Every finding on record at Northern Nevada State Veterans Home

Based on observation, interview and record review, the facility failed to reasonably accommodate the documented allergy of garlic for 1 of 19 sampled residents (Resident #20). This deficient practice had the potential to cause emotional distress and/or physical harm to the resident. Findings include:Resident #20Resident #20 was admitted to the facility on [DATE], with diagnoses including gastro-esophageal reflux disease without esophagitis, and muscle weakness.On 03/31/2026 at 12:57 PM, Resident #20 expressed fear of eating garlic due to concern it could result in an undignified death from colic and severe gastrointestinal distress. Resident #20 verbalized when receiving an alternate meal in place of the regular meal, the resident did not receive any side items, including dessert. Resident #20's clinical record section Allergies, dated 05/02/2025, documented Resident #20's allergens included garlic, and severe allergy type.Physician's order dated 05/05/2025, documented regular diet, regular texture, regular liquids/consistency, allergic to garlic.Resident #20's care plan dated 05/06/2025, documented Resident #20 was allergic to garlic. Be sure the food, including condiments, does not contain garlic.On 04/01/2026 at 12:30 PM, the Culinary Director explained resident allergies were documented on the tray card ticket to ensure allergies were not included in meals provided to the resident. The Culinary Director verbalized staff reviewed the list of foods with the allergen with Resident #20. The Culinary Director explained Resident #20 was too proud to request further accommodation with meals to ensure garlic was not present in the meal. The Culinary Director verbalized when a dish contained garlic, staff would ask the resident for an alternative meal choice. The Culinary Director verbalized the kitchen could not prepare a separate garlic free version of the scheduled meal option due to cost and production limitations.On 04/02/2026 at 10:00 AM, the Registered Dietician (RD) explained an alternate meal was not necessarily equal in calories to the regular meal being served. The RD did not explain if alternate meals were equal in nutritional value.The facility policy and procedure manual titled Food Allergies, undated, documented individuals with food allergies would be provided with safe foods and fluids, and appropriate substitution to maintain health.The facility policy and procedure manual titled Resident Rights, reviewed 04/16/2025, documented the community must protect and promote the rights of all residents and ensure residents were receiving the care and services needed.

Based on interview, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely per facility policy for 6 of 20 sampled employees (Employees #2, #3, #4, #15, #17, and #19). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include:Employee #2Employee #2 was hired as the Director of Nursing on 02/09/2026.Employee #2's personnel record documented initial abuse training completed on 02/15/2026, six days after hire.Employee #3Employee #3 was hired as the Activity Director on 05/13/2025.Employee #3's personnel record documented initial abuse training completed on 08/07/2025, nearly three months after hire.Employee #4Employee #4 was hired as the Registered Dietician on 07/13/2025.Employee #4's personnel record lacked documented evidence that initial abuse training was completed.Employee #15Employee #15 was hired as a Licensed Practical Nurse on 06/24/2025.Employee #15's personnel record documented initial abuse training completed on 07/22/2025, almost one month after hire.Employee #17Employee #17 was hired as a Certified Nursing Assistant on 04/22/2025.Employee #17's personnel record documented initial abuse training completed on 06/12/2025, more than seven weeks after hire.Employee #19Employee #19 was hired as a Dietary Aide on 09/09/2025.Employee #19's personnel record documented initial abuse training completed on 10/07/2025, nearly one month after hire.On 04/01/2026 at 12:03 PM, the Human Resources Director explained all staff in the facility were required to complete abuse training upon hire at the facility and annually thereafter. The Human Resources Director confirmed Employee #2, #3, #4, #15, #17, and #19, had not completed abuse training timely.The facility policy titled Abuse, Neglect, and Exploitation, suspected Crimes, last revised August 2025, documented all employees were to be trained during orientation to the facility on issues related to abuse prohibition practices and annually thereafter. The practices would detail appropriate interventions to deal with aggressive or catastrophic reactions of residents, how staff should report knowledge related to allegations of abuse without fear of reprisal, how to recognize sings of burnout, frustration, and stress that may lead to abuse, and what constitutes abuse, neglect, injuries of unknown origin, and misappropriation of resident property.

Based on observation, interview, and document review, the facility failed to ensure the outside garbage receptacle area was kept free from debris. This deficient practice had the potential to result in the harborage and feeding of pests. Findings include:On 03/30/2026 at 8:56 AM, the outside garbage receptacle area had an accumulation of leaf debris, gloves for medical care, and cardboard boxes to the rear and right sides of the receptacle.The Culinary Director (CD) was present and verbalized the receptacle area was managed by facility maintenance; however, all staff were responsible for ensuring the receptacle area was kept clean and free of debris. The CD confirmed the condition of the garbage receptacle area.On 04/02/2026 at 12:09 PM, the Plant Operations Director (maintenance) explained all staff were responsible for ensuring the receptacle area remained clean and free of debris. The Plant Operations Director verbalized the importance of keeping the receptacle area clean was to prevent rodents in the facility.The facility policy titled, Policy and Procedure Manual - Waste Disposal, dated 2021, documented trash would be deposited into a sealed container outside the premises.

Based on observation, interview and document review, the facility failed to ensure a dishwasher machine in 1 of 3 satellite pantries was maintained in good working order to keep dishes, utensils, and other cooking equipment properly sanitized. This deficient practice had the potential to expose residents to foodborne illnesses. Findings include:On 03/30/2026 at 10:29 AM, during a tour of the Reflections satellite pantry, the Culinary Director (CD) started a cycle on the dishwasher. A colorless transparent liquid seeped out from underneath the dishwasher into a puddle in front of the dishwasher. At the end of the cycle, the CD wiped a chlorine test strip on the door of the dishwasher. The test strip lacked a change of color. The CD wiped another chlorine test strip on the dishwasher door. The chlorine test strip did not change color. The CD started a second cycle on the dishwasher. At the end of the cycle, the CD used three chlorine test strips: one on the dishwasher door, one on the dish rack, and one in the water pooling at the bottom of the dishwasher. The test strips did not change color. Water seeped out from underneath the dishwasher to the front and right side of the dishwasher.The CD verbalized the dishwasher was a low temperature dishwasher with chemical sanitization. The CD explained the dishwashers used chlorine bleach. When tested, the chlorine testing strip should turn purple to indicate the ideal chlorine sanitizer concentration of 100 parts per million (ppm). The CD confirmed the observations and explained the chlorine test strips indicated a chemical concentration of zero ppm. The CD confirmed no sanitizing agent was being delivered to the dishwasher. The CD explained it was important dishes were properly washed and sanitized to prevent the spread of viruses and bacteria. The CD was previously unaware of the dishwasher seepage and sanitizer concentration.The facility policy titled, Policy and Procedure Manual - Cleaning Dishes/Dish Machine, dated 2021, documented all flatware, serving dishes, and cookware would be cleaned, rinsed and sanitized after each use. Dish machines must automatically dispense detergents and sanitizers.

Based on clinical record review, document review and interview, the facility failed to ensure an antibiotic medication was administered in a timely manner as ordered by the physician order for 1 of 19 sampled residents (Resident #3). This deficient practice had the potential to result in delayed treatment, worsening clinical condition, and avoidable decline in health status. Findings include:Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, unspecified, embolism and thrombosis of arteries of the lower extremities, acquired absence of right leg above knee, and infection following a procedure, deep incisional surgical site, sequela. Resident #3's Care Plan dated 02/02/2026, documented surgical wound to right above the knee amputation. Wound dehiscence with wound infection. A physician order dated 03/05/2026, documented Bactrim Double Strength Oral Tablet 800-160 milligrams (mg), give one tablet by mouth two times a day for wound infection suppressive therapy, 0800 and 2000 hours. Resident #3's Medication Administration Record dated April 2026, lacked documented evidence Bactrim Double Strength Oral Tablet was administered on April 1, 2026 at 0800 hours. On 04/01/2026 at 11:45 AM, the Licensed Practical Nurse (LPN) verbalized having administered Bactrim Double Strength Oral Tablet to Resident #3 at 11:01 AM, due to time having gotten away from the LPN. The LPN confirmed the order for the Bactrim Double Strength Oral Tablet documented the antibiotic was to be administrated at 8:00 AM, but was not. On 04/01/2026 at 2:29 PM, the Director of Nursing (DON) confirmed the Bactrim Double Strength Oral Tablet should have been administered to Resident #3 at 8:00 AM, and verbalized having expected medications to be administered at the time documented on the order. The facility policy titled, Medication Administration, dated 11/2024, documented all medications were to be administered as ordered by the physician. The standard of practice for medication administration was an hour before or an hour after unless the physician order documented a specific time for administration.

