Gardnerville Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review, the facility failed to ensure the administration of a controlled medication was documented in the controlled drug record for 1 unsampled resident (Resident #31). This deficient practice had the potential to result in inaccurate record keeping of the administration of controlled substances, misappropriation of a resident's medications and a resident's symptoms not being managed effectively.Findings include:Resident #31Resident #31 was admitted to the facility on [DATE], with a diagnosis of quadriplegia, C1-C4 incomplete.A medication order and the May 2026 Medication Administration Record (MAR) for Resident #31 documented oxycodone hydrochloride (HCl) oral tablet 10 milligrams (mg). Give 10 mg by mouth every six hours as needed for pain management.On 06/24/2026 at 2:35 PM, during a review of the controlled drug logbook in the 100-hall medication storage cart, page 11 of the logbook documented Resident #31 had one tablet remaining 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 Based on observation, interview, clinical record review and document review, the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 29 opportunities observed and two errors. The medication error rate was 6.9%. This deficient practice had the potential to result in residents receiving medications in a manner inconsistent with physician orders and professional standards, placing them at risk for ineffective treatment, adverse drug reactions, and compromised health outcomes.Findings include:Resident #4Resident #4 was admitted to the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.The June 2026 Medication Administration Record (MAR) for Resident #4 documented the following:-sennosides oral capsule 8.6 milligrams (mg). Give 8.6 mg by mouth one time a day for constipation - hold for loose stools give two tabs.-Zofran oral tablet 4 mg (ondansetron hydrochloride). Give 4 mg by…

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 Based on observation, interview, and record review, the facility failed to maintain accurate and complete clinical records for 1 of 14 sampled residents (Resident #44) when the facility did not ensure bathing documentation, refusal documentation was accurately recorded and to ensure residents with indwelling urinary catheters received care and services necessary to prevent Urinary Tract Infections (UTIs) including care planning and catheter care/cleaning for 3 of 14 sampled residents (Residents #59, #5, and #18). This deficient practice had the potential to result in incomplete medical records resulting in an inaccurate representation of the residents' care needs, services provided and risks for complications related to catheter use including obstruction, UTI, and sepsis. Findings include: Resident #44 Resident #44 was admitted on [DATE], with diagnoses including need for assistance with personal care, psychosis, and major depressive disorder. On 06/22/2026 at 11:22 AM, Resident #44 verbalized not 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.

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the facility lacked a process to ensure residents were screened for eligibility to receive an influenza and/or pneumococcal vaccine upon admit and annually thereafter. This deficient practice resulted in a substandard quality of care related to the facility's immunization program. Findings include:On 06/29/2026 at 3:03 PM, the Administrator confirmed the QAPI committee had not identified a concern related to screening residents for eligibility to receive influenza and/or pneumococcal vaccines at admit and annually thereafter. The Administrator explained the Administrator was not sure how the QAPI committee could have identified the concern and verbalized identifying the concern could have led to a change in the immunization process by adding a document with targeted questions. The facility policy titled QAPI Plan updated and approved 02/06/2026, documented QAPI was a dynamic process used to facilitate the identification of areas for improvement 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.

Based on interview, personnel record review, and document review, the facility failed to ensure initial and annual communication training was completed timely per facility policy for 8 of 20 sampled employees (Employee #4, #10, #11, #12, #13, #15, #16 and #17). This deficient practice had the potential to prevent residents with communication needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being. Findings include:Employee #4 Employee #4 was hired as the Registered Dietician on 12/08/2025. Employee #4's personnel record documented Communication Training completed on 05/13/2025; however, lacked annual training completed for 2026. Employee #10 Employee #10 was hired as a CNA hired on 01/16/2026. Employee #10's personnel record lacked documented evidence of Communication Training completed upon hire. Employee #11 Employee #11 was hired as a Speech Pathologist on 02/03/2026. Employee #11's personnel record lacked documented evidence of Communication Training completed upon hire. Employee #12 Employee #12 was hired as the Infection…

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.

Based on interview, personnel record review, and document review, the facility failed to ensure initial Quality Assurance and Performance Improvement (QAPI) training was completed timely per facility policy for 5 of 20 sampled employees (Employee #9, #10, #15, #16 and #17). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations. Findings include:Employee #9 Employee #9 was hired as a Certified Nursing Assistant (CNA) hired on 08/05/2020. Employee #9's personnel record documented QAPI training completed on 09/16/2024, however, lacked documented evidence of annual QAPI training completed in 2025. Employee #10 Employee #10 was hired as a CNA hired on 01/16/2026. Employee #10's personnel record lacked documented evidence of QAPI training completed upon hire. Employee #15 Employee #15 was hired as a Licensed Practical Nurse hired on 01/26/2026. Employee #15's personnel record lacked documented evidence of QAPI training completed upon hire. Employee #16 Employee #16 was hired as a CNA hired on 04/23/2026.…

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.

