cms_NV
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6,037 rows
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2019-02-06 | 641 | D | 0 | 1 | GLV211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to accurately assess a resident for the Minimum Data Set 3.0 (MDS) for 1 of 12 sampled residents (Resident #9). Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Resident #9's MDS 3.0 dated 01/14/19, Section K0200-Height and Weight, documented the resident's weight at 77 pounds. Section K0330-Weight Loss, documented the resident had a weight loss of 5% or more in the last month. Resident #9's weights were documented as follows: -01/11/19, 77 pounds -01/15/19, 78 pounds -01/23/19, 83 pounds -01/29/19, 85 pounds -02/01/19, 85 pounds -02/02/19, 85 pounds On 02/06/19 at 9:28 AM, the Chief Nursing Officer (CNO) confirmed Resident 9's MDS 3.0 Section K0330, dated 01/14/19, was incorrect. | 2020-09-01 |
| 2 | 2 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2019-02-06 | 679 | E | 0 | 1 | GLV211 | Based on interview and document review, the facility failed to implement additional activities into the activities program upon residents' requests. Findings include: On 02/05/19 at 10:21 AM, during the resident council meeting, two residents verbalized they wanted to do more activities. On 02/06/19 at 8:00 AM, the Activities Director verbalized she was made aware residents were requesting additional activities during the resident council meeting on 12/28/18, in-which she was in attendance. On 02/06/19 at 8:37 AM, the Activities Director confirmed no additional activities were added to the (MONTH) 2019 calendar. The Activities Director explained eight additional activities were added to the (MONTH) 2019 calendar without suggestions or input from the residents. The Activities Director verbalized she had not asked the residents what they would like to have included after becoming aware of their concern from the resident council meeting. Review of the activities calendar for (MONTH) 2019 documented one activity scheduled each day of the month except (MONTH) 1, 2019. An undated facility policy titled, Monthly Activity Calendar, Activities, LTC, documented the Activities Director shall identify the residents needs and interests to determine the calendars content. | 2020-09-01 |
| 3 | 3 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2019-02-06 | 700 | E | 0 | 1 | GLV211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review, the facility failed to assess for the risk of entrapment for the use of side rails for 10 of 12 sampled residents (Resident #2, #3, #4, #6, #9, #16, #18, #19, #20, and #23), and attempt to use appropriate alternatives prior to installation of side rails for 12 of 12 sampled residents (Resident #2, #3, #4, #6, #7, #9, #10, #16, #18, #19, #20, and #23). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:10 PM, Resident #2's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #2's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #3 Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:09 PM, Resident #3's bed had four, one-quarter (1/4) sized side rails attached to either side of the bed. Three of the four side rails were in the up position. Resident #3's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #4 Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:08 PM, Resident #4's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #4's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #6 Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:12 PM, Resident … | 2020-09-01 |
| 4 | 4 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2019-02-06 | 812 | F | 0 | 1 | GLV211 | Based on observation and staff interview, the facility did not maintain food preparation counters and equipment in food preparation areas in a clean and sanitized manner. Findings include: On 2/7/19, mid morning, the cook was observed washing dishes in the dishwashing area of the kitchen. No other dietary staff were working in the kitchen at the time, the Maintenance Director and the Food Service Director confirmed the observations: Personal items such as Eclipse gum, pink hand lotion and a bottle of medication were stored on a ledge directly in front of clean cups. A personal coffee cup was on the food preparation counter next to the food mixer, spilled food was on the other side of the mixer and had not been cleaned, a spoon with peanut butter and a used blue plastic glove was on the food preparation counter next to the [NAME]ot Coupe. Onion peels, a cut open green pepper cracked egg shells and used dirty blue plastic gloves were directly on the food preparation counter on the other side of the [NAME]ot Coupe machines. A plastic bag of sprouts that had been opened was on top of the recipe notebook and left on the counter next to a baked cake. The baked cake was not covered. A blue plastic used glove was on the floor in front of the food preparation counter. A dirty rag was placed on another food preparation counter and was touching the under side of the top of the butter container. A dirty apron and gloves had been removed from a dietary staff member and thrown on the food preparation counter. An opened can of beans was sitting on the counter. A red wire with no end cap or connector was left unprotected and placed under the office desk in the kitchen. The Food Service Director confirmed the apron and towels were not to be placed on the counters. There was no container/bucket of sanitizing solution for the cleaning towel, the only container available at the time of the observation was in the dishwashing area. Food preparation counters and equipment were not cleaned, food was not covered or stored in a safe/prote… | 2020-09-01 |
| 5 | 5 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2019-02-06 | 842 | D | 0 | 1 | GLV211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review the facility failed to ensure the Medication Administration Record [REDACTED] Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The MAR for Resident #2 for (MONTH) 2019, documented [MEDICATION NAME] tablet 1 mg, give 0.5 tablet by mouth as needed for breakthrough agitation every day PRN, order date 01/09/19. On 02/05/19 at 2:56 PM, the Registered Nurse (RN) verbalized PRN [MEDICAL CONDITION] medications were only to be used for 14 days. The night RN at the end of the month reviews the orders to be continued into the next month. The 14 days were complete in (MONTH) and the (MONTH) MAR indicated [REDACTED]. | 2020-09-01 |
| 6 | 6 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2020-02-12 | 552 | D | 0 | 1 | YHGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and document review, the facility failed to obtain an informed consent prior to the administration of a [MEDICAL CONDITION] medication for 1 of 12 sampled residents (Resident #16). Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #16's Medication Administration Record's dated from 03/01/19 through 02/11/20 documented the administration of [MEDICATION NAME] 10 mg to the resident each day per the physician's orders [REDACTED].>An informed consent for [MEDICATION NAME] 10 mg was signed by Resident #16's Public Guardian on 04/18/19. On 02/12/2020 at 10:29 AM, the Chief Nursing Officer confirmed the informed consent for Resident #16's prescribed use of [MEDICATION NAME] was not obtained prior to the first administration of the [MEDICAL CONDITION] medication. The facility policy titled, [MEDICAL CONDITION] Medications, updated 03/04/16, documented an informed consent for the use of [MEDICAL CONDITION] medications would be obtained prior to the administration of the medication. | 2020-09-01 |
| 7 | 7 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2020-02-12 | 600 | D | 0 | 1 | YHGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to protect a resident from verbal abuse from another resident in the dining room for 1 of 12 residents (Resident #2). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/09/20 at 12:06 PM, Resident #2 verbalized, on 02/08/20, the resident was eating dinner in the activity room at the table in front of the television. Resident #20 was seated at the table and called Resident #2 a derogatory name. Resident #2 verbalized the incident made Resident #2 feel bad. Resident #2 verbalized the resident notified a Certified Nursing Assistant (CNA) of the incident and was instructed by the CNA to give Resident #20 more space and recommended Resident #2 should allow Resident #20 to sit by the television alone. On 02/10/20 at 12:00 PM, Resident #2 was seated for lunch in the activity room. Resident #2 was seated in a chair with a bedside table pulled over the resident's lap. Resident #20 was seated approximately five feet to the left of Resident #2 at the table in front of the television. On 02/10/20 at 1:26 PM, Resident #2 verbalized the resident was instructed to sit away from the table so Resident #20 would not be bothered by Resident #2 sitting at the same table. A social services progress note, dated 02/10/20, documented Resident #2 verbalized Resident #20 had walked up to Resident #2 and called the resident a derogatory name. The resident had informed a dietary staff member. On 02/11/20 at 2:33 PM, the Chief Nursing Officer (CNO) verbalized the CNO was unaware of an incident of resident to resident verbal abuse involving Resident #2 and Resident #20. The CNO verbalized the incident of a resident calling Resident #2 a derogatory name would be considered verbal abuse. The CNO verbalized the staff notified of the inciden… | 2020-09-01 |
