Deficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 146
Deficiencies: 0
May 30, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 5/30/2025, in accordance with 42 CFR Part 483 - Requirements for Long Term Care Facilities.
Findings
One complaint was investigated and substantiated with no deficient practice found. The investigation included observations of facility conditions, temperature checks, interviews with staff and residents, and document reviews related to the complaint.
Complaint Details
Complaint # NV00074334 was substantiated with no deficient practice.
Report Facts
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the complaint investigation | |
| Director of Maintenance | Interviewed during the complaint investigation | |
| Regional Maintenance Director | Interviewed during the complaint investigation | |
| Maintenance Assistant | Interviewed during the complaint investigation | |
| Business Office Manager | Interviewed during the complaint investigation |
Inspection Report
Annual Inspection
Census: 145
Deficiencies: 4
Sep 27, 2024
Visit Reason
This report documents a State licensure survey conducted in conjunction with a Medicare annual recertification survey at the facility from 09/23/2024 through 09/27/2024.
Findings
The facility was found deficient in multiple areas including incomplete initial and annual tuberculosis screenings, lack of pre-employment physical examinations for many employees, failure to ensure the Director of Nursing met minimum qualifications, incomplete dementia training for some staff, and failure to post a non-discrimination statement and provide cultural competency training to all required employees.
Severity Breakdown
F: 1
D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure initial and annual tuberculosis screenings and pre-employment physical examinations were completed for sampled employees as required by Nevada Administrative Code. | F |
| Facility failed to ensure the Director of Nursing met minimum qualifications of three years nursing experience in hospital or long-term care. | D |
| Failure to ensure all employees completed required dementia training annually and initially. | D |
| Failure to post a statement of non-discrimination prominently in the facility and on the facility's Internet website and failure to ensure initial cultural competency training was completed for all required employees. | D |
Report Facts
Census: 145
Employees sampled: 35
Deficiencies cited: 4
Plan of correction completion date: Oct 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee 2 | Director of Nursing | Named in deficiency for not meeting minimum qualifications for DON position |
| Employee 8 | Certified Nursing Assistant | Named in deficiencies for missing initial TB screening, annual TB screening, dementia training, and pre-employment physical exam |
| Employee 15 | Licensed Practical Nurse | Named in deficiencies for missing initial TB screening and pre-employment physical exam |
| Employee 19 | Dietary Aide | Named in deficiencies for missing initial TB screening and pre-employment physical exam |
| Employee 20 | Housekeeping Aide | Named in deficiencies for missing initial TB screening and pre-employment physical exam; no longer employed |
| Employee 25 | Certified Nursing Assistant | Named in deficiencies for missing initial TB screening and cultural competency training |
| Employee 34 | Respiratory Therapist | Named in deficiency for missing initial TB screening |
| Employee 1 | Administrator | Named in deficiency for missing annual TB screening |
| Employee 9 | Registered Nurse | Named in deficiencies for missing annual TB screening and pre-employment physical exam |
| Employee 11 | Registered Nurse | Named in deficiency for missing annual TB screening |
| Employee 22 | Wound Care Nurse/Licensed Practical Nurse | Named in deficiency for missing annual TB screening |
| Employee 35 | Respiratory Therapist | Named in deficiency for missing annual TB screening |
| Employee 3 | Director of Activities | Named in deficiency for missing initial cultural competency training |
| Employee 4 | Registered Dietitian | Named in deficiencies for missing annual dementia training and initial cultural competency training |
| Employee 5 | Social Services Director | Named in deficiency for missing initial cultural competency training |
| Employee 13 | Registered Nurse | Named in deficiency for missing initial cultural competency training |
| Employee 17 | Certified Nursing Assistant | Named in deficiency for missing initial cultural competency training |
| Employee 26 | Certified Nursing Assistant | Named in deficiency for missing initial cultural competency training |
Inspection Report
Annual Inspection
Deficiencies: 4
Sep 27, 2024
Visit Reason
This inspection was conducted as a state licensure survey concurrently with a federal recertification survey at the facility on 09/26-27/2024, to assess compliance with Nevada Administrative Code (NAC) 449 for skilled nursing facilities and related health and safety codes.