Based on clinical record review, interviews, and document review, the facility failed to ensure that a resident remained free from physical and/or mental abuse for 2 of 19 sampled residents (Resident #10 and #13). This deficient practice resulted in the resident being subjected to both physical and mental abuse, causing emotional distress and posing a potential risk for physical injury and a decline in psychosocial well being.Findings include:Resident #10Resident #10 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, dementia in other disease classified elsewhere, severe, and schizoaffective disorder, bipolar type.A Facility Reported Incident (FRI) final report dated 09/30/2025, documented on 09/26/2025, a Certified Nursing Assistant (CNA1) had grabbed Resident #10 by the arm while attempting to take the resident to the resident's room. CNA1 had also roughly placed the resident's baseball cap on the resident's head.A Nursing Progress Note dated 09/26/2025, documented the night shift nurse heard CNA1 speaking in a loud tone to Resident #10 in an attempt to direct the resident to the resident's room. CNA1 was witnessed pulling Resident #10's left arm as the resident sat on a couch near the Nurse's Station. The resident initially refused to follow CNA1's direction and CNA1 continued to hold the resident by the left arm despite the resident eventually following directions.A Nursing Progress Noted dated 09/27/2025, documented Resident #10's left arm was assessed by the Assistant Director of Nursing and no injury was noted.Resident #10's Trauma Informed care plan initiated on 11/22/2024, documented the resident had the potential for complications related to experienced trauma in the military, triggers were negative people. Interventions included staff to maintain a calm, non-threatening manner, provide reassurance and comfort measures, provide positive interactions, respect boundaries, and offer emotional support when needed.Resident #13Resident #13 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease with dyskinesia and fluctuations, unspecified dementia, major depressive disorder, anxiety disorder, and post-traumatic stress disorder (PTSD), unspecified.A FRI final report dated 09/30/2025, documented on 09/26/2025, Resident #13 had witnessed CNA1 pull Resident #10's arm while at the Nurse's Station. When Resident #13 did not respond to CNA1 at the Nurse's Station, CNA1 snapped CNA1's fingers in front of Resident #13's face. The resident then asked the Nurse if the Nurse had seen how close CNA1 had come to the resident. A Nursing Progress Noted dated 09/27/2025, documented Resident #13 had witnessed the interaction between Resident #10 and CNA1 while at the Nurse's Station. Resident #13 had expressed the resident did not want CNA1 to provide the resident's bedtime care and verbalized discomfort with CNA1 after witnessing CNA1's interaction with Resident #10. The night shift Nurse assigned another CNA to provide Resident #13's evening care.Resident #13's Trauma Informed care plan initiated on 09/16/2025, and revised on 12/19/2025, documented the resident was at risk and/or potential for complications related to the military/war. Triggers were loud noises, easily startled, and nightmares. Interventions included staff approaching the resident from the front, monitoring surroundings for loud noises, avoiding television news casts, always announcing self when providing care, and maintaining a calm, non-threatening manner while working with the resident.A CNA witness statement dated 09/26/2025, documented staff witnessed CNA1 speak to Resident #10 in a loud voice and showed a lack of consideration for the resident's feelings. A Licensed Practical Nurse (LPN) witness statement dated 09/26/2025, documented the LPN had witnessed CNA1 using an aggressive tone with Resident #10. The LPN observed CNA1 grab the resident by the left arm with excessive force. CNA1 then grabbed the Resident #10's baseball cap out of the resident's hands in a rough manner and placed it on the resident's head while pulling the resident off the couch by the left arm.The LPN's witness statement also documented the LPN received a report from Resident #13 the resident did not want to receive care from CNA1. CNA1 was witnessed on 09/26/2025, to approach Resident #13 and told the resident it was time for bed. When Resident #13 did not engage back, CNA1 snapped CNA1's fingers twice in front of the resident's face while getting closer to the resident. Resident #13 looked away from CNA1 and asked the Nurse if the Nurse had seen how close CNA1 was to the resident. Resident #13 reported the resident was afraid of CNA1 and did not want to receive care from CNA1.A Registered Nurse's (RN) witness statement dated 09/26/2025, documented the RN had received report from the LPN regarding CNA1's behavior towards Resident #10 and Resident #13. The RN reported the behavior to the Director of Nursing and then had CNA1 meet with the RN and Security regarding CNA1's conduct with the residents. CNA1 was asked to surrender the employee badge and was notified CNA1 would be placed on suspension pending a formal investigation. CNA1 was then escorted from the facility property.On 03/31/2026 at 3:37 PM, the Administrator verbalized the facility investigation into the alleged abuse of Resident #10 and Resident #13 by CNA1 on 09/26/2025, was substantiated. The Administrator explained the incident with both residents occurred at the Nurse's Station. CNA1 was suspended immediately, surrendered the employee's badge, and then terminated in response to the investigation findings. The Administrator provided the investigation documentation, staff and resident witness statements from the investigation, a staff In-Service on abuse prevention and reporting, and a report to the Nursing Board regarding CNA1 dated 10/03/2025. On 04/02/2026 at 9:56 AM, the Human Resources Director confirmed CNA1 was terminated for resident rights violations and resident abuse on 10/10/2025.A CNA Job description signed on 8/26/2025, documented a common core role of quality of care included following all policies and procedures related to reporting and preventing abuse of vulnerable adults. The incumbent would ensure residents received the highest quality of service in a caring, compassionate, and dignified manner which recognized the individual's needs and rights. Residents would be assisted with activities of daily living in a manner conducive to the residents' safety and comfort. The facility policy titled Abuse, Neglect, and Exploitation, dated 01/2023, documented it was the policy of the facility to take appropriate steps to prevent the occurrence of abuse, neglect, and misappropriation of property. Abuse included verbal, sexual, physical and mental abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain, or mental anguish. Staff were supervised to identify inappropriate behaviors such as derogatory language, rough handling, and ignoring residents while giving care.FRI 2629530

Based on observation, interview, and document review, the facility failed to ensure an effective pest control program was maintained as evidenced by the presence of live ants in 1 of 6 serving kitchens in the facility. This deficient practice had the potential to contribute to ants and other pest infestations, contaminate food preparation areas, and increase the risk of foodborne illness. Findings include:On 03/30/2026 at 10:40 AM, during a tour of the facility's serving kitchens and in the presence of the Culinary Director, several ants were present on the floor of the Pyramid [NAME] Unit serving kitchen near the door to the satellite pantry and around the garbage bin.The Culinary Director confirmed the observation and explained being aware of ants present in the facility approximately one year prior; however, the Culinary Director believed the problem had been resolved. The Culinary Director verbalized when ants were identified, the Culinary Director would set out bait traps and disinfect the area to ensure the kitchen environment was insect free. On 04/02/2026 at 12:09 PM, the Plant Operations Director explained the facility was contracted with a pest control company for monthly services to prevent and address rodents, insects and other pests. The Plant Operations Director verbalized being made aware of the ants in the Pyramid [NAME] Unit serving kitchen that day. The Plant Operations Director explained when made aware of insects in the facility, the Plant Operations Director would reach out to the pest control company, the facility would be sprayed with insect repellant, and bait traps would be placed.A document titled, Industrial-Commercial-Institutional Pest Control Service Agreement, dated 03/12/2025, documented the facility would receive services for roaches, ants, silverfish, fire ants, rats, and mice.The facility policy titled, Policy and Procedure Manual - Pest Control, dated 2021, documented a pest control contractor would provide routine preventative treatments at prescheduled appointed times and if a pest situation was reported, the contractor would be notified and may be requested to make an unscheduled visit to address concerns.