| 8 | 8 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2020-02-12 | 609 | D | 0 | 1 | YHGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to report an allegation of resident to resident verbal abuse to the administrator and the State Survey Agency (SA) for 1 of 12 residents (Resident #2). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A social service's progress note, dated 02/10/20, documented Resident #2 had verbalized, to a Licensed Social Worker (LSW), another resident had called Resident #2 a derogatory name. The resident had informed a dietary staff member. On 02/11/20 at 2:33 PM, the Chief Nursing Officer (CNO) verbalized the CNO was unaware of the incident reported to the LSW. The CNO verbalized the incident would be considered verbal abuse. The CNO verbalized the staff notified of the incident should have reported the incident and the incident should have been reported to the SA and investigated by the facility. On 02/11/20 at 3:25 PM, the LSW verbalized the resident had notified the LSW of the verbal abuse on 02/10/20. The LSW verbalized the LSW wrote a progress note regarding the allegation but did not notify the CNO or Administrator verbally. The LSW verbalized there had not been an investigation initiated into the incident and the staff caring for the residents had not been notified of the allegation. The LSW confirmed an investigation should have been initiated. On 02/11/20 at 3:29 PM, the LSW verbalized Resident #2 had reported to the LSW the resident had notified a dietary staff member of the incidence of verbal abuse. The LSW verbalized dietary staff were trained on abuse prevention and reporting on hire and annually. The facility policy titled Abuse Prohibition and Prevention, dated 12/04/07, documented it was the facility policy to protect and promote the rights of each resident, including the right to be free from all forms of abuse. It was the policy of the facility to report all allegation of actual or suspected a… | 2020-09-01 |
| 9 | 9 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2020-02-12 | 610 | D | 0 | 1 | YHGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to initiate an investigation for a report of resident to resident verbal abuse and failed to protect a resident from further potential abuse for 1 of 12 residents (Resident #2). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/09/20 at 12:06 PM, Resident #2 verbalized on 02/08/20, the resident was eating dinner in the dining room at the table in front of the television and Resident #20 was seated at the same table and the resident called Resident #2 a derogatory name. Resident #2 verbalized the incident made the resident feel bad. Resident #2 verbalized the resident had notified a Certified Nursing Assistant (CNA) of the incident. On 02/10/20 at 12:00 PM, Resident #2 was seated for lunch in the activity room. Resident #20 was seated at a table in front of the television in the activity room and Resident #2 was seated approximately five feet to the right of Resident #20 in a chair with a bedside table pulled over the residents lap. A social services progress note, dated 02/10/20, documented Resident #2 had verbalized to the Licensed Social Worker (LSW), Resident #20 had called Resident #2 a derogatory name on 02/08/20. Resident #2 had verbalized the resident had informed a dietary staff member when the incident occurred. On 02/11/20 at 2:33 PM, the Chief Nursing Officer (CNO) verbalized the incident of a resident calling Resident #2 a derogatory name would be considered verbal abuse and should have been reported to a supervisor and an investigation should have been initiated by the facility. On 02/11/20 at 3:25 PM, the LSW verbalized there had not been an investigation initiated into the incident and staff caring for the residents had not been notified of the allegation. The LSW verbalized staff should have… | 2020-09-01 |
| 10 | 10 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2020-02-12 | 644 | D | 0 | 1 | YHGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to complete a pre-admission screening and resident review (PASARR) level II screening for a resident with a [DIAGNOSES REDACTED].#18). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record for Resident #18 contained a PASARR level I screening, dated 12/20/17. The level I screening documented Resident #18 had no mental illness. On 02/10/20 at 3:40 PM, the Licensed Social Worker (LSW) provided a PASARR level I screen for Resident #18 dated 02/05/19. The PASARR documented Resident #18 had a mental health [DIAGNOSES REDACTED]. The electronic communication between the facility social worker and the Medicaid social worker, dated 02/08/19, documented the Medicaid social worker had requested information from the facility including IQ testing from the resident's primary psychiatrist and the name of the resident's caseworker for the resident's diagnosed intellectual disability. The electronic communication from the Medicaid social worker, dated 03/22/19, documented there had been no response from the facility since 02/08/19. On 02/12/20 at 9:26 AM, the Chief Nursing Officer verbalized the PASSAR level II screen had not been completed and there was no documentation of further communication from the facility to the Medicaid social worker. The facility policy titled PASRR Pre-admission Screening and Resident Review, undated, documented the PASARR process required all applicants to Medicaid-certified nursing facilities would be given a preliminary assessment to determine whether they had a serious mental illness or intellectual disability. Those individuals who tested positive at a Level I screen would then be evaluated in depth, called a Level II PASARR. The results of the Level II screen would determine need, appropriate setting, and would provide a set of recommended services to inform the indivi… | 2020-09-01 |
| 11 | 11 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2020-02-12 | 730 | D | 0 | 1 | YHGA11 | Based on interview and record review the facility failed to ensure a Certified Nursing Assistant's annual performance evaluation was completed for 1 of 11 sampled employees (Employee #6). Findings include: On 02/11/2020, during the Personnel Record Review, the personnel record for Employee #6 with a start date of 02/08/18, lacked documented evidence an annual performance evaluation was completed for 2019. On 02/11/2020 at 11:35 AM, the Administrator confirmed an annual performance evaluation had not been completed for Employee #6 for calendar year 2019. | 2020-09-01 |
| 12 | 12 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2020-02-12 | 758 | D | 0 | 1 | YHGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and document review, the facility failed to ensure behavior monitoring and Gradual Dose Reductions (GDR) were completed for three [MEDICAL CONDITION] medications for 1 of 12 sampled residents (Resident #16). Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Behavior Monitoring A physician's orders [REDACTED]. Resident #16's Care Plan dated 12/10/19, documented the resident was prescribed the [MEDICAL CONDITION] medication [MEDICATION NAME], and to monitor and record target behavior symptoms. Resident #16's clinical record lacked documented evidence monitoring and recording of behavior symptoms for [MEDICATION NAME] use were completed from 01/15/20 through 01/31/20. On 02/12/20 at 10:06 AM, the Chief Nursing Officer confirmed monitoring and recording of behavior symptoms for Resident #16's prescribed use of [MEDICATION NAME] had not been completed from 01/15/20 through 01/31/20. The facility policy titled, [MEDICAL CONDITION] Medications, updated 03/04/16, documented residents with any type of [MEDICAL CONDITION] medication use would have resident specific target behaviors monitored on an ongoing basis and be documented daily in the resident's clinical record. Gradual Dose Reductions A physician's orders [REDACTED]. A physician's orders [REDACTED]. Resident #16's Medication Administration Record's dated from 03/01/19 through 02/11/20 documented the administration of [MEDICATION NAME] 10 mg to the resident each day per the physician's orders [REDACTED].>Resident #16's Medication Administration Record's dated from 05/01/19 through 02/11/20 documented the administration of [MEDICATION NAME] Solution 1 mg/ml, 0.5 ml by mouth two times a day to the resident per the physician's orders [REDACTED].>Resident #16's clinical record lacked documented evidence a GDR was attempted or completed for the prescribed use of [MEDICATION NAME] 10 mg or [MEDICATI… | 2020-09-01 |
