Northern Nevada State Veterans Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review the facility failed to protect a resident from neglect after a fall in the facility for 1 of 19 sampled residents (Resident #60). This deficient practice placed the resident at risk for changes in condition to go unnoticed by staff and a delay in transfer to the hospital. Findings include: Resident #60 Resident #60 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nontraumatic chronic subdural hemorrhage, hepatic encephalopathy, and alcohol dependence with alcohol-induced persisting dementia. A Progress Note dated 11/20/2024 at 4:30 PM, documented Resident #60 was found by a nurse on the floor, face down in the resident's room. The resident had no signs or symptoms of head injury, equal hand grips and denied pain. The resident had frequent falls. The resident was assisted to the shower and a skin assessment was performed. The resident had a large red scrape to the right chest, a skin tear on the lower right…

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 an allegation of neglect and a fall resulting in serious bodily injury was reported to the State Agency (SA) for 1 of 19 sampled residents (Resident #60). This deficient practice had the potential for allegations of neglect to not be investigated by the facility and/or the SA. Findings include: Resident #60 Resident #60 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nontraumatic chronic subdural hemorrhage, hepatic encephalopathy, and alcohol dependence with alcohol-induced persisting dementia. A Progress Note dated 11/20/2024 at 4:30 PM, documented Resident #60 was found by a nurse on the floor, face down in the resident's room. The resident had no signs or symptoms of head injury, equal hand grips and denied pain. The resident had frequent falls. The resident was assisted to the shower and a skin assessment was performed. The resident had a large red scrape to the right…

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 an allegation of neglect was thoroughly investigated for 1 of 19 sampled residents (Resident #60). This deficient practice had the potential for physical and/or emotional harm to residents due to allegations of neglect not being investigated and protections put in place to prevent future neglect. Findings include: Resident #60 Resident #60 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nontraumatic chronic subdural hemorrhage, hepatic encephalopathy, and alcohol dependence with alcohol-induced persisting dementia. A Progress Note dated 11/20/2024 at 4:30 PM, documented Resident #60 was found by a nurse on the floor, face down in the resident's room. The resident had no signs or symptoms of head injury, equal hand grips and denied pain. The resident had frequent falls. The resident was assisted to the shower and a skin assessment was performed. The resident had a large red…

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 nurses performed the job duties as outlined in the State Board of Nursing Nurse Practice Act with safe medication administration when 1) qualified Licensed Practical Nurses (LPN) and Registered Nurses failed to verify the appropriateness of a medication order for 1 of 19 sampled residents (Resident #69) and 2) eye drops were administered with incorrect technique for 1 of 4 residents observed during medication administration (Resident #72). The deficient practice resulted in a physician order being inaccurately transcribed onto a resident's electronic health record (EMR) and medication administration record (MAR), as well as the misadministration of ordered medication. Findings include: Resident #69 Resident #69 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of heart failure, unspecified. Resident #69's January, February, and March 2025 MARs documented Spironolactone oral…

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 personnel record review, document review, and interview, the facility failed to ensure direct care staff maintained current Cardio-Pulmonary Resuscitation (CPR) certification for 2 of 11 sampled direct care employees (Employee #11 and #12). This deficient practice could result in a negative outcome for a resident requiring CPR while awaiting the arrival of emergency medical personnel. Findings include: Employee #11 Employee #11 was hired by the facility as a Registered Nurse (RN) with a start date of [DATE]. The RN's personnel record lacked documented evidence of CPR training and certification. Employee #12 Employee #12 was hired by the facility as an RN/Infection Preventionist with a start date of [DATE]. The RN's personnel record documented CPR training and certification expired on 01/2025. The RNs' Job Description documented the minimum job requirements included CPR certified. On [DATE] at 1:17 PM, the Human Resources Director verbalized CPR certification was required of all direct care staff 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.

