White Pine Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ely, Nevada.
- Location
- 1500 Avenue G, Ely, Nevada 89301
- CMS Provider Number
- 295029
- Inspections on file
- 17
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at White Pine Care Center during CMS and state inspections, most recent first.
The facility did not create or implement comprehensive care plans for two residents with contractures and five residents receiving psychotropic medications. Observations and record reviews showed that contracture management, splint use, and interventions to prevent further loss of range of motion were not addressed in care plans. Similarly, care plans for residents on psychotropic medications lacked documentation of psychiatric diagnoses and medication management, despite facility policy requirements. Staff interviews confirmed these omissions.
The facility did not obtain or document informed consent for psychotropic medications for two residents with depression and agitation, despite physician orders for antipsychotic and antidepressant drugs. The required consents were not present in the medical records, contrary to facility policy, as confirmed by the interim DON during record review.
The facility did not consistently document or monitor side effects for psychotropic medications with black box warnings. For several residents prescribed antipsychotic and antidepressant medications, required monitoring was either inconsistently recorded or not ordered at all, and nursing staff did not always ensure that side effect monitoring orders were entered or documented in the medical record. This resulted in a lack of adequate monitoring for early signs of adverse effects as required by facility policy.
A resident with chronic health conditions experienced an incident involving physical contact with another resident, resulting in pain but no serious injury. Although the facility completed an investigation, the event was not reported to the State Agency within the required 24-hour timeframe, as mandated by facility policy. This delay could have impacted the timely review of the incident by authorities.
The facility did not complete neurological checks after a head injury for a resident with Parkinson's disease and failed to obtain a physician's order for the application and care of a right-hand splint for another resident with hemiparesis. These deficiencies were confirmed by staff and were not in accordance with facility policy.
A resident with spastic hemiplegic cerebral palsy and scoliosis was observed with a right arm contracture and no support or interventions in place to prevent further decline. Despite previous OT recommendations and a care plan noting limited mobility, there was no documentation of current rehabilitative services, physician orders, or care plan interventions to address or prevent the contracture. The DON confirmed the lack of assessment and intervention for the resident's condition.
Two residents with chronic medical conditions requiring supplemental oxygen did not have their O2 saturations consistently monitored or documented as ordered by their physicians. One resident received oxygen at a set rate without consistent documentation of O2 levels, while another had no specific flow rate ordered and also lacked regular O2 saturation documentation. The DON confirmed these inconsistencies, which were not in line with facility policy requiring monitoring as ordered.
The facility did not ensure that five CNAs completed the required 12-hour annual in-service training, including dementia care and abuse prevention. Employee files for CNA4, CNA6, CNA5, CNA3, and CNA2 lacked documentation of the necessary training within the last year. The DON, who recently joined the facility, was unaware of the specific in-service training provided. Although some training dates were provided, dementia care/behavior training was absent in the last 12 months, indicating non-compliance with the 12-hour training requirement.
The facility failed to ensure the accuracy of the MDS assessment for a resident with Alzheimer's disease. The resident, who had a severely impaired cognitive status, was incorrectly documented as having no falls since the previous assessment. However, records showed the resident had a fall resulting in a head laceration. The DON confirmed the inaccuracy was due to a coding error.
The facility failed to develop comprehensive care plans for a resident's communication needs and two residents' nutritional needs, despite clear indications from assessments and diagnoses. This was confirmed through observations, interviews, and record reviews.
The facility failed to update the care plans for two residents, one with cerebral palsy and severe intellectual disabilities, and another with Alzheimer's disease, despite changes in their needs and incidents of falls. The care plans did not reflect current physician orders or new preventive measures, as confirmed by the DON.
The facility failed to provide an ongoing program of activities for a resident with cerebral palsy, autistic disorder, and severe intellectual disabilities. Despite the care plan requiring one-on-one meaningful activities at least five times per week, the resident only received these activities 13 out of 80 possible times. Observations over four days showed the resident mostly lying in bed with no participation in activities, and staff confirmed the lack of adherence to the care plan.
A resident with hemiplegia and hemiparesis was not provided with necessary treatment to maintain or prevent further decrease in range of motion. Despite having a contracted right hand and a right leg strapped to the wheelchair bar, the resident was not receiving therapy or a restorative nursing program. The PT and CNA confirmed the absence of an RNP order, and no formal assessment had been conducted, placing the resident at risk for further contractures.
The facility failed to investigate and document a resident's falls, including a fall resulting in a head laceration. Despite having a care plan with specific interventions, the resident was often left unsupervised, and staff were unaware of the required interventions. The DON confirmed the lack of investigation and documentation, leading to unmet care needs and diminished quality of life for the resident.
The facility failed to provide adequate interventions and meal assistance for a resident with significant weight loss and did not ensure consistent weighing methods for another resident, leading to discrepancies in recorded weights. Staff were aware of the issues but did not take appropriate actions to address them.
A resident with depression and a history of mental health issues expressed suicidal ideation, but the facility failed to update the care plan or follow policies on behavior management and suicide threats. The resident's statements were not effectively communicated to the DON or MD, and the resident was not offered counseling services.
The facility failed to ensure a licensed consultant pharmacist performed a monthly medication regimen review for December 2023 for two residents, placing them at risk of unmonitored medication irregularities. The DON confirmed the absence of required reviews after contacting the pharmacist.
The facility failed to document indications and signs and symptoms for the use of antibiotic medications for a resident, leading to the potential for adverse side effects from unnecessary medications. The resident was treated with multiple antibiotics without proper documentation of UTI symptoms, and the nursing staff did not notify the attending physician of new antibiotic orders.