| 13 | 13 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2020-02-12 | 812 | F | 0 | 1 | YHGA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to properly label open food items and discard expired frozen food items in the kitchen. Findings include: Labeling On [DATE] at 10:48 AM, the reach-in freezer located next to the pan storage contained an opened bag of strawberries. The bag lacked a label identifying when the bag was opened. On [DATE] at 10:52 AM, the reach-in refrigerator located next to the dishwashing station against the back wall contained an opened container of grated Parmesan cheese. The container lacked a label identifying when the container was opened. On [DATE] at 11:03 AM, the reach-in freezer located next to the dry storage room contained one opened bag of French fries and one opened bag of biscuits. Each of the bags lacked a label identifying when the bags had been opened. On [DATE] at 11:07 AM, the Dietary Manager confirmed the strawberries, Parmesan cheese, French fries, and biscuits were not labeled with opened dates. The Dietary Manager verbalized all opened items should have been labeled with the open date after each food item was opened. The Dietary Manager removed and discarded the opened unlabeled food items from the freezers and refrigerator. The facility policy titled, Food Supply and Storage, dated [DATE], documented opened packages of food were to be labeled. Expired Food On [DATE] at 11:12 AM, the reach-in freezer located next to the kitchen staff workstation, contained six, 32-ounce bags of carrots. Three of the bags had an expiration date of [DATE] and three of the bags had an expiration date of [DATE]. The Dietary Manager verbalized the kitchen staff followed the facility policy on frozen food storage. On [DATE] at 12:27 PM, the six expired 32-ounce bags of carrots were still located in the reach-in freezer next to the kitchen staff workstation. On [DATE] at 12:51 PM, the Dietary Manager confirmed the six expired bags of carrots should have been removed and discarded per the fa… | 2020-09-01 |
| 14 | 14 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2020-02-12 | 943 | D | 0 | 1 | YHGA11 | Based on interview, personnel record review, and document review, the facility failed to provide abuse training to 1 of 11 sampled employees (Employee #9). Findings include: On 02/11/2020, during the Personnel Record Review, the personnel record for Employee #9 with a start date of 12/21/19, lacked documented evidence abuse training had been completed. On 02/11/2020 at 11:35 AM, the Administrator confirmed Employee #9 had not completed any abuse training since the employee's start date of 12/21/19. The facility policy titled, Abuse Prohibition and Prevention, effective date 12/04/07, documented employees were to receive abuse training during new hire orientation. | 2020-09-01 |
| 15 | 15 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2018-02-14 | 584 | D | 0 | 1 | OUMW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide a resident with comfortable room temperatures for 1 of 12 sampled residents (Resident #18). Findings include: Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/12/18 at 3:31 PM, Resident #18 verbalized the room was warm. The resident explained her family member had attempted to bring a fan into the facility but was told by the staff the resident could not have a fan. On 02/12/18 at 3:31 PM, Resident #18's room was warmer in comparison to other areas of the facility which included the opposite side of the room from where the bed was located. The afternoon sun was shining into the window located to the left of the bed. On 02/14/18 at 7:55 AM, Resident #18's family member confirmed earlier in the week she had attempted to bring in a fan and was stopped at the door and told she was not allowed to bring it in for Resident #18. The family member verbalized she did not understand why, as she had previously been allowed to bring in a fan for Resident #18 during a previous admission to the facility. On 02/14/18 at 08:01 AM, the Maintenance Director confirmed he stopped the family member in the lobby from entering the facility with the fan as the fan had a heating element and having the fan in the facility would have been against life safety code. The Maintenance Director confirmed he did not explain a fan was allowed without a heating element, such as a boxed fan, and verbalized he had fans he could provide if she just asked. The Maintenance Director confirmed he did not offer a fan to the resident or family member before today. The Maintenance Director confirmed he was aware other residents in the facility had fans without heating elements in the facility. On 02/14/18 at 08:13 AM, Resident #19 had an electric fan located on a bedside table. On 02/14/18 at 08:20 AM, Resident #8 had an electric fan located on … | 2020-09-01 |
| 16 | 16 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2018-02-14 | 623 | E | 1 | 0 | OUMW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to notify the Office of the State of Nevada Long-Term Care Ombudsman on an emergency facility initiated resident transfer for 1 unsampled resident, (Resident #173). Findings include: Resident #173 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility initiated the resident's emergency transfer on 01/17/18 to Pershing General Hospital's emergency department for evaluation due to a consciousness decline after treatment of [REDACTED]. Resident #173's clinical record lacked documented evidence the Office of the State of Nevada Long-Term Care Ombudsman was notified of the emergency transfer. On 02/14/18 at 10:07 AM, the Social Worker verbalized nursing staff completed all discharge documentation and notifications of emergency discharges and transfers. The Social Worker explained she was not aware of any Long-Term Care Ombudsman notification requirement and is not familiar with the process of transferring a resident from the Skilled Nursing Facility to Pershing General Hospital. On 02/14/18 at 10:34 AM, the Chief Nursing Officer (CNO), verbalized the facility did not have a formal process in place for resident transfers from the skilled nursing facility to Pershing General Hospital. The CNO explained nursing staff entered transfers in the resident's clinical record progress notes and verbally communicate the transfer or discharge to Pershing General Hospital during daily report. The CNO verbalized she was familiar with the requirement of notification to the Long-Term Care Ombudsman of resident transfers and discharges. The CNO explained the facility did not have a policy or procedure for the process of transfer or discharge notification to the Long-Term Care Ombudsman office. The CNO acknowledged no transfer or discharge letter was sent to the Office of the State of Nevada Long-Term Care Ombudsman for Resident #173. Complaint # NV 915 | 2020-09-01 |
| 17 | 17 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2018-02-14 | 655 | E | 0 | 1 | OUMW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and clinical record review, the facility failed to ensure baseline care plans were created for limited range of motion (ROM), wound care, depression, pain management and fall risk for 3 of 12 sampled residents (Resident #18, #123 and #124). Findings include: Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/12/18 at 3:46 PM, Resident #18 explained there was an open would located on her right leg and there was no longer an infection present within the wound. It was observed there was a wound vac present on the wound. Resident #18 verbalized she was readmitted to the facility due to the inability to manage the wound vac at home. Resident #18 confirmed base line care plans were not received in writing from the facility which included a care plan regarding the wound care for the resident's thigh. Resident #18's Progress Notes, dated 01/18/18, documented the following regarding wound care: the resident was agreeable to wound care by the facility. A new VAC Ulta was being supplied to the resident. Physical Therapist (PT) removed dry dressing with heavy serosanguinous drainage and mod order. PT cleansed and measured the wound 23 cm X 11 cm X 2.0 cm (centimeters) with undermining from 1 o'clock measuring 6 cm at greatest depth. PT used sharps to remove 30% of the wound dressing, remaining tightly adheredto the resident's right leg. Wound 90% smooth red moist, 10% slough. PT wound was dressed per protocol with VAC, achieving good suction with no troubleshooting. Wound was still progressing. Resident #18's base line care plan lacked documented evidence for wound care for the resident's open wound on the right thigh. On 02/14/18 at 11:26 AM, the Chief Nursing Officer (CNO) confirmed Resident #18 did not receive a copy of the baseline care plan as required. The CNO confirmed a baseline care plan for wound care was not initiated after Resident #18 was readmitted . … | 2020-09-01 |
