Alta Skilled Nursing And Rehabilitation Center

Based on observation and interview, the facility failed to ensure 500 and 600 hall satellite resident pantry and refrigerator food and drink items were protected from cross contamination. This deficient practice had the potential to affect residents in 500 and 600 hall by increasing the risk of cross contamination and causing infection and foodborne illnesses.Findings include:On 06/22/2026 at 9:15 AM, three refillable water bottles, one open soda can, one open Red Bull, one open Gatorade and one Starbucks drink which belonged to staff were on the countertop, which is part of the resident food service area in 500 and 600 satellite pantry. The Kitchen Manager confirmed the pantry was meant only for resident's food and drink items and that it could be much cleaner. On 06/23/2026 at 2:13 PM, a Certified Nursing Assistant (CNA) confirmed the 500 and 600 hall pantry were for resident's food and drink items. The CNA confirmed having staff personal drink containers in the pantry room posed the risk of cross contamination. CNA confirmed staff personal drinks were to be stored in the employee…

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 a resident's record contained accurate documentation of a resident's wound care for 1 of 31 sampled residents (Resident #56). This deficient practice had the potential to cause a resident's wound to worsen without staff's knowledge and cause a delay in necessary treatment to prevent infection or promote healing.Findings include: Resident #56 Resident #56 was admitted to the facility on [DATE], with diagnoses including unspecified open wound, right foot, subsequent encounter and other acute osteomyelitis, right ankle and foot. On 06/22/2026 at 1:30 PM, the resident verbalized the resident had injured the resident's foot recently. The resident verbalized the resident was not sure what had happened, but the resident's foot had started bleeding. A Nursing Narrative Note for Resident #56, dated 06/09/2026, documented a Certified Nursing Assistant (CNA) had noticed bright, red blood on the floor of 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 observation, interview, clinical record review, and document review, the facility failed to ensure staff performed hand hygiene in between glove changes when providing wound care to 1 of 31 sampled residents (Resident #9). This deficient practice had the potential to contaminate a wound and spread infection causing a resident to experience delayed healing or prolonged illness.Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified open wound, right thigh, subsequent encounter, unspecified open wound, left thigh, subsequent encounter, and pressure ulcer of sacral region, unspecified stage. The wound care orders for Resident #9 documented the following: Cleanse right buttock pressure injury with normal saline solution (NSS), pat dry with gauze, apply Medihoney and collagen particles to the wound bed followed by calcium alginate, apply barrier cream to peri wound and then cover with a silicone dressing daily. The start…

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 a resident's Care Plan was integrated with the hospice plan of care and included a care plan addressing the resident's wound care for 1 of 32 sampled residents (Resident #19). This deficient practice had the potential to result in staff caring for the resident not being aware of the care to be provided to the resident by hospice staff versus care to be provided by facility staff leading to a potential decline in the quality of care the resident received in the facility and the resident not receiving wound care as ordered. Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including encounter for palliative care and abnormal findings on diagnostic imaging of other specified body structures. On 05/12/2025 at 2:12 PM, the representative for Resident #19 verbalized the resident had a large mass on the resident's breast and the mass had begun tunnelling and now…

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 resident's care plans were updated to include a resident's need for an appointment with a neurologist due to an increase in the resident's tremors from Parkinson's disease and a resident's continued habit of smoking and storing smoking paraphernalia in the resident's room for 2 of 32 residents (Resident #25 and #13). This deficient practice had the potential to result in staff not being aware of a resident's need for an appointment with a specialist physician to address a resident's medical needs and staff not being aware of the need to continue to assess a resident for safety concerns related to the resident smoking independently and keeping smoking paraphernalia in the resident's room. Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations and multiple…

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 a resident's physician order for a neurologist referral due to an increase in the resident's tremors from Parkinson's disease was acted on in a timely manner and monitored for completeness by clinical leadership for 1 of 32 sampled residents (Resident #25). This deficient practice had the potential to result in a resident's symptoms not being managed timely and causing a resident unnecessary discomfort and decreased quality of life from a delay in care. Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations and multiple sclerosis. On 05/12/2025 at 1:16 PM, the representative for Resident #25 verbalized the resident needed to see a neurologist to adjust the resident's medications. The representative verbalized the representative had requested an appointment…

