Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medicalodges Nevada during CMS and state inspections, most recent first.
Cold Foods Served Above Required Temperature: A dietary aide and the DM served turkey and pasta salad plus chilled steamed vegetables without checking temperatures first, even though facility policy and recipes required cold foods to stay at or below 41 degrees F. During dinner serve-out, the turkey and pasta salad measured 80 degrees F and the vegetables measured 49.5 degrees F after several residents had already been served, and the DM then directed staff to remove the items.
Dietary staff failed to follow hand hygiene and glove-use expectations while preparing and serving food, including handling ready-to-eat items, ice, utensils, trash, refrigerators, and resident drinks without washing hands between tasks or after touching contaminated surfaces. Staff also failed to keep kitchen nonfood contact surfaces clean, with dirty floors, stove areas, carts, and a damaged vent cover observed in the prep and dish areas. Interviews with dietary leadership, RD, and the ADM confirmed the expected handwashing, glove changes, and cleaning practices.
The facility failed to complete NA Registry checks for three newly hired staff members, including the MDS Coordinator, DON, and an LPN. The abuse, neglect, and exploitation policy required pre-employment investigation and registry verification, but personnel files showed no NA Registry documentation for these employees. The Administrator stated that NA registries were expected for all staff except nurses, and that they were not completed on nurses.
Insulin pens were not primed before administration to three residents, resulting in an 11% medication error rate. An LPN gave Humalog and NovoLog insulin by SQ injection to residents with diabetes and cognitive impairment, but did not prime the pens as required by the pharmacy chart and manufacturer instructions. The LPN said he/she was unsure how to prime insulin pens and described turning the dial past the ordered dose and back without expelling air.
An LPN administered insulin to three residents without priming the insulin pens first. The residents had diabetes and were receiving Humalog or NovoLog by sliding scale or scheduled doses, and during observation the nurse removed each pen, inserted a disposable needle, dialed the ordered dose, and gave the SQ injection without first priming with two units as required by pharmacy guidance and manufacturer instructions. The LPN said he/she was unsure how to prime insulin pens and described a method that did not include pressing the button to expel air.
Failure to Honor Resident Choice for Food Requests: A resident with depression, muscle weakness, and dysarthria was denied food outside scheduled mealtimes after missing or refusing meals. Staff told the resident to wait for snack time or the next meal, even though other staff, including the DON and Administrator, stated the resident could have a sandwich or another alternate item from the Always Available Menu when hungry between meals. The record showed inconsistent staff understanding and a failure to honor the resident’s request for food.
A resident with ESRD and DM had multiple left foot wounds, including a toe amputation site, a great toe area wound, and later unstageable eschar areas. Staff did not keep the care plan updated for all skin areas, did not obtain/document orders for all identified wounds, and repeatedly failed to document ordered wound treatments on the TAR or explain why treatments were not completed. Observation also found an open bunion wound with slough and drainage, a bleeding third toe wrapped in a paper towel, and a scab at the amputation site.
Failure to care plan and follow EBP during wound care for two residents. One resident had a stage IV pressure ulcer of the buttock, and another had a history of cellulitis with draining right lower leg wounds. Both rooms had EBP signs posted, but an LPN and an RN performed wound care using gloves without gowns. Staff and the DON stated gowns and gloves should be used for wound care, and the facility did not have a specific EBP policy.
A resident did not receive a nourishing, palatable, and well-balanced diet that met daily nutritional and special dietary needs, resulting in a deficiency related to dietary services.
Staff failed to follow infection control policies and CDC guidance by wearing N95 masks incorrectly after two staff tested positive for Covid-19. Multiple staff, including a Restorative Aide, Nursing Assistant, Hospitality Aide, LPN, and the Administrator, were observed with the bottom strap of their N95 masks hanging below the chin, preventing a proper seal. Despite having received training, staff did not consistently don N95 masks as required by facility policy and CDC recommendations.
A facility failed to report abuse and neglect within the required timeframe. A CNA was accused of verbally and physically abusing three residents, including telling a resident with cerebral palsy to "shut up" and roughly pushing a resident with severe cognitive impairment in a wheelchair. The incidents were not reported to management or the state agency until two days later, violating the facility's policy and state regulations.
The facility failed to employ a qualified dietary manager, as the hired DM lacked the necessary certification and documentation of training. Despite having experience in the food industry, the DM's certification was expired, and they had not completed an online dietary certification program. The facility also lacked a written policy on certification requirements for the dietary manager position.
The facility failed to implement enhanced barrier precautions and proper hand hygiene during wound care for residents with MDROs and chronic wounds. Staff were not adequately trained on EBP, leading to improper use of PPE. Observations showed that an LPN did not change gloves or perform hand hygiene between stages of wound care, violating infection control protocols. Interviews confirmed that hand hygiene should be performed before and after resident care, but practices did not align with these expectations.
The facility did not designate a qualified infection preventionist (IP) for its infection prevention control program. The interim DON was enrolled in an IPC certification program but had not completed it, and no other staff were certified. The facility lacked a policy for the IP position and required certification.
The facility failed to maintain resident dignity and privacy by not providing dignity bags for catheter bags, not knocking before entering a resident's room, and standing over residents during meal assistance. Three residents had their catheter bags visibly exposed, and staff entered a resident's room without knocking during catheter care. Additionally, staff stood over residents while assisting with meals, rather than sitting next to them and interacting respectfully.
