LIFE CARE CENTER OF SOUTH LAS VEGAS
For profit - Limited Liability company
120 Beds
LIFE CARE CENTERS OF AMERICA
Data: November 2025
Trust Grade
60/100
#32 of 65 in NV
Photo by Life Care Center of South Las Vegas
Photo by Life Care Center of South Las Vegas
Photo by Life Care Center of South Las Vegas
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Life Care Center of South Las Vegas has a Trust Grade of C+, indicating it is decent and slightly above average compared to other facilities. It ranks #32 out of 65 in Nevada, placing it in the top half of state nursing homes, and #25 out of 42 in Clark County, meaning only a few local options are better. Unfortunately, the facility is showing a concerning trend, with issues increasing from 9 in 2024 to 10 in 2025. Staffing is rated below average at 2 out of 5 stars, with a turnover rate of 46%, which is the same as the state average, suggesting challenges in retaining staff. While there have been no fines, which is a positive sign, the facility has less RN coverage than 81% of Nevada facilities, which raises concerns about adequate nursing oversight. Specific incidents noted during inspections include the failure to properly date resident drink containers, which could lead to bacterial growth and foodborne illnesses, and a lack of dignity for a resident whose care needs were disclosed publicly through a sign above their bed. Overall, while there are strengths such as no fines and a decent Trust Grade, the facility does have significant weaknesses, particularly regarding staffing and care practices that need improvement.
- Trust Score
- C+
- In Nevada
- #32/65
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Nevada facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for Nevada. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 36 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 49%
No red flags
9 → 10 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 10 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Nevada average (3.0)
Meets federal standards, typical of most facilities
Staff Turnover: 46%
Near Nevada avg (46%)
Higher turnover may affect care consistency
Chain: LIFE CARE CENTERS OF AMERICA
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 36 deficiencies on record
Jun 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 maintain dignity for 1 of 24 sampled ...
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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 maintain dignity for 1 of 24 sampled residents (Resident 362). The deficient practice had the potential to result in unnecessary disclosure of resident care needs and failed to promote respect and individuality.
Findings include:
Resident 362 (R362)
R362 was admitted on [DATE] with diagnoses including metabolic encephalopathy, muscle weakness, and atrial fibrillation.
On 06/10/2025 at 9:19 AM, a handwritten sign posted on the wall above R362's bed documented Feeder Please.
A Physician order dated 05/30/3035 documented one to one assistance with meals.
The admission Minimum Data Set (MDS) dated [DATE] documented R362 required maximal assistance with eating: (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident).
On 06/11/2025 at 8:26 AM, a Certified Nurse Assistant (CNA) acknowledged the handwritten sign posted on the wall above R362's bed and explained the sign indicated R362 needed assistance with eating. The CNA explained usually the signage would be a typed or printed sign from the Speech Therapy (ST) department and it would indicate the need for assistance and would have instructions with the type of assistance to provide.
On 06/11/2025 at 9:51 AM, The Director of Rehab (DOR) explained signage placed above a resident's bed would be initiated by ST if the resident was on ST services and would require a focus on optimal swallowing, if not a swallowing related issue and the resident was only requiring assistance to maintain optimal intake or assistance physically with a meal, it would fall to nursing for assistance. The DOR explained a sign indicating Feeder Please would not be an appropriate sign to place. The DOR explained staff would use first person acknowledgment to maintain resident dignity.
On 06/11/2025 at 9:58 AM, a Registered Nurse (RN) explained R362's spouse placed the sign above R362's bed to ensure staff provided assistance with meals. The RN explained the sign was not appropriate and should be replaced with a more appropriated sign to indicate R362 required assistance. The RN explained the sign was not respectful to the dignity of the resident by indicating feeder.
On 06/13/2025 at 7:56 AM, a CNA was preparing to enter R362's room with a meal tray when stopped by another CNA who stated R362 was a feeder and to wait on the tray until staff were able to assist.
On 06/13/2025 at 12:58 PM, the Director of Nursing (DON) explained R362's family wanted the sign placed. The DON explained staff could have addressed R362's family wishes in a better way by getting ST involved to assist with creating and implementing another sign noting the assistance R362 required with meals. The DON further explained the staff would then be able to explain to R362's family the need to replace the sign. The DON explained the expectation for staff communication was to not refer to residents as feeders instead the DON would expect the staff to utilize a more dignified statement to state R362 required assistance with meals.
The facility policy titled Dignity, with review date 09/26/2024, documented all residents would be treated with dignity and respect. Examples of treating residents with dignity and respect include but are not limited to addressing residents by the name or pronoun of the resident's choice, avoiding the use of labels for residents such as feeders or walkers.
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
Report Alleged Abuse
(Tag F0609)
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 an incident of resident elopement was repo...
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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 an incident of resident elopement was reported to the State Agency (SA) within the required timeframe for 1 of 24 sampled residents (Resident 84). The deficient practice had the potential to place residents at risk for further incidents and to not be adequately protected.
Findings include:
Resident 84 (R84)
R84 was admitted on [DATE] with diagnoses including dementia, and displaced fracture of left tibia.
On 06/09/2025 the State Agency received an anonymous complaint alleging the facility had a resident elopement from the facility which was not reported as required.
On 06/12/2025 at 1:00 PM a Certified Nursing Assistant (CNA) verbalized during shift change, the CNA would walk down hall with previous CNA and updates were given regarding residents. The CNA explained the front inside automatic door was always locked and would have to be buzzed out or press button on wall adjacent to the front door prior to doors opening. The CNA indicated wander guards was a device used to alert staff of a resident walking near the exit doors and an audible alarm would go off when the resident wearing a wrist or ankle bracelet was within a few feet of exit and generally would be used for confused residents and not residents with intact cognitive awareness.
The CNA revealed residents at risk for elopement or residents with wandering or exit seeking behaviors were given a wander guard. The CNA verbalized the wander guard was a single use band as it would have to be cut off to be removed, the nurse would apply the wander guard. Once a resident was fitted with a wander guard the information would be put in a binder and kept at the nursing station. If a resident were to leave the facility without notifying a staff member it would be considered an elopement and code pink would be called overhead and staff would begin searching for resident.
On 06/12/2025 at 1:13 PM, the Unit Manager indicated rounds were conducted as often as possible, generally every 30 minutes residents were at least observed between the CNA and nurses overlapping rounds. The Unit Manager verbalized the only exit from the building was at the front where there were two automatic doors. The interior door was always locked, and a staff member was at the front desk to buzz people in and out until 8:00 PM. After 8:00 PM anyone entering would have to ring the bell and nursing staff had a monitor of camera view of the front door and could buzz person inside.
The unit manger explained wander guards were used for residents who were difficult to redirect, had exit seeking behaviors, and were impulsive with decision making. Wander guards required a physician order to be applied. The wander guard could not be pulled off or unsnapped once applied, it had to be cut off. The Unit Manager explained there was an elopement binder at the nursing station and front desk which includes a photo of residents who have wander guard in place.
R84 did not speak English and would require staff to call interpreter or use staff who spoke Korean in order to adequately communicate with resident.
The Unit Manager explained R84 would frequently walk in secured courtyard however one day went outside when the front door was open. The Unit Manager verbalized the resident did not leave the property however the resident was given a wander guard after incident. The Unit Manager verbalized resident was frequently considered confused in assessments due to language barrier however when speaking in native language R84 was alert and oriented to person, place, time, and events.
R84 had plan to be discharged on 06/06/2025 and wanted the wander guard removed the previous night. The Unit Manager explained there was no discharge order yet primarily because the facility needed to wait until R84's friend came to building to pick up R84 in order to get details of where R84 was going. The Unit Manager indicated sometime after 9:00 or 10:00 PM resident was noted to be missing, and code pink was called for elopement, the executive director was notified, and the police were contacted. The resident was never found and was discharged from facility system.
On 06/12/2025 at 1:47 PM, the Social Worker explained a cognitive assessment was conducted after admission using a translator.
On 06/12/2025 at 2:07 PM, a Case Manager indicated R84 was Korean speaking and did not understand English and would use language service to communicate with resident. The CM explained the discharge plan was for R84 to discharge with friend however had to wait until day of discharge to speak with R84's friend to get details on where the resident would be living. The CM explained a different CM was primarily handling case with R84 and had previously spoke to R84's friend.
The CM verbalized all communication with family or friends regarding discharge should be documented in the medical record however there were no notes regarding any communication with friend. There was no discharge order entered as the facility was waiting until day of discharge to discuss with R84's friend. The CM confirmed resident leaving the facility would not be considered a discharge and if it was a case of leaving against medical advice (AMA) it would generally still give the facility an opportunity to discuss risks associated and was not the case with R84.
On 06/12/2025 at 2:27 PM, Unit Manager indicated being able to speak Korean and was occasionally used to interpret for R84. The Unit Manager explained being able to communicate well with resident in Korean and English however it appeared as though resident could understand English and would need to respond in Korean in order to be fully understood.
On 06/13/25 at 11:00 AM, the Director of Nursing (DON) explained R84 should have interpreter with all staff not able to communicate in Korean. The DON indicated the facility would not usually give resident wander guard for alert and oriented and should not have been given wander guard and felt it was an overreaction from nurse due to previous incident with another resident eloping from facility. The DON confirmed the process for obtaining a wander guard would be to get order from physician, monitor every shift the wander guard was in place. and add in the care plan. The DON acknowledged there was no order for wander guard however there was a note in the electronic health record notifying the physician.
On 06/13/2025 in the afternoon, the Executive Director (ED) indicated the resident was officially discharged since R84 was scheduled to be discharged the following day and did not consider it an elopement. The ED explained the police were notified because all contact information for R84 did not produce any results. The ED verbalized understanding the resident did not have discharge order or any evidence the resident was considered leaving against medical advice. The ED indicated had spoken to member from corporate team and it was determined it did not meet the facility reporting standards however was not able to say if incident was considered a safe discharge, leaving against medical advice, or an elopement.
There was no record the State Agency was notified of elopement from facility for R84.
The facility policy titled Elopement (revised 11/19/2024) documented elopement occurs when a resident leaves the premises or a safe area without authorization such as an order for discharge.
Complaint NV00074431
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 resident baseline care plan ...
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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 resident baseline care plan fit the needs for 1 of 24 residents. The deficient practice had the potential to significantly impact the resident's well-being and safety.
Findings include:
Resident 316
Resident 316 (R316) was admitted on [DATE], with diagnoses of altered mental status.
On 06/10/2025 at 2:15 PM, observed the resident calling out for assistance in Spanish and did not understand how to utilize the call light.
On 06/11/2025 at 1:25 PM, a Certified Nursing Assistant (CNA), stated the resident is confused and not aware of the surroundings. The CNA voiced the resident does not understand how to utilize the call light and expressed the resident screams for assistance in Spanish. The CNA entered into the resident's room and asked the resident to push the call light button and verified the resident did not understand how to use the call light.
On 06/11/2025 at 1:42 PM, a Licensed Practical Nurse (LPN), expressed when a confused resident is newly admitted the nurse and CNA would orientate the resident into the room, frequent reminders on how to utilize the light, continuous rounding and update the care plan. The LPN clarified the resident should be close to the nurse's station and verbalized the current call light is not suitable and should be exchanged to the press pad.
On 06/11/2025 at 2:08 PM, the Unit Manager (UM), stated the resident was admitted on [DATE] and is alert and orientated times four. The UM explained the facility has Spanish speaking staff and can interpret. The UM expressed confused residents would have frequent checks, moved close to the nurse's station, the call light in reach and reminders with call light utilization.
On 06/11/2025 at 2:52 PM, review of the Minimum Data Set (MDS) dated on 06/08/2025, documented the facility conducted a brief interview for mental status, the resident did not understand. An evaluation for the residents short-term and long-term memory, which indicated the resident had a memory problem. An evaluation pertaining for the resident to recall the location of the room, staff names, faces and location, the resident was not able to recall during the interview. An evaluation for the resident's cognitive skills for daily decision making indicated the resident was severely impaired.
On 06/11/2025 at 3:03 PM, a skilled note dated 06/05/2025, documented upon arrival the resident is Spanish speaking who is alert and able to make needs known.
On 06/11/2025 at 3:05 PM, a health status note dated 06/05/2025, documented the resident was oriented to the room, facility and how to utilize the call light.
On 06/11/2025 at 3:17 PM, the care plan dated 06/05/2025, documented the resident has impaired cognitive ability, an impaired thought process and to allow extra time for resident to respond to questions and instructions. The care plan lacked documented evidence the resident was unable to utilize the call light and would call out for help in Spanish.
On 06/13/25 at 7:44 AM, review of policy titled baseline care plan dated, 09/05/2024, documented the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.
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
ADL Care
(Tag F0677)
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 incontinent care was provided...
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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 incontinent care was provided to a dependent resident who was soiled, wet, and had requested assistance for 1 of 24 sampled residents (Resident 111). This deficient practice had the potential to result in skin breakdown, infections, discomfort, and a diminished quality of life.
Resident 111 (R111)
R111 was admitted on [DATE] and discharged on 04/02/2025 with diagnoses including multiple sclerosis, difficulty walking, and need for assistance with personal care.
On 06/04/2025 the State Agency received a report detailing concerns related to R111. The report alleged R111 had been left in a soiled incontinence brief for several hours on 03/17/2025 while at the facility.
An admission minimum data set (MDS) assessment dated [DATE] documented R111:
- no mobility devices
- dependent on toileting
- dependent with lower body dressing
- dependent with mobility
On 06/13/2025 at 10:00 AM, the Unit Manager indicated being familiar with incident involving R111. The Unit Manager revealed R111 had incontinence brief changed at 11:30 AM on 03/17/2025 with assistance from certified nursing assistant (CNA). At approximately 5:00 PM on 03/17/2025 the night shift CNA indicated R111 had complained of not having brief changed since the morning and had been requesting assistance.
The Unit Manager explained the brief was immediately changed and it was discovered the day shift CNA had left the building for transport with another resident and did not notify the other CNAs in the building, only notifying the nurse for the unit. The Unit Manager indicated speaking with the nurse and was advised the nurse had seen the resident earlier in day for medication pass and then answered the call light later. The nurse verbalized R111 had requested assistance with changing brief and nurse obtained assistance from a CNA but did not follow up with CNA to ensure service was provided.
On 06/13/2025 at 11:22 AM, the Director of Nursing (DON) acknowledged incident and verbalized it did occur. The DON explained the day shift CNA went with another resident to medical appointment and did not notify the other CNAs in the facility only the nurse on unit. The DON indicated the expectation for staff when answering call lights was for staff to provide needed services or ensure it was completed and verbalized the nurse can follow up or change resident and does not necessarily always fall on the CNA to complete. The DON further explained it was normal for nurse to turn off call light after checking on resident and notify the CNA of what was needed, however it was important the nurse return to CNA to ensure task was completed.
The facility policy titled Resident Rights (revised 09/10/2024) documented residents have a right to dignified existence with access to persons and services inside and outside the facility. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment which promotes maintenance or enhancement of the quality of life.
Complaint NV00074387
Facility Reported Incident NV00073739
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 observation, interview, record review and document review, the facility failed to obtain physician orders for 2 of 24 s...
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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 obtain physician orders for 2 of 24 sampled residents (Resident 84 and Resident 51) and schedule a follow-up appointment as recommended for 1of 24 sampled residents (Resident 51). The deficient practice had the potential for inappropriate discharge and to delay treatment and healing of a fracture.
Findings include:
Resident 84 (R84)
R84 was admitted on [DATE] with diagnoses including dementia, and displaced fracture of left tibia.
The medical record lacked documented evidence of a physician order to discharge for R84.
The medical record lacked documented evidence of a physician order for use and monitoring of a wander guard for R84.
On 06/12/2025 at 1:13 PM, the unit manger explained wander guards were used for residents who were difficult to redirect, had exit seeking behaviors, and were impulsive with decision making. Wander guards required a physician order to be applied. The wander guard could not be pulled off or unsnapped, once applied, it had to be cut off. The Unit Manager verbalized there was an elopement binder at the nursing station and front desk which includes a photo of residents who have a wander guard in place.
The Unit Manager explained R84 would frequently walk in secured courtyard however one day went outside when the front door was open. The Unit Manager verbalized the resident did not leave the property however the resident was given a wander guard after incident. The Unit Manager verbalized resident was frequently considered confused in assessments due to language barrier, however when speaking in native language R84 was alert and oriented to person, place, time, and events.
