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
A resident with multiple medical and psychiatric diagnoses was subjected to rough handling by a CNA during personal care, including being tugged on while having their brief changed. The incident was reported, investigated, and substantiated as abuse, indicating the facility failed to ensure the resident was protected from abuse as required by policy.
Staff removed the battery from a resident's motorized wheelchair without first obtaining the resident's permission or providing an explanation, following an incident where the resident accidentally ran over another individual's foot. The action was taken while the resident was out of the room, and both the Administrator and Maintenance Director later acknowledged that consent should have been obtained in accordance with resident rights.
A resident with multiple psychiatric and medical diagnoses was administered Seroquel, a psychotropic medication, without documented informed consent prior to the first dose. Facility staff, including an RN and the DON, confirmed that policy requires consent before administration, but the required documentation was missing from the resident's medical record.
A resident with cognitive impairment and a history of wandering was able to exit the facility undetected while wearing a wander guard bracelet that failed to activate an alert. The resident was not discovered missing until several hours later and was found outside the facility. Investigation revealed that the wander guard device's functionality had not been properly tested for this resident, leading to the deficiency.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not upheld, reflecting a failure to ensure resident autonomy in medical decision-making.
Two residents with complex medical conditions were not provided with education on the risks and benefits of pneumococcal, influenza, and COVID-19 vaccines, nor was there documentation of vaccine administration or declination. Staff interviews confirmed that required procedures for reviewing and documenting immunization status were not followed for these residents.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not employ a qualified Infection Preventionist for several months, resulting in a lack of oversight for infection prevention, antibiotic stewardship, immunization, education, and infection control surveillance. Payroll records and staff interviews confirmed the absence of an IP, and other certified staff did not fulfill the IP role during this period.
A resident with chronic respiratory failure and COPD was ordered to receive oxygen at three LPM as needed, but was repeatedly administered oxygen at two LPM according to documentation and direct observation. The resident reported ongoing shortness of breath and did not adjust the oxygen flow independently. An LPN and the DON confirmed the absence of an order for titration and acknowledged the importance of administering medications, including oxygen, at the prescribed dose.
A resident with intellectual disabilities and dementia, who was prone to scratching and picking at their skin, did not receive consistent care to address these behaviors. Although interventions such as hydroxyzine and geri sleeves were ordered, staff relied on observing the resident's actions to administer PRN medication, despite the resident's inability to request it. Ongoing skin injuries and bleeding were documented, and staff expressed uncertainty about the appropriateness of PRN orders for this resident.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a certified nursing assistant (CNA) was reported to have been rough while changing the resident's brief, including tugging on the resident. The incident involved a resident with a history of cervical spine fusion, cocaine abuse with cocaine-induced psychotic disorder with hallucinations, depression, and pain. The resident reported the incident, and the CNA was removed from the resident's care for the remainder of the shift due to incompatibility between the resident and the CNA. The CNA resigned from the facility after the allegation was reported. An investigation was conducted, and the facility substantiated the allegation of abuse. The facility's policy prohibits all forms of abuse, neglect, and mistreatment, and requires immediate reporting and investigation of such incidents. The deficiency was identified through interviews, record review, and document review, which confirmed that the resident was not kept safe from abuse as required.
Failure to Obtain Resident Permission Before Removing Wheelchair Battery
Penalty
Summary
Staff failed to obtain permission from a resident prior to removing the battery from the resident's motorized wheelchair. The resident, who had diagnoses including multiple sclerosis, generalized anxiety disorder, and pain, was involved in an incident where the motorized wheelchair accidentally ran over another resident's foot. Following this incident, the resident was informed that they would be using a manual wheelchair for safety reasons. However, the battery of the motorized wheelchair was removed from the resident's room by the Maintenance Director, under the Administrator's instruction, without the resident's knowledge or consent while the resident was away at a doctor's appointment. The resident reported being upset that the battery was removed without their permission and confirmed that no one from the facility had asked for consent or explained the reason for the removal prior to the action. Both the Administrator and Maintenance Director acknowledged that the resident's permission should have been obtained and that the reason for the removal should have been communicated. The facility's own policy, as outlined in the Notice of Resident Rights, affirms the resident's right to a dignified existence, self-determination, and to be treated with respect and dignity.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering a psychotropic medication to a resident. The resident, who had diagnoses including type 2 diabetes mellitus, schizoaffective disorder bipolar type, major depressive disorder, and anxiety disorder, was prescribed Seroquel for paranoia, agitation, and irritability. Documentation showed that Seroquel was first administered on 07/17/2025, but there was no evidence in the medical record that informed consent had been obtained from the resident or their representative before the initial dose. Both a Registered Nurse and the Director of Nursing confirmed that facility policy requires informed consent prior to administering psychotropic medications, and that this was not documented for the resident in question.
