Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Northstar Post Acute during CMS and state inspections, most recent first.
Agency staff were assigned to resident care without documented facility orientation or competency-based training. The facility could not provide evidence that agency staff received training in elder abuse, dementia care, QAPI, communication, resident rights, infection control, or compliance and ethics, and the Administrator stated orientation was limited to showing staff around the unit and office areas. The facility also did not retain personnel files for agency staff or verify that the outside agency had completed the required SNF training before staff worked on the floor.
Failure to Offer and Administer Flu and PNA Vaccines: The facility did not ensure vaccination screening or administration was completed for 12 of 12 residents reviewed. Residents with conditions including COPD, asthma, CHF, respiratory failure, immunodeficiency, MS, and Alzheimer’s disease were not offered or did not receive flu vaccine, and several also did not receive PNA vaccine. The IP acknowledged the screening and administration process had not been completed as required, and record review confirmed the missed vaccinations despite facility policy requiring all residents to be offered vaccines and receive education before administration.
Missed Required Physician Face-to-Face Visits: The facility failed to ensure timely physician in-person visits for several residents. Records showed that multiple residents with conditions including depression, anxiety, insomnia, metabolic encephalopathy, acute kidney failure, respiratory failure, Alzheimer's disease, mild cognitive impairment, HTN, polyneuropathy, cirrhosis, CKD, and alcohol-induced dementia lacked required 30-day or 60-day physician visits. The Administrator said physician visits were at the doctor’s discretion, and the DON and DCO said they were unaware of the regulatory requirement and confirmed the visits were not completed.
Controlled Drug Records were not completed in a timely manner for 5 of 11 residents in the B wing controlled substance logbook, leading to inaccurate counts for pregabalin, morphine, oxycodone, lacosamide, clonazepam, and hydrocodone-acetaminophen. An RN stated she waited until the end of the shift to document controlled med administration, and the DON and RN confirmed multiple CDRs showed more tablets or capsules available than were actually on hand. The facility policy on Controlled Substances did not include guidance for documenting controlled med administration.
Medication Administration Errors and Late Doses: The facility had a medication error rate above 5%, with multiple errors identified during med pass observations. An RN removed unwanted Senna Plus from a resident’s med cup with a bare hand before giving the remaining meds, and other residents received scheduled meds late, including one resident whose losartan was unavailable in the med cart. The DON confirmed meds were expected to be given within one hour of the scheduled time and that gloves should be worn when removing medication from a cup.
QAPI committee meetings were not documented for 2 of 4 quarters reviewed. Surveyors found sign-in sheets for meetings in later months, but the Administrator stated there was no evidence of QAPI meetings in the first two quarters. The facility policy required the QAPI committee to meet quarterly and as needed to review reports, evaluate data, and monitor QAPI activities.
Missing Abuse Prevention and Dementia Training Documentation: The facility failed to document timely abuse prevention training and dementia-related training for multiple employees, including an RN, LPNs, a CNA, and a housekeeper. Several staff members had no personnel records showing training on abuse, neglect, exploitation, or how to identify and report abuse, and the Administrator stated the facility did not track start dates or maintain records for agency staff.
A facility failed to obtain or document informed consent before giving psychotropic meds and before using a Wander Guard. One resident received mirtazapine and olanzapine before consent was signed, and the consents listed the wrong dx/symptoms and, for olanzapine, the wrong dose. Another resident received zolpidem without any documented consent. A third resident had a Wander Guard secured to the wheelchair, but the DON and DCO could not find consent in the record at the time of survey.
A resident with panic disorder, MDD, and insomnia reported that a roommate’s TV was kept on at a loud volume throughout the night, creating repeated conflict in the room. The resident said nursing staff, the DON, and the Administrator were aware of the request for a room change, while the DON stated the facility only knew about a prior room issue and that quiet time began at 11 PM. The record also noted prior staff discussions about the loud TV, the resident’s refusal of earphones, and an episode where the resident called 911 while crying and asking for a new room.
Psychotropic Medication Consent and Monitoring Deficiencies: A resident receiving mirtazapine and olanzapine did not have non-pharmacological interventions documented, and the consent forms listed incorrect indications and a lower olanzapine dose than what was initially administered. Two other residents receiving zolpidem and clonazepam also lacked documented behavior monitoring and side effect monitoring in their records, and the DON confirmed the missing documentation and mismatched indication details.
A resident with anxiety disorder and schizophrenia did not have non-pharmacological interventions care planned or ordered to address behavioral symptoms tied to psychotropic use, and the DON stated such interventions were not necessary. Another resident with dementia and COPD was documented as able to smoke independently, but the smoking evaluation had an incomplete IDT sign-off, and cigarettes and a disposable lighter were found in the resident's room.
A resident with anxiety had a Clonazepam care plan marked resolved even though the PRN psychotropic order was reinitiated and doses were later administered, and a second resident with dementia had a Wander Guard in use without a current care plan focus, goal, or interventions. The DON confirmed the medication care plan was not reinitiated after the new order and that the Wander Guard should have remained on the care plan while it was still being used.
A resident with dementia and COPD was found with cigarettes and a disposable lighter in the room, while the smoking evaluation lacked full IDT sign-off and the DON and Administrator stated only one team member needed to sign off. The facility’s smoking policy required a fully completed safe smoking evaluation and only allowed safety lighters. In a separate event, a resident with dementia and a history of wandering eloped from the facility despite an ankle sensor intervention, and the elopement evaluation and care plan documentation were incomplete.
A resident with dementia had a Wander Guard order and the device remained attached to the wheelchair even though quarterly elopement and wandering assessments documented that a wander alarm was not indicated. The care plan lacked current goals and interventions related to the device, and staff interviews showed uncertainty about whether the resident had wandering or exit-seeking behaviors. The DON and DCO confirmed the device was still in use despite the assessment findings.
An unsecured medication cart was observed left unlocked and out of an RN’s sight, and the DON confirmed it should not be left unattended unlocked. Nine insulin pens for three residents with diabetes were stored together in the same cubby of a med cart without a barrier to prevent cross-contamination. Medication room and refrigerator temperature logs also had multiple missing entries, and the DON confirmed each shift was responsible for documenting those temperatures.
QAPI failed to maintain an ongoing, facility-wide, data-driven program and did not identify widespread concerns with the vaccine program, employee training, and background checks. The Administrator stated the IP and HR were part of QAPI, but the committee was unaware of the vaccine issue until it was raised by a State surveyor, and HR was not involved in training requirements because the facility had no SDC.
Infection Control Lapse During Medication Administration: An RN administered meds to a resident with diagnoses including cellulitis and constipation, then reached into the resident’s medication cup with a bare hand to remove unwanted Senna Plus tablets before giving the remaining meds. The RN confirmed the action and could not explain the correct process, and the DON stated gloves were expected before removing medication from a cup because of infection control and cross-contamination concerns.
Failure to Screen and Document Covid Vaccination Status: The facility failed to screen residents and staff for the Covid vaccine and failed to document vaccine education and status for 4 of 5 residents reviewed. Records for residents with diagnoses including acute respiratory failure, CHF, asthma, and chronic respiratory failure lacked documentation of screening and education for the 2025/2026 Covid vaccine. The IP stated screening had not been completed as required and that residents and staff had not been screened and offered the vaccine within the last year.
Inadequate Training Program for Agency Staff: The facility failed to provide an effective training program for agency staff before they were assigned to resident units. The Administrator stated the facility relied on an outside agency for staffing, did not retain personnel records for agency staff, and did not have an orientation program beyond basic unit directions. Survey review found no evidence of comprehensive training for elder abuse, dementia care, QAPI, communication, resident rights, infection control, or compliance and ethics.
An RN's personnel record lacked documentation showing required effective communication with residents and family training was completed upon hire and before working with residents. The Administrator confirmed the training was required for all employees and that orientation should occur before staff work on the floor, but the record for this RN did not show completion of the required initial training.
A facility failed to ensure an RN completed initial resident rights and responsibilities training upon hire. The RN's personnel record lacked documentation of the required orientation training, and the Administrator confirmed the training was expected before staff worked on the floor with residents. The facility policy stated all staff must participate in initial orientation and annual in-service training, including resident rights and responsibilities.
An RN’s personnel record lacked documentation showing initial QAPI training was completed upon hire or before working with residents. The Administrator confirmed QAPI training was required for all employees and that orientation was to be completed before staff worked on the floor, but the record for this RN did not show that training had been completed. The facility policy stated all staff must participate in initial orientation and may receive training on the facility QAPI program.
Missed Infection Control Training for Staff: The facility failed to ensure initial and annual infection control training was completed timely for 3 of 19 sampled employees. A RD and a Food Services Supervisor had documentation of infection control training in late 2024 but no evidence of annual training for 2025, and an RN had no documented evidence of infection control training upon hire or before working with residents. The Administrator confirmed infection control training was required for all employees and that staff were expected to complete orientation before working on the floor.
