Inspection Reports for White Pine Care Center

The inspection was conducted as a Medicare Recertification Survey, Complaint and Facility Reported Incident investigation from 05/04/2025 through 05/07/2025.

The facility had deficiencies related to failure to obtain informed consent for psychotropic medications, failure to monitor psychotropic medication side effects, failure to report an incident of abuse timely, incomplete comprehensive care plans for contractures and psychotropic medication use, failure to perform neurological checks after a head injury, failure to obtain physician orders for splint use, and failure to monitor oxygen saturations as ordered.

Complaint NV00073908 was substantiated. Two facility-reported incidents (FRIs) NV00073655 was substantiated and NV00073673 was unsubstantiated.

The inspection was conducted as a Medicare Recertification Survey, Complaint and Facility Reported Incident investigation from 05/04/2025 through 05/07/2025.

The facility was found deficient in multiple areas including failure to obtain consent for psychotropic medications, failure to monitor psychotropic medication side effects, untimely reporting of an abuse incident, lack of comprehensive care plans for contractures and psychotropic medication use, failure to conduct neurological checks after a head injury, lack of physician orders for splint application, failure to assess and intervene for contractures, and inconsistent oxygen saturation monitoring.

Complaint NV00073908 was substantiated. Two facility-reported incidents were investigated; one was substantiated (NV00073666) and one was unsubstantiated (NV00073673).

This inspection was conducted as a State Licensure desk review in accordance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities, reviewing personnel records for compliance.

The facility failed to ensure pre-employment physical examinations were completed for 3 of 10 sampled employees, with physicals conducted well after their hire dates, violating NAC 441A.375 requirements.

A Medicare Recertification survey and a Complaint and Facility Reported Incident Investigation was conducted from 2024-04-16 through 2024-04-19, including investigation of three complaints and one facility reported incident.

The investigation found no deficient practice for two complaints and one facility reported incident, while two complaints could not be verified. However, multiple regulatory deficiencies were identified related to accuracy of assessments, comprehensive care plans, nutrition, fall care, infection control, medication regimen review, resident rights, and staff training.

The survey included investigation of three complaints (#NV0070106, #NV00067252, #NV00067770, #NV00067192) and one Facility Reported Incident (FRI #NV00067252). Two complaints and one FRI were verified with no deficient practice, while two complaints could not be verified.

This inspection was conducted as an annual Medicare recertification revisit survey combined with a complaint investigation from May 15-17, 2023, in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.

The facility was found deficient in thoroughly investigating an allegation of neglect involving Resident #6, failing to report final findings to the state agency, and failing to provide cardiopulmonary resuscitation (CPR) and activate emergency medical services when needed. The facility also failed to follow the resident's POLST and did not report the certified nurse assistant to the nursing board. Systemic changes and corrective actions were implemented including staff training and monitoring.

Two complaints and two Facility Reported Incidents (FRIs) were investigated. Complaint #NV00067924 and Facility Reported Incident #NV00067887 were verified with deficiencies noted. Complaint #NV00068261 was not verified. The complaint investigation found neglect related to Resident #6.

This inspection was conducted as a State Licensure desk review in accordance with Nevada Administrative Code (NAC) Chapter 449 for Skilled Nursing Facilities, reviewing personnel records and compliance with TB testing and physical examination requirements.

The facility failed to complete required Tuberculosis (TB) testing for 9 of 10 sampled employees and failed to ensure pre-employment physical examinations were completed for 2 of 10 sampled employees, with documentation lacking times for TB tests and some physicals missing from files.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of Nevada Department of Health and Human Services from 03/06/23 to 03/09/23 to assess compliance with federal and state regulations.

The facility was found out of compliance with multiple regulatory requirements including failure to timely identify and assess resident complaints of pain after falls leading to serious injury, failure to provide accurate assessments and care plans, failure to provide proper Medicaid/Medicare notices, inadequate monitoring of residents on anticoagulants, deficient infection control practices, insufficient RN staffing coverage, and medication errors including inappropriate administration of clonidine and psychotropic medications.

This inspection was conducted as a State Licensure Desk review in accordance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities, focusing on personnel records related to licenses, tuberculosis (TB) testing, and physical examinations.

