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)
Some of the Latest Corrective Actions taken by Facilities in Nevada
Latest Citations in Nevada
A resident with severe cognitive impairment was admitted while restrained with abdominal and chest restraints, which were reapplied by an LPN without a physician order or assessment. The restraints confined the resident to bed, and staff failed to follow facility policy requiring immediate removal, assessment, and physician authorization for restraint use. The issue was discovered during a shift change when another LPN assessed the resident and removed the restraints.
A resident with end stage renal disease, muscle weakness, and diabetes, who was dependent on staff for toileting hygiene, had multiple shifts with no documentation that assistance was provided. Staff interviews confirmed that documentation was required each shift, and review found no care plan addressing the resident's incontinence, contrary to facility policy.
A resident with chronic respiratory conditions did not receive BiPAP therapy as ordered due to a missing device component after a room transfer. Nursing staff documented the BiPAP as applied even though it was not used, and the physician was not notified of the issue, resulting in a failure to implement alternative respiratory interventions.
The facility did not enforce or document its Legionella Water Management Program as required, with no evidence of regular monitoring or review prior to being notified of possible Legionella contamination. Two residents with complex respiratory and cardiac conditions tested positive for Legionella after being transferred to acute care, and the facility could not provide documentation of required water system inspections or control measures before the incident. The water management plan was found to be adequate but had not been periodically reviewed or tailored to the facility, and documentation of compliance only began after external notification.
A resident with intact cognition reported being inappropriately touched on the chest by another resident, who later admitted to the act. The incident was not immediately reported to staff, and the facility's investigation substantiated the abuse. Both residents had behavioral care plans addressing prior concerns, but the event was not prevented or promptly identified, resulting in a deficiency for failure to protect residents from abuse.
A resident with a kidney transplant was given Cialis tablets instead of the prescribed Tacrolimus capsules for several days due to a pharmacy mislabeling error. LPNs administered the medication based on the mislabeled bubble pack without recognizing the form discrepancy, and the error was only discovered after multiple doses when a nurse questioned the medication's appearance. The DON and Consultant Pharmacist confirmed the mislabeling and the failure to identify the error during medication administration.
A resident with a hospital-diagnosed anxiety disorder was admitted and exhibited repeated care refusals, aggression, and behavioral symptoms, but the facility failed to document anxiety as an active diagnosis, did not develop a care plan or interventions for anxiety, and did not provide behavioral health services until after the resident expressed suicidal ideation. Staff recognized the behaviors but did not address them through the care planning process, resulting in psychosocial harm.
Staff failed to properly disinfect a shared glucometer with EPA-approved wipes, did not consistently perform hand hygiene or use PPE when entering rooms of residents on contact isolation for C. diff and wound infection, and did not document required education for visitors regarding isolation precautions. These lapses involved both staff and visitors and affected multiple residents with infectious conditions.
A resident with multiple medical conditions was administered Lovenox for deep vein thrombosis without a care plan or physician order for monitoring anticoagulant therapy. Staff did not perform or document routine assessments for bleeding or adverse reactions, and the MAR lacked evidence of monitoring, despite facility policy requiring these actions.
A resident with COPD and acute respiratory failure was administered oxygen via nasal cannula without a physician's order specifying flow rate or care instructions. Nursing staff and the DON confirmed the absence of required orders, and facility policy required such orders for oxygen administration.
Resident Restrained Without Physician Order or Assessment
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of dementia was admitted to the facility while restrained with abdominal and chest restraints. Upon admission, the admitting nurse untied the restraints to transfer the resident to the facility bed and then reapplied the restraints, confining the resident to the bed. The nurse did not obtain a physician order for the use of these restraints, nor was an assessment conducted to determine the necessity or safety of the restraint use as required by facility policy. During the evening, a CNA questioned the use of the restraints and was instructed by the LPN to keep the restraints in place after providing care, citing a lack of time to check on the resident frequently. Video review confirmed that the LPN did not check on the resident until several hours later, during the early morning medication pass. At shift change, the incoming LPN was not informed about the restraints and only discovered them during an assessment, at which point the restraints were immediately removed due to the absence of a physician order. Interviews with facility leadership and nursing staff confirmed that the general practice is to avoid the use of restraints and that any resident arriving with restraints should have them removed immediately pending assessment and physician evaluation. The admitting nurse acknowledged being aware of the restraints and applying them without proper authorization or assessment, which was corroborated by video evidence and staff interviews.
