Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alpine Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Infection control failures occurred when staff caring for residents on COVID-related precautions cleaned goggles for only 90 seconds before placing them with clean PPE, and an OT wore a surgical mask instead of an N95 in a resident's room. An LPN also handled a glucometer without a barrier, placed it on a resident's overbed table, and returned it to the med cart drawer without cleaning it first.
A facility failed to maintain an effective antibiotic stewardship program for 4 residents reviewed. One resident had a urine dipstick and was started on Cipro without documented signs or symptoms, another had Bactrim ordered for UTI without a UA or urine culture, a third had Zyvox continued after hospital treatment without documentation supporting the need, and a fourth was started on cefpodoxime after hospital return even though the urine culture showed mixed flora. The record also showed missing antibiotic time-outs, incomplete documentation, and antibiotics not always given as ordered.
Failure to assess self-administration of a bedside nasal spray. A cognitively intact resident with an order for fluticasone nasal spray was observed with the medication on the over-bed table and stated she was giving it to herself. The care plan did not address self-administration, and the DON stated there was no self-administration form in the record; the DON also noted the nurse had the medication in the cart and had administered it that morning.
A resident with ALS, muscle weakness, and intact cognition stated he preferred showers, but staff documentation showed he received a mix of bed baths and showers instead of his preferred bathing method. The care plan directed staff to offer a bath or shower of choice, yet the resident reported bed baths were not as thorough and that a gurney shower bed had not been used for him; a CNA and the DON confirmed his shower preference was not being met consistently.
A resident admitted with ALS had an activities assessment documenting preferences such as bingo, social events, being outside, one-to-one visits, movies, an iPad, and audiobooks, and was cognitively intact with a BIMS of 15/15. However, the comprehensive care plan contained no activities focus, goal, or interventions. The AD stated an Activity Care Plan should have been developed.
Care Plans Not Updated With Resident-Specific Interventions: The comprehensive care plan was not revised for three residents. One resident with cognitive and behavioral diagnoses had care plans that listed verbal aggression and refusals, but lacked resident-specific interventions for handling those behaviors. A second resident with paraplegia and mood disorders frequently refused to get out of bed, yet the care plan did not address those refusals. A third resident with COPD and functional quadriplegia had generalized interventions for oxygen refusal, but the plan did not include individualized approaches, and observations showed the resident without the nasal cannula in place or positioned correctly while an LPN did not assess or reapply oxygen.
Failure to document and carry out CHF-related orders occurred for a resident with CHF, NSTEMI, pleural effusions, AFib, and CKD. The resident had no HF care plan or documented HF goals, a 1500 mL fluid restriction was not clearly tracked, a six-pound weight gain was not reported to the provider, and intake/output was not documented. IV fluids were ordered for dehydration, but there was no documentation that they were given or why they were not started, and a chest pain episode with lethargy and SOB was not documented in the EMR.
Failure to provide ordered oxygen and nebulizer treatments. A resident with COPD and heart failure was observed without the nasal cannula in place, with the O2 concentrator set below the ordered flow rate, and an LPN did not verify delivery or positioning. Another resident with acute respiratory failure and dementia received a nebulizer treatment while lying flat, with the medication chamber and tubing resting on the chest, no staff monitoring the treatment, and the equipment was later stored without cleaning.
Medication orders and labels did not match the actual route used for a resident with a G-tube. An LPN gave docusate sodium and hydralazine by mouth in pudding even though the orders and labels still showed G-tube administration, and the G-tube was only flushed for patency. The resident had aphasia following cerebral infarction and severe cognitive impairment, and the LPNUM said staff were responsible for checking orders against labels and following the medication rights.
A resident with a history of verbally aggressive behavior used a racial slur during a verbal altercation with another resident who has a history of racial trauma. The incident was confirmed by staff and both residents, but the affected resident's care plan was not updated and documentation of the event was minimal, despite facility policies prohibiting discrimination and requiring prompt reporting.
A verbal altercation involving racial slurs occurred between two residents, one with a history of trauma, and was witnessed by an LPN. The DON did not initiate an official investigation, submit a Facility Reported Incident, or notify required parties, despite facility policy mandating prompt investigation and reporting of all abuse allegations.
A resident with nicotine dependence and on oxygen therapy repeatedly expressed intent to continue smoking and was observed attempting to smoke, but staff did not develop a care plan to address these behaviors. This omission led to an incident where the resident's wheelchair caught fire, resulting in burns, as no interventions or monitoring were in place to manage the risk.
Two residents were involved in a verbal altercation that included racial slurs, but their care plans were not updated to reflect the incident or address new behavioral concerns. Staff, including a CNA and an LPN, were unaware of any changes or new interventions, and the care plans did not document the altercation or provide guidance for managing future interactions.
A resident with nicotine dependence and COPD was not adequately supervised or care planned for continued smoking while using oxygen, despite staff awareness and facility policies prohibiting smoking. The resident was injured when their wheelchair caught fire while smoking with oxygen in place, and other residents had to intervene.
The facility failed to maintain comfortable temperatures in communal shower rooms, with temperatures recorded at 62.1°F, 62.4°F, and 67.6°F. Residents expressed discomfort and reluctance to use the shower rooms, opting for personal hygiene in their rooms instead. Staff acknowledged the issue, and the Maintenance Director and Engineering Manager confirmed the low temperatures. Facility policies require temperatures between 71°F and 81°F, which were not met, leading to widespread resident discomfort.