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) a resident determined to be at risk for pressure injury did not develop a pressure injury, and 2) a resident received wound care per physician orders and the facility policy for 1 of 32 sampled residents (Resident #3). The deficient practices had the potential to place the resident at risk for delayed wound healing and infection. Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, long term use of anticoagulants, unspecified sequelae of cerebral infarction, and chronic kidney disease, stage III, unspecified. The admission Braden Scale for Predicting Pressure Score Risk assessment dated [DATE], documented Resident #3 did not have a skin impairment and was at risk for pressure-related skin impairment due to shear friction and bed confinement. A care plan with an initiation date of 01/21/2025, documented Resident #3 was at risk…

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 a resident's gastric residual volume (the amount of fluid remaining in the stomach) was checked prior to administration of a medication via the resident's gastrostomy tube (a feeding tube providing a direct path to the stomach for delivering nutrition, fluids, and medications) (G-tube) for 1 of 32 sampled residents (Resident #84). This deficient practice had the potential for delayed gastric emptying to not be recognized in a resident with the potential to result in aspiration pneumonia (a type of lung infection due to inhaling substances into the lungs). Findings include: Resident #84 Resident #84 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including dysphagia, oropharyngeal phase, gastroparesis, and gastrostomy status. On 05/12/2024 at 11:23 AM, Resident #84 was resting in bed and had a tube feeding pump administering formula to a G-tube. A Physician's Order for…

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 there were no discrepancies between a resident's available medications and the resident's medication orders and medication administration record (MAR) for 1 of 32 sampled residents (Resident #19). This deficient practice had the potential to result in a resident not receiving medications the resident could have potentially needed to alleviate symptoms of anxiety, agitation, restlessness, nausea, and vomiting. Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including anxiety disorder, unspecified and encounter for palliative care. On 05/15/2025 at 8:30 AM, during a review of Resident #19's medications with the resident's Registered Nurse (RN) the resident had a 30 milliliter (ml) bottle of lorazepam 2 milligrams (mg) per ml concentration located in the medication storage room. The label documented the medication had been prescribed for Resident #19 with 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 observation, interview, and document review, the facility failed to ensure an unattended medication cart was not left unlocked with the keys to the medication cart on top of the cart for 1 of 1 medication carts in use on the 300 hall. This deficient practice had the potential to result in facility residents accessing and ingesting medications with the potential for severe or lethal consequences and unauthorized individuals having access to resident's medications. Findings include: On 05/14/2025 at 7:22 AM, a medication cart was against the wall in the 300 hall, next to room [ROOM NUMBER], with the drawers facing the hallway. The medication cart was unlocked, and the medication cart keys were on top of the cart. There were no staff members in sight of the cart. On 05/14/2025 at 7:24 AM, a Registered Nurse (RN) came out of room [ROOM NUMBER] and confirmed the medication cart had been left unlocked with the keys for the medication cart on top of the cart while the cart was unattended and out of sight. 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 Based on observation, interview, clinical record review, and document review, the facility failed to ensure the facility coordinated care and services with a hospice agency providing care and medications to a resident residing in the facility for 1 of 32 sampled residents (Resident #19). This deficient practice had the potential to result in a resident not receiving care or medications as ordered due to a lack of coordination and communication between the facility and hospice agency with the potential for the resident to suffer neglect or end-of-life symptoms not managed by facility staff. Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including encounter for palliative care and anxiety disorder, unspecified. On 05/12/2025 at 2:12 PM, the representative for Resident #19 verbalized the resident had a large mass on the resident's breast and the mass was tunnelling. The representative verbalized the resident was on hospice and the hospice staff were caring 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a staff member conducted hand hygiene prior to entering a room on enhanced barrier precautions (EBP) for 1 of 44 rooms on EBP and for 1 of 32 sampled residents (Resident #73). This deficient practice had the potential to affect the resident population. Findings include: Resident #73 Resident #73 was admitted to the facility on [DATE], with diagnoses including extended-spectrum beta-lactamase (ESBL) resistance and urinary tract infection (UTI), site not specified. A physician's order dated 05/12/2025, documented EBP for ESBL in urine, every shift. On 05/14/2025 at 8:11 AM, a Certified Nursing Assistant (CNA) entered room [ROOM NUMBER] without having used alcohol-based hand rub (ABHR) or having washed hands. A sign outside the door identified the room as having been on EBP. ABHR was in a dispenser hanging on the wall outside the room. On 05/14/2025 at 8:12 AM, the CNA confirmed not having used ABHR or washing hands prior to entering…

