Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Carson City during CMS and state inspections, most recent first.
A resident with dementia, multiple comorbidities, and an ileostomy was determined by two MDs to lack capacity for medical decision-making and was left without an active POA after the designated family POA resigned in writing. Despite this, the facility had the resident sign a Medicare non-coverage notice, did not complete the care-planned home safety visit, and discharged the resident home based on the resident’s request and an assumption that the former POA would still provide support. Social services documented planned home health (PT, OT, nursing, HHA) and a PCP visit, but the listed home health agency later reported the resident was never evaluated or enrolled, and a family member found the resident at home alone in poor condition. The NHA and SSD acknowledged they did not seek emergency guardianship and could not confirm the resident’s safety or that appropriate support services and a patient representative were in place at discharge, and they did not inform a sister facility that the resident lacked a guardian or POA when asked for information.
Staff failed to use PPE as required for a resident on contact precautions for suspected MRSA, did not document interventions for repeated low chlorine levels in the facility's water management program, and did not dispose of soiled linens in a sanitary manner after providing peri-care to a resident with dementia and right-sided weakness.
Several residents dependent on staff for toileting and transfers experienced delayed call light responses, especially during evening and night shifts, leading to prolonged discomfort, incontinence, and feelings of embarrassment. Staff were observed turning off call lights without meeting residents' needs, and some were described as rough or inattentive. These actions were inconsistent with facility policies requiring timely and respectful care.
A resident with a history of sepsis, CHF, and endocarditis received hydralazine for hypertension despite a physician order to hold the medication if systolic blood pressure was below 140. The MAR showed multiple instances where the medication was administered with SBP values under the threshold, and the DON confirmed there was no documentation that the medication was held as ordered.
A resident with dementia and right-sided paralysis following a stroke was not provided with a prescribed hand splint to maintain range of motion, as outlined in her care plan. Observations showed the splint was not applied during multiple care interactions, and staff did not offer or ask about the splint, despite its availability at the bedside.
A resident with dementia, morbid obesity, and right-sided paralysis was assisted with bed mobility by only one CNA, despite a care plan requiring two staff for such assistance. The CNA instructed the resident to roll onto her sides without the required second staff member present, contrary to the documented safety intervention.
Surveyors observed that the facility did not provide a battery pack emergency light at the transfer switch in the main electrical room, failing to meet requirements for automatic emergency lighting. This was confirmed by the environmental supervisor and could impact all occupants, staff, and visitors if emergency power systems fail.
A wheelchair battery charger was found in use within a resident room in the sub-acute rehab wing, and the area lacked the required fire barrier or automatic fire extinguishing system. The environmental supervisor confirmed that wheelchair batteries are charged in resident rooms as needed, and the necessary fire protection measures, including self-closing doors, were not in place.
The facility did not provide documentation for the required semi-annual kitchen hood cleaning and monthly hood suppression inspection, as confirmed by regional staff during surveyor interviews. These deficiencies could potentially impact kitchen staff and occupants in the affected smoke compartment.
A resident with a history of heart issues experienced chest pain and took multiple doses of nitroglycerin without proper assessment or monitoring by the nursing staff. The LPN focused on removing the nitroglycerin bottle rather than evaluating the resident's condition, and vital signs were not documented. The ADON instructed the LPN to check vital signs, but this was not done, and the nurse practitioner was not informed of the chest pain. The DON confirmed that such complaints require immediate evaluation.
The facility failed to accurately assess, provide treatments as ordered, and ensure physician oversight for wounds for two residents, leading to significant deterioration of their conditions. One resident developed osteomyelitis due to delayed treatment, while another experienced worsening of a stage 3 pressure ulcer and the development of a new wound. The facility's documentation and follow-up were inconsistent, and necessary wound care supplies were not always available, exacerbating the residents' conditions.
The facility failed to promptly identify and manage outbreaks of COVID-19, Influenza, and RSV, leading to widespread transmission among residents and staff. There was inadequate implementation of transmission-based precautions, lack of prompt testing, and insufficient documentation of outbreak investigations and contact tracing.
The facility failed to provide the pneumococcal immunization to a resident who had consented to receive it. The resident was later admitted to the hospital with RSV and pneumonia. The Infection Control Preventionist admitted to missing the requirement, despite the facility's policy mandating the vaccine for residents aged [AGE] years or older or those with underlying conditions.
The facility failed to administer controlled medications following physician orders and professional standards of practice for six residents, resulting in medication errors and the withholding of medications without a physician order. Additionally, medications were not administered according to physician-ordered parameters for several residents, and there were issues with insulin administration and potential staff impairment.
The facility failed to ensure the DON did not serve as a charge nurse, leading to missed treatments and negative resident outcomes. The DON worked over 110 hours as a charge nurse, resulting in missed laboratory tests, treatments, and medications. An Immediate Jeopardy was identified due to improper pressure ulcer care and LPNs administering IV medications without proper training.
The facility failed to ensure call lights were within sight and reach for a resident with multiple diagnoses, including acute respiratory failure and COPD. The call light was observed out of reach on several occasions, despite the facility's policy requiring it to be within easy reach.
