Inspection Reports for
Medicalodges Nevada
1210 W ASHLAND ST, NEVADA, MO, 64772-1906
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
35% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The inspection was conducted following a complaint regarding a resident choking incident caused by being served a regular texture meal instead of the ordered mechanical soft diet.
Complaint Details
Complaint #1477259 involved a resident choking on a hotdog served at regular consistency instead of the ordered mechanical soft diet. The choking incident was substantiated with multiple staff interviews confirming the error and lack of proper meal verification procedures.
Findings
The facility failed to provide a resident with a diet meeting their special dietary needs, resulting in choking on a regular consistency hotdog instead of the prescribed mechanical soft diet. The investigation revealed issues with meal preparation, plating, and serving processes, including lack of consistent double-checks to ensure meals matched dietary orders.
Deficiencies (1)
F 0800: Facility staff failed to provide a resident with a diet meeting their special dietary needs when a regular texture meal was served instead of a mechanical soft diet, resulting in choking. The facility lacked consistent processes to ensure meals were prepared and served according to physician orders.
Report Facts
Residents present: 35
Length of hotdog piece removed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook F | Kitchen Staff | Prepared plates at time of choking incident |
| Certified Nurse Aide (CNA) A | Certified Nurse Aide | Responded to choking incident and assisted EMS |
| Licensed Practical Nurse (LPN) B | Licensed Practical Nurse | Responded to choking incident and provided nursing care |
| Licensed Practical Nurse (LPN) C | Licensed Practical Nurse | Observed choking incident and assisted with EMS |
| CNA D | Certified Nurse Aide | Dining room monitor during choking incident |
| Dietary Aide (DA) E | Dietary Aide | Passed resident's plate during meal service |
| [NAME] F | Dietary Manager | Worked at serve-out station preparing plates during incident |
| Registered Dietician | Registered Dietician | Provided expert opinion on dietary consistency and risks |
| Medical Director | Medical Director | Contacted regarding incident and provided clinical input |
| Director of Nursing (DON) | Director of Nursing | Oversaw meal preparation and serving processes |
| Administrator | Administrator | Managed facility response and investigation of incident |
Inspection Report
Routine
Census: 37
Deficiencies: 1
Date: Apr 9, 2025
Visit Reason
The inspection was conducted to assess the facility's implementation and maintenance of an infection prevention and control program, specifically regarding staff adherence to COVID-19 related mask-wearing policies after two staff tested positive for COVID-19.
Findings
The facility failed to ensure staff properly wore N95 masks as required by CDC guidance and facility policy, with multiple observations of staff wearing masks improperly, such as having the bottom strap hanging below the neck or chin, compromising the mask seal and protection.
Deficiencies (1)
F 0880: The facility failed to implement and maintain an effective infection prevention and control program when staff did not wear N95 masks properly after two staff tested positive for COVID-19. Observations showed multiple staff wearing masks with the bottom strap hanging below the neck or chin, preventing a proper seal.
Report Facts
Facility census: 37
Staff positive for COVID-19: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nursing Assistant | Interviewed and observed wearing N95 mask improperly with bottom strap hanging below chin |
| HA B | Hospitality Aide | Interviewed and observed wearing N95 mask improperly with bottom strap hanging below chin |
| RA | Restorative Aide | Interviewed and observed wearing N95 mask improperly with bottom strap hanging below chin |
| LPN C | Licensed Practical Nurse | Interviewed and observed wearing N95 mask improperly with bottom strap hanging below chin |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Dec 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to timely report allegations of employee to resident abuse involving three residents.
Complaint Details
The complaint involved allegations of verbal and physical abuse by a certified nurse aide toward three residents on 12/15/24 and 12/16/24. The facility self-reported the verbal allegation on 12/17/24. The investigation found staff failed to report abuse immediately, and the accused CNA was suspended. The Administrator confirmed the verbal abuse and rough handling were not reported timely.
Findings
The facility failed to immediately report allegations of abuse and neglect to management and the State Survey Agency within the required two-hour timeframe. The investigation confirmed verbal and physical abuse by a certified nurse aide toward residents, with corrective actions implemented promptly.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities. Staff did not report allegations of employee to resident abuse within the required two-hour timeframe.
