Inspection Reports for Marquis Centennial Hills

The inspection was conducted as a Medicare Recertification Survey and Complaint investigation from 2025-06-24 through 2025-06-27.

The facility was found deficient in multiple areas including medication administration accuracy, restorative nursing services, respiratory care, pharmacy services, and food safety. One complaint was investigated and found unsubstantiated.

One complaint (NV00074345) was investigated and found unsubstantiated with no regulatory deficiencies identified.

The inspection was conducted as a state licensure construction standards and bed reduction survey related to renovations converting three bedrooms into a dialysis suite, reducing bed count from 120 to 115 beds.

The facility was found deficient in infection control program design, compliance with construction and safety codes, and plumbing installation standards. Specific issues included improper air diffuser design, lack of sink labeling, missing isolation policies, inadequate dialysis suite design and equipment setup, lack of privacy screens, insufficient illumination, and improper installation and testing of a backflow prevention device.

The inspection was conducted as a result of a Facility Reported Incidents and Complaints investigation at Marquis Care at Centennial Hills on 03/15/2023.

The investigation substantiated one Facility Reported Incident related to deficiencies in comprehensive care planning, medication administration, and medication storage. Additional deficiencies unrelated to complaints were also noted. The facility failed to develop a comprehensive care plan for one resident, did not administer medications as ordered for the same resident, and failed to safely secure medications for two residents.

Six complaints and Facility Reported Incidents (FRIs) were investigated. One FRI (#NV00066601) was substantiated involving care plan and medication administration deficiencies. The other five FRIs and one complaint were unsubstantiated with no regulatory deficiencies identified.

The inspection was conducted as a result of a Facility Reported Incidents and Complaints investigation completed on 03/15/2023, investigating six complaints and Facility Reported Incidents (FRIs).

The investigation identified one substantiated Facility Reported Incident (#NV00066601) with related deficiencies in comprehensive care planning, quality of care, and drug labeling/storage. Other complaints were unsubstantiated with no regulatory deficiencies. Deficient practices unrelated to complaints were also noted.

Six complaints and Facility Reported Incidents were investigated. One Facility Reported Incident (#NV00066601) was substantiated. The other five FRIs and one complaint were unsubstantiated with no regulatory deficiencies identified.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey and Facility Reported Incident Investigation conducted from 04/12/2022 through 04/15/2022.

The survey identified multiple deficiencies including failure to ensure background checks for contract employees, incomplete care plans for contracture and oral thrush, medication administration errors, lack of therapy services, incomplete dialysis communication, improper medication storage and labeling, and food safety issues.

This inspection was conducted as a State Licensure Survey completed in conjunction with a Federal Recertification survey at the facility from 04/12/2022 through 04/15/2022, in accordance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.

The facility was found deficient in ensuring that criminal background checks, reference checks, tuberculosis (TB) screening, and physical exams were completed for contract employees hired through a staffing agency. Specifically, 2 of 15 sampled contract employees lacked documented evidence of completed background checks and TB screenings prior to resident contact.

This document is a Medicare Life Safety Code (LSC) recertification survey conducted at the facility on 04/13/2022 and 04/14/2022 to assess compliance with fire safety and life safety codes.

The survey identified multiple deficiencies related to fire safety, including failure to provide flame spread ratings for interior walls and ceilings, improper maintenance of sprinkler systems, unsealed smoke barrier penetrations, inadequate electrical panel labeling, missing elevator permits, incomplete evacuation plans, and deficiencies in fire drills and fire alarm systems.

The inspection was a Centers for Medicare and Medicaid Services (CMS) Focused Infection Control survey, Complaint survey, and Facility Reported Incident investigations initiated on 2021-07-27 and finalized on 2021-08-11.

The facility had multiple complaint investigations and facility-reported incidents related to resident care, abuse allegations, elopement, infection control, and injury of unknown origin. Several deficiencies were cited including failure to timely report injuries and abuse allegations, failure to follow resident care plans for transfers, and inadequate infection control practices including respirator fit testing and cleaning.

The inspection included complaint investigations for allegations such as resident abuse, neglect, failure to provide care, failure to notify power of attorney, and failure to comply with medical records requests. Most allegations were unsubstantiated or substantiated without regulatory deficiencies.

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

The facility was found to be compliant with infection control regulations, including proper use of PPE, screening procedures, and staff education. No regulatory deficiencies were identified during the survey.