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 received individualized activities to meet the resident's interests and need to have assistance with the use of electronic devices for 1 of 19 sampled residents (Resident #74). This deficient practice had the potential to result in a resident feeling isolated and frustrated from lack of social interaction and opportunities to pursue personalized interests. Findings include: Resident #74 Resident #74 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder, chronic and major depressive disorder, recurrent, moderate On 03/10/2025 at 11:31 AM, Resident #74 verbalized the resident did not enjoy participating in group activities but the resident felt very depressed and would have liked for someone to visit the resident in the resident's room when the resident wanted someone to talk to. The resident verbalized the resident wanted help with learning how to use 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.

Based on observation, interview, and document review, the facility failed to ensure a medication cart containing resident medications was secure and expired medications were removed from the active supply in 1 of 3 medication storage rooms and 1 of 3 medication carts reviewed for medication storage. The deficient practice could have facilitated unauthorized access to medications in the carts and had the potential for expired medications to be administered to residents. Findings include: On 03/11/2025 at 8:42 AM, a medication cart was left unlocked in the Tahoe/Truckee unit the with five residents sitting in the same area as the cart. On 03/11/2025 at 8:44 AM, a Registered Nurse (RN) returned to the unsecured medication cart and confirmed the cart was left unlocked. The RN confirmed there were five residents near the unsecured medication cart and could have accessed resident medications. The facility policy titled Medication Labeling and Storage, revised 11/2024, documented the community must store all drugs and biologicals in locked compartments. All medications would be stored…

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 culinary staff checked the holding temperatures for all hot foods to ensure the foods were at a safe temperature prior to beginning meal service from a satellite kitchen to residents in the [NAME]/Quail dining room during a lunch service with the potential to affect 15 of 15 residents residing on the unit and to ensure vegetables prepared for residents requiring a minced and moist diet in the Aspen/Pinion dining room were at a safe temperature prior to beginning lunch service with the potential to affect 1 of 15 residents residing on the unit. This deficient practice had the potential to result in food not held at appropriate temperatures resulting in the growth of pathogens that cause foodborne illness being served to residents. Findings include: [NAME]/Quail On 03/12/2025 at 11:57 AM, a Culinary Staff member entered the satellite serving kitchen to serve lunch to the 15 residents located in the [NAME]/Quail neighborhood 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 clinical record review, interview, and document review, the facility failed to ensure an electronic medical record (EMR) accurately reflected a resident's code status for 1 of 19 sampled residents (Resident #52) and physician orders were transcribed accurately into the resident's Medication Administration Record (MAR) and EMR to prevent medication errors for 1 of 19 sampled residents (Resident #69). This deficient practice had the potential for a resident's preference related to cardiopulmonary resuscitation (CPR) to not be followed and to result in a significant medication error and compromised resident safety. Findings include: Resident #52 Resident #52 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On [DATE] at 9:13 AM, Resident #52's EMR documented the resident was to receive full treatment CPR. A Physician's Order dated [DATE], documented physician…

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 residents were offered timely pneumonia vaccines to complete the recommended pneumonia vaccine schedule for 2 of 5 residents reviewed for immunizations (Residents #21 and #22). This deficient practice had the potential to result in a resident contracting a preventable illness. Findings include: Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including acute respiratory failure, unspecified whether with hypoxia or hypercapnia, pneumonitis due to inhalation of food and vomit, and heart failure, unspecified. The clinical record for Resident #21 did not include documentation of the resident receiving or being offered a pneumonia vaccine. On 03/13/2025 at 8:53 AM, the Infection Preventionist (IP) confirmed the clinical record for Resident #21 lacked documentation of a pneumonia vaccine being offered or administered to the resident. The IP verbalized the consent for vaccinations was 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.