Report Facts
Facility census: 31
Date of abuse incidents: 12/15/24 and 12/16/24 (dates of abuse incidents)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nurse Aide | Reported abuse incidents and contacted Administrator about concerns |
| CNA F | Certified Nurse Aide | Accused of verbal and physical abuse toward residents |
| LPN D | Licensed Practical Nurse | Described reporting procedures and confirmed no reports of abuse from staff |
| Administrator | Conducted investigation and confirmed abuse was not reported timely |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Dec 23, 2024
Visit Reason
The inspection was conducted in response to allegations of employee abuse involving three residents at Medicalodges Nevada.
Complaint Details
The complaint involved allegations of employee abuse of three residents. The allegations were substantiated as the facility failed to report the abuse immediately and a certified nurse aide was found to have verbally and physically abused residents. The noncompliance was corrected on 12/17/24.
Findings
The facility failed to immediately report allegations of abuse within the required two-hour timeframe. The investigation found that a certified nurse aide verbally and physically abused residents, and the facility implemented monitoring and corrective actions to address the noncompliance.
Deficiencies (1)
F 609: The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately within the required two-hour timeframe. The facility did not report allegations of abuse involving three residents promptly to management and the State Survey Agency.
Report Facts
Facility census: 31
Inspection Report
Routine
Census: 45
Deficiencies: 8
Date: Jun 18, 2024
Visit Reason
Routine inspection to assess compliance with regulatory requirements including activities program, treatment and care, nurse aide training, dietary services, infection prevention and control.
Findings
The facility failed to ensure a qualified activities program director, timely completion of ordered labs and x-rays, restorative therapy provision, nurse aide training completion, qualified dietary manager employment, adherence to approved menus, provision of suitable diabetic snacks, proper infection prevention practices including enhanced barrier precautions, and designation of a certified infection preventionist.
Deficiencies (8)
F0680: The facility failed to ensure a qualified individual was designated as the activities program director. No full-time activity director was present and residents lacked one-on-one activity interaction.
F0684: The facility failed to provide care per standard of practice by not completing ordered labs/x-rays for two residents and failing to provide restorative therapy for one resident.
F0728: The facility failed to ensure three nurse aides completed certified nurse aide training within four months of employment.
F0801: The facility failed to employ a qualified dietary manager with required certification and training.
F0803: The facility failed to follow approved menus and substituted nonequivalent items for pureed diets for two residents.
F0809: The facility failed to ensure suitable, nourishing snack alternatives were available for diabetic residents outside scheduled meal times.
F0880: The facility failed to maintain a complete infection prevention and control program by not implementing enhanced barrier precautions and failing to train staff properly, resulting in improper hand hygiene and wound care practices.
F0882: The facility failed to designate a qualified infection preventionist with required certification for the infection prevention and control program.
Report Facts
Facility census: 45
Number of diabetic residents: 13
Number of nurse aides sampled: 6
Number of nurse aides non-compliant: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA H | Nurse Aide | Did not complete nurse aide training program within 4 months |
| NA J | Nurse Aide | Did not complete nurse aide training program within 4 months |
| NA A | Nurse Aide | Did not complete nurse aide training program within 4 months |
| LPN I | Licensed Practical Nurse | Provided information on nurse aide training and lab/x-ray order processes |
| Director of Nursing | Director of Nursing | Discussed lack of activities program director, restorative therapy issues, infection prevention training, and nurse aide training |
| Administrator | Facility Administrator | Provided information on activities program staffing, dietary manager certification, snack provision, and infection preventionist certification |
| Dietary Manager | Dietary Manager | Lacked current certification and had not completed dietary certification course |
| Registered Dietician Z | Registered Dietician | Provided guidance on menu adherence and appropriate snack substitutions |
| Certified Medication Technician K | Certified Medication Technician | Unaware of need for gown use during catheter care |
| Registered Nurse D | Registered Nurse | Uncertain about gown use for catheter and wound care; observed improper hand hygiene |
| LPN B | Licensed Practical Nurse | Observed performing wound care with improper hand hygiene and glove use |
| CNA/RNA N | Certified Nursing Assistant/Restorative Nurse Aide | Unable to provide restorative therapy due to being pulled to floor duties |
| Certified Physical Therapy Assistant X | Certified Physical Therapy Assistant | Reported restorative therapy recommendations and lack of follow-through |
| Certified Occupational Therapy Assistant Y | Certified Occupational Therapy Assistant | Reported restorative therapy recommendations and lack of follow-through |
Inspection Report
Routine
Census: 45
Deficiencies: 14
Date: Jun 18, 2024
Visit Reason
Routine inspection of Medicalodges Nevada nursing home to assess compliance with regulatory requirements including resident care, safety, infection control, staffing, and dietary services.
