Citations in Nevada
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Nevada.
Statistics for Nevada (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Nevada
The governing body failed to oversee a contracted vendor that completed behavior documentation used for Medicaid Behaviorally Complex Care Program (BCCP) applications. Behavior Frequency Documentation Data Sheets for several residents with complex medical and psychiatric conditions contained daily behavior entries and numerous initials that could not be linked to facility staff, including repeated use of the initials "AB." The vendor’s staff documented multiple behavioral interventions—such as token economies, loss of privileges, PBIS-style strategies, classroom-type rewards, time-outs, and even corporal punishment—as effective or otherwise, despite these interventions not appearing in resident care plans and not being used by facility staff. The DON confirmed facility staff did not have access to or complete these sheets, while contracted agency leadership stated they used this documentation to prepare and submit BCCP applications without confirmed facility review.
Staff failed to provide adequate supervision and follow elopement procedures when an unsecured window was discovered on a secured memory care unit. A resident with schizophrenia and documented elopement risk, whose care plan included safety on a secured unit and monitoring for exit-seeking, was last seen near the nurses’ station early in the morning. When a restorative aide reported that plywood covering a previously broken window was missing, an LPN assumed another exit-seeking resident had removed it and did not conduct a head count, despite facility guidance requiring an immediate count when an open door or window was found. The resident was later found to be missing during breakfast, leading to a delayed recognition of the elopement and delayed activation of the facility’s elopement response.
Two residents, one with bipolar disorder and fall history and another with post-stroke hemiplegia, intellectual disabilities, and contractures, were found barricaded in their beds when an Activities Director observed mattresses placed against the beds and held in place by locked Geri-chairs, blocking the only open side. The assigned nurse stated this was done for safety, but the investigation determined the residents were deliberately confined to bed without consent, constituting involuntary seclusion in violation of the facility’s abuse and neglect policy. One resident later reported feeling that this confinement was not appropriate.
A resident dependent on staff for bathing, with multiple medical conditions, did not receive scheduled showers or bed baths as required. The resident reported a rash and itching, and review of records confirmed that scheduled bathing was not consistently provided, contrary to facility policy.
A resident with multiple diagnoses did not have monthly weights documented for three consecutive months, despite physician orders and facility policy requiring this monitoring. Staff interviews confirmed that CNAs had not consistently obtained weights, leading to gaps in care planning and delayed interventions.
A resident with multiple medical conditions was discharged against medical advice without documentation of risk discussion, a signed AMA form, or notification of the physician and administrative staff. Staff interviews confirmed that required AMA protocols were not followed, and the medical record lacked evidence of these actions.
A resident with a history of smoking and cognitive decline was not re-assessed for smoking safety or had their care plan updated after a significant change in condition. After being found smoking in their room while on oxygen, staff did not complete a new smoking safety assessment or revise the care plan. The facility also failed to secure the resident's lighter and cigarettes, resulting in a fire that caused burns and smoke inhalation, requiring hospitalization.
Surveyors identified that the facility did not maintain its fire alarm system, as the main panel displayed a trouble alarm for a missing duct detector and showed an incorrect date and time after a power outage. The facility also lacked documentation of annual portable fire extinguisher inspections and had a fire safety plan that omitted protocols for extinguisher use and procedures for reviewing the fire alarm panel during alarms. These deficiencies affected 36 residents in one smoke compartment.
The facility did not have a defined time frame in its Release of Information policy for providing medical records when requested. A home health agency made two requests for a resident's records, which were eventually sent electronically, but there was no documentation of the requests or calls, and the policy lacked specific processing time frames.
A resident with multiple serious diagnoses was discharged without receiving a documented medication list or education about their medications. Staff interviews confirmed that it was the nurse's responsibility to provide and review discharge instructions, including medications, but no documentation was available to show this occurred, in violation of facility policy.