The facility failed to remove expired medications from two medication storage rooms and left a wound care cart unlocked near the 400 Hall nurses' station. Expired Iron Liquid Supplement and Tubersol vials were found, and the wound care cart contained potentially hazardous opened items. An LPN confirmed the cart was unlocked and acknowledged the potential hazard. Facility policy required outdated drugs to be returned or destroyed and carts to be locked when not in use.
A resident's personal and medical records were left visible on an unattended computer attached to a medication cart, violating confidentiality protocols. The RN responsible admitted to leaving the information accessible while attending to another resident. The DON confirmed the breach of privacy and emphasized the importance of protecting electronic health records.
A resident with a Foley catheter did not have a comprehensive care plan developed in a timely manner, despite having an indwelling catheter documented in their MDS assessments. Facility staff acknowledged that the care plan should have included specific interventions to prevent complications, but these were not implemented as required by facility policy.
A resident at high risk for falls experienced two falls, but the care plan was not updated with new interventions after the second incident. Despite the facility's policy requiring care plan updates following falls, the DON confirmed that the care plan lacked necessary revisions, such as ensuring the resident's belongings were within reach.
A resident with a right elbow wound did not receive physician-ordered daily wound care, as documented in the facility's records. An LPN assigned to the resident was unaware of the wound and did not provide care on a specific date. The DON confirmed the lack of documentation and acknowledged the oversight, which contradicted the facility's policy on wound management.
A resident with a history of type II diabetes and sepsis repeatedly requested a dental appointment for broken teeth and pain, but the facility failed to schedule it. Despite documentation of oral pain in the resident's care plan and MDS notes, the process involving social services and transportation services did not result in an appointment. The Director of Nursing acknowledged the importance of addressing the resident's dental needs.
The facility failed to address low ambient temperatures in three communal shower rooms, with temperatures recorded at 62.1°F, 62.4°F, and 67.6°F. The Administrator was unaware of the issue, while the Director of Engineering had been aware of a thermostat problem since December 19, 2024, but believed it was resolved. Maintenance staff did not communicate the ongoing issue, highlighting a lapse in communication and oversight.
The facility failed to document wound care treatments for four residents, resulting in incomplete clinical records. An LPN admitted to providing care but forgetting to document it, which was confirmed by the DON. The facility's policies require all treatments to be recorded, but the lack of documentation indicates a failure to adhere to these policies.
A Social Services employee entered a resident's room on contact-based isolation precautions without donning the required PPE, despite the room being clearly marked with a sign indicating the need for such precautions. The employee acknowledged awareness of the precautions but believed PPE was unnecessary as no direct care was provided. The incident was observed by an LPN, who reiterated the PPE requirement, and the DON confirmed the need for PPE to prevent infection spread.
The facility did not update the nursing staff posting daily as required, with the last update being two days old. The DON confirmed the posting was only in one location, not on each unit, and the Administrator acknowledged the oversight, confirming the posting was outdated and not compliant with the facility's policy.
A resident with chronic hepatic failure was subjected to verbal and physical abuse by a CNA, who yelled at them and threw a pillow. The resident's roommate witnessed the incident. The facility's DON confirmed the abuse and reported it to the Nevada State Board of Nursing, substantiating the allegations.
A resident with severe protein-calorie malnutrition and a stage four pressure ulcer did not receive a timely dietary evaluation or the prescribed Pro-Stat supplement. Despite a physician's order and confirmation by an RN, the January MAR lacked documentation of Pro-Stat administration. The facility's policies required a comprehensive nutrition assessment for such cases, which was not completed.
A resident with chronic conditions was asked by a Housekeeper to borrow money, which was against facility policy. Although the money was repaid, this action violated the resident's right to be free from misappropriation of property. An investigation confirmed the incident, and other residents reported no similar requests.
The facility failed to administer medications per physician's orders for two residents. An LPN administered the wrong dosage of Calcium Citrate-Vitamin D to one resident and applied a Lidocaine patch to the wrong shoulder for another. Both errors were confirmed by the LPN and acknowledged by the DON and Administrator.