The facility failed to have a qualified activities program director, leading to inconsistent activity scheduling and resident boredom. Observations showed residents engaging in activities without staff leadership, and interviews confirmed the absence of a full-time director. The facility is seeking to hire a new director while department heads and volunteers temporarily lead activities.
The facility failed to complete ordered labs and x-rays for two residents, leading to potential delays in care. A resident with severe cognitive impairment did not have labs completed, resulting in a hospital visit. Another resident's hip x-rays were not done despite being ordered. Additionally, a resident did not receive restorative therapy due to staffing issues, leading to a decline in their ability to bear weight.
The facility failed to properly assess and document the use of side rails for residents, leading to deficiencies in care. Staff used side rails for residents assessed as inappropriate for their use, and failed to document risk reviews, obtain informed consent, or secure physician orders. Observations revealed improper use of grab bars without necessary documentation or assessments, highlighting a lack of compliance with regulatory requirements.
The facility failed to ensure that three nurse aides completed their CNA training within four months of hire. NA H, NA J, and NA A lacked documentation of training completion due to various issues, including technical problems and pending test results. The DON and Administrator acknowledged the deficiency, noting the absence of a facility policy on nurse aide certification.
The facility failed to provide suitable snack alternatives for diabetic residents outside of scheduled meal times. Observations showed that available snacks were mostly sugary, with limited protein options. Staff interviews confirmed that only a few sandwiches were provided, and the rest were sugary snacks. A diabetic resident expressed concern over the lack of non-sugary snacks, and the RD emphasized the need for appropriate options like fruit or protein snacks.
A long-term care facility failed to maintain a functional call light system, leading to delayed responses for residents needing assistance. One resident with moderate cognitive impairment experienced a nonfunctional call light, resulting in a fall and injury. Another resident with a hip fracture faced distress due to unanswered call lights. The facility lacked sufficient pagers, and the call light monitor was non-operational, contributing to the deficiency.
The facility failed to conduct a criminal background check and a Nurse Aide Registry check for a new employee, Housekeeping S, before they had contact with residents. The facility's policy requires these checks to be completed and documented before employment, but the personnel file lacked this documentation. Interviews confirmed the oversight, with the Business Office Manager acknowledging the absence of required checks and the Administrator noting the lack of a specific written policy.
A facility failed to complete the required PASARR screening for a resident with mental disorders and intellectual disabilities. The resident, admitted with conditions such as bipolar disorder and mild intellectual disabilities, did not have a PASARR screening completed prior to or upon admission, nor after changes in condition. The facility did not notify the state agency or re-complete the screening when the resident's stay extended beyond the 30-day respite period. Interviews revealed that staff were unable to locate a completed level 2 PASARR form and were unsure of the requirements.
A resident at risk for pressure ulcers developed a new ulcer on their toe, which was not documented or treated promptly by the LTC facility. Despite the podiatrist's orders, the facility delayed implementing wound care, leading to infection and deterioration. Interviews revealed communication and coordination issues among staff, contributing to the deficiency.
A non-weight bearing resident with severe cognitive impairment was improperly transferred using a gait belt instead of a mechanical lift, as required by their care plan. Observations showed staff lifting the resident with legs hanging in the air, contrary to the need for a mechanical lift due to the resident's inability to bear weight. Interviews revealed inconsistencies in staff understanding of the resident's transfer needs, with the Kardex and care plan not accurately reflecting the current requirements.
A facility failed to follow up on a pharmacist's recommendation to titrate a resident's dementia medication, despite physician approval. The resident, with multiple diagnoses including dementia, was not titrated as recommended. Interviews revealed a lack of a clear process for handling pharmacy recommendations, with confusion among staff about responsibilities for entering and reviewing orders.
The facility did not follow approved pureed diet menus for two residents, substituting non-equivalent items like cottage cheese and yogurt for vegetables. Staff interviews revealed a lack of adherence to prescribed menus and diet cards, with the Dietary Manager admitting to not knowing how to puree certain items. The facility also lacked a policy on pureed diets, leading to inconsistencies in meal preparation.
Cold Foods Served Above Required Temperature
Penalty
Summary
The facility failed to ensure cold food was served at a safe and appetizing temperature when turkey and pasta ranch salad and chilled steamed vegetables were served during dinner service above the facility’s stated limit of 41 degrees F. The facility policy required cold foods such as salads and desserts to be served at 41 degrees F or below, and the recipes for the turkey and pasta ranch salad and chilled steamed vegetables also required the finished products to remain below 41 degrees F during the entire service period. During observation of the dinner meal serve-out, a dietary aide removed the cold items from the refrigerator and placed them on a rolling cart, and the dietary manager brought the cart to the dining room and placed the containers in pans of ice on the steam table without taking temperatures first. During serve-out, staff plated the meals and delivered them to residents in the dining room. When the surveyor requested temperatures be taken, the dietary manager measured the turkey and pasta salad at 80 degrees F after eight to nine residents had already been served, and the chilled steamed vegetables later measured 49.5 degrees F. The dietary manager then instructed staff to remove the cold foods. Staff interviews showed the dietary aide believed the cook was responsible for taking temperatures, while the dietary manager, dietary coordinator, registered dietician, and administrator all stated cold foods should have been served below 41 degrees F and that the temperatures observed were not appropriate for serve-out.