The facility failed to maintain safe water temperatures, with measurements showing excessively high temperatures in bathroom sinks and spa rooms, posing a scalding risk to residents. The Maintenance Director admitted that the water temperature was turned up to 140 degrees last year and some sinks were missing point-of-use mixing valves, which had not yet been installed. Water temperature logs from January to April 2024 consistently showed temperatures exceeding 120 degrees in various locations.
The facility failed to ensure appropriate catheter care for a resident with dementia and other conditions. LPNs performed unnecessary catheter flushes without proper protective equipment, and the origin of the order was unclear. The resident's urologist confirmed that the flushes were not recommended, posing a significant infection risk.
The facility failed to follow best practice standards for two residents receiving supplemental oxygen. One resident had undated oxygen tubing and lacked proper documentation, while another had no documented oxygen delivery rate or regular observations, and her care plan lacked necessary interventions for COPD.
A facility failed to ensure IV medications were administered by trained and licensed nurses, leading to an LPN administering IV antibiotics to a resident without the required specialized training. The DON confirmed the lack of documentation for such training.
The facility failed to maintain clean ventilation filters, resulting in reduced air quality and circulation in several resident rooms. A resident reported that maintenance had not changed the filter since before winter, and the air seemed to come out slower. The Maintenance Director stated that filters are supposed to be checked monthly and changed as needed, but the facility's preventative maintenance program requires filters to be replaced or thoroughly cleaned every three months. The maintenance log showed the task was last completed on 3/31/2024.
The facility failed to properly assess and manage pain for a cognitively impaired resident with a history of stroke and contracture. Despite displaying signs of pain, the resident was not consistently assessed using the PAINAD scale, and there was inadequate documentation of pain characteristics. This led to an increased perception of pain and unmet pain needs, highlighting a significant deficiency in the facility's pain management practices.
A resident was administered an antibiotic daily for 12 days without a proper order from the urologist. The facility staff failed to verify the medication order and demonstrated a lack of knowledge regarding criteria for antibiotic use in residents with indwelling catheters.
A resident with chronic kidney disease was inappropriately prescribed Augmentin for a suspected UTI without waiting for urinalysis and culture results. The resident exhibited no UTI symptoms and did not meet the McGeer Criteria, leading to inappropriate antibiotic use.
Failure to Ensure Safe Discharge and Representative Support for Incapacitated Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate caregiver/support availability and a safe discharge plan for an incapacitated resident who lacked an active guardian or POA. The resident had dementia and multiple medical conditions, including vertebral compression fractures, CKD, ulcerative colitis, COPD, OSA, DM2, and an ileostomy, and required assistance with self-care and mobility. Although an earlier MDS showed intact cognition, subsequent documentation included a Statement of Capacity signed by two MDs in late January certifying the resident was incapable of making informed medical decisions, and the facility’s SSD acknowledged awareness of this determination. The resident’s POA succession documents showed that a family member (FM H) had become the active POA after the prior POA was revoked, and two physicians had already determined the resident was unable to participate in treatment decisions months before admission. On 1/29, FM H submitted a written memo resigning as the resident’s medical POA, leaving the resident without an active POA or guardian. Despite this, the facility had the resident sign a Notice of Medicare Non-Coverage on the same date, even though the resident had been deemed not capable of making medical or treatment decisions as of 1/23. The form was witnessed by the BOM. The care plan, initiated earlier in the stay, identified a functional ability deficit and required assistance with self-care/mobility, with an intervention for a home safety visit prior to discharge. However, the PTA later confirmed that no home safety visit was completed before the resident’s discharge. A Social Services note documented that the resident requested discharge home, that the former POA had expressed concerns about the resident’s safety at home alone, and that home health services (PT, OT, nursing, HHA) and a PCP appointment were planned, with the brother to transport the resident. The SSD reported that in cases where a resident lacked capacity and no POA was identified, the facility’s practice was to seek emergency guardianship, but this was not done because they believed the former POA was still supporting the resident despite the written resignation. The NHA and SSD stated they could not confirm the resident was safe to discharge home alone without confirmation of appropriate support services and a patient representative. A family member later reported finding the resident at home in poor condition, with no evidence of home health services having been initiated, and a representative from the listed home health agency confirmed the resident was never seen or enrolled for services. The SSD also acknowledged that when a sister facility later requested information, they did not disclose that the resident lacked a guardian or POA because they were not specifically asked.
Infection Control Failures in PPE Use, Water Management, and Linen Handling
Penalty
Summary
The facility failed to properly implement its infection prevention and control program in several areas. For one resident with dementia and muscle weakness, who was under contact precautions due to a suspected MRSA infection in a heel wound, staff did not follow required protocols. Despite clear signage on the resident's door instructing staff to don gloves and a gown before entry, a certified nursing assistant entered the room without the appropriate personal protective equipment. The infection preventionist confirmed that the resident's status had recently changed to contact precautions and that gloves and gowns were required prior to room entry. Additionally, the facility did not follow its water management policy and procedures. Chlorine level testing records showed multiple instances where chlorine levels were below the acceptable range, but there was no documentation of interventions or use of the Water Management Team Meeting Minutes form as required by policy. Furthermore, during peri-care for another resident with dementia and right-sided weakness following a stroke, a certified nurse aide placed soiled washcloths on the resident's over-bed table and did not clean or sanitize the table before leaving the room, failing to dispose of soiled linens in a sanitary manner.