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 provided education on the risks and benefits of COVID-19 vaccination and a resident was offered the COVID-19 vaccine for 2 of 5 residents reviewed for immunizations (Resident #21 and #22). This deficient practice had the potential to result in residents and their representatives not being given the opportunity to make informed decisions before accepting or declining vaccination and a resident not given the opportunity to accept the vaccine and potentially prevent severe illness and hospitalization from infection with COVID-19. Findings include: Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including acute respiratory failure, unspecified whether with hypoxia or hypercapnia, pneumonitis due to inhalation of food and vomit, and heart failure, unspecified. The clinical record for Resident #21 did not include documentation of the resident receiving or being offered 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 interview, clinical record review, and document review the facility failed to ensure a resident was not verbally abused by a Certified Nursing Assistant (CNA) when the CNA used profane language towards a resident for 1 of 5 sampled residents (Resident #2). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including post-traumatic stress disorder, chronic, major depressive disorder, single episode specified, and generalized anxiety disorder. An initial Facility Reported Incident (FRI) documented on the evening of 09/11/2024, Resident #2 reported the resident had been called a profanity by a CNA while in the resident's room. An investigation for verbal abuse was initiated. Resident #2 did not want the CNA to provide any further care to the resident. A final FRI documented the CNA was assigned to Resident #2's unit and had provided care to the resident that evening. The investigation was substantiated by the facility for 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 interview, clinical record review, and document review, the facility failed to 1) submit a Facility Reported Incident (FRI) initial report with accurate and complete information, and 2) submit a final report to the State Agency (SA) within the required five-day timeframe for 1 of 5 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including major depressive disorder, vascular dementia, moderate with other behavioral disturbance, and anxiety disorder. On 09/06/2024, an initial FRI was submitted to the State agency for employee to resident verbal abuse towards Resident #1 during medication administration in the resident's room. The initial FRI was completed by the Administrator and documented the incident occurred on 08/27/2024. A final FRI was not received by the SA. On 11/06/2024 at 2:51 PM, the Regional Director of Quality and Clinical Services (RDQ) confirmed the previous facility Administrator…

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 secured memory care unit did not contain potentially harmful and hazardous substances and materials for vulnerable, cognitively impaired residents for 22 of 32 residents residing in the secured unit (Residents #88, #31, #43, #22, #12, #82, #37, #52, #26, #81, #64, #40, #246, #4, #2, #5, #15, #45, #54, #63, #66, and #92). The deficient practice could result in vulnerable residents ingesting harmful and hazardous substances and materials with the potential for adverse health outcomes and hospitalization. Findings include: Resident #88 Resident #88 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and cognitive communication deficit. A Brief Interview for Mental Status (BIMS) for Resident #88, dated 09/25/2023, documented the resident had a score of four indicating severe cognitive…

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, observation, and document review, the facility failed to ensure a resident's dignity was maintained when maintenance staff opened a resident's closed bedroom door and entered without knocking or asking permission to enter for 1 of 19 sampled residents (Resident #60). Findings include: Resident #60 Resident #60 was admitted to the facility on [DATE], with diagnoses including cerebral infarction, bipolar disorder, unspecified, and post-traumatic stress disorder, chronic. On 04/15/2024 at 9:50 AM, Resident #60 explained facility staff did not always wait for a reply when knocking on the resident's bedroom door. The resident explained the resident would not want someone to enter the room without permission because sometimes the resident emptied their own catheter device or was in the bathroom and would not be fully dressed at the time. On 04/15/2024 at 9:56 AM, a maintenance worker opened the resident's bedroom door and walked into the resident's room without knocking or…

