deficiencies cited (F157 and F309).
Findings
The facility failed to promptly notify the resident's physician of ongoing pain complaints following a fall, resulting in delayed assessment and treatment. Deficiencies were cited for failure to ensure timely physician notification and inadequate reassessment and response to the resident's pain.
Deficiencies (2)
Failure to ensure that a resident's physician was promptly notified of ongoing complaints of pain following a fall.
Failure to ensure that staff reassessed and responded to a resident's ongoing complaints of pain following a fall.
Report Facts
Dates of investigation: Complaint investigation conducted from 2007-10-12 through 2007-10-19
Medication dosage: 5
Medication dosage: 500
Medication frequency: 4
Investigation date: 16
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2007
Visit Reason
The investigation was triggered by an allegation of inappropriate touching by Resident #1 reported by Resident #2, and the facility's failure to thoroughly investigate and report the alleged abuse in accordance with its abuse and neglect policy.
Complaint Details
The complaint involved an allegation of inappropriate touching by Resident #1 reported by Resident #2. The allegation was investigated but found unsubstantiated. The facility failed to report the incident timely to the Director of Nursing and state agencies, and failed to protect residents from retaliation or ensure confidentiality. Resident #2 was transferred to a senior mental health inpatient facility due to behaviors placing others at risk.
Findings
The facility failed to ensure that the allegation of abuse was properly investigated and reported to the Director of Nursing and state agencies in a timely manner. There was inadequate documentation, lack of staff interviews, and failure to protect residents from potential retaliation. The allegation was ultimately found to be unsubstantiated, but the facility did not follow its own abuse and neglect policies.
Deficiencies (1)
Facility failed to ensure that an allegation of abuse was investigated in accordance with the facility's abuse and neglect policy for 1 of 3 residents (Resident #1) and failed to thoroughly investigate and report a potentially abusive situation for 1 of 3 residents (Resident #3).
Report Facts
Date of alleged incident: Jun 26, 2007
Date of completed investigation summary: Jun 30, 2007
Date of interviews: Jul 19, 2007
Date of telephone interview: Aug 1, 2007
Date of resident transfer: Jun 28, 2007
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Author of entry documenting third party information about alleged abuse; interviewed regarding timing and details of the event |
| CNA #1 | Certified Nursing Assistant | Reported alleged abuse to LPN #1; interviewed about observations and communication with Resident #2 |
| Director of Nursing | Director of Nursing (DON) | Informed about the incident; interviewed about investigation and reporting; delegated investigation to social worker and nurse manager |
| Nurse Manager | Nurse Manager of Station 2 | Interviewed regarding investigation and awareness of incident timing |
| LPN #2 | Licensed Practical Nurse | Telephone interview confirming awareness of abuse and neglect policy and details of incident |
| RN #1 | Registered Nurse | Wrote incident reports; interviewed about observations and events on June 27-28, 2007 |
| Social Worker | Social Worker | Documented interviews and statements related to the investigation |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 21, 2006
Visit Reason
This plan of correction was submitted as a result of a complaint investigation conducted at the facility on 2006-04-21 and finalized on 2006-05-02. The complaint involved a self-reported incident of injury to a resident caused by a staff member and alleged staff abuse.
Complaint Details
Complaint # NV00011228 was a self-reported incident of injury to a resident caused by a staff member. The allegation of staff abuse was unsubstantiated. The deficiency cited related to the facility's timeliness of identifying and investigating the cause of the resident's injury and alleged staff abuse.
Findings
The investigation found that the facility failed to ensure timely identification and investigation of the resident's injury and alleged staff abuse. The facility did not thoroughly investigate the allegations or protect the resident from further potential abuse. The resident sustained a non-displaced distal ulnar fracture of unknown origin, and the investigation lacked documentation of timely initiation and staff in-service training.
Deficiencies (1)
Facility failed to ensure timely identification and investigation of resident injury and alleged staff abuse.