Focused Infection Control survey conducted in response to COVID-19 concerns, including review of infection control program, policies, staff practices, and COVID-19 cases in the facility.

The facility had 14 positive and 14 presumptive COVID-19 cases at the time of inspection. Infection control measures were reviewed, including PPE use, staff screening, and isolation practices. Deficiencies were found in fit testing of N95 masks for staff and improper storage of PPE, increasing risk of contamination.

This was a focused infection control survey triggered by concerns related to COVID-19 infection prevention and control practices in the facility.

This inspection was conducted as a state licensure construction standards survey related to renovations including the addition of a pre-fabricated, modular ante room and clean room in the facility's pharmacy.

No regulatory deficiencies were identified during the survey, and no further action is necessary.

This inspection was conducted as a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey initiated on 07/29/2020 and completed on 07/30/2020 to assess compliance with infection control requirements during the COVID-19 pandemic.

The facility failed to place a newly admitted resident in a private room while under observation for COVID-19 symptoms, failed to communicate pending COVID-19 test results to a dialysis center for a resident, failed to house residents with COVID-19 like symptoms on transmission-based precautions, and failed to ensure staff used proper personal protective equipment (PPE) prior to entering transmission-based precaution rooms. Several residents with respiratory symptoms were not isolated appropriately, and staff were not fully aware or compliant with PPE requirements.

The visit was complaint-related, triggered by concerns about infection control practices during the COVID-19 pandemic. The investigation included review of infection control policies, resident care practices, staff education, and PPE usage.

This inspection was conducted as a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey initiated on 04/22/2020 to assess compliance with infection prevention and control requirements for long-term care facilities.

The facility had no positive COVID-19 residents at the time of the survey, with 5 residents on isolation for carbapenem-resistant enterobacteriaceae (CRE). Deficiencies were identified related to infection prevention and control, including failure to consistently screen individuals for COVID-19, inadequate documentation of hand sanitizing and face mask application, and failure to conduct consistent temperature checks and screenings for visitors and staff.

The inspection was conducted as a result of an investigation of a complaint and Facility Reported Incidents on March 5, 2020, in accordance with federal regulations for long term care facilities.

Three Facility Reported Incidents were investigated, all substantiated with no regulatory deficiencies identified. Observations, interviews, medical record reviews, and document reviews were conducted as part of the investigation.

Three Facility Reported Incidents were investigated: two regarding resident to resident altercations and one regarding staff to resident abuse. All were substantiated with no regulatory deficiencies identified.

The inspection was a Medicare Life Safety Code (LSC) recertification survey conducted at the facility on 11/07/19 and 11/08/19 to assess compliance with NFPA 101 and NFPA 99 codes.

The facility was found deficient in multiple areas including emergency lighting testing, improper placement of alcohol-based hand rub dispensers near ignition sources, lack of sprinkler system maintenance documentation, inadequate electrical system maintenance and labeling, insufficient fire drill scheduling, failure to inspect and test fire doors annually, and lack of maintenance and testing programs for patient-care related electrical equipment.

Annual Medicare Recertification survey conducted from 2019-11-05 to 2019-11-07, including one complaint investigation which was not substantiated.

The facility had multiple deficiencies including failure to notify physicians of hypoglycemic episodes, inadequate activity programming for a bedbound resident, lack of follow-up on dental pre-authorizations and denture issues, unclean walk-in refrigerator and freezer, and infection control lapses such as improper hand hygiene and biohazard waste management.

Complaint #NV00058985 alleging poor indwelling catheter insertion and removal technique causing pain and bleeding was investigated and not substantiated.

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted at the facility on 11/6/19, in conjunction with a Medicare recertification survey, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z - Emergency Preparedness for All Provider and Certified Supplier Types.

The facility failed to meet several emergency preparedness requirements including lack of a process for collaboration with local, regional, State, and Federal Emergency Preparedness officials; absence of a policy regarding the use of volunteers in emergencies; failure to develop a facility-specific communication plan; and failure to include a means of providing information about the facility's occupancy and needs to the authority having jurisdiction and Incident Command Center.

The inspection was conducted as a result of a complaint investigation initiated at the facility on 03/14/19 regarding allegations related to residents' breathing and oxygen use.