Based on observation, interview, and document review, the facility failed to ensure 1) a handwashing station was stocked with disposable hand towels, 2) dry food was appropriately stored, and 3) food was prepared and served in a sanitary manner. These deficient practices had the potential to increase the risk of infection and foodborne illnesses in the facility. Findings include:Handwashing StationOn 03/30/2026 at 9:24 AM, during a tour of the Aspen Pinion Serving Kitchen, the handwashing station was not stocked with disposable hand towels.On 03/30/2026 at 9:24 AM, the Culinary Director (CD) confirmed the lack of disposable hand towels at the Aspen Pinion Serving Kitchen handwashing station and verbalized disposable hand towels should always be available at the handwashing stations.The facility policy titled, Policy and Procedure Manual - Hand Washing, dated 2021, documented handwashing facilities would be readily accessible and equipped with hot and cold running water, paper towels and/or automatic hand dryer, soap, trash cans and signage.Food StorageOn 03/30/2026 at 9:45 AM, during a tour of the Reflections Satellite Pantry, pouches of powdered fruit punch and lemonade were open and exposed to the air and other contaminants.On 03/30/2026 at 9:45 AM, the CD confirmed the observation and verbalized the powdered fruit punch and lemonade pouches should be folded and closed.The facility policy titled, Policy and Procedure Manual - Food Storage, dated 2021, documented food would be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Food would be stored and handled to maintain the integrity of the packaging until ready for use.Sanitary Food PreparationOn 04/01/2026, during lunch tray line observation in the [NAME] Quail Serving Kitchen, the following events occurred:-At 12:05 PM, the Dietary Supervisor (DS) took the temperature of the soft and bite sized asparagus. The thermometer indicated the asparagus was 132 degrees Fahrenheit (F).-At 12:05 PM, the DS verbalized the asparagus was under the appropriate temperature and should be sent back to the primary kitchen to be reheated to 140 F. The DS may also manually chop a portion of the regular diet asparagus to meet the needs of residents requiring a soft and bite sized diet.-At 12:12 PM, the DS took a knife out of the DS's pocket and washed the knife with hand soap in the handwashing sink. The DS plated a dish of bite sized chicken, rice, a minced and moist roll and four asparagus shoots. The DS used the knife to cut the asparagus shoots on the plate.On 04/01/2026 at 12:29 PM, the DS verbalized the DS always kept a personal knife on hand in case a knife was needed to prepare or serve food. The DS confirmed the DS took a personal knife out the DS's pocket and explained the DS washed the knife in the handwashing sink before using the knife to prepare resident food. The DS verbalized the DS should have gotten a clean and disinfected knife from the pantry as it was important utensils were properly sanitized.On 04/01/2026 at 1:03 PM, the CD explained it was important food preparation surfaces, utensils and kitchenware were sanitized to prevent the spread of disease.The facility policy titled, Policy and Procedure Manual - Cleaning Dishes/Dish Machine, dated 2021, documented all flatware, serving dishes, and cookware would be cleaned, rinsed and sanitized after each use. Dishes should be rinsed in the sink using hot soapy water if needed. Pots and pans should be scrubbed with a non-metallic scouring pad, when necessary, washed and rinsed using the three-sink method.

Based on record review and interview, the facility failed to maintain staffing hour postings for at least 18 months as required by federal regulation. This deficient practice had the potential to impede the facility's ability to demonstrate compliance with staffing requirements and hinders transparency for regulatory review. Findings include:On 03/31/2026, during record review, the surveyor requested staffing hour postings from 07/2025 - 09/2025. On 03/31/2026 at 11:10 AM, the Administrator verbalized the Staff Scheduler was not retaining the staffing hour postings. The Administrator confirmed staff postings were to be retained for 18 months. The Administrator verbalized being unaware the Staff Scheduler was discarding the staffing hour postings at the end of every week. The Administrator explained an in-service was provided to the Staff Scheduler for the required retention time of the staffing hour postings on 03/31/2026.

Based on personnel record review, interview and document review, the facility failed to ensure initial elder abuse prevention training was completed timely for 10 of 20 sampled employees (Employees #1, #5, #11, #12, #14, #15, #16, #18, #19, and #20). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include: Employee #1 Employee #1 was hired by the facility as the Executive Director with a start date of 09/03/2024. Employee #1's personnel file lacked documented evidence of elder abuse prevention training. Employee #5 Employee #5 was hired by the facility as the Social Services Director with a start date of 01/07/2025. Employee #5's personnel file documented elder abuse prevention training on 03/11/2025, 4 weeks late. Employee #11 Employee #11 was hired by the facility as an Agency Registered Nurse (RN) with a start date on 08/01/2024 and as a facility Registered Nurse with a start date on 01/28/2025. Employee #11's personnel file documented elder abuse training on 02/23/2025, six months late. Employee #12 Employee #12 was hired by the facility as an RN/Infection Preventionist with a start date of 08/01/2024. Employee #12's personnel file lacked documented elder abuse prevention training. Employee #13 Employee #13 was hired by the facility as an RN with a start date of 08/01/2024. Employee #13's personnel file documented elder abuse prevention training on 01/10/2025, five months late. Employee #14 Employee #14 was hired by the facility as a License Practical Nurse (LPN) with a start date of 08/27/2024. Employee #14's personnel file documented elder abuse prevention training on 12/27/2025, four months late. Employee #15 Employee #15 was hired by the facility as an LPN with a start date of 09/03/2024. Employee #15's personal file documented elder abuse prevention training on 12/17/2024, three months late. Employee #16 Employee #16 was hired by the facility as a Certified Nursing Assistant (CNA) with a start date of 08/01/2024. Employee #16's personnel file documented elder abuse prevention training on 12/23/2024, four months late. Employee #18 Employee #18 was hired by the facility as Culinary Staff with a start date of 01/28/2025. Employee #18's personnel file documented elder abuse prevention training on 03/11/2025, two weeks late. Employee #19 Employee #19 was hired by the facility as Culinary Staff with a start date on 10/28/2024. Employee #19's personnel file lacked documented evidence of elder abuse prevention training. Employee #20 Employee #20 was hired by the facility as a Housekeeper with a start date on 10/08/2024. Employee #20's personnel file lacked documented evidence of elder abuse prevention training. On 03/12/2025 at 2:00 PM, the Human Resources Director (HRD) verbalized elder abuse prevention training was to be completed by all staff within the first orientation, and prior to working with residents. The HRD confirmed Employee #1, #5, #11, #12, #14, #15, #16, #18, #19, and #20 lacked timely completion of elder abuse training and had been working with residents prior to completion. The facility policy titled, Abuse, Neglect and Exploitation, revised January 2023, documented employees are trained through orientation and on-going sessions on issues related to abuse prohibition practices. All employees will receive training no less frequently than annually on the requirements of the facility's policies and procedures regarding alleged violations and the requirements of federal and state laws.