The facility failed to complete TB testing for 3 of 10 sampled employees and did not ensure pre-employment physical examinations were completed for 7 of 10 sampled employees. Several employees had TB tests and physical exams completed after their hire dates, not prior to working with residents.

The inspection was a Medicare Life Safety Code (LSC) recertification survey conducted from 06/08/2022 through 06/09/2022 to assess compliance with NFPA 101 and NFPA 99 standards.

The facility was found deficient in several life safety areas including corridor door gaps, evacuation and relocation plan deficiencies, smoking regulations, electrical systems including lack of generator annunciator, and patient-care related electrical equipment testing and maintenance policies.

This inspection was a State Licensing resurvey conducted to assess compliance with Nevada Administrative Code for Skilled Nursing facilities.

The facility was found deficient in maintaining a safe physical environment by failing to secure harmful chemicals in the beauty shop, exposing occupants to potential harm. Corrective actions included installing a self-locking doorknob and locking cupboard for chemical storage.

A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services from 05/31/22 through 06/03/22.

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. No deficiencies were issued for complaint investigations. Deficiencies were identified related to resident rights, Medicare non-coverage notices, MDS submission timeliness, comprehensive care plans, medication cart security, RN staffing, nurse staffing posting, and food labeling and storage.

Medicare Life Safety Code recertification survey conducted at the facility.

The facility had multiple deficiencies related to life safety code including emergency lighting testing, exit signage, cooking facilities maintenance, fire alarm system identification and maintenance, sprinkler system inspection and maintenance, corridor door compliance, electrical system maintenance, fire drills, smoking regulations, evacuation and relocation plans, and oxygen storage safety.

This inspection was conducted as a State Licensure Desk review in accordance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities, focusing on personnel records compliance.

The facility failed to complete annual Tuberculosis screenings for 1 of 10 sampled employees, failed to ensure physical examinations were completed prior to start date for all 10 sampled employees, and failed to ensure submission of fingerprints for background clearance for 2 of 10 sampled employees.

Medicare Recertification survey including a review of the Emergency Preparedness Program conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health from March 8, 2021 through March 11, 2021.

The facility was found not in compliance with several regulatory requirements including resident rights notification, mail delivery, comprehensive care planning, medication regimen review, psychotropic drug monitoring, medication administration errors, expired medication storage, and COVID-19 reporting and notification.

A Medicare Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services from March 8, 2021 through March 11, 2021.

The facility was found not in compliance with several regulatory requirements including failure to deliver resident mail on Saturdays, incomplete comprehensive care plans, failure to conduct monthly pharmacist medication reviews, unnecessary psychotropic medication use without proper monitoring, medication administration errors, expired medication storage, and failure to notify residents and families timely about COVID-19 status and mitigation efforts.

The inspection was conducted as a result of a Focused Infection Control survey, Facility Reported Incident investigation, and Complaint investigation on 12/10/2020 and 12/11/2020.

The facility was found compliant with no regulatory deficiencies related to the substantiated complaint about lack of a Physical Therapist. However, a regulatory deficiency was identified related to infection prevention and control, specifically failure to ensure staff were fit-tested for N95 masks according to facility policy.

Complaint #NV00061896 alleging the facility did not have a Physical Therapist was substantiated with no regulatory deficiencies identified.

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

The facility had no COVID-19 positive or presumptive residents at the time of the survey. Infection control practices including screening, PPE use, and isolation procedures were observed and found to be in place. No regulatory deficiencies were identified.

The inspection was conducted as a result of facility reported incidents and complaint investigations from March 11, 2020 to March 12, 2020, including four facility reported incidents and five complaints.

The investigation substantiated two resident-to-resident altercation incidents and found deficiencies related to abuse/neglect policies, comprehensive person-centered care planning, quality of care, nursing services, and drug regimen. Several complaints were not substantiated. The facility failed to ensure proper training, reporting, and documentation in multiple areas.

Five complaints were investigated. Two resident-to-resident altercation incidents were substantiated. Complaints regarding staff shortage, untrained staff, firearm on premises, and unsafe resident discharge were not substantiated.

The inspection was conducted as an Emergency Preparedness survey in conjunction with a Medicare recertification survey, to assess compliance with emergency preparedness requirements.

