Deficiencies (last 5 years)
Deficiencies (over 5 years)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
168% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
226 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 31, 2025
Visit Reason
The inspection was conducted in response to complaints regarding failure to provide scheduled bathing for a resident and failure to follow physician orders for monthly weights for another resident.
Complaint Details
Complaint #2651495 involved failure to provide scheduled bathing. Complaint #2675657 involved failure to follow physician orders for monthly weights.
Findings
The facility failed to provide bathing as scheduled for one resident, placing them at risk for skin breakdown and poor hygiene. Additionally, the facility failed to ensure physician orders for monthly weights were followed for another resident, potentially impacting nutritional assessment and care planning.
Deficiencies (2)
Failure to provide bathing as scheduled for 1 of 6 sampled residents, risking skin breakdown, rashes, and poor hygiene.
Failure to ensure physician orders for monthly weights were followed for 1 of 6 sampled residents, risking inaccurate care planning and delayed interventions.
Report Facts
Weight loss: 8
Weight measurements missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed bathing schedule issues and weight measurement challenges. |
| Unit Manager | Unit Manager | Acknowledged challenges in obtaining consistent and accurate resident weights. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Reported challenges in obtaining accurate weights by CNAs. |
| Registered Dietitian | Registered Dietitian (RD) | Acknowledged challenges in obtaining accurate and consistent weight measurements. |
Inspection Report
Complaint Investigation
Census: 226
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation into the facility on 04/24/2025, focusing on compliance with 42 CFR Chapter IV, Part 483, Requirements for Long Term Care Facilities.
Complaint Details
One complaint (NV00074086) was investigated and substantiated. The investigation included observations of staff and resident interactions, interviews with multiple staff members, and clinical record review of five residents including the resident of concern.
Findings
The facility failed to ensure an orthopedic consult was obtained for one of five sampled residents, resulting in a delay in treatment and healing of a fracture. The complaint was substantiated based on observations, interviews, and record reviews.
Deficiencies (1)
Facility failed to ensure an orthopedic consult was obtained as per physician order for one of five sampled residents, causing potential delay in treatment and healing of a fracture.
Report Facts
Census: 226
Sample size: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure an orthopedic consult was obtained as per physician order for a resident with a left wrist fracture.
Complaint Details
The complaint investigation found that the orthopedic consult order dated 03/03/2025 was not acted upon promptly due to insurance authorization delays and lack of communication. Authorization was not requested until 04/11/2025, and the consult was finally conducted on 04/23/2025. The Nurse Practitioner stated the expectation was to obtain consult visits within 2 weeks, and the delay was unacceptable.
Findings
The facility failed to obtain an orthopedic consult for Resident 1 in a timely manner, resulting in a delay in treatment and healing of the fracture. The delay was attributed to issues with insurance authorization and communication breakdowns among staff responsible for scheduling the appointment.
Deficiencies (1)
Failed to ensure an orthopedic consult was obtained as per physician order for Resident 1 with a left wrist fracture, causing potential delay in treatment and healing.
Report Facts
Date of fall: Feb 22, 2025
Date of orthopedic consult order: Mar 3, 2025
Date insurance authorization requested: Apr 11, 2025
Date orthopedic consult completed: Apr 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Explained cast application and insurance issues | |
| Unit Manager (UM) | Explained delay in orthopedic appointment and communication issues | |
| Transportation Coordinator | Described process for arranging appointments and insurance authorization | |
| Case Manager (CM) | Responsible for obtaining insurance authorization; was on medical leave during delay | |
| Nurse Practitioner (NP) | Stated expectation for consult visits within 2 weeks and acknowledged delay was unacceptable |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 28, 2025
Visit Reason
The inspection was conducted due to complaints and facility reported incidents involving physical abuse, failure to timely report abuse, inadequate care for activities of daily living, medication administration errors, and incomplete medical records.
Complaint Details
The investigation was complaint-driven, involving substantiated physical abuse of Resident #43 by Employee 20, failure to timely report abuse, inadequate care for Residents 25, 417, and 468, medication errors affecting Residents 469, 219, 210, 147, 27, and 137, and incomplete medical records for Residents 98, 467, and 469.