Plan Of Correction
F tag 880 Infection Prevention and ControlSS=F 1. Staff member involved was immediately educated on the use of PPE for all residents in isolation. Soiled washcloths were immediately bagged and placed in the soiled utility room for laundering and the bedside stand disinfected. The water management meeting was held on 5/6/25. The following departments attended the meeting: Environmental Service Director, Maintenance, Infection Control (IC), Nursing, and NHA. 2. Residents residing in the house are at risk related to the deficient practice. Residents in the house were reviewed by the nursing team to ensure there was no spread of infection for failure to follow proper IC protocols when entering a room without proper PPE, no s/sx of legionella, and lack of proper handling of linen. The city's water department was contacted regarding the chlorine levels that were noted to be outside of parameters. A visit is scheduled for the week of 5/12 to test the facility's chlorine levels, using their device. If it is determined that the results are not within parameters, we will work with the water dept to regulate chlorine levels to appropriate parameters. 3. The QAPI Committee reviewed the policies and procedures related to Multi Route Transmission Based Precautions, Infection Control, and the Water Management Program and deemed it appropriate. Facility staff were re-educated by the DON/Designee on Multi Route Transmission Based Precautions and Infection Control. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. The Maintenance Director and ICP were re-educated on the water management program and the requirement of monthly meetings. The Maintenance Director was educated that if levels are not within parameters, an action plan needs to be developed and implemented to include rechecks on the levels. 4. The Infection Control Preventionist/Designee will observe 5 residents on isolation weekly times four weeks to ensure that staff are adhering to all IC protocols including Donning and Doffing PPE, handling of linen, water management program, then monthly for 3 months. The results of these audits will be forwarded to the QAPI Committee for further direction and guidance. The IC Preventionist is responsible for ongoing compliance. The NHA will review the monthly Water Management meetings to ensure that chlorine levels are within parameters. The NHA is responsible for ongoing compliance of the Water Management Program.
Failure to Ensure Timely Call Light Response and Dignified Care
Penalty
Summary
The facility failed to ensure dignified care for four residents who were dependent on staff for assistance with toileting and transfers. Multiple residents reported delayed responses to call lights, particularly during evening and night shifts, resulting in prolonged periods of discomfort and incontinence. One resident described staff turning off the call light and promising to return, but then failing to do so, leaving the resident wet and uncomfortable for extended periods. Another resident reported that staff were sometimes rough during transfers and that delays in call light response led to episodes of incontinence and soreness from sitting for long periods. Residents also reported that staff behavior varied, with some being attentive while others were described as crabby or rough. One resident noted that call lights were answered more promptly when family members were present, but otherwise, waits could exceed 30 minutes, sometimes resulting in accidents. Staff interviews confirmed that some staff members turned off call lights without meeting residents' needs, which is against facility policy. Observations included a resident waiting over 30 minutes for assistance after activating a call light, with staff walking past the room without responding. Facility policies require call lights to be answered in a timely manner and not to be turned off until the resident's needs are met. The failure to respond promptly to call lights and provide timely assistance with toileting and transfers compromised residents' dignity and comfort, as evidenced by their reports of embarrassment, discomfort, and feeling unwanted.
Plan Of Correction
F tag 550 Resident Rights/Exercise of Rights SS=E 1. Residents R50, and R4 have no LTC affects from not having their call lights answered in a timely manner. Resident R11 and R75 no longer reside at the facility. 2. Residents who reside in the facility are at risk of being affected by this deficient practice. Residents in-house were interviewed by the IDT team through Quality Rounds to ensure their needs are addressed timely. Any concerns were addressed through the guest assistance concern process. 3. The QAPI Committee reviewed the Call light Policy and Resident Rights Policy and deemed them appropriate. Facility staff were re-educated by the NHA/Designee on the policies and procedures related to Call lights, and Resident Rights. Staff who have not been educated by Date of Compliance will be re-educated prior to returning to work. 4. The IDT Team will interview 10 residents weekly to ensure that their needs are being met timely through the Quality Rounds Program. These audits will continue weekly times four than monthly x 3 months. The results of these audits will be forwarded to the QAPI Committee for further direction. The NHA is responsible for continued compliance.
Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency was identified when the facility failed to administer blood pressure medication in accordance with a physician's order for one resident. The resident, who had diagnoses including sepsis, congestive heart failure, and endocarditis, had an active order for hydralazine 25 mg by mouth twice daily, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 140. Despite this order, the Medication Administration Record (MAR) showed that hydralazine was administered multiple times when the resident's SBP was below 140, with recorded SBP values ranging from 106 to 138 at the time of administration. Interviews with the Director of Nursing (DON) confirmed that the medication was given contrary to the physician's order on several occasions, and a review of the electronic medical record did not reveal any documentation that the medication had been appropriately held on those dates. The facility's policy requires medications to be administered according to written physician orders, but this was not followed in the case of this resident.
