ADVANCED HEALTH CARE OF SUMMERLIN
For profit - Limited Liability company
38 Beds
ADVANCED HEALTH CARE
Data: November 2025
Trust Grade
68/100
#18 of 65 in NV
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Advanced Health Care of Summerlin has received a Trust Grade of C+, indicating it is slightly above average but not outstanding. It ranks #18 out of 65 facilities in Nevada, placing it in the top half, and #13 out of 42 in Clark County, meaning there are only a few local options that are better. However, the facility's trend is concerning as the number of issues reported has increased from 7 in 2023 to 8 in 2024. Staffing is a strength, with a 4 out of 5 rating and a turnover rate of 37%, which is below the state average, indicating that staff are stable and familiar with residents. While the facility has a fine of $4,194, which is average for the area, they do provide more registered nurse coverage than 75% of other Nevada facilities, enhancing care quality. However, there are some notable issues, including failing to provide adequate discharge planning for a resident, which could hinder their ability to appeal decisions about their care. Additionally, another resident did not have a proper care plan to manage their edema, which could lead to serious health risks if not addressed. Overall, while there are strengths in staffing and RN coverage, potential residents and their families should be aware of the facility's weaknesses in care planning and recent trends in issues.
- Trust Score
- C+
- In Nevada
- #18/65
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 37% turnover. Near Nevada's 48% average. Typical for the industry.
- Penalties ○ Average
- $4,194 in fines. Higher than 74% of Nevada facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 99 minutes of Registered Nurse (RN) attention daily — more than 97% of Nevada nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
68/100
Top 27%
No red flags
7 → 8 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 7 issues
2024: 8 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Nevada average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 37%
Near Nevada avg (46%)
Typical for the industry
Federal Fines: $4,194
Below median ($33,413)
Minor penalties assessed
Chain: ADVANCED HEALTH CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 21 deficiencies on record
Nov 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to properly discuss and provide document...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to properly discuss and provide documentation of resident's discharge planning and appeal rights for 1 of 14 sampled residents (Resident 95). The deficient practice had a potential for a resident to not be able to exercise the right to appeal a discharge decision from the Managed Medicare (MA) Plan and have the necessary planning for discharge.
Findings include:
Resident 95 (R95)
R95 was admitted on [DATE], with diagnoses including Parkinson's disease without dyskinesia and acute respiratory failure.
On 08/21/2024 at 12:10 PM, R95 verbalized being discharged tomorrow (08/22/2024). The resident voiced concerns regarding the continuation of care proposed by the facility and the quality of care to be received with the Home Health Agency (HHA). The resident had reservations the current functional capacity might not be fitting to be downgraded to a lower level of care. The resident verbalized signing a discharge notice and was sure no option to appeal was mentioned during the discussion with the Case Manager (CM). The resident did not have a copy of the Notice of Medicare Non-Coverage (NOMNC) and confirmed signing the document and no copy was provided. Observed R95 go thru documents received from the facility and only admission documents were in possession.
On 11/21/2024 at 12:31 PM, the CM indicated the resident signed the NOMNC and a copy was placed at the discharge packet to be sent home with the resident. The CM confirmed the resident was not provided a copy and the appeal option was discussed upon signing the NOMNC. The CM agreed a copy should have been left with the resident to be reviewed at a later time. The CM acknowledged having a copy would be good for the resident to have if in case a decision to appeal the discharge come into mind, the resident would have the appeals contact number. The CM agreed the resident had now passed the deadline to have an expedited independent review from the Quality Improvement Organization (QIO- an independent reviewer to ensure NOMNC was issued according to MA guidelines) and an insurance appeal was the only available option which was not expedited and could lead to a financial risk if the insurance appeal was not successful.
R95's MDS completed on admission had a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 reflects: 13 - 15 points: Cognitively intact.
R95's electronic health care records revealed one entry from Care Coordination. The documentation lacked the necessary details of discharge planning for the resident's continuation of care needs or any discussion with regards to the notice of discharge appeal rights.
On 11/21/2024 at 2:41 PM, the Director of Nursing (DON) and interim DON confirmed CM and discharge planning department was under nursing services. The DONs confirmed all documents signed by a resident and the representative; a copy of the signed document should be provided for further reference. The DONs expectation for discharge documentation was to document all the necessary discharge planning provided to the resident. R95 had a BIMS of 15 and the DONs agreed the resident was capable to fully express any desire of wanting to appeal if discussed or the resident had the capacity to read and digest any information on the NOMNC if provided. The DONs acknowledged R95 had missed an opportunity to have an independent review from the QIO due to the lack of provision of document material to further reference resident rights.
The facility policy titled Patient Discharge (undated), documented when the facility transfers or discharges a resident under any circumstances, the facility will ensure that the transfer or discharge is documented in the resident's medical record. #9. All other necessary information, as applicable to ensure a safe and effective transition of care.
The facility policy titled Resident Rights - facility version A0717, documented the resident has the right to receive notices orally (meaning spoken) and in writing (including braille) in a format and a language he or she understands, including: 1. Required notices: The facility must furnish to each resident a written description of legal rights which includes: state and local advocacy organizations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a baseline person-centered ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a baseline person-centered care plan to manage a resident's edema (swelling) following admission was completed for 1 of 14 sampled residents (Resident 146). This deficient practice had the potential for delayed interventions, worsening edema, increased risk of skin breakdown or infection, and compromised resident's overall health and well-being.
Findings include:
R146 was admitted on [DATE], with diagnoses including cardiogenic shock, chronic obstructive pulmonary disease, cardiomyopathy, hypertensive heart disease with heart failure, acute kidney failure, lymphedema and localized edema.
The Physician Progress Note dated 11/17/2024, documented R146 presented to the hospital with severe leg swelling and unable to ambulate. R146 was found to be in acute exacerbation of chronic congestive heart failure.
The Nursing Progress Notes dated 11/17/2024, documented R146 had bilateral lower extremities edema.
On 11/19/2024 at 11:07 AM, R146 sat in a wheelchair, alert and verbally responsive. The lower extremities showed weeping edema (water retention that occurs when fluid leaks through the skin due to swelling), legs were not elevated and had no compression stockings. The wound dressing on the left lateral lower leg was wet. R146 reported experiencing edema for a long time and mentioned multiple heart issues.
R146's medical records lacked documented evidence a baseline person-centered care plan to manage R146's edema following admission was completed.
On 11/20/2024 at 11:13 AM, the Wound Care Treatment Nurse (WCTN), indicated the wound dressing had been removed, it was wet, and a chuck had been placed to prevent the area from being left open due to Resident 146's severe weeping edema.
On 11/20/2024 in the afternoon, the Clinical Care Manager (CCM) confirmed the edema had not been identified upon admission, no care plan had been created, the legs were not elevated, and no compression stockings were in place. The CCM acknowledged the edema was present on admission.
On 11/21/2024 at 3:30 PM, the Director of Nursing (DON) confirmed the resident's edema was present but had not been identified upon admission, and a baseline care plan should have been completed within 48 hours. The DON emphasized the importance of the care plan in establishing goals and interventions to ensure timely and appropriate care.
A facility policy titled Baseline Person-Centered Care Plan (undated), indicated the baseline care plan was developed during the admission process to guide resident care before creating the comprehensive care plan. The baseline care plan was prepared at the time of admission, including the care to be provided, goals to be achieved, and actions necessary to reach those goals. The admitting nurse was responsible for utilizing and completing the baseline person-centered care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the resident's edema (swellin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the resident's edema (swelling) was appropriately assessed following admission and interventions implemented for 1 of 14 sampled residents (Resident 146). This deficient practice had the potential to result in delayed treatment, worsening edema, increased risk of skin breakdown or infection, and compromised overall health and well-being.
Findings include:
Resident 146 (R146)
R146 was admitted on [DATE], with diagnoses including cardiogenic shock, chronic obstructive pulmonary disease, cardiomyopathy, hypertensive heart disease with heart failure, acute kidney failure, lymphedema and localized edema.