Based on interview, personnel record review, and document review, the facility failed to ensure initial and annual infection control training was completed timely per facility policy for 3 of 20 sampled employees (Employee #9, #15 and #16). This deficient practice had the potential to put residents at risk of contracting avoidable infections and diseases. Findings include:Employee #9 Employee #9 was hired as a Certified Nursing Assistant (CNA) hired on 08/05/2020. Employee #9's personnel record documented Infection Control training completed on 09/23/2024, however, lacked documented evidence of annual QAPI training completed in 2025. Employee #15 Employee #15 was hired as a Licensed Practical Nurse hired on 01/26/2026. Employee #15's personnel record lacked documented evidence of Infection Control training completed upon hire. Employee #16 Employee #16 was hired as a CNA hired on 04/23/2026. Employee #16's personnel record lacked documented evidence of Infection Control training completed upon hire. On 06/29/2026 at 8:43 AM, the Business Office Manager (BOM) explained 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.

Based on interview, personnel record review, and document review, the facility failed to ensure initial and annual compliance and ethics training was completed timely per facility policy for 3 of 20 sampled employees (Employee #2, #9 and #16). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations. Findings include:Employee #2 Employee #2 was hired as the Director of Nursing on 07/29/2024. Employee #2's personnel record documented compliance and ethics training completed on 04/01/2025; however, lacked annual training completed for 2026. Employee #9 Employee #9 was hired as a Certified Nursing Assistant hired on 08/05/2020. Employee #9's personnel record documented compliance and ethics training completed on 05/02/2025; however, lacked annual training completed for 2026. Employee #16 Employee #16 was hired as a Certified Nursing Assistant hired on 04/23/2026. Employee #16's personnel record lacked documented evidence of initial compliance and ethics training. On 06/29/2026 at 8:43 AM, the Business Office…

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.

Based on interview, personnel record review, and document review, the facility failed to ensure initial and annual Behavioral Health training was completed timely per facility policy for 15 of 20 sampled employees (Employee #1, #2, #3, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, and #17). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations. Findings include:Employee #1 Employee #1 was hired as the Administrator on 07/16/2025. Employee #1's personnel record lacked documented evidence of initial behavioral health training. Employee #2 Employee #2 was hired as the Director of Nursing on 07/29/2024. Employee #2's personnel record lacked documented evidence of annual behavioral health training. Employee #3 Employee #3 was hired as the Activities Director on 03/04/2019. Employee #3's personnel record lacked documented evidence of annual behavioral health training. Employee #5 Employee #5 was hired as a Social Worker on 07/11/2022. Employee #5's personnel record lacked documented evidence of annual…

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 Based on clinical record review, employee record review, interviews, and document review, the facility failed to ensure a resident was protected from physical abuse by an employee (Employee #4) while providing care for 1 of 9 sampled residents (Resident #1). This deficient practice has the potential to place residents at risk for further abuse, compromised safety, and unmet care needs. Findings include:Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and unspecified lack of coordination. Employee #4 Employee #4 with a title of Certified Nursing Assistant (CNA) had a start date of 11/04/2025. The employee record documented abuse training had been completed on 11/03/2025. A Facility Reported Incident (FRI) dated 12/17/2025, documented Employee #4 (CNA) 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 Based on observation, interview, clinical record review, and document review, the facility failed to ensure Transmission-Based Precautions (TBP) were implemented according to facility policy and Centers for Disease Control and Prevention (CDC) recommendations for 1 of 13 sampled residents (Resident #27) and Enhanced-Barrier Precautions (EBP) were implemented for 3 of 5 residents meeting criteria for EBP (Resident #20, #6, and #15). This deficient practice had the potential to increase risk of spreading infectious organisms throughout the facility. Findings include: Transmission-Based Precautions Resident #32 Resident #32 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic respiratory failure with hypoxia and chronic kidney disease, stage four (severe). On 04/28/2025 at 7:31 AM, a sign was attached to the door frame of Resident #32 and Resident #27's room. The sign indicated the room had contact precautions in place, requiring a gown and gloves be donned prior to…

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.