Report Facts
Dates of staff statements: 4
Investigation timeframe: 5
Resident diagnosis date: 200203
MDS data date: Mar 20, 2006
Date of resident injury incident: Mar 15, 2006
Date of x-ray and diagnosis: Mar 17, 2006
Date of interviews: Apr 21, 2006
Compliance deadline: Jun 16, 2006
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James L. Dennis | Executive Director | Signed the plan of correction on 5/1/06. |
| LPN #1 | Provided statement dated 3/20/06 regarding resident injury and investigation. | |
| LPN #2 | Provided statement dated 3/20/06 about resident complaint of pain. | |
| LPN #3 | Provided statement dated 3/20/06 about resident behaviors and investigation. | |
| CNA #1 | Certified Nursing Assistant | Provided statement dated 3/20/06 about resident care and behaviors. |
| CNA #2 | Provided statement dated 3/21/06 about resident agitation and pain. | |
| CNA #3 | Provided statement dated 3/20/06 about resident complaint of arm pain. | |
| CNA #4 | Provided statement dated 3/22/06 about resident care and use of side rail. | |
| DON | Director of Nursing | Interviewed on 4/21/06 regarding investigation and resident injury. |
| ADON | Assistant Director of Nursing | Interviewed on 4/21/06 regarding investigation and resident injury. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 21, 2005
Visit Reason
The inspection was conducted as a result of three complaint investigations at the facility on 4/21/05, with investigations ongoing until 5/27/05. The complaints involved self-reported resident falls and allegations of neglect of care.
Complaint Details
Complaint #NV00007985 and #NV00007879 were self-reported resident falls and were substantiated with no deficiencies cited. Complaint #NV0007928 alleged neglect of care and was substantiated with deficiencies cited at F 309 and F 281.
Findings
Two complaints of resident falls were substantiated with no deficiencies cited. One complaint alleging neglect of care was substantiated with deficiencies cited at F 309 (Quality of Care) and F 281 (Resident Assessment). The facility failed to provide services meeting professional standards of quality, including inadequate monitoring and assessment of a resident's injuries and skin condition.
Deficiencies (2)
Failure to provide services that met professional standards of quality for a resident, including inadequate monitoring and assessment of injury to the left lower extremity.
Failure to ensure each resident received necessary care and services to attain or maintain the highest physical well-being, including lack of documentation and monitoring of skin tears, wounds, and adverse effects of antibiotic and anticoagulant therapy.
Report Facts
Complaint investigations: 3
Resident age: 90
Dates of events: Apr 1, 2005
Dates of events: Apr 11, 2005
Dates of events: Apr 14, 2005
Dates of events: Apr 16, 2005
Dates of events: Apr 23, 2005
IV antibiotic therapy duration: 7
Inspection Report
Annual Inspection
Census: 196
Deficiencies: 18
Date: Feb 14, 2005
Visit Reason
The inspection was conducted as an annual Medicare Re-certification Survey from February 14, 2005 through February 18, 2005.
Findings
The survey identified multiple deficiencies across various areas including notification of rights and services, quality of life, resident assessments, social services, medication administration, dietary services, and pharmacy services. Several residents were found to have unmet needs or inadequate care plans, and systemic issues were noted in documentation, communication, and care delivery.
Deficiencies (18)
Facility failed to notify the physician and responsible party regarding the wounds of Resident #18.
Facility failed to have the most recent annual survey results readily accessible to residents and failed to post notices that surveys were available for review.
Facility failed to ensure reasonable access to telephone calls without being overheard for Resident #33.
Facility failed to promote an environment that maintained or enhanced residents' dignity in five unsampled residents.
Facility staff failed to consistently accommodate all residents' needs during meal service.
Facility failed to provide medically-related social services to three sampled residents.
Facility failed to conduct a Minimum Data Set for a significant change in condition for Resident #17.
Facility failed to conduct quarterly review assessments every three months for Resident #22.
Facility failed to develop comprehensive care plans with measurable objectives for multiple residents.
Facility failed to assess, document, and revise the plan of care for wounds for 3 of 30 residents.
Facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 of 30 residents.
Facility failed to admit residents with mental illness only in accordance with state mental health authority requirements and failed to rescreen Resident #8 for PASARR.
Facility failed to provide adequate care and services related to pain management for Resident #11.
Facility failed to provide needed care and services related to hydration and nutrition for Resident #11 and others.
Facility failed to provide adequate bowel and bladder management for multiple residents.
Facility failed to provide adequate supervision and assistance to prevent accidents for Residents #17 and #18.
Facility failed to provide adequate pharmacy services including proper labeling, storage, and medication administration.
Facility failed to provide safe and sanitary dietary services including proper food storage and preparation.
Report Facts
Sample size: 30
Residents referenced: 196
Residents with deficiencies: 30
Beds lined up: 2
Residents observed: 11
Staff members observed: 3
Family members observed: 2
Residents needing assistance: 4
Residents with wounds: 3
Residents with PASARR issues: 1
Residents with pain management issues: 1
Residents with hydration issues: 1
Residents with bowel/bladder issues: 6
Residents with accident risk: 2
Medication doses documented: 6
Medication doses documented: 30
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