The Observation Detail List Report dated 11/15/2024, documented a brief interview of mental status score of 15/15, which indicated R146's cognitive status was intact.
The Observation Detail List Report dated 11/15/2024, documented R146 had no edema.
The admission Skin assessment dated [DATE], documented R146 had no edema.
An admission Physician order dated 11/15/2024, documented to assess edema every shift and apply interventions to include the following: elevate extremities, diet, compression, diuretics and to record edema amount.
The Medication Administration Record (MAR) from 11/16/2024 to 11/19/2024, showed inconsistencies in the documentation of edema, with alternating entries indicating both the presence and absence of edema on different days.
The Physician Progress Note dated 11/17/2024, documented R146 presented to the hospital with severe leg swelling and unable to ambulate. R146 was found to be in acute exacerbation of chronic congestive heart failure.
The Nursing Progress Notes dated 11/17/2024, documented R146 had bilateral lower extremities edema.
On 11/19/2024 at 11:07 AM, R146 sat in a wheelchair, alert and verbally responsive. The lower extremities showed weeping edema (water retention that occurs when fluid leaks through the skin due to swelling), legs were not elevated and had no compression stockings. The wound dressing on the left lateral lower leg was wet. R146 reported experiencing edema for a long time and mentioned multiple heart issues.
R146's medical records lacked documented evidence the edema was assessed, and interventions implemented following R146's admission.
On 11/19/2024 at 11:27 AM, the wound Nurse Practitioner (NP) indicated it was the first time R146 had been seen and noted R146 had severe edema, with the left lower extremity leaking fluid.
On 11/20/2024 at 11:13 AM, the Wound Care Treatment Nurse (WCTN) indicated the wound dressing had been removed, it was wet, and a chuck had been placed to prevent the area from being left open due to R146's severe weeping edema.
On 11/20/2024 in the afternoon, the Clinical Care Manager (CCM) confirmed the edema was not identified upon admission, and no compression stockings were applied. The CCM indicated there was an order to assess and to implement the interventions but was not implemented except for diuretics, which were discontinued. The CCM indicated if the interventions were not appropriate, the physician should have been notified and the order clarified. The CCM confirmed the edema was present on admission based on the hospital transfer summary.
On 11/21/2024 at 3:30 PM, the Director of Nursing (DON) indicated the process was to completely assess the resident upon admission, including the skin or edema. The DON confirmed the edema was present on admission, but it was not appropriately assessed, and the Licensed Nurses documented in the MAR, R146 had no edema while others documented the presence of edema.
A facility policy titled admission Skin Assessment (undated), documented upon admission, the resident would be examined to identify current issues. The physician would be contacted to initiate appropriate treatment orders if not addressed in the physician admit orders. The admission skin assessment would be uploaded into resident documents. The admitting nurse was responsible for ensuring the selected interventions were initiated, appropriate equipment was placed, and monitoring was placed on the treatment record and baseline-centered care plan as indicated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, and document reviews, the facility failed to ensure the fluid restriction was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, and document reviews, the facility failed to ensure the fluid restriction was followed, or the physician's order was clarified and communicated for 1 of 14 residents (Resident 146). This deficient practice had the potential to result in fluid overload, which could lead to complications such as edema, hypertension, or congestive heart failure, compromising the resident's overall health and safety.
Findings include:
Resident 146 (R146)
R146 was admitted on [DATE], with diagnoses including cardiogenic shock, chronic obstructive pulmonary disease, cardiomyopathy, hypertensive heart disease with heart failure, acute kidney failure, lymphedema, and localized edema.
The Observation Detail List Report dated 11/15/2024, documented a brief interview of mental status score of 15/15, which indicated R146's cognitive status was intact.
The physician progress note dated 11/17/2024, documented R146 presented to the hospital with severe leg swelling and was unable to ambulate. R146 was found to be in acute exacerbation of chronic congestive heart failure.
A physician order dated 11/17/2024, documented low sodium (NAS) diet: texture: soft and bitesize. Liquids: thin, Fluid restriction: 1000 milliliters (ml) per day (Nursing: 640 ml; kitchen 360 ml breakfast 120 ml, lunch 10 ml, dinner 120 ml).
A physician order dated 11/19/2024, documented NAS diet: texture: soft and bitesize. Liquids: thin, Fluid restriction: 1000 ml/day (Nursing: 260 ml; kitchen 840 ml breakfast 360 ml, lunch 24 ml, dinner 240 ml).
The Medication Administration Record from 11/15/2024-11/20/2024, documented fluid restriction of 1000 ml/day (Nursing 640 ml; Kitchen 360 ml (breakfast-120 ml, lunch 120 ml, and dinner 120 ml).
The meal tickets dated 11/19/2024 and 11/20/2024, documented R146 was on fluid restriction and the fluid or beverages being served: -Breakfast: 360 ml -Lunch: 240 ml -Dinner: 240 ml
On 11/19/2024 at 11:07 AM, R146 was seated in the wheelchair, alert and verbally responsive. Severe edema on bilateral lower legs was noted and legs were not elevated. A 355 ml bottle of water was at bedside with a straw.
On 11/20/2024 at 8:35 AM, R146 was in bed with eyes open. The breakfast tray was on the table, containing scrambled eggs, sausage, yogurt, and a glass of cranberry juice with a straw. The meal ticket, dated 11/20/2024, indicated breakfast included 360 ml of cranberry juice. A 355 ml bottle of water was on the table, with approximately 100 ml remaining. The Clinical Care Manager (CCM) confirmed the observation and indicated R146's fluid restrictions should have been timely communicated to staff and the kitchen to prevent fluid overdose, especially since R146 had severe edema.
On 11/20/2024 in the morning, the Wound Care Treatment Nurse (WCTN) was at bedside to provide wound care treatment to R146. R146 requested water, and the 355 bottled water was provided to R146, and then the WCTN proceeded to provide the wound care.
On 11/20/2024 in the afternoon, the WCTN confirmed R146 was given water as requested but was unaware R146 was on fluid restriction. The WCTN indicated previously the residents on fluid restriction had a log inside their room, but with R146, no indicator was noted the resident was on fluid restriction.
On 11/20/2024, at 11:35 AM, the dietary manager indicated the fluid restrictions orders would be obtained from the matrix, or the registered dietitian would provide the information. The dietary manager confirmed the fluids were provided to R146 on 11/19/2024: breakfast-360 ml, dinner-240 ml, and dinner-240 ml. The dietary manager confirmed there was no advice or order communicated to change the order distribution.
On 11/20/2024 at 11:37 AM, the Registered Dietitian (RD) indicated R146 was not evaluated yet since R146 was just admitted on [DATE]. The RD indicated the hydration was standard per policy to be distributed during breakfast-360 ml, dinner-240 ml, and dinner-240 ml. The RD verified R146 had a fluid restriction for 1000 ml due to edema. The RD confirmed the process; the fluid order restriction should have been communicated to the kitchen. The RD indicated there was a new diet order on 11/19/2024.
On 11/20/2024 at 1:30 PM, R146 was seated in the wheelchair with a lunch tray with 240 ml of colored juice. R146 indicated was aware of the fluid restriction but uncertain how much fluid daily would be allowed. R146 indicated the licensed nurse administered the medication with drinking water in a cup.
On 11/20/2024 at 1:41 PM, Licensed Practical Nurse (LPN) verified and confirmed R146 was on a fluid restriction of 1000 ml/day. The LPN indicated during each medication administration, R146 was given 120 ml of water and took a few sips.
On 11/20/24 in the afternoon, the Director of Nursing (DON) confirmed R146 was on fluid restriction for 1000 ml/day. The DON indicated the order should have been communicated to the kitchen in writing for proper distribution as prescribed, or the order should have been clarified if needed more. The DON indicated the order should have been matched with what was provided and the fluid intake should have been documented.