R84 had plan to be discharged on 06/06/2025 and wanted wander guard removed the previous night. The Unit Manager explained there was no discharge order yet primarily because the facility needed to wait until R84's friend came to building to pick up R84 in order to get details of where R84 was going. The Unit Manager indicated sometime after 9:00 or 10:00 PM, resident was noted to be missing, and code was called for elopement, the executive director was notified, and the police were contacted. The resident was never found and was discharged from facility.
On 06/12/2025 at 2:07 PM, a Case Manager (CM) explained the discharge plan was for R84 to discharge with friend however had to wait until day of discharge in order to speak with R84's friend to get details on where the resident would be living. The CM explained a different CM was primarily handling case with R84 and had previously spoke to R84's friend.
The CM verbalized all communication with family or friends regarding discharge should be documented in the medical record, however there were no notes regarding any communication with friend. There was no discharge order entered into computer as the facility was waiting until day of discharge to discuss with R84's friend.
On 06/13/25 at 11:00 AM, the Director of Nursing (DON) indicated the facility would not usually give resident a wander guard for alert/oriented residents and R84 should not have been given wander guard and felt it was an overreaction from nurse due to previous incident with another resident eloping from facility. The DON confirmed the process for obtaining a wander guard would be to get order from physician, monitor every shift the wander guard was in place. and add in the care plan. The DON acknowledged there was no order for wander guard however there was a note in the electronic health record notifying the physician.
On 06/13/2025 in the afternoon, the Executive Director (ED) indicated the resident was officially discharged since R84 was scheduled to be discharged the following day and did not consider elopement. The ED verbalized understanding the resident did not have discharge order or any evidence the resident was considered leaving against medical advice. The ED was not able to say if incident was considered a safe discharge, leaving against medical advice, or an elopement.
Complaint NV00074431
Resident 51 (R51)
R51 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including dysphagia, muscle weakness, and displaced fracture of surgical neck of right humerus.
On 06/10/2025 at 10:32 AM, R51 explained having had a fall several months ago resulting in a fracture of the right arm and needing a sling. R51 stated never had follow- up appointments or x-ray, and the sling was gone.
A Nursing progress note dated 12/07/2024 documented R51 had a witnessed fall. The CNA reported to the nurse R51 was on the floor.
A Nursing progress note dated 12/07/2024 documented upon follow-up, R51 had pain localized to the right shoulder and arm. R51 was receiving pain medication.
A Physician progress note dated 12/09/2024 documented R51 reported to have a fall during the weekend, Xray of right shoulders ordered, and R51 to be sent out to emergency room if Xray reports humeral fracture.
An imaging report for the right upper shoulder dated 12/09/2024 documented impression of acute comminuted (bone broken into three or more pieces) and displaced fracture of the neck of the humerus.
A Hospital Emergency Provider report dated 12/09/2024 documented diagnosis shoulder dislocation, humerus fracture right shoulder non-custom immobilization sling.
A Physician progress note dated 12/10/2024 documented R51 returned from emergency room with recommendation of right shoulder and right upper extremity immobilization. R51 was to follow up with Orthopedics.
An imaging report of the right humerus dated 01/14/2025 documented impression of humeral fracture.
An Orthopedic consult note dated 01/16/2025, documented R51 to remain in the sling, follow up in four to six weeks with updated x-rays of right shoulder.
A Nursing progress note dated 01/16/2025 documented R51 returned from orthopedic consult appointment for right shoulder fracture with orders to continue sling and follow up in four- six weeks. Transportation made aware.
R51's medical record lacked a physician order for right shoulder sling.
On 06/11/2025 at 11:50 AM, a Licensed Practical Nurse (LPN) explained when orders or requests for appointments were made an appointment request form was completed and given to case management for scheduling. Once the appointment was made the facility would transport the resident.
On 06/11/2025 at 11:58 AM, a Case Management staff member explained long term care resident's appointments were coordinated with the social service department.
On 06/11/2025 at 12:03 PM, the Social Services Director (SSD) explained remembering the orthopedic consult appointment for R51 and it being non-surgical interventions. The SSD reviewed the notes from R51's orthopedic appointment on 01/16/2025 and confirmed the recommendation was to follow up in four to six weeks. The DSS explained needing to review information to verify if an appointment was made.
On 06/12/2025 at 8:19 AM, R51's Nurse Practitioner (NP) explained R51 was sent to another hospital for an orthopedic visit. The NP stated the fracture was not operable. The NP stated R51 wore a sling for a while and explained being unaware there was no physician order for the sling. The NP confirmed an order should have been entered for R51's sling use and an order should have been written for when the sling was discontinued. The NP was unable to explain when the sling use was discontinued and what provider instructed R51 to no longer wear the sling.
On 06/12/2025 at 10:56 AM, the LPN confirmed R51's medical record lacked physicians orders for the right arm sling.
On 06/13/2025 at 8:42 AM, The Unit Manager (UM) for R51's unit confirmed R51 would require an order for the sling, and it should have been entered upon return from the hospital.
On 06/13/2025 at 9:10 AM, the Director of Nursing (DON), explained the expectation for a resident returning from the emergency room or hospital was for orders to be reviewed with the resident's attending physician. The orders would then be entered in the resident's medical record. The DON explained R51 would require orders for use of the sling. The DON explained residents who return with recommendations for appointments required the nurse to relay the recommendations to resident's physician and enter the orders. The DON explained for transportation arrangement the appointment form was to be completed and processed. The DON explained having reviewed R51's medical record and confirmed orders were not obtained for the use of the right arm sling and no orders were obtained to discontinue the use of the sling. The DON also confirmed the recommendation for the follow up appointment was not completed.
The facility policy titled Transportation Coordination and Services, with review date 05/15/2025, documented the facility would assist residents in making necessary appointments for services not provided in the facility and arranging for transportation to and from such appointments.
The facility policy titled admission Policy- Nevada Facilities, revised 01/07/2025, documented a physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.
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 interview, record review and document review, the facility failed to ensure weekly weights were obtained in accordance ...
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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 weekly weights were obtained in accordance with physician's order for 1 of 24 sampled residents (Resident 3). The failure potentially delayed identification of a significant weight change, nutritional re-assessment by a Registered Dietitian (RD) and appropriate interventions by the inter-disciplinary team (IDT).
Findings include:
Resident 3 (R3).
R3 was admitted on [DATE] with diagnoses including protein-calorie malnutrition and difficulty swallowing.
The medical record revealed the following weights documented for R3:
- on 05/20/2025 111 lbs. (pounds)
- on 06/09/2025 95 lbs.
Accounting for a 14.1% weight loss from 5/20/2025 to 06/09/2025.
The medical record lacked documented evidence of any further weights obtained.
A physician order dated 05/19/2025 documented to obtain weekly weights for one month and then monthly weights.
On 06/12/2025 at 11:42 AM, a Certified Nursing Assistant (CNA) explained the CNAs on the unit were only responsible for admission weights until about two or three weeks ago. A restorative nursing assistant (RNA) was dedicated to obtaining all weekly weights. The RNA was no longer at the facility and would be advised by nursing leadership if weights were needed for residents on unit. The CNAs would not enter the weight into the electronic medical record, weight results would be given to nurse to enter.
On 06/12/25 at 12:12 PM, the Registered Dietitian (RD) indicated being a contracted staff member and would normally visit facility twice per week. The RD explained once resident was admitted the RD would evaluate the resident within one week and was available by phone for staff. The RD indicated there was a meeting called if a resident was at risk and would discuss any concerns staff had about specific residents. R3 would have been discussed during the current weekly resident at risk meeting based on weight obtained on 06/09/2025.
The RD confirmed the facility policy was to obtain weekly weights during the first four weeks of admission and acknowledged R3 had missing entries for weights. The RD verbalized R3 did have weight obtained during second week, however it was only written down on an internal handwritten document which demonstrated R3 had gained two pounds since admission. The RD verified R3 was at risk for malnutrition and had been started on house shake and protein supplement and indicated missing weekly weight could delay new interventions from being implemented.
The RD verbalized the dietary manager was keeping track of residents requiring weights to be obtained and would notify nursing manager of any residents needing new weight measurement. The RD explained R3 was eating 50-75% of all meals.
On 06/13/25 at 8:01 AM, the Dietary Manager indicated the process for documenting weights was the dietary manager would run report to see what residents were required for weekly weights. The dietary manager explained a list of residents would be given to the Director of Nursing (DON) to follow up to ensure weights were obtained. The DON would designate a nursing staff member, CNA or nurse to obtain the weight. The weight would then be obtained, and the unit manager would give the list of residents and weights back to the dietary manager and weights would then be documented in the medical record. The Dietary Manager verbalized when the weight was added to the medical record and evaluated it may be the following week. The dietary manager confirmed weight was obtained on 05/25/2025, however it was missed the following week and was not documented in the electronic health record. The dietary manager explained the process could have identified the weight loss earlier if not missed.
On 06/13/25 at 10:34 AM, the Director of Nursing (DON) explained prior to two weeks ago, CNAs would get list and obtain weights, give back to dietary manager and would enter weights. and then dietitian would review. As of last week, the dietary manager will give to DON and would be divided out to the unit managers and unit managers would give to CNA on unit. The DON confirmed the facility process was under review to ensure weights were obtained and reviewed timelier. The DON acknowledged there was a weekly weight missed and could have identified significant weight loss sooner.
The facility policy titled Weights and Heights (revised 09/10/2024) documented all residents were weighed within 24 hours after admission and weekly for four weeks and as needed thereafter or more as determined by the resident at risk committee.
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: 1) follow a physician order for int...
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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: 1) follow a physician order for intravenous (IV) site care and 2) obtain a physician order for the use or removal of IV access for 2 of 24 sampled residents (Residents 9 and 261). This deficient practice had the potential to result in infection, phlebitis, infiltration, and compromised venous access.
Findings include:
1) Follow Physician order
Resident #9 (R9)
R9 was admitted on [DATE] with diagnoses including cellulitis of the left and right lower limb.
On 06/10/25 at 9:13 AM, R9 was observed lying in bed, alert and oriented, with a midline IV access site located in the right inner bicep. The dressing was dated 05/21/25.
A physician order dated 05/21/25 documented the following:
-
IV: Midline Catheter - Change needleless connector every day shift every 7 days.
-
IV: Midline Catheter - Change transparent dressing every day shift every 7 days. Change catheter securement device with dressing change. Measure external catheter length - notify physician if length had changed since last measurement.
On 06/10/25 at 12:05 PM, the Unit Manager confirmed the IV site had not been changed since 05/21/25.
2) Obtain a Physician order
Resident #261 (R261)
R261 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side and acute kidney failure.
On 06/10/25 at 10:59 AM, R261 was observed lying in bed, alert and oriented. The resident had two IV access sites on the right inner forearm-one near the inner wrist and one near the elbow-both of which lacked dated labels. R261 verbalized the IVs were inserted prior to admission and staff had not been caring for them during the facility stay.
On 06/10/25 at 12:06 PM, the Unit Manager confirmed both IV dressings were undated and verbalized there was no indication of when the sites had last been assessed or changed.
On 06/11/25 at 9:01 AM, the Unit Manager verbalized the IV site care and dressing changes were expected to be performed weekly on Sundays and as needed. The Unit Manager confirmed the two IV access sites were present upon admission, but no physician orders for IV access, IV medications, or hydration had been obtained for R261. The Unit Manager reported following up with the admitting nurse, who acknowledged overlooking the two IV sites during the admission process.
On 06/11/25 at 10:58 AM, the Director of Nursing (DON) confirmed the IV access sites should have been discontinued and removed if not supported by active physician orders. The DON further verbalized all IV dressings were expected to be labeled with the date and initials of the staff performing the dressing change.
R261's medical record lacked documented evidence of a physician order for the continued use, care, or removal of the two IV access sites.
The Facility policy titled IV Dressing Change, revised April 19, 2024, documented the transparent semipermeable dressings were to be changed at least every 7 days. The policy further instructed the IV catheters should be removed when no longer included in the patient's care plan or if unused for more than 24 hours. Dressings were required to be labeled with the date they were changed or when they were next due.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 it was free of a medication er...
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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 it was free of a medication error rate of less than five percent (%) for four residents (Resident 88, 29, 361, and 94). The deficient practice posed a potential risk of injury or harm to the resident.
Findings include:
On 06/12/2025 in the morning, a Medication Administration Pass observation was performed with 30 opportunities observed and revealed five errors. The medication error rate was 16.67%.
Resident 88 (R88)
R88 was admitted on [DATE] with diagnoses including malignant neoplasm of kidney, acute renal failure, and iron deficiency.
On 06/12/2025 at 7:28 AM, during the Medication Administration Pass observation, a Registered Nurse (RN) prepared and administered the following medications for R88:
- Carvedilol 25 milligram (mg) one tablet by mouth
- Levetiracetam 500 mg one tablet by mouth
- Ferosul 325 mg one tablet by mouth
- Losartan 100 mg one tablet by mouth
A physician order dated 05/05/2025 documented Midodrine hydrochloride (hcl) Tablet 10 mg. Give one tablet by mouth three times a day for hypotension hold if systolic blood pressure is greater than 120.
On 06/12/2025 10:03 AM, the RN confirmed R88's blood pressure was 110/74 and the Midodrine hcl 10 mg should have been administered but was not given to R88.
Resident 29 (R29)
R29 admitted on [DATE] with diagnoses including surgical aftercare following surgery on the circulatory system, presence of aortocoronary bypass graft, and atherosclerotic heart disease of native coronary artery.
On 06/12/2025 at 7:54 AM, during the Medication Administration Pass observation, the RN prepared and administered the following medications for R29:
- Aspirin enteric coated (EC) 81 mg one tablet by mouth
- Oxybutynin 5mg one tablet by mouth
- Gabapentin 100 mg one capsule by mouth
- Eliquis 5mg one tablet by mouth
- Lasix 40mg one tablet by mouth
- FeroSul 325mg one tablet by mouth
A physician order dated 05/14/2025 documented Aspirin chewable tablet 81 mg. Give one tablet by mouth one time a day for Heart health.
On 06/12/2025 at 10:11 AM, the RN confirmed R29's order was for Aspirin chewable tablet 81 mg and Aspirin 81mg enteric coated was administered.
Resident 361 (R361)
R361was admitted on [DATE] with diagnoses including peripheral vascular disease, atherosclerosis of renal artery, and dependence on renal dialysis.
On 06/12/2025 7:57 AM, during the Medication Administration Pass observation, a Registered Nurse (RN) prepared and administered the following medications for R361:
- Aspirin enteric coated (EC) 81 mg one tablet by mouth
- Carvedilol 12.5 mg one tablet by mouth
- Amlodipine 100mg one tablet by mouth
- Famotidine 40mg one tablet by mouth
A physician order dated 06/04/2025 documented Aspirin chewable tablet 81 mg. Give one tablet by mouth one time a day for myocardial infarction/stroke prevention.
On 06/12/2025 at 10:13 AM, the RN confirmed R361's order was for Aspirin chewable tablet 81 mg and Aspirin 81mg enteric coated was administered.
Resident 94 (R94)
R94 was admitted on [DATE] with diagnoses including Alzheimer's disease, altered mental status, and hyperlipidemia.
On 06/12/2025 at 8:06 AM, during the Medication Administration Pass observation, a Registered Nurse (RN) prepared and administered the following medications for R94:
- Tamsulosin hcl 0.4 mg one capsule by mouth
- Donepezil hcl 10 mg one tablet by mouth
- Finasteride 5 mg one tablet by mouth
A physician order dated 05/10/2025 documented Cyanocobalamin tablet 1000 microgram (mcg) Give one tablet by mouth one time a day for supplement.
A physician order dated 05/09/2025 documented Tamsulosin hcl capsule. Give 0.8 milligrams by mouth at bedtime for benign prostatic hyperplasia.
On 06/12/2025 at 10:14 AM, the RN confirmed the Tamsulosin hcl order would require two of the 0.4 mg tablets to be administered to equal 0.8 mg as ordered and only one tablet was administered. The RN also confirmed the medication was scheduled for bedtime. The RN explained giving medications at times by memory and it should not have been administered. The RN confirmed the Cyanocobalamin tablet was missed and not given.
On 06/13/2025 at 9:04 AM, the Director of Nursing (DON) explained the expectation of the nurse when administering medication was to ensure the correct resident, review the electronic Medication Administration Record (EMAR) and reference the medication card to the resident's medication order prior to administering the medication.
The facility policy titled Administration of Medications, with review date 09/16/2024, documented staff responsible for medication administration would adhere to the ten rights of medication administration of:
1) Right Drug
2) Right Resident
3) Right Dose
4) Right Route
5) Right Time and Frequency
6) Right Documentation
7) Right Assessment
8) Right to Refuse
9) Right Evaluation
10) Right Education and Information
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, interview and document review, the facility failed to dispose expired medications. This deficient practice has the potential to cause adverse reactions or worsened health conditi...