The investigation included observations, interviews, and medical record reviews, and concluded that the complaint allegations could not be substantiated. There were no regulatory deficiencies found.

Complaint #NV00056255 involved three allegations about residents' breathing difficulties and oxygen use; none of the allegations were substantiated.

Medicare Recertification Life Safety Code survey conducted at the facility on 10/3/18 - 10/4/18 in accordance with Chapter 19, EXISTING Health Occupancies, of the 2012 Edition of the National Fire Protections Association (NFPA) 101, Life Safety Code (LSC).

The facility failed to maintain the automatic fire sprinkler system, corridor doors, electrical wiring, and emergency preparedness requirements as required by NFPA codes. Specific deficiencies included dust buildup on sprinklers, damaged sprinkler deflector, unsecured flexible conduit, doors not latching properly, missing electrical panel directories, and failure to test emergency preparedness plans and electrical receptacles annually.

The inspection was conducted as a Medicare Recertification survey from October 2, 2018 through October 5, 2018, to assess compliance with federal regulations for long term care facilities.

The facility was found deficient in multiple areas including resident self-administration of medications, reporting of alleged violations, comprehensive care planning, quality of care, pain management, pharmacy services, medication error rates, dental services, food safety, infection prevention and control, and storage of medications. Several residents were involved in incidents of resident-to-resident altercations and abuse allegations that were not properly reported or investigated.

The inspection was conducted as a result of a complaint investigation regarding the facility's failure to provide notification of resident transfer/discharge to the State Long Term Care Ombudsman Program as required.

The complaint was investigated through facility tours, interviews, and record reviews. The allegation was not substantiated, and no regulatory deficiencies were identified.

Complaint #NV00051906 alleged failure to notify the State Long Term Care Ombudsman Program of resident transfer/discharge. The allegation was not substantiated.

This inspection was conducted as a Medicare Life Safety Code survey to assess compliance with NFPA 101 Life Safety Code standards, including fire protection and safety systems.

The facility was found deficient in several areas including kitchen hood system maintenance, smoke detector sensitivity testing, sprinkler system maintenance, corridor door smoke resistance, smoke barrier penetrations, and proper storage of oxygen cylinders. Deficiencies affected residents, staff, and guests and were acknowledged by the Plant Operations Manager or Director.

The inspection was conducted as a Medicare Recertification survey from October 17, 2017 through October 20, 2017, including investigation of one complaint (#NV00050277) with multiple allegations regarding resident care and facility practices.

The investigation found multiple deficiencies including failure to notify families of significant weight changes, failure to document physician orders and assessments for self-administered medications, failure to accommodate resident needs such as shower chair requests, failure to provide written notice before room changes, failure to ensure proper care such as TED hose application and fingernail trimming, and other care and dignity issues. The complaint allegations were not substantiated.

Complaint #NV00050277 with multiple allegations including neglect, inadequate pain management, failure to communicate, and resident neglect. The allegations could not be substantiated.

The inspection was conducted as a result of a complaint investigation regarding allegations of poor sanitation and presence of insects in the kitchen.

The facility was found to have live cockroaches, dead flies, soiled floors and floor sinks, open dumpster lids with foul odor, dust accumulation on light fixtures, and no means of controlling flying insects at the kitchen exterior door. These conditions violated NAC 446 standards for dietary services.

Complaint #NV00049586 was substantiated. The allegations of poor sanitation in the kitchen and the presence of insects in the kitchen were confirmed.

This inspection was conducted as a Medicare Life Safety Code survey on November 17 and 18, 2016, to assess compliance with NFPA 101 Life Safety Code standards.

The facility was found deficient in maintaining the automatic fire sprinkler system, corridor doors, fire drills, combustible decorations, and gas equipment signage. Deficiencies affected multiple smoke compartments and involved residents, staff, and guests.

This inspection was conducted as a Medicare Recertification survey from November 15, 2016 through November 18, 2016 to assess compliance with federal regulations for long term care facilities.

The facility was found deficient in multiple areas including failure to obtain physician orders for dialysis and oxygen use, inadequate assistance with grooming, medication error rates exceeding 5%, and improper food sanitation practices. Corrective actions and monitoring plans were outlined for each deficiency.

The survey was conducted as a construction standards survey to evaluate renovations and compliance with the 2015 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code and related guidelines.

No regulatory deficiencies were identified during the construction standards survey of the facility's renovated shelled space for a pharmacy and medication holding room.

