Inspection Reports for The Heights of Summerlin, Llc

The inspection was conducted as a Medicare Recertification Survey and Complaint investigation from 03/12/2025 through 03/18/2025.

The facility was found deficient in multiple areas including accuracy of assessments, care plan timing and revision, ADL care provision, smoking policy enforcement, catheter care, drug regimen monitoring, pain medication administration, and snack availability. Several residents were specifically cited for issues related to these deficiencies.

Five complaints were investigated; one was substantiated without deficient practice, and four were unsubstantiated with no regulatory deficiencies identified.

This inspection was conducted as a state survey of the skilled nursing facility in accordance with Nevada Administrative Code (NAC) 449, Facilities for Skilled Nursing, to assess compliance with regulatory requirements.

The facility failed to ensure the State of Nevada Exempt Laboratory license was renewed prior to expiration, resulting in an expired license as of 10/04/2024. This deficiency had the potential to cause the facility to conduct laboratory tests without an active license.

The inspection was conducted as a complaint investigation based on eighteen complaints received regarding the facility from 01/16/2025 to 01/17/2025.

The investigation found no regulatory deficiencies for most complaints, with seven complaints substantiated without deficiencies and eleven complaints unsubstantiated. One deficiency was identified related to improper storage and labeling of medicated wound care barrier cream, posing a risk of unauthorized access or misuse of medication.

Eighteen complaints were investigated; seven were substantiated without deficiencies and eleven were unsubstantiated with no regulatory deficiencies identified.

Medicare Recertification Survey, Complaint investigation and Facility Reported Incident investigation conducted from 2024-02-27 through 2024-03-01.

The facility was cited for multiple deficiencies including failure to coordinate PASARR assessments, incomplete comprehensive care plans, improper management of edema and dialysis access, incomplete wound care treatments, lack of informed consent for psychotropic medications, improper medication storage and labeling, food safety violations, and failure to monitor dialysis treatments and CPAP device use.

Complaint NV00070413 was verified with a regulatory deficiency identified (Tag F686). Other complaints were not substantiated or verified.

The inspection was conducted as a result of a State Licensure Survey completed in conjunction with a Federal complaint investigation survey at the facility from 11/28/2023 through 11/30/2023.

The facility failed to notify the State Licensing Agency within 10 days of a change in the administrator. Employee 1 acknowledged being the administrator since approximately 07/01/2023 and that notification was not done, despite awareness of the requirement.

The visit was complaint-related, conducted in conjunction with a Federal complaint investigation survey. The findings and conclusions of the investigation are documented but no explicit substantiation status is stated.

The inspection was conducted as a result of a Complaint and Facility Reported Incident Investigation from 11/28/2023 through 11/30/2023, investigating 15 complaints and 3 facility reported incidents.

Multiple regulatory deficiencies were identified related to call light response times, use of physical restraints, provision of ADL care, and provision of medically related social services. Several complaints were substantiated with deficiencies, while others were unverified or verified without deficiencies.

The investigation included 15 complaints and 3 facility reported incidents. Several complaints were verified with regulatory deficiencies, including complaints #NV00068563, #NV00068505, #NV00068965, #NV00068590, #NV00068269, #NV00068291, #NV00068355, #NV00068934, and #NV00069173. Some complaints were verified without deficiencies, and others could not be verified.

This inspection was conducted as a state licensure survey in conjunction with a Federal Recertification survey to assess compliance with Nevada Administrative Code (NAC) 449 for Skilled Nursing Facilities.

The facility failed to ensure that a state-approved cultural competency course was provided to 12 of 12 employees, which had the potential to result in discrimination against residents. The cultural competency course used by the facility was not approved by the Division of Public and Behavioral Health (DPBH).

The inspection was conducted as a result of a Medicare Recertification Survey, Complaint investigation, and Facility Reported Incident investigation from 02/07/2023 through 02/10/2023.

The investigation included five complaints and seven Facility Reported Incidents. Three complaints and one FRIs were substantiated, some without deficient practice, while others were unsubstantiated. Deficiencies were identified related to resident rights, ADL care, quality of care, treatment to prevent pressure ulcers, bowel/bladder incontinence, tube feeding, parenteral/IV fluids, pain management, and food safety.

Five complaints were investigated; Complaint #NV00067615 was substantiated, Complaints #NV00067878 and FRI #NV00066345 were substantiated without deficient practice, and Complaints #NV00067764 and #NV00067597 were unsubstantiated. The investigation included observations, interviews with residents and staff, clinical record reviews, and policy reviews.

The inspection was conducted as a Facility Reported Incident and Complaint Investigation survey from 11/15/2022 through 11/18/2022, investigating 16 complaints and one facility reported incident.

The survey substantiated multiple complaints including delays in care, wound dressing issues, hygiene concerns, and discharge coordination failures. Several deficiencies were identified related to care provision, wound treatment, bowel protocols, fall risk assessments, and menu planning. Some allegations were not substantiated. The facility failed to ensure timely interventions and proper documentation in several areas.

The complaint investigation included 16 complaints and one facility reported incident. Several allegations were substantiated, including delay of care after a fall, untimely wound dressing changes, inadequate hygiene, failure to provide physical therapy, and improper discharge coordination. Some allegations such as short staffing and call light response delays were not substantiated.

The inspection was conducted as a result of a complaint investigation regarding allegations that the facility was too hot and without air conditioning.

The complaint was not substantiated after temperature readings in common areas, corridors, and resident rooms ranged from 74 to 77 degrees Fahrenheit, and interviews with residents and staff revealed no complaints. The facility's grievance log for July 2022 was also reviewed.

Complaint #NV00066654 was investigated and found to be unsubstantiated.

Complaint investigation conducted from 11/30/2021 to 12/01/2021 regarding allegations of late medication administration and insufficient nursing staff coverage during night shift.

The facility failed to ensure medications were administered per physician prescribed times and facility policy for 5 of 17 sampled residents. Additionally, the facility did not have adequate nursing staff coverage on the night shift, resulting in call lights not being answered timely.

Complaint #NV00065322 was substantiated with allegations that medications were administered late and that the facility did not have a replacement nurse for a scheduled night shift, resulting in call lights not being answered timely.

The inspection was conducted as a result of a complaint investigation at the facility on 03/09/2021 and 03/10/2021, investigating seven complaints regarding resident care and facility practices.

The investigation substantiated some complaints including resident rashes and sores, involvement in care plans, medication administration, and medication list provision. Several allegations such as short staffing, food palatability, and improper PPE use were not substantiated. Deficiencies related to quality of care were identified.