An initial report for FRI #NV00073619, with an allegation a Certified Nursing Assistant was verbally abusive toward a resident was submitted to the SA on 03/06/2025. A review of progress notes related to the incident revealed the incident occurred on 03/04/2025. Based on interview and document review, the facility failed to ensure an allegation of abuse, neglect and a fall resulting in serious bodily injury was reported to the State Agency (SA) within the required time frame for 7 of 10 Facility Reported Incidents (FRI). This deficient practice could result in allegations of abuse and neglect not being investigated by the facility and/or the SA timely. An initial report for FRI #NV00073584, with an allegation of Resident-to-Resident physical abuse was submitted to the SA on 03/03/2025. The report documented the alleged incident occurred on 02/25/2025. A resident grabbed another resident's shoulders and shook them to wake them up. An initial report for FRI #NV00073594, with an allegation of Resident-to-Resident sexual abuse was submitted to the SA on 03/03/2025. The report documented…

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 Based on clinical record review, interview and document review the facility failed to ensure a device evaluation was completed and consent obtained prior to placing a resident's mattress on the floor for 1 of 24 residents sampled related to Facility Reported Incidents (FRIs). This deficient practice had the potential to deprive a resident/resident representative of the right to be informed of the risks and benefits of an intervention which could restrict the resident's freedom of movement. Findings include: Resident #45 Resident #45 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy and idiopathic normal pressure hydrocephalus. A final report for FRI #NV00073587, documented an allegation of neglect was substantiated by the facility when a Licensed Practical Nurse (LPN) placed Resident #45's mattress on the floor. A witness statement provided by a Certified Nursing Assistant (CNA), dated 03/05/2025, documented the LPN took Resident #45's bed frame away and placed 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 Based on interview, clinical record review, and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) treated a resident with dignity and did not seclude the resident, leaving the resident only in a brief and a t-shirt in the dining room while experiencing behaviors for 1 of 24 residents sampled related to facility reported incidents (FRI) (Resident #43). This deficient practice had the potential to result in the resident experiencing psychosocial harm or emotional distress due to not being treated with respect and dignity. Findings include: Resident #43 Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE], and discharged on 03/12/2025, with diagnoses including unspecified dementia, severe with other behavioral disturbance, anxiety disorder, unspecified, cognitive communication deficit, other seizures, and difficulty in walking, not elsewhere classified. A FRI, dated 03/06/2025, documented a Certified Nursing Assistant (CNA) entered Resident #43's room to assist…

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 Based on interview, clinical record review, and document review, the facility failed to protect 1 of 24 residents sampled for Facility Reported Incidents (FRI) free from involuntary seclusion. The deficient practice had the potential to cause the resident psychosocial harm or emotional distress by placing the resident alone in the common dining room, closing the door, and leaving the resident isolated from others. Findings include: Resident #43 Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE], and discharged on 03/12/2025, with diagnoses including unspecified dementia, severe with other behavioral disturbance, anxiety disorder, unspecified, cognitive communication deficit, other seizures, and difficulty in walking, not elsewhere classified. A FRI, dated 03/06/2025, documented a Certified Nursing Assistant (CNA) entered Resident #43's room to assist the resident with a brief change. The resident became verbally agitated and began to exhibit signs of psychosis, signaling a Licensed…

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 Based on clinical record review, interview, and document review the facility failed to ensure a Minimum Data Set 3.0 (MDS) assessment was accurate for 1 of 13 sampled residents (Resident #29). This deficient practice had the potential to deprive residents of necessary care and services relative to current health management needs in the facility. Findings include: Resident #29 Resident #29 was admitted to the facility on [DATE], with a diagnosis of type one diabetes mellitus with diabetic chronic kidney disease. A Physician's Order dated 08/20/2024, documented Eliquis oral tablet 5 milligrams (mg), give 5 mg by mouth two times a day for Deep Vein Thrombosis (DVT) prophylaxis. Resident #29's Medication Administration Record (MAR) for April 2025 documented Eliquis 5 mg was administered to the resident from 04/01/2025 through 04/30/2025. An MDS assessment dated [DATE], Section N - Medications, item E - Anticoagulant lacked an X or any other documentation indicating the resident was taking an anticoagulant…