Findings
The facility was found deficient in protecting a resident from physical abuse, timely reporting abuse to the State Agency, providing adequate incontinent care, following physician medication orders, timely medication administration, and maintaining complete and accurate medical records. Several residents were affected by these deficiencies, with potential for emotional, physical harm, and compromised care.
Deficiencies (6)
Failed to protect a resident from physical abuse by a staff member.
Failed to timely report suspected abuse to the State Agency within required timeframes.
Failed to provide incontinent care for residents, risking skin integrity.
Failed to follow physician medication orders and clarify unclear orders, risking therapeutic effect.
Failed to administer medications in a timely manner as ordered.
Failed to maintain complete and accurate medical records, including documentation of refusals, changes in condition, and medication administration.
Report Facts
Residents sampled: 35
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 20 | Named in substantiated physical abuse of Resident #43 and subsequent termination | |
| Employee 14 | Witnessed physical abuse incident involving Resident #43 and Employee 20 | |
| Employee 28 | Nurse who missed medication administration for multiple residents during a shift | |
| Director of Social Services | Director of Social Services | Reported abuse incident and coordinated investigation |
| Administrator/Abuse Coordinator | Administrator/Abuse Coordinator | Provided information on abuse reporting requirements |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Verified lack of toileting care and documentation |
| Minimum Data Set Nurse | Minimum Data Set Nurse | Reviewed medical records and confirmed lack of care documentation |
| Certified Nursing Assistant | Certified Nursing Assistant | Provided information on care and documentation practices |
| Licensed Practical Nurse | Licensed Practical Nurse | Explained documentation and care expectations |
| Registered Nurse | Registered Nurse | Explained medication administration and self-administration policies |
| Director of Nursing | Director of Nursing | Verified medication order deficiencies and administration expectations |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided information on medication administration and documentation |
| Nurse Practitioner | Nurse Practitioner | Provided information on resident change of condition and documentation expectations |
| Central Supply Clerk | Central Supply Clerk | Provided information on medication and supply availability |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Mar 28, 2025
Visit Reason
The inspection was conducted based on complaints and observations regarding medication self-administration, resident rights, abuse allegations, restraint use, care provision, medication administration, infection control, and quality assurance.
Complaint Details
The inspection was complaint-driven with multiple complaints including medication self-administration, resident rights, abuse allegations, restraint use, care provision, medication administration, infection control, and quality assurance. The abuse allegation involving Resident 43 was substantiated. The facility failed to timely report the abuse to the State Agency within required timeframes.
Findings
The facility was found deficient in multiple areas including failure to obtain physician orders and assessments for medication self-administration, failure to honor resident preferences and rights, substantiated physical abuse incident with inadequate reporting and follow-up, improper use and documentation of physical restraints and bed rails, failure to provide timely and documented care for activities of daily living, medication administration errors and omissions, unsecured oxygen tanks, improper food storage, incomplete medical records, and lack of effective quality assurance and infection control programs.
Deficiencies (13)
Failed to ensure a physician's order, assessment, and care plan for self-administration of medication for Resident 38.
Failed to ensure residents have a right to make choices about aspects of their life, including shower frequency for Resident 102.
Failed to document written responses to resident council complaints regarding call light delays and staff phone use.
Failed to protect Resident 43 from physical abuse; substantiated abuse by staff member with inadequate follow-up and reporting.
Failed to ensure Resident 168 remained free from restraints not needed for medical treatment, including improper use of lower bed rails without physician orders or assessments.
Failed to timely report alleged physical abuse incident involving Resident 43 to the State Agency within required timeframes.
Failed to develop a complete, resident-centered care plan within 7 days of assessment and obtain physician order for use of side rails for Resident 6.
Failed to provide and document toileting hygiene care for Residents 417, 468, and 25, resulting in potential compromise of skin integrity.
Failed to follow physician orders and clarify medication orders for Residents 469 and 219; failed to administer medications timely for Residents 210, 147, 27, and 137.
Failed to follow care plan and provide transfer training after a resident fall for Resident 25; failed to secure oxygen tank for Resident 98, leading to fall with injury.
Failed to ensure safe use of bed rails for Resident 168 including lack of assessment, consent, physician orders, and documentation of alternatives tried.
Failed to maintain complete and accurate medical records for Residents 98, 467, and 469, including lack of documentation of refusal of ordered drug test, change in condition, and medication self-administration assessment.