The facility failed to conduct required emergency preparedness exercises for the previous year, as confirmed by interviews with the Administrator, Director of Nursing, and Maintenance Director. An Emergency Preparedness Disaster Drill was conducted on 2019-09-09 to address this deficiency.

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

The facility was found deficient in maintaining cooking facility extinguishment systems, electrical wiring and equipment safety, fire drill procedures, smoking regulations, and gas equipment safety related to respiratory therapy sources. Several specific deficiencies were noted including outdated fire extinguishing system tags, improper use of extension cords and power taps, ineffective fire drill response, and inadequate smoking area policies.

This inspection was conducted as a State Licensure survey at the facility from 8/13/19 through 8/14/19 in accordance with Nevada Administrative Code for Facilities for Skilled Nursing and the NFPA 101 Life Safety Code.

The facility was found deficient in compliance with NFPA 101 Life Safety Code requirements related to electrical wiring and generator powered electrical outlets. Specifically, the facility did not ensure adequate generator powered outlets for patient care equipment, with only certain outlets powered by the generator and staff unaware of their locations.

This inspection was conducted as a State Licensure survey in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing, focusing on compliance with the NFPA 101 Life Safety Code.

The facility was found non-compliant with NFPA 101 Life Safety Code requirements related to electrical wiring installations and generator powered electrical outlets for patient care equipment. Specifically, inadequate generator powered outlets were observed in resident areas and patient rooms, impacting oxygen concentrator use.

This inspection was conducted as the annual Medicare recertification survey from August 12 through August 15, 2019, to assess compliance with federal regulations for long-term care facilities.

The facility was found deficient in multiple areas including resident self-determination, comprehensive care planning, quality of care related to medication management, psychotropic drug use, medication labeling and storage, facility assessment, and infection prevention and control. Several residents' care plans and monitoring were inadequate, and the facility failed to ensure proper documentation and adherence to policies.

The inspection was conducted as an annual Medicare Recertification Revisit survey from December 4, 2018 to December 7, 2018, including investigation of one complaint.

The survey identified several regulatory deficiencies related to resident rights, informed consent for psychotropic medications, baseline care planning, and quality of care including failure to follow physician orders for Foley catheter care. No residents were known to be adversely affected.

One complaint (#NV00055237) was investigated with allegations including unlocked medication carts, impaired staff working, drug-related arrests, abusive language, staffing issues, and inability to obtain policies. The complaint was not substantiated.

This document is a Statement of Deficiencies generated as a result of a revisit Medicare Life Safety Code (LSC) recertification survey conducted from 12/04/18 to 12/07/18 to assess compliance with fire safety regulations.

The facility was found deficient for combustible decorations that were not flame retardant or treated with fire retardant coating, specifically resident-made decorations covering more than half of a room's walls without approved flame retardant treatment. The resident was non-compliant and combative regarding correction efforts, and ongoing monitoring and interventions by the IDT team were documented.

This on-site initial State licensure survey was conducted to assess compliance for State license #10231 EXL at the facility.

The laboratory director failed to ensure compliance with manufacturer instructions for glucose testing, failed to ensure staff safety policies including accessible eyewash stations, and failed to maintain a current State of Nevada laboratory license while performing patient testing. All deficiencies were assigned a severity level 2.

The inspection was conducted as the annual Medicare Recertification survey from 09/10/18 to 09/13/18 with an extended survey from 09/25/18 to 09/28/18, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.

The facility failed to protect residents from harm related to resident-to-resident altercations and wandering behaviors, affecting multiple residents. Numerous incidents of resident #4 wandering into other residents' rooms and causing distress were documented, with inadequate staff monitoring and failure to report incidents timely. The facility implemented a plan of correction including staff re-education, QAPI interventions, and increased monitoring.

This document is the Statement of Deficiencies generated as a result of the annual Medicare Recertification survey conducted from 09/10/18 to 09/13/18 and an extended survey from 09/25/18 to 09/28/18, in accordance with 42 Code of Federal Regulations (CFR) Chapter IV, Part 483 - Requirements for Long Term Care Facilities.