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 Based on observation, interview, record review and document review, the facility failed to ensure 1) the facility had a process in place to identify and refer residents for pre-admission screening and resident review (PASARR) level II and 2) to initiate a submission for a determination of a Preadmission Screening and Resident Review (PASARR) level I for 1 of 13 sampled residents (Resident 4). The deficient practice had the potential to deprive residents from obtaining appropriate behavioral health services. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis not due to a substance or known physiological condition, depression, unspecified, and other symptoms and signs involving cognitive functions and awareness. Resident #4's PASARR Level I documented completion on 04/03/2013. The PASARR Level I documented IC-no Mental Illness, Mental Retardation, or Related Conditions. PASARR appropriate for Nursing Facility (NF) placement. Resident…

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 Based on observation, interview, clinical record review, and document review the facility failed to ensure Oxygen use and associated diagnoses were care planned for 1 of 13 sampled residents (Resident #34). This deficient practice had the potential to result in staff working with the resident to be unaware of the need to monitor the resident for shortness of breath or difficulty breathing, provide Oxygen as ordered, and monitor Oxygen saturation. Findings include: Resident #34 Resident #34 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and chronic systolic (congestive) heart failure. On 04/28/2025 at 9:45 AM, Resident #34 was receiving Oxygen via a Nasal Cannula (NC). The resident's Oxygen concentrator was set at 2.5 liters per minute (LPM). On 05/01/2025 at 7:49 AM, Resident #34 was sitting on the edge of the resident's bed. A NC was hanging below the resident's chin. A Registered Nurse (RN) entered Resident #34's…

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 Based on observation, interview, record review and document review, the facility failed to ensure a resident who relied on staff for Activities of Daily Living (ADLs) received scheduled showers or baths as required for 1 of 13 sampled residents (Resident #19). The deficient practice had the potential to increase skin breakdown, infections, odor, and bacteria buildup. Findings include: Resident #19 Resident #19 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including intervertebral disc degeneration, lumbar region with discogenic back pain, muscle weakness, and atrial fibrillation. On 04/28/2025 at 12:54 PM, Resident #19 verbalized not receiving showers regularly as scheduled and gave their own bed bath. The resident explained feeling itchy and bad about themselves when not receiving regular scheduled showers. The Minimum Data Set (MDS) 3.0 in section GG dated 02/13/2025, indicated substantial/maximal assistance with showering and bathing self. Resident #19's Care Plan initiated on 04/17/2025,…

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 Based on observation, interview, clinical record review, and document review the facility failed to ensure oxygen was administered according to a physician's order for 1 of 13 sampled residents (Resident #34). This deficient practice had the potential to cause worsening of the resident's diagnosed chronic obstructive pulmonary disease. Findings include: Resident #34 Resident #34 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and chronic systolic (congestive) heart failure. On 04/28/2025 at 9:45 AM, Resident #34 was receiving Oxygen via a Nasal Cannula (NC). The resident's Oxygen concentrator was set at 2.5 liters per minute (LPM). On 05/01/2025 at 7:49 AM, Resident #34 was sitting on the edge of the resident's bed. A NC was hanging below the resident's chin. A Registered Nurse (RN) entered Resident #34's room and adjusted the resident's NC. The RN explained Resident #34 was supposed to be on two liters of Oxygen. 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.

Based on personnel record review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) employed greater than one year had a performance review completed annually for 1 of 3 CNAs reviewed for completed performance review. This deficient practice had the potential to affect all residents when the facility did not identify areas of CNA performance in need of insevice education/training. Findings include: Employee #9 Employee #9 was hired on 08/31/2023 as a CNA. Employee #9's personnel record lacked documentation a performance review had been completed in 2024. On 04/30/2025 at 11:45 AM, the Director of Nursing verbalized having been responsible for completing CNA performance evaluations and confirmed Employee #9 had not received a performance review upon the employee's one year anniversary. The facility policy titled, Nursing Personnel Education and Training, published 11/2016, documented employee reviews were to be completed every 12 months and identify areas of improvement and competencies to be completed as needed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 26 opportunities observed and two errors. The medication error rate was 7.69%. Findings include: Resident #38 Resident #38 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery, intracardiac thrombosis, not elsewhere classified, and ventricular tachycardia, unspecified. On 04/30/2025 at 8:14 AM, a Registered Nurse (RN)1 began preparing medications for Resident #38. The RN1 verbalized some of the resident's ordered medications were out of stock in the medication cart and the RN1 would need to go to the medication storage room to see if there was additional stock of the medications available. On 04/30/2025 at 8:18 AM, while in the medication storage room, the RN1 accessed an automated medication dispensing system,…