| 18 | 18 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2018-02-14 | 684 | D | 0 | 1 | OUMW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure medications were administered as per Physicians' orders for 2 of 12 sampled residents (Resident #6 and #8) Findings include: Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record revealed a Physician order [REDACTED]. Medication Administration Record [REDACTED]. On 02/13/18 at 3:01 PM, the Chief Nursing Officer (CNO) confirmed the finding and acknowledged the dose was not administered as per physician order. Resident #8 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of medical record revealed a physician order [REDACTED]. Facility policy titled Medication Administration dated 05/16/06, documented medications would be administered according to the established administration times to ensure consistency in dosing intervals. Medication Administration Record [REDACTED]. On 02/13/18 at 7:37 AM, a medication pass observation was conducted with a Registered Nurse (RN). The medications administered during the observation included: [MEDICATION NAME] 100 mg 1 tablet. [MEDICATION NAME] 24 hours ER (extended release) 120 mg 1 tablet. Prednison 5 mg 1 1/2 tablet. [MEDICATION NAME] 20 mg 1 tablet. Milk of Magnesium 15 ml (milliliter) Potassium chloride 10 mEq (milliequivalent) 1 tablet. [MEDICATION NAME] 10 mg 1 tablet. [MEDICATION NAME] 10 mg 1 tablet. [MEDICATION NAME] 17 GM (gram) in 6 Oz (ounce) of water. [MEDICATION NAME] 3.125 mg 1 capsule. [MEDICATION NAME] 500 mg 1 tablet. [MEDICATION NAME] 5/325 mg 1 tablet. Iron sulfate 325 mg 1 tablet. Multivitamins 1 tablet. During the observation, the medication [MEDICATION NAME] was not administered. The MAR indicated [REDACTED]. On 02/13/18 at 4:24 PM, the RN confirmed the finding and indicated the medication [MEDICATION NAME] should have been administered with the morning medications. | 2020-09-01 |
| 19 | 19 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2018-02-14 | 695 | D | 0 | 1 | OUMW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure an oxygen humidifier was filled with solution for 1 of 12 sampled residents (Resident #6). Findings include: Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record revealed a Physician order [REDACTED].>On 02/13/18 at 2:10 PM, the resident was on her bed receiving oxygen at 2 liters per minute via nasal cannula from a concentrator. It was noted the humidifier in the oxygen concentrator was empty. On 02/13/18 at 2:17 PM, an RN confirmed the observation and indicated the Oxygen humidifier should have checked every shift and changed when the solution dried. Facility policy titled Respiratory Care Infection Control effective date 2004, revealed disposable humidifiers would be used and replaced every 7 days and as needed. | 2020-09-01 |
| 20 | 20 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2018-02-14 | 711 | D | 0 | 1 | OUMW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility failed to ensure a wound care order had been in place for a resident admitted with a wound, for 1 of 12 residents (Resident #18). Finding include: Resident #18 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Resident #18's physician order, dated 01/24/18 for wound care and strengthening had been completed 7 days after admission to facility. Documented on the physicians order resident to be treated for [REDACTED]. On 02/14/18 at 11:26 AM, the Chief Nursing Officer (CNO) confirmed there was not an order for [REDACTED]. Resident #18's clinical record lacked documented evidence of a physician order [REDACTED]. Resident #18's physician order [REDACTED]. Wound vac to right lateral thigh wound. Physical therapist to change wound vac dressing every three days and as needed for [DIAGNOSES REDACTED]. A facility policy titled, Written, Verbal, Electronic Physician Order, effective date 06/12/14, new orders must be written for the patient upon transfer into and out of the ICU/CCU, postoperatively and at each hospital admission, regardless of frequency of admission. Further, the policy documented all orders for treatment should include the type of treatment, specific requirements of the treatment (such as wet to dry dressings, etc.) and the frequency of treatment. | 2020-09-01 |
| 21 | 21 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2018-02-14 | 803 | F | 0 | 1 | OUMW11 | Based on observation, interview, and document review the facility failed to ensure residents received full entree portions according to the menu for 24 of 24 residents (Resident #19, #123, #13, #10, #15, #20, #22, #6, #21, #3, #2, #14, #1, #8, #124, #7, #17, #18, #12, #9, #4, #11, #16, and #5). Findings Include: On 02/13/18 at 12:18 PM, the cook was observed using one gray scoop, with a number 8 noted on the handle, to serve frank and beans and one gray spoodle, with a number 8 noted on the handle, to serve steamed vegetables on to resident trays for lunch service. The cook scooped a full scoop of franks and beans onto a tray and proceeded to add approximately an ounce more food onto the resident trays using the same gray handled scoop. The cook communicated the serving sizes were found on a blue sheet of paper, in a binder, in the kitchen and the sheet of paper was referred to prior to serving lunch on 02/12/18. No documentation was found in the kitchen documenting serving sizes for each numbered utensil. The cook verbalized the scoop size is about 3/4 cup in size and was adding extra food into the scoop to measure about a cup of food per resident. The cook admitted not knowing how much food was actually being served to each resident. The Dietary Manager verbalized a #8 scoop was approximately a serving size of 1 cup but there was no way to be exact with the measurement of food being served with the scoop. The Dietary Manager filled the gray handled scoop, with a number 8 notated on the handle, with water and poured water into a red drinking cup. The cup was measured at 1/2 cup. Documentation in the kitchen titled, Diet SpreadSheet X-Format, documented each resident will be given 1 cup of frank and beans for lunch service. The Dietary Manager and cook confirmed 22 total residents were served only a 1/2 cup of frank and beans. One cup should have been the serving size for each resident. The Dietary Manager expressed policies would be reviewed to see if there was a serving size definition located in the facility p… | 2020-09-01 |
| 22 | 22 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2018-02-14 | 812 | F | 0 | 1 | OUMW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store Mighty Shakes at proper temperature, follow proper hand hygiene, discard expired items and properly label opened food. Findings Include: Expired food items: On [DATE] at 10:35 AM, an opened container of mayonnaise was observed located in a refrigerator at the rear of the kitchen. The facility documented the jar of mayonnaise was opened on [DATE]. No manufacture expiration date could be found on container. The Dietary Manager confirmed no expiration date could be found on the manufactured jar of mayonnaise. A facility policy titled, Frozen, Refrigerated, & Dry Food Shelf Life, documented food shall be used within the recommended expiration periods to ensure food freshness and safety. Foods stored in the refrigerator that have a use by date or best before date will be used by that date, or discarded. The opened or prepared foods without a use by or best before date will be discarded after 7 days of opening. All foods would be checked daily and be discarded. Food labeling: On [DATE] at 10:35 AM, observed in a refrigerator, open containers of juice with no open date on the container. The juice in the refrigerator was Thirster Grape, 46 fluid oz. (ounce), Thirster prune juice, 46 oz., Monarch apple juice, 46 fluid oz., and Monarch cranberry juice, 46 oz. The cook and Dietary Manager verbalized facility does not mark juice containers as the containers are opened because the containers of juice were consumed the same day as they are opened. Proper food temperatures and labeling: On [DATE] at 10:35 AM, observed in a refrigerator, 29 dairy Mighty Shakes, to be stored frozen and a box containing 75 chocolate shakes, with a label of keep frozen on them. The Dietary Manager stated the shakes were removed from the freezer and stored in the refrigerator to defrost 48 hours prior to serving residents. It was observed the refrigerator felt warm to the touch on the bottom shelf. … | 2020-09-01 |
