Below 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 Nye Summit during CMS and state inspections, most recent first.
The facility failed to properly label and store food items in the kitchen's walk-in refrigerator and freezer. Undated and improperly stored items, including lettuce, celery, turkey slices, and cheeses, were found exposed to air. An expired container of cooked vegetables was also discovered. The Dietary Manager confirmed these items should have been labeled and dated, acknowledging the expired vegetables should have been discarded. This posed a risk of foodborne illness to 47 residents consuming food from the kitchen.
The facility failed to monitor and document weights for three residents, leading to a deficiency in nutritional care. One resident with failure to thrive was not weighed due to lack of equipment, another with multiple diagnoses was not weighed since November, and a hospice resident was not weighed since October. Staff interviews confirmed the absence of necessary equipment and failure to adhere to weight monitoring protocols.
The facility failed to maintain operational ventilation systems in 14 resident bathrooms, affecting 20 residents. Observations showed that the ventilation systems were non-functional, as confirmed by the Maintenance Director, potentially impacting odor control.
A resident with severe cognitive impairment and a history of attempting to leave the facility was not provided with a wander guard as required by their care plan. Despite being identified as at risk for elopement, the resident was able to leave the building unattended multiple times, without appropriate supervision or notification to staff. The facility's failure to implement necessary interventions resulted in the resident being exposed to cold weather conditions without proper clothing.
A resident with a gastrostomy tube did not receive proper care as the LPN failed to clean the G-tube insertion site before applying a new dressing, and the dressing was not correctly positioned. The resident had a history of gastrointestinal hemorrhage, quadriplegia, and other conditions, requiring full assistance for daily activities. The deficiency was due to a lack of communication from bath staff and non-adherence to the facility's wound care policy.
The facility failed to document a diagnosis supporting the use of antipsychotic medication for two residents. One resident was prescribed quetiapine for agitation without a supporting diagnosis, while another was given quetiapine for insomnia without necessary assessments. The facility's pharmacist recommended discontinuing quetiapine due to risks, but the provider did not respond. The ADON confirmed the lack of necessary assessments and communication with the provider.
Two residents with severe cognitive impairments eloped from the facility due to inadequate implementation of safety measures. One resident was found outside twice, resulting in hospitalization for injuries, while the other had a history of elopement risk but lacked proper assessments and documentation. The facility's failure to adhere to its elopement prevention policy contributed to these incidents.
A resident with severe cognitive impairment suffered burns from a hot coffee spill due to the facility's failure to assess their risk for handling hot liquids. The facility's policy required such assessments, but they were not conducted. Observations showed that dietary staff did not consistently check coffee temperatures before serving, contributing to the incident. Interviews revealed a lack of formal risk assessments, relying instead on informal observations to determine the need for lidded cups.
The facility failed to submit investigations to the state agency within the required five working days for three residents involved in separate incidents, including a physical altercation and a fall resulting in injury. The DON confirmed these lapses during interviews.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to adhere to proper food labeling and storage protocols, as observed during an inspection of the kitchen's walk-in refrigerator and freezer. Several food items, including a zip lock bag of lettuce, cut-up celery, turkey slices, and various cheeses, were found undated and improperly stored, exposing them to air. Additionally, a container of cooked vegetables was found with an expired date, and undated bags of unknown substances were discovered in the freezer. The Dietary Manager confirmed that these items should have been labeled and dated, and acknowledged that the expired vegetables should have been discarded. This oversight had the potential to affect 47 residents who consumed food from the kitchen, posing a risk of foodborne illness.
Failure to Monitor Resident Weights and Nutritional Status
Penalty
Summary
The facility failed to obtain and document resident weights for three residents, leading to a deficiency in monitoring potential nutritional problems. Resident 32, who was admitted with diagnoses including adult failure to thrive, a stage 4 pressure injury, and malnutrition, was not weighed since September 2024. The facility lacked the necessary equipment, such as a lift with a scale, to weigh the resident who refused to get out of bed. Interviews with staff confirmed the absence of appropriate equipment and the failure to adhere to the facility's policy of weekly weight monitoring. Resident 3, who had multiple diagnoses including stroke, memory deficit, and malnutrition, was also not weighed since November 2024. Despite being on a mechanically altered diet and having nutritional concerns, the resident's weights were not recorded in the Electronic Medical Record (EMR) after October 2024. Observations revealed that Resident 3 frequently left meals untouched, and interviews with staff confirmed the resident's refusal of the mechanically altered diet and nutritional shakes. The facility's expectation of weekly weight monitoring was not met for this resident. Resident 42, admitted with conditions such as heart failure and chronic kidney disease, was on hospice care and had not been weighed since October 2024. The facility did not have a method to weigh the resident in bed, and hospice staff did not perform weight checks. Interviews with the Assistant Director of Nursing and the dietitian confirmed that residents on hospice or with weight loss should be weighed at least monthly, but this was not done for Resident 42. The lack of equipment and failure to follow weight monitoring protocols contributed to the deficiency in nutritional care for these residents.