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 the facility's abuse policy was implemented to investigate and report a resident's injury of unknown origin for potential abuse (Resident #4) and the policy included the required time frames for investigation and reporting of potential abuse. The deficient practice could result in resident's injuries of unknown origin to continue without investigation resulting in the potential for resident harm. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease, unspecified and dementia in other diseases classified elsewhere, severe, with agitation. On 04/16/2024 at 11:56 AM, a Representative for Resident #4 verbalized the resident was found with a large wound to the resident's lower leg on 02/26/2024. The Representative verbalized the facility had informed the Representative the facility was unsure of the cause of the wound. 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 resident's injury of unknown origin was reported to the State Agency (Resident #4). The deficient practice could allow injuries of unknown origin to not be investigated for potential abuse to occur and not be reported to the State Agency (SA) and/or Law Enforcement. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease, unspecified and dementia in other diseases classified elsewhere, severe, with agitation. On 04/16/2024 at 11:56 AM, a Representative for Resident #4 verbalized the resident was found with a large wound to the resident's lower leg on 02/26/2024. The Representative verbalized the facility had informed the representative the facility was unsure of the cause of the wound. The resident had been sent to the emergency department for profuse bleeding for the wound and required stitches to close the wound 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review, and interview, the facility failed to ensure a baseline care plan was developed to address the care and interventions for oxygen therapy for 1 of 19 sampled residents (Resident #295). The deficient practice could result in a negative outcome for the resident if staff were not aware of the resident's chronic oxygen status. Findings include: Resident #295 Resident #295 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified, presence of other heart-valve replacement, and nonrheumatic aortic (valve) stenosis. Resident #295's baseline care plan dated 04/12/2024, lacked a care plan for the care and intervention for oxygen therapy. A Nursing Note, dated 4/12/2024 at 12:16 PM, documented the Nurse called the hospital to gather report on the resident. The resident had a history of hypertension, COPD, and hyperlipidemia, and was at baseline on 3 liter per minute (lpm) of oxygen via nasal cannula. 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 the Comprehensive Care Plan was updated to include the care and interventions for oxygen therapy for 1 of 19 sampled residents (Resident #145) and the care plan interventions were appropriate for 3 of 32 residents residing in the specialized care unit (memory care) (Residents #9, #56, and #67). Findings include: Resident #145 Resident #145 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute on chronic diastolic (congestive) heart failure, unspecified atrial fibrillation, and morbid obesity due to excess calories. Resident #145's Care Plan dated 03/20/24, documented Resident #145 had altered cardiovascular status related to chronic heart failure, with interventions to include oxygen therapy via nasal cannula at two liters per minute (lpm). A physician's order dated 03/20/24, documented to administer oxygen via nasal cannula at 1-3 lpm, may titrate to maintain…

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 meet professional standards of medication administration for 1 of 19 sampled residents (Resident #71). Findings include: Resident #71 Resident #71 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, moderate, with anxiety. A Physician's Order for Resident #71, dated 02/14/2024, documented Metoprolol Succinate Extended Release 25 milligrams (mg), give 1.5 tablets by mouth one time a day. On 04/15/2024 at 11:02 AM, a pill was located on Resident #71's side table. On 04/15/2024 at 11:03 AM, the Assistant Director of Nursing (ADON)/ Registered Nurse (RN) verbalized when medication was administered the nurse administering the medication was expected to stay with the resident until the medication was swallowed. On 04/15/2024 at 11:05 AM, the ADON confirmed a pill was located at Resident #71's bedside. The ADON looked up the medication and confirmed the medication was Metoprolol and 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 personnel record review, document review, and interview, 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 1 of 4 sampled licensed nurses (Employee #15). 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: Employee #15 Employee #15 was hired as a Licensed Practical Nurse (LPN) with a start date of [DATE]. The LPN's personnel record lacked documented evidence of CPR training and certification. On [DATE] at 2:30 PM, the Human Resources Director verbalized CPR was required to be taken by all licensed nurses upon hire and confirmed Employee #15 did not have current CPR certification. The facility policy titled Quality of Life: Cardiopulmonary Resuscitation (CPR), last reviewed [DATE], documented all licensed nursing staff would maintain a current CPR certification.

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 medication orders were coordinated with the contracted hospice agency providing the resident with end-of-life care for 1 of 19 sampled residents (Resident #26). The deficient practice could result in Resident #26 not receiving the correct medications for managing symptoms of the resident's terminal diagnosis. Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease, unspecified, unspecified cirrhosis of liver, and other chronic pain. An order for Resident #26 dated 02/22/2024, documented admit to hospice services related to Alzheimer's disease and cerebral atherosclerosis. The Order Summary Report (facility orders) and the Client Medication Report (CMR), dated 03/27/2024, from the contracted hospice agency and located in the hospice binder documented the following discrepancies: - The facility orders…