Infection control failures during PPE handling and glucometer use
Penalty
Summary
The facility failed to follow infection control guidelines during care of residents on droplet or contact/droplet precautions. R34 was admitted with Parkinson's disease and severe protein calorie malnutrition and later tested positive for COVID-19. During observation, a CNA and a housekeeper exited R34's room after providing care and removed the goggles they had worn inside the room, then wiped the goggles with a Sani-Cloth wipe from the orange-top container for 90 seconds before placing them directly into the isolation cart with clean, unused PPE. During the same resident's care, an OT was observed in the room assisting the resident while wearing a surgical mask. The Infection Preventionist later confirmed that the goggles should have been cleaned with a wet Sani-Cloth from the orange-top container for four minutes and that the OT should have worn an N95 mask instead of a surgical mask. R51 was admitted with unspecified sequelae of other nontraumatic intracranial hemorrhage and atrial fibrillation and later tested positive for COVID-19. The physician ordered contact/droplet isolation with 10-day monitoring. During observation, the CNA exited R51's room after care, removed the goggles worn in the room, wiped them with a Sani-Cloth wipe from the orange-top container for 90 seconds, and placed them directly into the isolation cart with clean PPE. R77 was admitted with COPD and later tested positive for COVID-19, with a physician order for contact/droplet isolation and 10-day monitoring. During observation, the same CNA exited R77's room, removed the goggles worn in the room, wiped them with a Sani-Cloth wipe from the orange-top container for 90 seconds, and placed them directly into the isolation cart with clean PPE. The facility also failed to ensure glucometer checks were performed in a manner to prevent infection for R60, who was admitted with diabetes. An LPN removed the glucometer from the medication cart drawer and placed it on top of the cart without a barrier, then placed it into her pocket and applied gloves without using hand sanitizer before entering the resident's room. In the room, the glucometer was placed on the resident's overbed table. After obtaining the blood sugar result, the LPN returned the glucometer to the medication cart drawer without cleaning it. The LPN later confirmed she should have cleaned the glucometer with the specialized wipes on the cart, and the unit manager confirmed the infection control practices were not maintained during the glucometer check.
Antibiotic stewardship deficiencies with unsupported UTI treatment
Penalty
Summary
The facility failed to have an Antibiotic Stewardship Program consistent with current standards of practice for 4 of 4 residents reviewed for antibiotic stewardship: R83, R33, R126, and R85. The report states that these residents received antibiotics without documentation supporting the indication, without required diagnostic testing in some cases, and without documentation of an antibiotic time-out or review of culture results to confirm the need for continued therapy. The facility’s Infection Control Surveillance Log also indicated these residents did not meet McGeer’s criteria for the infections documented in the record review. For R83, nursing documentation showed a urine dipstick was performed after leukocytes were noted, but there were no documented signs or symptoms supporting the test. Ciprofloxacin was ordered for three days, but the first dose was not given because the medication had not arrived from the pharmacy, and the resident received only part of the ordered course. A urine culture later showed usual skin flora and advised recollection, but there was no further documentation of another culture. The Infection Preventionist and VPCS confirmed there was no nursing documentation of signs and symptoms to support the dipstick, no repeat urine culture, and the antibiotic was not administered as ordered. For R33, a verbal order was given to collect a UA, but the record did not show UA results or a urine culture before Bactrim DS was ordered for UTI. The resident then received the antibiotic course as documented in the MAR. For R126, the record showed Zyvox was ordered for UTI after hospital treatment, but there was no documentation of a time-out, no UA or culture results from the hospital to support the diagnosis, and the resident received only three days of the five-day order. For R85, the resident was sent to the hospital with fever, muscle aches, migraine, nausea, and feeling generally unwell, then started on cefpodoxime for UTI after return; the IP later produced a urine culture showing mixed flora, which would not have required an antibiotic. The facility policy stated antibiotics should be used when clinical criteria for active infection or suspected sepsis are met and when culture and sensitivity support therapy, with documentation of the specific criteria in the resident’s record.
Failure to Assess Self-Administration of Bedside Medication
Penalty
Summary
The facility failed to ensure medication at the bedside was assessed for self-administration for one resident. The resident was admitted with allergic rhinitis and had an order for fluticasone propionate nasal suspension, 1 spray in both nostrils in the morning for allergies. The quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. During an observation and interview, the resident was seen with a bottle of fluticasone nasal spray on the over-bed table and stated that she administered the medication herself. She also stated that she thought she had signed a form, but staff did not watch her. The comprehensive care plan did not include a focus, goal, or intervention for self-administration of the medication. The DON reviewed the record and stated there was not a self-administration form. In a later interview, the resident stated the nasal spray had been on her over-bed table until staff removed it. The DON stated the facility’s process was to obtain a physician order, complete an assessment for safety, provide a lock box, update the care plan, and mark the eMAR for self-administration, and also stated that the nurse had the medication in her cart and had administered it that morning.
Failure to Honor Resident Shower Preference
Penalty
Summary
The facility failed to ensure that one sampled resident, who had ALS, muscle weakness, and needed assistance with personal care, was given the opportunity to make choices regarding shower preference. The resident’s admission interview showed he considered choosing between bath types somewhat important and stated that he preferred a shower. His MDS indicated intact cognition with a BIMS score of 15 out of 15, range of motion impairment in both upper extremities and one lower extremity, and a need for substantial assistance with bathing and showering. The resident’s care plan directed staff to offer a bath or shower of choice on scheduled days and as needed, and to provide a sponge bath only when a full bath or shower could not be tolerated. However, task documentation showed that between 02/08/26 and 04/01/26 he received a mix of partial bed baths, full bed baths, and showers, and refused one shower/bed bath. During interview, the resident stated he had been getting bed baths that were not as thorough, wanted his hair washed, and said he preferred a shower and had recently learned about a gurney shower bed that had not been used for him. A CNA stated the resident had been physically tired, that the facility was really struggling, and that the gurney shower bed had not been used yet. The DON confirmed the resident had not been getting his shower preference consistently.