Seven complaints were investigated. Complaint #NV00061623 was substantiated regarding resident rashes and sores. Complaint #NV00061915 was substantiated regarding resident involvement in care plans. Complaint #NV00062404 was substantiated regarding medication list provision. Other complaints including short staffing, food palatability, and PPE use were not substantiated.

The inspection was conducted as a follow-up complaint investigation survey triggered by two complaints alleging resident rights violations and COVID-19 related issues at the facility.

Two complaints were substantiated involving resident rights violations related to insulin medication administration and multiple COVID-19 related allegations. Several deficiencies were identified including failure to protect resident rights and failure to ensure proper COVID-19 reporting and infection control measures.

Two complaints were investigated and substantiated: 1) A resident's arms were held down to administer insulin against their will. 2) Multiple COVID-19 related allegations including failure to inform residents and families about COVID-19 cases, failure to properly document COVID-19 infections, and failure to quarantine exposed staff.

A COVID-19 Focused Emergency Preparedness Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) from 12/14/20 through 12/15/20.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.

A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) on 12/14/20 through 12/15/20 to assess the facility's compliance with infection control regulations.

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to ensure the designated Infection Preventionist had completed specialized infection prevention training and failure to ensure pneumococcal immunizations followed CDC recommendations for one resident, increasing risk of pneumonia.

The inspection was a Centers for Medicare and Medicaid Services (CMS) Focused Infection Control survey conducted on 10/01/2020, including investigation of three complaints related to resident care and facility practices.

The facility was found to have no regulatory deficiencies. The infection control program was reviewed, PPE supplies were adequate, and staff training was ongoing. Three complaints were investigated; one was substantiated without deficiencies, and two others were not substantiated.

Three complaints were investigated: 1) A resident had an injury of unknown origin and sustained a hip fracture; substantiated without deficiencies after internal investigation and reporting. 2) Multiple allegations including denial of access to records, delayed paperwork, medication issues, and inadequate therapy; none substantiated based on record reviews and staff interviews. 3) Allegation that staff were instructed to intimidate residents during state inspections; not substantiated based on resident and staff interviews.

The inspection was conducted to evaluate compliance with regulatory requirements related to reporting duties and infection control at a skilled nursing facility.

The facility failed to comply with reporting requirements regarding a suspected COVID-19 staff member, resulting in delayed reporting to the Office of Public Health Informatics and Epidemiology. Additionally, deficiencies were noted in maintaining a program for infection control within the facility.

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

The survey found that the facility had implemented effective infection prevention and control measures, including screening, PPE use, social distancing, and dedicated COVID-19 and quarantine units. No regulatory deficiencies were identified.

The inspection was a Centers for Medicare and Medicaid Services (CMS) Focused Infection Control survey initiated on 06/18/2020 and finalized on 06/19/2020, to assess compliance with infection control requirements related to COVID-19.

The facility was found to have no regulatory deficiencies. The survey reviewed the effectiveness of the Infection Prevention and Control Program, screening practices, PPE availability, staff training, and resident care practices related to COVID-19.

The inspection was initiated as a State Licensure Complaint Investigation at the facility on 06/18/2020 and finalized on 06/19/2020, in accordance with Nevada Administrative Code (NAC) Chapter 449, Skilled Nursing Facilities.

Fifteen complaints were investigated, with most allegations not substantiated. One complaint (#NV00061231) was substantiated without deficiencies. Several deficiencies were identified related to failure to ensure timely notification of family members, improper handling of medical records, and failure to notify physicians of resident conditions.

Fifteen complaints were investigated. Most allegations could not be substantiated. Complaint #NV00061231 was substantiated without deficiencies. Complaint #NV00061299 was substantiated with no deficiencies cited. Complaint #NV00061149 was substantiated without deficiencies. Complaint #NV00061204 was not substantiated. Complaint #NV00060982 was substantiated with Severity 2, Scope 1. Complaint #NV00061231 was substantiated without deficiencies.

This document is a Statement of Deficiencies generated as a result of a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey conducted from 2020-04-14 through 2020-05-08 at The Heights of Summerlin, LLC.

The facility failed to ensure proper infection control practices during the COVID-19 outbreak response, including incomplete medical screenings and fit testing for N95 respirators, improper use and storage of personal protective equipment (PPE), inadequate screening of visitors and staff, lack of signage for isolation rooms, and failure to follow cleaning and disinfection protocols for PPE. Multiple staff and vendors were observed not following PPE protocols, and deficiencies were noted in staff education and policy implementation.

The visit was complaint-related as it was a COVID-19 Focused Infection Control survey triggered by concerns about infection control practices during the pandemic.

The inspection was conducted as a COVID-19 Focused Infection Control survey initiated on 04/14/2020 and finalized on 05/08/2020 to evaluate the facility's infection prevention and control program during the COVID-19 outbreak.

The facility failed to ensure proper infection control practices including incomplete medical screenings and N95 fit testing for staff, improper use and storage of PPE, inadequate screening of visitors and staff, failure to enforce mask-wearing among residents, and inaccurate reporting of COVID-19 cases and deaths to public health authorities.

The inspection was conducted as a result of an investigation of Facility Reported Incidents and a complaint at the facility on 01/23/2020, in accordance with 42 CFR, Chapter IV, Part 483 - Requirements for Long Term Care Facilities.

The investigation included multiple facility reported incidents regarding resident to resident altercations, employee to resident abuse, injuries of unknown origin, falls, misappropriation of property, and a dog bite. Several allegations were substantiated with no regulatory deficiencies identified, while others could not be substantiated. The facility failed to submit a final report for 1 of 14 Facility Reported Incidents and failed to ensure comprehensive care plans and fall risk assessments for certain residents.

The complaint investigation included allegations of resident neglect, abuse, and failure to provide adequate supervision and care. Some allegations were substantiated, such as resident to resident altercations and falls, while others, including employee to resident abuse and misappropriation of property, were not substantiated.

The inspection was conducted as a complaint investigation following an allegation regarding a resident discharged with an open wound on the right foot. The investigation included observation, interviews, and medical record reviews.

The facility was found deficient in quality of care for failing to assess and obtain a physician's order for the use of a knee immobilizer for one resident, resulting in skin integrity issues including blisters. The deficiency was documented and corrective actions were planned.

One complaint was investigated (Complaint #NV00058959) with the allegation that a resident was discharged home with an open wound on the right foot. The allegation was not substantiated.

The inspection was conducted as a result of a complaint investigation completed at the facility on 09/18/19, in accordance with 42 CFR, Chapter IV, Part 483 - Requirements for Long Term Care Facilities.

Two complaints were investigated, both substantiated with no regulatory deficiencies cited. The investigation included observations, interviews with staff, and review of medical records and facility policies. No regulatory deficiencies were identified and no further action was necessary.