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 chest, a skin tear on the lower right arm and the left middle finger and thumb appeared purple and swollen. Per physician, continue checking neurological (neuro) signs as the fall was unwitnessed. The Director of Nursing (DON) and the oncoming nurse were made aware. The nurse did not see any head trauma, resident was alert, pleasant, and cooperative. A Progress Note dated 11/20/2024 at 10:46 PM, documented upon arrival to the unit, outgoing staff reported Resident #60 fell around 4:30 PM. Resident was on neurological checks. Noted resident's systolic blood pressure (SBP) from the time of the fall until the start of night shift were all high, as high as 193/74. Redness to the resident's forehead was noted. Staff reported to the night shift nurse the resident was found in resident's bathroom with the resident's forehead touching the floor. At 6:22 PM, the night shift nurse notified the physician of a possible head strike and high SBP. The physician ordered to resident to be sent out for further treatment due to head strike. At approximately 7:00 PM, Resident #60 was sent to the emergency room via emergency medical services. A Progress Note dated 11/20/2024 at 11:13 PM, documented a call was received by the facility at 10:15 PM from the emergency room (ER). The ER nurse reported the resident was being transferred to another hospital for further treatment due to computed tomography (CT) scan results showing a subdural hematoma. An acute care History and Physical dated 11/20/2024, documented Resident #60 was injured in a mechanical, ground-level fall with probable brief loss of consciousness. The resident was initially evaluated at an alternate hospital and transferred for a neurosurgical evaluation. Review of the resident's transfer CT imaging demonstrated a new acute left frontotemporal extra-axial hemorrhage with mild mass effect. An Issue Brief Form initiated by the facility on 11/21/2024, documented Resident #60 was found on the floor in the resident's bathroom with the resident's forehead touching the floor. The resident was sent to the emergency room for further evaluation, report received indicating the resident had a subdural hematoma. The facility's action steps following the incident included: -Medical evaluation and further management of the resident's subdural hematoma. The action step had a documented completion date of 11/20/2024. -Reassess if the subdural hematoma was acute or chronic. The action step included a note indicating acute on chronic and had a task completed date of 11/25/2024. The Issue Brief was signed by the Executive Director (ED). On 03/13/2025 at 11:35 AM, the Regional Director of Quality and Clinical Services (RDQCS) verbalized neglect was failure to provide care for a resident. Serious bodily injuries were injuries requiring further medical attention, if the resident had to be transferred to the hospital, if the resident needed a CT scan, if there was a closed head injury, or if the resident had altered mental status. The RDQCS confirmed a subdural hematoma was considered a serious bodily injury. All allegations of abuse, neglect, mistreatment, misappropriation of resident property, elopements, and injuries of unknown origin were required to be reported to the SA. If a resident sustained a serious bodily injury and the facility was unsure how the injury occurred or if it could have been preventable, the facility needed to rule out neglect and needed to be reported. On 03/13/2025 at 12:29 PM, the RDQCS denied the facility had received any concerns, complaints, or allegations regarding the failure of staff to follow post-fall policy or delay/refusal to transfer Resident #60 to the hospital after the fall on 11/20/2024 aside from a report filed against the facility's former Director of Nursing (DON). The RDQCS verbalized the facility had received a subpoena for records from the Nevada State Board of Nursing. The RDQCS explained the subpoena received did not include any allegations against the former DON however the former DON contacted the RDQCS via phone and informed the RDQCS the allegations included the former DON telling staff not to send Resident #60 to the hospital or the emergency room and not to care for Resident #60. The RDQCS believed the allegations were communicated to the RDQCS in January 2025. On 03/13/2025 at 2:53 PM, via phone call with the ED and with the RDQCS present, the ED denied Resident #60's fall on 11/20/2024 was reported to the SA. On 03/13/2025 at 2:54 PM, the RDQCS denied the allegations against the facility's former DON were thoroughly investigated or reported to the SA. It was the RDQCS's belief the allegations were not neglect and were allegations of the former DON working outside the former DON's scope of practice. The RDQCS explained the facility did not thoroughly investigate or report the allegations because the RDQCS had looked in the resident's record at the time the allegations were communicated to the RDQCS and did not believe the allegations had any merit. The facility policy titled Freedom from Abuse, Neglect and Exploitation - Abuse Reporting and Responsibilities of Covered Individuals, revised 09/13/2022, documented the facility would report alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property and results of investigations of the allegations according to regulatory guidelines and in accordance with state law within the required timeframes. Serious bodily injury was defined as an injury involving extreme physical pain, substantial risk of death, protracted loss or impairment of the function of a bodily member, organ, or mental faculty or requiring medical intervention such as surgery or hospitalization. Each covered individual was to report immediately, but not later than two hours after forming the suspicion, if the events resulted in serious bodily injury or not later than 24 hours if the events did not result in serious bodily injury. Cross reference tag F600 and F610. CPT #NV00072985