Failed to ensure infection control practices were maintained for Resident 25, including improper use of briefs from another resident's room causing risk of cross-contamination.
Report Facts
Deficiencies cited: 14
Residents sampled: 35
Dates of key events: Mar 28, 2025
Medication blood glucose results: Array
Medication doses missed: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 20 | Nurse | Substantiated physical abuse against Resident 43. |
| Employee 28 | Nurse | Missed multiple medication administrations during medication pass. |
| Certified Nurse Assistant 1 | CNA | Involved in fall incident with Resident 25; lacked documented education or counseling after fall. |
| Licensed Practical Nurse | LPN | Observed medication administration errors and acknowledged order discrepancies. |
| Assistant Director of Nursing | ADON | Provided multiple confirmations and explanations regarding deficiencies and policies. |
| Director of Nursing | DON | Reviewed records, verified orders, and acknowledged deficiencies. |
| Regional Director of Clinical Services | Regional Director | Verified findings and provided clarifications on medical records and care. |
| Administrator | Administrator | Acknowledged lack of QAPI documentation and committee meeting deficiencies. |
| Dietary Account Manager | Dietary Manager | Acknowledged unlabeled and undated food items in kitchen. |
| Infection Preventionist | Infection Preventionist | Confirmed infection control deficiencies related to cross-contamination. |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Dec 6, 2024
Visit Reason
The inspection was conducted based on multiple complaints alleging deficiencies in resident care, grievance handling, medication administration, discharge planning, activities of daily living assistance, wound care, psychiatric consultation, safety hazards, infection prevention, and staff training.
Complaint Details
Multiple complaints were investigated including grievance handling (Complaint #NV00070364), medication administration (Complaint #NV00072736), discharge planning (Complaint #NV00070559), activities of daily living assistance (Complaint #NV00070438), wound care and psychiatric consultation (Complaint #NV00072736), safety hazards related to smoking and sharps disposal (Complaint #NV00072348), and infection prevention and control (Complaint #NV00072348).
Findings
The facility was found deficient in multiple areas including failure to initiate and follow through on grievance reports, failure to initiate vancomycin medication upon admission, lack of documented discharge planning, inadequate assistance with activities of daily living, incomplete wound evaluations and inaccurate skin observations, failure to implement psychiatric consultations, unsafe environment with unsupervised smoking and improperly managed propane grill, improper sharps container management, and ineffective infection prevention and control program including lack of N-95 fit testing and failure to report a COVID-19 outbreak.
Deficiencies (11)
Failed to ensure a grievance report was initiated and followed through for 1 of 37 sampled residents.
Failed to initiate vancomycin medication upon admission for 1 of 37 sampled residents.
Failed to provide documented evidence of discharge planning for 1 of 37 sampled residents.
Failed to provide documented evidence assistance with activities of daily living for 1 of 37 sampled residents.
Failed to ensure weekly wound evaluations were completed and weekly skin observations were documented accurately for 1 of 37 sampled residents (Resident 1).
Failed to implement a physician order for a psychiatric consultation for 1 of 37 sampled residents (Resident 32).
Failed to ensure weekly wound evaluations were completed and weekly skin observations were documented accurately for 1 of 37 sampled residents (Resident 2).
Failed to provide a safe environment free from accident hazards and adequate supervision to prevent accidents related to smoking area supervision and propane grill safety.
Failed to ensure sharps containers were replaced after reaching the manufacturer fill line and properly secured.
Failed to ensure staff did not use personal blood pressure monitors for residents in transmission-based precautions when disposable cuffs were available.
Failed to designate a qualified infection preventionist with specialized training, failed to report a COVID-19 outbreak to the appropriate state agency, and failed to complete N-95 respirator fit testing and staff training.