Unsafe Food Handling and Poor Kitchen Sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards when dietary staff did not perform proper hand hygiene and did not keep nonfood contact surfaces clean. The report cites the facility’s policies and the FDA Food Code, which required hand hygiene before and after food handling, before donning gloves, after touching contaminated surfaces, and proper cleaning of food service areas and equipment. The facility census was 39.1. During multiple kitchen and dining observations, dietary staff were seen handling food and food service items with gloved and ungloved hands without washing hands between tasks or after touching surfaces. One dietary staff member wiped a prep counter with a cloth, opened the refrigerator with the same gloves, removed food pans, removed gloves without washing hands, returned salad dressing to the refrigerator, moved a cart between refrigerators, placed pans on the steam table, and scooped ice from the ice machine without washing hands or donning gloves. Another dietary staff member handled turkey, bread, mayonnaise, labels, trash can surfaces, the refrigerator, food pans, and the ice machine while changing gloves without washing hands, and served food at the steam table without washing hands. A third dietary staff member washed a blender bowl, donned gloves without washing hands, handled cooked ravioli and marinara sauce, touched recipes, removed gloves without washing hands, handled serving utensils and food pans, and later served food with gloves after returning from the kitchen without washing hands or using hand sanitizer. Additional observations showed a dietary aide scooping jello with gloved hands, then later handling saran wrap, a date sticker gun, trash, and the refrigerator with ungloved hands before leaving the kitchen to pour drinks. That staff member rubbed his or her nose and eyes and continued serving drinks, then handled a resident’s cup, ice, straw, and drink, including touching the top of the straw and inside the drink. Interviews with the dietary staff, dietary manager, registered dietician, and administrator confirmed expectations that staff should wash hands and change gloves between tasks, after touching contaminated surfaces, before handling ready-to-eat food, before scooping ice, and before serving residents. The facility also failed to keep kitchen nonfood contact surfaces clean. Observations showed dirty floors and surfaces under the dishwasher area, oven, prep counter, and three-vat sink; dirty stove burners, backsplash, and oven surfaces; debris and grime on the kitchen floor; buildup on the back side of the oven; crumbs and substances on the rolling cart; and peeling or bubbly paint on the vent cover above the dishwasher. Staff interviews indicated dietary staff were responsible for mopping kitchen floors and cleaning work areas, while maintenance staff stated they were unaware of some of the dirty areas and the vent condition.
Missing NA Registry Checks for New Hires
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to complete Nurse Aide (NA) Registry checks for three newly hired staff members. Review of the abuse, neglect, and exploitation policy dated 10/2022 showed that all new employees were to be investigated before employment for prior abuse, neglect, or exploitation history and that the appropriate certification and licensing agencies were to be contacted, with registry verification documented and maintained in the personnel file. However, personnel file review showed no NA Registry check documentation for the MDS Coordinator, hired 12/27/24; the DON, hired 11/21/25; and LPN H, hired 12/11/24. During interview, the Administrator stated that she and the Business Office Manager were responsible for pre-employment screenings, that all staff except nurses were expected to have an NA registry completed, and that NA registries were not completed on nurses.
Insulin Pens Not Primed Before Administration
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5% when a nurse did not prime insulin pens before administering insulin to three residents. Surveyors observed and reviewed records showing 3 errors out of 27 opportunities, for an error rate of 11%. The facility census was 39. The pharmacy insulin chart and manufacturer instructions for both Humalog KwikPen and NovoLog FlexPen required priming with two units before each injection to remove air from the needle and cartridge and ensure the pen was working properly. For one resident with type 2 diabetes mellitus and moderately impaired cognition, the nurse checked a blood sugar of 309 mg/dL and administered 8 units of Humalog insulin by SQ injection, but did not prime the pen first. For a second resident with type 2 diabetes mellitus and severe cognitive impairment, the nurse checked a blood sugar of 141 mg/dL and administered 4 units of NovoLog insulin by SQ injection, but again did not prime the pen prior to administration. For a third resident with type 2 diabetes mellitus and moderately impaired cognition, the nurse administered 15 units of NovoLog insulin by SQ injection and did not prime the pen before giving the dose. During interview, the nurse said he/she was unsure how to prime insulin pens and described turning the dial one unit past the ordered dose and then back to the ordered dose without compressing the button to eject air. The DON stated a nurse should prime an insulin pen with two units before each dose, and the MDS Coordinator/RN stated the pen should be primed by dialing two units and wasting the insulin prior to each injection. The Administrator stated nurses should prime insulin pens prior to administration unless pharmacy policy directed otherwise.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to prevent significant medication errors when an LPN administered insulin from pens to three residents without priming the pens first. Facility pharmacy guidance and manufacturer instructions for both NovoLog FlexPen and Humalog KwikPen required priming with two units before each injection, and the instructions stated that priming removes air from the needle and cartridge and helps ensure the pen is working properly. The report identified this failure during observation and interview while the nurse prepared and administered insulin to the residents. Resident #10 had type 2 diabetes mellitus with diabetic neuropathy and was moderately cognitively impaired. The resident had an order for insulin lispro by sliding scale, and when the blood sugar was 309 mg/dL, the nurse prepared and administered 8 units of Humalog insulin by SQ injection. During the observation, the nurse removed the Humalog KwikPen, inserted a disposable needle, dialed the dose, and gave the injection without priming the pen first. Resident #14 had type 2 diabetes mellitus and was severely cognitively impaired. The resident had an order for NovoLog FlexPen by sliding scale, and when the blood sugar was 141 mg/dL, the nurse prepared and administered 4 units of NovoLog insulin by SQ injection. Resident #17 had type 2 diabetes mellitus and was moderately cognitively impaired, with an order for NovoLog FlexPen 15 units three times daily; when the blood sugar was 154 mg/dL, the nurse prepared and administered 15 units of NovoLog insulin by SQ injection. In both cases, the nurse removed the pen, inserted a disposable needle, dialed the ordered dose, and administered the insulin without priming the pen. During interview, the nurse said he/she was unsure how to prime insulin pens and typically turned the dial one unit past the ordered dose and back without pressing the button to eject air. The DON and MDS Coordinator stated that insulin pens should be primed with two units before each dose.