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 arm and the left middle finger and thumb appeared purple and swollen. Per physician, continue checking neurological (neuro) signs as the fall was unwitnessed. The Director of Nursing (DON) and the oncoming nurse were made aware. The nurse did not see any head trauma, resident was alert, pleasant, and cooperative. A Progress Note dated 11/20/2024 at 10:46 PM, documented upon arrival to the unit, outgoing staff reported Resident #60 fell around 4:30 PM. The resident was on neuro checks. Noted resident's systolic blood pressure (SBP) from the time of the fall until the start of night shift were all high, as high as 193/74. Redness to the resident's forehead was noted. Staff reported to the night shift nurse the resident was found in the resident's bathroom with the resident's forehead touching the floor. At 6:22 PM, the night shift nurse notified the physician of a possible head strike and high SBP. The physician ordered to resident to be sent out for further treatment due to head strike. At approximately 7:00 PM, Resident #60 was sent to the emergency room via emergency medical services. A Neurological Assessment flowsheet dated 11/20/2024, included assessments for Resident #60 from 4:30 PM through 6:15 PM. The assessment items to be performed included vital signs (VS) and the flowsheet documented the following blood pressure (BP) readings: -4:30 PM, BP 193/74. -4:45 PM, BP 191/69. -5:00 PM, BP 193/65. -5:15 PM, BP 195/79. -5:45 PM, BP 187/67. -6:15 PM, BP 187/81. On 03/12/2025 at 4:02 PM, a Licensed Practical Nurse (LPN) verbalized the LPN had received training from the facility related to abuse and neglect. Neglect included not providing care to residents and not performing expected job functions. The LPN confirmed the LPN was familiar with Resident #60 and verbalized Resident #60 was confused at baseline, was unable to accurately recall recent events, was a fall risk, and fell frequently. The LPN recalled Resident #60 had a fall in November 2024. The resident was sent to the hospital for a few days prior to being transferred back to the facility. The LPN recalled the LPN found Resident #60 on the ground in the resident's room. The resident was lying face down on the floor, with the resident's head touching the ground. The LPN and Certified Nursing Assistants (CNAs) assisted the resident into the shower due to a large amount of bowel movement on the resident. The LPN recalled when the resident was assisted off the ground, a red spot in the middle of the resident's forehead was present. The LPN checked Resident #60's vital signs and performed a neuro check and everything seemed ok. The LPN explained neuro checks were documented on a flowsheet. The LPN verbalized the night shift nurse sent Resident #60 to the hospital after seeing the resident's vital signs, noting the resident's BP was high, and the nurse felt the resident seemed more confused. The LPN recalled the LPN initially checked the resident's blood pressure with the LPN's wrist cuff after the fall and the LPN did not notice anything wrong. The LPN denied the LPN documented the BP reading. The LPN reviewed the Neurological Assessment flowsheet dated 11/20/2024 and confirmed the initials at the bottom of the columns for assessments completed from 4:30 PM through 5:45 PM belonged to the LPN. The LPN verbalized the blood pressure readings documented on the flowsheet were documented by the CNA. The LPN verbalized the LPN had been busy with two resident falls, was focused on the residents' eyes and handgrips, and never saw the vital signs. The LPN denied the LPN followed up with the CNA to ask what the vital signs were following Resident #60's fall and denied the LPN reviewed the vital signs documented by the CNA prior to initialing the bottom of each column on the flowsheet. On 03/13/2025 at 8:59 AM, a CNA confirmed the CNA was familiar with Resident #60 and recalled the resident fell on [DATE]. The CNA recalled the resident was found flat on the floor, face down. The LPN stayed with the resident while the CNA retrieved a VS machine. When the CNA returned to the room, the resident was lying on the resident's back and had a red bump on the resident's forehead. The CNA and LPN assisted the resident with a shower, then assisted the resident to the dining room. The CNA recalled the CNA continued to check Resident #60's vital signs every 15 minutes for one hour, then every 30 minutes, and notified the LPN the resident's blood pressure was really high. The CNA verbalized the CNA had concerns related to the LPN's response to Resident #60's fall and the resident not being sent to the hospital despite the resident's vital signs and the bump on the resident's forehead. The CNA recalled the CNA voiced the CNA's concerns to the night shift nurse at change of shift. On 03/13/2025 at 10:19 AM, a Physician confirmed the Physician was familiar with Resident #60. The Physician verbalized the Physician was aware Resident #60 had fallen in the facility however could not recall specific details related to a fall on 11/20/2024. The Physician verbalized for unwitnessed falls in the facility with head strike the Physician had a low threshold for sending the resident to the hospital. The Physician explained if a resident fell, the Physician would want to know if the fall was witnessed or unwitnessed, if the fall was ground level, if the resident lost consciousness, the results of the nurse's head to toe assessment, and the resident's VS. VS after a fall were important and nursing assessment was key. The Physician affirmed a SBP reading in the 190's after an unwitnessed fall with possible head strike would be concerning and would likely prompt transfer of the resident to the hospital. On 03/13/2025 at 11:00 AM, a Registered Nurse (RN) verbalized the RN was familiar with Resident #60. The RN recalled Resident #60 had many falls in the facility and confirmed the RN was familiar with the fall on 11/20/2024. The RN recalled the RN came on shift, was informed the resident had fallen during the day shift and was on neuro checks. The RN noted Resident #60's SBP documented on the neuro check form was high, and verbalized the RN knew something was wrong. The day shift CNA informed the RN the resident had an indentation on the resident's head and asked the RN to reassess the resident. The RN recalled Resident #60 was alert and appropriate in responses during the assessment and the RN had a concern with an injury on the resident's forehead which prompted the RN to call the Physician. The RN explained it was the facility's protocol to send residents to the hospital after a fall if the resident struck the resident's head, especially if the resident was on a blood thinner or the resident had a bump. On 03/13/2025 at 11:35 AM, the Regional Director of Quality and Clinical Services (RDQCS) verbalized neglect was failure to provide care for a resident. If a resident sustained a serious bodily injury and the facility didn't know how the injury occurred or if it could have been preventable, the facility needed to rule out neglect. The RDQCS explained the facility's expectation of staff after a resident fell was for the nurse to assess the resident, get a set of VS, do a neuro check, and check range of motion. Based on the findings of the assessment and VS, staff were to contact the doctor. The RDQCS verbalized monitoring of VS after an unwitnessed fall was very important and neuro checks were to be done every 15 minutes. Increased blood pressure after a fall could indicate an injury or a subdural hematoma (a collection of blood between the outmost layer of the meninges and the surface of the brain). The RDQCS reviewed Resident #60's clinical record and explained after the Physician was notified of elevated SBP and redness to the resident's forehead, the resident was transferred to the hospital on [DATE] due to possible head strike during a fall. The RDQCS verbalized the RDQCS would expect a nurse to review and be aware of the resident's VS documented on the neuro flowsheet. The RDQCS verbalized if a CNA checked the VS and the nurse did not review the VS, did not recheck the VS, did not notify the physician of the VS, or did not look in the record to see if there were any as needed medications available to treat blood pressure then it would be considered neglect. If the nurse saw the VS and did not intervene it could be considered neglect. The State of Nevada Administrative Code 632 - Nursing, revised August 2019, documented a Practical Nurse may supervise other personnel in the provision of care (NAC 632.228, 3). Unprofessional conduct by a licensee or certificate holder included: failing to supervise a person to whom functions of nursing are delegated or assigned, if responsible for supervising that person (NAC 632.890, 7), failing to collaborate with other members of a health care team as necessary to meet the health needs of a patient (632.890, 24), and failing to observe the conditions, signs and symptoms of a patient, to record the information or to report significant changes to the appropriate persons (632.890, 25). The Nevada State Board of Nursing Decision Tree for Delegation by Advanced Practice Registered Nurse (APRN), RN, LPN to Assistive Personnel (AP), undated and viewed on the Nevada State Board of Nursing website on 03/18/2025, documented steps in the delegation of tasks to AP included supervision and monitoring. An LPN was to assure tasks had been performed as delegated. The nurse maintained accountability for nursing tasks/activities delegated and performed by the AP, monitored the outcomes of the delegated task/s, and recognized subtle signs and symptoms with appropriate intervention when the client's condition changed. AP included CNAs. The facility policy titled Accidents/Falls, reviewed 11/2024, documented if a fall occurred, nursing/emergency care was to be provided per the facility's policy/standard of practice. Neurological observations (neuros) would be conducted following any observation of a resident hitting their head during a fall or if it was unknown/not observed whether a resident hit their head or not during a fall. Even if a resident reported the head was not hit and the fall was not observed, neuros were required to be completed. The facility policy titled Freedom from Abuse, Neglect, and Exploitation, dated 09/13/2022, documented neglect occurred when the facility was aware of, or should have been aware of, goods or services a resident required but the facility failed to provide them to the resident. Neglect included cases where the facility's indifference or disregard for resident care, comfort or safety resulted or could result in physical harm, pain, mental anguish, or emotional distress. Neglect may have been the result of a pattern of failures or may have been the result of one or more failures involving one resident and one staff person. Cross reference tag F609 and F610. CPT #NV00072985

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's right to choose to not be approached by individuals providing pet therapy when the resident had a documented allergy to animal hair and a care plan addressing the resident's desire to not be asked about receiving pet therapy was respected for 1 of 19 sampled residents (Resident #16). This deficient practice had the potential to result in the resident feeling disrespected due to the resident's requests not being honored in the facility. Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified, and post-traumatic stress disorder, chronic. On 03/10/2025 at 1:27 PM, Resident #16 was sitting on the side of the resident's bed when a handler and a therapy dog stood at the doorway to the resident's room and asked Resident #16 if the resident would like a visit from the dog. Resident #16 responded by clenching the resident's fists and raising the resident's voice when answering the handler. The resident verbalized the resident had told the dog handler many times the resident was allergic. The handler informed the resident the handler was unaware the resident did not want to see the dog because there were several different handlers and dogs involved in the program and different people visited the facility. The resident responded by asking the handler how many times the resident would have to inform people he did not want to see the dogs. The resident verbalized the resident felt disrespected because the resident was unable to be around the dogs due to an allergy and had made the resident's wishes known but was still approached for pet therapy. The documented allergies in the electronic health record for Resident #16 included an allergy to animal hair/dander with an active date of 01/06/2025. The allergy severity was documented to be moderate. A care plan for Resident #16, revised on 12/21/2024, documented the resident preferred not to have dog therapy. On 03/11/2025 at 2:50 PM, the Licensed Practical Nurse (LPN) for Resident #16 verbalized the LPN was not aware of any residents the pet therapy handlers would need to avoid approaching. On 03/11/2025 at 2:51 PM, the Certified Nursing Assistant for Resident #16 verbalized the staff were not made aware of when the pet therapy handlers and dogs would be on the unit. On 03/12/2025 at 10:40 AM, the Volunteer Services Director/Interim Activities Director (AD) verbalized the pet therapy organization should have been informed of which residents did not wish to receive pet therapy and should have been escorted by a staff member who could have informed the handler to avoid Resident #16's room. On 03/13/2025 at 3:09 PM, the Director of Nursing (DON) verbalized a resident with a care plan indicating the resident was not to receive pet therapy should not have been approached for pet therapy. The DON confirmed the facility staff should have communicated with the animal's handler to ensure the resident was not approached. The facility document titled Visiting Pet Policies, undated, documented residents would not be forced to have contact with animals or pets. Contact would be based on the resident's verbal permission or preference. The facility policy titled Resident Rights, revised 01/2023, documented residents had the right to dignity, self-determined, and person-centered care.