The survey identified multiple deficiencies related to resident rights, abuse prevention, medication administration, care planning, infection control, and other regulatory requirements. Several allegations of abuse and neglect were investigated, with some substantiated and others not. The facility failed to meet several federal requirements including proper resident care, medication management, and infection control.

Two complaints were investigated. Complaint #NV00051949 was substantiated regarding failure to provide copies of discharge documentation to the Ombudsman. Complaint #NV00053798 contained multiple allegations, some substantiated without deficiencies and others not 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 09/12/18.

The facility failed to provide required policies and procedures for the use of volunteers and other emergency staffing strategies, the facility's role under a waiver declared by the Secretary, an emergency preparedness communication plan including names and contact information, and a method for sharing information from the emergency plan with residents or representatives.

This document is a Statement of Deficiencies generated as a result of a Medicare Life Safety Code (LSC) recertification survey conducted at the facility on 09/12/18.

The facility was surveyed using Chapter 19, 'EXISTING' Health Care Occupancies, of the 2012 Edition of the NFPA 101 Life Safety Code. Several deficiencies were identified related to means of egress, cooking facilities, sprinkler system maintenance, corridor doors, utilities, evacuation and relocation plans, fire drills, combustible decorations, maintenance and testing of doors, construction and repair operations, electrical systems, and gas equipment storage. No residents were known to be adversely affected by these deficiencies.

The inspection was conducted as an Annual Re-certification Survey and Complaint Investigation Survey from September 12, 2017 through September 19, 2017, including investigation of three complaints.

The facility was found deficient in maintaining Minimum Data Set (MDS) assessments for residents, coordination of dialysis care, medication administration, oxygen storage, nutrition status monitoring, and sanitation practices. Some complaints were substantiated, including improper oxygen storage and medication errors, while others were not substantiated.

Three complaints were investigated: Complaint #NV49747 was substantiated regarding improper oxygen storage; Complaint #NV00049796 was not substantiated; Complaint #NV00050486 was substantiated regarding missing Minimum Data Set (MDS) assessments.

The inspection was conducted as a Medicare Life Safety Code (LSC) survey at the facility from 09/12/17 through 09/15/17 to assess compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 Edition, Chapter 19 Existing Health Care Occupancy.

The facility was found deficient in maintaining patient sleeping room doors and corridor doors according to NFPA 101 standards, including issues with locking mechanisms and impediments to door movement. Electrical system deficiencies were also noted, such as unsecured panelboards and missing cover plates, with corrective actions initiated by the Maintenance and Environmental Managers.

The inspection was conducted as a result of a complaint investigation involving two complaints regarding wound treatment, call bell response, resident hygiene, food temperature, resident body odor, and staff-resident interactions.

The investigation included observations, interviews with residents and staff, and review of medical records and policies. Both complaints were found to be unsubstantiated, but regulatory deficiencies were identified.

Two complaints were investigated: Complaint #NV00047597 alleging improper wound treatment and use of an old mattress was unsubstantiated. Complaint #NV00047511 alleging untimely call bell response, residents left dirty and unturned, cold food, resident body odor, and inappropriate staff-resident interactions was also unsubstantiated.

This report documents a Medicare Life Safety Code (LSC) survey conducted at the facility on September 14, 2016, to assess compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code standards for existing health care occupancy.

The survey identified multiple deficiencies related to fire safety including improper flame spread ratings on interior finishes, corridor door latch failures, obstructed exit access, inadequate fire safety training, untested smoke detectors, sprinkler system maintenance issues, undercharged fire extinguishers, prohibited portable heaters, improper storage of medical gas cylinders, and electrical code violations. Corrective actions and monitoring plans were outlined for each deficiency.

This document is the Statement of Deficiencies generated as a result of the annual Medicare Recertification survey conducted from 9/12/16 to 9/15/16 at the facility, in accordance with federal regulations for long term care facilities.

The survey identified deficiencies related to accident hazards and supervision, drug regimen management, and medication storage and security. Specific failures included incomplete post-fall documentation and neurological checks, inadequate monitoring of antipsychotic medication use, and unlocked medication carts allowing unauthorized access.

This survey was conducted as a Medicare Life Safety Code (LSC) survey to assess compliance with Chapter 19, EXISTING Health Care Occupancies, of the 2000 Edition of the NFPA 101 Life Safety Code.