Failure to Develop an Activities Care Plan
Penalty
Summary
The facility failed to develop a care plan related to activities for R114, who was admitted with a diagnosis of amyotrophic lateral sclerosis (ALS). The Activities Initial Assessment documented that R114 enjoyed bingo, social events, being outside, one-to-one visits, movies, using an iPad, and audiobooks. The MDS with an ARD of 02/12/26 showed a BIMS score of 15 out of 15, indicating R114 was cognitively intact. Review of the 02/16/26 comprehensive care plan revealed no focus, goal, or interventions/approaches for activities. During interview, the Activity Director stated that an Activity Care Plan should have been developed and noted that R114 still liked to get up in his wheelchair and go to therapy first thing in the morning and come to activities later. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Care Plans Not Updated With Resident-Specific Interventions
Penalty
Summary
The comprehensive care plan was not updated or revised for 3 of 33 sampled residents. For R8, who was admitted with diagnoses including cognitive communication deficit and adjustment disorder with mixed disturbance of emotions and conduct, the behavior care plan listed verbally aggressive behaviors such as inappropriate language, racial slurs, accusatory statements, and yelling, while the comprehensive care plan listed resistive behaviors such as refusing medications, brief changes, peri care, meals, bathing, and turning. The record showed both plans contained generalized interventions, but they did not include resident-specific interventions for handling refusals or behaviors. The quarterly MDS showed a BIMS score of 11, verbal behaviors, and rejection of care one to three days out of seven. For R56, who had diagnoses including paraplegia, muscle weakness, major depressive disorder, unspecified mood disorder, and anxiety, the care plan addressed ADL performance deficit and altered physical mobility, including use of a mechanical lift and two staff for transfers. Interviews with CNAs showed that he often refused to get out of bed, would request to get up and then change his mind, and staff expected these refusals to be care planned because they occurred frequently. The DON stated that R56 refused to get out of bed often and that it should be care planned, but the care plan did not contain resident-specific interventions related to those refusals. For R68, who was re-admitted with diagnoses including COPD, hypertensive heart disease with heart failure, and functional quadriplegia, the care plan last revised 07/31/25 addressed resistive behaviors including resisting ADL care, medications, and wearing oxygen, but the interventions were generalized and did not include individualized approaches specific to oxygen refusal. Observations showed R68 in bed without the nasal cannula in place while oxygen was running, with tubing out of reach, and later with the nasal cannula incorrectly positioned next to the nose. An LPN entered the room to give medications without assessing for or reapplying oxygen, and later stated that R68 always removes the nasal cannula and could not identify how long the oxygen had been off or improperly worn.
Failure to Document and Carry Out CHF-Related Orders
Penalty
Summary
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals occurred for a resident with CHF, NSTEMI, bilateral pleural effusions, atrial fibrillation, and CKD stage III. The resident was admitted with a discharge order for a 1500 mL daily fluid restriction after thoracentesis removed 1.2 L of fluid. The admission assessment identified heart failure as the primary diagnosis for the most recent hospitalization, but the facility documented that HF goals had not been established, there were no comments about coordinating care, and the HF care plan had not been initiated. The baseline care plan also did not document CHF or the 1500 mL fluid restriction. The resident’s weight increased from 156 pounds on admission to 162 pounds five days later, but the physician was not notified of the six-pound gain. The weekly weight order did not specify when to notify the provider for weight gain. The record also showed an order for the 1500 mL fluid restriction without a breakdown of how much fluid was to be provided by nursing and dietary. CNA documentation showed fluids provided and consumed each shift, but there was no documentation of fluids given by nurses during medication passes and no documentation of output. A provider later ordered IV fluids for the resident after noting diarrhea, severe dehydration, fatigue, lethargy, low urine output, dry lips, and skin tenting. The MAR showed the IV fluid order was pending confirmation, but there was no documentation that the resident received the IV fluids, no nursing documentation explaining why the order was not started, and no documentation that the emergency contact was notified of the change in condition. In addition, when the resident complained of chest pain and appeared lethargic and short of breath, the nurse took vital signs and reported the resident to the NP, but the vital signs, the chest pain complaint, the provider notification, and the NP visit were not documented in the EMR. The DON and NP both confirmed that the chest pain episode and the lack of documentation were issues, and the NP stated she was not aware that the weight gain, lack of intake/output recording, and non-administration of IV fluids had not been documented or communicated.
Failure to Provide Ordered Oxygen and Nebulizer Treatments
Penalty
Summary
The facility failed to ensure oxygen therapy was administered according to physician orders for a resident with COPD, hypertensive heart disease with heart failure, and functional quadriplegia. The resident had an order for oxygen at 4 liters per minute continuously and a care plan intervention for oxygen via nasal prongs as ordered continuously and humidified continuously. During observation, the resident was found in bed without the nasal cannula in place, the oxygen concentrator was set at 2 liters per minute, and the tubing was out of reach. An LPN entered the room to give medications but did not assess oxygen use, ensure the cannula was in place, or verify the ordered flow rate. The LPN later stated the resident always removes the cannula and confirmed the oxygen was set at 2 liters per minute, while the physician order was for 4 liters per minute. The facility also failed to ensure the resident’s oxygen was properly positioned during a later observation. The resident was seen with the nasal cannula prongs placed to the left side of the nose, and the LPN agreed to assist but could not state how long the oxygen had been worn improperly. The DON stated that the resident always refused oxygen. For another resident with acute respiratory failure with hypoxia and unspecified dementia, the facility failed to ensure nebulizer treatment was delivered effectively. The resident had a nebulizer order and was observed receiving treatment while lying flat on her back in bed, with the medication chamber and tubing resting on her chest rather than positioned upright. No staff were present to monitor the treatment, and the nurse did not return until prompted by the surveyor. When the treatment was stopped, the LPN wrapped the tubing around the machine and placed it in the bedside drawer without cleaning the equipment. The LPN stated the resident should have been positioned upright and acknowledged that failure to clean nebulizer equipment can lead to bacterial growth and increase the risk of respiratory infection.