Non-Functional Ventilation System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the ventilation system was operational in 14 occupied rooms, specifically in the bathrooms of rooms 201, 202, 203, 204, 205, 206, 208, 209, 210, 211, 212, 213, 214, and 215. This deficiency affected 14 bathrooms used by 20 residents, potentially impacting odor control within the facility. Observations conducted on two separate occasions revealed that the ventilation systems in these bathrooms were not functional, as demonstrated by a test using a 1-ply square of toilet paper that did not adhere to the ventilation cover, indicating no air draw. The Maintenance Director confirmed the non-functionality of the ventilation system in the bathrooms along the 200 hallway, acknowledging that the system should be operational.
Failure to Implement Elopement Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate interventions were implemented to protect a resident from elopement. The resident, who was severely cognitively impaired with a BIMS score of 4, had a history of attempting to leave the facility without informing staff. Despite being identified as at risk for elopement, the resident did not have a wander guard as required by the care plan. Observations revealed that the resident attempted to leave the facility multiple times without appropriate supervision or notification to staff. The resident's care plan included interventions for elopement risk, such as wearing a wander guard on the wheelchair, but these were not implemented. The Assistant Director of Nursing (ADON) confirmed that the resident's care plan included an intervention for a wander guard, but there was no order for it, and the resident did not have one. Interviews with staff, including the Registered Nurse (RN), Office Manager (OM), and Medication Aide (MA), confirmed that the resident was not safe to be outside alone due to impulsivity and poor safety awareness. The facility's failure to implement the necessary interventions resulted in the resident being able to leave the building unattended on multiple occasions. Staff observed the resident exiting the facility without appropriate clothing for the cold weather, and the resident was stopped by staff only after leaving the building. The Director of Nursing (DON) acknowledged the need for a wander guard due to the resident's exit-seeking behaviors and safety concerns, but it was not in place at the time of the incidents.
Inadequate G-Tube Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with a gastrostomy tube (G-tube). The resident, who was dependent on staff for all activities of daily living and mobility, had a medical history including gastrointestinal hemorrhage, quadriplegia, traumatic brain injury, and depression. The facility's wound care policy required the G-tube insertion site to be cleansed with sterile water and gauze, and a clean, dry dressing applied. However, during an observation, it was noted that the Licensed Practical Nurse (LPN) did not clean the G-tube insertion site before placing a new split sponge dressing, which was not positioned correctly between the G-tube insertion site and the G-tube flange. The site appeared to have blood-tinged drainage, indicating improper care. The deficiency was further highlighted during interviews, where the LPN confirmed the failure to clean the site and the absence of a split sponge due to a lack of communication from the bath staff after the resident's shower. The Infection Preventionist (IP) also confirmed that the bath staff should have notified the LPN about the removal of the split sponge, and the LPN should have cleaned the site before applying a new dressing. This oversight in communication and adherence to the facility's wound care policy led to inadequate care for the resident's G-tube site.