Findings
The facility had multiple deficiencies including failure to provide dignity bags for catheter bags, failure to ensure staff treated residents with dignity during meals, incomplete background checks for employees, failure to complete PASARR screenings, lack of a qualified activities program director, failure to complete ordered labs and restorative therapy, inadequate pressure ulcer care, unsafe resident transfers, improper use and documentation of side rails and grab bars, nurse aides not certified within required timeframe, dietary manager lacking required certification, failure to follow approved pureed menus, incomplete infection prevention practices, and failure to maintain a fully functional call light system.
Deficiencies (14)
F 0550: Facility failed to provide dignity bags for catheter bags for three residents and failed to ensure staff treated residents with dignity during meals by standing over them. Staff also failed to knock before entering a resident's room.
F 0607: Facility failed to follow abuse prevention policy by not requesting criminal background checks and Nurse Aide Registry checks for one staff member prior to contact with residents.
F 0645: Facility failed to complete required PASARR screening for one resident prior to admission and after changes in condition.
F 0680: Facility failed to designate a qualified activities program director and failed to provide consistent activities and one-on-one interaction for residents.
F 0684: Facility failed to provide care per standard of practice by not completing ordered labs and x-rays timely for two residents and failing to provide restorative therapy as ordered for one resident.
F 0686: Facility failed to provide appropriate pressure ulcer care including timely implementation of new wound care orders, timely physician notification, and proper documentation and tracking for one resident with a pressure ulcer.
F 0689: Facility failed to ensure a safe environment by transferring a non-weight bearing resident with a gait belt instead of a mechanical lift, contrary to care plan and clinical assessments.
F 0700: Facility failed to properly assess, document, and obtain orders and consents for side rail and grab bar use for multiple residents, including failure to update care plans and complete safety measurements.
F 0728: Facility failed to ensure three nurse aides completed certified nurse aide training within four months of employment.
F 0801: Facility failed to employ a qualified dietary manager with required certification and sufficient training.
F 0803: Facility failed to follow approved pureed menus and substituted nonequivalent food items for residents requiring pureed diets.
F 0880: Facility failed to maintain a complete infection prevention and control program including failure to implement enhanced barrier precautions and failure to practice proper hand hygiene during wound care.
F 0882: Facility failed to designate a qualified infection preventionist with required certification for the infection prevention and control program.
F 0919: Facility failed to maintain a working call light system, failed to respond timely to call lights, and failed to ensure all staff had access to pagers to receive call light alerts.
Report Facts
Facility census: 45
Number of nurse aides not certified within 4 months: 3
Number of diabetic residents: 13
Number of call light alerts not responded: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN I | Licensed Practical Nurse | Named in findings related to failure to complete lab orders and wound care orders |
| RN D | Registered Nurse | Named in findings related to wound care and infection control |
| NA A | Nursing Assistant | Named in findings related to call light system and wound care |
| CMT K | Certified Medication Technician | Named in findings related to infection control and call light system |
| Director of Nursing | Director of Nursing | Named in multiple findings including infection control, call light response, and staff training |
| Administrator | Facility Administrator | Named in multiple findings including staff training, call light system, dietary services |
| Dietary Manager | Dietary Manager | Named in findings related to dietary certification and menu substitutions |
| LPN B | Licensed Practical Nurse | Named in wound care and infection control findings |
| LPN C | Licensed Practical Nurse | Named in grab bar and side rail assessment findings |
Inspection Report
Life Safety
Census: 45
Capacity: 100
Deficiencies: 5
Date: Jun 18, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations.