A facility policy titled Fluid Restriction (undated), documented fluid restrictions would be followed as per physician's orders and following the procedures: The amount of fluid per 24 hours would be specified in a written physician's order and sent to the food and nutrition service department in writing. The food and nutrition services department and the nursing department would determine how much fluid would be provided at meals and medication passes. Water provided at the bedside would be calculated into the daily total fluid restriction.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the peripheral intravenous (I...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the peripheral intravenous (IV) access was identified, flushed, and monitored, and a physician order was obtained or removed when not in use for 1 of 14 sampled residents (Resident 144). This deficient practice could have the potential to result in complications such as infection, infiltration, and phlebitis, or other adverse outcomes.
Findings:
Resident 144 (R144)
R144 was admitted on [DATE], with diagnoses including anemia and altered mental status.
On 11/19/2024 at 10:09 AM, R144 was in bed alert, verbally responsive but hard of hearing. A peripheral IV access was on the right arm; the dressing was undated, and skin redness was observed around the insertion site and had dried blood-like residue. R144 was unaware of the reason for the IV access placement and could not remember when it was inserted.
R144's admission Skin assessment dated [DATE], lacked documented evidence the peripheral IV access was identified.
On 11/19/2024 at 2:42 PM, R144's family was at bedside, indicating R144's IV access was inserted in the hospital prior to admission at the facility. The family indicated R144 had been admitted 11 days ago, and the family was told by the facility staff the peripheral IV access would be removed for non-use.
R144's medical records lacked documented evidence of the peripheral IV access, peripheral intravenous (IV) access was identified, flushed, monitored, and a physician order was obtained or removed when not in use.
On 11/19/2024 at 2:44 PM, a Registered Nurse (RN) verified and indicated R144's peripheral IV should have been removed for non-use. The RN confirmed there was no order in place for the utilization and management of R144's peripheral IV access. The RN indicated there should have been an assessment upon R144's admission; IV should have been flushed, monitored for signs and symptoms of infection, or discontinued for non-use. The RN proceeded to remove the peripheral IV and confirmed redness surrounding the insertion site.
On 11/20/2024 at 11:32 AM, the Clinical Care Manager (CCM) indicated the resident should have been assessed upon admission, and the admission Licensed Nurse should have completed the skin assessment. The CCM indicated any IV access should have been flushed, and the insertion site would be monitored for s/s of infection, and if not in use, should have been discontinued to prevent infection.
A facility policy titled admission Skin Assessment (undated), documented upon admission the resident would be examined to identify current issues. The physician would be contacted to initiate appropriate treatment orders if not addressed in the physician admit orders. The admission skin assessment would be uploaded into resident documents. The admitting nurse was responsible for ensuring the selected interventions were initiated, appropriate equipment was placed, and monitoring was placed on the treatment record and baseline-centered care plan as indicated. A facility policy titled Intravenous Access (undated), documented to appropriately maintain intravenous access devices.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure residents had physician orders...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure residents had physician orders and assessment for self-medicating; and medications were properly secured in the resident's room for 2 of 14 sampled residents (Resident 98 and 102). The deficient practices had a potential for a resident to improperly administer and store medications.
Findings include:
Resident 98 (R98)
R98 was admitted on [DATE], with diagnoses including fracture of left lower leg and end stage renal disease on hemodialysis.
On 11/19/2024 at 10:34 AM, observed at R98's bedside table was a Family Wellness brand Stomach Relief, Maximum Strength, bismuth subsalicylate 1050 milligram bottle.
R98 indicated bringing in the medication from home just in case of needing it. R98 indicated taking the medication for upset stomach or hyperacidity. The resident confirmed placing the medication at the bedside table ever since arrival and none of the staff had questioned its presence.
On 11/20/2024 at 11:45 AM, the nurse caring for R98 was not aware of the medication at the resident's bedside. The nurse confirmed all medications should be secured and if there was one, a Self-Administration assessment should be completed. The nurse confirmed R98 did not have a self-administration assessment completed.
R98's progress notes had an entry from the nurse dated 11/20/2024 at 12:01 PM, The nurse's note documented: noted patient had Pepto Bismol in room that family had brought in, the patient does not have an order for this medication and states not using it, reminded patient that medication cannot be kept in room per policy, and was in agreement to take med out of the room and place in med cart to give back to the family when they visit.
On 11/20/2024 at 12:59 PM, the Unit Manager (UM) indicated the nurse made an entry into the progress note indicating the presence of an unsecured medication and the resident had no self-administration assessment or physician's order. The UM confirmed a self-administration assessment should have been completed and the medication should have been secured.
Resident 102 (R102)
R102 was admitted on [DATE], with diagnoses including malignant neoplasm of the bronchus and open wound of the left lower leg.
On 11/19/2024 at 9:41 AM, R102 indicated having lung cancer and taking supplemental medications. Observed at R102's bedside table were bottles of supplemental medications:
1) [NAME] Vegetable Supplement,
2) [NAME] Energy - Oxygen,
2) [NAME] Energy - Lungs,
3) [NAME] Energy - Colosil Plus,
4) [NAME] Energy - VirX.
R102 indicated bringing the meds from home and has been taking it religiously. R102 indicated the medication was given by a friend living in Canada and was informed the medications should be good in fighting for cancer.
On 11/20/2024 at 11:45 AM, the nurse caring for R102 was aware of the medication at the resident's bedside. The nurse indicated completing the self-administration assessment and confirmed not having an actual physician's order. The nurse also confirmed medications should be kept secured even when inside the resident's room.
R102's electronic healthcare record had a Self-Medication Administration Assessment completed on 11/19/2024. R102's admission date was 11/12/2024.
On 11/20/24 at 12:59 PM, the UM indicated the nurse should have completed the self-assessment since admission and medications should be kept secured. The UM confirmed all medications a resident will be taking should have a physician's order.
The facility policy titled Self Medication Administration (Undated), documented as part of their overall evaluation, staff will assess each patient's mental and physical abilities to determine whether a patient is capable of self-administering medications. In addition to general evaluation of decision-making capacity, staff will perform a more specific skills assessment utilizing the Self-Medication Administration Assessment form. For self-administering patients, the nursing staff will be responsible for documenting that medications were taken on the eMAR. Self-administered medications must be stored in a safe and secure place, which is not accessible to other patients.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure: 1) visitors were educated on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure: 1) visitors were educated on the proper use of PPE and wore PPE inside the contact isolation precaution room (Resident 145) and 2) signage for Enhanced Barrier Precaution (EBP) was posted for a resident with a draining wound, personal protective equipment (PPE) was available, and staff used gowns when providing direct care to residents on precautions (Resident 146). The deficient practice could have the potential to increase cross-contamination and transmission of multidrug-resistant organisms (MDROs) and the spread of infectious agents, including multidrug-resistant organisms (MDROs), increasing the risk of healthcare-associated infections (HAIs) among residents, staff, and visitors.
Findings include:
Resident 145 (R145)
R145 was admitted on [DATE], with diagnoses including surgical care aftercare following surgery on the digestive system and sepsis.
A physician order dated 11/07/2024, documented R145 was on strict contact isolation for Vancomycin-Resistant Enterococci (VRE) wound.
On 11/19/2024 at 10:44 AM, contact precautions signage was posted by the entrance, and PPE supplies were available. The signage indicated to perform hand hygiene and wear PPE upon room entry. R145 was in bed with eyes closed with R145's family, who had not been wearing PPE, at the bedside. A staff member was present inside the room.
On 11/21/2024 in the afternoon, R145's family was at bedside with no PPE. The family indicated the staff did not say anything about wearing PPE.
On 11/21/2024 at 2:37 PM, the Infection Preventionist (IP) indicated R145 was admitted with a VRE wound infection and was placed on contact isolation. The IP indicated the PPE should have been worn before entering the room, including the staff and visitors. The IP indicated the family should have been provided education regarding the importance of wearing PPE in the contact isolation room to prevent cross-contamination.