The facility failed to ensure required compliance and ethics training was completed for 3 of 19 sampled employees. A DON and an LPN had documentation of prior training but no annual training on file for the following year, and an RN had no documented evidence of training upon hire. The Administrator confirmed training was required for all employees and that orientation should occur before working with residents, while the facility policy required initial orientation and annual in-service training.
Behavioral health training related to dementia was not completed timely for 4 of 20 sampled employees. The facility lacked personnel records showing required dementia training for an RN and an LPN who worked with residents, and a Dietary Aide and Housekeeper completed the training late. The Administrator confirmed all staff were required to complete initial dementia-related training before providing care and annually thereafter.
Failure to Reconcile and Administer Admission Medications: A resident with dementia and prior CVA returned from the hospital with discharge orders to continue multiple meds, including clopidogrel and several psychotropics, but the MAR showed no meds were administered for the first two days after readmission. The record lacked evidence that nursing completed the admission med reconciliation, contacted the physician for orders, or documented the required assessment. The DON and DCO confirmed the expected admission process was not followed and that the resident did not receive the ordered meds until later after APRN/pharmacy involvement.
The facility employed an RN whose NV SBON report showed an active, restricted license with discipline based on patient abuse. The RN remained on the employee list and work schedules, while the Administrator, DON, and DCO acknowledged awareness of the abuse-related discipline for several months. The facility policy stated it would not knowingly employ anyone with a disciplinary action in effect against a professional license for abuse-related findings.
A resident with dementia and a history of CVA returned from the hospital with multiple medications ordered to continue, including psychotropics and Clopidogrel. The MAR lacked evidence that medication reconciliation was completed or that any meds were administered for two days after readmission, and staff confirmed the admission assessment, physician notification, and order verification process were not completed. The DON and DCO stated this would be neglect, but the Administrator said the concern was not reported to the SA and was not investigated as possible neglect because the issue was not viewed that way.
A resident with dementia and a history of wandering eloped from the facility and was later found and sent to the ER for evaluation. The IDT reviewed the incident and determined the resident needed a locked unit due to daily wandering and exiting behaviors, but the facility lacked documentation that a thorough investigation was completed and retained for the event.
The facility failed to maintain staffing hour records for the required 18-month period. During survey record review, staff could provide only the last 30 days of records, and the Administrator and DCO stated the facility did not have the full 18 months and were unaware of the regulatory requirement.
The facility failed to offer a bowel and bladder retraining program for residents assessed as candidates for retraining. Despite having a policy stating that incontinent residents would receive appropriate treatment, the facility did not implement a program until late December 2024. The program lacked a policy, did not assess incontinence types, and did not document voiding patterns, resulting in residents being placed in briefs and only assessed for incontinence on a two-hour check and change schedule.
Expired medications, including Lidocaine patches and IV solution bags, were found in a medication cart and storage room. The ADON confirmed the expiration dates, and the DON stated that expired drugs should be destroyed according to facility policy.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. One resident did not receive Diclofenac Sodium gel due to unavailability, and another received Morphine Sulfate at a concentration not matching the eMAR. The LPN did not seek physician clarification for the discrepancy. The DON emphasized the need for staff to review eMARs and address discrepancies, as per facility policy.
A facility failed to protect resident information and update hospice medication orders in a timely manner. An unattended computer screen displayed resident data, and hospice orders for a resident with prostate cancer were not entered into the EMR. The DON confirmed the expectation for screens to be locked and orders to be updated promptly.
An RN failed to perform hand hygiene during a medication pass, affecting two residents and increasing infection risk. The RN did not wash hands before or after administering medications, adjusting a nasal cannula, or touching residents. The DON confirmed the necessity of hand hygiene as per facility policies.
The facility failed to ensure timely completion of abuse training for three staff members, including a DON, an LPN, and an RN. The training was completed late, contrary to the facility's policy requiring timely training during orientation and annually. This delay had the potential to place residents at risk for abuse and neglect.
The facility did not post current nursing staff information, as required. The posting, dated three days prior, was not updated by the weekend nurse, and the Administrator, who typically updates it in the mornings, had not arrived when surveyors entered the building. This resulted in outdated information being displayed.
A resident did not receive physician-ordered medications on time during the morning medication pass on two consecutive days. The medications were administered late on one day and not at all on the next. An LPN reported being shorthanded, which affected timely medication administration. The DON confirmed the omission and lack of documentation explaining the missed medications, contrary to facility policy.
A resident admitted for orthopedic aftercare following a surgical amputation did not receive the prescribed hydrocodone for severe pain. Instead, the resident was given acetaminophen, which was not effective for the level of pain experienced. The facility's failure to administer the appropriate medication resulted in the resident experiencing severe pain.
The facility failed to develop and implement comprehensive care plans for several residents, including the placement of beds against the wall, the use of bed rails, the administration and monitoring of medications, and the care of urinary catheters and lymphedema. These deficiencies were confirmed by the DON and identified through observations, interviews, and record reviews.
The facility failed to have a policy or process to assess for restraint and risk of entrapment before placing residents' beds against the wall. The DON confirmed that a bed against a wall could be considered a restraint if it restricted movement, and admitted there was no formal process to ensure residents were not restrained upon admission.
The facility failed to ensure communication training was completed by staff for 20 sampled employees, including the Administrator, DON, CNAs, RNs, LPNs, and other staff. Personnel records lacked evidence of the required training, and the Facility Assessment did not document staff completion or a plan for communication training.
The facility failed to ensure the privacy of residents' PHI by leaving computer screens unattended and displaying sensitive information. An LPN and the DON confirmed that the screens should have been locked, and the facility's policies on HIPAA and confidentiality were not followed.
The facility failed to ensure that QAPI training was completed for 11 out of 20 sampled employees, including the Administrator, Registered Dietician, CNAs, Wound Care Nurse, Infection Preventionist, RN, LPNs, Cook, and Housekeeper. The personnel records lacked documented evidence of the required training, as confirmed by the Business Office Manager.
The facility failed to obtain informed consent for the administration of psychoactive medication and for placing resident beds against the wall. A resident was given mirtazapine without consent, and 37 residents had their beds placed against the wall without being informed of the risks or providing consent. The facility's policies on informed consent and restraint use were not followed.
A resident with multiple health issues was unable to reach their call light, which was found draped behind a nightstand. The Executive Director confirmed the call light was not within reach and acknowledged it should always be accessible.
A resident with hemiplegia and hemiparesis requested a room change for more privacy due to cramped conditions and encroaching personal items from roommates. Despite repeated requests and a bed becoming available, the facility failed to move the resident due to poor communication and documentation among staff.
The facility failed to ensure written acknowledgement of the Advance Directive notice was provided to the resident or the resident's representative for three sampled residents. The Executive Director confirmed that the clinical records of these residents did not include signed Advanced Directive Acknowledgements, despite the facility's policy requiring it within 48 hours of admission.
The facility failed to provide a resident with a Notice of Medicare Non-Coverage (NOMNC) prior to discharge. The resident, admitted with acute respiratory failure with hypoxia, did not receive the required notice, as confirmed by the Assistant Social Worker and the Director of Nursing.
The facility failed to provide written notification of transfer or discharge to a resident and their representative. The resident, who had multiple diagnoses including hemiplegia and type II diabetes mellitus, was transferred to an acute care hospital due to abnormal vital signs. The required Notice of Transfer or Discharge form was not completed, and the Director of Nursing confirmed this oversight.
Agency Staff Lacked Required Orientation and Competency Training
Penalty
Summary
The facility failed to effectively and efficiently manage operations to ensure agency staff received training and orientation on facility policies, procedures, and resident care expectations before being assigned to provide care. During record review on 01/28/2026 and 02/02/2026, the State surveyor requested documentation showing training provided to agency staff prior to assignment on the units, but the facility could not provide evidence of comprehensive orientation or competency-based training for agency staff. The missing documentation included elder abuse training, dementia care training, QAPI training, communication training, resident rights, infection control training, and compliance and ethics training. The Administrator stated the facility used an outside agency for uncovered shifts and relied on the agency to provide staff with required training for their certifications, but could not confirm whether agency staff completed the training required for skilled nursing facility work. The Administrator also stated the facility did not keep personnel files for agency staff and that orientation consisted only of showing agency staff the unit layout and administrative office. The Administrator confirmed the facility did not have an orientation training program for agency staff, and that agency staff did not go directly through the facility to complete the required training before working on the floor with residents.