The facility failed to complete and accurately document care conferences for two residents and did not obtain a physician's order for an indwelling urinary catheter for another resident. The care conference forms were incomplete and not closed out, and the urinary catheter insertion was not documented in the resident's medical record.
The facility failed to ensure proper hand hygiene and glove changes during wound care for a resident with severe cognitive impairment and stage three pressure ulcers. An LPN and a CNA were observed not performing hand hygiene or changing gloves as required by facility policy.
Failure to Develop Comprehensive Care Plans for Contractures and Psychotropic Medication Management
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with contractures and those receiving psychotropic medications. For two residents with contractures, one was observed wearing a right arm splint and exhibiting deformity of the right lower extremity, while another had visible contractures of the right arm and hand. Despite documented diagnoses such as hemiparesis, muscle weakness, and spastic hemiplegic cerebral palsy, the care plans for these residents did not address the management of contractures, use of splints, or interventions to prevent further limitations in range of motion. Additionally, five residents with psychiatric diagnoses, including major depressive disorder, schizoaffective disorder, bipolar disorder, and depression, were receiving multiple psychotropic medications. However, their care plans did not include documentation addressing the residents' psychiatric diagnoses or the management and monitoring of their psychotropic medications. The facility's own policies require ongoing evaluation of the effects of psychotropic medications and the inclusion of measurable objectives and time frames in the comprehensive care plan, but these requirements were not met for the affected residents. Interviews with facility staff, including the DON and LPN, confirmed the lack of appropriate care plan interventions for both contracture management and psychotropic medication use. The DON acknowledged the importance of care planning for these areas and confirmed the deficiencies after reviewing the residents' medical records. The absence of these care plan elements was also confirmed through observation, record review, and document review.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document consent for psychotropic medications for two residents. For one resident with major depressive disorder and agitation, physician orders included Seroquel and Sertraline, but there was no documented evidence that consent was obtained prior to starting these medications. For another resident with adult failure to thrive and depression, physician orders included Duloxetine and Olanzapine, also without documented consent prior to initiation. The interim DON confirmed that consents for these medications were not present in the medical records and acknowledged that such consents are required to ensure residents or their representatives are informed about the medications' effects and possible side effects. Facility policy requires that, before starting or increasing psychotropic medications, residents, families, or representatives must be informed of the benefits, risks, and alternatives, including black box warnings for antipsychotics. Despite this policy, the required documentation of informed consent was missing for both residents at the time of the survey, as confirmed by record review and staff interview.
Failure to Document and Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of psychotropic medications for several residents. For two residents with diagnoses such as major depressive disorder, schizoaffective disorder, hallucinations, and insomnia, physician orders required daily monitoring for side effects associated with psychotropic medications, including those with black box warnings for increased risk of suicide and other psychiatric symptoms. However, review of the Medication Administration Records (MAR) revealed that monitoring was inconsistently documented, with numerical codes used in place of descriptive entries and a lack of corresponding progress notes to detail observations. Additionally, some shifts were not signed off to confirm that monitoring had occurred as ordered. For three other residents with diagnoses including bipolar disorder, depression, major depressive disorder, agitation, and failure to thrive, physician orders for psychotropic medications also included black box warnings. Despite this, there was no evidence that side effect monitoring orders were entered into the medical record as required. Interviews with nursing staff confirmed that the responsibility for entering such orders was not consistently fulfilled, resulting in the absence of documented side effect monitoring for these residents. The facility's policy on the use of psychotropic medications requires documentation of the resident's response to medication, including progress toward goals and the presence or absence of adverse consequences. The lack of consistent documentation and failure to enter required monitoring orders for psychotropic medications with black box warnings created a situation where residents were not adequately monitored for early signs of side effects.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting to the State Agency of an incident involving alleged abuse between two residents. One resident, with a history of hypertension and chronic obstructive pulmonary disease, was involved in an incident with another resident who has epilepsy and schizoaffective disorder. During the incident, one resident lost balance and placed a hand on the other's neck and shoulder area, while the other resident responded by placing a hand on the first resident's abdomen to prevent a fall. The incident resulted in the first resident experiencing pain but declining further medical evaluation. Staff statements indicated that the resident continued to allege physical abuse after the event. Although the facility conducted a thorough investigation and documented the incident, the Administrator in Training was not made aware of the situation until the following day, and the initial report to the State Agency was not filed until several days after the incident. This delay exceeded the facility's policy requirement to report all alleged violations within 24 hours, regardless of whether the event involved abuse or resulted in serious bodily injury. The delay in reporting had the potential to hinder timely review by the State Agency of the facility's investigative process.
Failure to Complete Neurological Checks and Obtain Splinting Orders
Penalty
Summary
The facility failed to complete required neurological checks following a head injury for one resident with Parkinson's disease and muscle weakness. After the resident experienced a fall, resulting in a laceration to the right ear and active bleeding while on a blood thinner, staff assisted the resident and transported them to the emergency department for evaluation and treatment. Despite a physician's order to initiate neurological checks for three days and monitor vital signs, the medical record lacked documentation of a post-fall assessment and neurological checks after the incident. The interim DON confirmed that these assessments were not completed as required by facility policy. Additionally, the facility did not obtain a physician's order for the application and care of a right-hand splint for another resident with hemiparesis following a cerebral infarction. The resident was observed wearing the splint, and therapy discharge recommendations included a splint and brace program. However, there was no documented physician order specifying the application or maintenance of the splint. Both the OTA and DON acknowledged the absence of a formal order and the importance of having one to ensure proper and consistent care, as outlined in facility policy.