Report Facts
Residents sampled: 37
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 4
Residents affected: 8
COVID-19 positive residents: 55
COVID-19 positive staff: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | RN Staff Development Coordinator/Infection Prevention RN | Infection Preventionist with no specialized training and responsible for infection control program |
| E33 | Licensed Practical Nurse | Assigned to medication cart with overfilled sharps container |
| E34 | 600 hall LPN Charge Nurse | Confirmed missing sharps container and unsecured sharps in wall mount |
| E35 | Central Supply Clerk | Confirmed no shortage of sharps containers in facility |
| E26 | Housekeeping Aide | Observed wearing N-95 respirator with only one strap and no fit testing or PPE training |
| E27 | Certified Nursing Assistant | Observed delivering meal tray without proper PPE in droplet precaution room |
| E20 | Licensed Practical Nurse | Indicated proper PPE for COVID-19 isolation but had not been fit tested for N-95 |
| E11 | Certified Nursing Assistant | Observed wearing personal N-95 respirator and unaware of facility supply |
| E31 | Maintenance Assistant | Had not been fit tested to wear N-95 mask |
| E32 | Registered Nurse | Used N-95 respirator on medication cart and was fit tested 2-3 years ago |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 9, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide restorative nursing services as recommended by therapy, and failure to implement an infection prevention and control program, including management of suspected scabies cases.
Complaint Details
Complaint #NV00069831 regarding failure to provide restorative nursing services and infection prevention and control deficiencies related to scabies management.
Findings
The facility failed to provide restorative nursing services (RNA) in accordance with therapy recommendations for three residents, resulting in potential decline in mobility. Additionally, the facility failed to implement proper infection control measures for suspected scabies cases, including lack of contact precautions, improper staff assignments, inadequate laundry handling, failure to notify the wound care team, and failure to report communicable disease cases to the health department.
Deficiencies (2)
Failure to provide restorative nursing services (RNA) as recommended by therapy for Residents 34, 108, and 110, resulting in potential decline in mobility.
Failure to implement infection prevention and control program including: not placing residents with suspected scabies on contact precautions, assigning a staff member with confirmed scabies to multiple units, improper handling of laundry items, failure to notify wound care team of residents with unconfirmed rashes, and failure to report suspected and confirmed scabies cases to the health department.
Report Facts
RNA sessions missed: 5
RNA sessions missed: 4
Residents with suspected scabies: 58
Residents screened for rashes: 24
Rooms in 400-Hall: 16
Residents on transmission-based precautions list: 13
Residents on contact precautions: 4
Residents on wound care team list: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Diagnosed with scabies, worked in multiple units including 400-Hall and 100-Hall, and was assigned to care for residents with suspected scabies. |
| Director of Nursing | Director of Nursing (DON) | Disclosed facility stopped using agency nurses, acknowledged delays in RNA services, and confirmed failures in infection control and reporting. |
| Director of Rehabilitation | Director of Rehabilitation | Reviewed clinical records and observed resident contractures, communicated therapy evaluations to RNA program. |
| Treatment Nurse | Treatment Nurse | Observed wound care practices, acknowledged lack of PPE use by wound care team, and lack of infection information sharing. |
| Infection Preventionist | Infection Preventionist (IP) | Confirmed scabies as highly contagious, confirmed lack of contact precautions, and emphasized reporting requirements. |
| Administrator | Administrator | Confirmed failures in laundry handling and reporting of communicable diseases. |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Feb 9, 2024
Visit Reason
The inspection was conducted based on a complaint investigation regarding multiple concerns including care planning, medication administration, infection control, and safety practices at the facility.
Complaint Details
Complaint #NV00069831
Findings
The facility was found deficient in multiple areas including failure to develop baseline care plans, delayed medication administration, inadequate restorative nursing services, unsecured medication and respiratory carts, improper storage of oxygen tanks, failure to implement contact precautions for scabies, and insufficient social services staffing. These deficiencies posed risks for resident safety, infection spread, and quality of care.
Deficiencies (11)
Failed to ensure baseline care plans were completed for residents with surgical wounds and contractures.
Failed to develop and implement complete care plans for residents with bed rails.
Failed to administer medications timely according to facility policy.
Failed to provide appropriate pressure ulcer care including implementation of physician-ordered pressure redistributing mattress.
Failed to provide restorative nursing services in accordance with therapy recommendations.
Failed to ensure medication carts and respiratory carts were locked and medications were not left unsecured at bedside.
Failed to provide appropriate catheter care including obtaining physician orders for catheter changes and perineal wash.
Failed to assess, obtain consent, and evaluate alternatives prior to installation of bed rails.
Failed to provide medically-related social services including timely social services assessments and follow-up on resident concerns.
Failed to procure, label, date, and discard food items in accordance with professional standards.