Resident 146 (R146)
R146 was admitted on [DATE], with diagnoses including cardiogenic shock, acute kidney failure, lymphedema, and localized edema (swelling).
The Observation Detail List Report dated 11/15/2024, documented a brief interview of mental status score of 15/15, which indicated R146's cognitive status was intact.
On 11/19/2024 at 11:07 AM, R146 was seated in the wheelchair, alert and verbally responsive. Severe weeping edema (water retention that occurs when fluid leaks through the skin due to swelling) on the bilateral lower legs and a soiled and wet wound dressing were noted on R146's left lower leg. R146 indicated had a chronic open wound on the leg and on the thigh prior to admission. R146 indicated the peripheral IV access was placed a few days ago by the licensed nurse. There was no EBP signage posted and no PPE available by the entrance door.
On 11/19/2024 at 11:27 AM, the Clinical Care Manager (CCM), the Wound Nurse Practitioner and the Wound Care Treatment Nurse (WCTN) entered R146's room, assessed, and treated the wound on the left lower leg and other parts of R146's body without wearing a gown. The wound NP indicated it was the first time R146 was seen and described the left lower lateral leg wound as non-pressure, but it was opened and draining. The NP indicated the dressing was wet and noted a scant amount of serous (clear to yellow fluid) drainage.
On 11/20/24 at 11:13 AM, the WCTN confirmed there was no EBP signage posted by the door and no PPE available in R146's room. The WCTN indicated a gown should have been worn to protect self, especially during direct contact for wound treatment, regardless of whether the resident was on precautions or not.
On 11/21/2024 at 8:10 AM, a Certified Nursing Assistant (CNA) provided direct care to R146 in the room without a gown, wheeled R146 to the dining room, and entered back into the room and fixed R146's bed without wearing a gown. The CNA confirmed was not wearing a gown and was aware R146 was on EBP. The CNA explained EBP protocol should have been followed to prevent contamination.
On 11/21/20 at 1:28 PM, the IP indicated there should have been an EBP signage and available PPE by the door to prompt the staff and visitors due to R146's open wound. The IP indicated regardless of what kind of wound it was, EBP protocol was required. The IP explained the admission nurse and the floor nurse were responsible for initiating the precautions upon the resident's admission. The IP indicated the staff were expected to follow the protocols by putting in an order, putting up signage, performing hand hygiene, and wearing the PPE to prevent cross-contamination.
A facility policy titled Enhanced Barrier Precautions (undated), documented the facility adhered to guidance by the Centers for Disease Control and Prevention (CDC) regarding the prevention of the spread of multidrug-resistant organisms through the use of Enhanced Barrier Precautions (EBP). Residents were placed on EBP for the following conditions: wounds, the presence of an indwelling medical device, or infection or colonization with a CDC-targeted multidrug-resistant organism. Staff members donned gowns and gloves during high-contact resident care activities, including changing linens, performing wound care, and providing hygiene. Signage was posted outside the resident's room indicating the type of precautions, the required personal protective equipment (PPE), and high-contact resident care activities.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to transcribe and implemented a wound treatment per ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to transcribe and implemented a wound treatment per physician order for 1 of 4 sampled residents (Resident 1). The deficient practice resulted in no follow up treatment and could potentially have led to a concern of an infection.
Findings include:
Resident 1 (R1)
R1 was admitted on [DATE] with diagnosis including dementia.
A discharge Minimum Data Set (MDS) dated [DATE] documented resident assessed with Brief Interview for Mental Status of 05, indicating severe cognitive impairment.
A progress note dated 01/27/2024 documented a CNA notified nursing staff the resident had a skin tear to right lateral shin. Measurements were obtained and found skin tear to be 1 cm x 1.5 cm with scant amount of sanguineous drainage. Provider made aware and orders were obtained for new wound.
Weekly skin assessments conducted and documented with negative skin issues identified on the following dates:
-01/07/2024
-01/14/2024
-01/21/2024
-01/28/2024
The medical record lacked documented evidence of a transcribed treatment order and any follow up treatment.
On 03/21/20204 at 1:05 PM, the Clinical Nurse Manager/Wound Care explained new skin concerns were reported to nurses or wound care staff to follow up and assess for treatment if needed. Wound care had standing orders for treatment, however, would consult with a physician and follow orders accordingly when in doubt and document in progress notes. Weekly skin assessments are conducted on all residents regardless if receiving wound care treatments. The Clinical Nurse Manager/Wound Care would have expected the skin tear to be documented on the weekly assessment, however confirmed the weekly assessments documented negative skin issues. The Clinical Nurse Manager/Wound Care was not familiar with R1 indicating R1 did not receive regular wound care treatments while at the facility.
The Clinical Nurse Manager/Wound Care acknowledged documentation of identified skin tear and physician order obtained in progress note dated 1/27/24, however, indicated the medical records lacked documented evidence of a physician order for treatment, completed follow-up treatments, or additional documentation related to the skin tear in progress notes. The Clinical Nurse Manager/Wound Care indicated the concern of the treatment order not being documented, staff would not be notified for follow-up treatment, and could potentially lead to a risk of an infection.
On 03/21/2024 at 1:43 PM, a Wound Care staff member recalled being informed about the skin tear, contacted a physician, and obtained orders after reviewing the progress note. The Wound Care staff member acknowledged a treatment order was not transcribed and without an order, upon starting shift, the resident would not be identified to be followed up with. If the resident was not followed-up with, the potential consequence may lead to an infection, or the skin tear could worsen.
The facility policy titled Care of Skin Tears and Abrasions (undated) documented to verify there was a physician order for treatment, and to check the treatment record.
Dec 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a medication dosage was specified or clarifi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a medication dosage was specified or clarified for 1 of 15 sampled residents (Resident 16). The deficient practice could potentially lead to medication errors, improper administration, and adverse effects.
Findings include:
Resident 16 (R16) was admitted on [DATE], with diagnoses including a pressure ulcer.
On 12/28/2023 at 8:44 AM, during medication pass, a Licensed Practical Nurse (LPN) prepared R16's medications. The Liquacel liquid protein order had no dosage specified. The LPN explained normally, the Liquacel dosage would be 30 milliliters (ml) and the LPN proceeded to administer the medications.
On 12/28/2023, at 9:10 AM, the LPN explained the Liquacel liquid protein order was incomplete due to the lack of dosage specification. The LPN indicated the order should have been clarified before administering the medication.
On 12/29/2023 at 2:32 PM, the Director of Nursing (DON) confirmed Liquacel had no indicated dosage, and it should have been clarified. The DON indicated the staff were expected to verify the completeness of the medication order for safe administration.
A facility policy titled Administration of Medication dated 07/25/2023, documented the Licensed Professional, following professional standards of practice, would appropriately administer prescribed medications. The policy emphasized the verification of the six medication administration rights, including the right dosage.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 141 (R141) was admitted on [DATE] with diagnoses including sacral pressure ulcer, multiple wounds, methicillin resis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 141 (R141) was admitted on [DATE] with diagnoses including sacral pressure ulcer, multiple wounds, methicillin resistant staphylococcus aureus in wounds (wound infection resistant to antibiotics).
A Physician Order dated 12/18/2023 documented heel riser while in bed, verify placement every shift.
On 12/27/2023 at 10:15 AM, R141 was lying in bed with eyes closed, no offloading of the heels was noted.
On 12/27/2023 in the afternoon, R141 was sitting up in bed with heels flat against the bed mattress.
On 12/28/2023 at 2:39 PM, R141 lying in bed, no heel riser in place. A Certified Nursing Assistant (CNA) on the unit confirmed there was no heel riser in place.
On 12/28/2023 at 11:11 AM, a Licensed Practical Nurse (LPN) verbalized physician orders should be followed and if order was not carried out physician should be contacted, and order clarified or updated.
Based on observation, interview, record review, and document review, the facility failed to ensure a heel riser was implemented as ordered for 2 of 15 sampled residents (Residents 19 and 141). The deficient practice had the potential to cause a pressure ulcer to develop.