Failure to Honor Resident Requests for Food Outside Scheduled Mealtimes
Penalty
Summary
The facility failed to protect the self-determination rights of residents when staff did not honor one resident’s request for food outside of scheduled mealtimes. The resident involved had diagnoses including depression, muscle weakness, and dysarthria, and the resident’s care plan noted the resident needed staff assistance with ADLs, sometimes needed help propelling a wheelchair, and could yell when needs were not being met. The resident’s diet order was for a liberalized geriatric diet with regular texture and consistency cut into quarter-sized pieces. The resident was documented as refusing lunch on one occasion and later going to the dining room requesting a sandwich because lunch had been missed. Staff told the resident that if a meal was declined, the resident had to wait until snack time or the next mealtime. On another occasion, the resident asked for breakfast after the breakfast window had passed and was told breakfast was over, that snacks would be passed at the scheduled snack time, and that staff could not force the resident to get up faster for meals. The SSD also documented placing meal and smoke-time sheets and a clock in the resident’s room to help the resident track time better. Multiple staff interviews showed inconsistent understanding of whether food could be provided outside scheduled mealtimes. Some staff said the resident should be offered a sandwich, snack, cereal, or another meal if a meal was missed or refused, and the DON stated dietary could make a plate of food or an alternative meal any time during the day or evening. However, the SSD stated the resident would need to wait for snack time if a meal was missed and that dietary did not provide substitute meals outside designated mealtimes. The Administrator also stated the resident could have something from the Always Available Menu if the resident missed a meal, and both the DON and Administrator said the SSD should have offered a sandwich or asked nursing or dietary what to do.
Missed wound documentation and incomplete skin care planning
Penalty
Summary
The facility failed to provide care according to orders, resident preferences, and goals when staff did not keep the care plan updated for all identified skin areas, did not obtain physician orders in a timely manner for all identified skin areas, and did not document completion of, or the reason for not completing, wound treatments for one resident. The resident had end stage renal disease and type 2 diabetes mellitus, and on admission was documented to have a left 4th toe amputation with sutures intact, multiple scabbed abrasions and lesions on both upper and lower extremities, and a deep red/purple area near the left great toe. The resident’s treatment records showed repeated missed documentation of ordered wound care. The TAR reflected that treatment for the left 4th toe amputation was not documented on multiple days in March, April, and May 2026, and progress notes did not explain why the treatments were not completed. The care plan was revised for the left 4th toe amputation, but later skin findings at the base of the left great toe were not added to the care plan, and no treatment order was documented for that area. Subsequent nursing assessments documented an open area at the base of the left great toe, then later unstageable areas with eschar on the left 5th toe and the right side of the great toe, but staff did not document physician notification for those areas. Later orders were entered for the left great metatarsal head diabetic foot ulcer and the left 4th toe amputation, but the TAR again showed multiple dates when treatment completion was not documented for either wound, and progress notes did not state why the treatments were not completed. During observation, the resident had an open wound at the left bunion area with slough and drainage, a scabbed area on the left second toe, a paper towel wrapped around the left third toe after it had bled earlier that day, and a scab at the left 4th toe amputation site. Staff interviews confirmed that wound treatments should be completed and documented on the TAR, that missed treatments should be reported, and that wounds, amputations, or surgical wounds should be on the care plan, but the record showed these actions were not consistently completed.
Failure to Care Plan and Follow EBP During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when it did not care plan or consistently follow enhanced barrier precautions (EBP) during wound care for two residents. The facility policy titled Infection Control Surveillance addressed hand hygiene, infection control education, and auditing, but the facility did not have a specific EBP policy. CDC guidance reviewed by surveyors stated that EBP includes gown and glove use during high-contact resident care activities, including wound care, for residents with wounds or indwelling medical devices. Resident #2 was admitted with a stage IV pressure ulcer of the right buttock, and the care plan included daily wound treatment but did not address EBP. During observation, the resident’s room had an EBP sign posted, and an LPN performed wound care using hand hygiene and gloves but did not don a gown. The LPN later stated the gown was forgotten, and the DON stated nurses should wear gowns and gloves when performing wound care for the resident. Resident #27 was admitted with a history of cellulitis of the right lower leg, and the care plan addressed skin breakdown and daily wound care but did not include EBP. The physician’s order directed cleansing and dressing of the right lower leg due to cellulitis. During observation, the resident’s room also had an EBP sign posted, and an RN performed wound care with gloves but without a gown. Staff interviews confirmed that nurses should wear gowns and gloves during wound care, and the DON and Administrator stated the facility relied on CDC guidance and used door signage to indicate when EBP was needed.