Findings
The facility failed to maintain fire safety standards including sprinkler system integrity, corridor door latching, electrical equipment safety, and oxygen storage requirements. Deficiencies had the potential to affect residents in multiple smoke compartments.
Deficiencies (5)
K161: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations, affecting 32 residents. Maintenance policies for ceiling inspections were lacking.
K353: The sprinkler system was not properly maintained; sprinkler heads were obstructed by dust, dirt, lint, and corrosion, potentially affecting all residents, staff, and visitors.
K363: Corridor doors failed to latch properly on two resident rooms, risking smoke passage and affecting 23 residents. No policy for corridor door maintenance was provided.
K920: Electrical system deficiencies included improper use of power strips in patient care areas, risking fire or electrical injury affecting 33 residents.
K923: Oxygen storage was not properly maintained; combustibles were stored within five feet of oxygen cylinders, risking fire hazards affecting 10 residents.
Report Facts
Residents potentially affected: 32
Residents potentially affected: 23
Residents potentially affected: 33
Residents potentially affected: 10
Facility capacity: 100
Census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Shuey | Administrator | Named in interviews regarding fire safety compliance and responsibility |
| Kayla Shuey | Administrator | Signed the report and plan of correction |
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 2
Date: Sep 11, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to the facility's governing body and administrator licensing.
Findings
The facility failed to ensure the administrator had an active license recognized by the state of Missouri. The governing body did not provide a policy regarding the administrator role and allowed an unlicensed administrator to function.
Deficiencies (2)
F837 Governing body failed to ensure the administrator had an active license and lacked a policy regarding the administrator role.
A4001 The operator did not designate a person holding a current nursing home administrator license in Missouri.
Report Facts
Facility census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Identified as the administrator without an active license | |
| Staff Member B | Licensed Nursing Home Administrator | Brought active license to facility and appointed as administrator |
Inspection Report
Census: 46
Deficiencies: 1
Date: Sep 11, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements, specifically regarding the appointment of a properly licensed administrator.
Findings
The facility's governing body failed to ensure that the appointed administrator held an active license recognized by the state. The facility census was 46, and no policy was provided regarding qualifications for the administrator role.
Deficiencies (1)
F 0837: The facility failed to appoint a properly licensed administrator as Staff Member A did not have an active administrator license recognized by the State of Missouri.
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 2
Date: Mar 28, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to medication administration and safety.
Findings
The facility failed to ensure residents were free of significant medication errors related to insulin administration. Observations, record reviews, and interviews revealed staff did not prime insulin pens prior to injection and did not hold the insulin pen in place for the recommended time after injection.
Deficiencies (2)
F760 Residents are free of significant medication errors. The facility failed to ensure residents were free of significant medication errors when staff administered insulin to three residents without priming the insulin pen prior to injection and without holding the insulin pen in place the recommended time after injection.
A4055 Safe/Effective Medication System. The facility failed to maintain a safe and effective system of medication distribution, administration, control, and use as evidenced by the deficiency cited under F760.
Report Facts
Facility census: 88
Number of residents with medication errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Coover | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Director of Nursing | Interviewed regarding insulin pen policy and administration procedures |
| LPN A | Licensed Practical Nurse | Observed administering insulin without priming the pen |
| LPN B | Licensed Practical Nurse | Observed administering insulin and interviewed about insulin pen priming |
Inspection Report
Routine
Census: 88
Deficiencies: 1
Date: Mar 28, 2023
Visit Reason
The inspection was conducted to evaluate medication administration practices, specifically ensuring residents were free from significant medication errors related to insulin pen use.
Findings
The facility failed to ensure proper insulin pen administration for three residents, including failure to prime the insulin pen prior to injection and not holding the insulin pen in place for the recommended time after injection. The facility census was 88 at the time of inspection.
Deficiencies (1)
F 0760: The facility failed to prime insulin pens before injection and did not hold the insulin pen in place for the recommended time after injection when administering insulin to three residents.