Findings include:
A facility policy titled Pressure Ulcer Prevention dated 09/11/2023, documented the residents would receive care consistent with professional standards of practice to prevent pressure ulcers, and or ensure the residents do not develop pressure ulcers unless unavoidable. A resident with a pressure ulcer received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing.
1) Resident (R19) was admitted on [DATE], with diagnoses including difficulty walking, body malaise, and weakness.
The Observation Detail Report dated 11/12/2023, documented a Braden scale score of 13-17, which indicated moderate risk and had a problem of impaired mobility. The interventions included offloading or elevating heels.
A Physician Order dated 11/12/2023, documented to place the heel riser while in bed and verify placement every shift.
The Post-admission Skin assessment dated [DATE], documented R19's heels were intact and there were no skin issues.
A Progress Note dated 11/26/2023, documented a fluid-filled blister on R19's right heel was identified.
The Wound Care Progress Note dated 12/07/2023, documented right heel blister and open wound abrasions.
A Care Plan dated 12/07/2023, documented R19 had impaired tissue integrity related to a right heel open blister. The interventions included providing treatment as ordered and elevating legs with a heel riser.
A Wound Care Progress Note dated 12/11/2023 documented a with a length of 2 centimeters (cm) and a width of 2.5 cm.
A Progress Note dated 12/13/2023, documented the right heel blister status post-debridement to continue foam dressing.
The Attending Physician Progress Note dated 12/13/2023, documented R19's heel with pressure injury.
The Weekly Wound Care Note dated 12/16/2023 and 12/21/2023, documented right heel chronic ulcer, with a length of 1.2 cm and a width of 1.4 cm, moist with redness, scant amount of serous drainage, no pain, no signs, and symptoms of infection, and changed treatment to Medihoney.
On 12/27/2023 at 11:05 AM, R19 was lying in bed in a supine position, with no heel riser in place. R19 heels were flat against the bed mattress.
The Medication Administration History from 12/01/2023 to 12/27/2023 documented R19's heels were offloaded or elevated, and the placement of a heel riser was verified.
On 12/28/2023 at 1:41 PM, WCN2 confirmed R19 had impaired mobility and could barely walk. WCN2 explained upon R19's admission, bilateral heels were intact and there were no issues but R19 developed a fluid-filled blister on 11/26/2023. WCN2 indicated was familiar with R19 and confirmed there was an order to place a heel riser even before the development of the blister. WCN2 further confirmed the heel riser had not been in place since, although the documentation indicated the placement was verified. WCN2 indicated the pressure ulcer on R19's right heel could have been avoided if the wound protocol had been implemented.
On 12/28/2023 at 2:25 PM, the CCM confirmed the existence of a heel riser order for offloading R19's heels but observed it was not in place during rounds. A single pillow was noted under R19's feet, yet R19's heels were flat against the bed mattress. The CCM explained the heel riser made of foam material was designed to offload the heels, preventing pressure. The CCM emphasized one pillow alone could not effectively offload the heels. The CCM confirmed R19's right heel pressure ulcer was a facility-acquired wound and could have been prevented if the wound protocol had been followed.
On 12/29/2023 in the morning, during a telephone interview, the Wound Physician indicated a heel riser could effectively offload heels and prevent pressure ulcers. The physician emphasized the importance of staff adherence to the wound prevention protocol, and staff were expected to follow the orders diligently.
On 12/29/2023 in the afternoon, WCN1 indicated the heel riser order should have been followed for pressure prevention. WCN1 indicated R19's pressure ulcer on the right heel was avoidable and could have been prevented if proper offloading measures had been implemented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 15 (R15) was admitted on [DATE] with diagnoses including obstructive and reflux uropathy, and acute kidney failure. ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 15 (R15) was admitted on [DATE] with diagnoses including obstructive and reflux uropathy, and acute kidney failure.
A Physician Order dated 11/17/2023 documented to flush nephrostomy tube with 10 milliliters (mL) of normal saline every shift. The physician order included a discontinuation date of 12/14/2023.
Nursing progress notes documented having flushed the nephrostomy tube on the following dates:
- 12/15/2023
- 12/16/2023
- 12/20/2023
- 12/21/2023
A care plan dated 12/17/2023 documented to monitor nephrostomy site including interventions to complete treatment as ordered by physician.
On 12/28/23 at 12:36 PM, a Certified Nursing Assistant (CNA) verbalized the CNA staff was only allowed to report to a nurse any concerns found with nephrostomy tube such as leaking, soiled dressing, collection bag full. The CNA indicated the nurse was responsible for changing the dressing and monitoring and emptying the collection bag.
On 12/28/23 at 12:41 PM, a Licensed Practical Nurse (LPN) verbalized the nurse provided all care for nephrostomy tube. If the CNA noticed a concern the CNA would notify the nurse and the nurse would assess and provide care if needed. The LPN indicated the nurses would provide the dressing changes and empty the collection bag when needed.
The LPN explained there was no current order for flushing the nephrostomy tube. The order to flush the nephrostomy tube was discontinued on 12/14/2023 and the nephrostomy tube should not be flushed without an order. If there was something wrong with the tube and collection bag the resident would be sent to nephrologist to have tube and bag changed.
On 12/28/23 at 1:28 PM, the Director of Nursing (DON) verbalized the order to flush the nephrostomy tube was discontinued on 12/14/2023 when a new tube was placed. The DON indicated an order to flush tube should have been obtained after 12/14/2023 if the nephrostomy tube required to be flushed by the nurse.
Based on observation, interview, record review, and document review, the facility failed to ensure the correct size of the Foley catheter was inserted as ordered, appropriately documented and care planned for 1 of 15 sampled residents (Resident 21) and the nephrostomy flushing order was followed for 1 of 15 sampled residents (Resident 15). The deficient practice could have the potential to develop urethral trauma, infections, discomfort, inadequate drainage and compromised renal function.
Findings include:
A facility policy titled Indwelling Foley Catheter Continued Use dated 07/25/2023, documented the nurse would obtain and follow through with the physician order regarding the indwelling urinary catheter following respective facility protocol.
1) Resident 21 (R21) was admitted on [DATE], with diagnoses including pressure ulcer.
On 12/27/2023 at 10:00 AM, R21 was seated in the wheelchair, verbally alert and oriented. R21 had an indwelling catheter, the Foley catheter in place was 20 French (Fr) times (x) 10 cubic centimeters (cc) water balloon, the Foley bag was empty, tubing was kinked.
A Physician Order dated 11/15/2023, documented insert Foley catheter 18 French (Foley size) times 10 cc water balloon for urinary retention.
On 12/28/2023 at 3:47 PM, the Clinical Care Manager (CCM) verified R21's Foley size order of 18 Fr and confirmed the Foley size in place was 20 Fr. The CCM indicated the Foley order was dated 11/15/2023 and inserted the same day for urinary retention. The CCM indicated R21 was retaining urine with distended abdomen and bladder scan was ordered. The CCM indicated the Foley was changed on 11/24/2023 with 16 Fr. The CCM indicated there was no care plan in place, no documentation when it was last changed using 20 French.
On 12/29/2023 at 1:37 PM, the Director of Nursing (DON) confirmed the Foley order size was 18 French and the Foley catheter in place was size 20 French which was a bigger size. The DON indicated the nurses were expected to verify and follow the orders for the resident's safety.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a physician order for the use...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a physician order for the use of Oxygen (O2) was obtained, transcribed and care planned for 1 of 15 sampled residents (Resident 9) and the O2 liter flow order was specified or clarified for 1 of 15 sampled residents (R83). The deficient practice could have the potential to compromise resident's respiratory care, leading to inadequate O2 administration, potential respiratory distress, and an increased risk of adverse respiratory events.
Findings include:
1) Resident 9 (R9) was admitted on [DATE], with diagnoses including multiple rib fractures and chronic kidney disease.