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 obtain and/or follow a physician's order for respiratory care for 2 of 19 sampled residents (Resident #145 and #295). Findings include: Resident #145 Resident #145 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute on chronic diastolic (congestive) heart failure, unspecified atrial fibrillation, and morbid obesity due to excess calories. On 04/16/2024 at 11:15 AM, Resident #145 was lying in bed with oxygen being administered via nasal cannula. The oxygen was set to 4 liters per minute (lpm). On 04/17/2024 at 11:28 AM, Resident #145 was in a wheelchair with oxygen being administered via nasal cannula. The oxygen was set to 4.5 lpm. A physician's order dated 03/20/2024, documented administer oxygen at 1-3 lpm via nasal cannula continuously, may titrate to maintain saturations greater than 90 percent, every shift. On 04/17/2024 at 11:46 AM, the Registered Nurse 1 (RN)…

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 Monthly Medication Reviews (MMR) were completed monthly for 2 of 5 residents reviewed for unnecessary medications (Resident #66 and #51). Findings include: Resident #66 Resident #66 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #66 lacked an MMR completed within thirty (30) days of the prior MMR for August 2023. The July 2023 review was completed 07/24/2023 and the August 2023 review was completed 09/01/2023. On 04/18/2024 at 2:19 PM, the Pharmacist verbalized the MMR should be completed monthly. The Pharmacist confirmed Resident #66's MMR for August was completed on 09/01/2023.Resident #51 Resident #51 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including adjustment disorder with mixed anxiety…

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 medication was administered with an error rate of less than 5 percent (%). There were 25 opportunities and two medication errors. The medication error rate was 8%. Findings include: Resident #43 Resident #43 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and adult failure to thrive. On 04/16/2024 at 8:30 AM, a Registered Nurse 1 (RN) was administering medications to Resident #43. The RN1 was preparing to apply a lidocaine patch to the resident's lower back. RN1 found the resident already had a patch on the resident's lower back. The RN1 removed the patch and applied the new lidocaine patch above the area where the previous patch had been removed. The April 2024 Medication Administration Record (MAR) and medication orders for Resident #43 documented the following:…

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 employee wore the appropriate hair restraints when working in the kitchen and hand hygeine was performed before and after resident contact during a lunch service. The deficient practice could impact the sanitary conditions of the working area for preparing resident food and meals and the potential to cause the spread of communicable disease to residents in the facility. Findings include: On 04/17/2024 at 12:05 PM, a Certified Nursing Assistant (CNA) entered the kitchen area on the Quail/[NAME] neighborhood to retrieve a beverage container from the refrigerator. The CNA lacked a hair restraint covering the CNA's full beard. On 04/17/2024 at 12:14 PM, the Dietary Services Director (DSD) verbalized staff should wear a hair restraint at all times when working in the kitchen. The facility policy titled Food Safety and Sanitation, last revised 05/2013, documented hair restraints are required and should cover all hair on the head. 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.

Based on observation, interview, and document review the Quality Assessment and Assurance (QAA) Committee failed to identify the lack of timely training (see Tag F678, F943, and F949). Findings include: On 04/18/2024 at 2:29 PM, the Administrator verbalized the QAA Committee had not identified concerns with timeliness of trainings. The Administrator explained the online training system tracked trainings and would allow for trainings to be completed by the end of the month the training the was due, allowing for the trainings to be completed late. The Administrator verbalized training was due upon hire and annually thereafter. The Administrator confirmed trainings were being completed by the online training company standards and not by the regulatory standards. The facility policy titled QAPI Plan, dated 2024, documented the facility used quality assurance and performance improvement to make decisions and guide their day-to-day operations. The Quality Assurance and Improvement (QAPI) Plan focused on systems and processes, rather than individuals. The emphasis was on identifying…

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 rubber seal on an insulin pen was disinfected with alcohol prior to inserting a needle, COVID-19 testing was performed in an appropriate area, and a used COVID-19 test was not left in a resident area. The deficient practices have the potential to cause the spread of communicable disease to residents in the facility. Findings include: Safe Injection Practices Resident #39 Resident #39 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with diabetic peripheral angiopathy without gangrene and type two diabetes mellitus with diabetic neuropathy, unspecified. On 04/17/2024 at 7:51 AM, an Registered Nurse1 (RN) began preparing an Insulin Glargine (Lantus) pen for Resident #39. The RN1 removed the cap from the insulin pen and screwed a needle onto the pen without first wiping the pen tip (rubber seal) with an alcohol swab. The RN1 explained the RN1 did not swab the pen…