Failed to implement infection prevention and control program including placing residents with suspected scabies on contact precautions, restricting staff with scabies from other units, proper handling of laundry, notifying wound care team of infectious residents, and reporting communicable diseases to health department.
Report Facts
Medication late administration instances: 7
Residents on rash line listing: 58
Residents screened for rashes: 24
Residents on transmission-based precautions list: 13
Residents with contact precautions: 4
RNA sessions missed: 5
RNA sessions missed: 4
Social workers needed: 3
Social workers employed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Diagnosed with scabies, worked on multiple units including 400-Hall and 100-Hall during investigation period. |
| Director of Nursing | Director of Nursing | Provided multiple confirmations and explanations regarding deficiencies in care planning, medication administration, infection control, and staffing. |
| Registered Nurse Unit Manager | Registered Nurse Unit Manager | Provided information on care planning processes and deficiencies for contracture care. |
| Director of Rehabilitation | Director of Rehabilitation | Provided information on occupational therapy evaluations and restorative nursing follow-up. |
| Social Worker | Licensed Social Worker | Acknowledged lack of social services assessments and staffing shortages. |
| Treatment Nurse | Treatment Nurse | Acknowledged lack of communication regarding infectious residents and improper PPE use. |
| Infection Preventionist | Infection Preventionist | Provided information on infection control deficiencies and reporting failures. |
| Hospice Nurse | Hospice Nurse | Communicated hospice physician's orders for scabies precautions not implemented by facility. |
Inspection Report
Complaint Investigation
Census: 231
Capacity: 255
Deficiencies: 12
Date: Feb 9, 2024
Visit Reason
The inspection was conducted as a Medicare Recertification Survey, Complaint and Facility-Reported Incident investigations from 2024-02-06 through 2024-02-09.
Complaint Details
Complaint #NV00069831 was verified with regulatory deficiencies identified related to infection control and other cited deficiencies.
Findings
The facility had multiple deficiencies including failure to develop baseline care plans for residents with wounds and contractures, untimely medication administration, inadequate care planning for bed rails, failure to provide restorative nursing services as recommended, unsecured oxygen tanks and medications, improper smoking supervision, lack of social services assessments and follow-up, failure to implement infection control precautions for scabies, and failure to properly handle linens and laundry for infectious cases.
Deficiencies (12)
Failure to develop baseline care plans for residents with surgical wounds and contractures.
Failure to administer medications timely according to physician orders.
Failure to develop care plans for residents with bed rails including assessment, consent, and physician orders.
Failure to provide restorative nursing services in accordance with therapy recommendations for multiple residents.
Unsecured oxygen tanks and medications in the facility, posing safety risks.
Failure to follow smoking policy including supervision and securing smoking materials.
Failure to obtain and implement care orders for indwelling catheter including Foley changes and perineal care.
Failure to complete social services assessments and follow-up for residents including missing dentures and psychosocial needs.
Failure to label and date food items and discard expired foods in the walk-in refrigerator.
Failure to implement hospice physician orders for residents including transmission-based precautions for scabies.
Failure to implement contact isolation precautions for resident with scabies and failure to prevent cross contamination including improper laundry handling and staff assignment.
Failure to secure medication carts and medication storage rooms, and medications left unsecured at bedside.
Report Facts
Number of residents present: 231
Total licensed capacity: 255
Number of complaints investigated: 4
Number of facility-reported incidents investigated: 5
Number of medication administration delays: 7
Number of residents on transmission-based precautions: 58
Number of residents on contact precautions: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Reported suspected scabies and was under treatment; worked on multiple units against policy |
| Director of Nursing | Director of Nursing | Provided multiple confirmations and statements regarding deficiencies and infection control |
| Licensed Practical Nurse | Licensed Practical Nurse | Observed medication cart unlocked and confirmed it should be locked |
| Social Worker | Licensed Social Worker | Reported difficulty completing social services assessments due to staffing shortage |
| Treatment Nurse | Treatment Nurse | Acknowledged wound care team did not don PPE properly and lacked infection control knowledge |
| Activities Assistant | Activities Assistant | Responsible for supervising smoking residents and securing smoking materials |
Inspection Report
Complaint Investigation
Census: 210
Deficiencies: 7
Date: Nov 1, 2023
Visit Reason
This document is an amended Statement of Deficiencies generated as a result of a Complaint and Facility Reported Incident Investigation conducted from 2023-10-31 to 2023-11-01 at TLC Care Center.