Plan Of Correction
F tag 658 Services Provided Meet Professional Standards SS=D 1. Resident R69 no longer resides at the facility. On 4/24, the DON notified the Nurse Practitioner of the findings. Patients' charts and vitals were reviewed. The patient was assessed and showed no signs of distress. Education was initiated. Resident discharged home with her spouse on 5/4/2025. 2. Residents residing in the facility receiving blood pressure medications are at risk of being affected by this deficient practice. Residents receiving BP meds with parameters were reviewed by the DON to ensure that medications were held if the BP was not within parameters. Any concerns were addressed. 3. The QAPI Committee reviewed the Medication Administration Policy and deemed it appropriate. Nursing staff were re-educated by the DON/Designee on the policies and procedures related to Medication Administration specific to medications with parameters. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review 5 residents weekly times four to ensure that physician orders are followed regarding medication parameters then monthly x 3 months. The results of these audits will be forwarded to the QA Committee for further guidance and direction. The NHA is responsible for continued compliance.
Failure to Implement Hand Splint Intervention for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with dementia and right-sided weakness and paralysis following a stroke was not provided with appropriate interventions to maintain or improve range of motion (ROM) as outlined in her care plan. The care plan specified that the resident should wear a right hand resting splint from morning to bedtime. However, multiple observations over several days revealed that the resident consistently did not have the splint on her right hand, despite the splint being present on the bedside table. Staff were observed providing care without offering or applying the splint, and the resident reported that staff had not asked her if she wanted the splint on during those times. The lack of adherence to the care plan was confirmed through both staff actions and resident interviews. The resident was observed in bed and in a wheelchair, participating in activities such as bingo, without the splint in place. At no point during the observed care interactions did staff attempt to apply the splint or inquire about its use, despite the resident's care plan directive. This failure to implement the prescribed intervention resulted in the facility not providing appropriate care to maintain or improve the resident's ROM.
Plan Of Correction
F tag 688 Increase/Prevent/Decrease in ROM/Mobility SS=D 1. Resident #25 was evaluated to determine if the resident had any new discomfort or worsening of contracture due to the staff's failure to offer and utilize her right-hand splint. The care plan was reviewed and updated as needed. 2. Residents residing in the facility with splints or other contractual devices have the potential to be affected by the deficient practice. The nursing team reviewed patients with contractual devices to ensure devices were being offered and utilized by physician order. Any refusals were documented, and care plans were updated to reflect preferences. 3. The QAPI Committee reviewed the Brace and Splint Program and deemed it appropriate. Nursing staff were re-educated by the DON/Designee on the Brace and Splint Program. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review 5 residents weekly for four weeks to ensure that their devices are being utilized by physician order, then monthly for 3 months. The results of these audits will be forwarded to the QAPI Committee for further guidance and direction. The NHA is responsible for continued compliance.
Failure to Follow Two-Person Assist for Bed Mobility
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) provided peri-care to a female resident with dementia, morbid obesity, and right-sided weakness and paralysis following a stroke, without following the resident's care plan intervention. The care plan specified that the resident was dependent on two staff members for bed mobility. However, during the observed care, only one staff member was present to assist the resident with bed mobility, and the CNA instructed the resident to roll onto her sides without additional assistance. This action was not in accordance with the documented safety intervention for the resident.
Plan Of Correction
F tag 689 Accidents SS=BAccidents 1. Resident #25 was evaluated to determine if any injuries were sustained due to staff's failure to follow the care plan/Kardex during repositioning the resident. No injuries noted due to deficient practice. The CNA involved received 1:1 education. 2. Residents who reside in-house are at risk due to the deficient practice. Residents in-house who sustained an accident in the last 10 days were reviewed by the nursing team to ensure that the care plan was followed and that the accident didn't occur based on failure to follow the care plan. Any concerns will be addressed. 3. The QAPI Committee reviewed the Standards of CNA/STNA Practice and deemed it appropriate. CNA's were re-educated by the DON/Designee on the Standards of CNA/STNA Practice. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review residents with accidents weekly times four to ensure that their care plans are being followed, then monthly x 3 months. The results of these audits will be forwarded to the QAPI Committee for ongoing direction and further guidance. The NHA is responsible for continued compliance.
Failure to Provide Emergency Lighting at Main Electrical Room Transfer Switch
Penalty
Summary
During an observation on April 24, 2025, at approximately 10:29 am, it was found that the facility did not provide a battery pack emergency light at the transfer switch located in the main electrical room. This was identified as a failure to ensure automatic emergency lighting in accordance with section 7.9. The deficiency was confirmed through an interview with the facility's environmental supervisor at the time of the observation. This deficiency could affect all occupants, staff, and visitors in the event that the emergency power systems fail to operate as designed during an electrical utility power outage.