This document is a follow-up Medicare Life Safety Code survey conducted to confirm Plan of Correction compliance for previously cited deficiencies related to fire safety at the facility.

No deficiencies were identified during this follow-up survey, and no further action is necessary according to the Statement of Deficiencies.

This inspection was conducted as a Medicare recertification and complaint investigation survey from October 19 through October 22, 2015, to investigate two complaints regarding call light response times, facility cleanliness, resident hydration, and blood pressure management.

The investigation found no substantiation for the complaints but identified multiple deficiencies related to bowel management, pressure sore prevention, infection control, medication security, and food safety. Deficiencies were documented with corrective actions planned and assigned to responsible individuals.

Two complaints were investigated: Complaint #NV00044339 regarding long call light wait times and facility cleanliness, and Complaint #NV00044304 regarding resident hydration and blood pressure management. Both complaints were not substantiated after observations, interviews, and record reviews.

This document is a Statement of Deficiencies generated as a result of a Medicare Life Safety Code survey conducted at the facility on October 20 and 21, 2015, to assess compliance with fire safety standards.

The facility was found to have multiple deficiencies related to life safety code standards, including issues with corridor doors not resisting smoke passage, missing fire-rated barriers, inadequate sprinkler coverage, improper fire drill documentation, and incomplete fire watch policies.

The inspection was conducted as a result of a complaint investigation initiated by the Division of Public and Behavioral Health on 2014-02-10, regarding three allegations related to resident care.

The complaint was substantiated overall with failure to appropriately arrange a follow-up physician's appointment identified as a deficiency. Other allegations regarding failure to prevent a resident's fall and failure to timely notify the physician for pneumonia symptoms were not substantiated. The facility failed to ensure a follow-up visit was arranged for one resident, leading to a regulatory deficiency.

Complaint #NV00041774 contained three allegations. The complaint was substantiated. Allegation #1 (failure to prevent a resident's fall) was not substantiated. Allegation #2 (failure to arrange a follow-up physician's appointment) was substantiated. Allegation #3 (failure to take action and notify the physician timely for pneumonia symptoms) was not substantiated.

The inspection was conducted as a complaint investigation survey triggered by Complaint #NV00041774, which contained three allegations regarding failure to prevent a resident's fall, failure to arrange a follow-up physician's appointment, and failure to notify the physician timely for a resident with pneumonia symptoms.

The complaint investigation found that none of the allegations could be substantiated. Interviews and medical record reviews showed that the facility followed appropriate fall precautions, physician communication, and documentation protocols.

Complaint #NV00041774 contained three allegations: failure to prevent a resident's fall, failure to arrange a follow-up physician's appointment, and failure to notify the physician timely for pneumonia symptoms. None of these allegations were substantiated after investigation.

The inspection was conducted as a complaint investigation triggered by an allegation that a resident had stage 4 bedsores when transferred to the hospital.

The investigation included observations, interviews, and medical record reviews, which revealed no documented evidence that the resident had stage 4 bedsores. No regulatory deficiencies were identified and no further action was necessary.

Complaint #NV00041072 alleged a resident had stage 4 bedsores upon hospital transfer; this allegation was not substantiated.

The inspection was conducted as an annual Medicare recertification survey from October 21 through October 24, 2014, including one complaint investigation.

The facility was found deficient in multiple areas including treatment and care for special needs, medication administration, medication availability, safety hazards, and life safety code compliance. One complaint was investigated and not substantiated. Several deficiencies were cited related to gastrostomy tube care, medication security, oxygen therapy, PICC line care, dialysis catheter management, and pharmaceutical services.

One complaint (#NV00040806) was investigated with two allegations: 1) Resident not seen by a Physician or Physician Assistant for over one week, which was not substantiated; 2) Resident did not receive correct medications, which was not substantiated.

The inspection was conducted as an annual Medicare recertification survey from October 21 through October 24, 2014, to assess compliance with federal regulations and state licensing requirements.

The facility was found deficient in multiple areas including life safety code compliance related to smoke damper testing, treatment and services to restore eating skills, medication storage and administration, oxygen administration, and pharmaceutical services. Several residents' care plans and documentation were incomplete or lacking, and medication delivery issues were identified.