Failure to Document and Provide Assistance with Toileting Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide documented evidence that assistance with activities of daily living (ADL), specifically toileting hygiene, was provided for one resident who was dependent on staff for this care. The resident in question was admitted with diagnoses including end stage renal disease, muscle weakness, and type 2 diabetes mellitus, and was assessed as frequently incontinent of bowel and bladder and dependent on staff for toileting hygiene. Review of the resident's ADL documentation revealed multiple shifts across several days where there was no documentation that toileting hygiene was performed. Interviews with CNAs, the MDS Coordinator, and the DON confirmed that the expectation was for staff to document toileting hygiene every shift, and that blank documentation indicated the task was not performed. Further review showed that the resident did not have a care plan addressing incontinence, despite being assessed as dependent and frequently incontinent. The facility's policy required CNAs to assist residents with ADLs and to document care accurately and timely. The lack of documentation and absence of a care plan for incontinence indicated that the required assistance with toileting hygiene may not have been provided as needed for this resident.
Failure to Follow Physician Orders for BiPAP Application Due to Missing Equipment
Penalty
Summary
The facility failed to follow physician orders for the application of a BiPAP device for a resident with a history of acute on chronic hypercapnic respiratory failure, COPD exacerbation, and chronic hypoxic respiratory failure. The resident was ordered to use BiPAP during sleep, with staff assistance for setup and documentation of any refusal. However, after a room transfer, a critical component of the BiPAP device (elbow connector) was lost, making the device unusable for two nights. During this period, the resident received oxygen via nasal cannula instead, as per physician orders, but the BiPAP was not applied as ordered. Nursing staff documented in the Medication Administration Record and progress notes that the BiPAP was applied, despite the device being inoperable due to the missing part. The attending physician was not notified about the inability to use the BiPAP, and no alternative respiratory interventions were implemented. The Director of Nursing confirmed that the missing connector was not reported to the physician and acknowledged that documentation inaccurately reflected the use of the BiPAP device.
Failure to Enforce Legionella Water Management Program and Document Required Activities
Penalty
Summary
The facility failed to enforce its Legionella Water Management Program (LWMP) as required by its own policy. The LWMP included a checklist of inspection items, frequencies, and documentation requirements, but there was little to no evidence that these activities were performed or recorded prior to notification from the local health department. The Maintenance Director confirmed that while some activities may have been conducted, there was no documentation to support ongoing compliance with the LWMP until after the facility was alerted to possible Legionella contamination. The LWMP itself was found to be adequate for the facility type, but it had not been periodically reviewed, and some of its documentation was not specific to the facility. The deficiency came to light during a complaint investigation after two residents who had been admitted with complex respiratory and cardiac conditions tested positive for Legionella following their transfer to acute care facilities. One resident experienced a significant drop in oxygen saturation and required emergency transfer, while the other was treated for a persistent cough and tested positive for Legionella antigen. The source of the Legionella could not be conclusively determined, but the facility's lack of documented implementation of its water management plan was evident. Interviews with facility leadership, including the Administrator, Maintenance Director, and DON, revealed that the LWMP had not been reviewed or updated except in response to the notification of possible Legionella cases. Water testing and mitigation activities were only documented after the facility was informed of the potential contamination. Prior to this, there was no evidence of regular monitoring, system flushing, or other control measures as outlined in the LWMP.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident reported that another resident had touched their chest under their shirt without permission. The incident was reported to the Director of Social Services and the Administrator, and the accused resident admitted to the inappropriate contact. The facility's investigation substantiated the allegation of abuse. Prior to the incident, the resident who committed the abuse had a behavioral care plan addressing inappropriate sexual comments, while the resident who reported the abuse had a care plan for making false accusations and having physical altercations. The incident was not immediately reported to staff, as the affected resident only disclosed it to a relative, who also did not inform the facility. Skin assessments conducted during the relevant period noted a rash on the upper left chest of the affected resident, but no complaints of pain or discomfort were documented. The facility's policy requires maintaining an environment free from abuse, neglect, and exploitation. The failure to promptly identify and address the abuse, as well as the delay in reporting, contributed to the deficiency cited in the report.
Medication Administration Error Due to Pharmacy Mislabeling
Penalty
Summary
A resident with end stage renal disease and a history of kidney transplant was admitted and had a physician's order for Tacrolimus 0.5 mg capsule, an anti-rejection medication. However, due to a pharmacy error, a medication bubble pack containing Cialis 5 mg tablets was mislabeled as Tacrolimus and dispensed with the resident's name. Over a period of six days, the resident was administered Cialis instead of the prescribed Tacrolimus. The medical record did not show any order for Cialis for this resident. Licensed Practical Nurses confirmed administering the mislabeled medication, relying on the label and the five rights of medication administration, but failed to notice the discrepancy between the ordered capsule form and the tablet form present in the bubble pack. The error was only identified after several doses when another nurse questioned the form of the medication. The Director of Nursing and Consultant Pharmacist acknowledged the pharmacy's mislabeling and the failure of nursing staff to detect the error before administration, despite facility policies requiring verification of medication form and label against physician orders.