Findings
The facility was found deficient in multiple areas including dietary services sanitation, respiratory staff knowledge of ventilator battery backup, nurse call system maintenance, and potable water backflow protection. Deficiencies were identified with food contact surface sanitation, ventilator battery backup knowledge, nurse call pull cord accessibility, and backflow prevention in plumbing systems.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure all food contact surfaces were cleaned and sanitized, including meat slicer with dried meat particles, large mixer with dried food splatter, and can opener with metal shavings. | 2 |
| Respiratory staff were unaware of ventilator machines' backup battery life, with actual battery life being two hours versus staff belief of 6-8 hours. | 2 |
| Nurse call system pull cords were not maintained properly; specifically, a pull cord was found 31 inches above the finished floor, exceeding the 18 inch maximum height requirement. | 2 |
| Potable water supply was not backflow protected; unprotected hose bibb and hose in trash compactor enclosure, boiler room hose, and invalidated atmospheric vacuum breakers in soiled workroom created cross connections with sewer. | 2 |
Report Facts
Deficiency severity: 2
Deficiency scope: 2
Deficiency scope: 3
Deficiency scope: 1
Deficiency scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Brantley | Administrator | Signed report and responsible for corrective actions |
| Dietary Manager | Interviewed regarding dietary equipment sanitation deficiencies | |
| Director of Respiratory | Interviewed regarding ventilator battery backup knowledge deficiency |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 0
Aug 9, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 08/06/2024, finalized on 08/08/2024, to evaluate compliance with federal regulations for long term care facilities.
Findings
The complaint investigation included observations, interviews with various staff, clinical record reviews, and document reviews. The complaint NV00071850 was substantiated without deficient practice, and no regulatory deficiencies were identified.
Complaint Details
Complaint NV00071850 was substantiated without deficient practice.
Report Facts
Sample size: 2
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 1
Feb 15, 2024
Visit Reason
The inspection was conducted as a result of a Complaint and Facility Reported Incident Investigation initiated on 2023-12-19 and finalized on 2024-02-15, investigating 11 complaints and 3 Facility Reported Incidents (FRIs).
Findings
Two complaints (#NV00069866 and #NV00069832) were verified with identified regulatory deficiencies related to pain management (Tag F697). The facility failed to ensure pain medications were administered as prescribed for one of 15 sampled residents, leading to uncontrolled pain and diminished quality of life. Multiple missed medication administrations were documented, and corrective actions were planned.
Complaint Details
There were 11 complaints and 3 Facility Reported Incidents investigated. Complaints #NV00069866 and #NV00069832 were verified with deficiencies identified. Complaints #NV00069412 and #NV00070082 were verified without deficiencies. Complaints #NV00069540, #NV00069928, #NV00069950, #NV00069961, #NV00067997, #NV00070068, #NV00070292, and FRIs #NV00067854, #NV00069543, #NV00069484 could not be verified and no deficiencies were identified.
Severity Breakdown
S=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Pain Management - The facility failed to ensure pain medications were administered as prescribed for 1 of 15 sampled residents, resulting in uncontrolled pain and diminished quality of life. | S=D |
Report Facts
Census at beginning of survey: 148
Sample size: 15
Number of complaints investigated: 11
Number of Facility Reported Incidents investigated: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Brantley | Administrator | Signed the Statement of Deficiencies on 3/1/24 |
| Assistant Director of Nursing | Indicated staff were expected to follow physician orders and notify deviations | |
| Director of Nursing | Verified and confirmed Hydromorphone was inconsistently given and lacked documentation | |
| Physician Assistant | Indicated pain medication should have been administered as prescribed | |
| Licensed Practical Nurse | Assigned to resident and explained medication administration issues |
Inspection Report
Annual Inspection
Census: 156
Deficiencies: 2
Sep 22, 2023
Visit Reason
The inspection was conducted as a Medicare Recertification Survey combined with a Complaint and Facility Reported Incident Investigation from 09/20/2023 through 09/22/2023.
Findings
The facility was found to have multiple regulatory deficiencies including failure to prevent neglect of a dependent, non-verbal resident left in a wet brief for an extended period, contributing to a urinary tract infection, and failure to properly report and treat a newly identified pressure ulcer for another resident. Several complaints and incidents were investigated with some verified deficiencies.