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Based on observation, interview and document review, the facility failed to dispose expired medications. This deficient practice has the potential to cause adverse reactions or worsened health conditions to residents.
Findings include:
On 06/13/2025 at 9:28 AM, the medication refrigerator contained five expired Covid-19 vaccines, 0.5 milliliter (mL) single dose pre-filled injectable syringes dated 06/08/2025.
On 06/13/2025 at 9:35 AM, the medication cabinet contained five expired 3000 milliliter (mL) normal saline irrigation bags for a discharged resident dated 03/08/2025.
On 06/13/2025 at 9:40 AM, the Unit Manager verified the medications were expired and should have been disposed.
06/13/2025 at 9:49 AM, facility policy titled destruction of medication dated 03/04/2025, documented the facility will destroy discontinued or outdated medications in accordance with federal, state, local laws and regulations for pharmaceutical waste disposal.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and document review, the facility failed to properly date resident drink containers in 2 of 2 nourishment refrigerators and employee food stored in the resident freezer...
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Based on observation, interview and document review, the facility failed to properly date resident drink containers in 2 of 2 nourishment refrigerators and employee food stored in the resident freezer. This deficient practice has the potential to lead bacterial growth and foodborne illnesses.
Findings include:
On 06/10/2025 at 8:37 AM, in the nourishment refrigerator located on the 100 and 200 hall there were three containers of juice, which had no start or end dates.
On 06/10/1025 at 8:38 AM, the nourishment freezer contained employee personal food items which included a TV dinner, breakfast burrito, yogurt, strawberries, and an ensure.
On 06/10/2025 at 8:42 AM, in the nourishment refrigerator located on the 300 and 400 hall there was one container of apple juice, which had no start or end date.
On 06/10/2025 at 8:44 AM, the Kitchen Director, stated food and drink items should be dated with a start and end date before items are placed in the refrigerator and employees are not allowed to store personal food items the resident's nourishment refrigerators.
On 06/12/2025 at 11:45 AM, the Registered Dietitian clarified any food or drinks placed into the nourishment refrigerator is labeled with a start and end date and employees are not allowed to store food in the resident's nourishment rooms.
On 06/13/2025 at 8:18 AM, facility undated policy titled, Use by date guide documented, all open containers of food in the dry storage area should be placed in an enclosed container, labeled and dated with the open date and the use by date.
On 06/13/2025 at 1:48 PM, facility policy titled food safety dated 05/01/2025, documented associate food will not be stored with resident food.
Aug 2024
9 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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review, the facility failed to ensure a safe discharge was planned and occurred...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review, the facility failed to ensure a safe discharge was planned and occurred for 2 of 2 unsampled residents (R214 and R219). This deficient practice had the potential for residents to be placed in an improper home setting and not receive the required care.
Findings include:
Resident 214 (R214)
R214 was admitted to the facility on [DATE], with a diagnosis including heart failure, unspecified dementia, mood disturbances, Type 2 diabetes, muscle weakness and difficulty walking.
At the bottom of the Face Sheet under Miscellaneous Information, it was documented the resident was discharged to a private home/apt with home health services on 01/09/2024.
A Discharge summary dated [DATE], documented the resident was discharged to Home and Other. The Summary detailed the group home address, transportation company, and reason for discharge which noted cleared for discharge. The summary further included the Home Health company name; telephone number listed along with Durable Medical Equipment (DME). Boxes selected for Referral for Physical Therapy, Occupational Therapy, Speech Language and Pathologist outpatient services. The Resident and Nurse signed the document.
A nurse Progress Note dated 01/09/2024, documented the resident was discharged to a group home with all medications, education and belongings.
A Notice of Medicare Non-Coverage document dated 01/04/2024 documented a family member was informed on 01/04/2024, the resident's last day of coverage would be 01/08/2024. Due to communication by phone call, the form was not signed.
08/08/2024 at 3:00 pm, the Case Manager and Director of Social Services indicated they were not involved in this resident's discharge. The former Social Worker involved was no longer employed at the facility. They indicated the process for Care Planning started at admission, included the resident goals, whether the resident will return to home or another placement and what dollar amount could be afforded, this information gets discussed in a care conference. To ensure financial payment is available, the Case Manager works with the insurance company, communicates with the weekly Interdisciplinary Team (IDT) to determine if the family would take the resident and what their needs will be. Family-if any and resident make the determination if the resident would come back home, go to a private home, or group home.
The Case Manager has a group home liaison who helps identify a group home in order to find placement for residents. If a person chooses to go to a group home, they are given a list of names to choose from that can be visited. Once a home has been selected, a representative from the group home comes to the facility to evaluate the resident to determine if the individual is right for their home.
The Case Manager ensures the insurance has approved Home Health and DME prior to the resident discharge. A resident will not be discharged without services. Ultimately, it is the resident's choice where to go.
There were no records documenting the representative of the group home had evaluated the resident, whether the resident agreed to go to the facility, and if the family was involved in the discharge.
Resident 219 (R219)
R219 was initially admitted [DATE] and readmitted [DATE], with diagnosis including heart failure, Type 2 diabetes, morbid obesity, ESRD, anemia, muscle weakness, hypotension, anxiety, and repeated falls. The resident's cognition was intact.
Case Management notes documented:
- 09/28/2023, resident to discharge to group home placement on 09/30/2023, per Interdisciplinary Team. Request for Home Health services were faxed to a named home health agency.
- 09/29/2023, R219 to be discharged on 09/30/2023, going to a group home level 3. Resident will receive care from nurses and certified nurse assistant.
- 09/30/2024, may discharge R219 to group home placement on 09/30/2023. Please provide instructions, prescription list, and leftover medications on hand. Follow-up with primary care physician in 5-7 days after discharge. Home health and durable medical equipment to be provided.
08/08/2024 at 3:00 pm, the Case Manager and Director of Social Services indicated were not involved in this resident's discharge. The former Social Worker involved was no longer employed at the facility.
There was no documentation in the resident's file the spouse was involved in the discharge process, or documentation the representative came to evaluate R219 for appropriate admission to their group home and if the resident agreed to go to the home. The was no documentation of an address where the resident was taken to or name of the group home.
Facility policy Discharge Plan last revised 08/18/2022. documented the facility resident and or their representative would be involved, the plan would document referrals to entities, the resident's interest regarding returning to the community, inform the resident/representative of the final plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, record and document review, the facility failed to ensure comprehensive care plans were implemented for the management of falls for 1 of 24 sampled residents (Resident...
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Based on observation, interview, record and document review, the facility failed to ensure comprehensive care plans were implemented for the management of falls for 1 of 24 sampled residents (Resident 50). The deficient practice had the potential for staff not to provide personalized care for the resident.
Findings include:
Resident 50 (R50)
R50 was a long-term resident at the facility, with diagnoses including cholecystectomy and dementia.
R50's medical records revealed a fall at the facility on 03/10/2024 at 1:15 PM.
R50's comprehensive care plan revised on 03/10/2024, addressed the resident's fall and goals and interventions. The comprehensive care plan lacked implementation to monitor and care for the resident fall management.
R50's medical records revealed a physical therapy consultation was suggested in the care plan on 03/10/2024, to consult for strength and mobility.
On 08/08/2024 at 1:10 PM, the director of rehabilitation (DOR) explained during the Clinical Inter Disciplinary Team (IDT) meeting, if it is suggested for a therapy screening, the screen request gets put into the care plan and then it is put on the therapist's schedule to complete the following day. When the screen is completed, if it is recommended to pick up the patient, they will complete the evaluation the next day. The screening form then gets scanned into the document section of the facility's electronic documentation system for the resident and a hard copy is stored in therapy. The DOR confirmed there had not been a screening documented for this resident stored in the documentation system nor in a hard copy stored in therapy.
On 08/08/2024 at 12:35 PM the director of nursing (DON) confirmed a screening was asked for in the resident care plan dated 03/10/2024. The DON stated it is expected the therapy screen/evaluation should take place within 3 to 5 business days, but preferably 72 hours from the date the screening was asked for. The DON acknowledged the screen/evaluation had not taken place for seven weeks.
The facility policy titled Fall Management, reviewed 9/22/2023, documented the facility is to monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice.
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
ADL Care
(Tag F0677)
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 scheduled showers were provid...
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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 scheduled showers were provided to dependent residents for 1 of 24 sampled residents (Resident 246) and 2 unsampled residents (Residents 215 and 213). This deficient practice could potentially compromise resident hygiene and comfort, and increase the risk of skin breakdown and infections.
Findings include:
A facility policy titled Activities of Daily Living dated 02/12/2024, indicated residents would receive assistance as needed to complete activities of daily living (ADLs), including bathing. Any change in the ability to perform ADLs would be reported to the nurse.
Resident 246 (R246)
R246 was admitted on [DATE], with diagnoses including dementia, difficulty in walking, and muscle weakness.
A Care Plan dated 07/24/2024, documented a self-care performance deficit for R246 related to dementia and disease process. Interventions included substantial assistance from one person.
A Care Plan dated 07/25/2024, documented the need for assistance with activities of daily living (ADLs) to maintain or attain the highest level of function for R246. Interventions included providing assistance with ADLs as needed.
On 08/06/2024 at 10:47 AM, R246 was in bed and verbally responsive. R246's hair was disheveled and resident was unshaven. A family was present at the bedside and verbalized only one shower had been provided since admission, with no sponge or bed baths during the missed showers. The family also verbalized R246 was dependent on staff for ADLs, including showers. Both the family and R246 expressed a desire to have the showers scheduled as planned.
R246's medical record lacked documented evidence of a completed scheduled shower or any refusal by R246 on 08/02/2024 (the previous Friday).
On 08/09/2024 at 7:55 AM, the Director of Staff Development (DSD) indicated R246's shower schedule was on Tuesdays and Fridays. The DSD confirmed there was no documented evidence of R246 receiving a shower or sponge bath on 08/02/2024, nor any record of refusal.
On 08/09/2024 at 12:36 PM, the Director of Rehabilitation Services (DORS) indicated R246 was evaluated on 07/24/2024, and the assessment showed substantial assistance was required for bathing. The DORS confirmed R246 could not shower independently and was dependent on staff for assistance.
On 08/09/2024 at 12:49 PM, a Certified Nursing Assistant (CNA) explained the shower should have been provided twice a week. The shower schedule appeared in the plan of care (POC) each day, and the actual shower tab displayed the residents own schedule. The CNA explained if a resident refused, the nurse would be informed, a reoffer made, and documentation completed. The CNA demonstrated on the tablet how to access the schedule and the POC. The CNA indicated the residents' shower schedules could be accessed either on the tablet or on the computer at the nurse station.
Resident 215 (R215)
R215 was admitted on [DATE], with diagnoses including dementia, fracture of upper end of the humerus (long bone in the arm) and lumbar vertebra, difficulty in walking and generalized muscle weakness.
R215's ADL flowsheet for November 2023, lacked documented evidence that a shower or bed bath was provided on the following dates:
-11/09/2023 (Thursday)
-11/14/2023 (Tuesday)
-11/16/2023 (Thursday)
-11/21/2023 (Tuesday)
-11/23/2023 (Thursday)
R215's medical records lacked documented evidence of any refusal of a shower by R215.
On 08/09/2024 at 7:58 AM, the DSD indicated R215 was admitted on [DATE], with the shower schedule on Tuesdays and Thursdays. The DSD confirmed there was no documentation showers were provided on 11/09/2023, 11/14/2023, 11/16/2023, 11/21/2023 and 11/23/2023. The DSD verified and confirmed there was no documentation of R246's refusal with showers, sponge or bed bath.
On 08/09/2024 at 12:36 PM, the DORS revealed R215 was evaluated and the assessment indicated substantial assistance was required for bathing. The DORS indicated R215 could not shower independently and was dependent on staff for assistance.
On 08/09/2024 at 2:08 PM, the Unit Manager (UM) explained the shower schedule was based on the resident's preference and should have been offered and provided at least twice a week. The UM confirmed the CNA was aware of how to access the POC. The UM verbalized showers were expected to be provided as scheduled and documented. The UM also mentioned if a resident refused, a bed bath or sponge bath should have been reoffered.
Resident 213 (R213)
R213 was admitted on [DATE] and discharged on 01/27/2024, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left-dominant side, difficulty in walking, and muscle weakness.
The Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE], documented the following:
- R213 had impairment on one side of upper and lower extremity.
- R213 required substantial/maximal assistance with shower/bath.
The Activities of Daily Living (ADL) flowsheet documented the type of bath and the corresponding code such as SW - Shower, BB - Bed Bath, SB - Sponge Bath, and TB - Tub Bath. The appropriate code was documented on the day ADL - Bathing was provided to a resident. RR was the code when resident refused.
R213's ADL flowsheet for November 2023 and December 2023 lacked documented evidence the resident received either a shower or bath on the following dates:
- 11/29/2023 (Wednesday)
- 12/04/2023 (Monday)
- 12/06/2023 (Wednesday)
- 12/25/2023 (Monday)
R213's medical record lacked documented evidence the resident refused shower or bath during the above-mentioned dates, and shower or bath were provided on other days to compensate for the missed shower or bath as scheduled.
On 08/08/2024 at 12:41 PM, a Certified Nursing Assistant (CNA) explained the residents were scheduled to receive either a shower, bed bath, or sponge bath twice weekly. The CNA would have documented the type of bath provided in the ADL - Bathing flowsheet including resident's refusal. The CNA would have reported to the nurse if a resident refused bathing. The CNA indicated ADL documentation including bathing/shower were entered electronically.
On 08/09/2024 at 7:35 AM the Director of Staff Development (DSD) revealed R213's shower schedule was every Monday and Wednesday. The resident would have received either a shower, bed bath, or sponge during those scheduled days and would have been documented in the ADL flowsheet under Bathing. The DSD confirmed R213 should have received shower or bath on the following days as scheduled:
- 11/29/2023 (Wednesday)
- 12/04/2023 (Monday)
- 12/06/2023 (Wednesday)
- 12/25/2023 (Monday)
The DSD confirmed there was no documentation R213 received shower or bath during the above-mentioned dates, and no documentation in the nurse's progress notes of resident's refusal.
The DSD explained the CNAs were expected to give shower or bath to the residents as scheduled and should have documented in the ADL - Bathing including refusal. The CNAs should have reported to the nurse if a resident refused. The nurse would have talked to the resident and explained the importance or taking a shower or bath. The nurse would have documented in the progress notes if the resident still refused despite the education provided.
On 08/09/2024 at 9:10 AM, the Assistant Director of Nursing (ADON) confirmed there was no ADL flowsheet for bathing in November 2023 for R213.
On 08/09/2024 at 11:53 AM, the Director of Nursing (DON) indicated the CNAs were expected to give a bath to the residents as scheduled. If a resident refused, the CNAs would have reported the refusal to the nurse. The nurse would have talked to the resident to provide education. If the resident still refused, the nurse should have documented the refusal in the nurse's progress notes.
The facility's policy titled Activities of Daily Living (ADLs) dated 02/12/2024, documented the resident would receive assistance as needed to complete ADLs. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Complaint #NV00070454
Complaint #NV00070146
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** Based on observation, interviews, record review, and document review, the facility failed to ensure a resident with a urinary ca...
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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 ensure a resident with a urinary catheter had appropriate diagnosis and a bladder training program was implemented for 1 of 24 sampled residents. The deficient practice had the potential for increased risk of infection.
Findings include:
Resident 203 (R203)
R203 was admitted on [DATE] with diagnosis including benign prostatic hyperplasia (BPH) without lower urinary tract symptoms.
On 08/06/2024 at 3:29 PM, R14 was sitting in room with catheter and verbalized being treated for wound on foot and was not able to explain why catheter was needed.
An admission minimum data set (MDS) assessment dated [DATE], documented resident was admitted with indwelling catheter and was not participating in a bladder training program.
On 08/09/2024 at 8:01 AM, the Director of Nursing (DON) indicated when resident was admitted with catheter, would ask for bladder training, urology consult. Diagnosis should be entered with the physician order for need of catheter. The DON verbalized for catheter placement, BPH alone was not sufficient for catheter and would need to be associated with urinary retention. The DON acknowledged the diagnosis does not meet criteria for catheter placement.
The medical record lacked documented evidence of a bladder training program or justification for catheter use for R203.