Failure to Offer and Administer Flu and Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure residents were offered and administered influenza and pneumococcal vaccinations in accordance with its policy for 12 of 12 residents reviewed for vaccination compliance. Record review and document review showed that residents including those with diagnoses such as COPD, asthma, heart failure, chronic respiratory failure, immunodeficiency, multiple sclerosis, Alzheimer’s disease, and acute respiratory failure were not offered or did not receive the flu vaccine, and several residents were also not offered or did not receive the pneumococcal vaccine. On 01/29/2026, the Infection Preventionist stated that screening for flu and PNA vaccines had not been completed as required and acknowledged awareness of the issue, describing the lack of vaccination screening and administration as a widespread concern. Review of the clinical records with the Director of Clinical Operations and the Infection Preventionist confirmed that the identified residents were not offered or administered the flu vaccine, and in some cases were not offered or administered the PNA vaccine. The facility policy titled Vaccination of Residents stated that all residents would be offered vaccines to help prevent infectious diseases and that education regarding benefits and potential side effects would be documented in the medical record.
Missed Required Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure physician face-to-face visits were completed on time for 5 of 15 sampled residents. Resident #37, admitted and later readmitted with diagnoses including depression, unspecified anxiety disorder, and insomnia, had no documented evidence of a physician 30-day in-person visit since admission. Resident #24, admitted and readmitted with diagnoses including metabolic encephalopathy, acute kidney failure, and acute respiratory failure, also lacked documented evidence of a physician 30-day in-person visit since admission. Resident #53, admitted and readmitted with diagnoses including Alzheimer's disease with late onset and a personal history of transient ischemic attack and cerebral infarction without residual deficits, likewise had no documented evidence of a physician 30-day in-person visit since admission. Resident #11, admitted and readmitted with diagnoses including mild cognitive impairment, essential hypertension, and polyneuropathy, had physician visits documented on 06/19/2025 and 12/25/2025, but the record lacked evidence of a physician 60-day in-person visit between July 2025 and November 2025. Resident #5, admitted and readmitted with diagnoses including alcoholic cirrhosis of the liver, chronic kidney disease, and alcohol dependence with alcohol-induced dementia, had no documented evidence of a physician 30-day in-person visit since admission. The Administrator stated the physician saw residents at their discretion and there was nothing specific on how often they had to be seen, while the DON and DCO said they were unaware of the regulation requirement for physician visits and confirmed the in-person visits were not completed for these residents.
Controlled substance records were not updated accurately for multiple residents
Penalty
Summary
Controlled Drug Records were not completed in a timely manner for 5 of 11 residents listed in the B wing controlled substance logbook, resulting in inaccurate reconciliation of controlled medications. Resident #51, admitted with Parkinson's disease without dyskinesia, had a physician order for pregabalin 50 mg three times daily for nerve pain, but the CDR showed four capsules remaining when only three were available; an RN stated the pregabalin had been given at 8:59 AM and had not yet been entered into the CDR because it was the nurse's routine to wait until the end of the shift to complete the record. Resident #4, admitted with diagnoses including osteoarthritis, spinal stenosis, and chronic pain, had a morphine sulfate 15 mg ER order for 30 mg every 12 hours, and the CDR documented 23 tablets when 21 were actually available. The DON confirmed the discrepancy between the documented and actual morphine count. Resident #52, admitted with pain related to orthopedic prosthetic devices and chronic pain, had an oxycodone HCL 5 mg PRN order, and the CDR documented one tablet when zero tablets were available. Resident #37, admitted and readmitted with seizure-related diagnoses and anxiety, had CDR discrepancies for both lacosamide 50 mg twice daily and clonazepam 0.25 mg PRN, with each record showing one more tablet than was actually available. Resident #10, admitted with acute on chronic systolic heart failure and a ventral hernia, had a hydrocodone-acetaminophen 5-325 mg PRN order, and the CDR documented four tablets when only three were available. The RN confirmed that 5 of the 11 residents in the B wing controlled substance logbook had CDRs that did not correctly document the amount of medication available for administration. A facility policy titled Controlled Substances, dated 2001, did not include guidance for documenting the administration of controlled substances.
Medication Administration Errors and Late Doses
Penalty
Summary
The facility failed to ensure medications were administered with an error rate of less than 5 percent. Surveyors identified 33 medication administration opportunities and 14 medication errors, resulting in a 42.42% medication error rate. The report states this deficient practice had the potential to cause residents to receive incorrect dosages, miss necessary medications, or experience adverse health outcomes, including ineffective treatment and harm. For Resident #69, who was admitted with cellulitis of the left lower limb and drug-induced constipation, a physician ordered Senna Plus 8.6-50 mg, two tablets by mouth twice daily for bowel management. During the morning medication pass, the resident stated they did not want to take the Senna Plus tablets. The RN reached into the medication cup with a bare hand, removed the unwanted Senna Plus tablets, and then administered the remaining medication. The RN later confirmed using an ungloved hand to retrieve the medication and was unable to explain the correct process. For Resident #2, who had diagnoses including acute and chronic respiratory failure with hypoxia and bilateral lower-limb swelling, the RN administered morphine sulfate concentrate via g-tube, Refresh Tears eye drops, and senna-docusate sodium later than the scheduled 8:00 AM time. The RN confirmed the medications were given late. For Resident #35, who had diagnoses including chronic systolic heart failure, major depressive disorder, generalized anxiety disorder, aphasia following cerebral infarction, and hypertensive heart and chronic kidney disease, losartan was not available in the medication cart during the morning pass, and the resident’s medications were administered late. The RN confirmed the medications were scheduled for 8:00 AM and were administered after 9:00 AM.
QAPI Committee Did Not Meet Quarterly as Required
Penalty
Summary
The facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met quarterly, at a minimum, for 2 of 4 quarters reviewed. Survey review found QAPI meeting sign-in sheets for meetings held in August, October, November, and December of 2025, but on 02/02/2026 at 4:49 PM the Administrator stated the facility did not have sign-in sheets or evidence of QAPI meetings conducted in the first two quarters of 2025. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated 2001, stated the committee would meet quarterly and as needed to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan.
Missing Abuse Prevention and Dementia Training Documentation
Penalty
Summary
The facility failed to ensure elder abuse prevention training was completed timely and that staff had documented training related to dementia care, abuse, neglect, exploitation, and reporting requirements for multiple employees. Personnel record review showed Employee #11, an RN, and Employee #12, an LPN, lacked documented evidence of completed behavioral health care training for dementia. Employee #14, an LPN hired on 09/30/2025, completed elder abuse prevention training on 10/06/2025, seven days late. Employee #16, a CNA hired on 08/01/2025, completed the training on 08/08/2025, seven days late. Employee #20, a housekeeper hired on 09/24/2025, completed the training on 12/30/2025, 97 days late. The Administrator stated on 01/28/2026 that the facility required all staff to complete initial abuse prevention training prior to providing care to residents and annually thereafter, but the facility did not keep track of employee start dates. The Administrator also stated Employees #11 and #12 were agency staff and the facility did not maintain personnel records for agency staff. For Employees #26, #27, #28, and #29, all of whom were sampled for investigation of complaints, the facility lacked personnel records showing training related to abuse identification and reporting. On 01/29/2026, the Administrator confirmed the facility did not have personnel files and/or documented evidence that these employees had received training related to the identification and reporting of abuse and neglect.
Missing and inaccurate consent for psychotropic medications and Wander Guard use
Penalty
Summary
The facility failed to ensure that psychotropic medication consents were obtained before administration and that the consents accurately reflected the medication, dose, and diagnosis or symptom being treated for Resident #9. Resident #9 was admitted with diagnoses including anxiety disorder and schizophrenia. The resident received mirtazapine 7.5 mg at bedtime starting on 11/21/2025, and olanzapine 10 mg at bedtime starting on 11/21/2025, with olanzapine later changed to 5 mg on 11/24/2025. The informed consent for mirtazapine listed major depressive disorder and insomnia, and the consent was signed by the resident’s representative on 11/22/2025 after the first dose had already been given. The olanzapine consent also listed 5 mg, major depressive disorder, and insomnia, and was signed on 11/22/2025 after the resident had already received 10 mg doses. The facility also failed to have documented informed consent for zolpidem for Resident #4 before the medication was started. Resident #4 was admitted and readmitted with a diagnosis of insomnia, and the physician ordered zolpidem tartrate 5 mg at bedtime for difficulty sleeping. The January 2026 MAR showed the medication was first administered on 01/15/2026, but the resident’s clinical record lacked evidence that informed consent had been completed for zolpidem. The DON confirmed that consent was required for hypnotic medications and that no consent was present for this resident. The facility further failed to obtain documented consent before implementing a Wander Guard for Resident #5. Resident #5 had diagnoses including alcohol dependence with alcohol-induced persisting dementia and alcoholic cirrhosis of the liver without ascites. A physician’s order dated 09/12/2024 directed Wander Guard placement on the left side back of the arm of the wheelchair, and the resident was observed with a small white plastic device secured to the left arm of the wheelchair. The care plan lacked a current focus, goal, and interventions related to the device. During interview, the DON and DCO could not locate documented evidence of informed consent for the Wander Guard, and the DON later contacted the resident’s representative and obtained consent after the interview.