Medication Orders and Labels Did Not Match Actual Route of Administration
Penalty
Summary
The facility failed to update physician orders and ensure medication labels accurately reflected the current route of administration for a resident with a feeding tube who had begun taking medications by mouth. The resident was admitted with diagnoses including aphasia following cerebral infarction and gastrostomy status, and the quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment. The MAR showed twelve medications scheduled by mouth and three medications scheduled via G-tube, including docusate sodium 100 mg daily, hydralazine HCl 100 mg twice daily, and atorvastatin 80 mg at bedtime, along with G-tube flushes twice daily. During observation, an LPN administered the docusate sodium and hydralazine by mouth in pudding, while the medication labels for both medications still reflected administration via G-tube. The LPN confirmed that the physician orders and labels indicated G-tube administration but stated the resident did not receive anything by G-tube and that the G-tube was only flushed for patency. The LPN also stated nursing staff were responsible for ensuring medication orders and labels reflected the correct route of administration and for obtaining physician clarification when discrepancies were identified. The LPNUM stated she was unaware of the inconsistency and that nurses were responsible for following the medication rights and validating orders against labels before administration.
Failure to Protect Resident from Racial Discrimination During Verbal Altercation
Penalty
Summary
The facility failed to protect a resident's right to a dignified existence and freedom from discrimination when a verbal altercation between two residents involved the use of racial slurs. One resident, with a diagnosis of bipolar disorder and a history of verbally aggressive behaviors, walked past another resident's room and, after being yelled at to leave, responded with a racial slur. The incident was confirmed by both residents and staff, with documentation indicating that the resident who used the slur had a care plan addressing verbally aggressive behaviors, but not specifically racial discrimination. The other resident, who has a history of post-traumatic stress disorder related to racial trauma, did not have their care plan updated following the incident. Staff interviews revealed that the incident was known to some, but not all, staff members, and that the facility's policies prohibit discrimination and require prompt reporting of such incidents. The Director of Nursing acknowledged the incident as racially abusive language and bullying, and noted that racism was a pervasive issue in the facility. Despite this, the clinical record for the resident who experienced the slur lacked documentation of the incident beyond a single communication note, and there was no evidence of additional interventions or care plan updates related to the racial discrimination event.
Failure to Investigate and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of verbal abuse involving two residents, one of whom had a history of post-traumatic stress disorder related to prior abuse and racial trauma. On the date of the incident, one resident walked past another resident's room, resulting in a verbal altercation where racial slurs were exchanged. The incident was witnessed by an LPN, who intervened after hearing the commotion from another hallway. Documentation shows that the social worker met with both residents the following day to discuss the incident, but the care plan for the resident with a history of trauma was not updated, and there was no further documentation or investigation into the event. The Director of Nursing (DON), who also served as the Abuse Coordinator, determined after a verbal conversation with the LPN that the incident did not constitute abuse and did not initiate an official investigation, submit a Facility Reported Incident (FRI) report, or notify the State Agency, Ombudsman, residents' families, or Medical Director. The facility's policy required that all allegations of abuse be investigated and reported within two hours, including interviews with all involved parties and appropriate notifications. However, the DON did not interview the residents involved or any potential witnesses, and the incident was not documented as an abuse allegation, resulting in a failure to follow established procedures.
Failure to Care Plan for Smoking Risk with Oxygen Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's ongoing nicotine dependence and stated intent to continue smoking, despite the resident's use of oxygen therapy and multiple documented behaviors indicating a desire to smoke. The resident, who had diagnoses including nicotine dependence and chronic obstructive pulmonary disease, repeatedly expressed intentions to smoke while on oxygen and was observed attempting to obtain cigarettes and expressing frustration over smoking restrictions. Staff were aware of the resident's behaviors and risk factors, as evidenced by nursing and behavioral notes, but did not include these issues in the resident's care plan. This lack of care planning resulted in staff being unaware of or unprepared for the resident's actions, culminating in a serious incident where the resident's wheelchair caught fire while the resident was outside, leading to burns on the resident's upper legs, abdomen, nostrils, and hands. Documentation shows that the resident had been counseled about the dangers of smoking with oxygen and had been prescribed nicotine replacement therapy, but no formal interventions or monitoring were established in the care plan to address the risk of smoking while using oxygen.
Failure to Update Care Plans After Resident Altercation Involving Racial Slurs
Penalty
Summary
The facility failed to update the care plans for two residents following a resident-to-resident altercation involving the use of racial slurs. One resident, with a diagnosis of bipolar disorder, was documented to have yelled a racial slur at another resident after being yelled at to leave the area. Both residents had a history of negative interactions, including police involvement. Despite documentation of the incident in nursing and social work notes, neither resident's care plan was revised to reflect the altercation or to address the new behavioral concerns that arose from the incident. Staff interviews revealed that direct care staff were unaware of any new interventions or changes to the care plans following the altercation. The care plans for both residents had not been updated to include the incident or to address the specific needs related to racial trauma and behavioral issues, as required by facility policy. The lack of care plan updates was confirmed by the Assistant Director of Nursing, who acknowledged that care plans should have been revised to document the incident and guide staff in preventing further occurrences.