Resident Elopement Due to Failure of Wander Guard System and Inadequate Supervision
Penalty
Summary
A resident with a history of Parkinsonism, major depressive disorder, and dementia with mood disturbance, who had demonstrated moderate to severe cognitive impairment, was able to elope from the facility without detection. The resident was last seen by staff in the evening and received medications and vital sign checks, but was later observed on security footage independently exiting the facility through a designated door in the early morning hours. The resident was not discovered missing until several hours later during a routine check, prompting a facility-wide search and eventual recovery of the resident outside the facility by a staff member. At the time of the elopement, the resident was wearing a wander guard bracelet, which failed to trigger an alert when the resident exited the building. The facility's investigation revealed that the functionality of the wander guard device had not been adequately tested for this resident, and the system did not activate as intended. Documentation showed that the maintenance department routinely checked the wander guard system at facility doors, but there was an oversight in ensuring the resident's individual device was operational, which contributed to the resident's ability to leave the facility undetected.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulation. Specific actions or inactions leading to this deficiency are not detailed in the provided excerpt, but the deficiency centers on the lack of adherence to resident autonomy in medical decision-making.
Failure to Document and Educate on Vaccination Status
Penalty
Summary
The facility failed to ensure that education regarding the risks and benefits of pneumococcal, influenza, and COVID-19 vaccines was provided to residents, and did not ensure administration or obtain documented declinations for two of five residents reviewed for infection control. Specifically, two residents with significant medical histories, including infection of an amputation stump, cellulitis, depression, and chronic systolic heart failure, could not recall being offered immunizations or receiving explanations about the risks and benefits. There was no documented evidence that these residents had been educated about or offered the relevant immunizations. Interviews with facility staff revealed that the process for new admissions included reviewing immunization status, offering vaccines, and obtaining signed consent or declination, but this process was not documented for the two residents in question. The Infection Preventionist and Director of Nursing both acknowledged the absence of documentation regarding vaccination status for these residents, despite facility policy requiring immunization status to be determined and recorded upon admission or soon after.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Employ Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was employed at least part time each month from late December 2024 to mid-May 2025. Payroll records confirmed that the previous IP's last day was 12/26/2024, and the next IP did not begin until 05/12/2025. During interviews, the Human Resource Manager verified that no other individual worked as an IP during this period. Although the CEO stated that two other employees held IP certification, it was confirmed that neither performed the duties of the IP, including oversight of the Antibiotic Stewardship Program, immunization, staff and resident education, or infection control surveillance. The interim Director of Nursing also confirmed that there was no IP in place during this time frame, resulting in a lack of oversight for the facility's Infection Prevention and Control Program and Antibiotic Stewardship Program. The absence of an IP was identified through document review and staff interviews, and the deficiency was cross-referenced with F881.
Failure to Administer Oxygen at Prescribed Dose
Penalty
Summary
A resident with chronic respiratory failure and chronic obstructive pulmonary disease was admitted to the facility with a physician's order for oxygen via nasal cannula at three liters per minute (LPM) as needed for shortness of breath, with the option to remove if breathing was comfortable. Despite this order, multiple entries in the Oxygen Saturations Summary Report documented that the resident received oxygen at two LPM on several occasions. Observations confirmed that the resident's oxygen concentrator was set to two LPM during multiple checks, and the resident reported wearing oxygen continuously and experiencing difficulty breathing. The resident also stated that they did not adjust the oxygen flow themselves and relied on facility staff for administration. Interviews with an LPN and the Interim Director of Nursing (DON) confirmed that the clinical record did not include an order for oxygen titration and that the expectation was for medications, including oxygen, to be administered at the correct dose as prescribed. The DON acknowledged that administering oxygen at an incorrect dose constituted a medication error. Facility policy required nurses to ensure the right dose when administering medications. The deficiency was identified through observation, interview, and record review, showing that the resident did not consistently receive oxygen at the prescribed rate.
Failure to Provide Necessary Care for Resident with Intellectual Disabilities and Skin Picking
Penalty
Summary
A resident with a history of traumatic subarachnoid hemorrhage, mild intellectual disabilities, and unspecified dementia with agitation was not provided with adequate care and services to address persistent scratching and picking at their arms and legs. The resident's care plan acknowledged communication challenges and included interventions for skin picking, such as the use of hydroxyzine and physical barriers like geri sleeves. Physician orders specified washing and applying lotion to the arms, using geri sleeves or tubi grip, and administering hydroxyzine as needed for itching and skin picking. Despite these interventions, clinical records and observations documented ongoing open areas, scratch marks, and active bleeding on the resident's extremities. Staff interviews revealed that the resident lacked the cognitive ability to request PRN (as needed) medications, and nursing staff administered hydroxyzine only when they observed scratching behavior. Both the LPN and RN confirmed uncertainty about why the medication was ordered as PRN rather than scheduled, given the resident's inability to communicate their needs. The facility's policy required individualized care for residents with intellectual disabilities, but the care provided did not ensure consistent management of the resident's skin picking behavior, resulting in preventable discomfort and risk of skin breakdown.
Some of the Latest Corrective Actions taken by Facilities in Nevada
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