Failure to Assess and Intervene for Upper Extremity Contracture
Penalty
Summary
A resident with spastic hemiplegic cerebral palsy and scoliosis was observed with a right arm contracture, specifically with the arm pulled to the upper chest and the wrist and hand curling, without any support to prevent involuntary flexion. Despite previous occupational therapy documentation indicating the resident could raise their arms and a prognosis to maintain function with consistent staff follow-through, there was no evidence of current rehabilitative services, physician orders, or care plan interventions to address or prevent the progression of the contracture. The resident's care plan noted limited physical mobility and the need to monitor for complications such as contractures, but the medical record lacked documentation of active interventions or assessments for the right arm contracture. The DON confirmed the absence of care plan interventions and rehabilitative service orders, acknowledging that early detection and intervention for contractures should have been implemented as part of nursing assessments.
Failure to Consistently Monitor and Document Oxygen Saturations as Ordered
Penalty
Summary
The facility failed to ensure that oxygen (O2) saturations were obtained and documented as ordered for two residents requiring respiratory care. One resident with chronic kidney disease and hypertension was observed receiving 4 liters of oxygen via cannula, but the medication administration records (MAR) for April and May showed inconsistent documentation of O2 saturation levels, despite a physician's order specifying O2 titration to maintain saturations above 90% every shift. The resident was unable to identify who adjusted the oxygen settings. Another resident with chronic ischemic heart disease and peripheral vascular disease was observed with an O2 concentrator set at 5 liters via nasal cannula. The physician's order for this resident required O2 saturation checks every shift, but did not specify the oxygen flow rate. MAR review for this resident also revealed inconsistent documentation of O2 saturations. The Director of Nursing confirmed the inconsistent documentation for both residents and acknowledged the importance of monitoring and titrating oxygen as ordered. Facility policy required monitoring O2 saturation levels as ordered by the physician.
Inadequate Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) received the required 12-hour annual in-service training, including education in dementia care and abuse prevention. Employee files for CNA4, CNA6, CNA5, CNA3, and CNA2 lacked documentation of completing the necessary training within the last year, putting residents at risk due to potential lack of knowledge and competency. The Director of Nursing (DON) acknowledged the deficiency, stating that they had recently joined the facility and were unaware of the specific in-service training provided. The DON provided some in-service training dates, including abuse/neglect, infection control, elopement process, and cultural competency, but noted the absence of dementia care/behavior training in the last 12 months, indicating that the provided training did not meet the required 12-hour criteria.
Inaccurate MDS Assessment for Resident with Alzheimer's Disease
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, identified as R5. R5 was admitted with a diagnosis of Alzheimer's disease and had a severely impaired cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The quarterly MDS assessment incorrectly documented that R5 had no falls since the previous assessment. However, a review of the Transfer to Hospital Summary revealed that R5 had a fall resulting in a small laceration on the head. The Director of Nursing (DON) confirmed that the MDS coding for falls was inaccurate, attributing it to a coding error.
Failure to Develop Comprehensive Care Plans for Communication and Nutrition
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed for Resident 10 (R10) to address communication needs. Despite R10's admission Minimum Data Set (MDS) indicating moderate cognitive impairment and a need for communication support, no care plan with measurable objectives and timeframes was created. Observations revealed that R10 had difficulty communicating and lacked a communication board, which was confirmed by the Social Services Designee (SSD) and the Director of Nursing (DON) upon review of the electronic medical record (EMR) and Care Area Assessment (CAA) summary. The facility also failed to develop a comprehensive care plan addressing nutrition for Resident 19 (R19). R19's admission record and MDS indicated the need for a nutrition care plan due to diagnoses including dehydration and dietary restrictions. However, no such care plan was found. Interviews with R19, the Registered Dietician (RD), and the Dietary Manager (DM) confirmed the absence of a nutrition care plan, despite R19 expressing concerns about the diet provided. Similarly, Resident 28 (R28) did not have a care plan that included interventions for weight loss prevention, despite having diagnoses that warranted nutritional monitoring. The DM confirmed responsibility for nutritional care plans but was unable to explain the omission. The RD also stated that they do not handle care plans for nutritional issues, highlighting a gap in the facility's care planning process.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents were revised in accordance with their current needs. Resident 13, who has diagnoses of cerebral palsy, autistic disorder, and severe intellectual disabilities, had a care plan that included the use of adaptive devices and nutritional supplements. However, during multiple meal observations, it was noted that these items were not provided on the resident's tray. Additionally, physician orders had discontinued these supplements and devices, but the care plan was not updated to reflect these changes. The Director of Nursing (DON) confirmed that the care plan had not been updated as required. Resident 5, diagnosed with Alzheimer's disease, had a care plan indicating a high risk for falls. Despite having two unwitnessed falls and a subsequent fall with injury, the care plan was not updated to include new approaches to prevent further falls. The DON confirmed that the fall care plan was not revised after the fall with injury. This failure to update care plans placed the residents at risk of not receiving care based on their current needs.
Failure to Provide Required Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to support the physical, mental, and psychosocial well-being for one resident (R13). R13, who has cerebral palsy, autistic disorder, and severe intellectual disabilities, was observed multiple times over a four-day period lying in bed with no evidence of participation in activities. The resident's care plan indicated a need for one-on-one meaningful activities at least five times per week, but records showed that R13 only received one-on-one activities 13 out of 80 possible times, resulting in an 81.25% non-participation rate. The Activity Director confirmed that R13 had not received the required one-on-one activities since January 2024 and acknowledged that follow-up visits were not conducted when R13 was found asleep during scheduled activity times. R13's guardian expressed concerns about the lack of activities, noting that R13 enjoyed water play and interacting with others at the nursing station, activities that had not been happening recently. The Activity Director and a Licensed Practical Nurse both confirmed that R13 loved water, music, and dancing but had not been receiving the activities as required. The facility's failure to adhere to the care plan and provide the necessary activities for R13 had the potential to negatively impact the resident's quality of life.