Failure to Provide Adequate and Appropriate Diet
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. This deficiency was identified based on observations and findings that residents did not consistently receive meals that were adequate in nutrition, taste, or tailored to their specific dietary requirements.
Failure to Ensure Proper Use of N95 Masks During Covid-19 Outbreak
Penalty
Summary
Staff at the facility failed to implement and maintain an effective infection prevention and control program as required by both facility policy and CDC guidance. Despite two staff members testing positive for Covid-19, multiple staff—including a Restorative Aide, Nursing Assistant, Hospitality Aide, LPN, and the Administrator—were observed wearing N95 masks incorrectly, with the bottom strap hanging below the chin rather than secured at the nape of the neck. This improper use of N95 masks prevented a proper seal, which is necessary for effective respiratory protection. Staff interviews confirmed that, although they had received training on proper PPE use, they were not consistently following the correct donning procedures for N95 masks. Facility policies and CDC guidance reviewed in the report clearly outlined the correct method for donning N95 respirators, including the placement of both straps and the importance of achieving a tight seal. Observations and interviews revealed that staff were aware of the requirement to wear N95 masks after exposure to Covid-19 positive individuals, but failed to adhere to these protocols in practice. The deficiency was identified through direct observation, staff interviews, and review of training and policy documents, with no mention of corrective actions or follow-up at the time of the report.
Failure to Timely Report Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect within the required two-hour timeframe to the State Survey Agency. The incident involved a certified nurse aide (CNA) who was accused of verbal and physical abuse towards three residents. The abuse occurred between 3:00 A.M. and 5:00 A.M. on 12/15/24, but the facility's management was not informed until 12/17/24. The delay in reporting the incident to the Department of Health and Senior Services (DHSS) was a violation of the facility's policy and state regulations. Resident #1, who has cerebral palsy and is dependent on others for activities of daily living, was reportedly told to "shut up" by CNA F after yelling for help. Resident #2, who has severe cognitive impairment and uses a wheelchair, was roughly pushed by CNA F, causing the resident's legs to bend back under the wheelchair. Resident #3 experienced rough handling when CNA F yanked the resident's brief down, causing the resident to scream. These actions were witnessed by CNA E, who did not report them immediately to the charge nurse or management. Interviews with staff revealed that they were aware of the requirement to report abuse and neglect within two hours, yet the incident was not reported in a timely manner. CNA E eventually reported the incidents to the Administrator two days later, prompting an investigation. The failure to report the abuse immediately and the rough handling of residents constituted a deficiency in the facility's adherence to its abuse, neglect, and exploitation policy.
Deficiency in Employing Qualified Dietary Manager
Penalty
Summary
The facility staff failed to employ a qualified dietary manager for food and nutrition services, as required by regulations. The dietary manager (DM) was hired without documentation of the necessary training, experience, or qualifications to meet the certification requirements for the position. Although the DM had six years of cooking experience and ten years as a food industry manager, their certification was from another state and had expired at the time of hiring. The DM had started an online dietary certification program but had not completed it. The facility did not provide a written policy regarding the certification requirements for the dietary manager, nor did they have documentation of the DM's current certification or sufficient training.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain a complete infection prevention and control program by not implementing the policy regarding enhanced barrier precautions (EBP) for residents infected with multidrug-resistant organisms (MDRO) or those with chronic wounds and indwelling medical devices. Staff were not adequately trained on EBP, leading to improper use of personal protective equipment (PPE) during high-contact resident care activities. Interviews with staff, including a Certified Medication Technician, a Registered Nurse, and the Director of Nursing, revealed a lack of awareness and understanding of the need for gowns during catheter and wound care unless there was a confirmed infection. The facility also failed to ensure proper hand hygiene practices during wound care for two residents. Observations showed that a Licensed Practical Nurse (LPN) did not change gloves or perform hand hygiene between different stages of wound care for a resident with a pressure ulcer. The LPN handled contaminated items and then proceeded to apply wound treatment without washing hands or changing gloves, which is against the facility's hand hygiene policy. Similarly, another LPN did not perform hand hygiene between glove changes while treating a resident's toe wound, further demonstrating non-compliance with infection control protocols. Interviews with staff, including a Certified Medication Technician, a Registered Nurse, and the Director of Nursing, confirmed that hand hygiene should be performed before and after resident care, between glove changes, and when transitioning from dirty to clean tasks. However, the observed practices did not align with these expectations, indicating a systemic issue in adhering to infection control policies. The facility's failure to provide a policy or procedures regarding wound care further contributed to the deficiency.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) with specialized training in infection prevention and control (IPC) for its infection prevention control program. The facility, with a census of 45, did not have a policy related to the IP position or the required certification. The interim Director of Nursing (DON), who had been in the position for about two months, was enrolled in the State's online IPC program but had not completed the certification. The facility offered other staff nurses the opportunity to enroll in the course, but none had completed it. The previous interim DON, who worked only as needed, was also not certified in the IPC program. The Administrator expected the current interim DON to complete the certification process, as no other staff members were certified.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents by not providing dignity bags for catheter bags for three residents. These residents, who were cognitively intact and dependent on staff for toileting, were observed with their catheter bags visibly exposed in common areas and from the hallway. Despite the residents' preferences for privacy, the staff did not ensure the catheter bags were covered, and the facility lacked a care plan addressing the use of dignity bags. Interviews with staff, including nurse aides and the Director of Nursing, confirmed that catheter bags should be covered at all times, especially in common areas. Additionally, the facility did not respect the privacy of a resident when staff entered the resident's room without knocking. This resident, who had moderate cognitive impairment and used a wheelchair, was receiving catheter care when multiple staff members entered the room without announcing themselves. This lack of privacy was acknowledged by various staff members, including the Administrator, who stated that residents have the right to privacy and that staff should knock before entering. The facility also failed to provide dignified meal assistance to three residents. Staff were observed standing over residents while assisting them with meals, rather than sitting next to them and interacting at their pace. Interviews with staff, including a CNA and the DON, indicated that staff should sit next to residents during meal assistance to ensure a respectful and interactive experience. The facility did not have a policy pertaining to meal assistance, which contributed to this deficiency.