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 Based on observation, interview, and document review the facility failed to ensure a multi-dose vial was labeled with the date the vial was opened in 1 of 1 medication storage rooms inspected. This deficient practice placed residents at risk for injection with expired Tuberculin Purified Protein Derivative (PPD) solution and potentially inaccurate Tuberculin PPD skin test results. Findings include: On [DATE] at 3:39 PM, during an inspection of the medication storage room and in the presence of the Infection Preventionist (IP), a vial of Tuberculin PPD (Mantoux) 5 Tuberculin Units (TU)/ 0.1 milliliters (ml) was found in the medication storage refrigerator. The vial lacked a cap, and a puncture site was observed in the rubber stopper. The vial and the manufacturer box lacked an open date. The manufacturer box included instructions to discard the vial within 30 days of opening. The IP confirmed the vial of Tuberculin PPD solution was open and lacked an open date written on the vial and the box. The IP verbalized…

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.

Based on interview and document review, the facility failed to ensure the Facility Assessment (FA) was reviewed, updated, included input from and was approved by facility leadership and management Quality Assessment and Assurance (QAA) Committee. The deficient practice could result in the facility not being able to determine what resources were necessary to care for its residents competently. Findings include: On 04/30/2025, a review of the FA presented by the Interim Executive Director (IED), dated 03/25/2025, lacked documented evidence of an attendance sheet indicating a review of the FA contents by facility QAA Committee. The previous FA was requested from the IED. However, the FA documented individuals involved in completing the FA, to include the following: -Administrator -Director of Nursing (DON) -Governing Body Representative -Medical Director -Direct Care Representative -Resident Representative. On 04/30/2025 at 8:40 AM, the IED presented the previous FA, dated 08/29/2024. The IED verbalized the previous FA was placed in the shred pile and had to be located by staff. The FA…

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 Based on observation, interview, clinical record review, and document review the facility failed to ensure 1) As Needed (PRN) medications were documented timely for 1 of 6 residents observed for medication administration (Resident #7) and 2) a wound care order was entered into the Electronic Medical Record (EMR) for 1 of 13 sampled residents (Resident #12). This deficient practice had the potential for duplicate administration of PRN medications, accurate Medication Administration Records (MARs) to not be available for review during a change in condition or required transfer to the hospital, and for staff providing care to a resident to not be aware of physician ordered care. Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including emphysema, unspecified and cervicalgia. On 05/01/2025 at 8:14 AM, during the AM medication administration pass, a Registered Nurse (RN) began preparing medication for Resident #7. The RN verbalized 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.

Based on interview, record review and document review, the facility failed to develop and implement at least one Performance Improvement Project (PIP) per year. This deficient practice had the potential to adversely impact each resident's well-being. Findings include: On 05/01/2025 at 5:12 PM, the Interim Executive Director (IED), Director of Nursing (DON) and the Lead Administrator of Nevada (LAN) revealed Quality Assurance Performance Improvement (QAPI) committee meetings were held monthly and usual attendees included the Administrator, the Medical Director, and the DON. On 05/01/2025 at 5:15 PM, the LAN explained the facility was unable to furnish documentation or describe a PIP completed within the past year due to the facility using an electronic system to document the PIP and after the former Administrator left, the Quality Assurance (QAA) committee, no longer had access. The IED was unsure and was not able to confirm if the facility had any current PIPs and was not able to provide documentation for one. The IED stated having been the Administrator at this facility for a short…

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 Based on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #12) was offered timely pneumococcal vaccination to complete the recommended pneumococcal vaccine schedule. This deficient practice had the potential to result in residents contracting a preventable illness. Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with other circulatory complications and chronic diastolic (congestive) heart failure. Resident #12's Immunization Audit Report documented the resident had received the 23-valent pneumococcal polysaccharide (PPSV23) vaccine on 06/17/2021, 12/03/2018, and 10/15/2013. The Immunization Audit Report and Resident #12's clinical record lacked documentation the resident previously received any other pneumococcal vaccines. The following vaccines were documented as pending immunization: PCV13, PPSV23, PCV15, and PCV20. A Resident…

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 Based on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #4) received or declined an updated/booster dose of COVID-19 (Covid) vaccine after being screened for eligibility. This deficient practice placed residents wishing to receive the Covid vaccine at risk of not receiving the vaccine and experiencing severe or prolonged illness, hospitalization, or death as a result of infection with the Covid virus. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications and hypertension. Resident #4's Immunization Audit Report lacked documented evidence the resident had received any doses of the covid vaccine. The form documented a status of pending immunization for covid vaccine, entered by the Infection Preventionist (IP) on 04/13/2025. A Resident Multi-Vaccine Consent Form dated 04/13/2025, documented Resident #4 was eligible for 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.