Lack of Diagnosis for Antipsychotic Use in Two Residents
Penalty
Summary
The facility failed to have a diagnosis in place to support the use of an antipsychotic medication for two residents. Resident 32 was admitted with diagnoses of dementia with behavioral disturbance and depression, but there was no documented diagnosis to support the use of quetiapine, an antipsychotic medication prescribed for agitation. The Assistant Director of Nursing (ADON) confirmed the absence of a documented diagnosis for the antipsychotic medication. Resident 7 was prescribed quetiapine for insomnia, despite having no documented sleep test, sleep diary, or sleep assessment to support the diagnosis of insomnia. The resident's care plan included quetiapine as an intervention for insomnia, but the ADON confirmed that necessary assessments were not completed. The facility's pharmacist recommended discontinuing quetiapine due to potential risks and suggested an alternative medication, but the provider did not respond to this recommendation. Interviews with the ADON and the facility's contracted pharmacist revealed that the provider who prescribed quetiapine for Resident 7 did not follow the necessary steps, such as conducting a sleep assessment or responding to pharmacy recommendations. The ADON acknowledged that the provider, who was not the facility's provider, took months to address pharmacy recommendations, and no attempts were made to contact the provider to address the issue. The pharmacist confirmed that quetiapine is not approved for treating insomnia and recommended a sleep assessment, which had not been completed.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility staff failed to evaluate and implement interventions to prevent elopement for two residents, leading to significant safety incidents. Resident 1, who was severely cognitively impaired and receiving hospice care, was found outside the facility on two occasions. The first incident occurred when Resident 1 was discovered in the facility parking lot, and the wander guard did not alarm. The second incident resulted in Resident 1 being found on the ground in the driveway, requiring hospitalization for multiple injuries, including subdural brain bleeds and fractures. It was later revealed that the wander guard was not transferred to a new wheelchair provided by hospice personnel. Resident 4, also severely cognitively impaired, had a history of elopement risk and had previously eloped to the assisted living side of the building. Despite this, the facility failed to conduct quarterly elopement risk assessments as required by their policy. Additionally, there were multiple instances of missing documentation for the monitoring of Resident 4's wander guard, indicating a lack of consistent oversight and adherence to safety protocols. The facility's policy outlined specific procedures for preventing elopement, including the use of wander guards and regular assessments. However, these measures were not effectively implemented or documented, contributing to the residents' ability to leave the facility unsupervised. The lack of timely updates to care plans and failure to conduct necessary risk assessments further exacerbated the situation, compromising the safety and well-being of the residents involved.
Failure to Assess Hot Liquid Burn Risk Leads to Resident Injury
Penalty
Summary
The facility failed to evaluate Resident 1's risk for hot liquid burns, resulting in a burn from a hot coffee spill. Resident 1, who had severe cognitive impairment due to Alzheimer's disease and other neurological conditions, required supervision with eating. Despite this, the resident was not assessed for their ability to handle hot liquids prior to the incident. On the day of the incident, Resident 1 spilled hot coffee in their lap, leading to burns on the inner thighs. The facility's policy on hot liquid safety, which was in place at the time, required that all residents be assessed for their ability to handle hot liquids, but this was not done for Resident 1. Observations revealed that the dietary staff did not consistently check the temperature of the coffee before serving it to residents. On the day of the incident, coffee was served at temperatures exceeding the facility's safe limit of 140 degrees Fahrenheit. The dietary aides were observed serving coffee without taking the temperature after it had been poured, and the coffee was served to residents, including Resident 1, without ensuring it had cooled to a safe temperature. This lack of adherence to the facility's hot liquid safety policy contributed to the incident. Interviews with staff, including dietary aides and nursing staff, indicated a lack of formal hot liquid risk assessments for residents. The staff relied on informal observations to determine which residents required lidded cups, and there was no systematic approach to identifying residents at risk for burns from hot liquids. The facility administrator confirmed that no hot liquid risk assessments had been completed for residents prior to the incident, highlighting a significant oversight in the facility's safety protocols.
Failure to Submit Timely Investigations
Penalty
Summary
The facility failed to submit an investigation to the state agency within the required five working days for three residents involved in separate incidents. For Resident 2, a progress note revealed that the resident was involved in a physical altercation with another resident, resulting in both residents hitting each other. The incident was reported to the primary care physician, supervisor, and Adult Protective Services (APS), but no investigation was completed and submitted to the state agency within the required timeframe. The Director of Nursing (DON) confirmed this oversight during an interview. For Resident 3, a progress note indicated that the resident was found on the floor with a laceration on their forehead after falling from their wheelchair. Emergency services were called, and the resident was transported to the hospital. APS was notified, but again, no investigation was completed and submitted to the state agency within the required five working days. The DON confirmed this lapse during an interview. These failures to report and investigate incidents in a timely manner were identified during a review of the facility's records and interviews with staff.
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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.
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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.