Lack of Designated Activities Program Director
Penalty
Summary
The facility failed to ensure that a qualified individual was designated as the activities program director, which is a requirement for maintaining an effective activities program. The facility, with a census of 45, did not have a policy pertaining to the activity program or the requirements for the program director. A review of the facility's staff listing and staffing schedules for May and June 2024 showed no individual listed or scheduled as an activities program director. Observations revealed that residents were engaging in activities such as Bingo and exercise without the presence of a designated staff member to lead these activities. Instead, a CNA/Staffing Coordinator was observed leading activities when available, indicating a lack of a full-time activity director. Interviews with staff and family members highlighted the absence of a designated activities program director. The Director of Nursing and the Administrator confirmed that the former activities director had changed positions, and the facility was in the process of hiring a new director. In the interim, department heads and volunteers were attempting to lead activities based on a previously set calendar, but there was no consistency in providing one-on-one activities for residents who did not attend group activities. A family member of a resident expressed concerns about the lack of one-on-one interaction and the residents' boredom, which was corroborated by the DON, who noted recent complaints from residents about being bored.
Failure to Complete Ordered Labs, X-rays, and Restorative Therapy
Penalty
Summary
The facility failed to provide care per standard practice by not completing ordered labs and x-rays for two residents, leading to potential delays in care. Resident #26, who had severe cognitive impairment and multiple diagnoses including dementia and hypertension, was ordered a urinalysis, complete blood count, and complete metabolic panel on 06/08/24 after exhibiting lethargy and low blood pressure. However, these labs were not entered or completed, and the resident was later sent to the hospital on 06/12/24 with a new order for antibiotics for a urinary tract infection. Interviews with staff revealed a lack of clarity on why the orders were not completed, and there was no policy or procedure in place for following physician orders for laboratory or diagnostic imaging. Resident #29, who was cognitively intact but dependent on staff for activities of daily living, was ordered bilateral hip x-rays on 05/24/24 due to hip pain. The order was not entered, and no x-ray results were found in the resident's medical record. Staff interviews indicated that the x-ray order was not completed, and the Director of Nursing noted that the mobile order company could have come out the same day the order was sent. The Administrator was unsure why the x-rays were not completed as ordered. Additionally, the facility failed to provide restorative therapy for Resident #33, who had multiple diagnoses including Parkinsonism and dementia with Lewy bodies. The resident was discharged from skilled physical therapy with recommendations for restorative nursing three to five times per week. However, the restorative nurse aide was often pulled to work the floor, resulting in no restorative therapy being done. Interviews with staff and the resident's family member confirmed the lack of consistent restorative therapy, and the resident experienced a decline in their ability to bear weight.
Deficiencies in Side Rail Use and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and documentation before the use of side rails for residents, leading to deficiencies in care. Specifically, staff used side rails for two residents who had been assessed as not appropriate for side rail use. Additionally, the facility did not document a risk versus benefit review, obtain informed consent, care plan side rail use, obtain physician orders for the use of side rails, or complete measurements to reduce the risk of entrapment for two other residents. These actions were observed and documented during a survey, highlighting a lack of compliance with regulatory requirements. Resident #39, who was severely cognitively impaired and dependent on staff for activities of daily living, was observed with a grab bar in the upright position on multiple occasions. Despite this, the resident's care plan did not include any mention of grab bar use, and a clinical health review had previously determined that side rails, grab, or transfer bars would not be utilized. Similarly, Resident #40, who was cognitively intact but required assistance for mobility, was observed with a grab bar installed by the therapy department without any documented consent or assessment. Further deficiencies were noted with Resident #10 and Resident #29, both of whom had side rails in use without proper documentation or physician orders. Resident #10, who had left-sided hemiparesis and used an electric wheelchair, had no documented consent or risk assessment for side rail use. Resident #29, who had a history of falls and used a wheelchair, also lacked documentation of consent, risk assessment, or physician orders for side rail use. Interviews with staff revealed a lack of awareness and understanding of the procedures required for the installation and use of grab bars, contributing to the facility's failure to comply with regulatory standards.