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 a wound cart and medication cart containing resident medications was secure. The deficient practice could have facilitated unauthorized access to medications in the carts. Findings include: On 02/24/2025 at 10:27 AM, a wound cart was left unlocked in the 200 hall entrance with four residents sitting in the same area as the cart. On 02/24/2025 at 10:32 AM, a Licensed Practical Nurse (LPN) returned to the unsecured wound care cart and confirmed the cart was left unlocked. The LPN confirmed there were four residents near the unsecured wound cart and could have accessed resident medications. On 02/24/2025 at 10:34 AM, the Director of Nursing (DON), verbalized the floor nurse was responsible to ensure carts were locked. It was important to ensure the cart was not left unlocked or unattended in order to avoid residents taking medication not intended for them. On 02/24/2025 at 1:27 PM, a medication cart was left unlocked in the 100 hall entrance. On 02/24/2025 at 1:29 PM, a Registered Nurse (RN) confirmed…

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 residents were screened for eligibility to receive a pneumococcal vaccination, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined for 28 of 163 residents in the facility (Resident #410, #158, #255, #163, #106, #112, #85, #17, #27, #124, #9, #83, #50, #156, #47, #155, #61, #8, #117, #81, #161, #310, #115, #55, #18, #122, #46 and #104). Findings include: Resident #410 Resident #410 was admitted to the facility on [DATE], with diagnoses including moderate protein-calorie malnutrition and alcohol abuse with withdrawal, unspecified. Resident #158 Resident #158 was admitted to the facility on [DATE], with diagnoses including saddle embolus of pulmonary artery without acute cor pulmonale and tobacco use. Resident #255 Resident #255 was admitted to the facility on [DATE], with diagnoses including unspecified symptoms…

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's representative and the resident's physician was notified of a change in the resident's condition for 1 of 3 sampled residents reviewed for closed records (Resident #305). This deficient practice had the potential to result in a resident's representative and physician being unaware of significant decline in a resident's physical well-being and the resident suffering physical harm without family support or medical intervention. Findings include: Resident #305 Resident #305 was admitted to the facility on [DATE], and discharged on 05/07/2024, with diagnoses including other pulmonary embolism without acute cor pulmonale, other specified peripheral vascular diseases, cognitive communication deficit, and disturbance, psychotic disturbance, mood disturbance, and anxiety. A Skin/Wound Note, dated 04/30/2024, documented the Nurse noticed bluish discoloration to the resident's right lower extremity. The affected…

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, and document review, the facility failed to provide a comfortable, homelike environment when the facility was made aware of a broken air conditioning (AC) unit in a resident room and did not act to fix the unit or offer an accommodation to the resident for 1 of 33 sampled residents (Resident #257). Findings include: Resident #257 Resident #257 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and unspecified systolic congestive heart failure. On 06/10/2024 at 1:08 PM, Resident #257's spouse verbalized the resident's room was often hot. They recalled they informed the Administrator earlier in the day and the Administrator told the resident's spouse they would consider moving the resident to a different room. On 06/13/2024 at 11:05 AM, Resident #257's spouse verbalized the AC unit in the room was broken and had been broken…

