Citations in Nevada
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Nevada.
Statistics for Nevada (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Nevada
A resident dependent on staff for bathing, with multiple medical conditions, did not receive scheduled showers or bed baths as required. The resident reported a rash and itching, and review of records confirmed that scheduled bathing was not consistently provided, contrary to facility policy.
A resident with multiple diagnoses did not have monthly weights documented for three consecutive months, despite physician orders and facility policy requiring this monitoring. Staff interviews confirmed that CNAs had not consistently obtained weights, leading to gaps in care planning and delayed interventions.
A resident with multiple medical conditions was discharged against medical advice without documentation of risk discussion, a signed AMA form, or notification of the physician and administrative staff. Staff interviews confirmed that required AMA protocols were not followed, and the medical record lacked evidence of these actions.
A resident with a history of smoking and cognitive decline was not re-assessed for smoking safety or had their care plan updated after a significant change in condition. After being found smoking in their room while on oxygen, staff did not complete a new smoking safety assessment or revise the care plan. The facility also failed to secure the resident's lighter and cigarettes, resulting in a fire that caused burns and smoke inhalation, requiring hospitalization.
Surveyors identified that the facility did not maintain its fire alarm system, as the main panel displayed a trouble alarm for a missing duct detector and showed an incorrect date and time after a power outage. The facility also lacked documentation of annual portable fire extinguisher inspections and had a fire safety plan that omitted protocols for extinguisher use and procedures for reviewing the fire alarm panel during alarms. These deficiencies affected 36 residents in one smoke compartment.
The facility did not have a defined time frame in its Release of Information policy for providing medical records when requested. A home health agency made two requests for a resident's records, which were eventually sent electronically, but there was no documentation of the requests or calls, and the policy lacked specific processing time frames.
A resident with multiple serious diagnoses was discharged without receiving a documented medication list or education about their medications. Staff interviews confirmed that it was the nurse's responsibility to provide and review discharge instructions, including medications, but no documentation was available to show this occurred, in violation of facility policy.
A resident on anticoagulation therapy experienced a fall with head injury and was not promptly reported to the on-call provider by the night shift RN. The resident was later found to have significant bruising and cognitive changes, prompting the day shift LPN to contact the NP, who arranged for hospital evaluation. Facility documentation and interviews confirmed delayed provider notification and lack of a clear policy for such events.
A newly hired CNA began work without documented completion of required elder abuse prevention training, contrary to facility policy mandating such training during initial orientation and before floor assignment. The Administrator confirmed the lapse in timely training for this staff member.
A resident with multiple medical conditions reported being handled roughly by several nurses during repositioning, resulting in bruising. Although the complaint was documented by a nurse, no investigation was initiated, and the DON and Administrator were not notified as required by facility policy. Interviews confirmed that standard procedures for abuse allegations were not followed, and no follow-up or documentation of actions taken was found.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for bathing due to medical conditions including dysphagia following cerebral infarction, type 2 diabetes mellitus, and essential hypertension, did not receive scheduled bathing as required. The resident reported experiencing a rash and itching, and stated that staff did not bathe or shower them regularly. Review of the facility's bathing schedule and medical records showed that the resident was assigned to receive showers or bed baths twice weekly, specifically on Wednesday and Saturday evenings, but these were not consistently provided as scheduled. A Certified Nurse Assistant confirmed the bathing schedule and that documentation was maintained in the medical record. The Director of Nursing also verified that the resident's scheduled showers were not provided as required. Facility policy stated that residents should be offered at least two full baths or showers per week, but this was not adhered to in the resident's case, as evidenced by gaps in the bathing documentation and the resident's own account of infrequent bathing.
Failure to Obtain and Document Monthly Weights as Ordered
Penalty
Summary
The facility failed to follow physician orders for obtaining monthly weights for a resident diagnosed with Parkinson's disease, dementia, and major depressive disorder. The physician had ordered monthly weights to be taken within the first week of each month for monitoring purposes. However, the medical record lacked documented weights for three consecutive months, specifically September, October, and November. This omission was identified through record review and confirmed by staff interviews, which revealed that Certified Nurse Assistants (CNAs) had not consistently obtained the required monthly weights. Multiple staff members, including the DON, Unit Manager, ADON, and Registered Dietitian, acknowledged ongoing challenges in obtaining accurate and consistent weight measurements. They indicated that missing or inaccurate weights had negatively impacted care planning and delayed timely interventions for residents experiencing weight loss or significant changes. The facility's policy required nursing staff to measure resident weights as ordered by the physician, but this was not consistently followed for the resident in question.