Two complaints were investigated: Complaint #NV00058236 was substantiated with no regulatory deficiencies; allegations included a soiled gown found in a resident's drawer and a pressure ulcer on the right heel. Complaint #NV00058314 was substantiated with no regulatory deficiencies; allegations included a wound doctor changing the surgical plan without consulting the surgeon and debriding a wound without anesthetic. Several other allegations were not substantiated.

Medicare Recertification survey conducted from August 6, 2019 through August 9, 2019, including one substantiated complaint investigation regarding cold plated food.

The facility had multiple deficiencies including failure to provide person-centered urostomy care, missed showers and nail care for residents, medication administration errors, incomplete dialysis agreements and assessments, improper food cooling and temperature control, unsecured crash cart, and broken resident call light without alternative communication provided.

Complaint #NV00057578 was substantiated regarding the allegation that plated food was cold when delivered.

The inspection was a Medicare Life Safety Code (LSC) recertification survey conducted to assess compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code and NFPA 99 Health Care Facilities Code.

The facility failed to provide documentation of biomedical inspection and testing for patient care electrical equipment and failed to properly store oxygen cylinders to protect them from mechanical damage. Specific equipment such as oxygen concentrators and beds were found not tagged or with expired tags, and oxygen cylinders were improperly stored beneath carts suspended by hooks.

This inspection was a Medicare Life Safety Code (LSC) recertification survey conducted at the facility on 08/06/2019 to assess compliance with the NFPA 101 Life Safety Code and NFPA 99 Health Care Facilities Code.

The facility was found to have multiple deficiencies related to life safety and electrical safety, including obstructed exits, improper use of flexible cords and power taps, electrical panel obstructions, lack of documentation for biomedical equipment testing, and improper storage of oxygen cylinders. Corrective actions and audits were planned to address these issues.

The inspection was conducted as a result of a complaint investigation regarding an allegation that a resident became ill after consuming food at the facility. The complaint could not be substantiated.

The investigation found critical and major violations related to dietary services, including no detectable chlorine sanitizer in the dishwasher, improper glove use by dietary staff, improper refrigerator temperatures, and black grime build-up on the ice machine. Other regulatory deficiencies unrelated to the complaint were also identified.

Complaint #NV00056864 alleged a resident became ill after consuming food in the facility; the allegation was not substantiated after investigation including observations, interviews, and record reviews.

The inspection was conducted as a result of a complaint investigation initiated at the facility on 2019-04-09 in accordance with federal regulations for long term care facilities.

Four complaints were investigated with one complaint substantiated involving a resident who was over medicated and sustained a spinal fracture after a fall. The other complaints were not substantiated and no regulatory deficiencies were identified.

Complaint #NV00056260 was substantiated with no regulatory deficiencies identified. Allegations included over medication leading to overdose of Xanax and a fall causing spinal fracture. Other allegations such as lack of assistance, medication errors, and staff conduct were not substantiated. Three additional complaints (#NV00056369, #NV00056380, #NV00056531) with multiple allegations each were investigated and none were substantiated.

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted in conjunction with a Medicare recertification survey at the facility on 02/20/19 - 02/21/19.

The facility was found to be in substantial compliance with the regulations regarding the Emergency Preparedness program. No further action is necessary concerning this report.

This document is a Medicare Life Safety Code recertification survey conducted at the facility to assess compliance with fire safety regulations.

The facility failed to maintain the automatic fire sprinkler system and portable fire extinguishers as required by NFPA standards. Specific issues included obstruction of a sprinkler head and missed monthly inspections of fire extinguishers.

The inspection was conducted as a Medicare/Medicaid recertification and complaint investigation survey initiated on February 12, 2019, including investigation of three complaints.

The survey found multiple deficiencies related to resident rights, self-administration of medications, abuse and neglect investigations, baseline care plans, ADL care, quality of care, treatment to prevent pressure ulcers, bowel/bladder incontinence, pain management, infection prevention and control, food procurement and sanitation, and labeling of drugs and biologicals. Several residents were found to be affected by these deficient practices.

Three complaints were investigated. Complaint #NV00053391 was not substantiated. Complaint #NV00056082 was not substantiated. Complaint #NV00056141 was not substantiated.

The inspection was conducted as a complaint investigation based on complaint #NV00055303, which was substantiated. The complaint involved allegations that residents were served cold food and that the facility was critically understaffed.

The investigation found deficiencies in nursing staff sufficiency, food temperature and quality, and facility assessment documentation. The facility failed to ensure adequate nursing staff scheduling, served food that was often cold or improperly cooked, and lacked an accurate and updated facility assessment. Multiple residents reported delays in staff response and dissatisfaction with food service.

Complaint #NV00055303 was substantiated. The complaint alleged residents were served cold food and that the facility was critically understaffed. The investigation confirmed these allegations through resident interviews, observations, and document reviews.

This was a follow-up survey and complaint investigation conducted in accordance with 42 CFR Part 483 for Long Term Care Facilities, triggered by a complaint regarding a resident smoking unattended with an oxygen tank.

The complaint was substantiated regarding the resident smoking unattended with an oxygen tank and causing a fire, but no regulatory deficiencies were cited. The investigation included observations, interviews, medical record reviews, and policy review.

Complaint #NV00053928 was substantiated with no regulatory deficiencies cited. The allegation involved a resident smoking unattended with a lighter and oxygen tank, resulting in ignition of the lighter, wheelchair, and resident's pants.

This inspection was conducted as a Medicare Life Safety Code (LSC) recertification survey and an Emergency Preparedness survey in conjunction with a Medicare recertification survey at the facility on 08/02/18 and 08/03/18.

The facility was found deficient in multiple areas including emergency preparedness planning, community-based risk assessment, medical documentation policies, volunteer and staffing strategies, waiver roles, emergency plan testing, and life safety code compliance such as exit discharge door pressure, smoke barrier doors, kitchen hood cleaning, electrical panel identification, and fire drills. Corrective actions and compliance plans were required with completion dates set for 09/14/2018.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Nevada. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.

Immediate Jeopardy was identified related to inadequate supervision leading to resident elopement and injury. Deficiencies included failure to maintain resident dignity, self-determination, advance directives, comprehensive care plans, accident hazard prevention, respiratory care, dialysis, and immunizations. The facility presented an acceptable Immediate Jeopardy removal plan and corrective actions were outlined for each deficiency.

The inspection was conducted as a result of a complaint investigation completed on 07/26/18, involving two complaints regarding resident care and facility conditions.

The investigation substantiated one complaint involving a resident with diarrhea and inadequate staff documentation. Several other allegations were not substantiated. Deficiencies were identified related to comprehensive care planning, infection control, and nursing staff reporting.

