Deficiencies (last 3 years)
Deficiencies (over 3 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 9, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, medication administration, employee performance evaluations, and medication storage and labeling at Skye Canyon Post Acute.
Findings
The facility was found deficient in protecting residents' private health information, following physician orders for medication administration, completing annual performance evaluations for nursing assistants, and properly labeling and discarding multi-dose vaccine vials. All deficiencies were cited with minimal harm or potential for actual harm affecting a few residents.
Deficiencies (4)
Failed to ensure protected health information was not visible to residents or visitors for 1 of 12 sampled residents (Resident 42).
Failed to ensure physician orders for medication administration were followed or clarified for 1 of 12 sampled residents (Resident 8), resulting in crushing medications without physician orders.
Failed to ensure an annual appraisal for 1 of 4 sampled Certified Nursing Assistants (CNA3) was completed.
Failed to ensure multi-dose vaccine vials were discarded after expiration date and labeled with open date once accessed for 1 of 2 medication refrigerators.
Report Facts
Residents sampled: 12
Certified Nursing Assistants sampled: 4
Physician orders dated: Mar 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN1) | Licensed Practical Nurse | Named in findings related to medication administration and privacy breach |
| Director of Nursing (DON) | Director of Nursing | Named in findings related to privacy expectations, medication administration, and vaccine storage |
| Human Services Director | Human Services Director | Named in findings related to CNA annual appraisal oversight |
| Consultant Pharmacist | Consultant Pharmacist | Named in findings related to medication crushing and physician orders |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 12, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication self-administration assessments and post-fall interdisciplinary team (IDT) meetings as part of routine regulatory oversight of the nursing home.
Findings
The facility failed to ensure a self-administration medication assessment was completed for 1 of 15 sampled residents, and failed to complete an IDT meeting post fall incident for 1 of 15 residents. Both deficiencies had potential for harm due to inadequate evaluation and monitoring.
Deficiencies (2)
Failed to ensure a self-administration of medication assessment was completed for 1 of 15 sampled residents (Resident 66).
Failed to complete an Interdisciplinary Team (IDT) meeting post fall incident for 1 of 15 residents (Resident 124).
Report Facts
Residents sampled: 15
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed that a self-administration assessment should have been completed for Resident 66 and confirmed lack of IDT post fall discussion for Resident 124 |
| Licensed Practical Nurse | Licensed Practical Nurse | Confirmed not aware of facility process to assess resident for safe medication administration for Resident 66 |
| Health Information Director | Health Information Director | Confirmed lack of documented IDT post fall discussion for Resident 124 |
| Unit Manager | Unit Manager | Reviewed medical record and confirmed lack of documented IDT post fall discussion for Resident 124 |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 12, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication self-administration, fall incident management, intravenous medication administration, and food safety in the nursing home facility.
Findings
The facility was found deficient in completing self-administration medication assessments, conducting interdisciplinary team meetings post-fall, ensuring complete administration of IV medications, and maintaining kitchen cleanliness and proper refrigerator temperatures. These deficiencies posed potential risks for resident safety and health.
Deficiencies (4)
Failed to ensure a self-administration of medication assessment was completed for 1 of 15 sampled residents (Resident 66).
Failed to complete an Interdisciplinary Team (IDT) meeting post fall incident for 1 of 15 residents (Resident 124).
Failed to ensure an intravenous (IV) medication was completely administered for 1 of 15 sampled residents (Resident 6).
Failed to maintain the kitchen floor's cleanliness and 1 of 2 nourishment refrigerator temperatures (Nurse Station One) was above acceptable range.
Report Facts
Residents sampled: 15
Temperature reading: 50
Temperature reading: 51.8
Medication left in IVPB bag: 10
Medication left in IVPB bag: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed self-administration assessment should have been completed and acknowledged incomplete IV medication infusion |
| Licensed Practical Nurse | Licensed Practical Nurse | Confirmed resident self-administers nasal spray and acknowledged incomplete IV medication infusion |
| Unit Manager | Unit Manager | Reviewed medical record and confirmed lack of documented IDT post fall meeting |
| Health Information Director | Health Information Director | Confirmed lack of documentation of IDT post fall discussion |
| Director of Culinary Services | Director of Culinary Services | Confirmed kitchen cleanliness issues and refrigerator temperature concerns |
| Chef | Chef | Confirmed kitchen staff responsibilities for cleaning and temperature log documentation |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 9, 2023
Visit Reason
The inspection was conducted due to complaints and facility reported incidents regarding delayed call light responses, resident abuse, failure to follow professional standards during CPR, failure to communicate with physicians about medication holds, and failure to prevent elopement.
Complaint Details
The visit was complaint-related involving Facility Reported Incidents (FRI) NV00068866, NV00068923, NV00066996, NV00068216, NV00068766 and Complaint NV00069162. Issues included delayed call light response, resident abuse by spouse, failure to follow CPR protocols, failure to communicate medication holds to physician, and failure to prevent elopement.
Findings
The facility was found deficient in timely call light response for residents, failure to protect a resident from abuse by a spouse, inadequate professional standards during CPR for an unresponsive resident, failure to communicate with physicians before holding blood pressure medications, and failure to implement interventions to prevent elopement of a resident at risk.
Deficiencies (5)
Failed to provide timely call light response for 2 of 8 sampled residents, resulting in potential loss of dignity and psychosocial harm.