Failure to Supervise Resident Smoking with Oxygen Resulting in Fire and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident with a history of nicotine dependence and chronic obstructive pulmonary disease who continued to smoke while using oxygen. Despite multiple documented instances where the resident expressed intent to smoke and was observed smoking on facility property, the care plan did not address the resident's risk factors related to smoking while on oxygen. Staff were aware of the resident's behavior, and there were several notes indicating the resident's frustration with smoking restrictions and attempts to smoke, including while on oxygen. The facility's policies required comprehensive care planning and strict adherence to oxygen and smoking safety, but these were not effectively implemented for this resident. On the date of the incident, the resident's wheelchair caught fire in the facility parking lot while the resident was smoking with oxygen in place, resulting in burns to the resident's upper legs, abdomen, nostrils, and hands. Other residents witnessed the event and intervened to help the resident. Staff interviews confirmed prior knowledge of the resident's unsafe smoking practices and lack of care plan interventions addressing these risks. The facility's smokefree policy and procedures for handling residents who refuse to follow safe smoking practices were not enforced in this case.
Inadequate Shower Room Temperatures
Penalty
Summary
The facility failed to ensure a comfortable ambient air temperature in the communal shower rooms, affecting multiple residents. Observations and interviews revealed that the temperatures in three shower rooms were recorded at 62.1°F, 62.4°F, and 67.6°F, which were considered too cold for comfortable use. Residents expressed discomfort and reluctance to use the shower rooms due to the chilly conditions, with some opting to perform personal hygiene in their rooms instead. Staff, including CNAs, RNs, and LPNs, acknowledged the residents' complaints and agreed that the shower rooms were too cold. The Maintenance Director and Engineering Manager confirmed the low temperatures and expressed that they would not want to shower in such conditions. The Administrator and Owner were aware of the issue, with the Owner noting that the facility had been waiting for a vendor to address the problem. The Director of Engineering became aware of a thermostat issue in December 2024 and believed it had been resolved, but maintenance staff did not communicate the ongoing problem. Facility policies guarantee residents the right to a safe, clean, comfortable, and homelike environment, with specified temperature ranges between 71°F and 81°F. The failure to maintain these temperatures in the shower rooms violated these policies, leading to widespread discomfort among residents. The report highlights the lack of effective communication and timely resolution of maintenance issues, contributing to the deficiency.
Expired Medications and Unsecured Wound Care Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from two of three medication storage rooms. During an observation, expired Geri Care Iron Liquid Supplement and Tubersol tuberculin purified protein derivative vials were found in the medication storage rooms. The Unit Manager confirmed the expiration of the Iron Liquid Supplement and the lack of opening dates on the Tubersol vials, which were considered expired. The Director of Nursing also confirmed the expiration of the Iron Liquid Supplement and acknowledged the potential adverse effects of administering expired medications. The facility's policy stated that outdated drugs should not be used and must be returned to the pharmacy or destroyed. Additionally, a wound care cart located near the 400 Hall nurses' station was found unlocked and unattended, containing potentially hazardous opened treatment items. These items included a bottle of sodium hypochlorite solution, a jar of Silver Sulfadiazine cream, and a tube of diclofenac sodium gel, all labeled for topical use only. An LPN confirmed the cart was unlocked and acknowledged the potential hazard if the items were consumed by residents. The LPN did not have a key to the cart, which was left open for scheduled wound care treatments. The facility policy required medication carts to be locked when not in use and not left unattended if opened.
Confidentiality Breach of Resident's Health Records
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records by leaving an electronic health record open and accessible on a computer attached to a medication cart. This incident involved a resident who was admitted with diagnoses including major depressive disorder and bipolar disorder. On the morning of January 6, 2025, the computer displayed the resident's name, picture, and current medications with associated diagnoses, while no staff member was present to monitor the cart. A Certified Nursing Assistant confirmed that the Registered Nurse responsible for the cart was attending to another resident on a different hall. The RN admitted to leaving the resident's information visible and unattended. The Director of Nursing acknowledged that the resident's personal information should not have been visible and emphasized the responsibility of staff to protect electronic health records from unauthorized access. The facility's policy on Protected Health Information mandates that such information should be managed and protected to prevent unauthorized disclosure.