Plan Of Correction
K291 Emergency Lighting SS=F 1. A battery pack emergency light was installed at the transfer switch located in the main electrical room on 5/15/25. 2. Residents residing within the facility have the potential to be affected. 3. Facility administrator has re-educated the maintenance director on the regulatory requirement for an emergency backup light at the transfer switch. The facility preventative maintenance system (TELS) has been updated to ensure that back up lighting is testing per regulatory standards. 4. Facility Administrator and/or designee will verify regulatory compliance with emergency backup lighting monthly x4. Findings will be reported to the QAPI committee for further review and/or recommendations. The Administrator is responsible for sustained compliance.
Failure to Provide Required Fire Protection for Hazardous Area
Penalty
Summary
A deficiency was identified when a wheelchair battery charger was observed in use within a resident room located in the sub-acute rehab wing. The facility failed to ensure that hazardous areas, such as those where battery charging occurs, were protected by a fire barrier with a 1-hour fire resistance rating and 3/4 hour fire rated doors, or by an automatic fire extinguishing system as required by code. The doors to these areas were also not self-closing or automatic-closing as specified by the regulations. During the survey, the environmental supervisor confirmed that residents' wheelchair batteries are charged within their rooms as needed. This practice was directly observed and verified through staff interviews. The deficiency was cited due to the lack of appropriate fire protection measures in areas where hazardous activities, such as battery charging, take place.
Plan Of Correction
K321 Hazardous Areas SS=E 1. The power chair in room 121 was unplugged immediately and relocated for charging. The resident residing in room 121 was educated that the facility will need to charge the chair in a safe area (Therapy Room). 2. Residents residing within the facility have the potential to be affected. Residents utilizing power chairs have been educated that chairs need to be charged in the Therapy Dept and not within their rooms. 3. Staff have been educated that wheelchairs cannot be charged in resident rooms but only in the Therapy Room. 4. The Maintenance Director and/or designee will audit weekly x4, monthly x3 to ensure that wheelchairs are being charged in the designated area. Findings will be reported to the QAPI Committee for further review and recommendations. The Administrator is responsible for sustained compliance.
Failure to Maintain Required Kitchen Hood Cleaning and Inspection Documentation
Penalty
Summary
The facility failed to provide documentation of the required semi-annual hood cleaning service report for the kitchen hood system, as required by NFPA 96. Although an invoice for the hood service was provided by regional staff, the actual cleaning report was not available for review. Additionally, the facility did not provide documentation of the required owner's monthly hood suppression inspection, as mandated by NFPA 17A. Both deficiencies were confirmed through interviews with regional staff at the time of observation. These lapses could potentially affect kitchen staff and 23 occupants within the nearest smoke compartment in the event of a fire within the kitchen hood system.
Plan Of Correction
K324 Cooking Facilities SS=E1. The required semiannual hood cleaning was completed on 4/9/25. The monthly hood suppression inspection was completed May 1, 2025, and signed off through TELS and signed off on the tag that is located in the dietary dept. The NHA validated that the TELS system has a monthly task to complete the monthly hood suppression inspection and that it was signed off in a timely manner by the Maintenance Director. The NHA educated the Maintenance Director on obtaining and uploading service inspections into the TELS system and completing the monthly hood suppression inspection. The NHA will validate that the monthly hood suppression inspections are completed and checked off monthly for 3 months and that service reports are uploaded into the TELS system from the Date of Compliance. The results of these audits will be forwarded to the QA Committee to ensure continued compliance. The NHA is responsible for ongoing compliance.
Failure to Monitor Resident with Chest Pain
Penalty
Summary
The facility failed to adequately assess and monitor a resident, identified as Resident #101, who was experiencing chest pain and using nitroglycerin. Resident #101, who was cognitively intact and had a history of congestive heart failure and hypertensive heart, reported chest pain to a family member over the phone. Despite the resident's complaints and the family member's insistence, the nurse on duty focused on removing the nitroglycerin bottle from the resident's room rather than assessing the resident's condition or taking vital signs. The nurse did not return to the resident's room for an extended period, during which the resident took multiple doses of nitroglycerin without proper monitoring. The nurse, identified as LPN B, documented the presence of the nitroglycerin bottle and the resident's refusal to relinquish it but failed to document any vital signs or assessments related to the resident's chest pain. The nurse contacted the Assistant Director of Nursing (ADON) and the on-call physician but did not communicate the resident's chest pain or nitroglycerin use. The ADON instructed the nurse to check vital signs every hour, but no such documentation was found in the resident's electronic medical record. The nurse practitioner was also not informed of the resident's chest pain or nitroglycerin use. Interviews with other staff members, including a CNA and RN, revealed that the resident's complaints of chest pain were not properly addressed, and the necessary evaluations were not conducted. The Director of Nursing (DON) confirmed that residents with chest pain should be promptly evaluated, including taking vital signs after each dose of nitroglycerin. The failure to assess and monitor the resident's condition resulted in incomplete information being communicated to medical practitioners and the potential for unnoticed cardiovascular compromise.