The facility policy titled Indwelling Urinary Catheter Management (revised 06/27/2023) documented the facility would ensure residents admitted with a urinary catheter would have a determined need and medical indication. The facility must ensure a resident who enters the facility with an indwelling catheter was assessed for removal of the catheter as soon as possible.
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, interview, record review, and document review, the facility failed to ensure the ordered fluid restriction...
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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 ordered fluid restriction was followed for a dialysis dependent resident and the actual fluid intake or consumption was monitored for 1 of 24 sampled residents (Resident 14). The deficient practice could have the potential to result in adverse health outcomes, including fluid overload, increased blood pressure, and complications related to the resident's dialysis treatment.
Findings include:
Resident 14 (R14)
R14 was admitted on [DATE], with diagnoses including end-stage renal disease, dependence on renal dialysis, atrial fibrillation, mitral valve insufficiency, and the presence of a cardiac pacemaker.
A physician's order dated 08/01/2024, documented a fluid restriction of 1000 milliliter per day (ml/day). The distribution was as follows: 240 ml for breakfast, 240 ml for lunch, and 240 ml for dinner from Dietary; 140 ml for days and 140 ml for nights from Nursing, each shift, for managing R14's excessive fluid retention. The order also required documentation of the amount consumed.
On 08/06/2024 at 10:30 AM, R14 was out of the facility for a hemodialysis treatment. A pink water pitcher full of water was on R14's bedside table.
On 08/06/2024 at 3:20 PM, R14 was in bed with eyes closed. A pitcher of water, containing approximately 1000 ml, was at the bedside, along with 2 bottles of Glucerna (237 ml per carton) and a cup with approximately 240 ml of a colored drink.
On 08/06/2024 at 4:10 PM, R14 was observed in bed, eating a burger. There was an open soda with approximately 350 ml remaining from a 500 ml bottle, a pitcher of water with approximately 800 ml remaining from a 1000 ml pitcher, two cartons of Glucerna (237 ml per carton), and two extra-large smoothies at the bedside. Family members were present and reported R14 had a good appetite. A Licensed Practical Nurse (LPN) confirmed the presence of the water pitcher, soda, Glucerna, and smoothies at the bedside. The LPN explained R14 was on hemodialysis and had a fluid restriction but was unaware of who had provided the water and expressed concerns about the soda.
R14's facility Weight Summary documented an increasing weights weekly:
7/31/2024
152.0 Lbs.
7/24/2024
150.0 Lbs.
7/19/2024 148.8 lbs.
The Pre/Post Dialysis Communication form dated 07/30/2024, documented to limit R14's fluid intake, R14's predialysis weight was 141 lbs. and postdialysis weight was 136 lbs., which revealed five (5) lbs. of fluids were removed.
On 08/08/2024 at 10:19 AM, a Registered Dietitian (RD) explained the nursing staff would obtain the fluid restriction order from the physician, as advised by the dialysis center. The RD indicated the order would specify the amounts of fluids to be provided on the meal tray, and nursing staff would monitor the resident's actual fluid intake. The RD had spoken with the dialysis center's RD, who confirmed R14's fluid restriction of 1000 ml per day was appropriate due to significant fluid retention. The RD indicated R14 was at risk for congestive heart failure and swelling or edema if retaining excessive fluid, which could compromise dialysis goals.
The RD explained the staff were expected to restrict fluids as ordered, but only 8 ounces were provided by Dietary. The 1000 ml water pitcher should not have been given to R14 due to the fluid restriction. The RD confirmed no fluid monitoring was in place, despite its necessity. On 07/30/2024, the dialysis center removed 5 lbs. of fluid from R14, which was excessive compared to previous dialysis days, and advised limiting fluid intake to 1000 ml/day. The RD confirmed the fluid restriction was not followed and actual fluid intake was not monitored.
On 08/08/2024 at 11:18 AM, a Certified Nursing Assistant (CNA) indicated was new to the facility. The CNA explained the water pitcher was passed at the beginning and end of shifts or as requested by residents and would need to check the resident's care plan for fluid restrictions.
On 08/08/2024 at 11:24 AM, another CNA, who was caring for R14 confirmed awareness R14 was on hemodialysis. This CNA indicated the pink water pitcher, containing 1000 ml, was passed throughout the day. This CNA explained R14, who was not listed as on fluid restriction in the care plan, had not been communicated as having any fluid restrictions.
On 08/08/2024 at 11:32 AM, a Licensed Practical Nurse (LPN) explained if a resident was on fluid restriction, it should have been documented in the care plan. The LPN indicated fluid intake should have been measured, limited as ordered, and monitored and documented throughout the day.
On 08/09/2024 at 10:28 AM, a dialysis Registered Dietitian (RD) confirmed R14's fluid intake was advised to be limited to 1000 ml or 4 cups per day due to weight gain. The dialysis RD indicated not following the fluid restriction could have resulted in severe hypertension, fluid overload, and hospitalization. The RD verbalized R14's actual fluid intake should have been monitored to assess tolerance and avoid fluid overload.
On 08/09/2024 at 12:06 PM, the Director of Rehabilitation Services (DORS) indicated R14 was functional in sitting up but did not ambulate. The DORS indicated R14's upper extremities had no limitations, and both arms were within functional limits, able to reach items freely.
On 08/09/2024 at 3:17 PM, the Assistant Director of Nursing (ADON) indicated the staff were expected to follow the fluid restriction orders for a dialysis-dependent resident.
On 08/09/2024 at 3:17 PM, the Director of Nursing (DON) indicated the resident's non-compliance with fluid restrictions should have been care planned and education provided to the family. The DON indicated the risk for non-compliance of the fluid restriction was fluid overload.
A facility policy titled Physician Orders revised 03/10/2023, documented the facility was obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines.
A facility policy titled Hemodialysis Offsite dated 08/23/2023, documented to observe fluid restriction as ordered by the physician. Nutritional/Fluid management including documentation resident compliance with food/fluid restrictions and monitoring intake as ordered. Follow routine dialysis instructions on dialysis form.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
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 account for narcotics (opioid) signed out on the c...
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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 account for narcotics (opioid) signed out on the controlled drug record for one unsampled resident (R213). The deficient practice had the potential to delay a resident's pain management and increase the risk for physical and psychosocial harm.
Findings include:
Resident 213 (R213)
R213 was admitted on [DATE] and discharged on 01/27/2024, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left-dominant side, difficulty in walking, and muscle weakness.
The physician's order dated 11/28/2023, documented Hydrocodone-Acetaminophen (a controlled substance/opioid) Oral Tablet 5-325 milligram (mg) give one tablet by mouth every four hours as needed for pain level 4-6 (moderate).
On 08/07/2024 at 3:20 PM, the Assistant Director of Nursing (ADON) indicated the Controlled or Antibiotic Drug Record (narcotic log) for R213's Hydrocodone-Acetaminophen 5-325 mg for November 2023, December 20, 2023 to December 31, 2023, and January 2024 could not be located. The ADON confirmed the facility only had a copy of the narcotic log for R213's Hydrocodone-Acetaminophen 5-325 mg from 12/01/2023 to 12/19/2023.
R213's Medication Administration Record (MAR) for December 2023 and January 2024, documented the resident had received Hydrocodone-Acetaminophen 5-325 mg one tablet occasionally from 12/20/2023 to 01/24/2024.
The narcotic log for R213's Hydrocodone-Acetaminophen 5-325 mg from 12/01/2023 to 12/19/2023, documented the medication was signed out to be administered on the following dates and times:
- 12/01/2023 at 11:42 PM.
- 12/03/2023 at 9:00 PM.
- 12/09/2023 at 10:00 PM.
- 12/19/2023 at 12:00 PM.
R213's MAR for December 2023 lacked documented evidence Hydrocodone-Acetaminophen 5-325 mg one tablet was administered to the resident when the medication was signed out on the above-mentioned dates and times.
On 08/08/2024 at 8:42 AM, a Licensed Practical Nurse (LPN) explained the narcotic log would have been filled out with the date, time, and signature of the nurse who pulled out the medication from the supply/stock. The MAR would have been signed every time the medication was administered to the resident to ensure the record between the narcotic log and MAR was reconciled.
On 08/09/2024 at 12:04 PM, the Director of Nursing (DON) indicated the nurses were expected to document in the narcotic log every time they pulled out a narcotic medication from the stock. The nurses had to sign out in the narcotic log. The medication should have been administered to the resident, then the nurses should have documented in the MAR for the medication as given. If the resident refused the medication, the nurses should have documented the medication as wasted in the narcotic log and should have been witnessed by two nurses. The resident's refusal should have been documented in the MAR.
The DON explained the copies of the narcotic log should have been submitted to the medical records.
The facility's policy titled Management of Controlled Substances dated 08/29/2023, documented the facility would maintain a system to account for controlled medications' receipt and disposition in sufficient detail to enable an accurate reconciliation, and the facility would conduct a periodic reconciliation. The facility should routinely reconcile the number of doses remaining in the package to the number of doses recorded on the Shift Change Controlled Substance Inventory Count Sheet, to the medication administration record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review, the facility failed to ensure a physician order to discontinue medicati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review, the facility failed to ensure a physician order to discontinue medication was completed for 1 of 24 sampled residents. The deficient practice had the potential for adverse effects on the resident and unnecessary medications.
Findings include:
Resident 14 (R14)
R14 was admitted on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis.
A pharmacist consultation report documented R14 medication regimen was reviewed on 07/23/2024 with the recommendation to discontinue the medication Spironolactone as it was contraindicated for residents on dialysis.
A physician response dated 07/29/2024 documented agreement with pharmacist recommendation and indicated the medication would be discontinued on 07/29/2024.
The medication administration record indicated Spironolactone was a current and active medication with the most recent dose given on 08/08/2024.
On 08/08/2024 in the afternoon, a Licensed Practical Nurse (LPN) indicated R14 was still receiving Spironolactone.
On 08/09/24 at 7:49 AM, the Director of Nursing verbalized the process for pharmacist review and recommendation was to ensure resident was not receiving unnecessary medications. The pharmacist would complete a review monthly and provide any recommendations as needed. The information was sent by email to the Director of Nursing and Assistant Director of Nursing. If there was a recommendation it would be sent directly to the physician for review. The DON explained the Unit Manager was responsible to ensure the physician response was documented and if any changes were required it would be completed.
The DON indicated the Spironolactone order was changed several times during R14's stay however the resident was still receiving the medication and it should have been discontinued based on recommendation and physician response.
The facility policy titled Pharmacy Services and Medication Regimen Review (reviewed 08/28/2023) documented the pharmacist must report any irregularities to the attending physician, the facility medical director, and director of nursing and the reports must be acted upon.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 it was free of a medication er...
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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 it was free of a medication error rate of five percent (%) or greater for one unsampled resident (Resident 37). Failure to administer medications as prescribed could have delayed the therapeutic treatment for the resident.
Findings include:
On 08/08/2024 in the morning, a Medication Administration Pass observation was performed with 27 opportunities observed and revealed two errors. The medication error rate was 7.41%.
Resident 37 (R37)
Resident 37 was admitted on [DATE], with diagnoses including chronic kidney disease, acute kidney failure, and polyneuropathy.
On 08/08/2024 at 8:00 AM, during the Medication Administration Pass observation, a Licensed Practical Nurse (LPN) prepared and administered the following medications to R37:
- Heparin 5,000 units subcutaneous (SQ/injection)
- Budesonide Suspension 0.5 milligram (mg)/2 milliliter (ml) inhale orally
- Cholestyramine one packet 4 grams by mouth
- Famotidine 20 mg one tablet by mouth
- Ferrous Sulfate one tablet 325 mg by mouth
- Fluticasone Propionate Nasal Spray 50 microgram one spray in both nostrils
- Gabapentin 100 mg 1 capsule by mouth
The LPN indicated there was a total of three tablets and capsule prepared and administered to Resident 37 during the Medication Administration Pass observation (Famotidine tablet, Ferrous Sulfate tablet, and Gabapentin capsule).
The physician's order dated 07/16/2024, documented Gabapentin Oral Capsule 100 mg, give two capsules by mouth three times a day for neuropathy.
The physician's order dated 07/31/2024, documented Oxybutynin Chloride Oral Tablet 5 mg, give one tablet by mouth every 12 hours for bladder spasm.
The Medication Administration Record (MAR) for August 2024, indicated Oxybutynin Chloride Oral Tablet 5 mg scheduled at 8:00 AM was documented as administered to R37 on 08/08/2024.
On 08/08/2024 at 10:35 AM, the LPN confirmed one capsule of Gabapentin 100 mg was administered to R37 and Oxybutynin 5 mg was not given to the resident during the Medication Administration Pass observation. The LPN confirmed Oxybutynin 5 mg was signed in the MAR as given. The LPN acknowledged two capsules of Gabapentin 100 mg and Oxybutynin 5 mg should have been administered to the resident.
On 08/09/2024 at 12:20 PM, the Director of Nursing (DON) indicated the nurses were expected to verify the five rights in medication administration including right dosage and right medication. The DON explained the nurses were expected to verify the orders and MAR before medication administration.
The facility's policy titled Administration of Medications dated 08/24/2023, documented the facility would ensure medications were administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Staff who were responsible for medication administration would check the MAR and the doctor's order before medicating.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
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 stored foods were labeled and dated and food ...
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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 stored foods were labeled and dated and food items were stored properly. This deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness.
Findings include:
On 08/06/2024 at 7:46 AM, open bags of green beans, asparagus, and peppers & onion mix were stored in the walk-in freezer without a date as to when the bag was opened.
The Dietary Manager explained the open bagged items should have been dated as to when the bag was opened and then placed back in the freezer.
On 08/06/2024 at 8:01 AM, a bottle of lemon juice, Jello packets, and canned pimentos were missing received on dates in the dry storage area. Also, silk, a milk substitute, was stored in the reach in cooler without a lid.
The Dietary Manager explained the items in the dry storage area should have been dated as to when the items were received from the [NAME] and the silk should have been covered before placing back in the reach in cooler.
On 08/07/2024 at 8:55 AM, a jug of pink liquid was in the reach-in cooler without a label as to what it was and no date as to when it was made/poured. There were also employee drinks (vitamin waters) stored in the reach-in cooler.
The Dietary Manager explained the pink liquid should have been labeled and dated and the employee drinks should not have been stored in the reach-in cooler.
On 08/07/2024 at 9:05 AM, cookie dough ice cream was found in a container of cookie dough in the ice cream shop's reach-in freezer.
The Activity Director stated was not sure how or why the cookie dough ice cream got into the container of cookie dough.
A document titled Food Safety, reviewed on 05/01/2024 revealed the following:
-original food containers that are considered to be 'disposable' (e.g., cottage cheese containers) are not reused.
-pre-packaged food is placed in leak-proof, pest-proof, non-absorbent, sanitary (NSF) container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). 'Use by date' is noted on the label or product when applicable.
- associate food will not be stored with resident food.
- food is labeled with the date received if not already indicated on the item.
- leftovers are dated properly and discarded after 72 hours unless otherwise indicated.
Nov 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 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 fall prevention interventions ...
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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 fall prevention interventions were included in the baseline care plan of a resident who was at risk for falls for 1 of 10 sampled residents (Resident 7). The deficient practice potentially contributed to an actual fall.
Findings include:
Resident 7 (R7)
R7 was admitted [DATE], with diagnoses including displaced mid cervical fracture of right femur.
On 11/14/2023 at 10:00 AM, R7 was alert and sitting on the side of a low bed. A walker and bedside commode were observed on the right side of the resident's bed. R7 recounted having a recent fall while ambulating to the toilet with walker assist. According to R7, the walker got caught on the bedside commode and the resident landed on bottom.
An alert charting dated 11/06/2023, revealed R7 was admitted to the facility following a right femur fracture sustained from a fall.
A fall risk assessment dated [DATE], revealed R7 had one to two falls prior to admission and was at risk for falls.
The medical record lacked documented evidence fall prevention interventions were included in R7's baseline care plan.
A facility document dated 11/12/2023, revealed R7 had a fall and landed on bottom and told staff R7 did not hit head.
On 11/15/2023 at 10:18 AM, the Director of Staff Development (DSD) reviewed R7's medical record and confirmed R7 was admitted with prior fall history, was assessed to be at risk for falls and did not have a care plan for falls. The DSD indicated R7 care plan for falls was initiated on 11/14/2023 after the resident had an actual fall on 11/12/2023.