No deficiencies were cited during this Life Safety Code survey conducted on 9/9/15 and 9/10/15 at the facility.

This inspection was conducted as an annual Medicare Recertification Survey from 8/31/15 through 9/3/15 to assess compliance with federal regulations for long term care facilities.

The facility was found deficient in multiple areas including failure to ensure resident privacy during insulin administration, inadequate housekeeping and maintenance in medication and nurses' stations, inappropriate catheter use without medical justification, improper drug storage and labeling, and infection control breaches during medication administration and in the medication room.

This document is a Statement of Deficiencies generated as a result of an annual Medicare Recertification Survey conducted from 8/31/15 through 9/3/15 to assess compliance with federal regulations for long term care facilities.

The survey identified multiple deficiencies including failure to ensure resident privacy during insulin injections, inadequate housekeeping and maintenance in the medication room, improper catheter use without medical justification, and medication storage and labeling issues. Infection control procedures were also found deficient, including improper medication handling and failure to ensure proper tuberculin skin testing.

The inspection was conducted as a complaint investigation triggered by allegations regarding staffing, quality of care, and fire safety/preparedness at the facility.

The investigation found that the allegations were not substantiated. Observations, interviews, and record reviews indicated that residents received appropriate care, staffing was generally consistent with only one brief period of understaffing, and fire safety drills were conducted regularly. No regulatory deficiencies were identified.

Complaint # NV00041161 regarding staffing and quality of care was not substantiated. Complaint # NV00041154 regarding staffing, quality of care, and fire safety/preparedness was also not substantiated.

The inspection was conducted as a Medicare recertification survey and included an immediate jeopardy situation related to resident mistreatment and abuse following a complaint.

The facility was found to have failed in preventing mistreatment, neglect, and abuse of a resident by a spouse, failed to conduct proper assessments and monitoring after incidents, and failed to provide adequate psychosocial services and activity participation documentation. Multiple deficiencies were cited including failure to report abuse timely, inadequate fall management, improper medication monitoring, and unsafe environment hazards.

The complaint investigation was substantiated with findings of immediate jeopardy related to resident #11 being mistreated and abused by a spouse. The facility failed to protect the resident and failed to implement adequate corrective actions and monitoring.

The inspection was conducted as a Medicare recertification survey to assess compliance with federal regulations for long term care facilities.

The facility was found to have multiple deficiencies including failure to prevent resident abuse, inadequate monitoring and reporting of incidents, incomplete activity documentation, failure to monitor pain and falls properly, improper medication management, unsafe environment hazards, and incomplete clinical records.

The inspection was conducted as a Medicare Life Safety Code (LSC) Survey to assess compliance with NFPA 101 Life Safety Code standards for existing health care occupancies.

The facility was found deficient in multiple Life Safety Code standards including cross-corridor doors not resisting smoke passage, unsealed penetrations in smoke barriers, insufficient clearance around electrical panels, and improper installation of alcohol-based hand rub dispensers over ignition sources.

This inspection was conducted as an annual Medicare Recertification survey from July 22-25, 2013, to assess compliance with federal regulations for long term care facilities.

The facility was found deficient in multiple areas including inaccurate resident assessments, incomplete care plans, failure to provide necessary care, medication errors exceeding 5%, inconsistent provision of bedtime snacks, inadequate food handling hygiene, infection control deficiencies, lack of emergency water supply plan, incomplete medical records, and insufficient staff training on emergency procedures.

The inspection was conducted as a complaint investigation based on allegations that a resident was put on DNR status without the Guardian's permission, the facility tried to redirect Social Security payments to themselves instead of the Guardian, and the facility failed to communicate with the Guardian or obtain permission for procedures.

After review of three resident files and interviews with facility staff including the Administrator and Interim Director of Nurses, the allegations were found to be unsubstantiated. The resident had properly completed DNR forms signed by both the resident and Guardian, medication consents were signed by the Guardian, and the facility had notified the Guardian regarding changes in condition and procedures. No evidence was found that the facility interfered with Social Security payments.

Complaint #NV000 35006 was investigated and found unsubstantiated based on record review and staff interviews.

This document is a follow-up survey conducted to address deficiencies found during the 09/13/12 recertification and state licensure surveys.