Based on interview and document review, the facility failed to ensure initial elder abuse prevention training was completed timely for an agency contracted Certified Nursing Assistant (CNA) involved in and terminated as a result of an abuse investigation (Employee #24). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include: Employee #24 Employee #24 was hired by the facility on 11/08/2024, and terminated on 03/05/2025, as a CNA. Employee #24's personnel record lacked documented evidence the employee had completed initial elder abuse training upon hire. A Facility Reported Incident (FRI), dated 03/06/2025, documented a Certified Nursing Assistant (CNA) entered Resident #43's room to assist the resident with a brief change. The resident became verbally agitated and began to exhibit signs of psychosis, signaling a Licensed Practical Nurse (LPN) to go to the resident's room to see what was happening. The CNA removed Resident #43 from the resident's room and transferred the resident to the community dining room. The resident had…

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 Based on observation, interview, clinical record review, and document review, the facility failed to ensure the medication room and a medication cart did not contain expired COVID-19 testing supplies and narcotic medications were stored appropriately to prevent a resident's narcotic pain medication from going missing for 1 of 1 residents sampled for Facility Reported Incident (FRI) investigations (Resident #188). This deficient practice had the potential to result in residents tested with the expired products receiving inaccurate results, delays in residents receiving pain medication, and unauthorized individuals having access to narcotics without a prescription, leading to the misuse of prescription opioids. Findings include: Expired Testing Supplies On [DATE] at 11:13 AM, the facility's medication storage room contained a box of COVID-19 test kits with an expiration date of [DATE], documented on the side of each test kit box. The box contained 73 test kits. The Resident Care Manager confirmed the expiration…

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.

Based on observation, interview and document review, the facility failed to ensure an ice machine's cleanliness was maintained, food was discarded per facility policy, and hand hygiene was performed during trayline observation. This deficient practice had the potential to affect the entire facility census. Findings include: Ice Machine On 06/24/2024 at 8:14 AM, the ice machine in the kitchen had a hard, white, flaky substance around the outside and inside of the door of the machine. An ice machine task sheet, posted on the side of the ice machine, documented routine maintenance was completed on 06/04/2024, and included door gasket cleaning. The task sheet documented a contracted maintenance company would complete a six month deep clean on the ice machine. On 06/24/2024 at 8:16 AM, the Nutrition Services Supervisor confirmed the ice machine had a hard, white, flaky substance around the door, and believed the cleaning of the door was completed during the deep cleaning of the ice machine by the contractor. On 06/24/2024 at 8:26 AM, the Nutrition Services Supervisor verbalized not…

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.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a staff member performed hand hygiene between contact with residents and environmental surfaces, a glucometer was sanitized correctly between residents, clean laundry was stored and handled in a sanitary manner and was not placed on a floor cleaner to finish drying, and a fan was not blowing air from the dirty laundry side of the laundry room to the clean laundry side of the laundry room. This deficient practice had the potential to result in the spread of infection and illness to residents throughout the facility due to lack of appropriate infection control practices. Findings include: Hand Hygiene On 06/20/2024 at 9:16 AM, the Activities Director (AD) entered a resident room and leaned down to speak with the resident in the bed nearest the door. The AD touched the resident's hand and the resident's bedding. The AD then left the resident's room and walked down the hallway toward the nurse's station. The AD placed both hands on the counter of the nurse's station and then…

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 Based on observation, interview, clinical record review and document review, the facility failed to ensure informed consents were obtained prior to administering two psychotropic medications for 1 of 13 sampled residents (Resident #288). Findings include: The facility policy titled Psychotropic Drugs, updated 08/2022, documented psychotropic drugs included anti-depressants and anti-anxiety agents. Resident #288 Resident #288 was admitted to the facility on [DATE], with diagnoses including unspecified dementia unspecified severity, obstructive sleep apnea, and anxiety disorder unspecified. The physician's orders for Resident #288 dated 06/18/2024, documented the following: -Amitriptyline Hydrochloride (HCl) oral tablet 25 milligrams (mg), give 25 mg by mouth one time a day for restlessness related to anxiety. -Buspirone HCl oral tablet 30 mg, give 30 mg by mouth two times a day for restlessness related to anxiety. The June 2024 medication administration record (MAR) for Resident #288 dated 06/25/2024, documented…