Report Facts
Facility census: 88
Insulin units: 8
Insulin units: 36
Insulin units: 6
Priming units: 2
Hold time seconds: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Administered insulin without priming pen and did not hold needle in place for recommended time | |
| Licensed Practical Nurse (LPN) B | Observed insulin administration and confirmed doses; noted LPN A did not prime pens | |
| Director of Nursing (DON) | Provided information on insulin administration procedures and facility policy | |
| Certified Medication Technician (CMT) | Performed blood sugar tests and documented results | |
| Administrator | Located facility policy on insulin pen priming and hold time | |
| Corporate Clinical Nurse Consultant | Participated in interview regarding insulin administration policy |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 6
Date: Jul 21, 2022
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations regarding resident care, abuse prevention, and facility policies.
Findings
The facility was found to have failed in ensuring residents were free from verbal and emotional abuse by staff members. The facility also failed to report allegations of abuse timely and did not protect residents from further harm during the investigation.
Deficiencies (6)
F600: The facility failed to ensure residents were free from verbal, mental, and emotional abuse as evidenced by staff making derogatory comments and threats to a resident. The facility census was 36.
F609: The facility failed to report allegations of abuse immediately and to the State Survey Agency within two hours as required. The facility census was 36.
F610: The facility failed to investigate and take corrective action regarding allegations of abuse and failed to protect residents during the investigation.
A4074: The facility failed to provide twenty-four-hour protective oversight for residents on voluntary leave.
A8023: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents and failed to report such incidents to the department as required.
A8030: The facility failed to ensure residents were treated with dignity and respect, including privacy in treatment and care.
Report Facts
Facility census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator M | Administrator | Received complaint from Social Services Director and involved in abuse reporting and investigation |
| SSD | Social Services Director | Reported allegations of verbal abuse by staff members |
| DAA | Dietary Aide verbally abused resident and was suspended and terminated | |
| CNAB | Certified Nurse Aide verbally abused resident and was suspended and terminated | |
| HKK | Housekeeper verbally abused resident and was suspended and terminated | |
| LPN G | Licensed Practical Nurse | Charge nurse involved in abuse reporting and investigation |
| DON | Director of Nursing | Involved in abuse reporting and investigation |
Inspection Report
Routine
Census: 32
Deficiencies: 3
Date: Jun 9, 2022
Visit Reason
The inspection was conducted to assess compliance with health and safety regulations related to maintaining a safe, clean, and homelike environment, food sanitation, infection control, and employee health screening.
Findings
The facility was found to have multiple deficiencies including unclean fluorescent light fixtures with dead bugs, unsanitary kitchen conditions with accumulation of lint and dust, improperly maintained dishwasher chemical levels, and failure to complete required employee tuberculosis screening tests.
Deficiencies (3)
F 0584: The facility failed to maintain a clean, comfortable, homelike environment in the dining room where fluorescent light fixtures contained dead bugs. The facility lacked a policy for maintaining cleanliness of light covers/fixtures.
F 0812: The facility failed to ensure food was stored, prepared, and served in sanitary conditions, including failure to clean kitchen surfaces, repair and clean fluorescent light covers, clean a window air conditioner near food, and maintain dishwasher chemical levels at recommended ppm.
F 0880: The facility failed to follow policy to ensure employee tuberculosis screening tests were completed on hire for three staff members, including missing documentation of two-step TB tests.
Report Facts
Facility census: 32
Dishwasher chemical ppm reading: 200
Dishwasher chemical ppm minimum acceptable: 50
Dishwasher chemical ppm recommended range: 120
Dishwasher chemical ppm recommended range: 200
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 9
Date: Jun 9, 2022
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for the facility Medicalodges Nevada.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, food procurement and sanitation, infection prevention and control, and resident fund bond requirements. Multiple deficiencies were cited related to cleanliness, maintenance, food safety, infection control, and employee health screening.
Deficiencies (9)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain a clean, comfortable environment in the dining room with fluorescent light fixtures containing dead bugs and lacked a policy for cleaning light covers.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to ensure staff stored, prepared, and served food in sanitary conditions, including failure to clean a metal shelf, fluorescent light covers, and a window air conditioner, and dishwasher chemicals were not at recommended levels.