Failure to Ensure Timely CNA Training Completion
Penalty
Summary
The facility failed to ensure that three nurse aides (NAs) completed a certified nurse aide (CNA) training program within four months of their employment. NA H, hired on September 7, 2023, had no documentation of completing the training program and was unsure about the start date of the online classes, although they were nearly completed. NA J, hired on September 11, 2023, also lacked documentation of training completion, with a Licensed Practical Nurse (LPN) indicating that NA J had taken the test recently, but results were pending. NA A, hired on October 19, 2023, had not completed the training due to technical issues with the online classes, which required a reset. The Director of Nursing (DON), who had been in the position for about two months, acknowledged that nurse aide training should be completed within four months of hire. The facility did not have a policy regarding nurse aide certification or training, relying instead on state guidelines. The Administrator confirmed that staff were hired as NAs and worked onsite, with the expectation of certification within four months. However, the facility was aware that they were not meeting this requirement for the staff in question.
Inadequate Snack Options for Diabetic Residents
Penalty
Summary
The facility failed to provide suitable and nourishing snack alternatives for diabetic residents outside of scheduled meal services. Observations revealed that the snacks available at the nurses' station after 7:00 P.M. were primarily sugary or salty, with no protein options available. The dietary staff placed a limited number of sandwiches on the tray, which were quickly consumed, leaving no suitable options for diabetic residents later in the evening. The evening and night shift staff did not have access to the kitchen or additional food items after 7:00 P.M., and there was no refrigerator available for storing protein-rich snacks. Interviews with staff and residents highlighted the inadequacy of the snack options provided. A diabetic resident expressed concern over the lack of non-sugary snacks available in the evening. The Dietary Manager confirmed that only a few sandwiches were provided for diabetic residents, and the rest of the snacks were sugary. The Registered Dietician emphasized the importance of offering appropriate snacks, such as fruit or protein options, to diabetic residents. The Administrator acknowledged that the kitchen staff prepared snacks before leaving at 7:00 P.M., but the available options were insufficient for the needs of diabetic residents throughout the night.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to maintain a properly functioning call light system, resulting in significant delays in response times for residents needing assistance. Resident #41, who has moderate cognitive impairment and is independent in personal care, experienced a nonfunctional call light system. Despite pressing the call light, staff did not respond for over twenty minutes, and the call light did not alert staff pagers. This led to the resident having to crawl to a roommate's side to use their call light for assistance. The maintenance director and administrator were unaware of the non-functioning call light, and the maintenance checks were reportedly conducted monthly. Resident #200, with a history of a right hip fracture and chronic atrial fibrillation, also faced issues with the call light system. The resident reported pressing the call light multiple times without receiving a response, leading to distress and the risk of incontinence. The facility's call light history showed multiple instances where the call light was activated but not responded to, with the alerts automatically resetting without staff intervention. Interviews with staff revealed a lack of awareness and understanding of the call light system's functionality and the expectation for timely responses. The facility's call light system was further compromised by a shortage of pagers, with some staff not having access to them. Observations showed that some staff did not have pagers, and the call light monitor at the nurse's station was not operational due to recent remodeling. The administrator acknowledged the shortage of pagers and the need for a system that escalates alerts to supervisory levels if not answered promptly. Despite the expectation that all staff should respond to call lights, the lack of functioning equipment and communication hindered their ability to do so effectively.
Failure to Conduct Required Background Checks for New Employee
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not conducting a criminal background check (CBC) and a Nurse Aide (NA) Registry check for a new employee, Housekeeping S, before they had contact with residents. The facility's policy mandates that all new employees be investigated for any history of abuse, neglect, or exploitation prior to employment. Additionally, non-licensed employees are required to undergo a CBC, and the results should be maintained in their personnel file. However, a review of Housekeeping S's personnel file revealed that there was no documentation of a CBC request or a NA Registry check, despite the employee being hired and having contact with residents. Interviews with the Business Office Manager (BOM) and the interim Director of Nursing (DON) confirmed that the facility uses an electronic system with a checklist to ensure all necessary background checks are completed before hiring. The BOM acknowledged the absence of CBC and NA Registry documentation for Housekeeping S and stated that these checks should be completed and documented before an employee begins orientation. The Administrator also confirmed that the facility lacked a specific written policy for CBC and NA Registry checks, relying instead on regulations, and emphasized that the BOM should ensure all checklist steps are completed and documented prior to hiring.
