Stanton Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(H)Based on interview and record review; the facility failed to ensure residents were protected from residents with adverse behaviors for 2 (Residents 5 and 10 ) of 11 sampled residents. The facility census was 52.Findings are: A. Review of the facility policy Abuse, Neglect, or Misappropriation of Property with a reviewed date of 7/15/25 revealed the policy was a mechanism for the prompt identification, investigation and reporting of any allegation or complaint of abuse, neglect, or exploitation. If a staff member witnessed or suspected resident to abuse resident, neglect or any type of crime, the staff were to immediately intervene and take steps to protect the resident. Staff were to keep residents and other staff away from any abusive/aggressive residents. The policy indicated allegations of potential abuse were to be immediately reported to a supervisor, the facility Administrator or designee and in accordance with the state and federal laws. If there was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number NAC 12-006.09Based on observations, interviews and record reviews; the facility failed to implement interventions to manage behaviors for 1 (Resident 1) of 11 sampled residents. The facility census was 52. Findings are:A. Review of the facility policy Behavior Management Program, last revised 7/13/25 revealed residents who displayed mental or psychosocial adjustment difficulty would receive appropriate services in an attempt to correct the problem. The guidelines included:-behaviors would be identified through the RAI (Resident Assessment Instruction Manual- a standardized comprehensive guide to evaluate resident's clinical, functional, and cognitive status) process and through staff interaction;-further assessments to identify and manage behaviors may be conducted;-identified behaviors should be evaluated through frequency, duration and intensity for a pattern;-the Interdisciplinary Team would decide which residents needed a behavior management program vs residents that were care planned with appropriate interventions by evaluating the behavior…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.05(S) Based on observation, interview, and record review; the facility failed to ensure Resident 46's dignity was maintained related to a transfer to the bathhouse. The sample size was 2 and the census was 49. Findings are: A record review of the undated facility Resident Rights provided to residents at the time of admission, revealed that all residents have the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and in care for his or her personal needs.During an observation on 7/8/25 at 8:17 AM, Resident 46 was positioned in a bath chair in the corridor outside of the resident's room. The resident's lower legs and feet were uncovered and were hanging suspended from the seat of the chair. The resident wore a hospital gown with the back open which exposed the resident's lower back and buttocks. The resident's legs, feet, back and buttocks were bare and were visible to any other residents, staff and/or visitors who were in the corridor or who were on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report, investigate, and submit a completed investigation report related to an allegation of potential abuse to the State Agency within the required time frame for Residents 3 and 39. The sample size was 5 and the facility census was 49. Findings are: A. Record review of the facility policy Abuse, Neglect, or Misappropriation of Property last revised 1/23/24 revealed the facility had a zero tolerance policy and mandated employees to immediately report any allegations/suspicions of:-any type of crime committed against a resident,-Resident abuse,-willful resident neglect, -misappropriation of resident property, and-exploitation of a resident. The Administrator, Director of Nursing (DON), or designee would interview the person reporting, any witnesses, the resident and the charge nurse, review the residents medical record, interview all staff members that had contact with the resident, interview the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09Based on interview and record review; the facility failed to complete neurological assessments (assessment of motor and sensory skills, hearing, speech, vision, coordination, and balance to determine a potential injury or change in status) after unwitnessed falls for 1 (Resident 46) of 4 sampled residents. The facility identified a census of 49.Findings are:Record review of the facility policy Resident Fall Assessments with a revision date of 8/24 revealed after an unwitnessed fall or a fall in which a head injury was identified, the staff were to complete a neurological assessment per policy:-every 15 minutes for 1 hour,-every hour for 4 hours, and-every 4 hours for 19 hours. Record review of Resident 46's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 5/15/25 revealed the resident was admitted on [DATE] with diagnoses of non-traumatic brain dysfunction, heart failure, diabetes, Alzheimer's dementia, anxiety, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.18(B)Based on observations, record review and interview; the facility failed to ensure respiratory care equipment was cleaned and stored in a sanitary manner to prevent the potential for cross contamination for Resident 6. The sample size was 1 and the facility census was 49. Findings are: Record review of the facility policy Respiratory Equipment Storage and Sanitation with a revision date of 7/1/24 revealed the purpose of the policy was to ensure respiratory equipment was stored and sanitized in a manner that prevented cross contamination, protected the resident's health and complied with infection prevention and control standards. Nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) equipment was to be dissembled and thoroughly rinsed after use, set out to dry on a clean dry surface and disinfected per policy using an approved disinfectant or sterilization method. Once the equipment was dry and ready for storage, it was to be placed in a clean, labeled, anti-microbial storage bag…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility failed to notify Resident 2's Primary Care Physician (PCP) of the resident's change in fluid buildup, mental status, and behaviors. The sample size was 1 and the facility census was 62. Findings are: A. Review of the facility policy Provider Notice of Adverse Event and/or Change in Condition with a review date of 6/5/23 revealed the facility staff were to assure timely and appropriate notification to the PCP regarding changes in condition and adverse events. A change in condition was defined as any significant alteration in a resident's physical, mental, or emotional state that may require medical intervention or adjustment of the resident's care plan. B. Review of Resident 2's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning ) dated 3/28/24 revealed the resident was admitted [DATE] with diagnoses of paranoid schizophrenia, diabetes, cerebral palsy, depression, and anxiety. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 09(G)(i) Based on record review and interview the facility failed to complete the required Discharge Summary for Resident 63. The sample size was 2 and the facility census was 62. Findings are: Review of the facility policy Transfer and Discharge with a revision date of 5/21/24 revealed the following: -The facility permitted each resident to remain in the facility and not initiate transfer and or discharge except in limited circumstances. -A Resident initiated transfer or discharge meant the resident and or their representative provide notice of their intent to leave the facility. -The facility evaluated and determined the level of care needed for residents leaving the facility, and -completed a Discharge Summary including a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of the resident's medications and a post discharge plan of care. Review of Resident 63's Admission/Discharge Record dated 6/13/24 revealed the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to follow Resident 2's physician order regarding a fluid restriction, and Resident 3's physician orders related to daily weights and use of an as needed diuretic. The sample size was 5 and the facility census was 62. The findings are: A. Review of Resident 2's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning ) dated 3/28/24 revealed the resident was admitted [DATE] with diagnoses of coronary artery disease, paranoid schizophrenia, diabetes, cerebral palsy, depression, and anxiety. The assessment identified the resident was having behavior symptoms not directed at others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily waste and verbal/vocal symptoms like screaming or making disruptive sounds) and rejection of cares. The assessment further indicated the resident was receiving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility failed to provide assessment and monitoring of Resident 114's pressure ulcer (injuries to the skin and the tissue below the skin due to pressure) to ensure healing. The sample size was 3 and the facility census was 62. Findings are: A. Review of the facility policy Skin Care and Management with a revision date of 4/23/24 revealed the facility had established a systemic approach for prevention and management of pressure ulcers which included prompt assessment and treatment; intervention to reduce or remove underlying risk factors; and monitoring/modifying interventions as appropriate. A Licensed Nurse was to conduct a full body assessment on all residents at admission/readmission then weekly and after any newly identified pressure ulcer or skin alteration. Findings were to be documented in the medical record and the Primary Care Physician (PCP) notified. Assessments of any new pressure ulcers were to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, record review and interview; the facility failed to maintain infection prevention measures for Enhanced Barrier Precautions (EBP-an infection control measure designed to reduce transmission of Multiple Drug Resistant Organisms (MDRO's-bacteria that have become resistant to certain antibiotics) during the provision of wound care for Residents 22 and 52, failed to implement EBP and best practice for catheter care to prevent potential infections for Resident 52, and failed to complete hand hygiene at appropriate intervals during the provision of care for Residents 22 and 52. The sample size was 20 and the facility census was 62. Findings are: A. Review of the facility policy Infection Prevention and Control Program with a revision date of 2/8/24 revealed the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, that helped to prevent the development and transmission of communicable diseases and infections, per accepted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to investigate and submit a report of the unexpected death of Resident 55 to the State Agency within the required time frames. The sample size was 20 and the facility census was 55. Findings are: A. Record review of the facility Abuse, Neglect, or Misappropriation of Property Policy dated [DATE] revealed the following; -The facility had a zero-tolerance policy for any type of crime committed against a resident, resident abuse, willful resident neglect, misappropriation of resident property, resident exploitation, and mandated all employees to immediately report an allegation and/or suspicions of those items. In addition, the facility did not continue to employ any employee found guilty of those items. -The facility took steps to prevent resident abuse, neglect, and misappropriation through screening of potential residents, background screening of potential employees and or volunteers, refrained from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09A1 Based on record review and interview; the facility failed to complete a revised level 1 Pre-admission Assessment and Resident Review (PASRR- a federally mandate screening assessment used to determine appropriate placement for individuals with Serious Mental Illness (SMI) or an Intellectual Disability (ID)) for Resident 34. The sample size was 20 and the facility census was 55. Findings are: Record review of the facility policy Admissions and Pre-admission Screening and Resident Review dated 3/5/22 revealed the facility's purpose was to establish a standardized process that facilitated comprehensive screening, assessment and decision making to determine eligibility and appropriate level of care determinations, for SMI or ID persons seeking admission to the nursing home, while promoting quality of care and support services. -Level 1 Evaluation or the initial screening would be conducted by a qualified mental health or healthcare provider to determine the presence of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure assessments were completed for Resident 53 to assess for potential adverse effects from antipsychotic medications (medications which alter consciousness, mood and thoughts). The sample size was 5 and the census was 55. Findings are: A. Record review of the facility Abnormal Involuntary Movement Scale (AIMS) Assessment Policy implemented on 2/2/22 revealed the following; -the purpose was to identify and monitor medication-induced movement disorders in residents, -a baseline assessment would be conducted for residents who were newly admitted to the nursing home and were prescribed medications with known movement disorder risks, -the baseline assessment would be completed within 2 weeks of admission, at least every 6 months, or within 10 days of medication initiation, - the AIMS assessment would evaluate the face, limbs, or trunk with severity scored on a scale, and -the AIMS assessment results would be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.