F880 Infection Prevention & Control: The facility failed to follow its policy ensuring staff completed tuberculosis screening tests and did not maintain proper documentation for employee TB testing.
A4031 Communicable Disease-Employees: The facility failed to develop and implement policies ensuring employees are screened for communicable diseases and do not expose residents.
A6012 Floor Surfaces: Floors and floor coverings were not maintained in good repair and cleanliness as evidenced by deficiencies noted in F812.
A6015 Walls/Ceilings/Doors/Windows Clean: Walls, ceilings, doors, and windows were not clean and maintained in good repair as evidenced by deficiencies noted in F812.
A7015 Food-Protected, Temp, Need to Contact DHSS: The facility failed to protect food from contamination and maintain proper temperatures as required by regulations.
A7076 Chemical Sanitization, PPM Measured: The facility failed to ensure chemical sanitizers were used at proper concentrations as required.
A9023 Resident Fund Bond Requirements: The facility failed to maintain a surety bond totaling one and one-half times the monthly average balance of resident trust accounts to ensure protection of resident funds.
Report Facts
Facility census: 32
Surety bond amount: 50000
Resident fund balances: 39442.01
Resident fund balances: 36382.9
Inspection Report
Annual Inspection
Census: 32
Capacity: 100
Deficiencies: 2
Date: Jun 9, 2022
Visit Reason
The inspection was an annual recertification survey to assess compliance with the Life Safety Code and related fire safety regulations.
Findings
The facility failed to meet the applicable provisions of the 2012 Life Safety Code regarding hazardous areas and smoke barrier construction. Deficiencies included doors to hazardous areas not being self-closing and smoke barrier walls not maintaining required fire resistance ratings.
Deficiencies (2)
K321 Hazardous Areas - Enclosure: Facility doors to hazardous areas were not self-closing, allowing smoke penetration and risking containment failure. The facility census was 32 with a capacity of 100.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Smoke barriers were not constructed to required fire resistance ratings and contained unsealed penetrations, compromising smoke containment.
Report Facts
Facility census: 32
Total capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding smoke barrier and hazardous area door issues | |
| Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 4
Date: Dec 1, 2021
Visit Reason
The inspection was conducted to assess compliance with safe, clean, and homelike environment regulations, including maintenance and housekeeping standards.
Findings
The facility failed to maintain a safe, clean, and homelike environment as evidenced by damaged walls, peeling paint, dust accumulation, and insect presence in multiple areas. Maintenance and housekeeping issues were noted, with staff shortages impacting timely repairs.
Deficiencies (4)
F 584 Safe Environment. The facility failed to ensure residents had a clean, comfortable, and homelike environment, with multiple areas showing damage, peeling paint, dust, and insect infestations.
A6012 Floor Surfaces. Floors and floor coverings were not maintained in good repair and cleanliness as required.
A6015 Walls/Ceilings/Doors/Windows Clean. Walls, ceilings, doors, and windows were not clean or maintained in good repair.
A6019 List Fixtures, Vent Covers, Décor Cleanable. Light fixtures, vent covers, and similar equipment were not clean or maintained in good repair.
Report Facts
Resident census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding repair issues and staff shortages | |
| Administrator | Interviewed regarding environmental issues and repair challenges |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant CMS and CDC guidelines related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness and infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Census: 52
Deficiencies: 3
Date: Aug 8, 2019
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident activities, use of bed rails, and facility-wide resource assessment.
Findings
The facility failed to provide an ongoing program of activities meeting residents' needs and did not document attendance accurately. The facility also failed to complete documented assessments, risk/benefit reviews, and obtain consent for side rail use for multiple residents. Additionally, the facility did not complete or document a facility-wide assessment to determine necessary resources for competent resident care during day-to-day operations and emergencies.
Deficiencies (3)
F 0679: Facility failed to provide an ongoing program of activities meeting residents' needs and failed to document attendance accurately for multiple residents.
F 0700: Facility failed to complete documented assessments, risk/benefit reviews, and obtain informed consent for side rail use for five residents, and did not evaluate dimensional limits of bed gaps.