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 Based on observation, interview, clinical record review, and document review, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 2 of 13 sampled residents (Resident #3 and #13). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including other cord compression, muscle weakness generalized, and contracture of muscle unspecified site. A physician's order dated 09/28/2019, documented Resident #3 required bilateral bed rails to increase safety and independence with bed mobility. Resident #3's care plan revised 10/10/2023, documented the resident had bilateral quarter size bed rails as it related to bed mobility and repositioning. An intervention documented the resident and the resident's family would understand the use of bed rails was for bed mobility and repositioning only. Resident #3's last quarterly MDS assessment dated [DATE], section P0100 (Restraints and Alarms - Physical Restraints) documented bed rails were used daily as…

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 Based on interview, clinical record review, and document review the facility failed to develop a care plan for a resident with a Deep Vein Thrombosis (DVT) (Resident #13) and a resident with insomnia (Resident #20) for 2 of 13 sampled residents. Findings include: Resident #13 Resident #13 was admitted to the facility 09/11/2021, with diagnoses including Parkinsonism and unspecified dementia, unspecified severity, with other, behavioral disturbance. On 06/25/2024 at 10:39 AM a Licensed Practical Nurse (LPN) verbalized Resident #13 received an anticoagulant for a DVT. The LPN confirmed the resident did not have a care plan for DVT. A Nurse Practitoner Progress Note dated 07/24/2023, documented Resident #13 had a left lower DVT of superficial and common femoral vein. A physician's order dated 07/26/2023, documented Eliquis, 5 milligram (mg) tablet. Give 5 mg by mouth two times a day for DVT. Resident #13's June Medication Administration Record (MAR) documented Eliquis 5 mg tablet was administered twice daily 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.

Based on interview, clinical record review, and document review, the facility failed to meet professional standards for accurate recording per the Nevada Nurse Practice Act for a Registered Nurse (RN) when the Minimum Data Set Coordinator, Registered Nurse (MDS Coordinator) backdated a resident's care plan for deep vein thrombosis (DVT) by 11 months (Resident #13). Findings include: Resident #13 Resident #13 was admitted to the facility 09/11/2021, with diagnoses including Parkinsonism and unspecified dementia, unspecified severity, with other, behavioral disturbance. On 06/25/2024 at 10:39 AM a Licensed Practical Nurse (LPN) verbalized Resident #13 received an anticoagulant for DVT. The LPN confirmed the resident's Comprehensive Care Plan lacked a care plan for DVT or the anticoagulant. On 06/25/2024 at 10:40 AM, Resident #13's Comprehensive Care Plan lacked documented evidence of a care plan for DVT. A Nurse Practitioner Progress Note dated 07/24/2023, documented Resident #13 had a left lower DVT of superficial and common femoral vein. A physician's order dated 07/26/2023,…

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 Based on record review, interview, and document review, the facility failed to ensure nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest for 2 of 5 sampled licensed nurses (Licensed Practical Nurse (LPN)1 and LPN2). The deficient practice could result in a negative outcome for a resident in cardiac arrest while awaiting the arrival of emergency medical personnel. Findings include: LPN1 LPN1 was hired on [DATE]. LPN2 LPN2 was hired on [DATE]. LPN1 and LPN2's personnel records lacked documented evidence of current CPR certifications. On [DATE], the Business Office Manager (BOM) confirmed responsibility for personnel record review conducted during the survey process. On [DATE] at 10:54 AM, during an interview for review of personnel records, the BOM verbalized being unsure about the policy for CPR training, including who was required to be certified and how often training was required. The BOM confirmed the personnel records for LPN1…