On 12/27/2023 at 10:30 AM, R9 was seated in the wheelchair, verbally alert and oriented. O2 was flowing at 2 liters per minute (LPM) through nasal cannula. R9 indicated was on O2 continuously but was unsure how many liters per minute. There were no signs of respiratory distress.
R9's medical record lacked documented evidence; a physician order for O2 use and care management was obtained and transcribed. There was no care plan in place.
On 12/28/2023 at 3:31 PM, the Clinical Care Manager (CCM) indicated an order for O2 was necessary, specifying details such as the prescribed liters, titration instructions, tubing change schedule, guidelines for humidifier replacement, and a care plan should have been initiated. The CCM confirmed there were no existing orders for oxygen utilization and no established care plan.
On 12/29/2023 at 11:00 AM, a Registered Nurse (RN) confirmed R9 was on O2 flowing at 2 LPM through nasal cannula but there was no physician order in place.
On 12/29/2023 at 11:26 AM, the Director of Nursing (DON) indicated O2 would require an order. Nurses were expected to verify the orders, and if there was no order in place, the physician should have been called to obtain an order and implemented.
2) Resident 83 (R83) was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia.
A Care Plan dated 11/21/2023, documented R83 had ineffective airway clearance related to COPD. The interventions included administering O2 as ordered.
On 12/27/2023 at 11:33 AM, R83 was seated in the wheelchair, verbally alert and oriented. O2 was flowing at 2 LPM through nasal cannula. R83 indicated having been on O2 continuously more than a year ago. R83 had shortness of breath.
A Physician Order dated 12/06/2023, documented Oxygen per nasal cannula to maintain O2 saturation at more than 90 percent (%). Document liters per minute every shift. May titrate or discontinue O2 LPM as tolerated, maintaining O2 saturation of more than 90%.
On 12/28/2023 at 3:20 PM, the CCM verified and confirmed R83's O2 order was incomplete and confusing. The CCM indicated the O2 liter flow and titration parameter should have been indicated for a clear direction.
A facility policy titled Oxygen Administration dated 07/25/2023, documented to verify there was a physician's order for administering Oxygen. The physician's order must include liter flow parameters, frequency, and duration of O2 treatment. If the order was unclear or incomplete, clarify the order with the physician. Review the physician's orders and the resident's care plan to identify any special needs of the resident.
A facility policy titled Physician Orders dated 09/28/2022, documented the medications and treatments were administered only upon a clear, complete, and signed order. The medication and treatment orders should have specified the dose and dosage form.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and document review the facility failed to ensure Aplisol (tuberculin solution) was dated when opened and the discontinued intravenous medication for a discharged res...
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Based on observation, interviews, and document review the facility failed to ensure Aplisol (tuberculin solution) was dated when opened and the discontinued intravenous medication for a discharged resident was taken out from the active supply. The deficient practice had the potential to put staff and residents at risk for inaccurate test results and improper medication administration.
Findings include:
On 12/29/2023 at 1:44 PM, in the medication room the refrigerator contained one open bottle of Aplisol solution used for tuberculosis testing which was not dated when opened.
On 12/29/2023 at 1:46 PM in the medication room there were intravenous (IV) medications hanging on the wall for current resident treatments. The IV medication for a discharged resident was still among the active medications.
On 12/29/2023 at 1:48 PM, a Registered Nurse (RN) indicated when a resident was discharged the medications would be reconciled by the nurse completing the discharge on unit. All oral medications would be given to the resident, any medications left over should be put in bin located in the medication room for destruction. The RN acknowledged the Aplisol solution was opened and should be dated, confirmed resident was discharged for the IV medication hanging in medication room.
On 12/29/2023 at 2:06 PM, the Director of Nursing (DON) indicated the case manager would contact physician and would obtain orders to release remaining oral medications. The DON verbalized staff would place the medications which were discontinued in bin for destruction. The DON explained when using multidose vial it would be dated when the vial was opened.
The undated facility policy titled Medication Storage documented all multi-dose bottles must be dated upon opening.
Jul 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documented evidence of the assessment of the insertion site...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documented evidence of the assessment of the insertion site, and the date and time when a midline catheter (intravenous line) was removed for 1 of 4 sampled residents (Resident 1). The deficient practice had the potential for the facility failing to provide timely interventions for possible complications of the removal of the intravenous line.
Findings include:
Resident 1
Resident 1 was admitted on [DATE], with diagnoses including surgical aftercare following surgery on the circulatory system and abdominal aortic aneurysm.
The Nurse's Progress Notes dated 10/11/2022, documented R1's left upper arm midline was dislodged and pressure dressing applied.
The physician's order dated 10/11/2022, documented removal of R1's dislodged midline.
R1's medical record lacked documented evidence of the assessment of the insertion site, and the date and time when the resident's midline catheter was removed.
On 07/20/2023 at 1:40 PM, the Director of Nursing (DON) confirmed the findings and explained the nurses were expected to monitor and assess the insertion site when an intravenous line was removed. The DON acknowledged the nurses should have documented in the progress notes the site assessment, and the date and time when R1's midline catheter was removed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a pain medication was administered per the physician's order...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a pain medication was administered per the physician's order for 1 of 4 sampled residents (Resident 3). The deficient practice had the potential to cause adverse effects and psychosocial consequences for the resident of concern.
Findings include:
Resident 3
Resident 3 was admitted on [DATE], with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease and age-related osteoporosis.
On 07/20/2023 at 11:00 AM, Resident 3 was lying in bed, alert and oriented. R3 indicated having right lower back pain and was waiting on a new patch for pain relief. R3 stated a Lidocaine patch was to be administered twice daily, but the resident had missed receiving the medication on certain days. The staff told the resident the medication was not available.
R3's care plan dated 07/06/2023, documented the resident was on a pain management regimen.
The physician's order dated 07/06/2023, documented Lidocaine Adhesive Patch 4% one patch topical, to be applied to affected area twice daily for pain.
R3's Medication Administration Record (MAR) for July 2023, documented Lidocaine Adhesive Patch was not administered to the resident on 07/08/2023 and 07/17/2023, per the physician's order. The MAR documented the medication was not administered to R3 due to drug (medication) not being available.
On 07/20/2023 at 2:30 PM, the Director of Nursing (DON) confirmed the findings and acknowledged the nurses were expected to administer the medications as ordered. The DON explained the nurses should have reordered the medication if only one remaining dose was available.
Dec 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review the facility failed to follow the resident's choice for life-sustaining t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review the facility failed to follow the resident's choice for life-sustaining treatment for 1 of 3 sampled closed records (Resident #23). The failed practice had the potential to revive the resident and not allow for a natural death as desired by the resident.
Findings include:
Resident #23 (R23)
R23 was admitted on [DATE] with medical diagnoses including encephalopathy (alteration in brain function), dementia, diabetes, and heart failure.
An Acknowledgement of Information on Advanced Directives dated [DATE], revealed R23 wanted to be kept comfortable and allowed a natural death. R23 did not want any life-sustaining treatment or other medical interventions to extend life.
A Physician Order for Life-Sustaining Treatment (POLST) dated [DATE], revealed if the resident did not have a pulse (heartbeat) or stopped breathing, an attempt to resuscitate would not be made and R23 would be allowed a natural death. The POLST was not signed by the physician, only signed by the family of R23.
A Physician Order dated [DATE] indicated R23 had a code status of Do Not Resuscitate (DNR) which reflected in the Electronic Medical Record (EMR).
On [DATE] at 1:00 PM, a Licensed Practical Nurse (LPN) confirmed R23 had a code status of Do Not Resuscitate in the Electronic Medical Record (EMR).
A Nursing Progress Note dated [DATE] revealed the resident became nonresponsive, code status was verified, and Cardiopulmonary Resuscitation (CPR) was started. When Emergency Medical Services (EMS) arrived, CPR was continued by the paramedics.