Excessive Room Noise and Roommate Conflict
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when Resident #10 reported excessive noise from a roommate’s television in the resident’s room. Resident #10 was admitted and later readmitted with diagnoses including panic disorder, major depressive disorder, recurrent, moderate, and insomnia, unspecified. On 01/27/2026 at 9:26 AM, the resident stated a room change was needed because the roommate’s TV stayed on throughout the night, and the TV was observed on at a loud volume audible throughout the room. The resident also reported having informed the DON and Administrator about wanting to move rooms. Later that day, Resident #10 stated that nursing staff were aware of verbal fights related to the loud television and said, “I yelled for the nurse and the head nurse and said I am done.” The DON stated at 3:15 PM that there was no awareness the resident was unhappy with the room and said the only known issue was a prior room situation; the DON also stated quiet time began at 11:00 PM and residents were expected to lower television volume. The resident record included a behavior note from 12/17/2025 documenting staff discussion of a room change, the resident’s desire to return to a previous room because of the roommate’s loud television, refusal of offered earphones, and a later note that the resident contacted 911 due to difficulty breathing and was crying, expressing a desire for a new room.
Psychotropic Medication Consent and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications had non-pharmacological interventions in place to manage behaviors. Resident #9 was admitted with diagnoses including anxiety disorder and schizophrenia and received mirtazapine and olanzapine. The informed consent for mirtazapine listed major depressive disorder as the indication and insomnia as the target behavior, and consent was obtained after the first dose had already been given. The informed consent for olanzapine listed a 5 mg dose and the indication of major depressive disorder with insomnia as the target behavior, but the resident had already received 10 mg before the representative consented to the lower dose. The DON stated that psychotropic consent should include the correct medication, dosage, and rationale, and confirmed that the resident received olanzapine 10 mg when consent had been obtained for 5 mg. The DON also stated that non-pharmacological interventions would not be necessary to manage the resident's behaviors. The DCO confirmed the diagnoses in the clinical record did not include major depressive disorder or insomnia, and the consent did not document the diagnoses the medication was ordered to treat. The DCO also confirmed the resident did not have non-pharmacological interventions care planned or ordered to manage behaviors documented on the psychotropic consents. The facility also failed to ensure adequate monitoring for behaviors and side effects and appropriate indication for psychotropic use for two residents. Resident #4, admitted and readmitted with insomnia, had an order for zolpidem tartrate 5 mg at bedtime for difficulty sleeping, but the clinical record lacked documented behavior monitoring before and after initiation and lacked side effect monitoring. Resident #37, admitted and readmitted with depression, anxiety disorder, and insomnia, had an order for clonazepam 0.25 mg every eight hours as needed for other specified anxiety disorders, but the clinical record also lacked documented behavior monitoring before and after initiation and lacked side effect monitoring. The DON confirmed that psychotropic medications required monitoring for behaviors and side effects and that the records for Resident #4 and Resident #37 did not contain that documentation.
Failure to Care Plan Behaviors and Smoking Safety
Penalty
Summary
The facility failed to ensure that Resident #9's behaviors were care planned with non-pharmacological interventions and that the resident care plan was implemented to address the resident's behavioral symptoms. Resident #9 was admitted with diagnoses including anxiety disorder and schizophrenia. The record showed orders for mirtazapine and olanzapine, and the informed consents listed indications and target behaviors related to major depressive disorder and insomnia. On 01/28/2026, the DON stated non-pharmacological interventions would not be necessary to manage the resident's behaviors, and the DCO confirmed the resident did not have nonpharmacological interventions care planned or ordered to manage behaviors documented on the psychotropic consents. The facility also failed to ensure Resident #7 was able to smoke independently and safely. Resident #7 was admitted with diagnoses including Alzheimer's disease, dementia with psychotic disturbance, and COPD. On 01/27/2026, observation of the resident's living area revealed a bedside table containing one and a half cigarettes and a disposable lighter, and the resident stated they were a former smoker. The care plan dated 11/21/2025 indicated the resident was able to smoke independently as determined by the IDT, but the smoking evaluation completed on 12/03/2025 had the IDT sign-off section left blank. During interview, the DON and Administrator stated the safety lighter required residents to demonstrate ability to use it during the smoking evaluation and that the IDT could consist of only one team member signing off on a resident's ability to smoke.
Care Plan Not Updated for Psychotropic Medication and Wander Guard Use
Penalty
Summary
The facility failed to revise and reinitiate the comprehensive care plan for a resident with depression, unspecified, other specified anxiety disorder, and insomnia after the resident’s Clonazepam care plan was marked resolved. The resident’s record showed a care plan for Clonazepam that included behavior monitoring, side effect monitoring, and non-pharmacological interventions, but it was resolved on 01/23/2026 and was not updated or reinitiated when the medication was continued. The physician’s order for Clonazepam 0.25 mg by mouth every eight hours as needed was reinitiated on 01/23/2026, and the MAR documented administrations on 01/24/2026 and 01/27/2026. The DON stated the care plan had been resolved when the medication was reviewed and was not reinitiated when the new order was entered. The facility also failed to maintain a current care plan for a resident with alcohol dependence with alcohol-induced persisting dementia and alcoholic cirrhosis of the liver who had a Wander Guard in use. A physician’s order directed Wander Guard placement checks every shift on the left side back of the arm of the wheelchair, and the resident was observed with a small white plastic device secured to the left arm of the wheelchair. However, the resident’s care plan lacked a current focus, goal, and interventions related to the Wander Guard, and the care plan report showed the wandering/elopement risk and Wander Guard intervention had been resolved on 12/05/2025. The DON confirmed the Wander Guard was currently being used and stated it should have remained on the care plan because the device was still in use.
Incomplete smoking evaluation and elopement supervision failure
Penalty
Summary
The facility failed to fully complete the smoking evaluation by the interdisciplinary team and failed to maintain safe smoking practices for a resident with Alzheimer’s disease, dementia, and COPD. Resident #7 was observed with one and a half cigarettes and a disposable lighter in the bedside table, and the resident stated they were a former smoker. During interview, the DON and Administrator stated the safety lighter was a device that was difficult to ignite and required the resident to demonstrate use during the smoking evaluation, and they stated the IDT could consist of only one team member signing off on the resident’s ability to smoke. However, the smoking evaluation completed on 12/03/2025 had the IDT sign-off section left blank, and the facility’s smoking policy required the safe smoking evaluation to be fully completed and allowed only disposable safety lighters. The facility also failed to provide supervision necessary to prevent the elopement of Resident #71, who had a diagnosis of unspecified dementia and a history of wandering. The resident had a care plan for elopement risk with a sensor device placed on the right ankle to alert staff to exit attempts, but the intervention did not include time frames or frequency for monitoring the device. Records also showed an elopement evaluation in which the section identifying risk for wandering/elopement, goals, interventions, and clinical suggestions was left blank. An IDT post-incident review documented that on the morning of 10/27/2024 the resident was noted missing from the facility and was later found and taken to the ER for evaluation.
Wander Guard Remained in Use Despite Assessments Showing It Was Not Indicated
Penalty
Summary
The facility failed to ensure interventions for a resident with dementia were revised based on assessment of the resident’s condition. Resident #5 was admitted and readmitted with diagnoses including alcohol dependence with alcohol-induced persisting dementia and alcoholic cirrhosis of the liver without ascites. The resident had a physician’s order for a Wander Guard device to be checked every shift, and the device was observed secured to the left arm of the resident’s wheelchair. However, quarterly elopement and wandering risk assessments documented scores of 6 and 8 and stated that a wander alarm was not indicated for the resident. Resident #5’s care plan did not contain a current focus, goal, or interventions related to the Wander Guard. Staff interviews showed CNA1 denied the resident had wandering or exit-seeking behaviors, while CNA2 identified the device as a Wander Guard but was unsure whether the resident had wandering or exit-seeking behavior. The DON and DCO confirmed the resident was still using a Wander Guard even though the quarterly assessments documented that a wander alarm was not indicated. A later progress note documented an IDT reassessment determined the Wander Guard was no longer necessary because the resident had not displayed exit-seeking behavior recently and the resident and spouse agreed to remove it.
Unsecured Medication Cart, Improper Insulin Pen Storage, and Incomplete Temperature Logs
Penalty
Summary
A medication cart containing resident medications was observed unsecured in the B wing hall entrance and later again left unlocked and out of the RN’s direct line of sight near the nursing station. The RN confirmed the cart was unsecured and stated it needed to be locked to prevent access to medications not belonging to residents. The DON stated the expectation was that if a nurse walked away from the medication cart, it needed to be locked and not left unattended. The facility’s policy on Storage of Medications, revised 11/2020, stated drugs and biologicals were to be stored in locked compartments and only authorized staff had access to locked medications. Nine insulin pens for three residents with diabetes were found stored together in the same cubby/section of the 300 Hall medication cart without plastic bags or any other barrier to prevent cross-contamination. The residents involved were admitted with diagnoses including type II diabetes mellitus, diabetic neuropathy, diabetic foot ulcer, and diabetic polyneuropathy. The DON confirmed the pens were stored together and not separated. In addition, the A Wing temperature control logs showed missing documentation for medication room and medication refrigerator temperatures across multiple shifts in December 2025 and January 2026, and the DON confirmed each shift was responsible for checking and documenting those temperatures. The facility policy lacked guidance related to refrigeration of medications, safe temperatures for the medication room, monitoring of temperatures, and corrective actions for out-of-range temperatures.