Deficiency in Foley Catheter Care Planning
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a Foley catheter, which was identified as a deficiency. The resident, who had been admitted and readmitted with diagnoses including an unstable burst fracture and paraplegia, had an indwelling catheter documented in their Minimum Data Set (MDS) assessments. Despite this, the care plan lacked specific focus areas, goals, or interventions related to the catheter's care, such as monitoring for infection, cleaning the insertion site, and ensuring proper positioning of the drainage bag. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that a care plan for a resident with a Foley catheter should include specific interventions to prevent complications. The DON confirmed that a care plan should have been developed for the resident's catheter care, but it was not done in a timely manner. The facility's policy required the Interdisciplinary Team (IDT) to develop and update comprehensive, person-centered care plans, but this was not adhered to in the case of the resident with the Foley catheter.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update the care plan for a resident identified as high risk for falls, following two documented falls. The resident, who was admitted with diagnoses including metabolic encephalopathy and osteonecrosis of the right femur, experienced falls on two separate occasions. Despite being identified as high risk for falls in evaluations conducted on three different dates, the care plan was not updated with new interventions after the second fall. The care plan initially included reminders for the resident to ask for help with transfers and to follow the facility's fall protocol, but it lacked updates after the second fall to include additional preventive measures. The Director of Nursing (DON) confirmed that the care plan was not revised after the resident's fall on the second occasion, despite the facility's policy requiring such updates. The DON acknowledged that an intervention to place the resident's belongings within reach should have been added to the care plan. The facility's policy on fall prevention and management mandates that individualized precautions be noted for high-risk residents and that care plans be updated with appropriate interventions following a fall to prevent recurrence or minimize injury.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that physician-ordered wound care was performed for a resident, identified as Resident #448, which had the potential to worsen the resident's wound or delay healing. Resident #448 was admitted with diagnoses including metabolic encephalopathy and osteonecrosis of the right femur. On a specific date, it was observed that the dressing on the resident's right elbow was dated the previous day, indicating a lapse in daily wound care. The Treatment Administration Record (TAR) for January lacked documentation of wound care being provided on another specific date, despite an active physician's order for daily treatment. Interviews with facility staff revealed that the LPN assigned to the resident on the date in question was unaware of the wound and did not provide the necessary care. The Director of Nursing confirmed the absence of documentation for the required wound care and acknowledged that the resident should have received treatment according to the physician's order. The facility's policy on Skin and Wound Management emphasized the importance of providing services and treatment to prevent infection and promote healing, which was not adhered to in this instance.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to address a resident's repeated requests for a dental appointment to address broken teeth and pain with chewing food. The resident, who was admitted with diagnoses including type II diabetes mellitus and other specified sepsis, had been asking to see a dentist since May 2024. Despite verbalizing these concerns to nursing staff and social services, the resident did not receive confirmation of any efforts made to schedule a dental appointment or any barriers to receiving dental care. The resident's Minimum Data Set (MDS) notes and care plan documented oral pain and chipped teeth, yet no dental appointment was scheduled. The facility's process for scheduling dental appointments involved notifying social services, who would then send a referral to the Social Work Coordinator (SWC). However, the SWC's request to Transportation Services (TS) was not documented, and TS did not have a record of scheduling a dental appointment for the resident. The Transportation Log showed two entries requesting dental appointments, but one was crossed out as a duplicate, and there was no documentation indicating the resident still needed an appointment. The Director of Nursing acknowledged the importance of dental care for the resident's well-being and the need for documentation if there were delays in scheduling appointments.
Failure to Address Low Temperatures in Shower Rooms
Penalty
Summary
The facility failed to effectively manage its resources by not addressing low ambient temperatures in three communal shower rooms. On January 7, 2025, temperatures were recorded at 62.1°F, 62.4°F, and 67.6°F in the Boundary Peak, [NAME], and [NAME] Peak communal shower rooms, respectively. The Administrator was unaware of these low temperatures and admitted discomfort with the idea of showering in such conditions. The Director of Engineering had been aware of a thermostat issue since December 19, 2024, and had contacted a repair company, believing the problem was resolved. However, the maintenance staff did not communicate the ongoing issue to the Director of Engineering. The job descriptions for both the Administrator and the Director of Engineering outline their responsibilities in maintaining facility operations and ensuring quality care. The Director of Engineering is tasked with managing contracts, overseeing facility maintenance, and ensuring timely completion of work orders. The Administrator's role includes consulting with department managers to address and correct problem areas. Despite these outlined responsibilities, the failure to address the low temperatures in the shower rooms indicates a lapse in communication and oversight between the facility's administration and maintenance departments.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure proper documentation of wound care treatments for four residents, leading to deficiencies in maintaining accurate clinical records. Resident #3, diagnosed with spastic quadriplegic cerebral palsy and a stage 3 pressure ulcer, had multiple instances of undocumented wound care treatments in November and December 2024, and January 2025. The LPN Wound Care Nurse admitted to providing care but forgetting to document it, which was confirmed by the Director of Nursing (DON). Resident #198, with a history of spinal fusion and other lumbar conditions, also had missing documentation for wound care treatments in December 2024 and January 2025. The LPN Wound Care Nurse was responsible for documenting these treatments but failed to do so, leaving no proof that the care was provided on specific dates. Similarly, Resident #448, who had a skin tear on the right elbow, and Resident #133, with a right hip wound, both had missing documentation for wound care treatments in January 2025. The LPN Wound Care Nurse acknowledged providing the care but did not document it. The facility's policies on charting and documentation, as well as wound care, require that all services and treatments be recorded in the resident's medical record. The DON emphasized the expectation for nursing staff to document care as soon as possible and before the end of their shift. However, the lack of documentation for these residents indicates a failure to adhere to these policies, resulting in incomplete clinical records.