Complaint Details
The investigation included 10 complaints and 5 Facility Reported Incidents (FRIs). Four complaints and one FRI were verified with regulatory deficiencies identified. Several other complaints and FRIs were verified with no deficiencies or could not be verified. Specific complaints verified with deficiencies include #NV00068504, #NV00068861, #NV00069158, and FRI #NV00069483.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a dependent, non-verbal resident was not left in a wet brief for an extended period, placing the resident at risk for skin impairments and urinary tract infection. | SS=D |
| Failure to ensure a newly identified pressure ulcer was reported to the physician and treatment orders were obtained and carried out. | SS=D |
Report Facts
Sample size: 31
Complaints investigated: 10
Facility Reported Incidents investigated: 5
Resident census: 156
Antibiotic dosage: 500
Chux pad dimensions: 34
Chux pad dimensions: 28
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 0
May 2, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 5/2/2023, in accordance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The complaint investigation included observations, temperature readings, and interviews with staff and residents. The complaint was verified with no deficient practice, and no regulatory deficiencies were identified.
Complaint Details
Complaint #NV00068394 was investigated and verified with no deficient practice found.
Report Facts
Residents present: 148
Complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 153
Deficiencies: 2
Feb 7, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility from 02/07/2023 through 02/08/2023 in accordance with 42 CFR Chapter IV, Part 483, Requirements for Long Term Care Facilities.
Findings
The investigation identified multiple deficiencies related to medication administration and quality of care, including failure to ensure medications ordered for residents were administered properly, leading to potential adverse reactions and delayed healing. Corrective actions and monitoring plans were outlined for affected residents.
Complaint Details
There were 10 complaints investigated; 3 complaints (#NV00067241, #NV00066745, #NV00066814) were substantiated, 1 complaint (#NV00067808) was substantiated without deficient practice, and 6 complaints were unsubstantiated with no regulatory deficiencies identified.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure medications ordered for a particular resident were administered to that resident, leading to potential adverse reactions and drug-to-drug interactions. | Level D |
| Failure to ensure a physician order for a resident's intravenous antibiotic was followed, potentially leading to delayed healing. | Level D |
Report Facts
Complaints investigated: 10
Sample size: 8
Census: 153
Deficiencies cited: 2
Inspection Report
Annual Inspection
Census: 158
Deficiencies: 5
Aug 2, 2022
Visit Reason
The inspection was conducted as a Medicare Recertification survey, complaint investigation, and facility reported incident investigation from July 26, 2022 through August 2, 2022.
Findings
The survey included investigation of ten complaints and two facility reported incidents. Several allegations were substantiated without regulatory deficiencies, including issues related to falls, notification of infection status, medication administration, nutrition, and therapy services. Some deficiencies were identified related to notification of family about Clostridium Difficile infection, inaccurate resident assessment coding, fall prevention interventions, oxygen cylinder safety, and nutrition monitoring.
Complaint Details
Multiple complaints investigated including allegations of mistreatment, medication issues, pain management, nutrition, staffing, infection control, and resident safety. Some complaints were substantiated without regulatory deficiencies; others resulted in citations for failure to notify family of infection, inaccurate assessments, fall prevention, oxygen safety, and nutrition monitoring.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify family of resident's Clostridium Difficile infection and placement on contact isolation precautions. | SS=D |
| Failed to ensure prompt follow up for a resident's grievance. | SS=D |
| Resident assessment was inaccurate; coded for tracheostomy care when resident did not have a tracheostomy. | SS=D |
| Failed to implement fall device and follow care plan for fall interventions for residents; oxygen cylinder was unsecured. | SS=D |
| Failed to consistently monitor fluid/meal intake and weight; failed to intervene timely for significant weight loss. | SS=D |
Report Facts
Census: 158
Sample size: 31
Complaints investigated: 10
Facility reported incidents investigated: 2
Weight loss percentage: 7.5
MDS cognitive score: 5
MDS cognitive score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in findings related to medication administration, infection notification, and resident care. | |
| Assistant Director of Nursing | Named in findings related to infection notification and family communication. | |
| Unit Manager | Named in findings related to fall prevention and resident safety. | |
| Registered Nurse | Named in findings related to infection notification and resident care. | |
| Licensed Practical Nurse | Named in findings related to fall prevention and oxygen safety. | |
| Director of Medical Records | Named in findings related to resident assessment accuracy. | |
| Director of Rehabilitation | Named in findings related to therapy services and resident care. | |
| Registered Dietitian | Named in findings related to nutrition monitoring and weight loss. | |
| Physical Therapist | Named in findings related to therapy services. | |
| Certified Nursing Assistant | Named in findings related to resident care and oxygen safety. |
Report
File
EP_poc.pdf
Report
File
LSC_poc.pdf
Report
File
U93P11_poc.pdf
Report
File
U93P21
Report
File
U93P21
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