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 physically abused by another resident for 2 of 2 residents investigated for resident to resident abuse (Resident #83 and #122). Findings include: The facility policy titled Abuse Prevention Program, adopted 02/01/2019, documented residents had the right to be free from neglect. The Centers for Disease Control and Prevention defines neglect in older persons as the failure to meet an older adult's basic needs. These needs include essential medical care. Complaint #NV00071241 Cross reference with tags F580 and F849 Resident to Resident Abuse Resident #83 Resident #83 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including schizophrenia, unspecified, and anxiety disorder with irritability and anger. An Incident Note dated 04/09/2024, documented a nurse had heard Resident #83 screaming and cursing while an aide had witnessed Resident #83 spit on and throw a cup with water…

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's report of missing money was investigated per facility policy for 1 of 33 sampled residents (Resident #149). The deficient practice had the potential to result in missing resident belongings not being recovered or misappropriation of resident property not being investigated by the facility. Findings include: Resident #149 Resident #149 was admitted to the facility on [DATE], with diagnoses including anxiety disorder, unspecified and homelessness unspecified. On 06/12/2024 at 10:02 AM, Resident #149 verbalized, after the resident had been admitted to the facility, the resident had told a Certified Nursing Assistant (CNA) the resident had had 20 dollars in the resident's wallet when the resident admitted to the facility and the 20 dollars was missing. The resident verbalized no facility staff had ever followed up with the resident after the resident had reported the missing money to the CNA. A Progress Note,…

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 a resident with a urinary catheter and the behavior of pulling out the urinary catheter had the resident's urinary catheter care plan revised to include interventions to prevent the resident from continuing to pull out the catheter for 1 of 33 sampled residents (Resident #98). This deficient practice had the potential to result in the resident sustaining further injury from the behavior. Findings include: Resident #98 Resident #98 was admitted to the facility on [DATE], with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, urinary tract infection, site not specified, and retention of urine, unspecified. On 06/10/2024 at 9:36 AM, Resident #98 was lying in bed and the resident had a urinary catheter draining to a collection bag at the bedside. On 06/10/2024 at 11:11 AM, the resident's representative verbalized the resident had a urinary catheter and the resident had pulled…

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 a resident's medical record was complete for 3 of 33 sampled residents (Resident #143, #455 and #205). This deficient practice had the potential to result in the resident sustaining significant weight loss and unrecognized complications from a improperly cared for G-tube. Findings include: Resident #143 Resident #143 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute duodenal ulcer with hemorrhage and age-related cognitive decline. A physician's order dated 04/06/2024, documented Resident #143 would have weekly weights for four weeks, if weights stable, then every month. A physician's order dated 04/11/2024, document Resident #143 would have a weight obtained and documented in the electronic health record every day shift, every Thursday, for 30 days. May use the Hoyer lift scale. A physician's order dated 04/20/2024, documented Resident #143 would have weekly…

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 provide protective supervision when a resident wearing a wander device followed an employee out of an alarmed exit door, the alarm system failed to work, and the resident was found wandering around in the parking lot for 1 of 1 residents investigated for elopement (Resident #411). Findings include: Resident #411 Resident #411 was admitted to the facility on [DATE], and discharged on 4/12/2024, with diagnoses including metabolic encephalopathy, cognitive communication deficit, and need for assistance with personal care. A Facility Reported Incident (FRI) #NV00070899 dated 04/08/2024, documented Resident #411's significant other found the resident wandering in the parking lot and brought the resident back into the facility. Video footage review showed Resident #411 had followed a Certified Nursing Assistant (CNA) out of the East exit door at 2:46 PM. The resident wore a Wanderguard device and the alarm failed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interview, and document review the facility failed to ensure 2 of 33 sampled residents (Resident #37 and #143) were weighed per facility policy. Findings include: Resident #37 Resident #37 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus, unspecified dementia, unspecified severity, with other behavioral disturbance, and adult failure to thrive. Resident #37's Weights and Vital Signs Summary (Weight) report, documented an initial weight of 232.0 pounds (lbs) on 02/01/2019. Resident #37's Weight Report documented weights from June 2023 through November 2023 as follows: -06/11/2023: 194.0 lbs. -07/09/2023: 196.0 lbs. -07/21/2023: 196.0 lbs. -09/29/2023: 198.5 lbs. -10/12/2023: 225.4 lbs. -11/27/2023: 222.1 lbs. Resident #37's Weight Report did not document a weight for August 2023. Resident #37's clinical record lacked documented evidence the resident was weighed between 11/28/2023 and 06/11/2024. Resident #37's Order Summary…