On 11/15/2023 at 10:40 AM, the Director of Nursing (DON) indicated R7 was admitted on [DATE] with a fall-related fracture. The resident's fall risk assessment on admission had a score of 14 which meant R7 was at risk for falls and interventions were required for a score of 10 or higher. According to the DON, fall prevention interventions must be initiated for residents who were identified to be fall risks and these interventions must be included in the resident's baseline care plan. The DON confirmed there were no fall prevention interventions in R7's baseline care plan. The DON explained common fall prevention measures include assistance with activities of daily living, orient resident to room and call light use, and ensure call button was within reach. The DON confirmed R7 had an unwitnessed fall on 11/12/2023 inside room while attempting to self-transfer.
The Fall Management policy revised 04/07/2022, documented resident will be assessed for fall indicators on admission, readmission, quarterly and change in condition using the fall risk assessment. A care plan will be developed and initiated by the admitting nurse on any resident assessed to be at risk for falls.
The Baseline Care Planning policy (undated), documented the baseline care plan must include the minimum health care information necessary to properly care for each resident immediately upon admission to include initial goals of the resident, treatments, services to be administered by the facility.
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 F0661
(Tag F0661)
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 1) document evidence at discharge of medication e...
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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 1) document evidence at discharge of medication education, instructions, and reconciliation, 2) follow-up for durable medical equipment (DME) recommendation, and 3) lacked a physician's discharge summary for 1 of 10 sampled residents (Resident 9). The deficient practice potentially contributed to the resident's lack of knowledge regarding their medication and delayed the resident from obtaining the recommended medical equipment.
Findings include:
R9 was admitted on [DATE] and discharged on 07/21/23, with diagnosis including atrial fibrillation, gout, and encephalopathy.
Medication Education, Instructions and Reconciliation:
A physician order dated 07/21/23, documented R9 was to go home with medications on hand and was to be provided instructions on medication administration.
The medical record lacked documented evidence the resident and/or family was educated, or provided instructions for medication and medication reconciliation was performed at the time of discharge from the facility.
On 11/15/23 at 09:13 AM, the Case Manager, explained the employee discharging the resident was to educate the resident regarding medication. The Case Manager confirmed the medical record lacked documented evidence medication reconciliation and education was provided to the resident at discharge.
On 11/15/23 at 10:47 AM, a Licensed Practical Nurse (LPN) explained at discharge the resident was to be educated and provided a list of medications and the medical record was to be updated to reflect the resident was provided education regarding their medication.
The facility policy titled Discharge summary dated [DATE], documented the discharge summary was to contain information including a reconciliation of all pre-discharge medications with the resident's post discharge medications (both prescribed and over the counter).
Follow-up for Durable Medical Equipment (DME) Recommendation:
The Physical Therapy (PT) Discharge summary dated [DATE], documented a recommendation for DME: a manual wheelchair.
The Occupational Therapy (OT) Discharge summary dated [DATE], documented discharge recommendations including DME: a manual wheelchair.
The clinical record lacked documented evidence the recommendation from PT and OT at discharge for a manual wheelchair was followed up on and lacked evidence an order was placed for DME.
A Nursing Progress Note dated 07/21/23, documented the resident's wife called and requested a wheelchair and the order was to be submitted. The medical record lacked documented evidence the request was followed up on.
On 11/15/23 at 09:13 AM, the Case Manager acknowledged did not find documentation in the system regarding the DME for the manual wheelchair. The Case Manager explained when DME was recommended a physician order should have been obtained. The Case Manager confirmed there was no documented evidence any follow through was done for the DME request, both at discharge and when the family called to request a wheelchair.
On 11/15/23 at 9:36 AM, the Director of Rehabilitation confirmed there was a recommendation for a manual wheelchair for R9 at discharge.
Physician's Discharge Summary:
The clinical record lacked documented evidence a Physician's Discharge Summary was completed.
On 11/15/23 at 12:02 PM, the Director of Medical Records, reported physician's discharge summaries were to be completed within 30 days of discharge. The Director of Medical Records confirmed there was no physician's discharge summary in the resident's medical record and reported at the time of the resident's discharge there was an issue with the electronic system and printers.
Complaint #NV00069044
Jun 2023
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and document review, the facility failed to ensure 1 of 22 residents (R7...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and document review, the facility failed to ensure 1 of 22 residents (R72) could safely self-administer medications. The failed practice had the potential to affect the resident's health and well-being.
Findings include:
Resident 72 (R72)
R72 was admitted on [DATE] with medical diagnoses to include displaced comminuted fracture of shaft of left tibia (shin bone) and unspecified fracture of shaft of humerus (upper arm bone) and left arm.
On 06/08/2023 at 7:30 AM, observed on R72's bedside tray table were three bottles containing: calcium, magnesium, and zinc supplement, advanced hemp gummies 900 milligrams (mg), and gummies 400 mg. R72 informed they self-administered the supplement before meals and the gummies as needed for their pain, in addition to oxycodone administered by the facility. R72 identified the gummies as a tetrahydrocannabinol (THC) (cannabis) product.
Licensed Practical Nurse (LPN) (LPN1) entered the room advising this was the first time seeing the supplement and recreational medications in R72's room. R72 informed LPN1 a family member brought them in for R72 and R72 was not aware they had to report them to the staff. LPN1 removed the supplement and recreational medications from R72's room and gave them to the floor nurse.
LPN1 explained, if a resident informed facility staffs the resident wanted to self-administer a medication, LPN1 would assess the resident for their cognitive and functional status and obtain a physician clearance and order. LPN1 was not sure if the facility had a policy regarding self-administration of medication. LPN1 reported were not familiar with the recreational medication, the reaction of the recreational medication with oxycodone, or the side effects of the supplement, but explained there was potential for a high chance of side effects, double medicating, or a safety element.
On 06/08/2023 at 7:49 AM, LPN2 advised were not sure if the facility had a policy, but residents were not allowed to self-administer medication.
On 06/08/2023 at 7:57 AM, LPN3 reported the facility did have a self-administration policy which documents a resident would have to be deemed alert and oriented, depending on the type of medication, at a physician's discretion, there must be an order, and included in a resident's care plan.
On 06/08/2023 at 8:07 AM, the Director of Nursing (DON), confirmed R72 did not have orders for any over the counter medications. The DON indicated in order to self-administer medication, a resident must be deemed appropriate and competent to self-administer. The DON explained a resident would be assessed for their cognitive and functional abilities and be capable of locking up medication and documenting when the resident self-administers the medication. The DON verbalized it should also be documented on the residents' care plan. The DON added, when a resident was taking opioids, the resident should not mix THC products as it can reduce the effectiveness of the prescribed medication.
The DON called the pharmacy to inquire of the possible chemical reaction of oxycodone and the recreational medication and reported the pharmacy refused to provide information on the interaction of the two medications as the pharmacy was not the involved dispensing party.
The DON called the on-site physician to inquire of the possible chemical reaction of oxycodone and recreational medication. The physician reported it can enhance central nervous system depression, and the resident was being monitored for any adverse reactions.
The medical record lacked documented evidence for orders of calcium, magnesium, and zinc supplement, advanced hemp gummies, or THC gummies, and a physician's order for self-administration of medication.
There was a physician's order on 05/12/2023 for oxycodone, 5 milligram (mg) tablet, give one tablet by mouth every six hours as needed for moderate to severe pain 4-10, which was administered as ordered.
A facility policy titled Self-Administration of Medication (revised on 10/31/2021) revealed the facility will determine through an interdisciplinary assessment if the resident is able to safely store the medication in a secure area in their room and safely administer the medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
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 an incident of misappropriation of propert...
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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 an incident of misappropriation of property was reported to the state agency following the occurrence per policies and regulations for 1 of 22 sampled residents (Resident 15). This deficient practice could potentially lead to psychological harm to the resident, undermine rights, compromise safety, and jeopardize their well-being.
Findings include:
Resident #15 (R15)
R15 was admitted on [DATE], with diagnoses including osteoarthritis and anemia.
On 06/06/23 at 9:53 AM, R15 indicated missing $100 dollars the resident had kept in the wallet since admission. Resident indicated informing the Assistant Director of Nursing (ADON) about the missing money but has not heard anything back. R15 claimed it had been at least 2 weeks since the occurrence.
The medical record lacked documented evidence an investigation was initiated with regards to R15's missing property.
Review of the Inventory of the Personal Effects Record dated 05/09/2023, revealed the resident had five twenty-dollar bills, total of $100 in possession. It was documented R15 was advised to have the money locked up in the facility safe which the resident refused. There was documentation the resident was advised, and the resident had signed the document taking full responsibility of the cash.
On 06/07/23 at 12:00 PM, the ADON indicated being aware of the missing $100. The DON confirmed performing searches for the missing money but was not successful in finding it. The DON cannot recall the exact date of the incident but confirmed it was more than a week ago. The DON reviewed the progress notes and confirmed there was no notation from any discipline about the incident. The DON indicated the social worker (SW), and the Administrator (abuse coordinator) was made aware of the incident.
On 06/08/23 at 9:30 AM, the SW confirmed R15 did report missing money and reported on 05/17/2023. The SW indicated talking to some staff and formulated the highest possibility was the money was taken by friends who frequently visited the resident. The SW confirmed there was no documentation in R15's medical record regarding the missing property.
On 06/07/23 at 2:11 PM, the Administrator indicated not being aware of the missing money for R15. The administrator confirmed if made aware of the incident an investigation would have been initiated, documented, and completed. The Administrator would then provide the bureau with the investigative report and notify the agency as a facility reportable incident.
The facility policy titled Abuse - Reporting and Response dated 10/04/2022, documented reporting incidents with written notifications to the State Survey Agency must be made within the specified time frames.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
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 lacked documented evidence a thorough investigation of a mi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility lacked documented evidence a thorough investigation of a misappropriation of property following the occurrence was completed for 1 of 22 sampled residents (Resident 15). The failed practice had the potential to create an environment where abuse or neglect could occur unchecked, affecting all residents.
Findings include:
Resident #15 (R15)
R15 was admitted on [DATE], with diagnoses including osteoarthritis and anemia.
On 06/06/23 at 9:53 AM, R15 indicated missing $100 dollars the resident had kept in the wallet since admission. Resident indicated informing the Assistant Director of Nursing (ADON) about the missing money but has not heard anything back. R15 claimed it had been at least 2 weeks since the occurrence.
The medical record lacked documented evidence an investigation was initiated with regards to R15's missing property.
Review of the Inventory of the Personal Effects Record dated 05/09/2023, revealed the resident had five twenty-dollar bills, total of $100 in possession. It was documented R15 was advised to have the money locked up in the facility safe which the resident refused. There was documentation the resident was advised, and the resident had signed the document taking full responsibility of the cash.
On 06/07/23 at 12:00 PM, the ADON indicated being aware of the missing $100. The DON confirmed performing searches for the missing money but was not successful in finding it. The DON cannot recall the exact date of the incident but confirmed it was more than a week ago. The DON reviewed the progress notes and confirmed there was no notation from any discipline about the incident. The DON indicated the Social Worker (SW), and the Administrator (abuse coordinator) was made aware of the incident.
On 06/08/23 at 9:30 AM, the SW confirmed R15 did report missing money and reported on 05/17/2023. The SW indicated talking to some staff and formulated the highest possibility was the money was taken by friends who frequently visits the resident. The SW confirmed there was no documentation in R15's medical record regarding the missing property. The SW confirmed all investigative actions should be documented and be part of an investigative packet.
On 06/07/23 at 2:11 PM, the Administrator indicated not being aware of the missing money for R15. The Administrator confirmed if made aware of the incident an investigation would have been initiated, documented, and completed.
On 06/08/23 at 12:41 PM, the Administrator acknowledged there was no investigation packet for the incident of misappropriation of property for R15. The Administrator confirmed any abuse incident investigated should have an investigation packet.
The facility policy titled Abuse - Reporting and Response dated 10/04/2022, documented the executive director is also responsible for ensuring that documentation requirement has been met.
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 F0655
(Tag F0655)
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 a baseline care plan to manage the residen...
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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 a baseline care plan to manage the resident's pain was formulated following admission, to provide effective and person-centered care for 1 of 22 sampled residents (Resident 230). This deficient practice could potentially result in complications, poor outcomes, and a diminished quality of life for the resident.
Findings include:
Resident 230 (R230)
R230 was admitted on [DATE], with diagnoses including sepsis, repeated falls, pressure ulcer, cognitive communication deficit, and difficulty walking.
The Nursing assessment dated [DATE], documented R230's acceptable pain level was 3/10 (with a pain scale of 1 - 10). R230 had a pressure wound on the coccyx stage 2. No history of opioid addiction or disorder.
A Physician order dated 05/23/2023, documented Percocet oral tablet 5-325 milligrams (mg) to give 1 tablet by mouth every 6 hours as needed (PRN) for pain.
A Physician order dated 05/26/2023, documented Acetaminophen tablet of 325 mg to give 2 tabs by mouth every 4 hours (hrs.) PRN for pain scales 1-3. None were administered.
The Medication Administration Record dated 06/22/2023, documented Percocet was administered PRN to R230 with a pain scale of 7-10/10.
R230's medical records lacked documented evidence the baseline care plan was formulated and completed.
On 06/07/2023 at 11:00 AM, a Licensed Practical Nurse (LPN) confirmed there was no care plan in place for R280's pain management. The LPN explained a baseline care plan should have been initiated upon admission or within 48 hours to provide initial instructions on how to manage the pain accordingly based on the resident's assessment and medications.
On 06/06/2023 at 10:11 AM, the Nurse Practitioner indicated the pain should have been assessed timely, care planned, and appropriately managed based on the assessment to prevent psychological harm.
On 06/08/2023 at 12:05 PM, the Occupational Therapist indicated R230 was evaluated on 05/24/2023, with physical, occupational, and speech therapy (PT/OT/ST) and discharged on 05/29/2023, from rehabilitation services. The OT indicated R230 stayed in the facility for a few days and self-discharged against medical advice (AMA).
The OT explained R230's functional status was minimum-moderate with bed mobility, maximum with transfers, moderate memory deficit and attention. The OT indicated R230's memory evaluation had worsened, and treatment was provided by the ST. R230 was seen for three days, and one day refused to get out of bed because of diarrhea and swollen scrotum. The OT indicated R230 required maximum encouragement to participate, even in the presence of the family. The OT confirmed the pain was assessed during therapy, but there was no documentation R230 complained of pain.
On 06/08/2023 at 12:59 PM, the Director of Nursing (DON) indicated upon a resident's admission, a baseline care plan would be reviewed accordingly within 48 hours. The DON indicated the interdisciplinary team was responsible for the review and confirmed there was no baseline care plan formulated for R230's pain. The DON indicated there should have been one.
On 06/08/2023 at 1:58 PM, the Wound Nurse indicated if a resident had a stage 2 pressure ulcer, it would benefit the resident to have pain medication. The Wound Nurse could not recall if the resident complained of pain during treatment. The Wound Nurse indicated a baseline care plan was required for pain to provide person-centered care.
On 06/08/2023 at 2:05 PM, the physician indicated R230 left AMA on 05/29/2023. The physician indicated R230 was an angry man who had been refusing everything, and the pain was identified and managed.
A facility policy titled Pain Assessment and Management revised 09/08/2022, documented to help residents attain or maintain their highest practicable level of well-being by proactively identifying, planning care, monitoring, and managing their pain indicators.
A facility policy titled Baseline Care Plan dated 08/17/2022, documented a baseline care plan would be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care for the resident that meets professional standards of care.
Complaint #NV00068683
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, medical record review, and document review, the facility failed to clarify blood pressure medication instruc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and document review, the facility failed to clarify blood pressure medication instructions for 1 of 22 residents (R380). The failed practice had the potential to affect the resident's health and well-being.
Findings include:
Resident 380 (R380)
R380 was admitted on [DATE] with medical diagnoses to include end stage renal disease, hypertension, diabetes type II, and chronic obstructive pulmonary disease.
On 06/06/23 at 10:37 AM, R380 shared had refused the second dose of blood pressure medication when a nurse offered the resident medication, advising the resident's blood pressure was 121/54. R380 indicated did not feel blood pressure reading was high.
A physician's order documented:
-Clonidine 0.1 mg tablet. Give one tablet by mouth three times a day for hypertension. Hold for systolic blood pressure greater than 110 or heart rate less than 90. Started on 06/05/2023.
-Clonidine 0.2 milligrams (mg) tablet. Give one tablet by mouth every six hours as needed for hypertension. Give for systolic blood pressure greater than 160 or diastolic blood pressure less than 90. Started on 06/05/2023.
The resident's medical record documented the following blood pressures:
On 06/05/2023 at 8:46 PM, blood pressure 121/64 millimeters of mercury (mmHg).
On 06/07/2023 at 7:26 AM, blood pressure 163/90 mmHg.