QAPI Program Failed to Identify Facility-Wide Concerns
Penalty
Summary
The facility failed to ensure the QAPI committee maintained an ongoing, facility-wide, data-driven QAPI program and did not identify widespread concerns with the vaccination program and employee training and background checks. The Administrator stated the Infection Preventionist was a member of the QAPI committee and would discuss infection prevention concerns during QAPI meetings and as needed, but the committee was unaware of an issue with the vaccine program until it was brought to the facility’s attention by a State surveyor on 01/29/2026. The Administrator also stated HR was part of the QAPI committee and would discuss HR concerns during QAPI meetings, but HR was not involved in employee training requirements, which were the responsibility of the Staff Development Coordinator; the Administrator further stated the facility did not have an SDC. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated 2001, stated the facility would develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program focused on indicators of outcomes of care and quality of life for residents.
Infection Control Lapse During Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when a Registered Nurse administered medications to Resident #69 using a bare, ungloved hand to reach into the resident’s medication cup and remove Senna Plus tablets after the resident said the medication was unwanted. Resident #69 was admitted with diagnoses including cellulitis of the left lower limb and drug induced constipation, and had a physician’s order for sennosides-docusate sodium 8.60-50 mg, two tablets by mouth two times per day for bowel management. During medication administration on 01/29/2026 at 8:13 AM, the RN reached into the medication cup containing the resident’s morning medications with an ungloved hand, retrieved the Senna Plus tablets, and then administered the remaining medication to the resident. At 8:24 AM, the RN confirmed the action and was unable to explain how to correctly remove the medication from the cup or why the action was incorrect. On 02/02/2026 at 9:57 AM, the DON stated gloves were expected before removing a medication from an administration cup containing additional medication and confirmed nurses were not to remove medications from a medication cup with bare hands because of infection control concerns related to cross contamination. The facility policy titled Administering Medications, revised April 2019, stated staff followed established infection control procedures such as handwashing and wearing gloves for medication administration.
Failure to Screen and Document Covid Vaccination Status
Penalty
Summary
The facility failed to ensure residents and staff were screened to receive the Coronavirus (Covid) vaccine for 4 of 5 residents reviewed for Covid vaccination compliance. The residents identified in the record review were Resident #24, Resident #3, Resident #8, and Resident #10. Their clinical records lacked documentation of screening and education on the 2025/2026 Covid vaccine. Resident #24 was admitted and later readmitted with diagnoses including acute respiratory failure with hypoxia and acute respiratory failure with hypercapnia. Resident #3 was admitted and later readmitted with diagnoses including chronic systolic congestive heart failure and dependence on supplemental oxygen. Resident #8 was admitted with diagnoses including unspecified asthma, uncomplicated, and heart failure, unspecified. Resident #10 was admitted and later readmitted with diagnoses including acute on chronic systolic congestive heart failure and chronic respiratory failure with hypoxia. On 01/29/2026 at 10:00 AM, the Infection Preventionist stated that screening for Covid had not been completed as required and was aware of the issue. The Infection Preventionist also stated the lack of vaccination screening was a widespread concern, and that residents and staff had not been screened and offered the Covid vaccine within the last year. The facility policy stated staff and residents would be encouraged to remain up to date with all Covid vaccines and that resources and counseling about the importance of receiving the vaccine would be provided.
Inadequate Training Program for Agency Staff
Penalty
Summary
The facility failed to provide an effective training program for agency staff to ensure they were knowledgeable about facility policies and resident care procedures. During personnel record review on 01/28/2026 and 02/02/2026, the surveyor requested documentation showing training provided to agency staff before they were assigned to units, but the facility could not provide evidence of comprehensive orientation or competency-based training for elder abuse, dementia care, QAPI, communication, resident rights, infection control, or compliance and ethics. The Administrator stated the facility used an outside agency to supply staff for uncovered shifts and relied on the contract to indicate that staff would have the training required for their certifications, but could not confirm that agency staff had completed the training required for work in a skilled nursing facility. The Administrator also stated the facility did not retain personnel records for agency staff, including behavioral health training related to dementia and abuse prevention training, and confirmed the facility did not have an orientation training program for agency staff beyond basic unit directions. The Facility Assessment Tool dated 08/01/2025 documented that the facility used the assessment to determine the resources needed to care for residents competently during day-to-day operations and emergencies.
Missing Required Communication Training Documentation for RN
Penalty
Summary
The facility failed to ensure initial effective communication with residents and family training was completed timely per facility policy for 1 of 19 sampled employees, Employee #11. Employee #11 was hired as a Registered Nurse on an unknown date, and the personnel record lacked documented evidence that effective communication with residents and family training was completed upon hire. During interview on 02/02/2026, the Administrator confirmed that effective communication with residents and family training was required for all employees and stated that orientation training was completed upon hire before staff worked on the floor. The Administrator also confirmed that agency staff did not go directly through the facility for orientation training and later verified that Employee #11's personnel record did not contain documentation showing the required training was completed upon hire and before working with residents. The facility policy titled, In-Service Training, All Staff, stated that all staff must participate in initial orientation and annual in-service training, and that training topics could include effective communication with residents and family.
Missing Initial Resident Rights Training for RN
Penalty
Summary
The facility failed to ensure that initial resident rights and responsibilities training was completed timely for 1 of 19 sampled employees, Employee #11, a Registered Nurse. Employee #11's personnel record lacked documented evidence that resident rights training was completed upon hire. During interview, the Administrator stated that resident rights and responsibilities training was required for all employees and that orientation training was to be completed before working on the floor. The Administrator also stated that agency staff do not go directly through the facility for orientation training. On further review, the Administrator confirmed that Employee #11's personnel record did not contain documented evidence of resident rights and responsibilities training completed upon hire and before working with residents. The facility policy titled, In-Service Training, All Staff, stated that all staff must participate in initial orientation and annual in-service training, and that training topics could include resident rights and responsibilities.
Missing Initial QAPI Training Documentation for an RN
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not completed timely for 1 of 19 sampled employees, Employee #11, a Registered Nurse. The employee’s personnel record did not contain documented evidence that QAPI training was completed upon hire or before working on the floor with residents. During interviews on 02/02/2026, the Administrator confirmed that QAPI training was required for all employees and stated that orientation training was provided upon hire before staff worked on the floor. The Administrator also confirmed that Employee #11’s record lacked documentation of QAPI training completed upon hire. The facility policy titled, In-Service Training, All Staff, stated that all staff must participate in initial orientation and that training topics could include elements and goals of the facility QAPI program.
Missed Infection Control Training for Staff
Penalty
Summary
The facility failed to ensure initial and annual infection control training was completed timely for 3 of 19 sampled employees. Employee #4, a Registered Dietician hired on 08/16/2021, had infection control training documented on 11/20/2024, but the personnel record lacked evidence of annual training for 2025. Employee #6, the Food Services Supervisor hired on 08/16/2021, had infection control training documented on 11/26/2024, but the personnel record also lacked annual training for 2025. Employee #11, a Registered Nurse with an unknown hire date, had no documented evidence of infection control training completed upon hire. The Administrator confirmed on 02/02/2026 that infection control training was required for all employees and stated there was orientation training upon hire before working on the floor. The Administrator also confirmed that agency staff did not go directly through the facility for orientation training, and that Employee #11's personnel record lacked documented evidence of infection control training completed upon hire and before working with residents. The facility policy titled, In-Service Training, All Staff, stated all staff must participate in initial orientation and annual in-service training, and training topics could include infection prevention and control program standards, policies, and procedures.
Missing Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure initial and annual compliance and ethics training was completed timely for 3 of 19 sampled employees. Employee #2, hired as the Director of Nursing on 03/24/2020, had compliance and ethics training documented on 10/14/2024, but the personnel record lacked annual training for 2025. Employee #12, hired as a Licensed Practical Nurse on an unknown date, had compliance and ethics training documented on 10/06/2024, but the personnel record also lacked annual training for 2025. Employee #11, a Registered Nurse hired on an unknown date, had no documented evidence of compliance and ethics training completed upon hire. On 02/02/2026, the Administrator confirmed compliance and ethics training was required for all employees and stated there was orientation training upon hire before working on the floor. The Administrator also confirmed Employee #2 and Employee #12 did not complete compliance and ethics training annually in 2025, and Employee #11's record lacked documented evidence of training upon hire and before working with residents. The facility policy, In-Service Training, All Staff, stated all staff must participate in initial orientation and annual in-service training, and training topics could include compliance and ethics program standards, policies, and procedures.
