Inspection Report Summary
The most recent inspection on August 22, 2025, identified deficiencies related to maintenance of air conditioning units and several care and infection control issues. Earlier inspections showed a pattern of deficiencies involving resident care practices, medication administration, infection prevention, staff training, and facility maintenance, with substantiated complaints including abuse and pain management concerns. Inspectors cited issues such as failure to implement physician orders, incomplete infection control measures, unsecured medications, and unsafe oxygen storage. Complaint investigations were mixed, with some substantiated findings including abuse and environmental concerns, while others found no deficiencies. The facility’s deficiencies appear consistent over time, with ongoing challenges in care implementation and environmental maintenance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
21.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
203% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
92% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 22
Capacity: 24
Deficiencies: 1
Date: Aug 22, 2025
Visit Reason
The inspection was conducted due to complaints regarding the air conditioning units not working properly in two resident room halls (1300 Hall and 2300 Hall), causing uncomfortable room temperatures.
Complaint Details
Complaint 2289515 regarding air conditioning not working in resident rooms, substantiated by observations, interviews, and document review.
Findings
The facility failed to maintain the air conditioning units in good working condition in 2 of 12 resident room halls, resulting in hot room temperatures ranging from 83 to 84 degrees Fahrenheit. Repairs were ongoing, with affected halls closed and portable cooling units provided. The issue stemmed from a power surge and wiring problems causing intermittent outages and shutdowns.
Deficiencies (1)
Failed to ensure the air conditioning unit in 2 of 12 resident room halls (1300 Hall and 2300 Hall) was maintained in good working condition, causing uncomfortable room temperatures.
Report Facts
Rooms affected: 24
Residents affected: 17
Occupancy rate: 90
Rooms per hall: 12
Temperature range: 83
Temperature range: 84
Temperature range: 70.2
Temperature range: 79
Residents in attendance: 10
Duration residents remained in affected rooms: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided information about resident room transfers and affected rooms |
| Administrator | Administrator | Provided timeline of events, details on repairs, occupancy, and mitigation efforts |
| Maintenance Director | Maintenance Director | Responsible for resetting the air conditioning system and provided information on resident room occupancy during outage |
| Certified Nursing Assistant | Certified Nursing Assistant | Reported on resident complaints and room temperatures during the outage |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 22, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, facility maintenance, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide proper fingernail care, failure to implement physician orders for pressure relief boots, incomplete urinary catheter changes, lack of physician orders for IV line care, failure to provide ordered glaucoma medication, inadequate infection prevention practices including enhanced barrier precautions and water management program deficiencies, and failure to maintain air conditioning units in resident hallways.
Deficiencies (7)
Failure to ensure fingernail care was provided for 4 of 40 sampled residents.
Failure to ensure physician order for Pressure Relief Ankle Foot Orthosis boots was implemented for 2 of 40 sampled residents.
Failure to ensure physician order for monthly urinary catheter change was completed for 1 of 40 sampled residents.
Failure to ensure physician order was obtained for PICC line and heparin lock care and maintenance for 1 of 40 sampled residents.
Failure to provide medication for glaucoma as ordered for 1 of 40 sampled residents.
Failure to maintain enhanced barrier precautions and implement provisions in the water management program for 1 of 40 sampled residents.
Failure to ensure air conditioning units in 2 of 12 resident room halls were maintained in good working condition.
Report Facts
Residents sampled: 40
Residents affected by fingernail care deficiency: 4
Residents affected by PRAFO boots deficiency: 2
Residents affected by urinary catheter change deficiency: 1
Residents affected by IV line order deficiency: 1
Residents affected by glaucoma medication deficiency: 1
Residents affected by infection prevention deficiency: 1
Residents affected by air conditioning deficiency: 17
Private rooms in 1300 Hall: 12
Private rooms in 2300 Hall: 12
Occupancy rate: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed fingernail care deficiencies and acknowledged need for routine nail care |
| Director of Nursing | Director of Nursing (DON) | Reviewed orders and confirmed deficiencies related to PRAFO boots, urinary catheter changes, IV line orders, glaucoma medication, and air conditioning issues |
| Infection Preventionist | Infection Preventionist (IP) | Indicated importance of nail care and acknowledged deficiencies in infection prevention and water management program |
| Registered Nurse | Registered Nurse (RN) | Acknowledged responsibility for fingernail care and confirmed lack of documentation for PRAFO boots application and urinary catheter changes |
| Licensed Practical Nurse | Licensed Practical Nurse | Confirmed lack of physician orders for IV line care and maintenance |
| Physical Therapist | Physical Therapist (PT) | Indicated PRAFO boots must be applied daily to be effective |
| Certified Nursing Aide | Certified Nursing Aide (CNA) | Acknowledged responsibility for fingernail care and application of PRAFO boots |
| Maintenance Director | Maintenance Director | Responsible for water management plan and air conditioning repairs |
| Administrator | Administrator | Provided timeline and explanation of air conditioning unit failures and repairs |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 5, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to an allegation of abuse by a Certified Nursing Assistant (Employee 1) against Resident 1, who reported the CNA took away their room phone because the resident kept calling the desk.