On 06/07/2023 at 3:02 PM, blood pressure 150/94 mmHg.
The June 2023 medication administration record (MAR) revealed the resident's blood pressure was 163/90 mmHg and was administered the routine medication, Clonidine 0.1 mg, instead of the as needed medication, Clonidine 0.2 mg.
On 06/07/2023 at 1:50 PM, after reviewing the MAR which included the parameters of the two Clonidine medications, a Licensed Practical Nurse (LPN) (LPN1) acknowledged had made a mistake of administering R380 routine medication instead of the as needed medication based on the parameters documented. LPN1 later informed had spoken with a nurse practitioner (NP) on site who advised the routine medication (0.1 mg Clonidine) should be administered first and if a resident's blood pressure was high after, then administer the as needed medication (0.2 mg clonidine). The LPN1 and NP acknowledged the medication instructions should have been clarified.
On 06/07/2023 at 2:40 PM, LPN2 explained if a resident had a routine and an as needed blood pressure medication, both with parameters, and a resident had a blood pressure reading over the as needed medication parameter, the LPN2 would contact a physician to decide which of the two medications to administer to a resident. If a routine and an as needed medication was administered, it may be considered double medication.
On 06/07/2023 at 3:12 PM, a NP explained routine medication was given as treatment for a resident's blood pressure regimen and if the resident's blood pressure was still high after a couple of hours, the as needed medication would be administered. The NP explained an example of when an as needed medication would be administered, without the routine medication initially, was possibly if a resident had a high blood pressure over 180, but it would be a case-by-case scenario and has been explained to staff.
On 06/07/2023 at 3:42 PM, the Director of Nursing (DON), explained the facility had no policy regarding parameters or medication pass for blood pressure medications, only the medication administration policy. Staff were trained on routine and as needed medication during their orientation. The DON explained staff should have administered the routine medication and then the as needed medication if the resident's blood pressure was high after reassessment.
The DON shared if the resident's blood pressure reading was high, staff should call a physician to clarify which of the two medications to administer. If the resident's blood pressure reading was high, outside of the routine administration window, staff should administer the as needed medication and notify a physician. The DON verbalized they understood how the medication instruction was confusing.
On 06/07/2023 at 4:14 PM, LPN3 explained would administer the routine medication during the scheduled medication pass and an as needed medication if a resident's blood pressure was elevated during reassessment.
A facility policy titled Administration of Medications, last revised on 02/13/2023, revealed an order that is incomplete, illegible, or unclear should be clarified.
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 a low bed position, or a haza...
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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 low bed position, or a hazard-free environment was timely implemented for 1 of 22 sampled residents. This deficient practice could lead to an increased risk of falls and potential injuries for the resident.
Findings include:
Resident 86 (R86)
R86 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease and a fracture of the left femur (thigh bone).
The Nursing Fall Risk Evaluation dated 06/02/2023, documented R86 had a history of falls and had experienced a change in cognitive status in the last 90 days. R86 was moderately impaired with limited vision. Assistance was required for elimination, and ambulation was problematic. The resident had three or more risk factors present and was taking three or more medications, which put R86 at risk for falls.
A Care Plan dated 06/05/2023, documented R86 was a fall risk with an intervention to ensure a call light was within reach and orient the resident to the room.
On 06/06/2023 at 10:15 AM, R86's family member was overheard discussing with the staff side rail placement and expressed concerns regarding R86's fall tendencies.
On 06/06/2023 at 10:23 AM, R86 was in bed, incoherent and hard of hearing. A yellow bracelet was worn, indicating R86 was a fall risk and the bed was in a high position. R86's family was at the bedside and indicated prior to admission at the facility, R86 had a broken left femur sustained from the fall on 05/22/2023, and had surgery on 05/23/2023. R86's family expressed concerns about R86's tendency to fall because it was observed not many staff were available to monitor the resident.
On 06/06/2023 at 11:35 AM, the Nurse Practitioner (NP) was at the facility and indicated had spoken to R86's family. The NP indicated R86 was a high fall risk and had a recent fall. The NP indicated fall devices should be in place and the bed should be in the lowest position to ensure safety.
On 06/07/2023 at 8:30 AM, R86 laid in bed in a supine position, the bed was in a high position and unattended. No fall device was in place. A Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), confirmed R86's bed was in a high position. The LPN lowered the bed and indicated the bed should be in a low position because R86 was a fall risk.
On 06/08/2023 at 11:39 AM, R86 was in bed, eyes closed, call light on the floor, bed in a high position, and unattended.
On 06/08/2023 at 11:42 AM, the Occupational Therapist (OT) indicated R86 needed maximum assistance with bed mobility and transfers. The OT indicated R86 was seen for physical and occupational therapy (PT/OT). The OT indicated R86 had confusion, was hard of hearing, and had echolalia (unsolicited repetition of vocalizations made by another person), and as discussed, a psychiatric consultation would be requested for further evaluation of R86's cognitive status.
The OT indicated R86 could not walk or stand and had difficulties even with assistance, was resistant to care, and could be afraid of falling due to a fall history. The OT indicated was working on R86's stability for getting in and out of bed without falling over. The OT indicated R6 was at high risk of falling.
On 06/08/2023 at 1:30 PM, the Director of Nursing (DON) indicated upon admission, the nurses were expected to initiate fall interventions like low beds and fall mats if warranted based on the assessment.
A facility policy titled Fall Management dated 11/30/2022, documented to promote resident safety and reduce resident falls by proactively identifying, planning care, and monitoring residents' fall indicators. The facility must ensure the resident environment remains as free of accident hazards as possible. Each resident receives adequate supervision and assistive devices to prevent accidents.
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** Based on observation, interview, record review, and document review, the facility failed to ensure: 1) the correct size of an in...
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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) the correct size of an indwelling urinary catheter (Foley) was followed as ordered or clarified; 2) the Foley catheter assessment was completed; and 3) Foley use was care planned for 1 of 22 sampled residents. The deficient practices could lead to potential urinary tract infections (UTIs), an increased risk of catheter-associated complications, dehydration, blockage, and discomfort or pain for the resident.
Findings include:
Resident 86 (R86)
R86 was admitted on [DATE], with diagnoses including hyperplasia (enlargement of an organ or tissue) without lower urinary tract, benign prostatic disease, and a fracture of the left femur.
On 06/06/2023 at 10:23 AM, R86 was in bed, incoherent, and the family was at the bedside. The family indicated R86 was admitted to the facility with a Foley catheter from the hospital. R86's Foley, 16 French catheter was in place, anchored, and draining with 175 cubic centimeters (cc) of tea-colored urine with sediments.
The Hospital History and Physical dated 05/29/2023, documented the Foley catheter was ordered due to persistent acute urinary retention.
A Physician order dated 06/03/2023, documented indwelling catheter for straight drainage. Size: French (Fr) 18 Bulb: 10 cc.
On 06/06/2023 at 12:14 PM, a Certified Nursing Assistant confirmed the Foley catheter in place was 16 Fr. The CNA indicated the nurses were responsible for the verification of Foley orders.
On 06/06/2023 at 11:00 AM, the Nurse Practitioner (NP) confirmed R86's Foley size order was 18 Fr but the Foley in place was 16 Fr. The NP indicated the order should have been clarified to avoid confusion when the Foley was dislodged and needed to be replaced.
On 06/06/2023 at 11:45 AM, a Licensed Practical Nurse (LPN) indicated upon resident's admission the Foley orders should have been verified and to notify the physician if clarification was needed.
2) R86's medical records lacked documented evidence the utilization of the Foley catheter was appropriately assessed.
The Nursing admission Collection Tool, dated 06/03/2023, documented the genitourinary-urinary status of R86, who had an indwelling catheter for retention.
R86's medical records lacked documented evidence the Foley was appropriately assessed.
On 06/06/2023 at 11:00 AM, the NP indicated R86 was admitted with Foley and an appropriate assessment was expected.
On 06/07/2023 at 10:30 AM, the Director of Nursing (DON) indicated the use of Foley required an order and there should have been a Foley assessment.
On 06/07/2023 at 4:36 PM, the Director of Staff Development (DSD) explained the process of admitting the resident with a Foley catheter was to verify the orders and indication of Foley usage and, if the Foley use was justified, to assess the resident's Foley at bedside, verify the size, placement, assess the flow, the color of the urine, the presence of sediments, the volume output, the condition of the surrounding skin, and check for possible obstructions or kinks, pain, discomfort or bleeding. The Foley assessment would be documented in the medical records.
3) R86's medical records lacked documented evidence a care plan for utilization of the Foley was formulated until 06/07/2023, five days following admission.
On 06/07/2023 in the morning, the LPN confirmed there was no care plan formulated for R86's Foley catheter until 06/07/2023. The LPN indicated the baseline care plan should have been completed within 48 hours following admission.
On 06/08/2023 at 12:59 PM, the Director of Nursing (DON) indicated a baseline care plan would be reviewed accordingly within 48 hours. The DON indicated the interdisciplinary team was responsible for the review. The DON indicated there should have been a baseline care plan for R86's Foley usage.
A facility policy titled Indwelling Urinary Catheter (Foley) Management dated 08/22/2022, documented the facility aimed to ensure that residents admitted with a Foley catheter for medical reasons would receive timely and appropriate assessments regarding the need for the catheter. This included identifying and documenting the clinical indications for catheter use and establishing criteria for discontinuing the catheter when the need was no longer present. Ongoing monitoring of catheter usage was also emphasized. Residents with catheters are assessed promptly for removal unless their clinical condition necessitates continued catheterization.
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** Resident #345 (R345)
The resident was admitted to the facility on [DATE] with medical diagnoses including osteomyelitis (inflam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #345 (R345)
The resident was admitted to the facility on [DATE] with medical diagnoses including osteomyelitis (inflammation in the bone) with infection of the right ankle and foot on antibiotic (medication to treat infection) therapy.
On 06/06/2023 at 11:15 AM, R345 had a peripherally inserted central catheter (flexible catheter inserted in the vein) to the right upper arm with a dressing dated 05/30/2023.
An Admissions Progress Note dated 06/03/2023 documented a Peripherally Inserted Central Catheter (PICC) to the right arm for R345.
A review of physician orders from 06/03/2023 through 06/06/2023 lacked documented evidence of physician orders for the care and maintenance of the PICC line for R345.
On 06/07/2023 at 10:19 AM, Licensed Practical Nurse #1 (LPN1) confirmed R345 had a PICC line in the right upper arm with a dressing dated 05/30/2023. LPN1 verbalized the PICC line was inserted in the hospital and was being used for the administration of antibiotics. LPN1 explained PICC line dressing changes were completed weekly and as needed. LPN1 indicated the PICC line dressing change for R345 was due on 06/06/2023.
On 06/07/23 at 12:11 PM, the Assistant Director of Nursing (ADON) indicated PICC lines were identified when a resident was admitted to the facility. The ADON verbalized physician orders for the care and maintenance of PICC lines were entered in the Electronic Medical Record (EMR). The ADON explained once orders were entered, orders were reflected in the Medication Administration Record and Treatment Administration Record for the documentation of care. The ADON confirmed orders for the care of the PICC line for R345 should have been entered in the EMR on the day R345 was admitted to the facility, 06/03/2023. The ADON confirmed PICC line dressing change for R345 was due on 06/06/2023. The ADON explained care and maintenance of PICC lines including dressing changes were completed to prevent infection.
Resident #339 (R339)
The resident was admitted to the facility on [DATE] with medical diagnoses including dementia and muscle weakness.
On 06/06/2023 at 10:24 AM, R339 had a peripheral intravenous (in the vein) line in the right lower arm.
A Skin/ Wound Progress Note dated 05/31/2023 documented the peripheral IV line in the right forearm.
A review of physician orders from 05/30/2023 through 06/06/2023 lacked documented evidence of orders for the care and maintenance of the peripheral IV line for R339.
On 06/07/2023 at 11:01 AM, Licensed Practical Nurse #2 (LPN2) confirmed R339 had a peripheral IV line in the right lower arm. LPN2 indicated the peripheral IV line was placed in the hospital and was being used for the administration of fluids. LPN2 explained when a resident was admitted to the facility with a peripheral IV line, the physician was notified, and orders for the care and maintenance of the peripheral IV line were entered in the Electronic Medical Record (EMR).
On 06/07/23 at 12:11 PM, the ADON indicated peripheral IV lines were identified when a resident was admitted to the facility. The ADON indicated for a peripheral IV line there needed to be physician orders. The ADON verbalized physician orders for the care and maintenance of peripheral IV lines were entered in the EMR which then were reflected in the Medication Administration Record and Treatment Administration Record for the documentation of care.
Based on observation, interview, record review, and document review, the facility failed to ensure: 1) the dressings of midline intravenous access and Peripherally Inserted Central Catheter (PICC) lines were changed as scheduled for 3 of 22 sampled residents (Residents 80, 68 and 345), 2) physician orders were obtained for 3 of 22 sampled residents (Residents 68, 345, 339). This deficient practice could lead to potential risks such as increased infection risk, compromised intravenous line integrity, delayed healing, and other complications associated with improper dressing maintenance.
Findings include:
A facility policy titled Central Vascular Device Dressing Change dated 06/01/2023, documented the catheter insertion site was a potential site for bacteria that may cause a catheter-related infection. A transparent dressing was the preferred dressing. To perform sterile dressing changes upon admission, at least weekly, if the integrity of the dressing has been compromised (wet, loose, or soiled).
Resident 80 (R80) was admitted on [DATE], with diagnoses including dementia, Alzheimer's disease, osteomyelitis right ankle and foot.
A Care plan undated, documented R80 was on IV antibiotic medication related to osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the right great toe-Ceftriaxone 2 gm daily until 06/30/2023. The interventions included to observe the dressing daily and change the dressing per facility protocol and record observations at the site every shift. Observe signs and symptoms for infection at the site.
On 06/06/2023 at 9:28 AM, R80 was verbal but incoherent. A midline (intravenous line (IV)) was inserted in the left upper arm (LUA) with a single port, wrapped with a kerlix bandage, the intravenous line was not visible, and an empty bag of IV fluids was hanging on the pole. The midline was soiled, and the dressing was dated 05/26/2023. A Licensed Practical Nurse (LPN) indicated R80 was receiving Ceftriaxone IV antibiotic to treat the lower extremity osteomyelitis. The LPN confirmed the IV dressing was soiled and dated 05/26/2023. The LPN indicated the IV line dressing should have been changed weekly on Sundays but was not done due to staffing issues. The LPN indicated the LPN could change the IV line dressings if IV certified. The LPN indicated was not IV certified, was working alone that day and was in a hurry to get things done.
A Physician order dated 05/31/2023, documented to change the midline transparent dressing every Monday at day shift, change the catheter securement device with a dressing change, measure the external catheter length and notify the physician if the length has changed since the last measurement.
The Medication Administration Record dated 06/05/2023, documented the midline dressing was changed.
On 06/07/23 at 9:34 AM, the LPN confirmed the dressing change was documented. The LPN was unsure why it was documented the dressing was changed when it was not. The LPN indicated the facility had no specific assigned nurse to do the dressing and sometimes there was no RN available at the facility.
On 06/06/23 at 11:00 AM, the Nurse Practitioner indicated the midline IV dressing should have been changed weekly as scheduled to prevent infection on the insertion site.
Resident #68 (R68)
R68 was readmitted on [DATE] with diagnoses including urinary tract infection and chronic wound.
On 06/06/23 at 11:56 AM, observed R68's left upper arm PICC line had no date and resident was not able to say when was the last dressing change was completed. The IV pole had three bags of 100 milliliter (ml) IV antibiotics attached to a dial-a-flow (a medical device that is used when regulating the flow of a liquid or fluid through an IV) tubing with no dates. There was a .45 normal saline (NS) one liter bag with an attached tubing with no date on the bag and tubing. Observed three partially used NS 10 ml flushes at the desk with no caps.
Review of R68's physician's orders and medication administration record (MAR) revealed there was no care and maintenance orders for the left upper arm PICC line.
On 06/06/23 at 11:51 AM, the wound care nurse confirmed the observation and agreed IV lines should have been dated and discarded within 24 hours. IV lines should have been dated, and NS saline should have been discarded even if not completely finished. The wound care nurse indicated NS flushes should be discarded once used.
06/07/23 12:28 PM, the Assistant Director of Nursing (ADON) reviewed R68's medical record and confirmed the resident did not have orders for care and maintenance of the PICC line. The ADON indicated a batch set orders for care and maintenance should be initiated upon placement of the PICC line and during the duration the resident has a PICC line. The ADON confirmed all IV lines should have a date label and discarded when not labeled. Partially used NS flushes should be discarded and PICC line dressing should be dated.