| 23 | 23 | PERSHING GENERAL HOSPITAL SNF | 295000 | 855 6TH STREET | LOVELOCK | NV | 89419 | 2018-02-14 | 883 | D | 0 | 1 | OUMW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 1 of 12 sampled residents, or the resident's representative, received education regarding the benefits and potential side effects of the influenza and Pneumococcal immunizations (Resident #6). Findings include: Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6's clinical record lacked documented evidence the resident or the resident's representative received education regarding the benefits and potential side effects of the influenza and Pneumococcal immunizations. On 02/14/18 at 01:34 PM, the Chief Nursing Officer (CNO), verbalized Resident #6's clinical record lacked documentation the resident or her representative received education on the risks and benefits of the influenza and Pneumococcal vaccines. A facility policy, titled Immunization Program for Long Term Care, Effective Date: 11/18/11, documented the appropriate vaccine information statement was to have been provided to the resident and/or the resident representative prior to administration of a vaccine. | 2020-09-01 |
| 24 | 24 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 552 | D | 0 | 1 | 0DP411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to obtain an informed consent outlining the risks and benefits of a [MEDICAL CONDITION] medication prior to administration for 1 of 12 residents (Resident #8). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #8's Medication Administration Record [REDACTED]. Resident #8's clinical record lacked documented evidence of a signed informed consent outlining the risks and benefits for donepezil [MEDICATION NAME]. On 01/09/19 at 2:32 PM, the Assistant Director of Nursing (ADON), confirmed Resident #8's clinical record lacked documented evidence a signed consent for donepezil [MEDICATION NAME] was obtained prior to administration. The facility policy titled, Medication, [MEDICAL CONDITION] Consents, revised 11/21/17, documented a consent was to have been obtained prior to the administration of the [MEDICAL CONDITION] medication. | 2020-09-01 |
| 25 | 25 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 610 | D | 0 | 1 | 0DP411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure allegations of verbal and physical abuse were investigated and reported for 1 of 12 sampled residents (Resident #3). Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/08/19 at 11:06 AM, a Resident Council Interview was held with four members of the Resident Council. The residents expressed concerns with Resident #3. Resident #3 was not present at the interview. The residents in the meeting verbalized the following statements: -Everyone had to do what Resident #3 wanted and the residents felt the facility lets Resident #3 do what Resident #3 wanted. -Resident #3 swore at residents. One resident recalled Resident #3 had made the statement fxxx you bxxch to the resident and had also been called names. -One resident explained Resident #3 had stated drop dead to the resident. -The facility staff had explained other residents have the right to be foul mouthed. Resident #3's progress notes revealed the following: -12/22/18 Resident #3 engaged into a few arguments with a couple of residents, took phone from a resident and hung up on the conversation. -12/23/2018 Resident #3 was stopping visitors in the hallway and talking on the phone about another resident. Resident #3 kept going on about how this particular resident was dying. The staff told her to stop saying things like that and Resident #3 just turned away and ignored the staff acting like Resident #3 could not hear the staff. -01/01/2019 Resident #3 was bothering residents by yelling at them from the doorway. The resident who was being yelled at had complained to the staff. Resident #3 has been very demanding about the TV in the den room, even to the extent of yelling down the hall. On 01/08/19 at 5:25 PM, the Assistant Director of Nursing (ADON) verbalized the Resident #3 had been verbally abusive to other residents and staff. Resident … | 2020-09-01 |
| 26 | 26 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 689 | D | 0 | 1 | 0DP411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to remove and secure a cigarette lighter from a resident's room for 1 of 12 sampled residents (Resident #8). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 01/08/19 at 2:56 PM, Resident #8 was alone, sitting in a wheel chair, smoking a cigarette in the smoking shed. The resident had an unzipped cigarette pouch on her lap containing an opened pack of menthol cigarettes and a black BIC lighter. On 01/08/19 at 3:00 PM, Resident #8 left the smoking shed and re-entered the facility. The resident wheeled directly into her room, with the unzipped cigarette pouch on her lap, and did not speak to any facility staff. Resident #8 placed the cigarette pouch in the top drawer of a small two-drawer table under the T.V. A facility smoking assessment dated [DATE], documented Resident #8 was to have the facility store the lighter. On 01/08/19 at 3:07 PM, the Certified Nursing Assistant (CNA) verbalized Resident #8 had always kept her cigarettes and lighter in her room. On 01/08/19 at 3:09 PM, the Licensed Practical Nurse (LPN) verbalized only cigarettes could be kept in the resident's room and lighters were to be kept at the nursing station. The LPN entered Resident #8's room and verified the lighter was in the resident's drawer in the resident's room. The LPN confirmed the lighter should have been kept at the nursing station to prevent fire hazards. The facility policy titled, Fire Safety-Smoking Policy, revised 10/20/17, documented any paraphernalia capable of igniting smoking material must be obtained from, and returned to, the nursing staff. | 2020-09-01 |
| 27 | 27 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 711 | D | 0 | 1 | 0DP411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to ensure a physician documented a progress note after a visit for 1 of 12 sampled residents (Resident #18). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #18's nursing progress notes dated 11/30/18, documented resident was seen by a physician for coughing and shortness of breath. A physician order [REDACTED]. On 01/10/19 at 11:05 AM, the Assistant Director of Nursing (ADON) verbalized the facility did not have a physician progress notes [REDACTED].#18's assessment on 11/30/18, only the narrative note entered by the nursing staff. The facility policy titled, Physician Visits and Medical Orders, effective 11/17, documented physicians had to write, sign and date program notes at each visit. | 2020-09-01 |
| 28 | 28 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 712 | E | 0 | 1 | 0DP411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure physician visits occurred within the required time frames for 5 of 12 sampled residents (Resident #8, #14, #15, #17, and 18). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's clinical record lacked documented evidence a physician visit occurred between 01/23/18 and 05/16/18. On 01/10/19 at 11:46 AM, the Assistant Director of Nursing (ADON), confirmed the facility lacked documented evidence a physician visit occurred for Resident #8 between (MONTH) (YEAR) and (MONTH) (YEAR). Resident #14 Resident #14 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #14's clinical record lacked documented evidence a physician visit occurred from 08/20/18 to present. On 01/10/19 at 11:46 AM, the ADON confirmed the facility lacked documented evidence a physician visit occurred for Resident #14 after 08/20/18. Resident #17 Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 01/10/19 at 10:00 AM, the ADON confirmed the facility lacked evidence a physician visit occurred for Resident #17 between 09/2018 and present. Resident #15 Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 01/10/19 at 10:02 AM, the ADON confirmed the facility lacked evidence a physician visit occurred for Resident #15 from admission to 01/02/19. The ADON confirmed a physician visit was required every 30 days for the first 90 days after admission and every 60 days after the first 90 days. Resident #18 Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/10/19 at 11:15 AM, Resident #18 verbalized she did not see her doctor for a long time and she would not have refused a physician visit. Resident #18's Minimum Data Set (MDS) 3.0 , section C - cognitive patterns, dated 11/09/18, docum… | 2020-09-01 |
| 29 | 29 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 730 | D | 0 | 1 | 0DP411 | Based on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual review to determine specific in-service education training needs for 1 of 9 sampled CNAs. Findings include: A CNA with a start date of 06/25/09, lacked an annual performance review for (YEAR). On 01/09/19 at 3:03 PM, the Human Resources/Payroll Manager confirmed the CNA's personnel record lacked an annual performance review for (YEAR) to determine specific in-service education training needs. | 2020-09-01 |