Complaint Details
The investigation involved 18 complaints and 11 facility reported incidents. Verified complaints with deficiencies include #NV00069314, #NV00069681, #NV00068794, #NV00067469, and #NV00068753. Other complaints were either verified with no deficiencies or not verified.
Findings
The investigation included 18 complaints and 11 facility reported incidents. Several deficiencies were identified related to notification of changes, baseline care plans, comprehensive care plans, pressure ulcer treatment, accident hazards, pain management, and pharmacy services. Some complaints were verified with deficiencies, while others were not verified.
Deficiencies (7)
Failed to promptly notify attending physician of urinary catheter dislodgement causing trauma and hematuria.
Failed to develop and implement a baseline care plan for surgical wound care in a timely manner.
Failed to develop and implement a comprehensive care plan for pain management in a resident with communication problems.
Failed to provide wound treatments per physician orders and conduct weekly wound assessments.
Failed to ensure post-fall protocol including neurological checks was implemented following an unwitnessed fall.
Failed to accurately assess and manage pain for a resident with communication problems using appropriate pain scales.
Failed to account for narcotics signed out on controlled drug record and document administration in medication records.
Report Facts
Complaints investigated: 18
Facility Reported Incidents (FRIs) investigated: 11
Sample size: 33
Resident census: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to findings about failure to notify physician and pain management. |
| Lead Treatment Nurse | Treatment Nurse | Named in relation to wound care deficiencies. |
| Registered Nurse | Registered Nurse | Named in relation to pain assessment and catheter care findings. |
Inspection Report
Complaint Investigation
Census: 210
Deficiencies: 8
Date: Nov 1, 2023
Visit Reason
The inspection was conducted as a result of a Complaint and Facility Reported Incident Investigation from 10/31/2023 to 11/01/2023, investigating 18 complaints and 11 facility reported incidents.
Complaint Details
The investigation included 18 complaints and 11 facility reported incidents. Verified complaints with deficiencies included #NV00069314, #NV00069681, #NV00068794, #NV00067469, and #NV00068753. Multiple unverified complaints and FRIs were also investigated with no deficiencies found.
Findings
Multiple deficiencies were identified including failure to notify physicians of significant changes, inadequate baseline and comprehensive care plans, failure to provide timely wound care and assessments, inadequate pain management, failure to implement post-fall protocols, and issues with pharmacy controlled substance records.
Deficiencies (8)
Failure to promptly notify attending physician of urinary catheter dislodgement resulting in urethral trauma and hematuria for Resident #1.
Failure to develop a baseline care plan for surgical wound care for Resident #1.
Failure to develop and implement a comprehensive care plan to manage pain for ventilator-dependent Resident #32.
Failure to perform initial wound assessment, obtain physician orders, and provide timely wound care for surgical wounds for Resident #1.
Failure to provide wound treatments per physician orders and conduct weekly wound assessments for Resident #6 with pressure ulcer.
Failure to implement post-fall protocol including neuro checks after an unwitnessed fall for Resident #22.
Failure to accurately assess pain and document non-pharmacological interventions for ventilator-dependent Resident #33.
Failure to account for narcotics signed out on controlled drug record and document administration for Resident #29.
Report Facts
Sample size: 33
Number of complaints investigated: 18
Number of facility reported incidents investigated: 11
Missed wound care treatments: 13
Pressure ulcer measurement: 11
Pressure ulcer measurement: 4.5
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Nov 1, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to multiple allegations including failure to promptly report catheter dislodgement, inadequate wound care planning and treatment, pain management deficiencies, missed medication administration, and failure to implement post-fall protocols.
Complaint Details
Complaint #NV00069314 related to catheter dislodgement and wound care; Complaint #NV00069681 related to pain management; Complaint #NV00068794 related to wound care for pressure ulcer; Complaint #NV00067469 related to post-fall protocol; Complaint #NV00068753 related to narcotic medication accounting.