One complaint was investigated (Complaint #NV00040806) containing two allegations: 1) Resident was not seen by a physician or physician assistant for over one week; 2) Resident did not receive correct medications. The complaint was not substantiated.

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

The facility was found deficient in several Life Safety Code standards including failure of corridor doors to latch properly, inadequate fire drills especially for the night shift, lack of required fire alarm system testing, missing functional testing of smoke detectors, and absence of proper no smoking signage in oxygen storage areas.

This inspection was conducted as a Medicare recertification and Life Safety Code (LSC) survey of the facility on 10/21/2014.

The facility was found deficient in several Life Safety Code standards including failure of five corridor doors to latch properly, inadequate frequency of fire drills for all shifts, lack of documented testing for smoke detectors, and missing safety signage on oxygen storage rooms.

The inspection was conducted as a result of a complaint investigation regarding an allegation that the facility did not have a Licensed Administrator during the approximate dates 2/9/14 through 2/15/14.

The complaint was not substantiated. Interviews and review of public records confirmed that the facility did have a licensed administrator during the specified dates. No regulatory deficiencies were identified.

Complaint #NV00038428 was investigated and found to be unsubstantiated regarding the absence of a Licensed Administrator during 2/9/14 through 2/15/14.

The inspection was conducted as an annual Medicare recertification survey from December 3, 2013 through December 10, 2013, including a Life Safety Code survey on December 11, 2013.

The facility had multiple deficiencies related to dignity and respect of individuality, professional standards of care, medication administration, pressure sore prevention, accident hazards, sanitation, pharmaceutical services, and life safety code violations. One complaint was investigated and found not substantiated. The facility was required to implement corrective actions and plans of correction were accepted.

One complaint (NV00037532) was investigated related to resident transfer notification, change of condition notification, and hydration consent. The complaint was not substantiated based on review of medical records, interviews with staff, and the complainant.

Annual Medicare recertification survey conducted from December 3, 2013 through December 10, 2013, including one complaint investigation which was not substantiated.

The facility had multiple deficiencies including failure to provide timely toileting assistance, improper medication administration and documentation, failure to follow physician orders for gastrostomy tube feeding, inadequate pressure sore prevention, failure to prevent an avoidable fall, failure to provide continuous oxygen, medication administration errors, improper food sanitation and storage, delayed medication delivery, expired medical supplies, and life safety code violations including unsecured doors and lack of sprinkler coverage in some areas.

One complaint investigated regarding resident transfer and notification, hydration without consent, and change of condition notification; all allegations were not substantiated.

The inspection was conducted as a result of multiple complaint investigations initiated on October 9, 2013, concerning kitchen staff qualifications, infection control, resident privacy, staff verbal abuse, and other allegations at Marquis Care at Centennial Hills.

The investigation substantiated complaints regarding kitchen staff qualifications, infection control issues, resident privacy violations, and staff to resident verbal abuse. Other allegations such as hot water issues, insufficient medical supplies, and insufficient diets were unsubstantiated. Several regulatory deficiencies were identified including failure to provide privacy during care, failure to properly report and investigate verbal abuse, and failure to have properly certified kitchen staff and proper food storage.

Complaint #NV00037039 substantiated kitchen staff qualifications, infection control, and proper storage issues. Complaint #NV00037141 substantiated resident privacy issues and staff to resident verbal abuse but unsubstantiated insufficient medical supplies and insufficient diets. Complaint #NV00036766 unsubstantiated insufficient staffing and mistreatment of staff.

The inspection was conducted as a result of two complaint investigations initiated on 10/29/12 and 11/7/12 regarding allegations of insufficient monitoring, dehydration, failure to notify physician, and other care concerns at Marquis Care at Centennial Hills.

The facility was found to have substantiated deficiencies including failure to monitor a resident's change in condition leading to hospitalization, failure to maintain proper hydration resulting in dehydration and hospital transfer, and failure to notify family of changes in condition. Other allegations such as overmedication, assistance with eating, and blood thinner administration were not substantiated. Additional deficiencies related to nutrition care planning were also identified.

Two complaints were investigated: Complaint #NV00033546 regarding insufficient monitoring and care leading to hospitalization, substantiated; Complaint #NV00033354 regarding swollen leg and blood thinner use, weight loss, overmedication, assistance with eating and hydration, with some allegations substantiated (dehydration, failure to notify physician) and others not substantiated.