Delayed Dementia Training for Multiple Employees
Penalty
Summary
Behavioral health care training related to dementia was not completed timely for 4 of 20 sampled employees. The facility did not have personnel records showing dementia-related behavioral health training for Employee #11, an RN hired as agency staff, or Employee #12, an LPN hired as agency staff. The Administrator stated the facility did not maintain personnel records for agency staff and was unsure of the hire or start dates for these two employees, although both were confirmed to have worked on the floor with residents in the facility. Employee #19, a Dietary Aide hired on 09/02/2025, completed initial behavioral health care training for dementia on 12/25/2025, which was 84 days late. Employee #20, a Housekeeper hired on 09/24/2025, completed the same training on 12/30/2025, which was 67 days late. The Administrator confirmed that all staff were required to complete initial behavioral health training related to dementia prior to providing care to residents and annually thereafter, and the facility policy required initial training and annual in-services on dementia-related care and behavioral health management.
Failure to Reconcile and Administer Admission Medications
Penalty
Summary
The facility failed to ensure one resident was free from neglect when staff did not reconcile medications from the acute care hospital discharge summary, did not contact the physician to verify and obtain orders for care and medications, and did not administer medications during the first two days after admission. The resident had diagnoses including Alzheimer's disease with late onset and a personal history of transient ischemic attack and cerebral infarction without residual deficits. The hospital discharge summary stated the resident had been treated for fever and sepsis, completed Tamiflu, and was to continue the home medication regimen, including multiple medications such as clopidogrel, divalproex, donepezil, lurasidone, quetiapine, sertraline, and tamsulosin. The resident's MAR documented a one-time medication reconciliation task with a start date of 12/30/2025, but the record lacked evidence that the reconciliation was completed or that any medications were administered on 12/30/2025 or 12/31/2025. A nurse note on 01/01/2026 documented that the resident was readmitted, medications were verified with the APRN, pharmacy was called, and medications could be delivered and administered within a few hours. The record lacked documented evidence that the resident's medications were reconciled and that the physician was contacted by nursing staff to obtain or confirm orders before that date. During interviews, an RN stated that admission medication orders were entered based on the discharge summary from the previous facility. The DON and DCO confirmed that reconciliation of medications was expected upon admission, that the admitting nurse was to review the discharge medications with the physician and enter orders into the EMR after approval, and that if the physician was not in the facility the on-call physician should be contacted. They also confirmed that no medications were administered to the resident on the two days after readmission, that the resident had several medications recommended on the discharge summary including psychotropics and clopidogrel, and that the record lacked evidence of a nurse assessment, physician notification, or completion of the medication reconciliation process as expected. The facility policies reviewed stated that admission assessments, medication reconciliation, and physician contact were required, and that neglect included indifference to or disregard for resident care, comfort, or safety resulting in or potentially resulting in physical harm, mental anguish, or emotional distress.
Employment of RN with license discipline for patient abuse
Penalty
Summary
The facility failed to ensure it did not employ an RN with a disciplinary action against the RN’s professional license as a result of a finding of abuse of a patient. The RN was listed as a current employee with an original hire date of 12/11/2017 and was scheduled to work in January and February 2026. A Primary Source Board of Nursing Report Summary from the Nevada State Board of Nursing showed the RN’s license was active and restricted, with discipline, and the basis for action was violation code 14, patient abuse, with an initial action date of 09/21/2023. During interview, the Administrator, who was also the Abuse Coordinator, stated the facility reviewed background checks and professional licenses on hire and relied on licensing boards to notify the facility of new actions against licenses. The Administrator reviewed the board report and confirmed it documented discipline for patient abuse. The DON and DCO stated they became aware of the discipline against the RN’s license at the beginning of August 2025 when the facility was contacted by the Nevada State Board of Nursing, and they confirmed they had been aware for several months that the disciplinary action was related to a finding of abuse. The facility policy stated it would not knowingly employ or otherwise engage any individual who had a disciplinary action in effect against a professional license as a result of a finding of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property.
Failure to Report Suspected Neglect After Missed Admission Medications
Penalty
Summary
The facility failed to identify and report suspected neglect to the State Agency for one resident who returned to the facility after an acute care hospital stay. The resident had diagnoses including Alzheimer's disease with late onset and a history of transient ischemic attack and cerebral infarction without residual deficits. The hospital discharge summary documented severe dementia and a history of CVA, and listed multiple medications to continue, including Clopidogrel, Donepezil, Divalproex, Lurasidone, Quetiapine, Sertraline, and Tamsulosin. The resident's MAR documented a medication reconciliation task, but the record lacked evidence that reconciliation was completed or that any medications were administered on the day of readmission or the following day. A nurse documented that medications were verified with the APRN and pharmacy was called so medications could be delivered and administered within a few hours, but the record still lacked evidence that the resident's medications were reconciled and that the physician was contacted to obtain or confirm orders before the medications were given. Facility staff confirmed the resident did not receive medications for two days after readmission and confirmed the record lacked documentation of an admission assessment, physician notification, and completion of the medication reconciliation process. During interviews, the DON and DCO stated that failure to complete and document assessments, failure to contact the physician on admission, and failure to administer medications would be considered neglect. The Administrator, who was also the Abuse Coordinator, stated the facility waited to report incidents until the issue was understood and confirmed the concern involving the resident not receiving medications was not reported to the SA and was not investigated for possible neglect because the Administrator did not suspect abuse or neglect had occurred. Facility policy required admission assessment, medication reconciliation, physician contact for admission orders, and immediate reporting of suspected neglect to the state licensing/certification agency.
Failure to Document Investigation After Resident Elopement
Penalty
Summary
The facility failed to ensure a thorough investigation was conducted and documented and/or retained for Resident #71 after the resident eloped from the facility. Resident #71 was admitted and later readmitted with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. An IDT post-incident review note dated 10/29/2024 documented that on the morning of 10/27/2024 at 7:30 AM the resident was noted missing from the facility, and the resident had a history of wandering. The note further documented that on 10/27/2024 at 5:30 PM the resident was found and taken to an ER for evaluation, and the IDT determined the resident needed to be in a locked unit due to daily habits of wandering and exiting the facility. On 01/29/2026, the Administrator confirmed the facility lacked documentation that an investigation was completed for the elopement event. The facility policy stated that reports of resident abuse, neglect, exploitation, or misappropriation were to be thoroughly investigated by facility management and all findings documented.
Missing 18-Month Staffing Hour Records
Penalty
Summary
The facility failed to maintain staffing hour records for at least 18 months as required by federal regulation. During record review on 01/28/2026, the surveyor requested staffing hour records for the last 30 days, and the facility provided those records. At a later time, the surveyor requested the last 18 months of staffing hour records, but no additional documentation was available to show compliance with the 18-month retention requirement. On 1/29/2026 at 12:17 PM, the Administrator and Director of Clinical Operations stated the facility did not have the last 18 months of staffing hour records, and both were unaware of the regulation's requirements.
Failure to Implement Bowel and Bladder Retraining Program
Penalty
Summary
The facility failed to offer a bowel and bladder retraining program for residents assessed to be candidates for retraining. This deficiency was identified for 11 out of 49 residents, including those with various medical conditions such as muscle weakness, parkinsonism, Alzheimer's disease, and others. The Minimum Data Set (MDS) assessments for these residents documented varying levels of incontinence, yet no trial of a toileting program was attempted, and no program was in place to manage their incontinence. The Director of Nursing (DON) confirmed that the facility did not have a bowel and bladder program until the week of December 16, 2024. The program that was eventually implemented consisted of scheduled toileting on a two-hour schedule. However, the facility lacked a policy for a bowel and bladder program, did not assess the type of incontinence, and did not document voiding patterns. All residents were placed in briefs unless they refused, and they were only assessed for incontinence and put on a two-hour check and change schedule. The facility's policy on incontinence, dated December 2021, stated that residents who were incontinent of bladder or bowel would receive appropriate treatment to prevent infections and restore continence to the extent possible. Despite this policy, the facility's failure to implement a bowel and bladder retraining program for eligible residents represents a significant oversight in providing appropriate care to maintain and achieve the highest continent status for residents.
Expired Medications Found in Medication Cart and Storage Room
Penalty
Summary
The facility failed to ensure expired medications were removed from a medication cart and a medication storage room, as observed during a survey. During the inspection of the B hall medication cart, a box of Aspercreme Lidocaine patches with an expiration date of 10/2024 was found, which should have been discarded by 10/31/2024. The Assistant Director of Nursing (ADON) confirmed the expiration date and acknowledged that the patches should have been removed and discarded. Additionally, in the B hall medication storage room, two IV solution bags containing Normal Saline with an expiration date of 10/2024 and one IV solution bag containing Dextrose with an expiration date of 11/2024 were found. The ADON confirmed these IV solution bags had expired and should have been discarded. The Director of Nursing (DON) stated that expired drugs were to be destroyed and confirmed that expired medications should be removed from medication carts. The facility's policy required that medications and biologicals not be retained longer than recommended by the manufacturer and that outdated/expired medications be destroyed or returned.