No deficiencies were identified during this follow-up survey, and no further action is necessary.

This survey was conducted as a Medicare Life Safety Code (LSC) survey using Chapter 19, EXISTING Health Care Occupancies, of the 2000 Edition of the National Fire Protection Association's (NFPA) 101, Life Safety Code.

There were no deficiencies cited during this survey.

This annual Medicare recertification survey was conducted from September 10, 2012 through September 13, 2012 to assess compliance with federal regulations for long term care facilities.

The survey identified multiple deficiencies related to resident abuse, neglect, dignity, comprehensive care plans, pain management, medication administration, infection control, staffing, and other care standards. Several residents reported verbal abuse by staff, and the facility failed to ensure adequate investigation and prevention of abuse and neglect. Corrective actions and systemic changes were mandated.

This document is a Statement of Deficiencies generated as a result of the annual Medicare recertification survey conducted at the facility from September 10, 2012 through September 13, 2012.

The survey identified multiple deficiencies related to abuse prevention, dignity and respect, comprehensive care plans, medication administration, infection control, and emergency procedures. Several residents reported verbal abuse by staff, and the facility failed to ensure adequate investigation and prevention of abuse and neglect. Deficiencies also included failure to maintain dignity, inadequate care plans, improper medication administration, and failure to maintain sanitary conditions.

The inspection was conducted as a complaint investigation initiated on 5/7/12 and finalized on 5/29/12 regarding an allegation that the facility failed to ensure resident safety related to multiple falls with injury.

The facility was found to have failed to provide adequate supervision and assistive devices to prevent falls for one of eight sampled residents, resulting in multiple falls with injuries including lacerations and fractures. The facility lacked policies regarding volunteer transfers and training, and the resident's care plan was updated to address fall risks.

Complaint #NV00030790 was substantiated, alleging failure to ensure resident safety related to multiple falls with injury.

The inspection was conducted as a complaint investigation survey initiated on 2012-05-07 and finalized on 2012-05-29, related to an allegation that the facility failed to ensure resident safety concerning multiple falls with injury.

The facility was found to have failed to provide adequate supervision and assistive devices to prevent falls for one sampled resident, resulting in multiple falls with injuries including lacerations, fractures, and dislocated ribs. The complaint was substantiated based on clinical record review, observations, and interviews.

Complaint #NV00030790 was substantiated. The allegation was that the facility failed to ensure resident safety related to multiple falls with injury for Resident #1.

The inspection was conducted as a federal comparative survey by the Centers for Medicare and Medicaid Services (CMS) on July 26-29, 2011, to assess compliance with Medicare and Medicaid regulations, including investigation of complaints related to resident rights, privacy, care, and safety.

The facility was found deficient in multiple areas including failure to post required information on advocacy groups, failure to ensure resident privacy and confidentiality, inadequate notification of survey results, failure to ensure timely receipt of unopened mail, inadequate investigation of abuse allegations, failure to provide dignified care, unsafe environment, incomplete care plans, medication errors, inadequate housekeeping, infection control deficiencies, and failure to maintain safe food storage and preparation. Corrective actions and plans were provided with anticipated correction dates mostly by 9/30/2011 or 10/10/2011.

The visit was complaint-related, investigating allegations of abuse, neglect, mistreatment, and inadequate care. The facility was found to have failed to thoroughly investigate abuse allegations and prevent further potential abuse. Specific complaints included bruising, privacy violations, failure to provide dignified care, and inadequate supervision. The complaint was substantiated with multiple deficiencies cited.

The federal comparative survey was conducted to assess compliance with Medicare and Medicaid regulations, including resident rights, privacy, care, safety, and facility environment.

The survey identified multiple deficiencies including failure to post required resident information, breaches of resident privacy, inadequate investigation of abuse allegations, unsafe environment, deficient care planning, medication errors, infection control lapses, and failure to maintain safe equipment and sanitary conditions.

The inspection was conducted as a result of complaint #NV00026825 regarding concerns about resident safety related to oxygen cannula supervision and the nurse call system.

The facility was found to have deficiencies in ensuring residents with cannulas received adequate supervision to prevent accidents and that the nurse call system was not sufficiently audible in all areas. The complaint was substantiated with observations and interviews confirming these issues.