F 0838: Facility failed to complete and document a facility-wide assessment to determine necessary resources for competent resident care during day-to-day operations and emergencies.
Report Facts
Facility census: 52
Residents with depression: 28
Residents with psychiatric diagnosis: 21
Residents with behavioral healthcare needs: 24
Residents on psychoactive medication: 32
Residents on pain management program: 37
Residents requiring tracheostomy care: 2
Residents requiring ostomy care: 2
Residents requiring tube feeding: 2
Residents using non-oral communication devices: 2
Sample size: 15
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 3
Date: Aug 8, 2019
Visit Reason
The document is a Plan of Correction submitted by Medicalodges Nevada following a survey conducted on 08/08/2019. It addresses deficiencies cited during the inspection related to activities and bed rails.
Findings
The facility failed to provide an ongoing program of activities meeting residents' needs and preferences, and did not provide a policy for scheduling and attendance of activities. The facility also failed to complete proper assessments and documentation related to bed rails, including consent forms and risk assessments.
Deficiencies (3)
F679 Activities Meet Interest/Needs Each Resident. The facility failed to provide an ongoing program of activities designed to meet residents' interests and needs and did not accurately document attendance or provide a scheduling policy.
F700 Bedrails. The facility failed to complete assessments, obtain consent, and properly document the use and risks of bed rails for residents, including failure to follow manufacturer guidelines and ensure safety.
F838 Facility Assessment. The facility failed to complete a comprehensive facility-wide assessment to determine resources necessary to care for residents competently during day-to-day operations and emergencies.
Report Facts
Facility census: 52
Sample size for resident review: 15
Sample size for bed rail assessment: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Lowe | Administrator | Signed the Plan of Correction and is mentioned as the administrator in interviews |
Inspection Report
Annual Inspection
Census: 52
Capacity: 100
Deficiencies: 2
Date: Aug 6, 2019
Visit Reason
Annual recertification survey to assess compliance with the Life Safety Code and related regulations.
Findings
The facility failed to maintain the electrical system by allowing improper use of power strips, which posed a potential fire or electrical injury hazard. No emergency preparedness deficiencies were cited.
Deficiencies (2)
K920 Electrical Equipment - Power cords and extension cords were improperly used as power strips in patient care areas, which could cause fire or electrical injury. Observations included refrigerators and powered recliners plugged into power strips.
A3037 Extension cords/duplex receptacles were not compliant with Underwriters Laboratories (UL) standards and were improperly placed under rugs or doorways. This deficiency references K920.
Report Facts
Facility capacity: 100
Census: 52
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 5, 2018
Visit Reason
The inspection was conducted as a licensure inspection and complaint investigation for Medicalodges Nevada.
Complaint Details
No deficiencies were cited as a result of the complaint investigation.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection and complaint investigation.
Inspection Report
Annual Inspection
Census: 53
Capacity: 100
Deficiencies: 5
Date: Oct 5, 2018
Visit Reason
The inspection was an annual recertification survey focused on Life Safety Code compliance and fire safety systems.
Findings
The facility failed to conduct a required semi-annual fire alarm inspection and did not meet several Life Safety Code requirements including fire alarm testing, smoking regulations signage, and proper use of electrical power strips. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (5)
K345 Fire Alarm System - The facility failed to conduct a semi-annual fire alarm inspection as required by NFPA 70, NFPA 72, and NFPA 101. Records of system acceptance, maintenance, and testing were not readily available.
K741 Smoking Regulations - The facility did not have 'No Smoking' signs at entrances and failed to properly identify rooms where oxygen was in use, including missing 'No Smoking Oxygen in Use' signs in resident rooms.
K920 Electrical Equipment - Power strips in patient care areas were improperly used and not secured, creating a potential electrical hazard that could affect residents, staff, and visitors.
A2020 Fire Alarm System Inspections - The facility did not have annual inspections and written certifications of the complete fire alarm system by an approved qualified service representative as required by regulation.
A3030 Electrical Wiring & Equipment Maintenance - Electrical wiring and equipment were not maintained in accordance with NFPA 70 standards, posing a risk to resident safety.
Report Facts
Facility capacity: 100
Resident census: 53
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