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 scrape to the right chest, a skin tear on the lower right arm and the left middle finger and thumb appeared purple and swollen. Per physician, continue checking neurological (neuro) signs as the fall was unwitnessed. The Director of Nursing (DON) and the oncoming nurse were made aware. The nurse did not see any head trauma, resident was alert, pleasant, and cooperative. A Progress Note dated 11/20/2024 at 10:46 PM, documented upon arrival to the unit, outgoing staff reported Resident #60 fell around 4:30 PM. Resident was on neurological checks. Noted resident's systolic blood pressure (SBP) from the time of the fall until the start of night shift were all high, as high as 193/74. Redness to the resident's forehead was noted. Staff reported to the night shift nurse the resident was found in resident's bathroom with the resident's forehead touching the floor. At 6:22 PM, the night shift nurse notified the physician of a possible head strike and high SBP. The physician ordered to resident to be sent out for further treatment due to head strike. At approximately 7:00 PM, Resident #60 was sent to the emergency room via emergency medical services. A Progress Note dated 11/20/2024 at 11:13 PM, documented a call was received by the facility at 10:15 PM from the emergency room (ER). The ER nurse reported the resident was being transferred to another hospital for further treatment due to computed tomography (CT) scan results showing a subdural hematoma. An acute care History and Physical dated 11/20/2024, documented Resident #60 was injured in a mechanical, ground-level fall with probable brief loss of consciousness. The resident was initially evaluated at an alternate hospital and transferred for a neurosurgical evaluation. Review of the resident's transfer CT imaging demonstrated a new acute left frontotemporal extra-axial hemorrhage with mild mass effect. An Issue Brief Form initiated by the facility on 11/21/2024, documented Resident #60 was found on the floor in the resident's bathroom with the resident's forehead touching the floor. The resident was sent to the emergency room for further evaluation, report received indicating the resident had a subdural hematoma. The facility's action steps following the incident included: -Medical evaluation and further management of the resident's subdural hematoma. The action step had a documented completion date of 11/20/2024. -Reassess if the subdural hematoma was acute or chronic. The action step included a note indicating acute on chronic and had a task completed date of 11/25/2024. The Issue Brief was signed by the Executive Director (ED). On 03/13/2025 at 11:35 AM, the Regional Director of Quality and Clinical Services (RDQCS) verbalized neglect was failure to provide care for a resident. All allegations of abuse, neglect, mistreatment, misappropriation of resident property, elopements, and injuries of unknown origin were required to be reported to the SA. On 03/13/2025 at 12:29 PM, the RDQCS denied the facility had received any concerns, complaints, or allegations regarding the failure of staff to follow post-fall policy or delay/refusal to transfer Resident #60 to hospital after the fall on 11/20/2024 aside from a report filed against the facility's former Director of Nursing (DON). The RDQCS verbalized the facility had received a subpoena for records from the Nevada State Board of Nursing. The RDQCS explained the subpoena received did not include any allegations against the former DON however the former DON contacted the RDQCS via phone and informed the RDQCS the allegations included the former DON telling staff not to send Resident #60 to the hospital or the emergency room and not to care for Resident #60. The RDQCS believed the allegations were communicated to the RDQCS in January 2025. On 03/13/2025 at 2:54 PM, the RDQCS denied the allegations against the facility's former DON were thoroughly investigated or reported to the SA. It was the RDQCS's belief the allegations were not neglect and were allegations of the former DON working outside the former DON's scope of practice. The RDQCS explained the facility did not thoroughly investigate or report the allegations because the RDQCS had looked in the resident's record at the time the allegations were communicated to the RDQCS and did not believe the allegations had any merit. The facility policy titled Freedom from Abuse, Neglect and Exploitation - Abuse Reporting and Responsibilities of Covered Individuals, revised 09/13/2022, documented the facility would report alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property and results of investigations of the allegations according to regulatory guidelines and in accordance with state law and within the required timeframes. The facility policy titled Freedom from Abuse, Neglect, and Exploitation, reviewed 11/2024, documented allegations of abuse, neglect, or exploitation would be thoroughly investigated, and the investigation would be initiated upon receipt of the allegation. The investigation could include but was not limited to: the names of the resident/s involved, the date and time of the incident, the circumstances surrounding the incident, where the incident took place, the names of any witnesses, and the name of the person alleged to have committed the act. The results of all investigations were to be reported to the Administrator and the SA within five working days of the alleged violation. Cross reference tag F600 and F609. CPT #NV00072985

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 tablet. Give 12.5 milligrams (mg) by mouth one time a day. Hold if heart rate was less than 60 beats per minute, related to heart failure, unspecified. The list of chart codes documented a check mark indicated the medication was administered, and 11 indicated vitals were outside of parameters. Spironolactone had check marks on the following dates when the resident's heart rate was below 60 beats per minute: -On 01/08/2025 pulse was 58 -On 01/29/2025 pulse was 55 -On 02/17/2025 pulse was 58 -On 02/19/2025 pulse was 58 -On 02/23/2025 pulse was 58 -On 02/24/2025 pulse was 58 -On 02/25/2025 pulse was 58 -On 03/04/2025 pulse was 58 -On 03/05/2025 pulse was 59 -On 03/07/2025 pulse was 59 Spironolactone had 11s on the following dates when the resident's heart rate was below 60 beats per minute: -On 01/07/2025 pulse was 58 -On 02/09/2025 pulse was 58 An order audit report, dated 03/12/2025, included a physician order dated 05/25/2024, documenting Spironolactone oral tablet. Give 12.5 mg by mouth one time a day related to heart failure, unspecified. On 03/13/2025 at 8:54 AM, a Registered Nurse (RN) verbalized Resident #69's EMR order for Spironolactone documented to hold when the resident's heart rate was less than 60 beats per minute. The nurse confirmed if the resident's heart rate was under 60 beats per minute, the nurse would hold the medication. On 03/13/2025 at 12:04 PM, the Director of Nursing (DON) verbalized the DON expected nurses to adhere to professional standards of medication administration by verifying the right person, time, route, dosage, medication, and documentation of medication administration. The DON confirmed Resident #69's EMR physician orders documented to hold Spironolactone if heart rate was less than 60 beats per minute. The DON verbalized a check mark on the MAR would indicate the nurse verified and followed the order while a 5 or 11 on the MAR would indicate the medication was held. The DON confirmed Resident #69's 2025 MARs documented check marks for the Spironolactone on the dates above. The DON verbalized Resident #69's EMR lacked documentation the physician was asked for clarification regarding the Spironolactone order. On 03/13/2025 at 12:44 PM, the DON explained after the DON was made aware of concerns regarding Resident #69's Spironolactone order, the DON sought clarification from the Physician. The DON was informed the original Spironolactone order lacked parameters, and pulse rate did not need to be monitored for Spironolactone. The DON explained the nurses were responsible for reviewing medication orders daily. The DON explained when the facility went through a change of ownership, physician orders were transcribed from the previous EMR to the current EMR and some orders were transcribed inaccurately, including Resident #69's Spironolactone. The Nurse Practice Act Nevada Administrative Code (NAC) 632.236 Understanding and verifying orders, documented before an LPN carried out a physician order, the Licensed Practical Nurse must understand the reason for the order, verify the order was appropriate, and verify there were no documented contraindications in carrying out the order. An RN would perform or supervise the verification of an order given to ensure the order was appropriate, properly authorized and lacked documented contraindications in carrying out the order. The facility policy titled, Medication Administration, dated 11/2024, documented all medication would be administered per physician orders. Medication orders initiated by the pharmacy were verified by the DON, executive director, or designee. Staff members responsible for administering medications reviewed the physician's order prior to administering medications. Cross reference with F842. 49557 Resident #72 Resident #72 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Physician's Order dated 12/25/2024, document Artificial Tears ophthalmic solution one percent (Carboxymethylcellulose Sodium), instill one drop in both eyes three times a day for dry eye. On 03/12/2025 at 9:04 AM, an LPN administered Artificial Tears to Resident #72. During administration, the LPN failed to draw the resident's lower eyelid down prior to administration of the medication. A portion of the eye drops fell below the resident's eye, onto the resident's skin. The LPN handed Resident #72 a tissue, and the resident wiped the medication from below the resident's eyes. On 03/13/2025 at 8:12 AM, the DON explained it was the DON's expectation of nursing staff to adhere to nursing standards of practice as well as state and federal guidelines when administering medications to residents. The correct process for administering eye drops to residents was to perform hand hygiene, open the medication, ensure the eye was free from any discharge, hold the eye open (the DON demonstrated pulling the lower eye lid down), and administer the eye drop. The DON explained if an eye drop was not administered with correct technique an infection could occur, or the medication could be less effective when the eye/eyelid was not held open as the resident could receive less than the ordered amount of the medication. The facility policy titled Eye - Instillation of Medications, dated 04/01/2008, documented all eye medications would be administered appropriately and with a physician's order. The procedure included having the resident tilt the resident's head backward, drawing the lower eyelid down, having the resident look up, and dropping one drop of medication every three to five minutes in the pouch of the lower lid.