Complaint #NV00026825 was substantiated. The complaint alleged that Resident #1 was found with her cannula removed from her nose causing discoloration due to lack of oxygen. Observations and interviews confirmed insufficient supervision and issues with oxygen cannula placement and nurse call system audibility.

The inspection was conducted as a complaint investigation following complaint #NV00026825 regarding a resident found with her cannula removed and discoloration due to lack of oxygen.

The facility was found deficient in providing sufficient supervision to prevent accidents and ensuring the nurse call system was audibly effective. Three of fifteen residents with cannulas did not have them properly in place, and the nurse call system could not be heard over background noise in certain areas.

Complaint #NV00026825 was substantiated. The complaint alleged a resident was found with her cannula removed and discoloration due to lack of oxygen. Observations confirmed insufficient supervision and improper cannula placement for some residents.

This document is a Plan of Correction submitted in response to a complaint investigation initiated off site on 2010-03-23 and finalized at the facility on 2010-03-31, related to notification of changes or conditions for a skilled nursing facility.

The facility failed to notify the resident's family of a change in condition that required a change of the treatment plan for Resident #1, violating NAC449.74493. The complaint was substantiated with a cited deficiency.

Complaint #NV00024857 was substantiated with a deficiency cited. Complaint #NV00022069 was unsubstantiated.

This inspection was conducted as a result of a complaint investigation initiated off site on 2010-03-23 and finalized at the facility on 2010-03-31.

The facility was found to have failed to notify the resident's family of a change in condition that required a change in the treatment plan for Resident #1. Complaint #NV00024857 was substantiated with a deficiency cited, while Complaint #NV00022069 was unsubstantiated.

Complaint #NV00024857 was substantiated with a deficiency cited. Complaint #NV00022069 was unsubstantiated.

Annual Medicare recertification survey conducted from August 18, 2008 through August 21, 2008, including investigation of several complaints.

The facility was found deficient in multiple areas including failure to notify physicians timely about medication issues, lack of written consents for physical restraints, inadequate accommodation of resident needs, insufficient activities program, incomplete medication orders, failure to address residents' psychosocial needs, nutritional decline in a resident, unsafe medication storage, and sanitary issues in food service.

Four complaints were investigated: Complaint #NV00018338 substantiated with deficiencies cited; Complaint #NV00018514 unsubstantiated; Complaint #NV00018748 substantiated with no federal deficiencies cited; Complaint #NV00018872 substantiated with no federal deficiencies cited.

This report documents a State licensure survey conducted at White Pine Care Center from August 18, 2008 through August 21, 2008, to assess compliance with Nevada Administrative Code (NAC) 449 Skilled Nursing Facilities Regulations.

The survey identified deficiencies related to personnel records, specifically failure to provide evidence of a two-step tuberculin skin test for 2 of 10 employees and failure to provide evidence of required dementia training within 30 days of hire for 4 of 10 employees.

This document is a Statement of Deficiencies generated as a result of an annual Medicare recertification survey conducted from August 18, 2008 through August 21, 2008 at White Pine Care Center.

The survey investigated multiple complaints, some substantiated and some unsubstantiated. Deficiencies were identified related to notification of changes, physical restraints, accommodation of needs, activities, comprehensive care plans, mental and psychosocial functioning, nutrition, sanitary conditions, unnecessary drugs, specialized rehabilitative services, and pharmacy services. Corrective actions and measures to prevent recurrence were outlined for each deficiency.

Four complaints were investigated: Complaint #NV00018338 was substantiated; Complaint #NV00018514 was unsubstantiated; Complaint #NV00018748 was substantiated with no federal deficiencies cited; Complaint #NV00018872 was substantiated with no federal deficiencies cited.

The inspection was conducted as a State licensure survey at White Pine Care Center from August 18, 2008 through August 21, 2008, to assess compliance with Nevada Administrative Code (NAC) regulations for skilled nursing facilities.

The facility was found deficient in maintaining accurate personnel records, specifically failing to provide evidence of two-step tuberculin skin tests for 2 of 10 employees and dementia training within 30 days of hire for 4 of 10 employees. Corrective actions and monitoring measures were outlined to address these deficiencies.

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