Failure to Provide Treatment for Range of Motion
Penalty
Summary
The facility failed to provide treatment to maintain or prevent further decrease in range of motion for a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who had moderate cognitive impairment, was observed with a contracted right hand and a right leg strapped to the wheelchair bar. Despite having a history of receiving therapy services and being prescribed a splint at previous nursing homes, the resident was not receiving any therapy or restorative nursing program (RNP) at the current facility. The physical therapist (PT) and certified nurse aide (CNA) confirmed that the resident was not on the RNP and that there was no order for such services. The PT stated that the resident did not need additional services because they were maintaining range of motion with the activities program exercise, but this was contradicted by the resident who reported not receiving sufficient exercise beyond the activity program. The PT also admitted that no formal assessment had been conducted for the resident, relying instead on observation and familiarity from a previous facility. The licensed practical nurse (LPN) indicated that a brace might help prevent further contractures and that an order for RNP could come from the doctor, not just therapy. The lack of a formal assessment and appropriate interventions placed the resident at risk for developing decreased motion or contractures.
Failure to Investigate and Document Resident Falls
Penalty
Summary
The facility failed to ensure an investigation was performed and a root cause analysis was established for a resident reviewed for falls. The resident, who had diagnoses including Alzheimer's disease, dementia, adult failure to thrive, and blindness, experienced multiple falls, including an unwitnessed fall that resulted in a head laceration requiring staples. Despite the facility's policy on fall evaluation and management, there was no documentation of a fall investigation, care plan revision, or root cause analysis for the fall incident on 01/17/24. The resident's care plan included several interventions to prevent falls, such as the use of a hi-lo bed, landing mats, and supervision while in a wheelchair. However, observations revealed that the resident was often left unsupervised, and staff were not aware of the specific care plan interventions. For instance, a CNA was unaware that the resident required supervision while in the room and had not been informed of the care plan updates. The Director of Nursing (DON) confirmed that there was no investigation or documentation of the resident's condition for 72 hours following the fall, as required by the facility's policy. The lack of proper documentation and communication among staff placed the resident at risk for unmet care needs and a diminished quality of life. The facility's failure to adhere to its own policies and ensure staff awareness of care plan interventions contributed to the deficiency identified by the surveyors.
Failure to Address Significant Weight Loss and Inconsistent Weighing Methods
Penalty
Summary
The facility failed to provide adequate interventions and meal assistance to address significant weight loss for Resident 13, who had diagnoses of cerebral palsy, autistic disorder, and severe intellectual disabilities. Despite the resident's guardian expressing concerns about weight loss and requesting a list of snacks and foods that the resident would eat, the facility did not provide this information. The resident's weight continued to decline significantly over several months, and there was no evidence of an appetite stimulant or tube feeding being ordered. Observations revealed that the resident often refused meals and supplements, and staff did not consistently assist the resident with eating or offer alternative food options when meals were refused. Additionally, the facility failed to ensure consistent weighing methods for Resident 16, who had diagnoses of end-stage renal disease, diabetes mellitus, congestive heart failure, and malnutrition. The resident's weights were inconsistently recorded, sometimes taken while standing and other times in a wheelchair, leading to significant discrepancies between the facility's weights and the dialysis center's weights. The facility did not reweigh the resident when there was a significant variance, and the dietary staff missed opportunities to provide additional calories by not including cereal in the resident's breakfast as per the menu. Interviews with staff, including the Medical Director, Dietary Manager, and Registered Dietitian, revealed a lack of communication and coordination in addressing the residents' nutritional needs. The Medical Director and staff were aware of the weight loss issues but did not take appropriate actions to address them. The facility's policies on nutrition and weight management were not effectively implemented, resulting in continued weight loss and inadequate nutritional support for the residents involved.
Failure to Provide Appropriate Behavioral Healthcare
Penalty
Summary
The facility failed to provide appropriate person-centered and individualized treatment and services for a resident diagnosed with depression and a history of mental health issues. The resident, who was admitted with diagnoses including depression and a urinary tract infection, expressed suicidal ideation during an emergency evaluation. Despite this, the facility's social services assessment did not identify any behavioral concerns or history of behavioral symptoms, and the resident's care plan was not updated to reflect the new behaviors or suicidal ideation. The resident's statements of wanting to die were documented in progress notes, but these were not communicated effectively to the Director of Nursing (DON) or the Medical Director (MD), who were unaware of the resident's suicidal statements. The facility's policies on behavior management and suicide threats were not followed. The Behavior Monitor Flowsheet was not implemented, and the Social Services Director (SSD) and interdisciplinary team (IDT) were not notified via the 24-hour report. Additionally, the resident's care plan was not updated with new behaviors, and no new approaches were developed. The SSD, who was responsible for developing the behavior care plan, did not identify the resident's depression or suicidal ideation during the initial assessment and was unaware of the resident's extensive mental health background until informed by the resident's representative. The DON, who had recently been hired, acknowledged the need for better correlation between psychotropic medications, behaviors, and care plans. The MD, who documented the resident's suicidal ideation in the admission note, was not aware of the resident's other statements of wanting to die. The facility had a contract with a behavioral health care professional, but the resident had not been offered counseling services since admission. This lack of communication and failure to follow established policies placed the resident at risk for increased distress and a diminished quality of life.