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to accurately assess, provide treatments as ordered, and ensure physician oversight for wounds for two residents, resulting in significant deficiencies. Resident #276, a male with a history of chronic osteomyelitis and other conditions, was not provided care in accordance with professional standards. His left heel wound was not accurately assessed or treated promptly, leading to the development of osteomyelitis. Despite the wound being identified on 12/21/23, appropriate treatment was delayed, and the wound deteriorated significantly, showing signs of infection and requiring hospitalization for severe bone infection and surgical intervention. The facility's documentation and follow-up were inconsistent, and the wound team did not adequately monitor or update the treatment plan, resulting in further complications for the resident. Additionally, the facility failed to ensure the availability of necessary wound care supplies, further delaying treatment and exacerbating the resident's condition. Resident #64 experienced a similar lack of proper wound care. The resident's right heel wound, initially identified as a stage 3 pressure ulcer, was not treated consistently as per the orders. The dressing changes were not performed as scheduled, and the wound showed signs of maceration and significant deterioration. A new wound on the left heel was also identified but not promptly addressed. The facility's documentation of wound measurements was inconsistent, and there was a lack of manual measurements and depth recording, leading to inadequate monitoring and treatment of the wounds. The care plan for this resident did not focus on healing or preventing the worsening of the wound, and the facility failed to ensure timely and appropriate wound care interventions. The deficient practices in the facility placed all residents at risk for pressure injuries and delayed wound healing. The facility's failure to accurately assess, document, and treat wounds as ordered, along with inadequate physician oversight and lack of timely interventions, resulted in significant harm to the residents. The facility's policies and procedures for wound care were not followed, leading to the deterioration of existing wounds and the development of new pressure injuries. The lack of proper wound care management and oversight highlights serious deficiencies in the facility's ability to provide adequate care for residents with skin integrity issues.
Failure to Manage Respiratory Illness Outbreaks
Penalty
Summary
The facility failed to promptly identify and manage an outbreak of acute respiratory illness, including COVID-19, Influenza, and Respiratory Syncytial Virus (RSV). The facility did not implement transmission-based precautions for residents showing symptoms, nor did it ensure prompt testing and documentation of surveillance for respiratory infections. This led to widespread transmission among residents and staff. Specific instances included a CNA testing positive for COVID-19 without subsequent contact tracing or testing of potentially exposed individuals, and multiple residents and staff members testing positive for COVID-19 over several months without adequate outbreak investigation or containment measures being documented or implemented. The facility also failed to manage an influenza outbreak effectively. Staff members and residents who exhibited symptoms or tested positive for influenza were not promptly isolated or treated with antiviral medications. For example, a resident who tested positive for Influenza A was not placed in droplet isolation while symptomatic, and there was no documentation of contact tracing or offering of antiviral medications to exposed individuals. This lack of action contributed to the spread of influenza within the facility. Additionally, the facility did not properly handle an RSV outbreak. Residents and staff who tested positive for RSV were not placed in appropriate isolation, and there was no outbreak investigation or contact tracing conducted. The facility's infection control practices were inadequate, as evidenced by the lack of training and proper implementation of transmission-based precautions. This resulted in multiple residents testing positive for RSV over several months without adequate measures to prevent further transmission.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide the pneumococcal immunization to a resident as per consent and CDC recommendations. The resident, a [AGE] year-old female, was admitted to the facility on 1/23/24 and had consented to receive the pneumonia vaccine on the same day. However, the resident did not receive the vaccine before being discharged. The resident was later admitted to the hospital with RSV and right lobe pneumonia, which was confirmed by a chest x-ray. The Infection Control Preventionist acknowledged that the resident did not receive the vaccine and admitted to missing this requirement. The facility's policy on pneumococcal vaccination, last revised on 3/27/23, states that all residents aged [AGE] years or older, or younger residents with underlying conditions, should receive the pneumococcal vaccine. Despite this policy, the resident did not receive the vaccine, leading to a failure in adhering to the established guidelines. This oversight was identified during an interview with the Infection Control Preventionist, who confirmed the lapse in administering the vaccine to the resident.
Medication Administration Deficiencies and Staff Conduct Issues
Penalty
Summary
The facility failed to administer controlled medications following physician orders and professional standards of practice for six residents, resulting in medication errors and the withholding of medications without a physician order. For example, Resident #13 did not receive a scheduled dose of gabapentin, and the documentation was inconsistent between the Controlled Substances Proof of Use form and the Medication Administration Record. Similarly, Resident #25 did not receive multiple doses of tramadol, despite documentation indicating otherwise. Resident #58 also missed a dose of tramadol, with discrepancies noted in the records. The Director of Nursing confirmed these medication errors and reported immediate education on narcotic administration would begin. Additionally, the facility failed to administer medications according to physician-ordered parameters for several residents. Resident #11 received metoprolol despite having a heart rate below the prescribed threshold on multiple occasions. Resident #275 was administered glipizide even when blood sugar levels were below the specified limit. Resident #43 received midodrine despite having a systolic blood pressure above the ordered parameter. These actions indicate a lack of adherence to physician orders and professional standards of practice. Furthermore, there were issues with the administration of insulin and potential staff impairment. Resident #2's insulin was administered without priming the pen or holding it to the skin for the required time, contrary to manufacturer guidelines. Resident #225 reported that an LPN who administered her nighttime medications appeared to be under the influence of alcohol. These incidents highlight significant lapses in medication administration and staff conduct, contributing to the overall deficiencies noted in the facility.