The inspection was conducted as a complaint investigation initiated on 10/29/12 and finalized on 12/07/12, involving two complaints regarding resident care and monitoring.

The facility was found to have deficiencies related to failure to monitor residents adequately, resulting in issues such as dehydration, overmedication, and failure to notify family members of changes in condition. Specific residents had documented incidents of blood clots, dehydration, and insufficient hydration. The facility failed to ensure proper notification and monitoring as required by regulations.

Two complaints were investigated: Complaint #NV00033546 initiated on 10/29/12 and Complaint #NV00033354 initiated on 11/7/12. The first complaint was substantiated regarding failure to monitor a resident to prevent hospitalization. The second complaint involved allegations of a swollen leg not placed on blood thinners, weight loss, overmedication, inability to reach food trays, dehydration, and failure to ensure physician visits. Some allegations were substantiated, others were not.

Annual Medicare recertification survey conducted from October 9, 2012 through October 12, 2012, including one complaint investigation which was not substantiated.

The survey identified multiple deficiencies including failure to notify physicians of significant changes, failure to maintain dignity and respect, incomplete care plans, medication administration errors, unsafe storage of chemicals and medications, infection control lapses, ineffective call light system, incomplete clinical records, and inadequate emergency training.

Complaint #NV00033211 was investigated from 10/9/12 to 10/12/12 and was not substantiated regarding dehydration, bed sores, and oxygen monitoring.

The inspection was conducted as a result of a complaint investigation (Complaint #NV00032520) at Marquis Care at Centennial Hills on 08/30/2012, in accordance with federal regulations for long term care facilities.

The investigation found that the facility failed to provide timely response to call lights, adequate supervision to prevent falls, and accessibility to call lights for residents. Specifically, Resident #3 was found at risk due to inaccessible call lights and insufficient supervision, resulting in a fall and injury. The facility identified deficiencies related to accident hazards and supervision.

Complaint #NV00032520 contained five allegations including denial of family member access to medical records, untimely response to call lights, residents left sitting in urine for extended periods, call lights not being accessible, and resident safety and falls. Some allegations were not substantiated, but failure to provide supervision and accessible call lights was substantiated.

The inspection was conducted as a complaint investigation (Complaint #NV00032520) at the facility on 08/30/2012, triggered by five allegations related to resident rights, call light accessibility and response, resident safety, and falls.

The investigation found two allegations substantiated: call lights not being accessible and resident safety and falls issues. Specifically, the facility failed to provide one resident access to the call light and failed to provide supervision to prevent a fall with injury for one resident. Other allegations were not substantiated.

Complaint #NV00032520 contained five allegations: denial of family member access to medical records (not substantiated), call lights not answered timely (not substantiated), residents left sitting in urine (not substantiated), call lights not accessible (substantiated), and resident safety and falls (substantiated).

The inspection was conducted as a result of complaint investigations initiated on March 21, 2012, regarding allegations of inadequate resident assessment and medication, failure to address resident grooming and linen care, and concerns about certified nursing assistant competency and abuse.

The investigation found that the facility failed to coordinate care with hospice for pain management, did not ensure competency documentation for certified nursing assistants, and had personnel files lacking current criminal background clearances. No evidence of resident abuse was found. Deficiencies were cited related to care coordination, nurse aide competency, and personnel records.

Complaints investigated included allegations that residents were not assessed and medicated appropriately, failure to address a rash and grooming issues, and that a certified nursing assistant abused a resident and lacked competency documentation. The investigation concluded no documented evidence of abuse was found and that the issue was personnel-related.

The inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on March 21, 2012, based on complaints alleging inadequate resident assessment and medication, failure to address a rash and grooming issues, and abuse by a certified nursing assistant.

The investigation found that the facility failed to coordinate care with the hospice agency to address pain management for one resident, and failed to ensure a certified nursing assistant demonstrated competency in skills and techniques necessary to care for residents. No evidence of abuse was found. Deficiencies were cited related to care coordination and nurse aide competency.

Complaint #NV00031909 alleged residents were not assessed and medicated appropriately. Complaint #NV00031373 alleged failure to address rash and grooming issues. Complaint #NV00030795 alleged failure to ensure competent certified nursing assistant and abuse by the same assistant. The investigation concluded no documented evidence of abuse and cited personnel competency deficiencies.

Annual Medicare recertification survey conducted from December 6, 2011 through December 9, 2011, including one complaint investigation regarding inadequate staffing which was not substantiated.