Resident #187 (R187)
R187 was admitted on [DATE] with diagnoses including chronic viral hepatitis and weakness.
On 06/06/23 at 11:23 AM, R187 was observed with a left forearm heplock with no date. The resident indicated the heplock has been there since admission and no antibiotic was given.
On 06/06/23 at 11:23 AM, The ADON confirmed the heplock had no date and indicated the heplock was just placed yesterday due to the patient receiving antibiotics.
Review of R187's physician orders revealed no antibiotic orders, no heplock care and maintenance orders.
Review of R187's progress notes lacked documentation regarding the heplock maintenance and a reinsertion of a new heplock.
On 06/07/23 at 12:28 PM, the ADON reviewed R187's medical record and confirmed the resident did not have orders for care and maintenance of the heplock. The ADON indicated the batch set orders for care and maintenance should be initiated upon identifying the patient had an IV during the admission assessment. The ADON verbalized documentation of a heplock reinsertion was expected for all nurses.
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** Resident #9 (R9)
R9 was admitted on [DATE] with diagnoses including end stage renal disease, dependence of renal dialysis.
On 06...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #9 (R9)
R9 was admitted on [DATE] with diagnoses including end stage renal disease, dependence of renal dialysis.
On 06/06/23 at 12:05 PM, R9 was sitting in bed and bedside table was over bed with lunch tray being set up. There was an oxygen concentrator currently powered on and providing oxygen at 4 liters per minute with oxygen tubing connected to concentrator and nasal cannula laying on mattress while R9 starting to eat lunch. No date was noted to be on the oxygen tubing.
On 06/07/2023 at 10:00 AM, R9 was resting in bed with eyes closed, oxygen tubing was connected to concentrator and running at 4 liters per minute and nasal cannula was being used by resident.
The medical record lacked documented evidence of physician orders for oxygen or maintenance of oxygen and equipment and supplies
On 06/07/23 at 11:42 AM, a Licensed Practical Nurse (LPN) indicated when resident required supplemental oxygen an order would be obtained from physician and would document the frequency such as continuous or as needed. The LPN explained there would be orders to monitor the tubing for kinks and when to replace tubing.
The LPN verbalized when hospice agency was involved and orders were obtained, facility staff would fax the orders and the orders would be scanned and placed in chart. The LPN indicated there were no orders for oxygen use or maintenance of supplies, there was no information in chart or paper chart for orders from the hospice agency regarding oxygen.
On 06/07/23 at 12:55 PM, the Director of Nursing (DON) indicated when a resident was using supplemental oxygen there would need to be a physician order to include rate and frequency of oxygen use. The DON explained the orders should include changing the tubing weekly if on continuous use. The DON verbalized if a resident was on hospice or palliative care there should still be orders in the electronic health record or documentation of hospice order. The DON acknowledged Resident # 9 did not have any oxygen orders or maintenance of tubing, no care plan, and no monitoring in the medication and treatment administration record.
On 06/07/23 at 4:32 PM, the Infection Preventionist (IP) indicated the oxygen tubing needed to be dated, labeled with initials and time, and indicated if the nasal cannula was dropped and hit the floor, pathogens can enter through the tubing. If either part of the tubing is not connected to either the resident or the oxygen then there is risk for pathogen entry. The IP indicated if the nasal cannula was off the resident and just placed on the mattress it was not appropriate.
Based on observation, interview, record review, and document review, the facility failed to ensure a physician order was obtained and care orders were transcribed and implemented before the administration of Oxygen (O2) for 2 of 22 sampled residents (Residents 7 and 9). The deficient practice could lead to the potential risk of administering incorrect or inappropriate oxygen levels to residents, compromising their respiratory health and overall well-being.
Findings include:
A facility policy titled Oxygen Administration, Safety, Storage, and Maintenance, dated revised 10/07/2022, documented Oxygen would be administered in accordance with physician orders and current standards of practice. Change O2 supplies weekly and when visibly soiled. Equipment should be dated when set up or changed out.
Resident 7 (R7)
R7 was admitted on [DATE], with diagnoses including pneumonia, emphysema, asthma, and acute respiratory failure with hypoxia (low levels of oxygen) and hypercapnia (high levels of carbon dioxide in the bloodstream).
The Brief Interview of Mental Status dated 05/17/2023, documented a score of 15/15, which indicated R7's cognitive status was intact.
The History and Physical dated 05/18/2023, documented R7 was admitted to the hospital due to shortness of breath. R7 was found to be hypoxic (having too little oxygen) in the emergency room and was treated. The plan was to continue inhalation and Oxygen treatments.
On 06/06/2023 at 10:00 AM, R7 was in bed, alert, oriented, and verbally responsive. R7 was receiving O2 at 3 liters per minute (LPM) via a nasal cannula. The O2 concentrator was placed in the bathroom. R7 indicated the O2 concentrator was put away due to the noise, as requested. The O2 tubing was lying from the bathroom's floor to the room floor, and the tubing was connected to R7; the tubing was undated.
The medical records lacked documented evidence a physician order for the use of Oxygen and care orders were obtained, implemented, and the O2 saturation was monitored.
On 06/07/2023 at 9:00 AM, R7 lay in bed, and O2 was on via nasal cannula at a little under 3 LPM via nasal cannula. R7 had been coughing and indicated had asthma and had been dependent on O2 continuously. R7 indicated the O2 had been helpful for breathing and maintaining saturation because before admission to acute care, the O2 level had dropped. A Licensed Practical Nurse (LPN)confirmed R7 had O2 running continuously via nasal cannula without a physician order. The LPN indicated the utilization of the O2 required an order immediately before the administration, or upon administration, an O2 care order should have been obtained and transcribed.
On 06/07/23 at 10:19 AM, the Director of Nursing indicated the utilization of O2 required an order and the nurses were expected to obtain orders.
On 06/07/2023 at 11:00 AM, the Nurse Practitioner (NP) indicated the use of O2 required an order, and the nurses were expected to notify and obtain the orders.
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** 2) Resident 72 (R72)
R72 was admitted on [DATE] with medical diagnoses to include displaced comminuted fracture of shaft of left...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 72 (R72)
R72 was admitted on [DATE] with medical diagnoses to include displaced comminuted fracture of shaft of left tibia (shin bone) and unspecified fracture of shaft of humerus (upper arm bone) and left arm.
On 06/08/2023 at 7:30 AM, observed on R72's bedside tray table were three bottles containing: calcium, magnesium, and zinc supplement, advanced hemp gummies 900 milligrams (mg), and gummies 400 mg. R72 informed they self-administered the supplement before meals and the gummies as needed for their pain, in addition to oxycodone administered by the facility. R72 identified the gummies as a tetrahydrocannabinol (THC) (cannabis) product.
Licensed Practical Nurse (LPN) (LPN1) entered the room advising this was the first time seeing the supplement and recreational medications in R72's room. R72 informed LPN1 a family member brought them in for R72 and R72 was not aware they had to report them to the staff. LPN1 removed the supplement and recreational medications from R72's room and gave them to the floor nurse.
LPN1 explained the expectation of staff would be to remove unknown medications from a resident's bedside and inform the resident's nurse. Typically, residents are not allowed to have medications at their bedside unless a physician had cleared them and there was an order for them to be at the bedside; however, LPN1 was not clear of the facility's policy. There are no wandering residents in that hall.
On 06/08/2023 at 7:49 AM, LPN2 informed they had no knowledge of any resident having medication at the bedside, but sometimes a family member would bring in medications for a resident for the facility to store. If LPN2 saw medications in a resident's room, they would remove them, inquire with the resident about it, and inform their supervisor. A resident would need an order to have medications at their bedside.
On 06/08/2023 at 8:07 AM, the Director of Nursing (DON), confirmed R72 did not have orders to have the supplement or two recreational medications. The DON indicated the facility did not allow any THC products in the facility.
The medical record lacked documented evidence for orders of calcium, magnesium, and zinc supplement, advanced hemp gummies, or THC gummies, and a physician's order for medications to be stored at bedside.
A facility policy titled, Storage and Expiring Dating of Medications, Biologicals (revised on 07/21/2022) revealed the facility should ensure all medications, including bedside medications, were securely stored in a locked compartment.
Based on observation, interview and document review, the facility failed to 1) label a multi-dose vial with an open and discard date. The failure can lead to administering a nonviable medication to resident or staff member and 2) ensure supplements and recreational medications were safely stored for 1 of 22 residents (R72). The failed practice had the potential for resident to self-administer medication that could interact with facility prescribed medication.
Findings include:
1) On 06/07/23 at 4:02 PM, inside the medication refrigerator of the medication room at 100 and 200 Hall, was an opened Tubersol (Tuberculin PPD) 5 Units/0.1 milliliter solution for injection, with a lot #61619, expiration date of 09/2024. The vial had no open date and discard date.
A nurse confirmed the finding and acknowledged the vial should have been labeled with an open and discard date. The nurse indicated a multi-dose vial was only safe to be administered for 28 days once opened.
The facility policy titled Storage and Expiration Dating of Medications and Biologicals revised 07/21/2022, documented if a multidose vial of injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for that opened vial.
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** The facility failed to ensure transmission-based precautions were correctly implemented based on medical indication for 1 of 22 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure transmission-based precautions were correctly implemented based on medical indication for 1 of 22 sampled residents (Resident 336). The deficient practice could lead to potential breaches in infection control.
Findings include:
A review of the facility's policy titled Transmission- Based Precautions and Isolation Procedures last revised on 05/24/2023 revealed contact precautions were intended to prevent transmission of pathogens which were spread by direct person- to- person contact. The policy indicated enhanced barrier precautions were used when exposure to blood and body fluids was anticipated such as during device care or use of central lines, urinary catheters, feeding tubes, and tracheostomy/ ventilators.
Resident #336 (R336)
R336 was admitted to the facility on [DATE] with medical diagnoses including dementia.
On 06/06/2023 at 9:51 AM, a sign outside of R366's room indicated the resident was on contact precautions. The Assistant Director of Nursing (ADON) was observed donning Personal Protective Equipment (PPE) and entering the room of R336.
On 06/06/2023 at approximately 9:54 AM, the ADON exited the room of R336. The ADON confirmed R336 was on contact isolation but was unable to verbalize medical indication for the specified precaution. The ADON explained needing to look in the computer.
On 06/06/2023 at approximately 9:55 AM, the ADON indicated R336 was a new admission and was on contact isolation as a precaution in case R336 had a rash or a wound.
A review of medical records lacked documented evidence of a physician order or medical indication for R336 having been placed on contact precautions.
On 06/07/2023 at approximately 10:50 AM, a contact precautions sign remained outside of the room for R336.
On 06/07/2023 at 11:01 AM, Licensed Practical Nurse #2 (LPN2) was assigned to care for R336. LPN2 was asked why R336 was on contact precautions. LPN2 stated, 'Let's find out together.' LPN2 proceeded to pull the physical chart for R336 and began reviewing hospital records. LPN2 explained maybe R336 was on contact precautions because while in the hospital R336 was consulted by infectious disease or maybe because R336 had medical history of breast cancer with chemotherapy.
On 06/07/2023 at 3:00 PM, the Infection Preventionist (IP) explained there was no medical indication for R336 to be on contact precautions and the contact precautions sign outside the room of R336 was incorrect. The IP indicated R336 was admitted to the facility with an intravenous line in the right hand and needed to be on enhanced barrier precautions. The IP verbalized when a resident was on any Transmission Based Precautions (TBP) there was a physician order for it and a medical indication as to why the resident was on TBP.
On 06/08/2023 at approximately 8:00 AM, the IP explained staff was expected to know why a resident was on TBP through the review of labs, medications, and physician orders. The IP indicated to properly care for a resident, nursing staff was expected to know what kind of precautions a resident was on and also why those precautions were ordered. The IP verbalized the lack of follow up regarding the isolation status of R336 could potentially lead to infection control breaches in the future.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 19 (R19)
R19 was readmitted on [DATE] with medical diagnoses including adult failure to thrive, type II diabetes, Alzhe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 19 (R19)
R19 was readmitted on [DATE] with medical diagnoses including adult failure to thrive, type II diabetes, Alzheimer, and dementia with behavioral disturbance.
A facility policy titled Hospice Coordination of Care (reviewed on 08/18/2022), documented the facility must have a written agreement with the hospice that includes a communication process, to include how the communication will be documented between the facility and hospice provider.
-The facility must designate a member of the interdisciplinary team (IDT) who is responsible for working with hospice representatives.
-The facility's IDT, hospice, and the resident/responsible party collaborate to develop the resident's plan of care.
The facility's contract with a specific Hospice agency, dated 12/11/2019, documented the following:
-The Hospice plan of care should be coordinated with and integrated into the facility's plan of care for the resident.
-The facility agreed to develop and devise a system of communication wherein the Hospice team can give and receive messages regarding changes in the level of care of a resident.
-Hospice shall promptly communicate orally and in writing any changes in the Hospice plan of care to the facility. Documentation must be maintained in the resident's medical record.
On 06/08/2023, R19 was observed lying in bed with their eyes closed, connected to an oxygen concentrator with a nasal canula, and an aspiration precaution sign posted behind the bed.
On 06/08/2023 at 10:54 AM, a Certified Nursing Assistant (CNA) indicated a Hospice CNA met with R19 today. The Hospice CNA normally came on Tuesdays and Thursdays. The facility CNA verbalized there was no documentation completed by the Hospice CNA. The facility CNA indicated there would be a verbal report if there was a change in condition for R19.
On 06/08/2023 at 10:59 AM, a Licensed Practical Nurse (LPN) 2 explained R19's Hospice nurse would verbally inform the facility nurse if there were interventions performed and did not document in the facility binder for the hospice resident. LPN2 has seen other Hospice agencies documenting in a resident's Hospice binder located in the facility.
LPN2 acknowledged if the Hospice staff did not document their visit, the facility staff would not be aware of what Hospice services and care were being provided to R19. LPN2 acknowledged there was no documentation noted from the different disciplines (nurse, social worker, or chaplain) from Hospice agency responsible for care of R19. LPN2 indicated if there was a need to verify information regarding care plan they would contact the hospice agency.
On 06/08/2023 at 12:20 PM, a Registered Nurse (RN) for Hospice was in R19's room. The RN explained they visited R19 once a week to check on R19's vitals, skin, respiration precaution, pain management, and any other concerning signs and symptoms. The RN indicated they did not document their visits in the hospice binder and verbalized the hospice staff use their own devices for all documentation. The RN would provide the facility nurse with verbal updates regarding R19.
To the RN's knowledge, hospice staff members did not attend R19's Interdisciplinary Team (IDT) meetings, but there may be a contact personnel between the hospice agency and the facility regarding any concerns. The RN would send the facility a copy of any updated plan or change in order.
A physician order dated 03/29/2022 documented resident was receiving hospice services and was renewed on 12/01/2022.
R19's Hospice binder included the following:
-The contact information of the Hospice agency.
-A DNR/DNI request form; signed and dated 03/29/2022.
-A verbal order confirmation, documented to discontinue regular diet, start puree diabetic diet; signed and dated 10/31/2022.
A Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated 03/22/2023, documented the need for facility staff care coordination.
On 06/08/2023 at 1:05 PM, a social services assistant explained the process of offering and initiating hospice services for a resident would include an order for a hospice consult. Each hospice agency has a liaison or a nurse as a contact personnel for the facility to contact. The social services assistant indicated the facility care plans were based off residents needs and preferences and confirmed the facility did not coordinate an initial care plan with hospice once services were established for a resident.
On 06/08/2023 at 1:10 PM, LPN3 reported communication and documentation was not uniform across all hospice agencies with the facility and each hospice agency may have their own protocols. LPN3 verbalized facility nursing staff should be documenting information provided by hospice staff in the electronic record system and it was expected for facility staff to document verbal and written communication, any changes, and any visits from hospice staff.
LPN3 explained any change or update in care or plans should be documented in their electronic record system and the resident's care plan. LPN3 verbalized some hospice agencies provided a carbon copy to include in a resident's hospice binder. The facility's IDT included a physician and the rehabilitation team, and the facility has not held an IDT meeting to include a hospice agency staff member.
LPN3 and the social services assistant indicated the most recent hospice visit for R19 was documented on 05/24/2023.
Based on observation, interviews, record review, and document review, the facility failed to ensure a physician order was obtained prior to evaluation and admission to hospice, and there was a process in place to ensure communication between the facility and the hospice agency for 2 of 3 hospice residents. The deficient practice had the potential to have adverse effects on the resident's well-being and continuity of care.