Complaint Details
The complaint investigation was substantiated. Employee 1 was found to have willfully inflicted punishment on Resident 1 by unplugging the phone and telling the resident to stop calling downstairs. Employee 1 was suspended pending investigation and terminated on 02/06/2025. The facility reported the employee to the Board of Nursing. Resident 1 reported no ongoing psychosocial harm and felt safe at the facility during the onsite investigation.
Findings
The facility substantiated the abuse allegation where Employee 1 unplugged the resident's phone and placed it out of reach, causing emotional distress. Employee 1 was suspended and terminated for abuse. The facility failed to provide ongoing abuse training related to the incident, which was acknowledged by the Director of Nursing and Administrator. The facility corrected the non-compliance by terminating the employee and reporting to the Board of Nursing, and resident interactions were observed to be respectful.
Deficiencies (2)
Failed to protect resident from abuse when a CNA unplugged the resident's phone and placed it out of reach, causing emotional distress.
Failed to implement abuse policies and procedures, including ongoing staff training related to abuse prevention.
Report Facts
Residents sampled: 6
Residents affected: 1
Date of abuse incident: Feb 1, 2025
Date of employee termination: Feb 6, 2025
Date of survey completion: Jun 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Certified Nursing Assistant (CNA) | Admitted to unplugging the resident's phone and was terminated for abuse |
| Director of Nursing | Director of Nursing (DON) | Acknowledged need for ongoing abuse training after abuse allegation |
| Administrator | Administrator | Acknowledged policy steps to prevent abuse and need for ongoing abuse training |
Inspection Report
Complaint Investigation
Census: 146
Deficiencies: 0
Date: 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.
Complaint Details
Complaint # NV00074334 was substantiated with no deficient practice.
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.
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
Complaint Investigation
Deficiencies: 5
Date: Jan 9, 2025
Visit Reason
The inspection was conducted based on complaints regarding resident dignity, discharge planning, shower provision, oxygen cylinder storage, and medication security at the facility.
Complaint Details
Complaint #NV00073092 related to dignity issues; Complaint #NV00071075 related to shower provision; other complaints related to oxygen storage and medication security.
Findings
The facility was found deficient in multiple areas including failure to treat a resident with dignity by directing urination in briefs, inadequate discharge planning and documentation, failure to provide scheduled showers, unsafe storage of oxygen cylinders, and unsecured medication left unattended in a resident's room.
Deficiencies (5)
Failed to ensure a resident was treated with dignity and respect by directing the resident to urinate in their incontinence brief.
Failed to clarify discrepancies in the appeal decision resulting in a resident being discharged and lacked documented evidence of well-coordinated discharge planning.
Failed to ensure showers were provided as scheduled, increasing risk of skin breakdown and infections.
Failed to ensure two free standing portable oxygen cylinders were safely stored, increasing risk of accidents.
Failed to ensure medications were secured; a medication cup with cream was left unattended in a resident's room.
Report Facts
Residents Sampled: 16
Residents Affected: 1
Dates of missed showers: Missed showers for Resident 14 on 01/11/24 through 01/15/24, 01/18/2024, and 01/22/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Verified dignity issues and oxygen cylinder storage requirements | |
| Director of Rehabilitation (DOR) | Provided information on discharge planning and resident mobility | |
| Case Manager | Discussed discharge appeal process and documentation issues | |
| Registered Nurse (RN) | Commented on oxygen cylinder storage and medication security | |
| Certified Nursing Assistant (CNA) | Provided information on dignity issues and oxygen cylinder placement | |
| Wound Care Nurse | Responsible for applying moisture barrier cream to Resident 19 |
Inspection Report
Annual Inspection
Census: 145
Deficiencies: 4
Date: 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.
Deficiencies (4)
Failure to ensure initial and annual tuberculosis screenings and pre-employment physical examinations were completed for sampled employees as required by Nevada Administrative Code.