Failure to Follow Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed when a Social Services employee entered the room of a resident on contact-based isolation precautions without donning the required personal protective equipment (PPE). The resident, who was admitted with diagnoses including methicillin-resistant staphylococcus aureus (MRSA) and a recurrent urinary tract infection, was in a room clearly marked with a sign indicating the need for contact-based precautions. Despite this, the employee entered the room without wearing PPE, only using alcohol-based hand rub, and later confirmed awareness of the isolation precautions but believed PPE was unnecessary as no direct care was provided. The incident was observed by a Licensed Practical Nurse (LPN) who reiterated the requirement for PPE to the Social Services employee. The Director of Nursing (DON) also confirmed that the employee should have donned PPE to prevent infection spread. The facility's policy on isolation and transmission-based precautions, adopted in 2019, mandates that staff and visitors adhere to proper hand hygiene and wear gloves and disposable gowns when entering rooms under contact precautions. The resident expressed uncertainty about whether all individuals entering the room complied with the PPE requirements.
Failure to Post Current Nursing Staff Information
Penalty
Summary
The facility failed to ensure that current nursing hours were posted daily, as required by their policy. On January 5, 2025, it was observed that the nursing staff posting, located in the hallway near the entrance, was dated January 3, 2025, indicating it was not updated daily. The Director of Nursing (DON) acknowledged that the staffing information was only posted in one location and not on each unit. The Administrator confirmed that the posting was supposed to be updated daily and admitted that the current posting was outdated and not in compliance with the facility's policy, which mandates daily updates of nursing personnel responsible for direct care to residents.
Failure to Protect Resident from Verbal and Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Aide (CNA). The incident involved a resident who was admitted with a primary diagnosis of chronic hepatic failure without coma. The resident reported that the CNA was rude, yelled at them, threw a pillow at them, and shoved a pillow under their back. The resident expressed fear of asking for help due to the treatment received from the CNA. A witness statement from the resident's roommate corroborated the resident's account, observing the CNA yelling and throwing a pillow at the resident. The facility's Director of Nursing/Abuse Coordinator confirmed that the incident was reported to the Nevada State Board of Nursing and substantiated the allegations of abuse. The CNA's job description required treating residents with courtesy, respect, and dignity, which was not adhered to in this case. The facility's policies on recognizing signs of abuse and the abuse prevention program emphasized protecting residents from abuse by staff, which was not effectively implemented in this instance.
Failure to Administer Nutritional Supplement and Conduct Timely Dietary Evaluation
Penalty
Summary
The facility failed to ensure timely evaluation and administration of nutritional supplements for a resident with a stage four pressure ulcer. The resident, who was admitted with severe protein-calorie malnutrition and a stage four pressure ulcer of the sacral region, had a physician's plan that included a dietary evaluation and the administration of Pro-Stat, a concentrated liquid protein drink. However, the resident's clinical record lacked evidence of a dietary evaluation being completed in January or February, and the January Medication Administration Record (MAR) showed no documentation of Pro-Stat being administered. The Director of Nursing (DON) and the Administrator confirmed the absence of a timely dietary evaluation and the lack of Pro-Stat administration, despite a physician's order and confirmation by a registered nurse. The facility's policies required a comprehensive nutrition and hydration assessment for residents with stage two or greater pressure ulcers, which was not completed in this case. The DON explained that Pro-Stat was intended to help residents who might not be getting enough protein or to aid in wound healing, but it was not delivered or administered as required.
Misappropriation of Resident Property by Housekeeper
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a Housekeeper asked the resident for money. The incident involved a resident with chronic obstructive pulmonary disease, major depressive disorder, and anxiety, who was approached by a Housekeeper requesting to borrow money. The resident provided the money, and although the Housekeeper repaid the amount in full, this action was against the facility's policy. The facility's investigation revealed that the Housekeeper had indeed asked the resident for money, which was confirmed by both the resident and the Director of Nursing. The facility's policy clearly states that residents have the right to be free from misappropriation of property, and the Housekeeper's actions violated this policy. The incident was reported as a Facility Reported Incident (FRI), and the facility conducted interviews with 16 other residents, who confirmed they had not been asked for money by staff.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications per a physician's order for two residents. For Resident #2, the LPN administered a Calcium Citrate-Vitamin D tablet with a dosage of 400 mg-12.5 mcg instead of the prescribed 500 mg-10 mcg. This discrepancy was confirmed by the LPN upon reviewing the medication orders. Resident #2 had diagnoses including vitamin D deficiency and mild protein-calorie malnutrition at the time of the incident. For Resident #3, the LPN applied a Lidocaine patch to the resident's right shoulder instead of the prescribed left shoulder. The LPN acknowledged the error and confirmed that the order should have been verified prior to administration. Resident #3 had a diagnosis of unspecified pain. Both the Director of Nursing and the Administrator confirmed that these actions did not follow the physician's orders, as per the facility's policies and the Nevada Nurse Practice Act.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 263 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Reno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alta Skilled Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 19 | 0 |
| Advanced Health Care Of Reno | 2.4 mi | ★★★★★ | 12 | 0 |
| Caremeridian Llc, Dba Neurorestorative | 2.9 mi | ★★★★★ | 28 | 0 |
| Life Care Center Of Reno | 3.8 mi | ★★★★★ | 0 | 0 |
| Rosewood Rehabilitation Center | 4.1 mi | ★★★★★ | 30 | 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 August 2026) and official state health department websites.