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 personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 1 of 2 CNAs employed greater than one year, sampled for personnel record review (Employee #8). Findings include: On 06/11/2024 at 10:55 AM, the Human Resources Manager and Regional Human Resources participated in an interview to confirm the accuracy of the Personnel Records Checklist completed by the facility for 20 employees. Employee #8 Employee #8 was hired as a CNA with a start date of 05/18/2022. The CNA's last performance evaluation was documented as completed on 07/11/2023. On 06/11/2024 at 1:53 PM, the Human Resources Manager provided Employee #8's date of last performance evaluation. The Human Resources Manager and Regional Human Resource were unable to provide evidence the CNA had an annual performance evaluation completed by 05/18/2023. The Human Resources Manager and Regional Human Resource confirmed the CNA annual performance evaluation was completed late. The facility policy titled Annual Review…

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 ordered medications were available and administered for 1 of 33 sampled residents (Resident #18). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other chronic pancreatitis, chronic pain, and other muscle spasms. On 06/10/2024 at 3:04 PM, Resident #18 verbalized they were out of medication for their muscle spasms and pancreatitis sometime last month. The resident explained they have chronic pain and not having the medication for their muscle spasms made their pain worse. A physician order dated 12/09/2022, documented Cyclobenzaprine HCl, 5 milligram tablet, give one tablet by mouth every six hours for muscle spasm. A physician order dated 12/09/2022, documented Creon Capsule Delayed Release Particles, 12000-38000 unit. Give one capsule by mouth with meals related to other chronic pancreatitis. On 06/12/2024 at 1:56 PM, a…

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)a resident with a urinary catheter and the behavior of pulling out the urinary catheter had interventions in place to reduce the risk of the resident continuing the behavior and prevent further physical trauma related to the behavior for 1 of 33 sampled residents (Resident #98), 2) the facility provided care according to the facilities standard of practice to a resident with a deep vein thrombosis (DVT) (a blood clot in one or more of the deep veins in the body) for 1 of 3 residents reviewed for closed records (Resident #305) and 3) a physician's order from hospice was communicated to the facility's physician and the resident received an ordered medication for 1 of 33 sampled residents (Resident #455). This deficient practice had the potential to result in the resident sustaining further injury to the resident's lower urinary tract and residents having significant adverse health outcomes from delayed…

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 Enhanced Barrier Precautions (EBP) were implemented when providing care to a resident's jejunostomy tube (J-tube) for 1 of 33 sampled residents (Resident #109). Findings include: Resident #109 Resident #109 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of other artificial openings of gastrointestinal tract status. On 06/10/2024 at 10:00 AM, a sign outside Resident #109's room indicated the resident was on EBP. The sign instructed staff to wear a gown and gloves while providing high-contact care. On 06/10/2024 at 10:05 AM, Resident #109 was receiving tube feeding via an enteral feeding pump. A Licensed Practical Nurse (LPN) entered Resident #109's room, stopped the pump, and disconnected the tube feeding from the resident's J-tube. The LPN was not wearing a gown or gloves. On 06/10/2024 at 10:07 AM, while in the hallway outside the resident's room, the LPN explained 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 clinical record review, interview, and document review, the facility failed to ensure a resident's dignity was maintained for 1 of 18 sampled residents (Resident #9). Resident #9 Resident #9 was admitted to the facility on [DATE] with a diagnosis including hydrocephalus and difficulty walking. A Facility Reported Incident (FRI) documented on 02/23/2024, the allegation a Physical Therapist (PT) was witnessed verbally berating a resident at the nurse's station. A Communication Note dated 02/23/2024, documented the writer spoke with Resident #9 regarding the interaction with the PT. Resident #9 expressed the resident was okay and the interaction was just a misunderstanding. The writer expressed to the resident the PT was just trying to make sure the resident was safe since the resident was not cleared to ambulate on their own. The resident agreed and expressed the PT's demeanor needed to be gentler. Resident #9's Comprehensive Care Plan initiated 02/23/2024, documented the resident was at risk for loss 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 clinical record review, interview, and document review the facility failed to ensure 1) a resident was kept safe from verbal abuse by a staff member for 1 of 18 sampled residents (Resident #7). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including unspecified chronic bronchitis, unspecified severe protein calorie malnutrition, and depression. Resident #19 Resident #19 was admitted to the facility on [DATE], with a diagnosis of paroxysmal atrial fibrillation. A Facility Reported Incident (FRI) documented on 03/20/2024, the allegation of a staff member witnessed verbally berating a resident at the nurse's station. A Nursing Note dated 02/11/2024, documented the Director of Nursing (DON) received a telephone call from a Certified Nursing Assistant (CNA) who, along with a family member of a resident witnessed a Registered Nurse (RN) verbally berate Resident #7 at the nurse's station. The nurse was cursing and throwing medication bottles around the nurses'…