Failure to Complete PASARR Screening for Resident
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident with mental disorders and intellectual disabilities. The resident, who was admitted with diagnoses including bipolar disorder, major depressive disorder, mild intellectual disabilities, and impulse disorder, did not have a completed PASARR screening prior to or upon admission, nor after changes in condition. The resident's care plan indicated mood and behavior problems, and the resident was at risk for aggression. Despite these issues, the facility did not notify the state agency or re-complete the PASARR screening when the resident's stay extended beyond the 30-day respite period. Additionally, the facility did not conduct a new PASARR screening after the resident experienced changes in condition, including a new diagnosis in 2020 and a psychiatric hospital stay in 2022. Interviews with the Social Services Director and the Administrator revealed that they were unable to locate a completed level 2 PASARR form for the resident and were unsure of the requirements for completing the form. This lack of documentation and understanding of the PASARR process contributed to the deficiency in ensuring the resident received appropriate care and services.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for a resident, leading to a deficiency. The resident, who was at risk for developing pressure ulcers, was admitted with diagnoses including diabetes and required pressure-reducing devices for bed and chair. Despite these precautions, a new ulcer developed on the resident's left second toe, which was not documented or treated in a timely manner. The nursing assistant reported the issue to the charge nurse, but the conversation and the condition of the resident's toe were not documented in the progress notes. The podiatrist identified the ulcer as a pressure wound and provided specific treatment orders, which were not added to the resident's Physician Order Sheet or care plan. The facility staff delayed implementing the podiatrist's orders, and the resident's wound care was not initiated until several days later. The wound showed signs of infection and deterioration, with the resident experiencing pain and the wound not improving until a referral to a wound care clinic was made. The facility's failure to document, track, and implement timely wound care orders contributed to the worsening of the resident's condition. Interviews with facility staff revealed a lack of communication and coordination in managing the resident's wound care. The LPN responsible for wound care did not promptly enter new orders into the system, and there was confusion among staff regarding the current treatment plan. The Director of Nursing and the Administrator were unaware of the delay in treatment initiation, highlighting systemic issues in the facility's wound care management process.
Improper Transfer of Non-Weight Bearing Resident
Penalty
Summary
The facility failed to ensure an environment as free of accident hazards as possible when staff transferred a non-weight bearing resident using a gait belt instead of a mechanical lift. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed being transferred by CNAs and nursing staff using a gait belt, despite the resident's care plan indicating the need for a mechanical lift due to the inability to bear weight and other health considerations. The resident's care plan and clinical health review indicated total dependence on staff for transfers and the requirement of a mechanical lift due to the resident's inability to consistently bear weight, history of falls, and fragile skin. However, observations showed that staff used a gait belt to lift the resident from a wheelchair to a bed, with the resident's legs hanging in the air and not bearing any weight. Interviews with staff revealed inconsistencies in the understanding and implementation of the resident's transfer needs, with some staff believing the resident was a one-to-two-person pivot transfer, while others acknowledged the need for a mechanical lift. The facility did not provide a policy regarding transferring residents, gait belt use, or mechanical lift use, contributing to the deficiency. Interviews with the Director of Nursing and the Administrator highlighted a lack of clarity and communication regarding the resident's transfer status, with the Kardex and care plan not accurately reflecting the resident's current needs. This lack of proper documentation and adherence to the resident's care plan led to unsafe transfer practices, putting the resident at risk of harm.
Failure to Implement Pharmacist Recommendations for Medication Titration
Penalty
Summary
The facility failed to implement a process to ensure that pharmacist recommendations were followed up and implemented when approved by a physician. This deficiency was identified when the facility did not adjust a resident's medication as recommended by the pharmacist and agreed to by the physician. The resident, who had diagnoses including left-sided hemiplegia, dementia, diabetes, and heart failure, was receiving Namenda for dementia. The pharmacist recommended a titration of the medication, which was agreed upon by the physician, but no titration attempts were documented in the resident's physician order sheet. Interviews with facility staff revealed a lack of a clear process for following up on pharmacy recommendations. The Registered Nurse mentioned that orders received via fax should be entered in a timely manner, but there was confusion about who was responsible for entering these orders. The Director of Nursing indicated that it was the responsibility of a specific LPN to ensure orders were taken off, but was unsure why the titration was not completed. The Administrator stated that new orders should be entered into the computer system and reviewed within 24 hours, but acknowledged issues with staff not following through with orders. There was no established process for ensuring pharmacy recommendations were followed up on, leading to the oversight in the resident's medication management.
Failure to Follow Approved Pureed Diet Menus
Penalty
Summary
The facility failed to adhere to approved menus to meet the nutritional needs of residents requiring pureed diets. Specifically, two residents who required pureed meals were not provided with the approved menu items. Instead, the dietary staff substituted non-equivalent items, such as cottage cheese and yogurt, for vegetables. The Dietary Manager admitted to not knowing how to puree certain menu items, leading to inappropriate substitutions. The Registered Dietician confirmed that substitutions should be like-kind and nutrient equivalent, which was not the case in this situation. Interviews with various staff members, including the Dietary Manager, Dietary Aide, Registered Dietician, Director of Nursing, and the Administrator, revealed a lack of adherence to the prescribed menu and diet cards. The staff acknowledged that the substitutions made were not equivalent and did not meet the residents' dietary needs. The facility also lacked a policy regarding pureed diets, contributing to the inconsistency in meal preparation and delivery.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Nevada
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Moore Few Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Nathan Richard Health Care Center | 1.6 mi | ★★★★★ | 2 | 0 |
| Medicalodges Fort Scott | 18.6 mi | ★★★★★ | 8 | 0 |
| Community Springs Healthcare Facility | 19.4 mi | ★★★★★ | 0 | 0 |
| Truman Healthcare & Rehabilitation Center | 23.9 mi | ★★★★★ | 6 | 0 |
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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 October 2026) and official state health department websites.