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 personnel record review, document review and interview, the facility failed to ensure elder abuse prevention training was completed timely for 3 of 20 sampled employees (Employee #4, #7, and #9). Findings include: The Facility assessment dated [DATE], documented all staff would go through the initial general orientation upon hire. All training would be in accordance with state and federal guidelines. Employee #4 Employee #4 was hired as the Registered Dietitian with a start date of 04/21/2022. Employee #4's personnel record documented abuse prevention training dated 05/22/2023, one month past the employee's anniversary date. Employee #7 Employee #7 was hired as a Certified Nursing Assistant with a start date of 04/10/2023. Employee #7's personnel record documented an abuse prevention training dated 04/10/2023. The employee's file lacked documented evidence of abuse training for 2024, prior to the anniversary date of the training. Employee #9 Employee #9 was hired as a Registered Nurse with a start date…

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 personnel record review, interview, and document review, the facility failed to ensure annual behavioral health training was completed for 6 of 20 sampled employees (Employee #1, #2, #3, #7, #9, and #12). Findings include: The Facility assessment dated [DATE], documented all staff would go through the initial general orientation upon hire. All training would be in accordance with state and federal guidelines. The following employees lacked documented evidence of behavioral health training for 2024: - Employee #1 was hired as the Administrator with a start date of 01/03/2022. Employee #1's personnel file documented dementia training dated 04/16/2023. - Employee #2 was hired as the Director of Nursing with a start date of 01/10/2022. Employee #2's personnel file documented dementia training dated 04/16/2023. - Employee #3 was hired as the Recreation Director with a start date of 01/07/2020. Employee #3's personnel file documented dementia training dated 04/16/2023. - Employee #7 was hired as a Certified…

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 required documentation was entered into the clinical record by a physician when residents were transferred to another facility for 5 of 5 sampled residents (Residents #1, #2, #3, #4, and #5). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease, unspecified and anxiety disorder, unspecified. A Physician Discharge Summary signed by the Physician on 10/23/23, documented the resident's name, date of birth , admission date, discharge date , disposition, admission diagnoses, attending physician's name, and Summary of Care / Reason for Transfer. The section titled Summary of Care / Reason for Transfer documented Resident #1 was transported to inpatient behavioral health. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other seizures and acute on chronic…

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 a Comprehensive Care Plan was updated to include a care plan related to constipation and abdominal distention for 1 of 5 sampled residents (Resident #4) Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including abdominal distention (gaseous), constipation, unspecified, and other chronic pain. Resident #4's Comprehensive Care Plan did not include a care plan related to constipation and/or abdominal distention. On 12/28/23 at 2:49 PM, the Director of Nursing (DON) verbalized the expectation was when a resident had a diagnosis of constipation and/or abdominal distention, a care plan would be created to ensure the resident did not have future complications. The DON confirmed Resident #4's Comprehensive Care Plan did not include a care plan related to constipation and abdominal distention. The DON confirmed the purpose of the care plan…

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 policy review the facility failed to ensure quality of care was provided for 1 of 5 sampled residents (Resident #4) by failing to ensure a resident with ongoing abdominal distention and pain received the care and treatment necessary to identify and treat a bowel obstruction. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including abdominal distention (gaseous), constipation, unspecified, and other chronic pain. A nurse progress note dated [DATE], documented Resident #4 had not had a bowel movement (BM) for three days and Milk of Magnesia was administered to the resident. A nurse progress note dated [DATE], documented Resident #4's abdomen was bloated, and the resident complained of discomfort with palpation. An order for simethicone, a medication used to relieve gas, was received. A nurse progress note dated [DATE], documented Resident #4 had not had a BM for three days. Milk of Magnesia was 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.