Failure to Perform Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed consultant pharmacist performed a monthly medication regimen review for December 2023 for two residents, R16 and R18, who were reviewed for unnecessary medications. This deficiency was identified through interviews and record reviews. R18, who was admitted with diagnoses including alcohol-induced dementia with violent behaviors and diabetes, had a severely impaired cognitive status and was on antipsychotic and antidepressant medications. The Medication Regimen Review book and R18's progress notes lacked documentation of a December 2023 medication review, which was confirmed by the Director of Nursing (DON) after contacting the pharmacist, who admitted to not having the reviews. Similarly, R16, who had multiple diagnoses including chronic kidney disease, congestive heart failure, and diabetes, and was on several medications including insulin, antidepressants, and anticoagulants, also did not have a documented medication review for December 2023. The care plan for R16 indicated a need for monthly pharmacy reviews, which were not found in the pharmacist's records or the electronic medical record (EMR) for the specified month. The absence of the required monthly medication regimen reviews for these residents placed them at risk of their physician and nursing staff not being aware of any medication irregularities. This oversight could potentially lead to adverse effects due to unmonitored medication regimens. The DON confirmed the lack of documentation and the pharmacist's failure to perform the reviews, highlighting a significant lapse in the facility's adherence to its medication review policies and procedures.
Failure to Document Indications for Antibiotic Use
Penalty
Summary
The facility failed to ensure that indications and signs and symptoms for the use of antibiotic medications were documented for one resident, resulting in the potential for adverse side effects from unnecessary medications. The facility's policy on urinary tract infections (UTIs) required empirical treatment to be based on documented symptoms and relevant test results. However, for Resident 2 (R2), there was no documentation indicating signs and symptoms of a UTI prior to the administration of antibiotics. R2 was treated with Cefdinir and later with Keflex without proper documentation of clinical indicators for a UTI. Additionally, the nursing staff failed to notify R2's attending physician of the new antibiotic order when R2 returned from the emergency department (ED). Further, a urinalysis ordered for a change in urine color and strong odor lacked documentation of these symptoms, and non-pharmacological interventions were not attempted before administering Bactrim DS. R2's medical records revealed multiple instances where antibiotics were administered without clear documentation of UTI symptoms. The urinalysis and culture results did not meet the clinical indicators for a UTI, yet antibiotics were still prescribed. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the absence of documentation indicating R2 was showing signs and symptoms of a UTI. The DON acknowledged that the nursing staff did not meet the facility's expectations for documenting indications of a possible UTI and the rationale for obtaining a urine specimen and starting an antibiotic.
Incomplete Medical Records and Missing Physician Order
Penalty
Summary
The facility failed to ensure the medical records for two residents were completed and accurate, specifically regarding the documentation of care conferences. For Resident 18, the care conference forms dated 05/23/23 and 02/05/24 were incomplete, missing the date, time, and attendees, and were not closed out and locked. The Social Service Designee admitted to not fully documenting the care conferences due to being busy. Similarly, for Resident 13, the care conference forms dated 04/11/23, 07/17/23, and 10/09/23 were unsigned, in progress, and lacked summaries from various departments. The Social Service Director confirmed these forms were incomplete and should have been completed by the respective departments before being signed off. Additionally, the facility failed to obtain a physician's order for an indwelling urinary catheter for Resident 2. The resident returned from an emergency department visit with a urinary catheter inserted and a diagnosis of a urinary tract infection, but there was no order for the catheter in the resident's electronic medical record. The Director of Nursing was unable to find documentation for the catheter insertion or the rationale behind it. The Licensed Practical Nurse stated that the process for new or changed orders after an emergency department visit was to notify the attending physician, which was not done in this case.
Failure to Ensure Hand Hygiene and Glove Changes During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during wound care for a resident with severe cognitive impairment and stage three pressure ulcers. During an observation, an LPN and a CNA were seen donning gloves without performing hand hygiene. The CNA removed a soiled dressing and continued to assist the resident without changing gloves or performing hand hygiene. The LPN also failed to change gloves or perform hand hygiene before and after handling a marker from their pocket during the wound care procedure. The resident involved had a history of stroke, peripheral vascular disease, and chronic kidney disease, and was severely impaired in cognition. The facility's policy on hand hygiene was not followed, as both the LPN and CNA admitted to not performing hand hygiene or changing gloves as required. The LPN acknowledged the lapse in infection control practices, and the CNA admitted to realizing the mistake immediately but did not correct it during the procedure.
Latest citations in Nevada
A resident with multiple medical conditions, including ESBL resistance and neuromuscular bladder dysfunction, was injured when a roommate pushed or slammed a bedside table toward their face during an argument about television volume, causing a cut lip and a loose tooth. The incident occurred in a shared room, involved resident-to-resident physical contact, and required assessment and law enforcement notification, demonstrating a failure to protect the resident from physical abuse.
An unauthorized male intruder repeatedly gained access to the facility through unsecured or inadequately controlled entry points, including following someone into the kitchen, bypassing the front lobby visitor kiosk, and entering through a window that was not fully locked. On one occasion he entered a resident’s room, identified himself as kitchen staff, and stole the resident’s cellphone containing personal identification and financial cards; on other occasions he stole personal items from staff, including a cellphone, wallet, and keys. Door alarms did not sound when he entered during at least one event, and staff initially considered the resident’s report possibly delusional before connecting it to prior and subsequent thefts and video evidence showing the same individual inside the building and on the grounds.
Multiple residents with psychiatric and behavioral histories physically assaulted other residents, including those with impaired cognition and significant medical conditions, resulting in documented injuries such as facial redness, bleeding, skin tears, abrasions, swelling, and periorbital discoloration. In separate episodes, one resident was slapped and nearly burned with a lit cigarette in a smoking area, another was pushed to the floor and kicked after entering a room, and two different roommates were punched on consecutive nights by the same hostile, non-redirectable resident. Facility leadership acknowledged a high behavior population, confirmed these events met the definition of willful infliction of injury and physical abuse, and reported that the aggressors had intact cognition, prior psychiatric hospitalizations, refusal of psychotropic medications, and a history that included homicidal ideation and threats with a weapon.