Failure to Complete Required AMA Discharge Procedures
Penalty
Summary
The facility failed to follow required procedures when a resident was discharged against medical advice (AMA). Specifically, there was no documentation that nursing staff discussed the risks associated with leaving AMA, no signed AMA form was present, and there was no evidence that the physician, administrator, or director of nursing were notified as required by facility policy. The incident involved a resident with multiple medical conditions, including narcolepsy, edema, type 2 diabetes mellitus, and morbid obesity, who had been admitted for therapies and ongoing medical management. Prior to the discharge, the resident's family expressed a desire to take the resident home, and caregiver training was scheduled for a later date. On the day of discharge, the family demanded an in-person visit from a provider, which was not accommodated as providers did not come in on weekends unless it was an emergency. The family then called 911, and EMS arrived to transfer the resident. The family informed staff they were leaving, and EMS removed the resident without speaking to facility staff about the discharge. Interviews with facility staff confirmed that the expected protocol for AMA discharges was not followed. Staff acknowledged that the AMA form should have been explained and signed, or refusal documented, and that the physician and administrative staff should have been notified. However, there was no documentation of these actions in the resident's medical record. The facility's policy required these steps, but the record lacked evidence that they were completed in this case.
Failure to Reassess Smoking Safety and Secure Smoking Materials Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff re-assessed a resident's smoking status and updated the care plan following a significant change in the resident's cognitive condition. The resident, who had a history of cigarette smoking and was at risk for injury and inappropriate behaviors, experienced a decline in cognition as documented by a lower BIMS score. Despite this significant change, the resident's smoking safety was not re-evaluated, and the Minimum Data Set (MDS) inaccurately reflected no tobacco use. The medical record lacked a corresponding Smoking Safety evaluation and care plan update after the change in condition. Additionally, after an incident where the resident was found smoking inside their room while using oxygen, staff did not complete a new smoking safety assessment or update the care plan as required by facility protocol. The Activity Director and DON confirmed that the event should have triggered a reassessment and care plan revision, but these actions were not taken. The resident's medical record did not reflect any follow-up or documentation of the incident in the smoking safety evaluation. Furthermore, the facility failed to secure the resident's lighter and cigarettes, contrary to the facility's protocol that prohibited residents from retaining smoking paraphernalia. Despite the implementation of a new smoking program protocol, the resident was able to access smoking materials and subsequently caused a fire in their room while using oxygen. This resulted in the resident sustaining burns and smoke inhalation, requiring hospitalization.
Failure to Maintain Fire Alarm System, Fire Extinguishers, and Fire Safety Plan
Penalty
Summary
The facility failed to maintain its fire alarm system, portable fire extinguishers, and fire safety plan in accordance with National Fire Protection Association (NFPA) standards. During a facility tour, the main fire alarm panel was observed to display a system trouble alarm, specifically indicating a missing duct detector in the water heater room. The fire alarm panel also showed an incorrect date and time, which the Maintenance Director attributed to a recent power outage and subsequent hard reset of the system. The facility was aware of the trouble alarm but had only scheduled future repairs with the vendor. Additionally, document review revealed that the facility could not provide evidence of annual inspections for portable fire extinguishers. Review of the facility's evacuation and fire safety plan showed that it lacked protocols for the use of portable fire extinguishers, such as the P.A.S.S. method, and did not include procedures for reviewing the fire alarm annunciator panel during an alarm condition. These deficiencies affected 36 residents in one of six smoke compartments, with the facility having a census of 137 residents at the time of the survey.
Lack of Defined Time Frame for Release of Medical Records
Penalty
Summary
The facility failed to ensure its Release of Information policy included a defined time frame for providing resident medical records upon request. A home health agency requested medical records for a resident on two occasions, with the first request made on 05/01/2025 and a second on 05/20/2025. The records were sent electronically on 05/20/2025 and 05/21/2025. The Medical Records Director stated that records would not be released without a request and that staff typically documented the portion of the record provided, but was unsure if other staff had documented the requests. There were no documented requests or phone calls from the home health agency regarding the resident, and fax cover sheets and written requests were only kept for 30 days. Review of the facility's Release of Information policy revealed it lacked documented time frames for processing such requests.