Complaint #NV00053635 was substantiated involving a resident with diarrhea for 6-7 days and staff not properly noting resident condition. Complaint #NV00053325 was not substantiated.

The inspection was conducted as a result of a complaint investigation triggered by two complaints alleging issues such as resident diarrhea not properly noted, understaffing, residents laying in fecal matter, weight loss, and other care concerns.

The investigation substantiated one complaint regarding inadequate documentation of a resident's diarrhea condition and identified multiple regulatory deficiencies including failure to develop a comprehensive care plan for a resident with C-diff infection, failure to follow infection control practices, and inaccurate posting of nurse staffing reports.

Two complaints were investigated. Complaint #NV00053635 was substantiated regarding a resident with diarrhea not properly noted by staff. Several other allegations in the complaints were not substantiated.

The inspection was conducted as a result of a complaint investigation completed on June 13, 2018, regarding allegations that a resident did not receive some medications in a timely manner.

The investigation substantiated one complaint about medication administration delays and failures for two residents. The facility was found deficient in timely administration of medications and pharmacy services procedures. Other allegations related to understaffing and staff attitude were not substantiated.

Complaint #NV00053299 was substantiated regarding a resident receiving morning medication late or not at all. Other allegations about understaffing, staff attitude, and night shift RN attitude were not substantiated.

This report documents a Medicare Life Safety Code (LSC) recertification survey conducted on 02/08/18 and 02/09/18 at a skilled nursing facility to assess compliance with NFPA 101 Life Safety Code standards.

The facility was found deficient in several areas related to emergency lighting, sprinkler system maintenance and testing, utilities (gas and electric), smoke control systems, electrical systems, and gas equipment storage. Deficiencies included failure to document emergency lighting testing, sprinkler system issues such as gaps and corrosion, electrical panel issues, delayed repairs of fire smoke dampers, and improper storage of oxygen cylinders. Corrective actions and completion dates were provided for each deficiency.

The inspection was conducted as a Medicare/Medicaid Certification and Complaint Investigation Survey at the facility from 2/6/18 through 2/9/18, investigating four complaints regarding discharge documentation, medication and discharge papers, call light response, and alcohol pad use causing blisters.

Four complaints were investigated with one substantiated related to failure to ensure resident discharge with interim care instructions. Deficiencies were identified related to sexual abuse investigation, resident rights, accuracy of assessments, care planning, medication administration, and other care standards. Corrective actions and plans of correction were documented with completion dates mostly on March 20, 2018.

Four complaints were investigated. Complaint #NV00051966 was not substantiated regarding failure to provide copies of discharge documentation. Complaint #NV00051855 was substantiated regarding failure to ensure resident was discharged with interim care instructions. Complaint #NV00051778 was not substantiated regarding multiple allegations including medication and call light response. Complaint #NV00051728 was not substantiated regarding failure to provide copies of Notice of Discharge documentation.

This Statement of Deficiencies was generated as a result of a complaint investigation completed on December 14, 2017, in accordance with 42 Code of Federal Regulations (CFR), Chapter IV, Part 483 - Requirements for Long Term Care Facilities. Three complaints were investigated during this survey.

Multiple deficiencies were identified related to resident care, including failure to prevent abuse, neglect, misappropriation of resident property, and failure to maintain accurate and confidential medical records. Specific issues included missing personal belongings, inadequate skin assessments, infection control lapses, and improper isolation procedures.

Three complaints were investigated. Complaint #NV00051401 allegations included resident sustained bedsores and infection, resident never turned, failure to transport resident to medical appointment, and delayed wound care. Complaint #NV00050984 was substantiated regarding a resident leaving an iPad on bedside and not seeing it again. Complaint #NV00051382 allegations of loud noise, frequent waking of resident, and inadequate nursing care were not substantiated.

The inspection was conducted as a result of a complaint investigation involving multiple allegations related to resident care, property misappropriation, staff practices, and infection control at the facility.

The investigation substantiated one complaint regarding misappropriation of resident property (an I-pad). Several other allegations were not substantiated. Deficiencies were identified related to resident property documentation, medical record accuracy, and infection prevention and control practices, including failure to post isolation signs and improper use of personal protective equipment.

Three complaints were investigated. Complaint #NV00051401 was not substantiated. Complaint #NV00050984 was substantiated regarding a resident's missing I-pad. Complaint #NV00051382 was not substantiated.

The inspection was conducted as a result of a complaint investigation involving two complaints with multiple allegations regarding resident care and facility procedures.

The investigation included tours, observations, interviews with staff and residents, and review of medical records and facility policies. None of the allegations were substantiated and no regulatory deficiencies were identified.

Two complaints were investigated: Complaint #NV00050725 with four allegations related to resident assistance, fall response, notification to spouse, and admission status; and Complaint #NV00050787 alleging an LPN refused to call a doctor for pain medication. All allegations were found unsubstantiated.

The inspection was conducted as a complaint investigation initiated on September 14, 2017, involving four complaints related to resident care and facility practices.

The investigation substantiated one complaint regarding a resident's urine specimen not being sent for laboratory examination. Other allegations related to resident harassment, family notification, facility cleanliness, staffing, and care were not substantiated. A regulatory deficiency was identified related to providing care and services for the highest well-being of residents.

Four complaints were investigated. Complaint #NV00050315 was substantiated regarding a resident's urine specimen not sent for laboratory examination. Complaints #NV00050315, #NV00049513, #NV00050532, and #NV00049990 had various allegations, most of which were not substantiated.

The inspection was conducted as a complaint investigation at the facility on 5/25/17, triggered by four complaints alleging various deficiencies including failure to follow up on a physician recommendation for an X-ray and improper use of psychotherapeutic drugs.

The investigation substantiated one complaint regarding failure to timely follow up on a physician's recommendation for an X-ray and identified a deficiency in the use of psychotherapeutic drugs for a resident. Several other allegations were not substantiated. The facility failed to ensure a resident's right to be informed in advance of risks and benefits associated with psychotherapeutic drugs.

Four complaints were investigated. Complaint #NV00048413 was substantiated, involving failure to follow up on a physician's X-ray recommendation and psychotherapeutic drug use. Other complaints (#NV00048472, #NV00048627, #NV00048782) were not substantiated.

The survey was conducted as a Medicare Recertification survey from February 7, 2017 through February 16, 2017, including investigation of three complaints related to quality of care, lost belongings, medication administration, and colostomy care.

The facility had multiple deficiencies including failure to obtain informed consent for psychoactive medications, failure to secure resident belongings, medication administration errors including delayed and missed medications, inadequate pain management, incomplete dialysis communication records, failure to follow colostomy care orders, failure to maintain proper food temperatures, and medication storage issues. Several complaints were substantiated related to quality of care and lost belongings.