Facility failed to ensure the Director of Nursing met minimum qualifications of three years nursing experience in hospital or long-term care.
Failure to ensure all employees completed required dementia training annually and initially.
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.
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
Date: 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.
Deficiencies (4)
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.
Respiratory staff were unaware of ventilator machines' backup battery life, with actual battery life being two hours versus staff belief of 6-8 hours.
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.
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.
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
Routine
Census: 129
Deficiencies: 16
Date: Sep 27, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including residents' rights, care planning, medication administration, infection control, dietary services, and staff training.
Findings
The facility was found deficient in multiple areas including failure to inform residents of pass rules, incomplete care plans, medication administration errors, expired and discontinued medications not removed, improper food handling and storage, inconsistent resident weight measurements, incomplete dialysis communication, inaccurate code status documentation, and lack of staff abuse training.
Deficiencies (16)
Failed to ensure residents were informed orally and in writing of rules related to leaving on pass prior to or upon admission.
Failed to ensure a resident or representative was provided information about the right to formulate an advance directive.
Failed to maintain a comfortable home-like environment by storing medical equipment in dining areas.
Failed to develop and implement complete care plans for residents with hospice, respiratory dependence, and anxiety.
Failed to meet professional standards of medication administration by leaving medications unsecured at resident bedside.
Failed to document code status accurately in electronic health records for residents with DNR orders.
Failed to provide ordered therapeutic diet on resident meal card and served regular diet instead.
Failed to obtain dialysis communication forms for a resident receiving hemodialysis.
Failed to discontinue a medication after receiving an order to discontinue, resulting in unnecessary medication.
Medication error rate was 19.35%, exceeding the acceptable threshold of 5%.
Failed to remove expired medications from medication carts and storage rooms, failed to remove unsealed and discontinued medications.
Failed to ensure menus were followed for meal service, resulting in incorrect breakfast served.
Failed to ensure safe food handling practices including improper storage of personal items with food, lack of hairnets, inadequate hand hygiene, uncovered beverages, improper food storage temperatures, and improper thermometer sanitation.
Failed to ensure Enhanced Barrier Precautions were in place for a resident with chronic wounds and failed to perform hand hygiene during medication administration.
Failed to ensure resident records were complete and accurate, including inconsistent weight measurement methods.
Failed to ensure an employee completed required abuse training.
Report Facts
Residents affected: 129
Medication error rate: 19.35
Medication opportunities: 31
Medication errors: 6
Expired medication dates: 202205
Expired medication dates: 202405
Temperature: 47.6
Temperature: 50
Temperature: 50.1
Temperature: 41.6
Temperature: 54.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #8 | Certified Nursing Assistant | Lacked documented evidence of abuse training completion |
| Director of Nursing | Provided multiple clarifications and confirmations regarding deficiencies | |
| Dietary Manager | Confirmed food handling and storage deficiencies | |
| Licensed Practical Nurse (LPN) | Involved in medication administration and food handling observations |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 0
Date: 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.
Complaint Details
Complaint NV00071850 was substantiated without deficient practice.
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.
Report Facts
Sample size: 2
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 1
Date: 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).
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.
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.
Deficiencies (1)
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.
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
Date: 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.
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.
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.
Deficiencies (2)
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.
Failure to ensure a newly identified pressure ulcer was reported to the physician and treatment orders were obtained and carried out.
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
Date: 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.
Complaint Details
Complaint #NV00068394 was investigated and verified with no deficient practice found.
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.
Report Facts
Residents present: 148
Complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 153
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
Failure to ensure medications ordered for a particular resident were administered to that resident, leading to potential adverse reactions and drug-to-drug interactions.
Failure to ensure a physician order for a resident's intravenous antibiotic was followed, potentially leading to delayed healing.
Report Facts
Complaints investigated: 10
Sample size: 8
Census: 153
Deficiencies cited: 2
Inspection Report
Complaint Investigation
Census: 159
Deficiencies: 37
Date: 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.
Complaint Details
Complaint investigation included 10 allegations related to resident care, medication, infection control, environment, and resident rights. Several allegations were substantiated including unwitnessed falls, lack of family notification, weight loss, infection control breaches, and failure to follow physician orders. Some allegations were unsubstantiated.
Findings
The facility was investigated for multiple complaints including medication administration, pain management, resident mistreatment, nutrition, staffing, infection control, and environmental concerns. Several allegations were substantiated such as unwitnessed falls, lack of family notification, weight loss, and failure to notify family of C. difficile infection. Other allegations were unsubstantiated. Deficiencies were noted in medication administration, infection control, resident rights, and care planning.