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 Based on interview, clinical record review, and document review, the facility failed to ensure a resident was not administered a pain medication outside physician parameters resulting in a resident receiving acetaminophen unnecessarily for 1 of 13 sampled residents (Resident #288). Findings include: Resident #288 Resident #288 was admitted to the facility on [DATE], with diagnoses including encephalopathy unspecified, hypothyroidism unspecified, and hypertension. A physician's order dated 06/18/2024, documented acetaminophen oral tablet. Give 650 milligrams (mg) by mouth every six hours as need for one to four moderate pain. Resident #288's care plan documented the resident had identified pain interfering with sleep, rehabilitation activities, and day to day activities related to migraines and headaches. An intervention revised on 06/25/2024, documented to administer analgesia as per orders. The June 2024 medication administration record (MAR) for Resident #288 dated 06/25/2024, documented the acetaminophen 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 Based on interview, clinical record review, and document review, the facility failed to ensure a psychotropic medication was prescribed to a resident with a diagnosed indication for use for 1 of 13 sampled residents (Resident #20). Findings include: Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including anxiety, unspecified and cellulitis of left lower limb. On 06/25/2024 at 10:29 AM, a Licensed Practical Nurse (LPN) verbalized Resident #20 received Trazadone for insomnia. The LPN confirmed the resident did not have a diagnosis of insomnia, for which the medication was to treat. A physician's order dated 03/12/2024, documented Trazodone Hydrochloride oral tablet 50 milligram (mg). Give one tablet by mouth one time a day for insomnia. Resident #20's June Medication Administration Record (MAR) documented Trazodone 50 mg tablet was administered once daily from 06/01/2024-06/25/2024. Resident #20's Comprehensive Care Plan lacked a care plan for insomnia. On 06/26/2024 at 9:16 AM,…

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 Based on interview, clinical record review, and document review, the facility failed to ensure 4 of 15 residents reviewed for vaccinations were offered a pneumonia vaccine upon admission (Residents #239, #88, #89, and #288) and 1 of 15 residents reviewed for vaccinations and residing in the facility during the 2023 to 2024 influenza (flu) season was offered a flu vaccine (Resident #33). This deficient practice had the potential for residents to become ill with a preventable illness due to lack of vaccinations. Findings include: Resident #239 Resident #239 was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, type two diabetes mellitus without complications, and heart failure, unspecified. The clinical record for Resident #239 lacked documentation the resident was screened for or offered a pneumonia vaccine. Resident #33 Resident #33 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications,…

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 Based on interview, clinical record review, and document review, the facility failed to ensure 4 of 15 residents reviewed for vaccinations were offered a COVID-19 vaccine upon admission (Residents #239, #88, #89, and #288) and 1 of 15 residents was offered an updated 2023 to 2024 COVID vaccine (Resident #30). This deficient practice had the potential for residents to become ill with a preventable illness due to lack of vaccinations. Findings include: Resident #239 Resident #239 was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, type two diabetes mellitus without complications, and heart failure, unspecified. The clinical record for Resident #239 lacked documentation the resident was screened for or offered a COVID vaccination. Resident #88 Resident #88 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus without complications, hyperlipidemia, unspecified, and essential (primary)…

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.

Based on observation and interview, the facility failed to ensure the laundry room was a safe and comfortable temperature. This deficient practice had the potential to result in staff experiencing adverse effects from working in unsafe temperatures while providing laundry services for residents of the facility. Findings include: On 06/26/2024 at 9:33 AM, during a tour of the laundry room, a fan was blowing air from the dirty side of the room to the clean side of the room. The Housekeeper confirmed the fan was in use to prevent the housekeeping staff from overheating as the room had not had air conditioning for the past year. On 06/26/2024 at 10:07 AM, the Administrator confirmed the laundry room was without air conditioning. On 06/26/2024 at 10:47 AM, the Maintenance Director verbalized the laundry room had been without out air conditioning off and on for the past year and the temperature should be maintained between 71- and 81-degrees Fahrenheit. On 06/26/2024 at 1:25 PM, the washing machine and dryers were not operating in the laundry room and the ambient temperature in 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.

Based on personnel record review, interview and document review, the facility failed to ensure annual elder abuse training was completed 1 of 20 sampled employees (Housekeeper). Findings include: The Housekeeper was hired on 09/17/2019. Employee #20's personnel record documented elder abuse training completed 05/04/2023, but lacked documented evidence elder abuse training was completed in 2024. On 06/25/2024, the Business Office Manager (BOM) confirmed responsibility for personnel record review conducted during the survey process. On 06/26/2024 at 10:54 AM, during an interview for review of personnel records, the BOM verbalized all staff were required to complete elder abuse training upon hire and annually thereafter. The BOM explained being unsure about the expected timeframes for elder abuse training. The BOM confirmed Employee #20's personnel record lacked elder abuse training in 2024. The facility policy titled Abuse Training, updated 10/2022, documented center staff were trained on abuse prevention, reporting, and intervention upon hire, annually and periodically thereafter.