Three complaints were investigated. Complaint #NV00048008 regarding Quality of Care/Treatment was not substantiated. Complaint #NV00048135 was substantiated regarding lost resident belongings and medication administration delays. Complaint #NV00048328 was substantiated regarding colostomy care, medication administration delays, and feeding despite NPO status.

This document is a Medicare Life Safety Code recertification survey conducted to assess compliance with NFPA 101 Life Safety Code standards, including fire safety, means of egress, sprinkler systems, and corridor door integrity.

The facility was found deficient in multiple areas including obstructed means of egress, smoke barrier doors not closing properly, inappropriate flame spread classification of ceiling panels, deficiencies in the automatic fire sprinkler system, corridor doors not resisting smoke passage, improper use of electrical cords, and improper storage and segregation of oxygen cylinders.

This document is a Medicare Life Safety Code recertification survey conducted at the facility to assess compliance with fire safety codes and regulations.

The facility was found deficient in several life safety code areas including means of egress, doors with self-closing devices, interior wall and ceiling finishes, sprinkler system installation, corridor doors, electrical equipment power cords, and gas equipment storage. Deficiencies affected multiple smoke compartments and involved residents, staff, and guests.

This document is a Medicare Recertification survey conducted from February 7, 2017 through February 16, 2017, including investigation of three complaints related to quality of care, lost resident belongings, and medication administration.

The survey investigated multiple complaints, substantiating two of them related to lost resident belongings and inadequate medication administration, while one complaint regarding quality of care was not substantiated. Several deficiencies were identified including failure to obtain informed consent for psychoactive medications, failure to secure resident belongings, and failure to ensure timely medication administration.

Three complaints were investigated. Complaint #NV00048008 regarding quality of care was not substantiated. Complaint #NV00048135 regarding lost resident belongings was substantiated. Complaint #NV00048328 regarding medication administration was substantiated.

The inspection was conducted as a result of a complaint investigation involving multiple complaints alleging neglect, overmedication, missed medical appointments, inadequate care, and other concerns at the facility.

The investigation substantiated some allegations including a missed follow-up medical appointment for one resident and failure to assess and document the condition of a resident's fractured leg under a knee immobilizer. Several other allegations were not substantiated. The facility failed to ensure timely medical follow-up and proper nursing assessment consistent with professional standards.

Multiple complaints were investigated. Complaint #NV00047120 and #NV00047484 had allegations that were not substantiated. Complaint #NV00046879 was substantiated regarding a resident's leg brace causing a lesion. Complaint #NV00047344 regarding call bell response was not substantiated. Complaint #NV00047781 was substantiated for missed follow-up appointment but other allegations were not substantiated.

The inspection was conducted as a complaint investigation completed from 12/8/16 through 12/14/16 in accordance with 42 CFR Part 483 for Long Term Care Facilities, investigating five complaints regarding resident care and facility practices.

The investigation included observations, interviews with staff and residents, and medical record reviews. Some allegations were substantiated, including failure to ensure follow-up medical appointments and proper nursing assessments, while others were not substantiated. Deficiencies were identified related to care and services for residents, including pain management and skin integrity.

Five complaints were investigated. Some allegations were substantiated, such as a resident's adjustable brace causing a large lesion and missed follow-up appointments. Other allegations, including neglect, overmedication, and call bell response times, were not substantiated.

This inspection was initiated as a complaint investigation starting on 8/25/16 and continued until 9/28/16, involving five complaints and a sixth complaint related to a previous Statement of Deficiencies.

The investigation substantiated several allegations including failure to administer medications and intravenous fluids timely, and failure to answer call lights promptly. Multiple allegations of resident neglect and other complaints were not substantiated. Deficiencies related to dignity and respect of individuality and significant medication errors were identified.

Five complaints were investigated with substantiation for complaint #NV00046850 regarding failure to administer medications and intravenous fluids timely, and complaint #NV00046808 regarding call lights not answered promptly. Other allegations related to resident neglect and abuse were not substantiated.

The inspection was conducted as a result of a State Licensure Complaint Investigation Survey completed on July 21, 2016, to investigate five complaints regarding resident care and facility practices.

Five complaints were investigated with some substantiated, including failure to resolve a grievance about missing money and loss of resident clothing. Other allegations were not substantiated. The investigation included observations, interviews with residents and staff, and review of medical records and facility policies.

Five complaints were investigated. Complaint #NV00048124 and #NV00046254 were substantiated. Complaint #NV00046373, #NV00046257, and #NV00048412 were not substantiated.

This inspection was conducted as a State Licensure Complaint Investigation Survey triggered by five complaints alleging various issues including missing money, lost clothing, failure to complete care plans, lack of social services director, discharge planning deficiencies, and fall risk precautions.

The investigation substantiated two complaints: failure to resolve a resident's grievance about missing money and loss of a resident's clothing. Other allegations including weight loss, care plan updates, social services staffing, fall risk precautions, and discharge planning were not substantiated. Deficiencies were identified related to residents' rights and proper maintenance of resident belongings.

Five complaints were investigated. Complaint #NV00046124 was substantiated regarding missing money grievance. Complaint #NV00046254 was substantiated regarding lost resident clothing. Other complaints including allegations of hospital gown use, weight loss, care plan completion, social services staffing, fall risk precautions, and discharge planning were not substantiated.

The inspection was a revisited survey and complaint investigation conducted from 5/31/16 to 6/1/16 in response to findings from the annual Medicare recertification survey completed on 3/24/16.

The investigation substantiated one complaint regarding the worsening of a resident's open wounds. Multiple allegations related to wound care, hygiene, and staff response were investigated. Deficiencies were noted in clinical record documentation, wound care, medication administration, and treatment documentation for several residents.

Complaint #NV 00045739 was substantiated. Allegations included worsening of resident's open wounds, lack of dressing and staff assistance, poor communication with family, lack of personal hygiene supplies, failure to contact physician when resident became lethargic, and resident left lying in feces.

The revisit survey and complaint investigation were conducted from 5/31/16 to 6/1/16 in response to findings from the annual Medicare recertification survey completed on 3/24/16.

The investigation substantiated one complaint regarding worsening open wounds of a resident and identified deficiencies in wound care, documentation of bowel movements, medication administration, and treatment completion. Several allegations related to wound care and hygiene were not substantiated.

Complaint #NV 00045739 was substantiated regarding a resident's open wounds worsening while staying at the facility. Other allegations related to wound care staff availability, family notification, hygiene supplies, physician contact, and resident care were not substantiated.

The inspection was conducted as a complaint investigation survey triggered by Complaint #NV 00045759, which was substantiated.

The investigation found substantiated allegations that the facility failed to follow physician orders and initiate therapy services, and that a call light was out of reach preventing a resident from obtaining assistance. Other allegations such as verbal abuse by a nurse and understaffing were not substantiated.