Failure of Governing Body to Oversee Contracted Behavioral Documentation for Medicaid BCCP
Penalty
Summary
The governing body failed to oversee services performed by a contracted vendor responsible for behavior documentation used in Medicaid Behaviorally Complex Care Program (BCCP) applications. Surveyors reviewed Behavior Frequency Documentation Data Sheets for multiple residents and found that behaviors were checked off daily and initialed, but many entries were associated with initials that could not be verified as any facility staff member. The Director of Nursing (DON) stated that facility staff did not have access to these behavior documentation sheets and did not complete them. A Care Coordination Director from the contracted agency reported that their staff completed the documentation based on nursing notes, care plans, meetings, and personal observations, and that this information was used to complete BCCP applications on behalf of the facility, without knowing if anyone at the facility reviewed the applications before submission. For one resident with peripheral vascular disease, COPD, type 2 DM, and a history of TIA, the September 2025 behavior sheets showed daily behaviors and interventions such as token economy systems, loss of privileges, group contingency systems, seating arrangement changes, and frequent movement breaks, all marked as effective. Fourteen entries were initialed with “AB,” an identity that could not be verified, and the DON confirmed these interventions were not part of the resident’s care plan and were not being used by facility staff. Another resident with unspecified dementia, cognitive communication deficit, atherosclerosis of the aorta, and anxiety disorder had behavior sheets listing interventions such as scheduled movement breaks, clear consequences, quiet corner or calming space, student-teacher conferences, school-wide PBIS, behavior tracking apps, classroom jobs, and whole-class reward systems, documented as effective, successful, or somewhat effective, even though these interventions were not approved in the care plan. Additional residents with diagnoses including hemiplegia and hemiparesis after cerebrovascular disease, cerebral infarction, metabolic encephalopathy, bipolar disorder, atrial fibrillation, aneurysm of the carotid artery, atherosclerotic heart disease, schizophrenia, gastrostomy malfunction, hypotension, dementia, morbid obesity, drug-induced akathisia, and abnormal involuntary movements also had behavior sheets with numerous entries initialed by “AB” or otherwise unidentified. For one resident with schizophrenia and movement disorders, interventions such as time-outs, loss of privileges, proximity control, calm down corner, teacher praise, expulsion, detention, and corporal punishment were documented as effective, successful, failed, or ineffective, despite not being approved or used by the facility. The Chief Clinical Officer of the contracted agency reported not noticing any abnormalities in the documentation for these residents and had approved the documentation to be sent with BCCP applications, while the DON verified that the listed interventions did not come from the residents’ care plans and were not being implemented by facility staff.
Failure to Verify Resident Presence After Discovery of Unsecured Window on Secured Unit
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention on a secured memory care unit when staff did not verify that all residents were present after discovering an unsecured window. A resident with paranoid schizophrenia and unspecified psychosis, identified through multiple elopement risk evaluations as an elopement risk due to schizophrenia and wandering behaviors, had care plan interventions that included ensuring safety on a secured unit and monitoring exit-seeking behaviors such as pushing on exit doors. On the morning of the incident, a restorative nurse aide notified an LPN that the plywood covering a previously broken window on the secured unit was missing. The LPN, who had last seen the resident near the nurses’ station at approximately 6:00 AM, assumed the plywood had been removed by another resident known for breaking windows and exit-seeking, and did not initiate a head count or otherwise confirm that all residents on the unit were present. Later that morning during breakfast, staff noticed the resident was not present in the dining room and began searching for the resident on the unit and then in the surrounding area after the resident could not be located. The administrator confirmed that when staff discovered the missing plywood and unsecured window between 7:00 AM and 8:00 AM, they notified the administrator and confirmed only that the resident assigned to that room was present, but did not complete a full resident count on the secured unit. The facility’s elopement policy defined elopement as a resident exiting the facility or entering an unsafe area without staff knowledge and required care plan interventions based on elopement risk evaluations. An additional facility document on elopement risk directed staff to ensure all doors and windows in the memory care unit were locked and secured and to complete an immediate head count for the entire facility if any potential elopement risk, such as an open door or window, was identified. Staff’s failure to follow these procedures resulted in delayed identification of the resident’s elopement and delayed implementation of the facility’s elopement response procedures.