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 ,d+[DATE]. 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 confirmed Employees #11 and #12 did not have a current CPR certification and their respective Job Description documented the requirement. The Facility Assessment, last revised ,d+[DATE], documented licensed nurses and certified nursing assistants would maintain cardiopulmonary resuscitation certification.

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 smart phone and a tablet a family member had sent to the resident. The resident verbalized the resident needed someone to show the resident how to answer the phone and the resident wanted assistance with learning how to access a video streaming application on the tablet. An Activities/Life Enrichment care plan for Resident #74, dated 09/26/2024, documented the resident did not like groups and would rather stay in the resident's room. The goals included for the resident to engage in activities of interest and offer alternate activities the resident could do alone. The activities task in the electronic health record included one date with documentation of a self-directed engagement for Resident #74 in the 14 day look back period. The task documented the resident participated in the self-directed activity of movies and or television on 02/28/2025. On 03/12/2025 at 10:38 AM, the Director of Volunteer Services/Interim Activities Director (AD) verbalized the activities staff would document individualized interactions with the resident under the activities task in the electronic health record. The AD verbalized the activity staff should have been checking in with the resident daily to ensure the resident had what the resident needed to meet the resident's interests and keep the resident occupied and happy while providing the resident with some socialization if the resident wanted to talk. The AD confirmed the activity program would have been able to assist the resident with learning how to use a smartphone or access an application on the resident's tablet. The AD confirmed the last documented activity for Resident #74 was the self-directed activity of movies or television on 02/28/2025. The facility policy titled Activities, revised 10/2022, documented the facility would provide an ongoing program of activities designed to meet the preferences of each resident, including individual activities.

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 facility. The items brought in to be placed on the holding table included the following: - fried fish. - garlic mashed potatoes. - gravy. - steamed vegetables. - mechanical soft fried fish. - mechanical soft steamed vegetables. - corn. On 03/12/2025 at 11:59 AM, the Culinary Staff member checked the holding temperature of the following hot foods: - fried fish was 155 degrees Fahrenheit (F). - gravy was 154 F. - steamed vegetables were 154 F On 03/12/2025 at 12:07 PM, the Culinary Staff member began plating food including the mashed potatoes, mechanical soft vegetables, and mechanical soft fish for residents in the [NAME]/Quail neighborhood. On 03/12/2025 at 12:09 PM, the Culinary Staff member confirmed the Culinary Staff member had not checked the temperature for all hot food items on the holding table prior to beginning to plate food for the residents. On 03/12/2025 at 12:10 PM, the Dietary Manager (DM) entered the satellite kitchen and assisted the Culinary Staff member to complete the temperature checks of the hot food. The DM found the mechanical soft fish was 128 F. The DM pulled the mechanical soft fish to reheat the fish to a safe temperature. On 03/12/2025 at 12:15 PM, the DM verbalized all hot foods should have been checked for an appropriate holding temperature of at least 135 F before the Culinary Staff started plating the food. The DM confirmed the Culinary Staff had not recorded the temperature for all hot foods prior to serving the food. 49557 Aspen/Pinion On 03/12/2025 at 11:51 AM, a Culinary Staff member began checking and recording temperatures of the food prepared for lunch on the Aspen/Pinion unit. Vegetables prepared for residents requiring a minced and moist texture diet had a temperature reading of 132 F. The Culinary Staff member verbalized the temperature for the mechanical soft vegetables was out of range. When a temperature was out of range the Culinary Staff member would place the food on the hot holding table and recheck the temperature prior to serving the food to residents to ensure the temperature was within a safe range for consumption. On 03/12/2025 at 12:03 PM, the Culinary Staff member placed the prepared food items on the hot holding table in the Aspen/Pinion unit. On 03/12/2025 at 12:10 PM, the Culinary Staff member began preparing plates for residents. Once prepared, the Culinary Staff member passed the plates to the staff on the opposite side of the counter and the staff would deliver the plates to residents in the dining room. On 03/12/2025 at 12:13 PM, the Culinary Staff member placed a serving of the mechanical soft vegetables on a plate and handed the plate to a staff member in the dining room. The staff member took the plate and turned toward the dining room. On 03/12/2025 at 12:14 PM, the Culinary Staff member confirmed the Culinary Staff member had not rechecked the temperature of the vegetables prior to placing the vegetables on the plate and handing the plate to the staff member in the dining room. On 03/12/2025 at 12:15 PM, the Culinary Staff member rechecked the temperature of the mechanical soft vegetables and the reading on the thermometer was 125 F. On 03/12/2025 at 12:27 PM, the DM arrived in the satellite kitchen on the Aspen/Pinion unit. The Culinary Staff member explained the temperature of the mechanical soft vegetables was too low. The DM explained when the temperature of food was too low, the food should have been taken off the line and reheated in the microwave until the food was 165 F for at least 15 seconds prior to serving to residents. The facility policy titled Food Temperature, dated 2021, documented the temperature of all food items would be taken and properly recorded prior to service of each meal. All hot food items would be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 F.

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 order for life-sustaining treatment (POLST): full treatment CPR. A Nevada POLST dated [DATE], documented do not resuscitate (DNR) and the resident was to receive selective treatment. The POLST was signed by the resident and the physician. On [DATE] at 4:00 PM, a Registered Nurse (RN) explained the RN knew a resident's code status and how to respond in the event of a medical emergency by looking in the resident's EMR. The code status was at the top of the screen when the RN opened a resident's record. The facility social worker and the physician would communicate updates in a resident's code status to the resident's nurse and paper copies of the resident's POLST were kept in a binder at the nurses' station. The RN reviewed Resident #52's EMR and verbalized the resident was a full code (all life-saving measures to be taken). On [DATE] at 4:04 PM, the RN reviewed Resident #52's POLST and verbalized the POLST indicated the resident was a DNR and only selective treatment was to be implemented. The RN confirmed the resident's EMR and POLST did not match. On [DATE] at 8:23 AM, the Director of Nursing (DON) explained a resident's code status was reflected in the EMR at the top of the page when the record was opened and POLSTs were kept in a binder at the nurses' station. Updates in residents' code status were communicated to staff immediately by the POLST being uploaded to the EMR and the physician's order being changed. If a resident's POLST and the code status in the EMR did not match, staff would verify the correct code status with the resident or guardian and assure the update was reflected in the EMR. The DON reviewed Resident #52's clinical record and verbalized the EMR and POLST indicated Resident #52 was to only receive selective treatment and was a DNR. The DON verbalized DNR was added to the EMR on [DATE], and a full code order was active from [DATE] through [DATE]. The DON confirmed the physician order related to code status in the resident's EMR was changed several days late. It was important to update the EMR immediately when any changes were made so staff were honoring the resident's wishes. The facility policy titled Cardiopulmonary Resuscitation (CPR), reviewed ,d+[DATE], documented each resident's CPR preference would be expressed in an advance directive document. Each resident's choice regarding CPR or DNR code status would be readily available for quick identification. Staff were to provide CPR in accordance with the resident's advance directive and any related physician order such as code status. The facility policy titled Advanced Directives and Rights Regarding Treatment, reviewed ,d+[DATE], documented residents had the right to refuse treatment. The community would document in the EMR any advance directive the resident executed. Resident choices would be documented and communicated to the interdisciplinary team. 50210 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 [DATE] MARs documented Spironolactone oral tablet. Give 12.5 milligrams (mg) by mouth one time a day. Hold if heart rate was less than 60 beats per minute, related to heart failure, unspecified. On [DATE] at 12:04 PM, Resident #69's EMR documented a physician order dated [DATE], for Spironolactone oral tablet. Give 12.5 mg by mouth one time a day. Hold if heart rate less than 60 beats per minute, related to heart failure, unspecified. An order audit report, dated [DATE], included a physician order dated [DATE], documenting Spironolactone oral tablet. Give 12.5 mg by mouth one time a day related to heart failure, unspecified. On [DATE] at 8:54 AM, an RN verbalized Resident #69 EMR order for Spironolactone documented to hold when the resident's heart rate was less than 60 beats per minute. The nurse confirmed if the resident's heart rate was under 60 beats per minute, the nurse would hold the medication. On [DATE] at 12:04 PM, the DON verbalized the DON expected nurses to adhere to professional standards of medication administration by verifying the right person, time, route, dosage medication, and documentation of medication administration. The DON confirmed Resident #69's MARs and EMR documented to hold Spironolactone if heart rate was less than 60 beats per minute. On [DATE] at 12:44 PM, the DON explained after the DON was made aware of concerns regarding Resident #69's Spironolactone order, the DON sought clarification from the Physician. The DON was informed the original Spironolactone order lacked parameters, and pulse rate did not need to be monitored for Spironolactone. The DON explained the nurses were responsible for reviewing medication orders daily. The DON explained when the facility went through a change of ownership, physician orders were transcribed from the previous EMR to the current EMR and some orders were transcribed inaccurately, including Resident #69's Spironolactone. Cross reference with F658.