Complaint #NV 00045759 was substantiated. Allegation #1: failure to follow physician orders and initiate therapy services was substantiated. Allegation #2: call light out of reach and resident unable to obtain assistance was substantiated. Allegation #3: nurse verbally abusing a resident was not substantiated. Allegation #4: facility was understaffed was not substantiated.

The inspection was conducted as a complaint investigation survey triggered by Complaint #NV 00045759, which was substantiated.

The facility was found to have substantiated deficiencies including failure to follow physician orders and initiate therapy services, and failure to ensure a call light was within reach for a resident. Other allegations such as verbal abuse and understaffing were not substantiated.

Complaint #NV 00045759 was substantiated. Allegation #1 regarding failure to follow physician orders and initiate therapy services was substantiated. Allegation #2 regarding call light being out of reach was substantiated. Allegations #3 (nurse verbally abusing a resident) and #4 (facility understaffed) were not substantiated.

The inspection was conducted as a result of a Medicare Recertification survey and complaint investigations of multiple allegations regarding resident care, medication administration, and facility practices.

The report details multiple substantiated and unsubstantiated complaints involving improper medical care, medication errors, inadequate staffing, failure to follow physician orders, and deficient facility policies and procedures. The facility was found to have multiple deficiencies affecting resident care and safety.

Multiple complaints were investigated, with several substantiated including medication errors, inadequate resident care, failure to follow physician orders, and staff misconduct. Some allegations were not substantiated.

This report is the result of a Medicare Recertification survey conducted from March 15, 2016 through March 22, 2016, including investigation of five complaints.

The survey found multiple deficiencies including failure to notify physicians timely of significant weight loss, failure to ensure abuse allegations were properly reported, inadequate dignity and respect in resident care, medication administration errors, incomplete nursing assessments, failure to follow pressure ulcer treatment protocols, improper catheter care, incomplete monitoring of psychotropic medications, and issues with food preparation and medication storage.

Five complaints were investigated. Several allegations were substantiated including medication errors, lack of bathing, pressure ulcer risk, delayed pain medication, and wound care issues. Some allegations such as missed meals, call bell out of reach, and environmental issues were not substantiated.

The inspection was conducted as a Medicare recertification Life Safety Code (LSC) survey to assess compliance with NFPA 101 (LSC) 2000 edition and related fire safety standards.

The facility was found deficient in securing oxygen cylinder storage against unauthorized access and in electrical wiring and equipment compliance, including improper use of extension cords and missing junction box covers.

This report was generated as a result of a Medicare recertification Life Safety Code (LSC) survey conducted on 03/17/16 and 03/18/16 to assess compliance with NFPA 101 Life Safety Code standards.

The facility was found deficient in multiple Life Safety Code standards including smoke barrier door closures, fire alarm pull box accessibility, smoke detector maintenance, sprinkler system clearance and maintenance, fire extinguisher accessibility, heating equipment suitability, commercial cooking fire-extinguishing equipment maintenance, oxygen cylinder storage segregation, and electrical wiring safety related to extension cords.

This document is a Medicare recertification Life Safety Code (LSC) survey conducted at The Heights of Summerlin, LLC on 03/17/16 and 03/18/16 to assess compliance with NFPA 101 Life Safety Code standards.

The survey identified multiple deficiencies related to fire safety, including improper storage and separation of oxygen tanks, unsecured oxygen cylinder storage, failure to ensure smoke barrier doors fully closed, obstructed fire alarm pull boxes, inadequate maintenance of fire sprinkler systems, and issues with electrical wiring and equipment. Corrective actions and responsible parties were noted for each deficiency.

The inspection was conducted as a complaint investigation survey from 2015-12-03 to 2016-01-22, triggered by five complaints alleging failures in medication administration, fall prevention, physical therapy assistance, discharge procedures, and other care concerns.

The investigation substantiated two complaints related to improper administration of blood thinning medications and failure to properly administer medications as ordered by the physician. Multiple other allegations were not substantiated. Deficiencies were identified in following physician orders for blood thinning medication and failure to obtain physician orders for Iron Sulfate administration for two residents.

Five complaints were investigated. Complaint #NV00044211 was substantiated regarding failure to properly administer blood thinning medications. Complaint #NV00044925 was substantiated regarding failure to properly administer medications as ordered. Other allegations related to wheelchair repair, fall prevention, physical therapy assistance, diabetic diet, discharge safety, wound care, and home health agency referrals were not substantiated.

The inspection was conducted as a complaint investigation survey from 12/3/15 to 1/22/16, triggered by five complaints regarding resident care and facility practices.

The investigation substantiated failures in properly administering blood thinning medications as ordered by physicians for two residents. Several other allegations related to falls, treatment, discharge, and care were not substantiated after review of records, interviews, and observations.

Five complaints were investigated. Complaint #NV00044211 was substantiated regarding failure to properly administer blood thinning medications. Complaint #NV00044925 was substantiated for failure to properly administer medications as ordered. Other allegations related to falls, treatment, discharge, and care were not substantiated.

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

The facility failed to ensure that all staff understood how to initiate and respond to a fire event, with staff unfamiliar with fire safety plans and equipment. Additionally, storage was found closer than 18 inches to sprinkler heads, and egress corridors were obstructed by stored items, reducing corridor width.

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

The facility was found deficient in multiple Life Safety Code standards including interior finish flame spread ratings, documentation for flame spread and radiant flux ratings, corridor door impediments, delayed-egress locks, exit access obstructions, sprinkler system maintenance, and electrical wiring safety. Several deficiencies were acknowledged by the Regional Facility Director and corrective actions were planned or taken.

This inspection was conducted as a State Licensure Survey in conjunction with a federal survey to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.

The facility was found deficient in maintaining valid nursing licenses for employees, ensuring safe and sanitary physical environment conditions including ice dispensing methods, and compliance with resident living area space requirements. Several regulatory deficiencies were cited with severity level 2.

The inspection was conducted as a result of a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 3/5/15 regarding whether the attending physician was promptly notified of laboratory results.

The facility failed to ensure that the attending physician was promptly notified of laboratory results and cancellation of laboratory tests for Resident #1. The laboratory report was received six days after the specimen was collected and after the resident was discharged, and the attending physician was not notified in a timely manner.

Complaint #NV00041917 contained one allegation that the attending physician was not notified of laboratory results, which was substantiated.

The inspection was conducted as a result of complaint investigations initiated by the Bureau of Health Care Quality and Compliance on 3/5/15 regarding failure to promptly notify the attending physician of laboratory results.