Involuntary Seclusion of Two Residents by Barricading Beds
Penalty
Summary
The deficiency involves the involuntary seclusion and confinement of two residents to their beds by staff using physical barriers. One resident had bipolar disorder and a history of falling, and the other had hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, intellectual disabilities, and contractures. Facility reports documented that during early-morning rounds, the Activities Director observed that both residents’ beds, which were permitted to be placed against a wall with one open side, had the open side blocked by a mattress propped up and held in place by a locked Geri-chair, effectively barricading the residents in bed. When questioned, the nurse assigned to the hallway stated this was done for safety. The investigation determined that the residents were deliberately barricaded in bed, resulting in their confinement without consent. One of the residents later recalled the incident and stated that being confined to bed in this manner felt inappropriate at the time. Staff interviews confirmed awareness of the facility’s abuse policy and protocols for reporting allegations, and staff acknowledged that the incident involved involuntary seclusion of the two residents. The facility’s written policy on abuse, neglect, exploitation, mistreatment, and involuntary seclusion prohibited such practices and required thorough investigation of all allegations, including identification and removal of alleged perpetrators, identification of victims, and documentation of where and when the incident occurred and interview summaries.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for bathing due to medical conditions including dysphagia following cerebral infarction, type 2 diabetes mellitus, and essential hypertension, did not receive scheduled bathing as required. The resident reported experiencing a rash and itching, and stated that staff did not bathe or shower them regularly. Review of the facility's bathing schedule and medical records showed that the resident was assigned to receive showers or bed baths twice weekly, specifically on Wednesday and Saturday evenings, but these were not consistently provided as scheduled. A Certified Nurse Assistant confirmed the bathing schedule and that documentation was maintained in the medical record. The Director of Nursing also verified that the resident's scheduled showers were not provided as required. Facility policy stated that residents should be offered at least two full baths or showers per week, but this was not adhered to in the resident's case, as evidenced by gaps in the bathing documentation and the resident's own account of infrequent bathing.
Failure to Obtain and Document Monthly Weights as Ordered
Penalty
Summary
The facility failed to follow physician orders for obtaining monthly weights for a resident diagnosed with Parkinson's disease, dementia, and major depressive disorder. The physician had ordered monthly weights to be taken within the first week of each month for monitoring purposes. However, the medical record lacked documented weights for three consecutive months, specifically September, October, and November. This omission was identified through record review and confirmed by staff interviews, which revealed that Certified Nurse Assistants (CNAs) had not consistently obtained the required monthly weights. Multiple staff members, including the DON, Unit Manager, ADON, and Registered Dietitian, acknowledged ongoing challenges in obtaining accurate and consistent weight measurements. They indicated that missing or inaccurate weights had negatively impacted care planning and delayed timely interventions for residents experiencing weight loss or significant changes. The facility's policy required nursing staff to measure resident weights as ordered by the physician, but this was not consistently followed for the resident in question.
Failure to Complete Required AMA Discharge Procedures
Penalty
Summary
The facility failed to follow required procedures when a resident was discharged against medical advice (AMA). Specifically, there was no documentation that nursing staff discussed the risks associated with leaving AMA, no signed AMA form was present, and there was no evidence that the physician, administrator, or director of nursing were notified as required by facility policy. The incident involved a resident with multiple medical conditions, including narcolepsy, edema, type 2 diabetes mellitus, and morbid obesity, who had been admitted for therapies and ongoing medical management. Prior to the discharge, the resident's family expressed a desire to take the resident home, and caregiver training was scheduled for a later date. On the day of discharge, the family demanded an in-person visit from a provider, which was not accommodated as providers did not come in on weekends unless it was an emergency. The family then called 911, and EMS arrived to transfer the resident. The family informed staff they were leaving, and EMS removed the resident without speaking to facility staff about the discharge. Interviews with facility staff confirmed that the expected protocol for AMA discharges was not followed. Staff acknowledged that the AMA form should have been explained and signed, or refusal documented, and that the physician and administrative staff should have been notified. However, there was no documentation of these actions in the resident's medical record. The facility's policy required these steps, but the record lacked evidence that they were completed in this case.