Medication Error Rate Exceeds 5% Due to Omission and Dose Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate. This was identified through observation, interview, clinical record review, and document review. There were 25 medication administration opportunities, and two errors were noted. One error involved a resident who did not receive Diclofenac Sodium gel as it was not available in the facility, leading to a documented omission in the Medication Administration Record (MAR). Another error involved a resident receiving Morphine Sulfate at a different concentration than what was ordered in the electronic Medication Administration Record (eMAR). The first resident was supposed to receive Diclofenac Sodium gel for osteoarthritis, but the medication was marked as not available in the MAR. The second resident was administered Morphine Sulfate at a concentration that matched a hospice provider's order but did not match the eMAR. The Licensed Practical Nurse (LPN) did not contact the physician for clarification before administering the medication. The Director of Nursing (DON) stated that the expectation was for nursing staff to review the eMAR and contact the physician if discrepancies were found. The facility's policy defined medication errors as dose errors and omission errors, which were evident in these cases.
Failure to Safeguard Resident Information and Update Hospice Orders
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain complete medical records in accordance with professional standards. An unattended computer screen on a medication cart displayed resident information, which was confirmed by a Registered Nurse (RN) who acknowledged the screen was unlocked and unattended. The Director of Nursing (DON) stated that the expectation was for computer screens to be locked when not in use, as per the facility's policy to protect resident privacy. Additionally, the facility did not enter hospice medication orders into the electronic medical record (EMR) in a timely manner for a resident diagnosed with malignant neoplasm of the prostate. The resident's hospice communication binder contained a physician order for medications that were not reflected in the EMR. A Licensed Practical Nurse (LPN) confirmed the oversight and acknowledged forgetting to update the EMR with the new orders. The DON explained that hospice orders should be entered into the EMR the same day they are received, as per facility policy.
Failure to Perform Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) performed proper hand hygiene during a medication pass, which had the potential to affect all residents receiving medication from the RN and increased the risk of infection spread. On December 18, 2024, during a medication pass from 8:44 AM to 9:12 AM, the RN administered medications to two residents, adjusted a resident's nasal cannula, touched a resident's shoulder, and donned and doffed gloves without performing hand hygiene at any point. The RN confirmed the lack of hand hygiene before and after medication preparation and administration, as well as after contact with residents and their environment. The Director of Nursing (DON) explained that hand hygiene was required between care of different residents and confirmed that it should be performed after adjusting a resident's nasal cannula, touching a resident, and removing gloves. The facility's policies on Medication Administration and Hand Hygiene, revised in 2023 and 2024 respectively, documented the necessity of hand hygiene before and after administering medications and contact with residents. The failure to adhere to these policies was acknowledged by the RN and DON, highlighting the potential for infection spread due to inadequate hand hygiene practices.
Delayed Abuse Training for Staff
Penalty
Summary
The facility failed to ensure timely completion of initial and annual training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation for three employees. Employee #2, hired as the Director of Nursing, completed the required abuse training one month late. Employee #9, a Licensed Practical Nurse, completed their annual abuse training eight months late. Employee #13, a Registered Nurse, completed their initial abuse training 14 days late. The facility's policy required all new employees to be trained in abuse during orientation and existing staff to receive planned education on abuse. The Payroll Human Resources employee confirmed the delay in training for these employees, which had the potential to place residents at risk for abuse and neglect.
Failure to Post Current Nursing Staff Information
Penalty
Summary
The facility failed to ensure that the current nursing hours were posted daily, as required. On December 16, 2024, at 8:05 AM, the nursing staff posting, located across from the main nursing station, was observed to be dated December 13, 2024. This outdated posting was confirmed by the Director of Nursing (DON) at 9:42 AM, who stated that it was the responsibility of the weekend nurse to update and post the nursing staff and hours during weekends. However, this was not done. Additionally, the Administrator, who usually updated the staff posting in the mornings, had not arrived by the time surveyors entered the building, resulting in the staff posting not being current when surveyors arrived.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that physician-ordered medications were administered to a resident during the morning medication pass on two consecutive days. On 08/01/2024, the medications were administered late, and on 08/02/2024, they were not administered at all. The resident, who had a history of hemiplegia, chronic respiratory failure, and hypertensive heart disease, reported receiving morning medications late. A Licensed Practical Nurse (LPN) confirmed that due to being shorthanded, they often struggled to administer medications on time. The Medication Administration Audit Report showed that several medications scheduled for 7:00 AM and 8:00 AM on 08/01/2024 were administered around 11:00 AM. On 08/02/2024, the Medication Administration Record (MAR) lacked documentation of the administration of the resident's medications, indicating they were not given. The Director of Nursing (DON) confirmed the omission and noted that the resident's clinical record lacked documentation explaining why the medications were not administered. The facility's policy required medications to be administered at the correct time, and the DON confirmed that the medications were not administered within the facility's flex time schedule.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to ensure appropriate pain management for a resident admitted for orthopedic aftercare following a surgical amputation. Resident #403, who had a left foot amputation, reported not receiving the prescribed hydrocodone for severe pain since admission. Instead, the resident was given acetaminophen, which was not effective for the level of pain experienced. The resident's pain levels were consistently high, ranging from six to eight on a scale of one to ten, and the facility did not administer the hydrocodone as ordered by the physician. The Licensed Practical Nurse (LPN) confirmed that the facility was unable to fill the hydrocodone order and that acetaminophen was administered in its place. The Director of Nursing (DON) acknowledged that the hydrocodone was not administered and that the facility had an emergency supply (medbank) that could have been used. The DON also confirmed that the resident's pain levels were not adequately managed with acetaminophen and that the medication administration record (MAR) lacked proper documentation for acetaminophen administration. The facility's pain management policy, dated 11/12/19, stated that pain management should be provided consistent with professional standards of practice. However, the facility did not adhere to this policy, resulting in Resident #403 experiencing severe pain without appropriate medication. The DON admitted that the lack of proper pain assessment and medication administration could lead to psychological harm and other complications for the resident.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to multiple deficiencies. Specifically, the facility did not create care plans for the placement of beds against the wall for 31 out of 49 residents, the use of bed rails for one resident, the administration and monitoring of anticoagulant and diuretic medications for one resident, and the monitoring and care of a urinary catheter and lymphedema for another resident. These omissions were identified through observations, interviews, clinical record reviews, and document reviews conducted by surveyors. For instance, Resident #34's bed was observed to be against the wall with two quarter-size bed rails, but there was no care plan addressing the use of these bed rails. Similarly, Resident #39 had physician orders for anticoagulant and diuretic medications, but the clinical record lacked a care plan for the use and monitoring of these medications. Additionally, Resident #308 had diagnoses of lymphedema and a urinary catheter in place at the time of admission, yet there were no care plans for the monitoring and care of these conditions. The Director of Nursing (DON) confirmed that the facility lacked policies or processes for determining if a bed against the wall restricted movement and acted as a restraint. The DON also acknowledged that care plans should be developed and implemented for all aspects of a resident's care, including the use of medications and the monitoring of specific conditions. The facility's policies on care planning and restraint use were not followed, resulting in the identified deficiencies.
Lack of Policy for Bed Placement Against Wall
Penalty
Summary
The facility failed to demonstrate effective administration by not having a policy or process in place to assess for restraint and risk of entrapment before placing residents' beds against the wall. The Director of Nursing (DON) confirmed that a bed against a wall could be considered a restraint if it restricted the resident's movement, especially if a full bed rail was present on the open side or if the resident had deficits on the open side of the bed. The DON acknowledged that an assessment for risk of entrapment, physician order, care plan, and informed consent were required for the use of physical restraints but admitted that the facility lacked a formal policy or process for this assessment. The DON explained that the current process relied on communication between staff members to ensure residents were not restrained upon admission by being placed in a bed positioned against a wall. However, the DON admitted there was no formal process in place to determine the appropriateness of beds against the wall and bedrails for residents with cognitive disabilities. The facility's policies on bed rails and restraints outlined the need for assessments, physician orders, care plans, and informed consent, but these were not being followed due to the lack of a formal process. The DON's uncertainty about how to determine the appropriateness of bed placement for residents with cognitive disabilities further highlighted the deficiency in the facility's administration and policy implementation.