Deficiencies (37)
Resident #102's upper and lower back was uncovered and visible from the hallway.
Resident #83's catheter drainage bag was uncovered and visible from the hallway.
Resident #64's physician order for use of PRAFO boots was not followed; boots were not used.
Resident #368 developed a facility-acquired sacral wound due to lack of consistent skin assessments and interventions.
Resident #52 had an external condom catheter without a physician order.
Resident #93 had an indwelling Foley catheter without physician orders and no documented justification for continued use after wounds healed.
Resident #24 had long, thick, yellowish toenails and no documented podiatry consultation or physician order for foot care.
Residents #423, #5, #113, #424, and #429 had oxygen nasal cannulas without dates indicating last change.
Resident #97 had a soiled and undated Heplock intravenous dressing without physician order for care and management.
Resident #366 had a PICC line dressing not changed weekly as ordered and no physician order for care and management.
Resident #367 had a Foley catheter without physician order for use and care.
Resident #5 had an IV dressing not changed weekly as ordered.
Resident #113 had oxygen nasal cannula without physician order for oxygen treatment and care.
Resident #423 had oxygen nasal cannula without physician order for oxygen treatment and care.
Resident #91 was a fall risk but fall mats were not placed as ordered; bed was in high position.
Expired biologicals and discontinued medications were found in medication carts and medication room.
Residents #423, #5, #119, and #118 had visitors who did not wear required PPE prior to entering isolation rooms.
Resident #1 reported the room temperature was too cold and staff were unable to adjust the locked thermostat.
Resident #368 had significant weight loss without timely weight monitoring or nutritional interventions.
Resident #64 had an indwelling Foley catheter without documented justification; diabetic wounds on legs were not acceptable justification.
Resident #24 had an indwelling Foley catheter without physician order for use and care.
Resident #367 had a Foley catheter without physician order for use and care.
Resident #369 had a Foley catheter without physician order for use and care.
Resident #97 had a soiled and undated Heplock intravenous dressing without physician order for care and management.
Resident #366 had a PICC line dressing not changed weekly as ordered and no physician order for care and management.
Resident #5 had an IV dressing not changed weekly as ordered.
Resident #113 had no physician order for oxygen treatment and care.
Resident #423 had no physician order for oxygen treatment and care.
Resident #102 had oxygen nasal cannula without date indicating last change.
Resident #5 had oxygen nasal cannula without date indicating last change.
Resident #113 had oxygen nasal cannula without date indicating last change.
Resident #424 had oxygen nasal cannula without date indicating last change.
Resident #429 had oxygen nasal cannula without date indicating last change.
Resident #116 received fewer physical therapy sessions than ordered by physician.
Expired eye saline, Fluticasone, Dextrose 5%, and Octreotide were found in medication carts and medication room.
Resident #119 and #118 had visitors who did not wear required PPE prior to entering isolation rooms.
Resident #91 was a fall risk but fall mats were not placed as ordered; bed was in high position.
Report Facts
Complaints investigated: 10
Sample size: 31
Residents present: 159
Weight loss: 7.5
Weight loss in pounds: 10.3
Physical therapy sessions: 3
Physical therapy sessions ordered: 4
Physical therapy sessions ordered: 6
PICC dressing change interval: 7
PICC dressing last changed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple findings related to failure to follow physician orders and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in infection control and family notification findings |
| Licensed Practical Nurse | LPN | Observed medication and catheter care deficiencies |
| Registered Nurse | RN | Observed medication and catheter care deficiencies |
| Unit Manager | Unit Manager | Named in multiple findings related to medication carts, catheter care, and environment |
| Wound Care Nurse | Wound Care Nurse | Named in wound care findings |
| Dietary Manager | Dietary Manager | Named in food labeling and storage findings |
| Respiratory Therapist | Respiratory Therapist | Named in oxygen therapy findings |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Named in infection control findings |
Inspection Report
Annual Inspection
Census: 158
Deficiencies: 5
Date: 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.
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.
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.
Deficiencies (5)
Failed to notify family of resident's Clostridium Difficile infection and placement on contact isolation precautions.
Failed to ensure prompt follow up for a resident's grievance.
Resident assessment was inaccurate; coded for tracheostomy care when resident did not have a tracheostomy.
Failed to implement fall device and follow care plan for fall interventions for residents; oxygen cylinder was unsecured.
Failed to consistently monitor fluid/meal intake and weight; failed to intervene timely for significant weight loss.
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
Report
Report
Viewing
Loading inspection reports...