On [DATE] in the afternoon, the Director of Nursing (DON) indicated the Physician Order for Life-Sustaining Treatment (POLST) needed to be signed first since it was a legal document and then the Physician Order was signed in the Electronic Medical System (EMR). The DON confirmed for R23 there was a physician order for code status of Do Not Resuscitate (DNR), however, there was not a Physician Order for Life-Sustaining Treatment (POLST) signed by the Physician.
A review of the facility's policy titled Advanced Directives revised on [DATE] was reviewed. The policy revealed nursing staff was to inform emergency medical personnel of the resident's advanced directive.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review the facility failed to have a physician order for a resident being transf...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review the facility failed to have a physician order for a resident being transferred out to the hospital for 1 of 3 sampled closed records (Resident #24). The failed practice had the potential to lead to an inappropriate and unsafe transfer.
Findings include:
Resident #24 (R24)
R24 was admitted on [DATE] with medical diagnoses including surgical amputation (removal) of the right great toe, Parkinson's disease (affecting the central nervous system), diabetes, and heart failure.
A Nursing Progress Note dated 09/10/2022, revealed the Director of Nursing gave orders from a provider to send R24 to the hospital.
There was no documented evidence a physician order was obtained and signed by the physician to transfer the resident to the hospital on [DATE].
On 12/09/2022 in the morning, the Director of Nursing (DON) indicated there was not a physician order to transfer the resident out to the hospital. The DON stated there needed to be a physician order to transfer the resident out to the hospital in an emergent or non-emergent situation.
A review of the facility's policy titled Physician Orders undated revealed treatment orders were documented in the resident's medical record with the date, time, and signature of the person receiving the order. The policy indicated verbal, or telephone orders were promptly entered into the electronic administration system.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review the facility failed to ensure medications found at the bedsi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review the facility failed to ensure medications found at the bedside were reported to the physician and the resident was properly assessed for self-administration for 1 of 13 sampled residents (Resident #175). The failed practice had the potential to lead to the resident taking additional doses of the same medication leading to potential side effects impacting the well-being of the resident.
Findings include:
Resident #175 (R175)
R175 was admitted on [DATE] with medical diagnoses including Parkinson's disease, altered mental status, muscle weakness, age-related physical debility, and repeated falls.
On 12/06/2022 in the morning, medications were observed in the room of R175, on the counter near the sink. The medications included Refresh Tears (eye drops), Tylenol (medication used for pain), a bottle of Collagen (protein) with Vitamin C and Biotin (vitamin B7), and a bottle of Calcium (mineral). R175 indicated their family member brought in the medication bottles and the nursing staff was aware of them. R175 indicated they took the medications on their own.
On 12/06/22 at 1:22 PM, a Registered Nurse (RN) indicated for residents to have medications at the bedside there needed to be a physician order and an assessment of the resident for self-administration which included cognitive status, the ability to see color, and the ability to take the medication on their own. The RN stated R175 was alert and oriented but forgetful. R175 did not have orders for medications at the bedside. The RN stated a resident with medications at the bedside without a physician order and receiving scheduled medications could lead to overdose.
There was no documented evidence of a physician order for the medications found at the bedside or an assessment for self-administration of medication for R175.
On 12/06/22 at 1:30 PM, Registered Nurse (RN) indicated nurses and Certified Nursing Assistants were going into the resident rooms at least six to seven times and the expectation was if medications were observed at the bedside, it was to be reported for further follow up.
On 12/09/2022 at 8:30 AM, the Director of Nursing (DON) indicated the potential outcome of unverified medications at the bedside and a resident also receiving scheduled medications could lead to contraindications with other medications and double dosing of medications.
The facility's policy titled Self-Medication Administration last revised 09/28/2022 indicated residents may self- administer medications if it was determined they were capable of doing so in a safe and consistent manner. The staff was to assess each resident's mental and physical abilities to determine whether a resident was capable of self- administering medications using the Self-Administration Assessment form. The Self-Administration Assessment form included assessing the resident's ability to read and understand medication labels, comprehension of the purpose and proper dosage and administration time for their medications, and ability to remove medication from a container and to ingest and swallow them. The policy indicated staff shall identify and remove any medications found at the bedside which had not been authorized for bedside storage for proper storage or return to the family or responsible party.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and document review the facility failed to complete a dressing change and site r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and document review the facility failed to complete a dressing change and site rotation of a peripheral (through the skin) intravenous (in the vein) line for 1 of 13 sampled residents (Resident #181). The failed practice had the potential to lead to infection.
Findings include:
Resident #181 (R181)
R181 was admitted to the facility on [DATE] with medical diagnoses including clostridium difficile (bacteria causing inflammation of the colon), interstitial pneumonitis (lung disease caused by long-term exposure to hazardous material), and urinary tract infection (bacteria in the urine).
On 12/06/2022 in the afternoon, R181 had a peripheral intravenous line on the right forearm. The peripheral intravenous (IV) line dressing had a date of 11/26/2022.
12/06/2022 at 2:00 PM, a Licensed Practical Nurse (LPN) indicated R181 had a peripheral intravenous (IV) line with a dressing date of 11/26/2022. The LPN stated the physician order for the peripheral IV line was to change the site every three days. The LPN indicated the resident was admitted on [DATE] with the peripheral IV line. The expectation was for the admitting nurse to have called the doctor to see if a peripheral IV line was necessary. If the peripheral IV line was not necessary, then it could have been discontinued. If the peripheral IV line was necessary, then the expectation was for the admitting nurse to take out the peripheral IV which was placed in the hospital and insert a new one in a different site with a new dressing.
A Physician Order dated 12/02/2022 indicated the peripheral IV line site change was to be done every three days.
A Nursing Progress Note dated 12/03/2022 revealed the resident was receiving an intravenous antibiotic Cefepime (medication to treat infection) for a urinary tract infection (bacteria in the urine).
On 12/09/2022 at 8:30 AM, the Director of Nursing (DON) indicated if a resident came in with a peripheral IV line which had been inserted more than three days prior, the expectation was for a new peripheral IV line to be inserted. The DON stated a peripheral IV site rotation was done every three days.
A review of the facility's policy titled Preventing IV Catheter Related Infections last revised on 09/28/2022, revealed catheter dressings were replaced as indicated by the policy or by the physician order. Peripheral IV catheters were rotated/ replaced every 72 to 96 hours to prevent phlebitis (inflammation of the vein) or infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview and document review, the facility failed to ensure the testing strips used to test the solution contained in the sanitizing bucket and food products stored inside the w...
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Based on observation, interview and document review, the facility failed to ensure the testing strips used to test the solution contained in the sanitizing bucket and food products stored inside the walk-in cooler were not expired. Failure to maintain and use unexpired testing strips had the potential to produce inaccurate results in testing the potency of the solution used in cleaning and sanitizing the food contact surfaces in the kitchen. Failure to discard expired food products had the potential for causing foodborne illness when served to the residents.
Findings include:
1) Expired testing strips
On 12/06/2022 at 8:19 AM, during the initial tour of the kitchen, the Nutrition Services Director (NSD) explained the process of cleaning and sanitizing the surfaces in the kitchen. The NSD showed the testing strips (a reactive paper to test the chemical potency) used for testing the solution (chemical and water) contained in the sanitizing bucket. The testing strips had an expiration date of 01/15/2022. The NSD and the Lead [NAME] confirmed the testing strips were expired and acknowledged using expired testing strips could have resulted in inaccurate results. The NSD and the Lead [NAME] confirmed the facility had no current supply of unexpired testing strips.
The facility's policy titled Cleaning Instructions - Cloths, Pads, Mops and Buckets dated 03/26/2021, documented the sanitizing solution would be tested periodically to assure it maintained the correct concentration.
2) Expired food products
On 12/06/2022 at 8:25 AM, during the initial tour of the kitchen, the following expired food products were found inside the walk-in cooler:
- A container of six-pound Pistachio Desserts with expiration date of 12/04/2022
- Four containers of one-gallon Lemonade with expiration date of 12/01/2022
On 12/06/2022 at 8:30 AM, the NSD confirmed the observation and indicated the Pistachio Desserts and Lemonade should have been discarded and not stored inside the walk-in cooler.