Failed to ensure a resident was safe from abuse by spouse, exposing residents to potential abuse.
Failed to ensure professional standards were followed for an unresponsive resident by administering CPR and following the facility code blue process.
Failed to communicate with the physician before holding blood pressure medication for 1 of 8 sampled residents.
Failed to implement interventions to prevent a resident at risk for elopement from leaving the facility.
Report Facts
Call light wait times: 7
Call light wait times: 7
Medication orders: 3
Staff: 2
Staff: 3
Care plan checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding call light response expectations, CPR incident, and communication protocols |
| Social Worker | Social Worker (SW) | Discussed resident abuse incident and supervision measures |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Involved in CPR incident and provided statements about alerts and abuse notifications |
| Registered Nurse | Registered Nurse (RN) | Provided statements about call light system and CPR training |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Performed CPR during incident and provided statements about call light response and elopement |
| Unit Manager | Unit Manager | Provided statements about communication of blood pressure parameters to physician |
| Administrator | Administrator | Provided statements about CPR incident and staff training |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
Date: Apr 28, 2023
Visit Reason
The inspection was conducted based on complaints regarding misappropriation of a resident's property, failure to follow post-fall interventions, and insufficient nursing staff to meet resident needs.
Complaint Details
Complaints investigated included misappropriation of property (Complaint #NV00067460), failure to follow post-fall interventions (Complaint #NV00067041), and insufficient staffing (Complaints #NV00067839, #NV00068275, #NV00067041).
Findings
The facility failed to protect a resident from financial exploitation by a staff member, did not ensure post-fall neurological assessments were conducted for an unwitnessed fall, and lacked sufficient nursing staff to meet resident care needs, resulting in delayed and inappropriate care.
Deficiencies (3)
Failed to ensure a resident's debit card was not misappropriated by a staff member.
Failed to ensure post-fall interventions, including neurological assessments, were followed for an unwitnessed fall.
Failed to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 31
Licensed nurses scheduled: 4
Certified Nursing Assistants (CNAs) scheduled: 6
Residents with indwelling catheter: 8
Residents with pressure ulcers: 5
Residents on intravenous therapy: 5
Residents treated for infections: 11
Residents on transmission-based precautions: 2
Dialysis residents: 3
Residents with Alzheimer's dementia: 3
Inspection Report
Routine
Census: 29
Deficiencies: 15
Date: Apr 28, 2023
Visit Reason
Routine inspection of Skye Canyon Post Acute to assess compliance with regulatory requirements including resident care, medication management, infection control, staffing, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure communication boards were used for hearing-impaired residents, misappropriation prevention of resident belongings, comprehensive care plan updates, consistent provision of showers and bed baths, timely wound care and treatment orders, post-fall interventions, Foley catheter care, IV fluid administration orders and care, oxygen order clarification and implementation, medication regimen review follow-up, medication cart security, food storage labeling, and infection prevention and control protocols.
Deficiencies (15)
Failed to ensure a communication board was utilized for a hearing-impaired resident, causing potential psychosocial harm.
Failed to prevent misappropriation of a resident's debit card by a staff member, risking financial exploitation.
Failed to revise comprehensive care plan to include behavior monitoring for a resident on depression medication.
Failed to consistently provide showers or bed baths to dependent residents, risking poor hygiene and related complications.
Failed to obtain and carry out timely treatment orders for a surgical wound, risking wound complications.
Failed to provide timely wound care and dressing changes for a resident with a pressure injury.
Failed to ensure post-fall interventions including neurological assessments were followed for a resident after an unwitnessed fall.
Failed to provide appropriate Foley catheter care, including emptying urinary bag and perineal care, placing resident at risk for recurrent UTI.
Failed to obtain and transcribe physician orders for IV midline and heplock insertion and care, risking infection and complications.
Failed to clarify oxygen order and ensure current oxygen orders were implemented appropriately.
Failed to ensure sufficient nursing staff to meet resident needs, resulting in delayed and compromised care.
Failed to ensure medication regimen review recommendations were acted on by a physician.
Failed to ensure medication cart was locked when unattended, risking unauthorized access and drug diversion.
Failed to ensure food items were labeled and dated properly and free from expired or damaged products.
Failed to ensure physician orders for contact and droplet precautions were obtained and transcribed timely and isolation precautions implemented, risking spread of infection.
Report Facts
Residents with indwelling catheter: 8
Residents with pressure ulcers: 5
Residents on intravenous therapy: 5
Residents on transmission-based precautions: 2
Dialysis residents: 3
Residents with Alzheimer's dementia: 3
Medication regimen review recommendations: 3
Medication regimen review monitoring score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided multiple clarifications and acknowledgments regarding deficiencies and facility policies | |
| Unit Manager | Provided information on staffing, wound care, and medication cart security | |
| Certified Nursing Assistant | Reported on staffing challenges and care provision issues | |
| Licensed Practical Nurse | Provided observations on catheter care and fall interventions | |
| Registered Nurse | Provided observations on communication board use, catheter care, and oxygen therapy | |
| Director of Nutrition Services | Verified food storage and labeling issues | |
| Infection Preventionist | Provided information on transmission-based precautions and infection control | |
| Dialysis Registered Nurse | Provided information on central venous catheter care | |
| Administrator | Provided information on staffing and policy implementation |
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