| 30 | 30 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 758 | D | 0 | 1 | 0DP411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to implement gradual dose reductions or provide a clinical justification for continued use of a [MEDICAL CONDITION] medication for 1 of 12 sampled residents (Resident #8). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #8's clinical record lacked documented evidence a gradual dose reduction was implemented, or a clinical justification for the continued use was provided, for donepezil [MEDICATION NAME]. On 01/09/19 at 2:32 PM, the Assistant Director of Nursing (ADON) confirmed Resident #8's clinical record lacked documented evidence a gradual dose reduction was implemented for donepezil [MEDICATION NAME]. The ADON confirmed the facility was administering donepezil [MEDICATION NAME] to Resident #8 for the [DIAGNOSES REDACTED]. The facility policy titled, Drug Reduction, revised 10/12/16, documented psychoactive drugs administered to residents, should have received a gradual dose reduction. | 2020-09-01 |
| 31 | 31 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 761 | D | 0 | 1 | 0DP411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure medications were secured for 1 of 12 sampled residents (Resident #7) and to discard opened bottles containing Sodium Chloride 9 % and Sterile Water used for wound care. Findings include: Resident #7 Resident # 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/07/19 at 11:23 AM, a bottle of 1000 milliliters (ml) Sterile Water for irrigation and a bottle of 500 ml of 0.9 % Sodium Chloride solution for irrigation were found opened on the Resident #7's bedside table. The Sterile Water bottle contained approximately 800 ml and the 0.9% Sodium Chloride bottle had approximately 300 ml solution and had been used to care for Resident #7's suprapubic catheter. On 01/07/19 at 11:28 AM, a Licensed Practical Nurse (LPN) confirmed the presence of the two bottles with Sterile Water and Sodium Chloride solutions on Resident #7's bedside table. The LPN verbalized the Sterile Water and Sodium Chloride should not have been left in the resident's room. On 01/10/18 at 10:35 AM, the Assistant Director of Nursing (ADON) verbalized Resident #7 was not self-administering medications or cleaning the suprapubic catheter site on her own. The ADON explained the solutions left after wound irrigation should have been discarded and no medication should be kept in the residents' rooms. On 01/09/19 at 12:26 PM, the treatment room was observed with a LPN. A bottle of 1000 ml Sterile Water for irrigation and a bottle of 500 ml of 0.9 % Sodium Chloride solution for irrigation were found opened in the treatment room in the wound cart. The Sterile Water bottle contained approximately 800 ml and the 0.9% Sodium Chloride bottle had approximately 300 ml solution. The LPN confirmed both bottles in the wound cart were opened, used once and needed to be discarded. She verbalized the bottles did not have an opening date and the labels indicated not to be used if the seal was broken.… | 2020-09-01 |
| 32 | 32 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 880 | D | 0 | 1 | 0DP411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to perform hand hygiene during wound care for 1 of 12 sampled residents (Resident #3). Findings include: Resident #3 Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Dressing with 4x4 and [MEDICATION NAME] gauze. On 01/09/19 at 4:05 PM, wound care treatment observation was conducted with a Licensed Practical Nurse (LPN). The LPN removed the old dressing from Resident #3's left foot and proceeded to perform wound care. The LPN flushed the wound with a prefilled syringe with Normal Saline, patted dry the wound, applied the [MEDICATION NAME] ointment and covered it with a [MEDICATION NAME] non-adhering dressing. The LPN removed the gloves on both hands and donned a new pair of gloves without washing hands with soap and water or using an alcohol-based sanitizer. Then the LPN applied the [MEDICATION NAME] gauze to cover the wound. On 01/09/19 at 4:10 PM, the LPN confirmed not washing hands after the dirty gloves were removed and before donning the new pair of gloves and using dirty gloves for a clean procedure. The LPN verbalized not following the hand washing procedure could have contaminated the wound. On 01/09/19 at 4:10 PM, the Chief Nursing Officer/Infection Control verbalized the hand washing had to be done before donning gloves and before applying the new dressing to prevent spreading infections. The facility policy titled, Hand Hygiene, effective 01/23/12, documented to use antimicrobial soap and water or an alcohol-based hand rub after contact with a patient's intact skin, after coming in contact with bodily fluids and dressings and always after removing gloves. | 2020-09-01 |
| 33 | 33 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 881 | D | 0 | 1 | 0DP411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to monitor the administration of antibiotics in the Antibiotic Stewardship Program for 2 of 12 sampled residents (Resident #3 and #18). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], with dementia without behavioral disturbance, history of [MEDICAL CONDITION] and cerebral infarction, open wound, left foot. A physician's orders [REDACTED]. A physician order [REDACTED]. Resident #3's Medication Administration Record [REDACTED]. On 01/09/19 at 4:15 PM, review of the Antimicrobial Stewardship Program revealed the facility's antibiotic tracking sheet and the infection control log for (MONTH) (YEAR) lacked documented evidence of any resident on antibiotic treatment. On 01/09/19 at 4:20 PM, the Chief Nursing Officer (CNO) confirmed Resident #3 had been on antibiotic treatment on (MONTH) (YEAR) for a wound at left foot. The CNO verbalized the purpose of the antibiotic stewardship program was monitoring of the use of the antibiotics. Resident #18 Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #18's MAR for (MONTH) (YEAR) indicated [MEDICATION NAME] 250 mg twice a day started on 11/30/18. On 01/10/19 at 10:30 AM, the Assistant Director of Nursing (ADON) confirmed Resident #18 had been on an antibiotic in (MONTH) and the antibiotic tracking sheet and the infection control log lacked documented evidence of the antibiotic monitoring for Resident #18. The facility policy titled, Anticrobial (antimicrobial) Stewardship Program, effective 07/17, documented the purpose was to provide a reliable, consistent method of surveillance and documentation regarding appropriate antibiotic usage for patients. | 2020-09-01 |
| 34 | 34 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-01-10 | 943 | E | 0 | 1 | 0DP411 | Based on interview, personnel record review, and document review, the facility failed to provide annual abuse training to 9 of 20 sampled employees. Findings include: On 01/09/19 at 3:03 PM, the Human Resources/Payroll Manager confirmed the following employee personnel records lacked documented evidence of abuse training for (YEAR): -The Administrator with a start date of 07/25/17. -The Chief Nursing Officer/Director of Nursing/Infection Control with a start date of 09/08/80. -The Director of Nursing with a start date of 04/13/17. -The Assistant Director of Nursing with a start date of 06/03/13. -The Registered Dietician with a start date of 02/06/17. -A Licensed Practical Nurse with a start date of 05/03/13. -A Certified Nursing Assistant with a start date of 07/03/04. -A Certified Nursing Assistant with a start date of 06/25/09. -A Certified Nursing Assistant with a start date of 01/23/13. The facility policy titled, Abuse; Suspected Abuse and Reporting Unwitnessed Injuries and Abuse Prevention, revised 10/11/17, documented all employees were to have received abuse training annually. | 2020-09-01 |
| 35 | 35 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2018-02-16 | 700 | E | 1 | 0 | T81R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review, and document review, the facility failed to ensure the residents were offered alternatives prior to the use of bed rails, evaluated for safety to include entrapment, informed on the reason the resident required the use of side rails, monitored usage, and implemented a reduction of use for 20 of 24 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #16, #17, #18, #20, #21, #22, #23, #24). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:36 AM, Resident #18 was in bed with a half side rails up on each side of the bed. Resident #18's physicians order, dated 04/17/14, documented the resident may use side rails for bed mobility. Resident #18's care plans lacked documented evidence of side rails. A care plan for high risk for falls, last revised on 05/05/14, indicated slide fails were to be used as ordered. Resident #18's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage, and a care plan specific to side rail usage. Resident #13 Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:38 AM, Resident #13's bed had quarter side rails up on each side of the bed. Resident #13's care plan, revised on 09/13/17, documented the resident had impaired physical mobility , impaired coordination, inability to move independently in bed and required half rails to turn and reposition. The intervention/tasks indicated the resident will be independent with half rails. Resident #13's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments fo… | 2020-09-01 |