The facility failed to provide necessary behavioral health services, including trauma evaluations and meaningful interventions, for several residents involved in physical altercations and with significant psychiatric histories. After two residents were physically assaulted by roommates and sustained injuries, psychiatric providers were notified but did not document trauma-focused evaluations or address contributing behaviors such as wandering. Two other residents with schizophrenia, schizoaffective disorder, violent behavior, and documented noncompliance with psychotropic medications were involved in repeated aggressive incidents toward peers and staff, yet records showed only routine refusals of medication without evidence of effective, individualized behavioral interventions. The facility acknowledged a high-behavior population and a pattern of resident altercations, along with dissatisfaction with the psychiatric NP’s limited and delayed evaluations.
Failure to report resident-to-resident physical abuse: A resident with Alzheimer's disease was documented slapping another resident, and the other resident slapped back. The on-call manager was notified, but the incident was not reported to the SA. The DON later stated it was probably mutual combat and the MDS Coordinator, who was the DON at the time, confirmed physical abuse includes hitting and slapping and denied the incident was reported.
A resident with MS and polyneuropathy developed new occasional urinary incontinence after previously being continent, but the care plan did not include a focused care area or interventions to address the change. The resident reported not recalling staff prompting toileting at timed intervals, and the DON confirmed the care plan lacked urinary incontinence interventions and that the facility did not have a bladder training or retraining policy.
Failure to address new urinary incontinence: A resident with MS and polyneuropathy, previously continent of bladder, began having occasional urine incontinence but did not recall staff prompting toileting at timed intervals. The MDS later documented occasional bladder incontinence, yet the care plan had no focused interventions for the change in condition. The CNA was unaware of any bladder training/retraining program, and the DON confirmed the care plan lacked related interventions and the facility had no bladder training/retraining policy.
The facility failed to complete a required annual CNA performance review for one CNA, Employee #8, whose personnel record had no documented evaluation. The HR Director stated CNA evaluations were done each year on Oct. 1 to review the prior year and confirmed this CNA was not reviewed 12 months after starting at the facility. The Facility Assessment stated weaknesses identified in CNA performance reviews and annual competency assessments would be addressed through in-service training.
Facility Assessment did not match actual night shift staffing. The assessment stated Harmony Manor and Quail Corner each required an LPN on nights, with consistent staffing prioritized in the memory care unit, but the April schedule showed both units sharing one licensed nurse on multiple nights. The DON confirmed one nurse was responsible for all 32 residents on those nights and acknowledged the assessment needed to reflect the staffing schedule.
Unsanitary Kitchen Floor Drain: A kitchen floor drain was observed with a buildup of debris and grime, and the Kitchen Mgr confirmed it was dirty and could spread contamination. The Mgr stated floor cleaning was the responsibility of Maintenance, and the Maint Mgr later confirmed the drain had not been recently cleaned and was not sanitary. The facility policy required strict sanitary conditions in Dietary and Nutrition to prevent food contamination and growth of disease-producing organisms.
Failure to Protect Resident From Roommate’s Physical Abuse During Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. The resident was admitted with diagnoses including local infection of the skin and subcutaneous tissue, ESBL resistance, and neuromuscular dysfunction of the bladder. On the evening of 04/10/2026, while in a shared room, the roommate pushed or slammed a bedside table toward the resident during a dispute about the television volume being too loud. The bedside table struck the resident in the face, resulting in a bleeding lip and a loose tooth. The resident reported that the roommate became angry about the television volume and then pushed the bedside table toward their face. Following the incident, the resident was observed with blood on the face and lip, and a loose tooth was noted. The resident declined transfer to the hospital. Law enforcement was contacted, and both residents provided statements to the responding officer, with the injured resident declining to press charges. The roommate later stated that the bedside table had been positioned on the side of the bed and that they were pushing it back toward the other side, claiming they were simply returning the bedside table to its proper place. The facility’s failure to prevent this resident-to-resident physical altercation and resulting injury constituted a failure to protect the resident from physical abuse.
Unauthorized Intruder Repeatedly Accesses Facility and Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment for residents and staff when an unauthorized male intruder repeatedly gained access to the building and entered resident and staff areas, including a resident room. One resident, identified as R94, had been admitted with anxiety disorder, major depressive disorder, and left knee pain, and was alert and oriented at the time of the incident. Around 5:00 AM in December 2025, R94 observed an unknown man enter the resident’s room, state that he was kitchen staff checking the table for breakfast, and then take the resident’s cellphone, which contained a driver’s license, debit card, health insurance card, and bus card. R94 reported that the door alarms did not sound when the man entered the facility and that the resident typically heard alarms when someone entered without using the correct code. After the theft, there were two unauthorized charges on the resident’s debit card. Staff interviews revealed that this was not an isolated security breach. An LPN reported that in December 2025, R94’s report of a man entering the room and taking the cellphone was initially considered possibly delusional due to the resident’s history of seeing a person, but during the same IDT discussion another nurse reported that the day before R94’s report, a stranger had entered the kitchen and stolen a dietary staff member’s iPhone around 5:30 PM. Security camera footage showed the same man entering through a kitchen door by following someone from behind, indicating that he was able to bypass normal access controls. The same individual was later seen twice in the parking lot, and staff contacted police on those occasions. A CNA also recalled interacting with a man who claimed he was there to pick up belongings of a discharged resident and asked for the Wi‑Fi password, which the CNA provided; during the subsequent investigation, this man was identified as the same individual seen on video breaking into the building. The Administrator’s review of the January 24–25, 2026 incident documented that during a night shift, an unauthorized individual gained access by exploiting a window on the south side of the building that was not fully seated in the locked position, allowing him to shimmy the frame open and enter an unoccupied case management office. From there, he exited into the hallway, went to the nurse station, and took a nurse’s wallet and keys. As he attempted to exit through a west door, the door alarm sounded, but he was able to reach a vehicle and flee before staff arrived. The Administrator also confirmed a prior December 24, 2025 security breach in which an unauthorized male bypassed the front lobby visitor kiosk, entered the facility, and went into R94’s room, where he removed the resident’s cellphone and attached personal items from the bedside. Investigation of that December incident showed the individual was not an authorized visitor, family member, or vendor, and that he had been able to enter the building and a resident room without being stopped at the kiosk or by staff. The DON stated that R94’s report was handled as a grievance and resolved, but there were no IDT notes related to the incident, and the Administrator was not aware of the earlier kitchen theft when first discussing the December event.