Failure to Provide Communication Training to Staff
Penalty
Summary
The facility failed to ensure that communication training was completed by staff for 20 of 20 sampled employees. The personnel records of employees, including the Administrator, Director of Nursing, Activity Manager, Registered Dietician, Assistant Social Worker, Dietary Manager, Certified Nursing Assistants, Registered Nurses, Licensed Practical Nurses, Infection Preventionist, Cook, Dietary Aide, and Housekeeper, lacked documented evidence of communication training. This deficiency was identified through personnel record review, interviews, and document review, revealing that none of the sampled employees had completed the required communication training upon hire or as needed. The facility's policy, last updated in December 2022, mandated that all staff take Effective Communications training to demonstrate competency and skills necessary for resident care. The Facility Assessment, last reviewed in January 2024, also lacked documented evidence of staff completing communication training or a plan for such training. The Business Office Manager confirmed that all staff were required to take communication training and acknowledged the necessity of this training for effectively communicating with residents who have communication deficits. However, the records showed that the required training was not provided to the sampled employees.
Failure to Ensure Privacy of Residents' PHI
Penalty
Summary
The facility failed to ensure the privacy of residents' protected health information (PHI) for multiple residents. Specifically, a medication cart located in the facility's lobby had an open computer terminal screen displaying Resident #27's PHI, including the resident's photograph, room number, age, date of birth, vital signs, and a list of medications. This occurred while the computer was left unattended, and a nurse was not present at or near the cart. The Licensed Practical Nurse (LPN) confirmed the computer terminal was left unattended and should have been logged off before walking away. The Administrator also confirmed that staff were expected to lock computer terminals prior to leaving them unattended. Additionally, another incident was observed where a medication cart located at the main entrance to the facility was left unattended with the computer screen displaying PHI for five residents. The LPN approached the cart after approximately one minute and confirmed that the computer screen should have been locked when not attended. The Director of Nursing (DON) also confirmed that leaving resident information exposed was a violation of the Health Insurance Portability and Accountability Act (HIPAA). The facility's policies on HIPAA and confidentiality of personal and medical records were not followed, leading to these deficiencies.
Failure to Ensure QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) training was completed for 11 out of 20 sampled employees. These employees included the Administrator, Registered Dietician, Certified Nursing Assistants (CNAs), Wound Care Nurse, Infection Preventionist, Registered Nurse (RN), Licensed Practical Nurses (LPNs), Cook, and Housekeeper. The personnel records for these employees lacked documented evidence of QAPI training, which is required by the facility's policy. The Business Office Manager confirmed that all staff were required to take QAPI training upon hire, but the records showed that this training had not been completed for the specified employees. The facility's policy, last updated in December 2022, mandated that all staff take QAPI training during new hire orientation and annually thereafter. However, the personnel records for the sampled employees did not reflect compliance with this policy. The Business Office Manager acknowledged the deficiency, confirming that the required QAPI training was missing for the identified employees. This lapse in training was identified through interviews and document reviews conducted by the surveyors.
Failure to Obtain Informed Consent for Medications and Bed Placement
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychoactive medication and for the placement of resident beds against the wall. Specifically, Resident #12 was administered mirtazapine for depression without documented informed consent. Additionally, the consent for buspirone HCl did not match the current dosage being administered. The Director of Nursing (DON) confirmed that informed consent was required for both medications and acknowledged the discrepancy in the documentation. The facility's policy on Psychotropic Medication Management mandates that informed consent must be verified prior to the use of psychoactive medications, which was not adhered to in this case. Furthermore, the facility did not obtain informed consent for placing the beds of 37 out of 49 residents against the wall. This included residents with various diagnoses such as dementia, chronic obstructive pulmonary disease, and muscle weakness. The clinical records of these residents lacked documented evidence that they were notified of the risks of restraints and entrapment, and no signed consent was obtained prior to the bed placement. The DON explained that a bed against a wall could be considered a restraint if it restricted the resident's movement, especially in cases where the resident had deficits on the open side of the bed. The facility lacked a policy or process for determining if the bed placement acted as a restraint. The facility's policies on Proper Use of Bed Rails, Resident Rights, and Restraint Policy all emphasize the need for informed consent and proper documentation when using restraints or making significant changes to a resident's environment. Despite these policies, the facility failed to comply, leading to deficiencies in both medication management and resident safety. The DON confirmed that assessments, physician's orders, care plans, and informed consent were required but not obtained in these instances.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure a call light was within reach for one resident. Resident #308, who has multiple diagnoses including a displaced fracture, severe obesity, lymphedema, and chronic kidney disease, was found sitting in a wheelchair in their room. The resident expressed discomfort and the need for padding under their left lower extremity. The call light was observed to be draped across the nightstand and resting behind it, approximately four feet away from the resident, making it impossible for the wheelchair-bound resident to reach it. The Executive Director confirmed the call light was not within reach and acknowledged that it should always be accessible to the resident.
Failure to Honor Resident's Room Change Request
Penalty
Summary
The facility failed to honor a resident's request for a room change, which was first verbalized on 02/12/24. Resident #35, who was diagnosed with hemiplegia and hemiparesis following a cerebral infarction, expressed a desire for a room with more privacy due to feeling cramped and uncomfortable with the current living conditions. The resident's room had three occupants, and personal items from roommates were encroaching on the resident's space, including incontinence briefs in direct line of sight. Despite the resident's repeated requests, the facility did not take appropriate action to address the issue in a timely manner. Interviews with facility staff, including the Admissions Manager, Assistant Social Worker, Licensed Practical Nurse, and Director of Nursing, revealed a lack of communication and follow-through on the room change request. The process for handling such requests was not consistently followed, and Resident #35's request was not documented or communicated effectively. Although a bed became available over the weekend, the resident was not moved as the Director of Nursing had failed to coordinate with social services. The facility's policy on room changes and resident rights was not adhered to, resulting in the resident's continued dissatisfaction and discomfort.
Failure to Provide Advance Directive Acknowledgement
Penalty
Summary
The facility failed to ensure written acknowledgement of the Advance Directive notice was provided to the resident or the resident's representative for three sampled residents. Resident #306, who was admitted with diagnoses including traumatic hemorrhage of the cerebrum and a fall, did not have a signed Advanced Directive Acknowledgement in their clinical record. This was confirmed by the Executive Director. Similarly, Resident #12, admitted with chronic obstructive pulmonary disease and chronic respiratory failure, and Resident #305, admitted with encephalopathy and repeated falls, also lacked signed Advanced Directive Acknowledgements in their clinical records. The Executive Director confirmed these omissions and stated that the expectation was for the form to be signed within 48 hours of admission. The facility's policy, dated November 2016, outlined that an advance directive is a document where a person states their choices for medical treatment and/or designates who would make healthcare decisions for them. The policy also stated that residents and/or their legal healthcare decision-makers should be informed upon admission and periodically about their rights concerning self-determination of preferred intensity of care and the process for creating and implementing advanced healthcare directives. Despite this policy, the facility did not ensure that the required acknowledgements were signed and included in the clinical records of the three residents in question.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure a resident received a Notice of Medicare Non-Coverage (NOMNC) prior to discharge. Resident #55, who was admitted with a diagnosis of acute respiratory failure with hypoxia, did not have documented evidence of receiving a NOMNC before discharge. The Director of Nursing indicated that the social services department was responsible for handling all beneficiary notices. The Assistant Social Worker confirmed that a NOMNC should have been provided no later than two days before the last day of covered services and acknowledged that there was no documented evidence that Resident #55 received the required notice.
Failure to Provide Written Notification of Transfer or Discharge
Penalty
Summary
The facility failed to ensure that Resident #30 and the Resident's Representative received written notification of transfer or discharge. Resident #30, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, cognitive social or emotional deficit following cerebral infarction, and type II diabetes mellitus with diabetic chronic kidney disease, was transferred to an acute care hospital on 01/14/24 due to abnormal vital signs. The clinical record lacked documented evidence that the required Notice of Transfer or Discharge form was completed, which should have included details such as the effective transfer date, the facility to which the resident was transferred, the reason for the transfer, and instructions for an appeal, among other required information. The Director of Nursing confirmed that the facility used the Notice of Transfer or Discharge form to notify residents and their representatives of transfer circumstances but acknowledged that the form was not completed for Resident #30's transfer. The facility's policy required that the transfer/discharge notice be provided to the resident, the resident's representative, and the Long-Term Care Ombudsman as soon as practicable when an immediate transfer was necessitated by urgent medical needs. However, the facility failed to maintain evidence that the notice was sent to the Ombudsman, as required by their policy.
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What surveyors actually found near you
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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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Nursing homes near Carson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sierra Basin Post Acute | 1.7 mi | ★★★★★ | 13 | 0 |
| Ormsby Post Acute Rehabilitation | 2.3 mi | — | 34 | 0 |
| Mountain View Health And Rehabilitation | 3.3 mi | ★★★★★ | 22 | 0 |
| Gardnerville Health & Rehabilitation Center | 16 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Reno | 18.6 mi | ★★★★★ | 0 | 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.