On 12/08/2022 at 1:10 PM, the NSD explained all dietary staff were expected to check the expiration dates of all food products every shift. The NSD revealed there could have been a potential for any foodborne illness if food products were expired.
The facility's policy titled Food Storage dated 03/15/2021, documented all foods would be checked to assure the foods would be consumed by their safe use by dates, or frozen (where applicable), or discarded.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure the urine culture and sensitivity tests wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure the urine culture and sensitivity tests were completed per the physician's order for 1 of 13 sampled residents (Resident #12). The failure to complete the urine culture and sensitivity tests had the potential for the resident to receive inappropriate antibiotics and delay the treatment of the resident's infection.
Findings include:
Resident #12 (R12)
R12 was admitted on [DATE], with diagnoses including other specified noninfective gastroenteritis and colitis, acute kidney failure, and calculus of kidney.
Review of R12's medical record revealed the following antibiotics were ordered:
- 11/14/2022 Ciprofloxacin Hydrochloride (HCl) tablet 500 milligram (mg) by mouth (po) every 12 hours for urinary tract infection (UTI). End Date 11/21/2022.
- 11/23/2022 Ciprofloxacin HCl tablet 500 mg po at bedtime for UTI. End Date 11/30/2022.
- 12/01/2022 Fluconazole tablet 150 mg po daily times three days for UTI. End date 12/05/2022.
- 12/06/2022 Pyridium tablet 100 mg po three times a day for UTI symptoms. End date 12/08/2022.
- 12/07/2022 Ciprofloxacin in 5% dextrose piggyback 400 mg/200 milliliter (ml), amount = 200 ml intravenous twice a day for UTI times seven days. Start date 12/08/2022, End Date 12/15/2022.
1) The Nurse's Progress Notes dated 11/08/2022, documented R12 complained of urinary burning and requested urinalysis (UA/urine test). The physician was informed, to collect UA.
The Nurse's Progress Notes dated 11/09/2022, documented R12 complained of burning on urination and UA was collected and sent to the laboratory.
The laboratory results reported on 11/09/2022 at 9:28 PM, documented the final UA report, and urine culture (a test to find germs such as bacteria or a fungus which could cause an infection) was pending.
The Nurse's Progress Notes dated 11/11/2022 at 11:08 AM, documented UA results received, pending culture and sensitivity (urine sensitivity checked to see what kind of medicine, such as an antibiotic, would work best to treat the illness or infection).
The laboratory results reported on 11/11/2022 at 5:29 PM, documented test not performed, no sample received, and please collect urine.
R12's medical record lacked documented evidence the results of urine culture and sensitivity tests were obtained.
On 12/09/2022 at 9:25 AM, the Infection Preventionist (IP) Nurse confirmed the findings and acknowledged R12's urine culture and sensitivity tests were not completed because the urine specimen was not collected and sent to the laboratory. The IP Nurse indicated another urine sample should have been sent to the laboratory per report dated 11/11/2022 at 5:29 PM. The IP Nurse revealed the physician ordered UA and urine culture and sensitivity, but the order was not transcribed.
The IP Nurse explained urine culture and sensitivity tests were important to identify the microorganisms present and determine the appropriate antibiotic for the resident. The tests would have determined if the resident was resistant with certain microorganisms.
On 12/09/2022 at 10:30 AM, the Director of Nursing (DON) revealed the nurses were expected to call the physician when a resident reported symptoms of urinary tract infection (UTI) such as burning during urination. The nurses should have obtained and transcribed the physician's orders such as laboratory tests.
The DON explained upon receipt of the laboratory results dated [DATE] at 5:29 PM, the nurses should have recollected R12's urine specimen and sent to the laboratory for urine culture and sensitivity tests. The DON indicated urine culture and sensitivity tests were done to make sure the right antibiotic would be given to the resident. The tests would have determined which microorganisms were present and microorganisms the resident was resistant with.
On 12/09/2022 at 2:36 PM, a Licensed Practical Nurse (LPN) indicated the nurses should have recollected R12's urine sample when the laboratory results were received on 11/11/2022 because the urine culture and sensitivity tests were not completed.
2) The Nurse's Progress Notes dated 11/21/2022, documented R12 still reported burning with urination and urine was cloudy. Today was the last day of the antibiotic treatment.
The Nurse's Progress Notes dated 11/22/2022, documented antibiotic completed, status-post day one, R12 still complained of burning with urination and cloudy urine. The Nurse Practitioner (NP) was notified.
The physician's order dated 11/23/2022, documented UA, urine culture and sensitivity on 11/25/2022.
The laboratory results reported on 11/25/2022 at 3:33 PM, documented the final UA report.
The laboratory results reported on 11/27/2022 at 2:20 PM, documented the urine culture result which was yeast isolated, and no further testing was performed.
R12's medical record lacked documented evidence the result of urine sensitivity test was obtained per the physician's order dated 11/23/2022.
On 12/09/2022 at 12:50 PM, the IP Nurse confirmed the findings and acknowledged the physician ordered UA, urine culture and sensitivity tests on 11/23/2022 for R12. The IP Nurse indicated the nurses should have followed up with the laboratory about the urine sensitivity results when only the urine culture results were received on 11/27/2022.
The IP Nurse explained obtaining culture and sensitivity test results was part of the facility's antibiotic stewardship program to determine the appropriate antibiotic for the resident.
On 12/09/2022 at 2:36 PM, an LPN confirmed the urine sensitivity test was not completed for R12 per the physician's order. The results obtained were for UA and urine culture only.
The facility's policy titled Laboratory Orders, undated, documented all laboratory services were provided upon the order of the resident's attending physician or a consulting physician.
The facility's policy titled Laboratory Results, undated, documented if a laboratory result was not received as expected, call the laboratory to inquire about the status of the test/result. If the test was not complete, inquire as to the expected time of completion and document the information in the resident's progress notes.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • $4,194 in fines. Lower than most Nevada facilities. Relatively clean record.
- • 37% turnover. Below Nevada's 48% average. Good staff retention means consistent care.
Concerns
- • 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.
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About This Facility
What is Advanced Health Care Of Summerlin's CMS Rating?
CMS assigns ADVANCED HEALTH CARE OF SUMMERLIN an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Nevada, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Advanced Health Care Of Summerlin Staffed?
CMS rates ADVANCED HEALTH CARE OF SUMMERLIN's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 37%, compared to the Nevada average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Advanced Health Care Of Summerlin?
State health inspectors documented 21 deficiencies at ADVANCED HEALTH CARE OF SUMMERLIN during 2022 to 2024. These included: 21 with potential for harm.
Who Owns and Operates Advanced Health Care Of Summerlin?
ADVANCED HEALTH CARE OF SUMMERLIN is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ADVANCED HEALTH CARE, a chain that manages multiple nursing homes. With 38 certified beds and approximately 37 residents (about 97% occupancy), it is a smaller facility located in LAS VEGAS, Nevada.
How Does Advanced Health Care Of Summerlin Compare to Other Nevada Nursing Homes?
Compared to the 100 nursing homes in Nevada, ADVANCED HEALTH CARE OF SUMMERLIN's overall rating (4 stars) is above the state average of 3.0, staff turnover (37%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Advanced Health Care Of Summerlin?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Advanced Health Care Of Summerlin Safe?
Based on CMS inspection data, ADVANCED HEALTH CARE OF SUMMERLIN has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Nevada. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Advanced Health Care Of Summerlin Stick Around?
ADVANCED HEALTH CARE OF SUMMERLIN has a staff turnover rate of 37%, which is about average for Nevada nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Advanced Health Care Of Summerlin Ever Fined?
ADVANCED HEALTH CARE OF SUMMERLIN has been fined $4,194 across 1 penalty action. This is below the Nevada average of $33,121. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Advanced Health Care Of Summerlin on Any Federal Watch List?
ADVANCED HEALTH CARE OF SUMMERLIN is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.