Failure to Ensure Proper Oversight and Care by Director of Nursing
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse in a facility with a daily average census of more than 60 residents. This resulted in a lack of consistent clinical services oversight and negative resident outcomes. The DON worked as a charge nurse for over 110 hours since January 2024, which prevented her from fulfilling her full-time responsibilities as the DON. This led to missed laboratory testing, treatments, and medications, as reported by a Licensed Practical Nurse (LPN). The DON admitted to working as a charge nurse and acknowledged the difficulty in keeping track of her hours for the Payroll Based Journal (PBJ) report. The deficiency was further highlighted by the identification of an Immediate Jeopardy (IJ) at F-686, Pressure Ulcer Prevention and Care. This began when facility licensed nurses failed to accurately assess, provide treatments as ordered, and ensure physician oversight for a resident's newly identified pressure injury. Another resident experienced the worsening of a wound on his right heel and developed an additional wound on his left heel due to missed treatments and delayed care. Additionally, it was found that LPNs were administering IV medications through Peripherally Inserted Central Catheters (PICC) lines without evidence of specialized training or oversight, which is outside the scope of practice for LPNs.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure call lights were within sight and reach for a resident reviewed for call light placement. The resident, a [AGE] year old female with diagnoses including acute respiratory failure with hypoxia, COPD, chronic pain, retention of urine, and severe protein-calorie malnutrition, was observed multiple times with the call light out of reach. On several occasions, the call light was draped over the footboard or curled up at the head of the bed, making it inaccessible to the resident. This was confirmed through interviews and observations over several days, despite the facility's policy requiring call lights to be within easy reach when a resident is in bed or confined to a chair.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain safe water temperatures, resulting in the potential for scalding residents. On 4/22/24, the hot water temperatures in the bathroom sinks of two rooms and the 200 hall spa room were measured and found to be excessively high, ranging from 123 to 130 degrees Fahrenheit. Resident #52 confirmed that the water gets very hot. During an interview, the Maintenance Director admitted that the water temperature was turned up to 140 degrees last year and some sinks were missing point-of-use mixing valves, which had not yet been installed. The facility's water temperature logs from January to April 2024 consistently showed temperatures exceeding 120 degrees in various locations, including the Beauty Shop Hair Sink and multiple showers in the 300 Spa area.
Failure to Ensure Appropriate Catheter Care
Penalty
Summary
The facility failed to ensure appropriate treatments and orders were in place to prevent catheter-associated urinary tract infections for a resident with a primary diagnosis of unspecified dementia, pressure ulcer, MSSA, and obstructive and reflux uropathy. During an observation, two LPNs were seen performing a catheter flush on the resident using normal saline, despite not knowing the reason for the procedure. They did not use gowns or face shields, increasing the risk of infection. The order for the catheter flush had been in place since the resident's admission, but neither the LPNs nor the Director of Nursing (DON) could identify its origin or necessity. The DON speculated that the order might have come from a hospitalization but could not confirm this. Upon contacting the resident's urologist, it was confirmed that the urologist did not order the catheter flushes and would not recommend them due to the significant risk of infection from opening the closed drainage system twice a day. This lack of clarity and improper procedure led to the potential for complications from cross-contamination and infections.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to ensure best practice standards for residents receiving supplemental oxygen. Resident #67, a female with chronic obstructive pulmonary disease and obstructive sleep apnea, was observed receiving oxygen at 2.5 liters per minute via nasal cannula on multiple occasions without a date on the oxygen tubing indicating when it had last been changed. This lack of documentation and monitoring could lead to potential health risks for the resident. Resident #70, a female with acute respiratory failure with hypoxia and chronic obstructive pulmonary disease, also experienced deficiencies in her respiratory care. Her electronic medication and treatment administration record did not contain an order for the rate of oxygen delivery, nor did it document regular observations by nursing staff to ensure the oxygen was set correctly. Additionally, her care plan lacked interventions for supplemental oxygen use and concerns for COPD. Observations revealed undated oxygen tubing and humidifier bottles, and reports indicated that the oxygen concentrator was sometimes set incorrectly. The Director of Nursing was unable to explain the discrepancies in the dating of the oxygen tubing.
Untrained LPN Administers IV Medication
Penalty
Summary
The facility failed to ensure that intravenous (IV) medications were administered by licensed nurses who had demonstrated proficiency with IV medication administration through training and monitoring in accordance with State professional standards of practice. This deficiency was observed when a Licensed Practical Nurse (LPN) administered IV antibiotics to a resident without having the required specialized training. The facility's Charge Nurse Job Description and Medication Administration policy both emphasize the need for safe and accurate medication administration by qualified personnel, but these standards were not met in this instance. The Director of Nursing (DON) confirmed that the LPN did not have specialized training at the facility and could not provide proof of such training from any other facility. The incident involved a resident who was admitted with diagnoses including discitis of the lumbosacral region, cellulitis of the back, streptococcus infection, and a pressure ulcer of the sacral region. The resident had an order for Penicillin G Potassium to be administered intravenously for sepsis and wound care. During an observation, the LPN was seen performing tasks such as flushing the PICC line and administering the IV antibiotics, which are outside the scope of practice for an LPN in the State of Michigan. The DON later confirmed that there was no documentation of specialized training for any LPN to administer IV medications through PICC lines at the facility.