Findings
The facility was found deficient in several areas including failure to notify the attending physician promptly after catheter dislodgement causing urethral trauma, lack of baseline and comprehensive care plans for surgical wounds and pain management, failure to provide timely wound care and assessments, missed wound treatment administrations, failure to document neuro checks after an unwitnessed fall, inaccurate pain assessments for a ventilator-dependent resident, and failure to properly document administration of narcotic medications.
Deficiencies (8)
Failure to ensure prompt reporting of urinary catheter dislodgement resulting in urethral trauma and hematuria to the attending physician.
Failure to develop a baseline care plan for surgical wound care within 48 hours of admission.
Failure to develop and implement a comprehensive care plan to manage pain for a ventilator-dependent resident.
Failure to perform initial wound assessment, obtain physician orders, and provide timely wound care treatment for surgical wounds.
Failure to provide wound treatments per physician's orders and conduct weekly wound assessments for a resident with an existing pressure ulcer.
Failure to implement post-fall protocol including neuro checks after an unwitnessed fall.
Failure to accurately assess pain and document use of appropriate pain scales for a ventilator-dependent resident.
Failure to account for narcotics signed out on the controlled drug record and document administration.
Report Facts
Residents sampled: 33
Staples in surgical wound: 27
Staples in surgical wound: 9
Missed wound treatment administrations: 13
Pain medication administrations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided explanations and confirmations regarding deficiencies in catheter reporting, wound care, pain management, and medication documentation. |
| Registered Nurse | Registered Nurse (RN) | Explained standing orders for catheter replacement and pain assessment practices. |
| Lead Treatment Nurse | Lead Treatment Nurse | Reviewed wound care records and confirmed missed treatments. |
| Treatment Nurse | Treatment Nurse | Discussed wound care procedures and assessments. |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Explained post-fall protocol and neuro-check documentation. |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Explained post-fall vital sign monitoring protocol. |
Inspection Report
Complaint Investigation
Census: 224
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
The inspection was conducted as a result of complaints and a Facility Reported Incident (FRI) investigation at the facility.
Complaint Details
Two complaints (#NV00064997 and #NV00066234) and one Facility Reported Incident (#NV00063883) were investigated. The first complaint and the FRI were unverified with no deficiencies. The second complaint was verified but with no regulatory deficiencies.
Findings
Three investigations were conducted: two complaints and one FRI. Two complaints and the FRI could not be verified with no regulatory deficiencies identified. One complaint was verified but also found no regulatory deficiencies. Overall, no regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 2
Inspection Report
Complaint Investigation
Census: 205
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation survey triggered by Complaint #NV00068863.
Complaint Details
Complaint #NV00068863 was unverified and no regulatory deficiencies were found.
Findings
The complaint could not be verified and no regulatory deficiencies were identified. The investigation included observations, interviews, clinical record reviews, and document reviews.
Report Facts
Sample size: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the complaint investigation | |
| Administrator | Interviewed during the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 11, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to update resident care plans after falls, medication administration delays, improper infection control practices, and maintenance issues with leaking showers.
Complaint Details
Complaint #NV00063271 related to medication administration delay and infection control; Complaint #NV00068331 related to leaking showers.
Findings
The facility failed to update a resident's care plan after two falls, delayed medication administration for a resident, did not ensure proper PPE usage for a resident with C-Diff, and failed to address leaking showers that posed slip hazards.
Deficiencies (4)
Failed to update a resident's care plan after two falls, risking further harm.
Failed to administer medication in a timely manner according to physician's order.
Failed to monitor proper PPE usage for entering a resident's room with C-Diff, risking spread of infection.
Failed to ensure two showers were not leaking, placing staff and residents at risk of slip and fall.