| 36 | 36 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 202 | D | 0 | 1 | Z18S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to obtain a physician's order for discharge for 1 of 10 sampled residents (Resident #7). Findings include: Resident #7 Resident #7 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #7's discharge instructions dated 07/01/17, documented the resident was discharged to home. The discharge instructions were signed by a nurse and Resident #7. Resident #7's clinical record lacked documented evidence of a physician's order for the discharge to home. On 10/12/17 at 10:03 AM, the Director of Nursing (DON) confirmed Resident #7's clinical record lacked a physician's order to discharge home. The DON verbalized it was required and the physician's responsibility to provide an order. The facility policy titled Discharge of Resident, revised 08/13/11, documented an order must be received from the physician to transfer or discharge a resident. | 2020-09-01 |
| 37 | 37 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 221 | E | 0 | 1 | Z18S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure residents were assessed, care planned, and physician's orders were obtained for the use of geriatric chairs for 2 of 10 sampled residents (Resident #1, #6) and 1 unsampled resident (Resident #11). Findings include: Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was observed repeatedly from the hours of 7:30 AM to 5:00 PM, on 10/09/17 through 10/12/17, sitting in a geriatric chair (Geri-Chair a large padded chair with wheeled bases designed to assist seniors with limited mobility) in the dining room. Resident #1's clinical record lacked documented evidence of a physician's order for a Geri-Chair, an assessment for the use, and a care plan for the Geri-Chair. On 10/12/17 at 10:12 AM, a Registered Nurse (RN) verbalized Resident #1's Geri-Chair was not a restraint because the resident needed the device. The RN confirmed Resident #1's clinical record lacked documented evidence of the need for a Geri-Chair. Resident #6 Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6 was observed 10/9/17 through 10/12/17 from the hours of 7:30 AM to 5:00 PM, sitting in a Geri-Chair in the dining room. Resident #6's clinical record lacked documented evidence of a physician order, assessment and care plan for the use of the Geri-Chair. Resident #11 Resident #11 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #11 was observed 10/9/17 through 10/12/17 from the hours of 7:30 AM to 5:00 PM, sitting in a Geri-Chair in the dining room. Resident #11's clinical record lacked documented evidence of a physician order, assessment and care plan for the use of the Geri-Chair. On 10/11/17 at 3:00 PM, a Unit Manager and a Certified Nursing Aide (CNA) confirmed Resident #1, #6 and #11 had not been assessed, a care plan implemented, or a physician's order obtained for the use of the Geri-Chair. The CNA verbalized a Geri-Chai… | 2020-09-01 |
| 38 | 38 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 278 | D | 0 | 1 | Z18S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate for the use of antipsychotic medications for 1 of 10 sampled residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident received antipsychotic medications in the last seven days. Resident #5's physician orders [REDACTED]. On 10/11/17 at 11:50 AM, the MDS Coordinator acknowledged the inaccurate documentation of medication. The MDS Coordinator confirmed the resident had not taken an antipsychotic medication. On 10/11/17 at 2:15 PM, the Director of Nursing (DON) reviewed the documentation and verbalized the MDS Coordinator should have not documented an antipsychotic for Resident #5. | 2020-09-01 |
| 39 | 39 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 283 | D | 0 | 1 | Z18S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to obtain a physician's discharge summary for 1 of 10 sampled residents (Resident #7). Findings include: Resident #7 Resident #7 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Discharge instructions dated 07/01/17, revealed Resident #7 was discharged to home. Resident #7's clinical record lacked documented evidence of a physician's discharge summary. On 10/12/17 at 10:03 AM, the Director of Nursing (DON) confirmed Resident#7's clinical record lacked a physician's discharge summary. The DON verbalized it was required and the physician's responsibility to provide the discharge summary. | 2020-09-01 |
| 40 | 40 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 285 | E | 0 | 1 | Z18S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an updated Pre-Admission Screening and Resident Review (PASRR) for residents with Mental Illness (MI) for 5 of 10 sampled residents (Resident #1, #2, #7, #9, and #8). Findings include: Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. The onset date of the major [MEDICAL CONDITION] was 02/11/16. Resident #1's PASRR, with a determination date of 06/05/09, documented the resident had no MI. Resident #2 Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The onset date of the major [MEDICAL CONDITION] and anxiety disorder was 07/13/17. Resident #2's PASRR, with a determination date of 03/07/17, documented the resident had no MI. Resident #7 Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The onset date of the [MEDICAL CONDITION] and anxiety disorder was 07/13/17. Resident #7's PASRR, with a determination date of 09/10/13, documented the resident had no MI. Resident #9 Resident #9 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #9's PASRR, with a determination date of 04/20/15, documented the resident had no MI. Resident #8 Resident #8 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #8's Pre-Admission Screening and Resident Review (PASRR), dated 02/26/13, documented no mental illness, mental [MEDICAL CONDITION], related conditions, or dementia. The facility Roster/Sample Matrix dated 10/09/17, documented Resident #8 triggered for mental illness (non-dementia), or intellectual disability/developmental disability. Resident #8's clinical record lacked documented evidence the facility coordinated with the PASRR program to assess the resident for mental illness. On 10/11/17 at 3:30 PM, the Risk Manager explained the facility process was to establish a PASRR upon admission. The Risk Manager verbalized a new PASRR would have been re… | 2020-09-01 |
| 41 | 41 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 287 | F | 0 | 1 | Z18S11 | Based on interview and document review, the facility failed to ensure resident assessments and care plans were submitted timely to the Centers for Medicare and Medicaid Services (CMS) system. Findings include: For six of the months since the facility's last annual Recertification survey, the facility exceeded the threshold of 10 percent (%) as follows: November (YEAR), the facility completed 36.36% of the care plans late. December (YEAR), the facility submitted 15.38% of the assessments late. January (YEAR), the facility completed 16.67% of the care plans late. March (YEAR), the facility submitted 11.11% of the assessments late and completed 11.11% of the care plans late. August (YEAR), the facility completed 15.62% of the assessments late. September (YEAR), the facility completed 50% of the assessments late and 16.67% of the care plans late. On 10/11/17 at 2:26 PM, the Minimum Data Set (MDS) Coordinator verbalized from (MONTH) (YEAR) through (MONTH) (YEAR), she did not know how to do the work on the computer. The MDS Coordinator explained in (MONTH) (YEAR) her schedule went back to night shift and she was unable to complete everything. On 10/11/17 in the afternoon, the Director of Nursing (DON) verbalized she was unaware the facility had been late with the submission to CMS. | 2020-09-01 |