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, record review, and document review, the facility failed to ensure the policy pertaining to abuse investigations and reporting was implemented. An allegation of abuse was not investigated or reported to law enforcement or the State agency for 1 of 18 sampled residents (Resident #2) placing the resident at continued risk of physical abuse by a staff member. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic (diastolic) congestive heart failure, type 2 diabetes mellitus with diabetic neuropathy, unspecified, and anxiety disorder, unspecified. An Adult Protective Services (APS) report documented an APS Social Worker (SW) met with Resident #2 on 12/08/2023 and the resident had informed the SW a CNA had handled the resident roughly when providing care and had slapped the resident on the cheek. The APS SW discussed the incident, including the name of the CNA, the resident alleged to be the perpetrator, with 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, record review, and document review, the facility failed to ensure an allegation of physical abuse against a resident by a staff member was reported within the two-hour time frame for 1 of 18 sampled residents (Resident #2). This deficient practice could allow allegations of abuse to occur and not be reported for investigation. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic (diastolic) congestive heart failure, type 2 diabetes mellitus with diabetic neuropathy, unspecified, and anxiety disorder, unspecified. An Adult Protective Services (APS) report documented an APS Social Worker (SW) met with Resident #2 on 12/08/2023 and the resident had informed the SW a CNA had handled the resident roughly when providing care and had slapped the resident on the cheek. The APS SW discussed the incident, including the name of the CNA, the resident alleged to be the perpetrator, with the Administrator of 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, record review, and document review, the facility failed to investigate a resident's allegation of abuse for 1 of 18 sampled residents (Resident #2). Resident #2 alleged a Certified Nursing Assistant (CNA) slapped the resident and handled the resident roughly when providing care. The CNA named in the abuse allegation was scheduled to work with the resident of concern and throughout the facility from the time the facility was made aware of the allegation on [DATE], until [DATE]. The facility did not report the incident to the State Survey Agency or law enforcement. The lack of investigation and measures to prevent further potential abuse allowed the alleged perpetrator continued access, with the potential for further physical abuse and harm, to the alleged victim and all residents within the CNA's assignment. Furthermore, the facility failed to conduct a thorough investigation into an allegation of a Registered Nurse (RN) verbally abusing a resident for 1 of 18 sampled residents (Resident #7).…

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 Licensed Practical Nurse (LPN) had the competencies necessary to safely perform medication administration for 1 of 2 nurses observed for medication administration observations. Findings include: On 04/04/2024 at 7:22 AM, an LPN was administering medications to residents on the 400 hall. Three clear plastic cups containing a clear liquid were sitting on top of the medication cart. The LPN verbalized the LPN had premixed 17-gram doses of the Polyethylene Glycol 3350 (MiraLAX) and stored the doses on top of the cart. The LPN confirmed the cups containing the MiraLAX had the same appearance as cups of plain water and could have been ingested by other residents or visitors. On 04/04/2024 at 7:30 AM, the LPN entered room [ROOM NUMBER] and two cups of the MiraLAX solution remained on top of the medication cart in the hallway out of the view of the LPN. On 04/04/2024 at 7:36 AM, the LPN entered room [ROOM NUMBER] and two…