The facility failed to ensure the attending physician was promptly notified of laboratory results and cancellation of laboratory tests ordered for Resident #1. The laboratory report was delayed and lacked documentation of notification to the physician, constituting a breakdown in communication between the contracted laboratory, the facility, and the outsourced laboratory.

Complaint #NV00041917 contained one allegation that the attending physician was not notified of laboratory results, which was substantiated.

The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health on January 6, 2015, to investigate multiple complaints regarding medication return, pressure sores, bed hold notices, psychotropic medication management, and resident safety.

The investigation found that several complaints were unsubstantiated, but one complaint was substantiated involving failure to properly diagnose, treat, and monitor residents receiving psychotropic medication, lack of diapers and linen, and a resident's skin tear from an unsafe transfer. A regulatory deficiency was identified related to psychotropic medication reviews and consents.

Complaint #NV00041374 was unsubstantiated. Complaint #NV00041416 was unsubstantiated. Complaint #NV00041437 was substantiated. Allegations included failure to properly diagnose, treat, and monitor psychotropic medication, lack of diapers and linen, and causing a resident's skin tear by unsafe transfer.

The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health on January 6, 2015, to investigate multiple complaints including medication return at discharge, pressure sores, bed hold notices, psychotropic medication management, supply shortages, and unsafe resident transfers.

The investigation found several complaints unsubstantiated, including failure to return medication at discharge, causing pressure sores, improper bed hold notices, lack of diapers and linen, and unsafe transfer causing skin tears. However, one complaint was substantiated regarding failure to properly diagnose, treat, and monitor residents receiving psychotropic medication, including failure to conduct quarterly reviews and obtain required consents.

Complaint #NV00041374 was unsubstantiated regarding medication return and pressure sores. Complaint #NV00041416 was unsubstantiated regarding bed hold notices. Complaint #NV00041437 was substantiated regarding psychotropic medication management failures, unsubstantiated regarding lack of diapers and linen, and unsubstantiated regarding unsafe transfer causing skin tear.

The inspection was conducted as a complaint investigation survey at the facility on 8/14/14, triggered by four complaints, one of which was substantiated.

The investigation found deficiencies related to the assessment and maintenance of a resident's gastrostomy tube and failure to appropriately assess a resident's condition after a change. One complaint was substantiated involving two allegations, while others were not substantiated. The facility failed to ensure medications were administered as ordered and gastrostomy tube care was provided as required for sampled residents.

Four complaints were investigated. Complaint #NV00040052 was substantiated with two allegations: failure to assess and maintain the resident's gastrostomy tube and failure to appropriately assess the resident's condition after a change. Complaint #NV00039761 and #NV00039138 were not substantiated. Complaint #NV00039609 contained three allegations which were not substantiated.

The inspection was conducted as a complaint investigation survey triggered by four complaints alleging issues such as gastrostomy tube care, assessment of condition changes, delays in response to call lights and acute care transfers, and care for bowel incontinence and Foley catheter care.

The investigation substantiated one complaint related to inadequate gastrostomy tube care and failure to assess condition changes appropriately for one resident. Other complaints regarding delays in care and environmental issues were not substantiated. Deficiencies were identified in medication administration, respiratory assessments, gastrostomy tube care, and clinical record documentation for one sampled resident.

Four complaints were investigated. Complaint #NV00040052 was substantiated with two allegations: inadequate gastrostomy tube care and failure to assess condition changes. Complaint #NV00039761 alleging delays in call light response and acute care transfer was not substantiated. Complaint #NV00039138 alleging inadequate bowel incontinence and Foley catheter care was not substantiated. Complaint #NV00039609 alleging scratches from staff, pills left bedside, and cold shower was not substantiated.

This Statement of Deficiencies was generated as a result of a Medicare Re-visit survey for the original Medicare Recertification Survey completed on 2014-05-13. The re-visit survey was conducted to verify compliance with federal regulations for long term care facilities.

The facility failed to ensure that Resident #1's heels were off-loaded as ordered by the physician. Despite physician orders and nursing documentation indicating offloading, observations showed no pillow or device was used to off-load the heels, and the resident refused offloading due to pain and inability to turn. The nursing staff failed to properly notify the physician of the resident's refusal as required by policy.

This Statement of Deficiencies was generated as a result of a Medicare Re-visit survey for the original Medicare Recertification Survey completed on 5/13/14. The survey was conducted on 7/9/14 in accordance with 42 CFR Chapter IV Part 483, Requirements for Long Term Care Facilities.

The facility failed to ensure that one of sixteen sampled residents had their heels off-loaded as ordered by the physician, with multiple observations confirming the resident refused offloading and no pillow or device was used. The facility implemented corrective actions including discontinuing the offloading order, updating care plans, and in-service training for staff to prevent recurrence.

This inspection was a Medicare Re-visit survey conducted on 7/9/2014 following the original Medicare Recertification Survey completed on 5/13/2014, to assess compliance with federal regulations for long term care facilities.

The facility was found deficient for failing to ensure that one sampled resident's heels were off-loaded as ordered by the physician. Despite physician orders and nursing documentation, the resident's heels were not off-loaded due to the resident's refusal, and nursing staff failed to properly document and notify the physician of the refusal as required by policy.

The inspection was conducted as a result of a Medicare recertification and complaint investigation initiated on 2014-05-06 and finalized on 2014-05-13, including 4 complaint investigations.

The facility was found to have multiple deficiencies including failure to obtain consents for psychoactive medications, failure to notify family of condition changes, improper medication self-administration evaluation, improper use of physical restraints without physician orders or consents, incomplete admission assessments, medication administration errors, failure to provide timely treatment to prevent pressure ulcers, inadequate infection control practices, and failure to monitor psychotropic medication side effects and behaviors.

Complaint #NV00038994 initiated on 5/6/14 by the Division of Public and Behavioral Health with multiple allegations including medication administration, resident neglect, malnourishment, and incontinent care. Some allegations were substantiated, including medication administration and malnourishment.

This inspection was conducted as a state licensure survey in conjunction with a federal survey for a skilled nursing facility, The Heights of Summerlin, LLC, to assess compliance with Nevada Administrative Code Chapter 449.

The survey identified multiple deficiencies including failure to timely provide dietary supplements and durable medical equipment to prevent pressure ulcers, failure to submit timely self-reports of abuse and injuries, and inadequate ventilation in the beauty/barber shop. Specific resident care issues involved Resident #2 developing a sacral pressure ulcer due to delayed interventions, and multiple residents with delayed abuse reporting. The beauty/barber shop ventilation did not meet required air exchange and negative pressure standards.

The inspection was a state licensure survey completed in conjunction with a federal survey to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.