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 appropriately, either in the locked medication cart or medication room. 49557 On 03/13/2025 at 9:16 AM, in the presence of an RN, a medication cart on the Pinion/Aspen unit was inspected. The following items were found in the cart, stored with active medications: -A bottle of Docusate Sodium stool softener, 100 milligram (mg) capsules. The expiration date printed on the bottle was 12/2024. -A bubble pack containing seven tablets of Ondansetron four mg tablets. The expiration date printed on the pharmacy label was 12/03/2024. The RN confirmed the Docusate Sodium capsules and the Ondansetron tablets had expired. The RN verbalized the expired medications should have been removed from the medication cart and destroyed using Drug Buster (a drug disposal system) on or before the expiration date. On 03/13/2025 at 9:31 AM, in the presence of the RN, the medication storage room on the Pinion/Aspen unit was inspected. An intravenous (IV) solution bag containing 1000 milliliters of five percent Dextrose was found in a cabinet. The expiration date printed on the IV solution bag was November 2024. A vial of Tuberculin Purified Protein Derivative with an open date of 01/28/2025 written on the vial and the box was found in the refrigerator. The RN confirmed the IV solution bag had expired. The RN confirmed the open date written on the vial and the box of Tuberculin Purified Protein Derivative was 01/28/2025, and explained the vial should have been discarded within 30 days of the open date. The Tuberculin Purified Protein Derivative (Tubersol) package insert, with product information as of October 2021, documented a vial of Tubersol which had been entered and in use for 30 days should be discarded. On 03/12/2025 at 1:46 PM, the Director of Nursing (DON) verbalized expired medications were to be removed from the medication cart and the medication storage room immediately to prevent the expired medication from being administered to a resident. If expired medications were administered to a resident, the medications could make the resident sick or could be less effective. The facility policy titled Medications - Discontinued for deceased or discharged Residents, revised 03/01/2024, documented all medications which were no longer being administered to residents would be removed and appropriately discarded. All medications which had passed the expiration date on the label were to be properly disposed of and re-ordered if necessary.

Based on clinical record review, interview, and document review the facility failed to ensure 1 of 6 FRI sampled residents (Resident # 4) received the care required to prevent urinary retention and urethral trauma (bleeding from the urethra). Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses including neuromuscular dysfunction of the bladder, unspecified, presence of urogenital implants, and vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A physician's order dated 02/28/22, documented an order to change an indwelling Foley 16 French (Fr)/10 cubic centimeters (cc) balloon (urinary) catheter every 30 days on night shift. A physician's order dated 05/04/22, documented an order to change an indwelling 16 fr/30 cc catheter every 30 days and check for functionality every shift. A nurse progress note dated 05/05/22 at 1:12 AM, documented Resident #4's urinary catheter was changed and a 16 Fr/30 cc urinary catheter was inserted. Resident #4's bladder elimination record documented Resident #4's urinary output as follows: -On 05/05/22 at 5:18 AM, 250 cc of urine, and -On 05/05/22 at 1:51 PM, 0 cc of urine, a notation documented the resident had not voided. The bladder elimination record lacked documented evidence Resident #4's urinary drainage bag was checked for urinary output from 05/05/22 at 5:19 AM, until 5/05/22 at 1:51 PM. A nurse progress note dated 05/05/22 at 3:09 PM, documented Resident #4's urinary drainage bag contained a small amount of dark colored urine with sediment. A nurse progress note dated 05/05/22 at 3:52 PM, documented a bladder scan was completed and Resident #4 was retaining 275 milliliters (ml) of urine. Urine was not draining into the drainage bag and the drainage bag contained less than 10 cc of urine. The catheter balloon was deflated, and a 16 Fr/30 cc catheter was removed. Upon removal of fluid from the balloon, a large amount of bright blood was noted coming from the urethra, and light pressure was applied. The resident was sent via ambulance to the emergency room for evaluation and treatment. A facility Physician Discharge Summary note, dated 05/05/23, documented Resident #4's summary of care/reason for transfer was bleeding with foley (urinary catheter) removal. An emergency room Progress note dated 05/05/22, documented Resident #4 had an abnormal genitourinary exam related to blood draining from the urethra status post traumatic foley placement A physician's order dated 05/06/22, documented an order to change an indwelling 16 fr/10 cc catheter every 30 days on night shift. A physician's order dated 05/06/22, documented to flush Resident #4's urinary catheter with 30 milliliters of normal saline three times per day for three days due to bleeding from urethra. A nurse progress note dated 05/06/22, documented Resident #4 continued to have a fair amount of red blood inside of the resident's brief, coming from the resident's urethra. On 12/20/22 at 4:48 PM, the Director of Nursing (DON) explained when Resident #4's urinary catheter was replaced on 05/05/22 at 1:12 AM, the catheter was inserted into the urethra and was not advance far enough. The DON explained when the night shift nurse inserted the catheter, the nurse reported urinary return was noted. On 05/05/22, at 1:51 PM, the day shift nurse assessed the urniary drainage bag and noted there was no evidence of urinary out put. On 12/20/22 at 4:51 PM, the Administrator communicated Resident #4's urinary catheter was changed around 1:00 AM on 05/05/22, and no urine was present in the drainage bag when assessed by the day shift nurse around 3:00 PM on 05/05/22. The Administrator confirmed the incident occurred and could have been prevented by more closely monitoring the resident's urinary output. On 12/21/22 at 12:22 PM, the DON explained the order for a urinary catheter with a 30-cc balloon was a transcription error and a 10-cc balloon should have been ordered. The DON confirmed the order to place a urinary catheter with a 30-cc balloon was an inaccurately written order and confirmed when the order was written, the order was not read back to the physician. On 12/21/22 at 12:37 PM, the DON confirmed on 05/05/22 between 5:19 AM and 1:51 PM, Resident #4 did not have any urinary output resulting in urinary retention and urethral trauma. The DON confirmed the lack of urinary output should have been identified during hourly rounds and reported to physician immediately. The facility policy titled Quality of Care, Urinary Catheterization, dated 04/2021, documented if a resident had an indwelling catheter, the medical record would reflect the resident's response to treatment and on-going monitoring for a potential change in condition. FRI #NV00066278