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's medications were administered as ordered and not left at the bedside for 1 of 18 sampled residents (Resident #1). Bedtime medications from 04/02/2024 and morning medications from 04/03/2024 were left at the bedside of the resident for the resident to take without staff supervision for a total of 10 out of 10 medications not administered as ordered, creating the potential for oversedation and a higher risk of drug-to-drug interactions. The medication error rate was 100 percent (%). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, and major depressive disorder, single episode, mild. On 04/03/2024 at 9:00 AM, Resident #1 was laying in bed and two medication cups were on the resident's bedside…

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 cups containing a laxative powder dissolved in cups of water, were not stored on the top of the medication cart when not in sight of a staff member with the potential for the medication to be ingested by other residents or visitors for 3 of 3 premixed cups of the medication and unlocked medication carts were not left unattended. The laxative powder had potential common side effects including bloating, gas, upset stomach, and dizziness. Findings include: On 04/04/2024 at 7:22 AM, a Licensed Practical Nurse (LPN) was administering medications to residents on the 400 hall. Three clear plastic cups containing a clear liquid were sitting on top of the medication cart. The LPN verbalized the LPN had premixed 17-gram doses of the Polyethylene Glycol 3350 (MiraLAX) and stored the doses on top of the cart. The LPN confirmed the cups containing the MiraLAX had the same appearance as cups of plain water and could have been ingested by other…

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 protect the residents' right to be free from physical abuse by a resident for 2 of 13 Facility Reported Incidents (FRI) (Resident #8, #9, #7 and #5). Findings include: An FRI final report, dated 11/10/23, documented on 11/08/23 nursing staff witnessed a resident to resident altercation between Resident #8 and Resident #9. Resident #9 was wheeling down the 400 hall and Resident #8 was about to run into Resident #9. Both residents started cursing at each other and Resident #8 said if Resident #9 did not leave would punch Resident #9. Resident #9 leaned forward and Resident #8 punched Resident #9 in the chin. Resident #9 retaliated and grabbed Resident #8 by the forearm. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including major depressive disorder and anxiety disorder. Resident #9 Resident #9 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including major…

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 Facility Reported Incidents (FRI) were completed and submitted to the State Survey Agency within the required time for an allegation of resident to resident physical abuse for 1 out of 18 sampled residents (Resident #5 and #7) Findings include: An FRI initial, received 12/02/23 at 9:49 AM, documented on 12/02/23, a Registered Nurse (RN) was walking down hallway towards East Nursing Station and saw Resident #7 at the nurse's station yelling I want my pain pill!! Resident #5 was at the nurse's station nearby after getting a juice and told Resident #7 to calm down and Resident #7 started screaming at Resident #5. Resident #7 assaulted Resident #5 by slamming the walker into Resident #5's legs, bruising the resident's upper shin, and scraping the resident's lower shin. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, Alzheimer's disease, and anxiety disorder.…

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 medications were not left unsecured in a medication cart on the 300 hallway. Findings include: On 12/06/23 at 2:18 PM, the medication cart in the 300 hallway was observed unlocked by room [ROOM NUMBER]. There were no staff in the hallway or within sight of the medication cart. A resident was observed in a wheelchair moving past the cart. On 12/06/23 at 2:24 PM, a Registered Nurse was at the nurse's station and confirmed the medication cart was unlocked and verbalized the cart should be locked. On 12/06 23 at 2:25 PM, the Licensed Practical Nurse (LPN) using the cart, was at the nurse's station and confirmed the medication cart was unlocked and verbalized the cart should be locked when not in use. The LPN verbalized residents could access the medications in an unlocked cart. On 12/06/23 at 2:35 PM, the Director of Nursing (DON) verbalized the DON expected the medication cart to be locked when a nurse was not standing by the cart…

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.