Report Facts
Date of survey completion: May 11, 2023
Number of residents affected: 1
Number of residents affected: 1
Number of residents affected: 1
Number of residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Indicated care plan should have been updated after falls | |
| Registered Nurse (RN) | Indicated medication should be administered right away | |
| Licensed Practical Nurse (LPN) | Indicated medication should be administered right away | |
| Housekeeping Aide | Observed not wearing proper PPE in resident room with C-Diff | |
| Certified Nurse Assistant (CNA) | Indicated proper PPE required for entering C-Diff isolation room | |
| Respiratory Therapist | Observed lack of PPE supplies outside C-Diff isolation room | |
| Licensed Practical Nurse (LPN) | Confirmed diagnosis of C-Diff and importance of PPE | |
| Unit Manager | Responsible for monitoring PPE usage and acknowledged lack of PPE supplies | |
| Central Supply staff member | Acknowledged lack of PPE supplies and placement of isolation caddy | |
| Infection Preventionist (IP) | Explained PPE requirements and monitoring for C-Diff isolation | |
| Maintenance Manager | Observed leaking showers and lack of work orders | |
| Certified Nursing Assistants (CNAs) | Reported noticing leaks in showers |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Nov 18, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for oxygen therapy and medication administration, failure to timely report urinary tract infection signs and justify continued catheter use, failure to ensure attending physician visits, failure to notify physicians timely of lab results, failure to honor resident food preferences, failure to provide palatable food, and failure to offer pneumococcal vaccines as required.
Deficiencies (7)
Failure to ensure physician orders were followed for oxygen therapy and medication administration.
Failure to report signs of possible urinary tract infection timely and ensure medical justification for continued catheter use.
Failure to ensure attending physician personally visited a resident.
Failure to ensure documented evidence that physician was notified timely of laboratory results.
Failure to ensure resident's food preferences were honored, resulting in offering disliked foods.
Failure to ensure food and drink were palatable, including serving burnt Brussels sprouts.
Failure to offer and re-offer pneumococcal vaccine to residents as required.
Report Facts
Residents sampled: 32
Deficiencies cited: 7
Oxygen liters per minute: 3
Medication dose: 100
Medication dose ordered: 200
Laboratory result date: Nov 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Confirmed oxygen tank was empty but did not replace it; acknowledged medication dose error | |
| Unit Manager (UM) | Confirmed physician orders and expectations for oxygen therapy and catheter use | |
| Director of Nursing (DON) | Confirmed expectations for nursing staff regarding oxygen tanks and catheter use | |
| Physician Assistant (PA) | Could not recall reason for Foley catheter use for Resident 134 | |
| Nurse Practitioner (NP) | Provided clinical expectations for catheter use and notification of lab results | |
| Medical Director | Conveyed requirements for physician visits and catheter use justification | |
| Dietary Manager | Confirmed meal ticket discrepancies and food preference errors | |
| Registered Dietitian (RD) | Provided resident meal tracker document confirming food dislikes | |
| Infection Preventionist (IP) | Confirmed failure to offer pneumococcal vaccine to residents |
Inspection Report
Complaint Investigation
Census: 179
Deficiencies: 2
Date: Jun 10, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on June 4, 2021, regarding allegations of a cockroach infestation in the kitchen and related sanitation issues.
Complaint Details
Complaint NV00064069 was substantiated. The allegation that the kitchen was infested with cockroaches was substantiated. An allegation that a cockroach was found in a resident's ice cream could not be substantiated due to inability to identify the resident.
Findings
The facility was found to have an infestation of German cockroaches throughout the kitchen, poor kitchen sanitation, and poor equipment and facility maintenance, which posed an immediate jeopardy to residents. The kitchen was closed and meals were catered off-site until the issues were corrected. The facility failed to maintain sanitary conditions and adequate pest control despite ongoing awareness and multiple pest control treatments over 15 months. The quality assurance program failed to develop and implement effective corrective actions to address the infestation and sanitation problems.
Deficiencies (2)
Failure to ensure food procurement, storage, preparation, and service in a sanitary manner due to infestation of German cockroaches and poor kitchen sanitation.
Failure of the quality assessment and assurance committee to develop and implement appropriate plans of action to correct identified quality deficiencies related to kitchen sanitation and pest control.
Report Facts
Census: 179
Date of inspection: Jun 10, 2021
Date of complaint initiation: Jun 4, 2021
Date of kitchen closure: Jun 4, 2021
Date of kitchen re-opening: Jun 15, 2021
Date of compliance: Jul 26, 2021
Duration of pest control contract: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Named in relation to findings about pest control and sanitation oversight. | |
| Dietary Manager | Named in relation to findings about kitchen sanitation and pest control issues. | |
| Administrator | Named in relation to oversight and responsibility for kitchen sanitation and pest control. | |
| District Manager of contracted kitchen service | Named in relation to cleaning schedules and pest control coordination. | |
| Director of Nursing | Named in relation to quality assurance committee and oversight. |
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