Failure to Develop and Implement Behavioral Health Care Plan for Resident with Anxiety
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's hospital-diagnosed anxiety, did not monitor behavioral symptoms, and did not provide necessary behavioral health services. Despite documentation from the hospital discharge summary, physician assessments, and therapy evaluations all identifying anxiety as an active medical condition, the facility did not code anxiety as an active diagnosis in the medical record until several days after admission. The baseline care plan created at admission did not include any focus, goals, or interventions related to anxiety, and there was no evidence of individualized behavioral health interventions being developed or implemented. Throughout the resident's stay, multiple instances of care refusal, verbal aggression, and behavioral symptoms such as yelling and use of abusive language were documented. Staff, including therapy and nursing, observed and reported these behaviors, but there was no documented evidence that these symptoms were addressed through the care planning process or that the interdisciplinary team (IDT) discussed or intervened regarding the resident's anxiety prior to the resident expressing suicidal ideation. The resident also reported to surveyors feelings of depression, hopelessness, and ongoing suicidal thoughts, and stated that requests for medication to address anxiety and sleep issues were denied by staff. Interviews with staff confirmed that the resident's behavioral symptoms and refusals were recognized but not addressed through a care plan or IDT intervention. The facility's own policy required assessment and individualized care planning for behavioral health symptoms, but this was not followed. The lack of timely recognition, documentation, and intervention for the resident's anxiety and behavioral health needs resulted in psychosocial harm, as evidenced by the resident's reported suicidal ideation.
Failure to Adhere to Infection Control Protocols and Contact Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances involving the use of shared medical equipment, adherence to contact isolation protocols, and education of staff and visitors regarding transmission-based precautions. In one case, a registered nurse disinfected a shared glucometer with an alcohol pad after use on a resident with diabetes and chronic kidney disease, despite the availability of EPA-approved disinfectant wipes and facility protocols requiring their use. The nurse believed alcohol pads were acceptable based on previous pharmacy guidance, but both the Director of Nursing and Infection Preventionist later confirmed that only EPA-approved wipes with a specified contact time were appropriate for disinfecting shared glucometers to prevent cross-contamination. In another instance, staff failed to follow contact isolation procedures for a resident on precautions for possible Clostridium difficile infection. Despite clear signage and the availability of personal protective equipment (PPE) at the room entrance, multiple staff members entered and exited the resident's room without donning the required PPE or performing hand hygiene with soap and water, as mandated for C. difficile precautions. Staff later acknowledged that they had not paid attention to the isolation signage and were aware that proper handwashing and PPE use were required but had not been performed. Additionally, the facility did not ensure that visitors and staff consistently adhered to contact precautions for a resident with a wound infection. A visitor entered and remained in the resident's room without wearing the required gown and gloves, stating they were unaware of the need for PPE. The facility's care plan and policies required education for visitors and documentation of such education, but there was no evidence in the medical record that the visitor had been informed about the precautions. Furthermore, a licensed practical nurse was observed entering the same resident's room without donning PPE, despite acknowledging the necessity of these measures to prevent infection spread.
Failure to Implement Care Plan and Monitoring for Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to formulate a care plan for anticoagulant use and did not obtain a physician order for monitoring a resident receiving anticoagulant therapy. The resident, who had diagnoses including dementia, Parkinson's disease, and gait abnormalities, was admitted and prescribed Lovenox for deep vein thrombosis. Although the medication was administered as ordered, there was no documented evidence of a care plan addressing anticoagulant use, nor was there a physician order in place for monitoring the resident for potential bleeding or adverse reactions during the course of therapy. Staff interviews confirmed that routine assessments for signs of bleeding, such as bruising, bleeding gums, hematuria, and black tarry stools, were not conducted or documented prior to or during the administration of Lovenox. The lack of a monitoring order meant that no prompts were generated for staff to implement necessary assessments, and the Medication Administration Record did not reflect any monitoring for bleeding or coagulation issues. The facility's own policy required such monitoring and documentation, but these steps were not followed for this resident.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen therapy for a resident with diagnoses including COPD with exacerbation, acute respiratory failure, and dementia. The resident was observed receiving oxygen via nasal cannula at varying flow rates without a humidifier, and there was no documented physician order specifying the use, flow rate, or care instructions for the oxygen therapy. Medical records did not contain evidence of an order for oxygen or for changing the nasal cannula, despite the resident's continuous dependence on supplemental oxygen. Interviews with nursing staff and the Director of Nursing confirmed that no physician order was in place for the oxygen therapy or related care, and that staff were expected to obtain such orders at the onset of oxygen use. The Physician Assistant also confirmed that a physician's order specifying flow rate, delivery method, and monitoring parameters was required for supplemental oxygen. Facility policies reviewed indicated that a physician's order was necessary for oxygen administration and for all medications and treatments.
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