Failure to Reassess Smoking Safety and Secure Smoking Materials Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff re-assessed a resident's smoking status and updated the care plan following a significant change in the resident's cognitive condition. The resident, who had a history of cigarette smoking and was at risk for injury and inappropriate behaviors, experienced a decline in cognition as documented by a lower BIMS score. Despite this significant change, the resident's smoking safety was not re-evaluated, and the Minimum Data Set (MDS) inaccurately reflected no tobacco use. The medical record lacked a corresponding Smoking Safety evaluation and care plan update after the change in condition. Additionally, after an incident where the resident was found smoking inside their room while using oxygen, staff did not complete a new smoking safety assessment or update the care plan as required by facility protocol. The Activity Director and DON confirmed that the event should have triggered a reassessment and care plan revision, but these actions were not taken. The resident's medical record did not reflect any follow-up or documentation of the incident in the smoking safety evaluation. Furthermore, the facility failed to secure the resident's lighter and cigarettes, contrary to the facility's protocol that prohibited residents from retaining smoking paraphernalia. Despite the implementation of a new smoking program protocol, the resident was able to access smoking materials and subsequently caused a fire in their room while using oxygen. This resulted in the resident sustaining burns and smoke inhalation, requiring hospitalization.
Failure to Maintain Fire Alarm System, Fire Extinguishers, and Fire Safety Plan
Penalty
Summary
The facility failed to maintain its fire alarm system, portable fire extinguishers, and fire safety plan in accordance with National Fire Protection Association (NFPA) standards. During a facility tour, the main fire alarm panel was observed to display a system trouble alarm, specifically indicating a missing duct detector in the water heater room. The fire alarm panel also showed an incorrect date and time, which the Maintenance Director attributed to a recent power outage and subsequent hard reset of the system. The facility was aware of the trouble alarm but had only scheduled future repairs with the vendor. Additionally, document review revealed that the facility could not provide evidence of annual inspections for portable fire extinguishers. Review of the facility's evacuation and fire safety plan showed that it lacked protocols for the use of portable fire extinguishers, such as the P.A.S.S. method, and did not include procedures for reviewing the fire alarm annunciator panel during an alarm condition. These deficiencies affected 36 residents in one of six smoke compartments, with the facility having a census of 137 residents at the time of the survey.
Lack of Defined Time Frame for Release of Medical Records
Penalty
Summary
The facility failed to ensure its Release of Information policy included a defined time frame for providing resident medical records upon request. A home health agency requested medical records for a resident on two occasions, with the first request made on 05/01/2025 and a second on 05/20/2025. The records were sent electronically on 05/20/2025 and 05/21/2025. The Medical Records Director stated that records would not be released without a request and that staff typically documented the portion of the record provided, but was unsure if other staff had documented the requests. There were no documented requests or phone calls from the home health agency regarding the resident, and fax cover sheets and written requests were only kept for 30 days. Review of the facility's Release of Information policy revealed it lacked documented time frames for processing such requests.
Failure to Provide Discharge Medication List and Education
Penalty
Summary
The facility failed to provide a copy of the discharge medication list and education about the medications to a resident upon discharge. The resident, who had been admitted with acute respiratory failure, chronic obstructive pulmonary disease, local infection of the skin and subcutaneous tissue, and sepsis, was discharged without documentation showing that a medication list or medication education was given. Interviews with facility staff, including a registered nurse, social services assistant, and the Director of Nursing (DON), confirmed that it was the nurse's responsibility to review and educate the resident on their discharge medications and instructions, and to ensure the resident understood and signed the discharge instructions. However, no such documentation was available for this resident. Review of the facility's policy titled Discharge Planning indicated that the nursing department was responsible for assessing and coordinating health and medical education needs, and that the discharge packet should include a medication list and prescriptions. The former DON also confirmed that there should have been documentation of medications provided and education given to the resident at discharge. The lack of documentation and education regarding discharge medications constituted a deficiency in the facility's discharge process for this resident.
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