The facility was found deficient in multiple areas including failure to timely provide dietary supplements and durable medical equipment to prevent pressure ulcers, failure to timely report incidents of abuse and injuries to the state, and failure to ensure proper ventilation and air exchanges in the beauty/barber shop. Several residents developed pressure ulcers due to delayed interventions, and multiple self-reports of abuse and injuries were submitted late. The beauty/barber shop ventilation did not meet required negative airflow and air exchange standards.

This inspection was conducted as a Medicare recertification Life Safety Code (LSC) survey of the facility on May 6 and 7, 2014, to assess compliance with fire safety standards.

The facility failed to comply with its smoking policy by allowing smoking in a non-designated area, specifically the Express Recovery Patio, where signage prohibited smoking but cigarette butts and ashes were found. The facility's smoking policy designates a specific outdoor smoking area, which was not adhered to.

The inspection was conducted as a complaint investigation survey initiated on 2014-01-16 and finalized on 2014-01-22, triggered by two complaints regarding discharge planning, documentation of Power of Attorney, and alleged exploitation of resident funds.

The investigation substantiated two allegations: lack of discharge planning and lack of documentation of Power of Attorney for two residents. The allegation of exploitation of a resident's funds was not substantiated. Deficiencies included failure to obtain documented legal Power of Attorney for health care decisions for two residents and failure to complete an accurate and timely discharge planning assessment for one resident.

Two complaints were investigated: Complaint #NV00037864 with two substantiated allegations regarding lack of discharge planning and lack of documentation of Power of Attorney; Complaint #NV00038144 regarding alleged exploitation of resident funds, which was not substantiated.

The inspection was initiated as a complaint investigation survey based on two complaints received by the Division of Public and Behavioral Health, conducted from 2014-01-16 to 2014-01-22.

Two complaints were substantiated: lack of discharge planning and lack of documentation of Power of Attorney for certain residents. The facility failed to obtain documented evidence of legal Power of Attorney for health care decisions for 2 of 6 sampled residents and failed to ensure an accurate and timely discharge planning assessment for 1 of 6 sampled residents.

Two complaints were investigated: Complaint #NV00037864 was substantiated with two allegations regarding lack of discharge planning and lack of documentation of Power of Attorney. Complaint #NV00038144 was not substantiated regarding exploitation of a resident's funds.

The inspection was conducted as a Medicare Medicaid complaint investigation initiated by the Division of Public and Behavioral Health on 12/3/13, addressing multiple allegations including pain medication administration, call light response times, infection control, and clinical documentation.

The investigation substantiated deficiencies related to failure to administer pain medication per physician orders, failure to answer call lights timely, improper infection control practices, and incomplete clinical documentation. Several other allegations such as lack of access to water, blankets, offensive odors, and inadequate staffing were not substantiated.

Complaint #NV00037463 substantiated pain medication not administered per physician orders; other allegations including blood glucose monitoring, access to water, and blankets were not substantiated. Complaint #NV00037567 substantiated call lights not answered timely and improper infection control. Complaint #NV00037309 substantiated incomplete clinical documentation; inadequate staffing and timely resident care allegations were not substantiated.

The inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 9/24/13, investigating multiple allegations including resident wandering, misappropriation of property, failure to provide ordered medications and equipment upon discharge.

The investigation substantiated that the facility failed to return a resident's pillow after death, failed to provide a bedside commode as ordered for a resident, and failed to provide medications upon discharge as ordered by the physician. Other allegations such as wandering residents and nurse staffing were not substantiated.

The complaint investigation included allegations of residents wandering into another resident's room (not substantiated), receipt of condolence letter with wrong resident name (substantiated but no regulatory deficiency), failure to return resident's pillow (substantiated), failure to provide drugs upon discharge (substantiated), failure to provide bedside commode as ordered (substantiated), and other allegations such as nurse staffing and delays in medication (not substantiated).

The inspection was initiated as a complaint investigation survey based on two complaints filed with the Nevada State Health Division on 7/9/13, finalized on 7/23/13, involving allegations of improper infection control, resident care issues, and safety concerns.

The investigation substantiated several deficiencies including failure to notify physicians timely of significant changes, improper incontinent care, failure to provide adequate supervision during medical appointments, failure to follow physician orders for medication administration, failure to reassess fall risk and implement interventions post-fall, and incomplete clinical documentation regarding BiPAP treatments.

Two complaints were investigated. Complaint #NV00036005 contained four allegations including improper infection control (not substantiated), resident left soiled for extended periods (substantiated), resident not assessed after change of condition (substantiated), and improper incontinent care (not substantiated). Complaint #NV00035838 contained two allegations including resident not assessed after change of condition (substantiated) and resident safety and falls (substantiated).

The inspection was a complaint investigation initiated by the Nevada State Health Division on 7/9/13 and finalized on 7/23/13, triggered by two complaints containing multiple allegations regarding infection control, resident care, and safety.

The investigation found some allegations substantiated, including improper infection control practices, resident left soiled for extended periods, failure to assess residents after condition changes, failure to notify physicians timely, dignity and respect issues, failure to provide care for highest well-being, free of accident hazards, and accurate clinical records. Several residents were affected, and corrective actions were required.

Complaint #NV00036005 was initiated on 7/9/13 with four allegations; Allegation #1 (improper infection control) was not substantiated. Complaint #NV00035838 was initiated on 7/9/13 with two allegations; both were substantiated including failure to assess residents after condition changes and resident safety/falls.

This Statement of Deficiencies was generated as a result of an annual Medicare Recertification survey conducted at the facility from 5/7/13 to 5/17/13 in accordance with 42 CFR Chapter IV Part 483 - Requirements for States and Long Term Care Facilities.

The survey included investigation of 4 complaints, all of which were substantiated. The facility was found deficient in multiple areas including informed consent for physical restraints, medication administration, care planning, emergency procedures, personnel records, and training requirements.

Four complaints were investigated during the survey period. All complaints (#NV00034558, #NV00035375, #NV00034635, #NV00034628) were substantiated. Allegations included improper use of restraints, loss of dignity, loss of valuables, medication errors, inadequate pain management, and failure to provide assistance with hygiene and continence care.

Annual Medicare Recertification survey conducted from 2013-05-07 to 2013-05-17 including complaint investigations.

Multiple deficiencies were identified including failure to obtain informed consent for physical restraints, inadequate notification of significant change in condition, unresolved grievances regarding loss of valuables, improper use and documentation of restraints, medication administration errors, incomplete care plans, unsigned physician orders, and incomplete staff training on dementia care.

Four complaints were investigated during the survey period. Complaints included use of restraints, loss of valuables, decline in condition, medication administration, unclean environment, call bell functionality, infection control, staffing sufficiency, and privacy concerns. Several allegations were substantiated including improper use of restraints, medication errors, and failure to notify family of significant decline.