Failure to Prevent Resident-on-Resident Physical Abuse in High-Behavior Population
Penalty
Summary
The facility failed to protect residents from physical abuse when multiple residents with known psychiatric and behavioral histories physically assaulted other residents on several occasions. In the first incident, one resident with fibromyalgia and an unspecified intracranial injury reported being slapped, cursed at, and nearly struck in the face with a lit cigarette by another resident in the smoking area, resulting in redness to the mandible area and involvement of law enforcement. The aggressor stated the victim was being annoying and deserved the assault. In a separate incident, a resident with moderately impaired cognition and no documented aggressive or wandering behaviors was pushed to the floor and kicked by another cognitively intact resident with schizophrenia and paranoid personality disorder after entering that resident’s room, causing a bleeding nose, a skin tear to the left forearm, and redness of the left forehead. Additional incidents involved a resident with moderately impaired cognition who reported being punched by a roommate, resulting in mild forehead swelling, and another resident with chronic obstructive pulmonary disease, heart failure, and schizoaffective disorder who was punched by the same aggressor after being moved into the room, sustaining discoloration around the left eye socket, a nose bridge abrasion, and a skin tear to the left forehead. Documentation showed that the aggressive resident was screaming violently, hostile, physically aggressive, and non-redirectable toward both residents and staff. The wound care team’s head-to-toe assessments confirmed the physical injuries sustained by the assaulted residents. Interviews with the DON, SSD, and DSD confirmed that these incidents met the facility’s own definition of willful infliction of injury and were classified as physical abuse. The DON stated that the aggressors had intact cognition, histories of inpatient psychiatric stays, and, in one case, a history of homicidal ideation and prior psychiatric hospitalization for chasing a person with a knife and threatening police. Facility leadership acknowledged a high behavioral population, an average of 45 residents with behavioral issues, and identified a pattern of resident altercations and physical abuse. They reported that the aggressors were refusing psychotropic medications and that concerns about psychiatric support, admission screening, and limitations on use of IM psychotropics had been communicated to the psychiatric provider and medical director, but these issues remained unresolved at the time of the incidents.
Failure to Provide Trauma Evaluations and Effective Behavioral Health Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including trauma evaluations, following resident-to-resident physical abuse incidents. One resident with psychosis, schizophrenia, and major depressive disorder was found on the floor with a bleeding nose, a skin tear, and forehead redness after being pushed and kicked by another resident. A psychiatry progress note documented that the psychiatric NP saw the resident per staff request, but the record lacked documentation that the altercation or physical abuse incident was discussed or that the resident’s newly identified wandering behavior, which led to the altercation, was addressed. Another resident with COPD, heart failure, and schizoaffective disorder was punched by a roommate, resulting in discoloration around the eye, a nose bridge abrasion, and a forehead skin tear. Although the care plan for emotional distress included a psychiatry evaluation and the NP was informed of the incident, there was no documented evidence that a psychiatric trauma evaluation was completed. The facility also failed to implement meaningful behavioral health interventions for residents with psychiatric histories, aggressive behaviors, and refusal of psychotropic medications. One resident with schizophrenia and paranoid personality disorder, intact cognition, and a history of violent behavior and homicidal ideation, including chasing a person with a knife and threatening police, was involved in multiple physical altercations. This resident punched another resident in the smoking area and later admitted to pushing and kicking a different resident who entered the room. The care plan identified behavioral problems such as irritability, anger, violent behavior, homicidal ideations, mood swings, and a tendency to push and kick other residents, with interventions including attempts to identify underlying causes. However, the medical record showed the resident routinely refused medications, and there was no documentation of effective, meaningful interventions addressing this ongoing refusal and associated behaviors. Another resident with neuroleptic-induced Parkinsonism, schizoaffective bipolar type, and psychosis, recently transferred from a psychiatric hospital after an exacerbation of schizophrenia symptoms and noncompliance with psychotropic medications, was also involved in a physical altercation. Progress notes documented that this resident punched a roommate, was screaming violently, hostile, physically aggressive, and non-redirectable toward residents and staff. A social services note indicated that when staff attempted to discuss the altercation, the resident became agitated, screamed, yelled, and used inappropriate language, preventing further information gathering. A refusal of treatment form showed the resident had declined medications after being informed that refusal could affect mood stabilization and worsen behaviors. Despite the facility’s acknowledgment of a high-behavior population and multiple resident altercations, the report describes a pattern of inadequate psychiatric support and lack of thorough evaluations and timely, effective behavioral interventions for these residents.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure an incident of resident-to-resident physical abuse was reported to the State Agency for 1 of 12 sampled residents. Resident #10, who was admitted with diagnoses including Alzheimer's disease and episodic tension-type headache, was documented in a nursing progress note as having been seen by a CNA slapping another resident, after which the other resident slapped Resident #10 back. The on-call manager was notified and directed staff to keep the residents apart and maintain them in eyesight if together. A physician progress note later documented that Resident #10 had been involved in a behavioral disturbance in which a heated exchange led to physical aggression between the two residents, with each resident physically striking the other. The DON stated the incident would probably not be considered resident-to-resident abuse because it was mutual combat and said the DON did not know whether either resident had been assessed for pain, injury, or mental anguish. The MDS Coordinator, who was the DON at the time of the incident, confirmed physical abuse includes hitting and slapping, denied being aware of the incident at the time, and denied that it was reported to the SA.