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 a physician's order for an x-ray and a physician's order to transfer a resident to an acute care emergency room were entered into the residents clinical record and signed by the physician for 1 of 5 sampled residents (Resident #4). Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including abdominal distention (gaseous), constipation, unspecified, and other chronic pain. A nurse progress note dated 12/16/23, documented Resident #4 had a distended abdomen for three days, the resident was given simethicone to treat the distention but remained distended. Resident #4 had hypoactive bowel sounds in all four quadrants and complained of discomfort with abdominal palpation. Resident #4 had been eating less than the resident's usual baseline. The nurse notified the physician and received orders for a kidney, ureter, and bladder (KUB) x-ray. 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 interview, clinical record review, and document review, the facility failed to ensure a resident was not verbally abused by an employee for 1 of 7 sampled residents (Resident #6). Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including polyneuropathy, anxiety disorder, and muscle wasting. Resident #6 was discharged on 09/12/23. A Performance Documentation form dated 09/08/23, documented Resident #6 reported poor customer service when discussing end of benefits. Resident #6 reported the Business Office Manager told Resident #6 You're taking a bed away from a Veteran who needs it. Resident #6 expressed having felt sad by the statement made by the Business Office Manager. The clinical records for Resident #6 lacked documentation of the incident. On 10/12/23 at 2:07 PM, the Social Worker Director (SWD) verbalized if there was an allegation of employee to resident verbal abuse, the supervisor of the staff in question would be notified and an in-service…

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 Facility Reported Incident (FRI) was completed and submitted to the state agency for an allegation of staff to resident verbal abuse for 1 of 7 sampled residents (Resident #6) and for an allegation of exploitation for 1 of 7 sampled residents (Resident #1). Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including polyneuropathy, anxiety disorder, and muscle wasting. Resident #6 was discharged on 09/12/23. A Performance Documentation form dated 09/08/23, documented Resident #6 reported poor customer service when discussing end of benefits. Resident #6 reported the Business Office Manager told Resident #6 You're taking a bed away from a Veteran who needs it. Resident #6 expressed having felt sad by the statement made by the Business Office Manager. On 10/12/23 at 2:25 PM, the Business Office Manager verbalized employee to resident abuse was to be documented within 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.

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 dignity was maintained when a resident fell in the shower and a Certified Nursing Assistant (CNA) disregarded the fall as a purposeful behavior and laughed at the resident for 1 of 15 Facility Reported Incident (FRI) residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction (CVA), vascular dementia, moderate, with mood disturbance, and pain disorder with related psychological factors. On 06/01/23 at 3:02 PM, Resident #1 verbalized the resident slipped and fell off a shower chair during a shower. The resident explained the resident had placed the resident's buttocks on the edge of the shower chair and slipped off the chair to the ground while washing self. The resident recalled the CNA laughed and told the resident to get up. The CNA told the resident to get up using the hand rails 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview and document review, the facility failed to prevent resident to resident physical abuse for 3 of 15 Facility Reported Incident (FRI) residents (Resident #3, #4, and #5). Findings include: Facility Reported Incident (FRI) #NV00068418 documented on 04/19/23, Resident #2 approached Resident #3 and hit Resident #3 on the cheek. An Abuse/Neglect Allegation Investigation Witness Interview Note dated 04/20/23, documented a Licensed Practical Nurse (LPN) witnessed the incident. The LPN stated Resident #3 was yelling and Resident #2 was getting agitated. Resident #2 hit Resident #3 on the cheek with the back of the hand. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including vascular dementia, severe, with agitation, mood disturbance, anxiety, and psychotic disturbance and post-traumatic stress disorder, chronic. A Progress Note dated 04/19/23, documented Resident #3 was hit on the cheek by another resident when the other resident was agitated.…

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 post fall protocol was followed and supervision was provided when a resident fell for 1 of 15 Facility Reported Incident (FRI) residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction (CVA), vascular dementia, moderate, with mood disturbance, and pain disorder with related psychological factors. On 06/01/23 at 3:02 PM, Resident #1 verbalized the resident slipped and fell off a shower chair during a shower. The resident explained the resident had placed the resident's buttocks on the edge of the shower chair and slipped off the chair to the ground while washing self. On 06/01/23 at 3:23 PM, a Licensed Practical Nurse (LPN) verbalized on 05/18/23, Resident #1 reported to the LPN the resident had fallen in the shower in the evening on 05/17/23. The LPN explained the Registered Nurse (RN) had mentioned…

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.