The survey identified multiple deficiencies including failure to implement abuse prevention policies and training, incomplete abuse investigations, food served at improper temperatures, unsanitary kitchen conditions, and inadequate infection control measures.

One complaint investigated (Complaint #NV00029788) regarding inadequate staffing, especially on the overnight shift, was not substantiated based on staffing schedules, observations, resident interviews, and staff interviews.

The inspection was a Medicare recertification Life Safety Code (LSC) survey conducted to assess compliance with fire safety standards at the facility.

The facility failed to maintain corridor doors properly, provide adequate separation of hazardous areas, conduct quarterly fire drills for each shift, prominently place no smoking signs, and ensure proper segregation and signage in oxygen storage areas. These deficiencies affected staff and residents in multiple smoke compartments.

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

The facility was found deficient in maintaining corridor doors that failed to latch properly, inadequate separation of hazardous areas, failure to conduct quarterly fire drills on all shifts, insufficient 'No Smoking' signage at major entrances, and improper segregation of full and empty oxygen cylinders in storage areas.

The inspection was conducted as an annual Medicare recertification survey from December 6, 2011 through December 9, 2011, to assess compliance with federal regulations for long term care facilities.

The survey identified deficiencies including failure to implement abuse prevention policies and training, incomplete investigations of abuse allegations, and issues with food temperature and sanitation. One complaint regarding inadequate staffing was investigated and found not substantiated.

One complaint (#NV00029788) regarding inadequate staffing, especially on the overnight shift, was investigated and found not substantiated based on review of staffing schedules, resident interviews, and interviews with the Director of Nursing and Administrator.

The inspection was conducted as a Medicare complaint investigation regarding allegations that nurses were not properly trained to provide adequate intravenous therapy.

The complaint was not substantiated based on interviews with residents and staff, clinical record review, and document and policy review. No regulatory deficiencies were identified.

Complaint NV00029020 alleged inadequate nurse training for intravenous therapy; the complaint was not substantiated.

This inspection was conducted as a result of a Medicare complaint survey on June 1, 2011, triggered by two separate allegations: Resident Neglect related to oxygen tank monitoring and non-treatment of a hand wound, and Quality of Care related to call bell response times.

The investigation found the neglect allegation was not substantiated, but identified a deficiency in medication administration documentation regarding oxygen saturation checks. The quality of care allegation was substantiated, with documented extensive delays in call light response times and cancel times.

The complaint contained two allegations: Resident Neglect due to oxygen tank monitoring and wound care, which was not substantiated; and Quality of Care related to call bell response times, which was substantiated.

The inspection was conducted as a Medicare complaint survey triggered by two allegations: Resident Neglect related to monitoring portable oxygen tanks and non-treatment of a hand wound, and Quality of Care related to call bells not being answered in a timely manner.

The facility was found not to have substantiated neglect regarding oxygen tank monitoring and hand wound treatment, but failed to ensure physician's orders for oxygen saturation checks were followed for one resident and call lights were not answered timely in four sampled rooms, with documented extensive wait times up to 155 minutes.

The complaint contained two allegations: Resident Neglect due to issues with monitoring portable oxygen tanks and non-treatment of a hand wound, which was not substantiated; and Quality of Care related to delayed response to call bells, which was substantiated.

The visit was conducted as an initial Medicare certification survey for the facility from 11/08/10 through 11/09/10.

No regulatory deficiencies were identified during the survey. Four active charts, one closed record, and ten employee files were reviewed. No complaints were investigated.

This document is a Statement of Deficiencies generated as a result of an initial Medicare Life Safety Code (LSC) survey conducted at the facility on November 8 and November 9, 2010.

The survey found no regulatory deficiencies at the time of the initial Life Safety Code survey.

This inspection was conducted as the Initial State Licensure survey for the facility in accordance with Nevada Administrative Code 449.

The facility failed to ensure the environment was free from potential accidental hazards, specifically due to the Lobby Patio's close proximity to motor vehicle traffic and the risk of residents being locked out and exposed to extreme temperatures.

This report was generated as a result of an initial state licensure construction standards survey conducted at the facility on 2010-08-31 and 2010-09-01.

The facility was found to be in substantial compliance with the regulations regarding the construction project. No deficiencies were cited and no further action is necessary.

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