Failure to Maintain Clean Ventilation Filters
Penalty
Summary
The facility failed to maintain clean ventilation filters, resulting in reduced air quality and circulation in resident rooms 204, 214, 326, and 327. On multiple occasions, PTAC units in these rooms were observed to be caked with dust. A resident reported that maintenance had not changed the filter since before winter, and the air seemed to come out slower. The Maintenance Director stated that filters are supposed to be checked monthly and changed as needed, but the facility's preventative maintenance program requires filters to be replaced or thoroughly cleaned every three months. The maintenance log showed the task was last completed on 3/31/2024.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to operationalize policies and procedures to appropriately evaluate and assess pain for a resident, resulting in the absence of pain assessments and unmet pain needs. Resident #27, a [AGE] year-old female with severe cognitive impairment and a history of stroke with right-sided hemiplegia and contracture, was not consistently assessed for pain using the appropriate Pain Assessment in Advanced Dementia (PAINAD) scale. Despite having a history of pain and being prescribed pain medication, the resident's pain was not adequately monitored or documented, leading to an increased perception of pain and unmet pain needs. Observations and interviews revealed that the resident displayed signs of pain, such as facial grimacing and verbalizing pain, but staff did not consistently use the PAINAD scale to assess her pain. The resident's pain assessments were sporadic, with significant gaps between assessments, and there was a lack of documentation regarding the type, severity, onset, duration, location, or quality of pain. This inconsistency in pain assessment and documentation indicates a failure to follow the facility's pain management policy, which requires regular monitoring and evaluation of pain, especially for residents with cognitive impairments. The facility's policy on pain management emphasizes the importance of evaluating and identifying pain, developing a care plan, and monitoring residents for pain regularly. However, the facility did not adhere to these guidelines, as evidenced by the lack of consistent pain assessments and inadequate documentation of the resident's pain. This failure to properly assess and manage pain for Resident #27 highlights a significant deficiency in the facility's pain management practices, resulting in the resident's increased perception of pain and unmet pain needs.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that Resident #64 received medications as ordered. Resident #64 was admitted with a primary diagnosis of unspecified dementia, pressure ulcer of the right heel, stage 3, Methicillin Susceptible Staphylococcus Aureus (MSSA), and obstructive and reflux uropathy. The resident was seen by a urologist for urinary retention and bilateral hydronephrosis, and the urologist prescribed a single-day antibiotic prophylaxis. However, the facility administered the antibiotic Bactrim DS daily from 4/16/2024 to 4/28/2024 without an order from the urologist to do so. During interviews, the Medical Assistant for the urologist confirmed that the antibiotic was intended for one day only. The Director of Nursing was unable to explain why the antibiotic was started without a proper order, and the Infection Control Nurse admitted to not having a copy of the urologist's order and failing to verify the transcription. The Infection Control Nurse also demonstrated a lack of knowledge regarding McGeer's criteria for starting an antibiotic in a resident with an indwelling catheter.
Inappropriate Antibiotic Utilization
Penalty
Summary
The facility failed to ensure that a resident who required an antibiotic was prescribed the appropriate antibiotic. A resident, a [AGE] year-old female with chronic kidney disease, was admitted to the facility and later reported not voiding for 12 hours. A straight catheterization was performed, and a urine dipstick test indicated a urinary tract infection (UTI). Consequently, the resident was prescribed Augmentin 500 mg three times a day for 10 days without waiting for the results of a urinalysis and culture and sensitivity test. The resident received the antibiotic from the morning of 4/14/24 through the evening of 4/23/24, despite the absence of a positive urinalysis and culture and sensitivity results. The Infection Control Preventionist (ICP) confirmed that the resident exhibited no signs or symptoms of a UTI, did not meet the McGeer Criteria for diagnosing a UTI, and had no history of UTIs. The facility's policy on antibiotic stewardship emphasizes the importance of prescribing antibiotics only when appropriate and discourages the use of broad-spectrum antibiotics while a culture is pending. The ICP reported that a culture and sensitivity should be reviewed prior to initiating antibiotic treatment to ensure the appropriate antibiotic is prescribed. The facility's failure to adhere to these guidelines resulted in inappropriate antibiotic utilization for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 92 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Fulton | 7.7 mi | ★★★★★ | 19 | 1 |
| Michigan Masonic Home | 16.9 mi | ★★★★★ | 17 | 0 |
| Optalis Health & Rehabilitation Of Ionia | 16.9 mi | ★★★★★ | 5 | 0 |
| Ashley Healthcare Center | 18.5 mi | ★★★★★ | 20 | 0 |
| Riverside Healthcare Center | 18.9 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.