Failure to Provide Discharge Medication List and Education
Penalty
Summary
The facility failed to provide a copy of the discharge medication list and education about the medications to a resident upon discharge. The resident, who had been admitted with acute respiratory failure, chronic obstructive pulmonary disease, local infection of the skin and subcutaneous tissue, and sepsis, was discharged without documentation showing that a medication list or medication education was given. Interviews with facility staff, including a registered nurse, social services assistant, and the Director of Nursing (DON), confirmed that it was the nurse's responsibility to review and educate the resident on their discharge medications and instructions, and to ensure the resident understood and signed the discharge instructions. However, no such documentation was available for this resident. Review of the facility's policy titled Discharge Planning indicated that the nursing department was responsible for assessing and coordinating health and medical education needs, and that the discharge packet should include a medication list and prescriptions. The former DON also confirmed that there should have been documentation of medications provided and education given to the resident at discharge. The lack of documentation and education regarding discharge medications constituted a deficiency in the facility's discharge process for this resident.
Failure to Notify Provider After Resident Fall with Injury
Penalty
Summary
The facility failed to notify the on-call medical provider after a resident experienced a fall with injury, resulting in bruising to the forehead. The resident, who had a history of traumatic subdural hemorrhage, atrial fibrillation, congestive heart failure, and was on anticoagulation therapy, was found on the floor with purple lumps on the forehead and a small skin tear on the left wrist. The RN on duty performed an assessment, provided basic wound care, and notified the Executive Director, Resident Care Manager, Nurse Practitioner (NP), and Guardian, but did not contact the on-call medical provider at the time of the incident. The resident was monitored, and pain medication was administered. Later, during the day shift, an LPN noticed additional bruising and changes in the resident's cognition and reached out to the NP, who then assessed the resident and decided to send the resident to the emergency department for further evaluation due to the high risk associated with anticoagulation. Review of facility documentation and interviews confirmed that the NP was not notified of the fall and injury until the day shift, several hours after the incident. The facility lacked a clear policy for physician notification related to change of condition, and the relevant fall management policy did not specify provider notification requirements.
Failure to Complete Timely Elder Abuse Prevention Training for New CNA
Penalty
Summary
The facility failed to ensure that initial elder abuse prevention training was completed in a timely manner for one newly hired Certified Nursing Assistant. Personnel records showed that this staff member, hired on 11/01/2025, did not have documented evidence of completing elder abuse prevention training upon hire. According to the facility's policy, all staff, including contract staff and volunteers, are required to receive training on abuse prevention, reporting, and intervention upon hire, annually, and as needed. The Administrator confirmed that abuse training should be completed during the first orientation and that staff are not permitted to work on the floor prior to completing this training. However, the record review and Administrator interview confirmed that this requirement was not met for the identified employee.
Failure to Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse for one resident who reported that several nurses had been rough while repositioning, resulting in bruising on the left arm and inner elbow. The resident, who had diagnoses including intervertebral disc degeneration, morbid obesity, and long-term opiate use, could not recall the exact date of the incident but reported the event to a nurse, who documented the complaint in the progress notes. Despite this documentation, there was no evidence that an investigation was initiated or that the required notifications to the Director of Nursing (DON) or Administrator were made at the time of the allegation. Interviews with nursing staff revealed that the standard procedure for abuse allegations included immediate reporting to the Administrator and DON, conducting interviews with involved staff and residents, performing a head-to-toe skin assessment, and documenting all actions taken. However, the nurse who received the complaint did not initiate an investigation, citing uncertainty about which staff were involved due to the resident's inability to specify the date. The DON and Administrator both confirmed they were not informed of the allegation and that no investigation or follow-up was conducted as required by facility policy. The facility's abuse policy required immediate notification of the DON and Administrator for any suspected or reported abuse, initiation of an investigation, and completion of a written summary of findings. In this case, the lack of communication and failure to follow established procedures resulted in the absence of an investigation into the resident's allegation of physical abuse, as well as a lack of documentation regarding any follow-up or actions taken to ensure the resident's safety.
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