Findings include:
Resident #9 (R9)
R9 was admitted on [DATE] with diagnoses including end stage renal disease, dependence of renal dialysis.
Brief Interview for Mental Status (BIMS) score was 15/15 indicating R9 was cognitively intact.
The facility policy titled Hospice (revised 11/23/2022) documented if the resident or responsible party chooses to receive hospice services, the attending physician must write an order referring the resident to hospice.
A physician order dated 05/22/2023 documented, Admit to hospice services as of 3/18/23 to Harbor Hospice Services.
On 06/06/23 at 12:27 PM, the only documentation in paper chart for hospice was a single piece of paper with the hospice name and number hand written in chart.
On 06/07/23 at 11:42 AM, a Licensed Practical Nurse (LPN) verbalized when hospice agency was involved and orders were obtained, facility staff would fax the orders and the orders would be scanned and placed in paper chart. The LPN indicated there were no hospice orders in the resident's paper chart.
The LPN explained communication between hospice agency and staff at facility was sometimes done with conversation prior to hospice nurse leaving facility. The LPN verbalized there was no log for hospice agencies to sign or document interventions worked on during the visit. The LPN indicated they sometimes were not aware a hospice nurse or aide visited until after they were gone, and nurse spoke to resident.
On 06/07/23 at 12:55 PM, the Director of Nursing (DON) verbalized if a resident was on hospice or palliative care there should be orders in the electronic health record or documentation of hospice order. The DON confirmed the physician order for hospice services was documented after hospice services were established.
On 06/08/23 at 9:47 AM, the Social Services Director verbalized when a resident was determined by interdisciplinary team (IDT) to benefit from hospice and resident agreed, an order for evaluation and admission to hospice should be entered prior to hospice services starting. If a resident was a new admission or had already been admitted to hospice, the physician would review discharge paperwork from previous facility and sign off on new orders.
Jan 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review the facility failed to ensure wound care treatments and monitoring of wo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review the facility failed to ensure wound care treatments and monitoring of wounds were provided as ordered by physician for 2 of 10 sampled residents (Resident #2 and Resident #4). This failure has the potential to cause harm to residents by allowing wounds to deteriorate and potentially become infected.
Findings include:
The facility policy Skin Integrity & Pressure Ulcer/Injury Prevention and Management revised 08/25/2021 and reviewed on 04/19/2022, documented the facility must ensure the resident receives care, consistent with professional standards of practice to prevent pressure ulcers. The resident's pressure ulcer receives necessary treatment and services. The physician order was to be followed.
Resident 2 (R2) was admitted on [DATE] with diagnoses including surgical aftercare following surgery on the skin and subcutaneous tissue and burn of the third degree of the buttock and lower left leg.
The physician order dated 11/23/2022 documented the following:
- monitor left buttock burn/skin graft for worsening and or signs and symptoms of infection daily.
- apply skin-prep to left buttock skin graft with dry dressing daily every Monday, Wednesday, and Friday.
- apply Silvadene cream 1% to left buttock topically daily every Monday, Wednesday, and Friday for burn wound care.
The Treatment Administration Record (TAR) dated 11/01/2022-11/30/2022, lacked documented evidence of treatment provided per the above-mentioned Physician's orders for R2 on 11/25/2022, 11/28/2022, and was not monitored daily on 11/25/2022, 11/26/2022, 11/27/2022, and 11/28/2022.
The TAR dated 12/01/2022-12/31/2022 lacked documented evidence of treatment provided per the above-mentioned Physicians orders for R2 on 12/02/2022 and was not monitored daily on 12/02/2022, 12/03/2022, and 12/04/2022.
The physician order dated 11/30/2022 documented the following:
- cleanse moisture associated skin damage (MASD) to sacral area with normal saline, pat dry, apply barrier cream for comfort daily.
- monitor MASD to sacral area for worsening and or signs and symptoms of infection daily.
The TAR dated 12/01/2022-12/31/2022 lacked documented evidence treatment was provided, or monitoring was completed per the above-mentioned Physician order for R2 on 12/02/2022, 12/03/2022, 12/04/2022, and 12/05/2022.
The medical record revealed on 12/05/2022 a new order was obtained documenting the following:
- cleanse unstageable sacral pressure ulcer with normal saline, pat dry, apply triad and Silvadene cream daily on Monday, Wednesday, and Friday.
- monitor unstageable sacral pressure ulcer for worsening and or sign and symptoms of infection daily on Monday, Wednesday, and Friday.
A skin wound progress note dated 11/30/2022 documented patient was saturated with urine, found MASD to sacral area. Advised certified nursing assistant (CNA) to frequently check and change.
A skin wound progress note dated 12/05/2022 documented R2 was examined by wound care Physician Assistant on wound rounds; Left buttock surgical site is pink, and with scant drainage; Wound to sacral was declining, upgraded to unstageable pressure ulcer. New order made and carried out.
On 01/03/2022 at 1:30 PM, a licensed practical nurse (LPN) indicated there was a wound nurse to monitor and treat residents with wound needs. The LPN revealed the wound care nurse generally was not available on weekends and the facility expectation was the unit nurses would provide care for residents as needed.
On 01/04/2022 at 8:50 AM, the wound care nurse indicated they will provide wound care when primary wound nurse was on vacation or not available. The wound nurse revealed they provide wound care on Fridays when primary wound nurse was off however there was no wound nurse assigned on weekends. The wound nurse explained most residents had simple wounds with only barrier cream applied on weekend and the expectation was the floor nurses and CNA could assist in providing care on weekends. Once wound care was provided it would be documented in the electronic health record. The wound nurse indicated wound care did not appear to be provided to the resident of concern for four days which could lead to deterioration in the wound and possibly infection.
On 01/04/2022 at 9:30 PM, the Director of Nursing (DON) indicated wound care nurse was expected to complete daily monitoring, assessment, and treatment of wounds. The DON explained the facility expectation was unit nurses would provide care for resident wounds if wound care nurse was not available. The DON confirmed R2 did not receive monitoring or treatment of wounds on above specified dates. The DON verbalized documenting in the electronic health record should be completed after every procedure and progress note should be completed for any alteration of the schedule in wound care. The DON indicated when wound orders are not followed it could lead to deterioration of wound or possible infection.
Resident #4 (R4) was admitted on [DATE], with diagnoses including orthopedic aftercare following amputation, acquired absence of left leg below knee, and sepsis.
Review of R4's medical record which contained the physician's orders and TAR for December 2022 revealed the following:
1) The physician's order dated 12/07/2022, documented cleanse bilateral legs surgical site with Normal Saline (NS), pat dry, apply Xeroform with Kerlix and Coban wrap daily on Monday, Wednesday, and Friday.
The TAR for December 2022 lacked documented evidence the resident received the treatment on 12/16/2022 and 12/19/2022 per the physician's order.
2) The physician's order dated 12/01/2022, documented cleanse bilateral lower knees surgical site with NS, pat dry, apply Xeroform with Kerlix and Coban wrap daily on Monday, Wednesday, and Friday.
The TAR for December 2022 lacked documented evidence the resident received the treatment on 12/02/2022 per the physician's order.
3) The physician's order dated 12/20/2022, documented cleanse right leg below knee amputation with NS, pat dry, apply Puracol with dry dressing with Kerlix and Coban daily on Monday, Wednesday, and Friday.
The TAR for December 2022 lacked documented evidence the resident received the treatment on 12/23/2022 per the physician's order.
4) The physician's order dated 12/01/2022, documented cleanse sacral pressure ulcer with NS, pat dry, apply Medihoney with dry dressing daily on Monday, Wednesday, and Friday.
The TAR for December 2022 lacked documented evidence the resident received the treatment on 12/16/2022 and 12/23/2022 per the physician's order.
5) The physician's order dated 12/07/2022, documented cleanse right upper chest with NS, pat dry, apply Tao with dry dressing daily on Monday, Wednesday, and Friday.
The TAR for December 2022 lacked documented evidence the resident received the treatment on 12/16/2022 and 12/19/2022 per the physician's order.
6) The physician's order dated 12/01/2022, documented monitor bilateral knee surgical site for worsening and or signs and symptoms of infection daily.
The TAR for December 2022 lacked documented evidence the resident's surgical site was monitored on 12/02/2022, 12/03/2022, 12/04/2022, and 12/06/2022 per the physician's order.
7) The physician's order dated 12/06/2022, documented monitor bilateral legs surgical site for worsening and or signs and symptoms of infection daily.
The TAR for December 2022 lacked documented evidence the resident's surgical site was monitored on 12/08/2022, 12/10/2022, 12/11/2022, 12/16/2022, 12/17/2022, 12/18/2022, and 12/19/2022 per the physician's order.
8) The physician's order dated 12/01/2022, documented monitor sacral pressure ulcer for worsening and or signs and symptoms of infection daily.
The TAR for December 2022 lacked documented evidence the resident's pressure ulcer was monitored on 12/02/2022, 12/03/2022, 12/04/2022, 12/08/2022. 12/10/2022, 12/11/2022, 12/16/2022, 12/17/2022, and 12/18/2022 per the physician's order.
On 01/03/2023 at 1:22 PM, an LPN indicated the treatment orders should have been done by the floor nurse or the wound care nurse per the physician order and documented the treatment provided in the TAR.
On 01/03/2023 at 1:45 PM, the DON explained the wound care nurse, or the floor nurse were expected to perform the wound care treatments for the residents as ordered by the physician. The DON confirmed the wound treatments, and the monitoring of the surgical sites and pressure ulcer were not followed for December 2022. The DON indicated the wound care nurse, or the floor nurse should have provided treatment following the physician orders. The DON indicated resident wounds and surgical sites may worsen and not heal if treatments were not provided according to physician orders.
Complaint #NV00067611
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 F0839
(Tag F0839)
Could have caused harm · This affected 1 resident
Based on interview and document review, the facility failed to ensure a Nursing Assistant had a Nevada certification upon hire for 1 of 4 sampled employees (Employee 1).
Findings include:
Employee 1 (...
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Based on interview and document review, the facility failed to ensure a Nursing Assistant had a Nevada certification upon hire for 1 of 4 sampled employees (Employee 1).
Findings include:
Employee 1 (E1)
E1 was hired on 05/13/2022 as a Certified Nursing Assistant (CNA).
E1's Background Check Authorization dated 05/13/2022, documented a California certification number for a Nursing Assistant and a Primary Source License Verification from Nevada Board of Nursing was printed on 09/21/2022. E1's file lacked documented evidence E1 had a Nevada certification at the time of hire.
The facility's document titled Personnel File Contents (undated) documented the personnel file should include a copy of an employee's license or certificates.
The facility's document titled Certified Nursing Aide (CNA) Job Description revised 11/10/2016, documented a CNA must be currently registered/licensed in applicable State. Must maintain an active license in good standing throughout employment.
On 01/03/2023 at 10:28 AM, a representative from Nevada Board of Nursing conveyed the COVID-19 Emergency Declaration Blanket Waiver ended on 05/20/2022.
On 01/03/2023 at 9:24 AM, the Human Resources (HR) Personnel worked alongside the Director of Staff Development (DSD) in processing new employees by checking the fingerprints, background checks and verification of state licenses and certifications. The HR Personnel confirmed E1 was hired on 05/13/2022 as a CNA and was processed by the previous DSD. The HR Personnel confirmed E1's certification from Nevada Board of Nursing was issued on 08/04/2022.
The HR Personnel indicated it was important to ensure nursing staff members had an active state license or certification upon hire and they were licensed or certified to care for residents.
On 01/03/2023 at 1:59 PM, the Director of Nursing (DON) confirmed E1 was hired as a CNA but was not aware E1 did not have a Nevada certification at the time of hire. The DON indicated hiring staff members without the proper license or certification could place the facility in jeopardy.
CPT # NV00067549
Nov 2022
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
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review the facility failed to administer intravenous (through the vein) antibio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review the facility failed to administer intravenous (through the vein) antibiotics (medications used to treat infections) in a timely manner for 2 of 6 sampled residents (Resident #1 and #2). The failed practice had the potential to delay the treatment of infection impacting the wellbeing of the residents.
Findings include:
Resident #1 (R1) was admitted on [DATE] with medical diagnoses including urinary tract infection (bacteria in the urine causing infection), diabetes (high levels of blood sugar), and encephalopathy (disease affecting brain function).
Resident #2 (R2) was admitted on [DATE] with medical diagnoses including discitis (infection of the discs located in the spine) and weakness.
A review of the Medication Administration Record (MAR) for June of 2022 for R1 revealed documented evidence of the following late administration times for intravenous Zosyn (medication used to treat an infection):
-Scheduled 06/24/2022 at 10:00 PM and administered on 06/25/2022 at 4:46 AM.
-Scheduled 06/26/2022 at 6:00 AM and administered on 06/26/202 at 3:46 PM.
-Scheduled 06/26/2022 at 2:00 PM and administered on 06/26/2022 at 4:01 PM.
-Scheduled 06/27/2022 at 10:00 PM and administered on 06/27/2022 at 11:10 PM.
-Scheduled 06/29/2022 at 10:00 PM and administered on 06/30/2022 at 12:14 AM.
-Scheduled 06/30/2022 at 2:00 PM and administered on 06/30/2022 at 5:45 PM.
A review of the Medication Administration Record (MAR) for November of 2022 for R2 revealed documented evidence of the following late administration times for intravenous Ceftriaxone (medication used to treat an infection):
-Scheduled 11/12/2022 at 8:00 PM and administered 11/13/2022 at 1:10 AM.
-Scheduled 11/13/2022 at 8:00 PM and administered on 11/13/2022 at 10:11 PM.
-Scheduled 11/14/2022 at 8:00 PM and administered on 11/14/2022 at 10:29 PM.
-Scheduled 11/15/2022 at 8:00 PM and administered on 11/16/2022 at 1:01 AM.
On 11/17/2022 at 2:15 PM, the Director of Nursing (DON) reviewed the MAR for R2 and indicated the medication was scheduled for 8:00 PM and based on the documented administration time, the medication was administered late. The DON verbalized the administration time was when the medication was given to the resident and not when the medication was documented. The DON stated the medication timeframe was 60 minutes before and 60 minutes after the scheduled time.
On 11/18/2022 at 9:00 AM, the DON reviewed the MAR for R1 for the following dates: 06/26/2022, 06/29/2022 and 06/30/2022 and indicated the medication was administered late.
The facility's policy titled Medication Administration Times, last revised 01/01/2022, revealed medication was to be administered within 60 minutes before the designated times of administration and was to be completed by 60 minutes after the designated times of administration.
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.
- • No fines on record. Clean compliance history, better than most Nevada facilities.
Concerns
- • 36 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Life Of South Las Vegas's CMS Rating?
CMS assigns LIFE CARE CENTER OF SOUTH LAS VEGAS an overall rating of 3 out of 5 stars, which is considered average nationally. Within Nevada, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Life Of South Las Vegas Staffed?
CMS rates LIFE CARE CENTER OF SOUTH LAS VEGAS's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 46%, compared to the Nevada average of 46%.
What Have Inspectors Found at Life Of South Las Vegas?
State health inspectors documented 36 deficiencies at LIFE CARE CENTER OF SOUTH LAS VEGAS during 2022 to 2025. These included: 36 with potential for harm.
Who Owns and Operates Life Of South Las Vegas?
LIFE CARE CENTER OF SOUTH LAS VEGAS 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 LIFE CARE CENTERS OF AMERICA, a chain that manages multiple nursing homes. With 120 certified beds and approximately 111 residents (about 92% occupancy), it is a mid-sized facility located in LAS VEGAS, Nevada.
How Does Life Of South Las Vegas Compare to Other Nevada Nursing Homes?
Compared to the 100 nursing homes in Nevada, LIFE CARE CENTER OF SOUTH LAS VEGAS's overall rating (3 stars) is below the state average of 3.0, staff turnover (46%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Life Of South Las Vegas?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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?" These questions are particularly relevant given the below-average staffing rating.
Is Life Of South Las Vegas Safe?
Based on CMS inspection data, LIFE CARE CENTER OF SOUTH LAS VEGAS 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 3-star overall rating and ranks #100 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 Life Of South Las Vegas Stick Around?
LIFE CARE CENTER OF SOUTH LAS VEGAS has a staff turnover rate of 46%, 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 Life Of South Las Vegas Ever Fined?
LIFE CARE CENTER OF SOUTH LAS VEGAS has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Life Of South Las Vegas on Any Federal Watch List?
LIFE CARE CENTER OF SOUTH LAS VEGAS 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.