Care Plan Missing Interventions for New Urinary Incontinence
Penalty
Summary
The facility failed to develop a care plan with interventions to assist Resident #24 in maintaining continence after the resident, who had previously been continent, began experiencing occasional urinary incontinence. Resident #24 was admitted and later readmitted with diagnoses including multiple sclerosis and unspecified polyneuropathy. On 04/20/2026, the resident stated they had recently started having occasional urinary incontinence but could still get to the bathroom once they realized they were urinating, and the resident could not recall staff prompting them to toilet at timed intervals. An MDS assessment dated 07/07/2025 documented the resident was always continent of bladder, while an MDS assessment dated 04/06/2026 documented the resident was occasionally incontinent of bladder. The care plan did not include a focused care area or interventions related to the resident’s new urinary incontinence. On 04/22/2026, the DON stated the resident had become increasingly incontinent over the last several months and believed it was related to the resident’s multiple sclerosis. The DON also stated the facility could try offering assistance with a toileting schedule and confirmed the care plan did not include a care area or interventions related to the resident’s urinary incontinence, and that the facility did not have a policy for a bladder training or retraining program.
Failure to Address New Urinary Incontinence
Penalty
Summary
The facility failed to ensure a previously continent resident received assistance or interventions to maintain or improve urinary continence after the resident began experiencing occasional urinary incontinence. Resident #24 was admitted with diagnoses including multiple sclerosis and unspecified polyneuropathy. The resident stated that the resident had recently started having occasional urinary incontinence but could still reach the bathroom once the resident realized the resident was urinating, and the resident could not recall staff prompting bathroom use at timed intervals. Record review showed an MDS dated 07/07/2025 documented the resident was always continent of bladder, while an MDS dated 04/06/2026 documented the resident was occasionally incontinent of bladder. The care plan did not include a focused care area or interventions related to the new urinary incontinence. The CNA stated the resident had begun experiencing incontinence several months earlier and was not aware of any bladder training or retraining program, while the DON stated the resident had become increasingly incontinent over the last several months and that the facility could try a toileting schedule; the DON also confirmed the care plan lacked interventions related to the resident's new urinary incontinence and that the facility did not have a policy for a bladder training or retraining program.
Missing Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure a nurse aide performance review was completed at least once every 12 months and that areas of weakness were identified and addressed for 1 of 2 sampled CNAs, Employee #8. Employee #8 was hired as a CNA on 10/21/2024, and the personnel record lacked documented evidence of a nurse aide performance evaluation. During interview on 04/22/2026, the HR Director stated CNA performance evaluations were completed every year on October 1st to review the prior year and explained that, because of the date of hire, Employee #8 was not reviewed for performance. The HR Director confirmed Employee #8's nurse aide performance review was not completed 12 months after starting at the facility. The Facility Assessment, updated 03/2026, documented that areas of weakness identified in nurse aide performance reviews and annual competency assessments would be addressed through in-service training.
Facility Assessment Did Not Match Night Shift Staffing
Penalty
Summary
The facility failed to ensure its Facility Assessment accurately reflected current staffing needs. The Facility Assessment, updated 03/26/2026, stated the staffing plan included one licensed nurse on night shift for Harmony Manor and one licensed nurse on night shift for Quail Corner, and that consistent staffing would be prioritized in the memory care unit, with staffing levels not adjusted for low census or low acuity so resident needs would be met during call-ins and other staffing shortages. However, the April 2026 staffing schedule showed Quail Corner and Harmony Manor sharing a licensed nurse during night shift on multiple nights. During an interview on 04/24/2026, the DON stated that on Saturday, Sunday, Monday, and Tuesday nights, both units shared one licensed nurse during night shift, and that the nurse was responsible for all 32 residents in the facility. The DON confirmed the Facility Assessment indicated each unit required a licensed nurse during night shift and stated the Facility Assessment needed to be updated to reflect the staffing schedule.
Unsanitary Kitchen Floor Drain
Penalty
Summary
The facility failed to ensure staff maintained sanitary floor drains in the kitchen. On 04/20/2026 at approximately 10:45 AM, a kitchen floor drain was observed with a buildup of debris and grime. At approximately 10:50 AM the same day, the Kitchen Manager confirmed the drain had buildup of grime and acknowledged the potential spread of contamination, and stated that cleaning of the floor was the responsibility of the Maintenance Department. On 04/23/2026 at approximately 9:15 AM, the Maintenance Manager confirmed the kitchen floor drain had not been recently cleaned, was not sanitary, and acknowledged the potential spread of contamination. The facility policy titled, Maintenance of Strict Sanitary Conditions, dated 07/12/2022 and reviewed 07/08/2024, stated that maintaining strict sanitary conditions was of paramount importance in the Dietary and Nutrition Departments to eliminate food contamination and prevent growth of disease producing organisms, and to ensure maximum cleanliness and sanitation in the department.
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