| 42 | 42 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 309 | E | 0 | 1 | Z18S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess and document pain levels for 6 of 10 sampled residents and to ensure a physician order [REDACTED].#1, #2, #4, #5, #6, #8). Findings include: Resident #5 Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. A physician order [REDACTED]. The Treatment Administration Record (TAR) for (MONTH) (YEAR) and (MONTH) (YEAR), indicated the resident's pain level had not been documented for the following dates: October Day Shift: On 10/08/17, 10/ , 10/03/17, 10/01/17. September Day Shift: On 09/30/17, 09/28/17, 09/26/17, 09/25/17, 09/24/17, 09/23/17, 09/19/17, 09/18/17, 09/15/17, 09/14/17, 09/12/17, 09/10/17, 09/08/17, 09/07/17, 09/05/17, 09/04/17, and 09/03/17. Night Shift: On 09/10/17 and 09/07/17. On 10/11/17 at 3:45 PM, the Director of Nursing (DON) confirmed the facility lacked documented evidence of pain monitoring for Resident #5. The DON acknowledged the physician's orders [REDACTED]. Resident #4 Resident #4 was admitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #4's clinical record lacked documented evidence the resident's pain level was documented for the day shifts on 10/03/17, 10/06/17, 10/08/17, and 10/09/17, and for the night shift on 10/09/17. On 10/12/17 at 9:44 AM, the Director of Nursing (DON) confirmed Resident #4's clinical record lacked documentation of the resident's pain level on the above shifts and dates. Resident #8 Resident #8 was admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #8's clinical record lacked documented evidence the resident's pain level was documented for the day shifts on 10/03/17, 10/06/17, and 10/08/17. On 10/12/17 at 1:58 PM, the DON verbalized Resident #8's pain was to be evaluated and documented on both the day and night shifts. The DON confirmed Resident #8's clinical record lacked documentation of the resident's pain level on th… | 2020-09-01 |
| 43 | 43 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 323 | D | 0 | 1 | Z18S11 | Based on observation, interview and record review, the facility failed to provide an environment free from fire hazards and failed to protect residents from biohazard materials. Findings include: On 10/10/17 at 3:25 PM during a tour of the facility, a metal trash can lined with a plastic bag and contained paper bags, ashes, and cigarette butts, was observed in the southwest area of the Skilled Nursing Facility (SNF) exit-patio within a designated smoking area. On 10/11/17 at 3:45 PM, the trash can lined with plastic bag and contained cigarette butts and ashes was observed in the residents' smoke shed area. The Director of Nursing (DON) confirmed the trash can had a plastic bag with holes from the cigarettes and contained paper cups, cigarettes butts and ashes. The DON verbalized the trash can was a fire hazard. The facility policy titled Fire Safety-Smoking Policy, revised 04/02/12, indicated waste baskets shall be made of noncombustible materials and shall not be used as an ashtray. On 10/09/17 through 10/12/17, multiple observations of a storage area for the biohazard materials were conducted. The door to the storage area for biohazard materials did not have a lock. A red biohazard container inside the storage area was also unsecured. On 10/9/17 in the afternoon, Janitorial staff confirmed the door to the biohazard storage area did not have a lock and residents could have accessed the room. On 10/12/17 in the morning, a Registered Nurse (RN) indicated the door should probably have a lock, although not much biohazard was acquired on the unit, there was no barrier that would prevent residents from accessing the storage area and container. | 2020-09-01 |
| 44 | 44 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 328 | D | 0 | 1 | Z18S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review, the facility failed to administer and monitor Oxygen usage according physician orders [REDACTED].#2). Findings include: Resident #2 Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 10/09/17 at approximately 11:30 AM, Resident #2 was observed with Oxygen at 2 liters per minute (L/m) via nasal cannula. Resident #2's medication review report documented the resident was to be administered Oxygen, with a start date of 07/13/17, at 4 L/m at all times. Resident #2's Treatment Administration Records (TAR) for (MONTH) (YEAR) - (MONTH) (YEAR) lacked documented evidence the administration of Oxygen was monitored on the day shift in (MONTH) (YEAR) for 4 of 18 days, (MONTH) (YEAR) for 9 of 31 days, (MONTH) (YEAR) for 19 of 30 days and (MONTH) (YEAR) for 3 of 11 days. On 10/12/17 at 10:25 AM, a Registered Nurse (RN) confirmed Resident #2's Oxygen was at 2 L/m via nasal cannula. The RN confirmed the current physician's orders [REDACTED]. The RN verbalized the administration at 2 L/m should have been noticed by the nurse when monitoring the Oxygen. The facility policy titled Oxygen Administration Physician Orders, effective 12/08/15, documented the Five Patient Rights of Medication Administration would be followed: right person, right medication, right dose, right time, and right route. | 2020-09-01 |
| 45 | 45 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 329 | E | 0 | 1 | Z18S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and document review, the facility failed to ensure resident's received timely Gradual Dose Reduction's (GDR's), for 2 of 10 sampled residents (Resident #1, #4) specific rational for continued usage for 1 of 10 sampled residents (Resident #4) and obtain informed consents for [MEDICAL CONDITION] medications for 4 of 10 sampled residents (Resident #4, #8, #9 and #10). Findings include: Resident #8 Resident #8 was admitted on [DATE] and re-admitted on [DATE], with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #8's clinical record documented the resident was continuously administered [MEDICATION NAME] tablet 0.5 mg, and lacked documented evidence of a signed informed consent for the use of [MEDICATION NAME]. On 10/12/17 at 9:40 AM, the Director of Nursing (DON) confirmed there was no signed informed consent for the use of [MEDICATION NAME] in Resident #8's clinical record. The DON verbalized a consent was required prior to the administration of [MEDICATION NAME]. Resident #4 Resident #4 was admitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #4's Medication Administration Record [REDACTED]. Resident #4's clinical record revealed an informed consent for [MEDICATION NAME] tablet 2.5 mg signed and dated by the resident 05/08/17. On 10/09/17 at 4:31 PM, the Director of Nursing (DON), confirmed Resident #4 signed the informed consent for [MEDICATION NAME] tablet 2.5 MG on 05/08/17. The DON verbalized the resident received [MEDICATION NAME] on 05/05/17, 05/06/17, and 05/07/17 prior to the informed consent having been signed. A physician's orders [REDACTED]. A Psychoactive Medication Review Form dated 07/25/17, for [MEDICATION NAME] 0.5 mg documented the rational to decline an attempt for a gradual dose reduction was,would cont. option for use. (sic) On 10/12/17 at 2:00 PM, the DON explained the rational provided for Resident #4's Psychoactive Medication Review Fo… | 2020-09-01 |
| 46 | 46 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 387 | F | 0 | 1 | Z18S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure residents' received physician visits within the regulated time frames for 8 of 10 residents sampled (Resident #6, #9, #7, #8, #1, #4, #10, and #5). Findings include: Resident #6 Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6's clinical record revealed physician's visits dated 10/7/16, 08/9/17 and 09/20/17. On 10/11/17 in the afternoon, the Director of Nursing (DON) indicated documentation of additional physician's visits were not found in either electronic medical record for this resident. Resident #9 Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #9's clinical record revealed physician visits were conducted on 10/14/16, 10/15/16, 10/26/16 (specialist eye physician), 03/20/17 and 08/31/17. On 10/11/17, the DON indicated documentation of additional physician visits were not found in the electronic medical record for this resident. Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1's clinical record revealed physician visits dated 11/03/16 and 02/14/17. On 10/11/17 at 9:32 AM, the Unit Secretary confirmed Resident #1's clinical record lacked documented evidence of physician visits after 02/14/17. The Unit Secretary explained it was her responsibility to track physician visits for the facility. Resident #7 Resident #7 was admitted on [DATE] and readmitted on [DATE], and discharged on [DATE], with [DIAGNOSES REDACTED]. Resident #7's clinical record revealed physician visits dated 11/21/16 and 05/10/17. On 10/12/17 at 10:03 AM, the Director of Nursing (DON) confirmed Resident #7 had not had a physician visit between 11/21/16 and 05/10/17 as required. The facility policy titled Progress Notes by Medical Providers, effective 10/04/11, documented physician progress notes [REDACTED]. Resident #4 Resident #4 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #4's clinical … | 2020-09-01 |
| 47 | 47 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 406 | D | 0 | 1 | Z18S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and document review, the facility failed to ensure specialized rehabilitative services were coordinated per the Pre-Admission Screening and Resident Review (PASRR) for 1 of 10 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #3's Pre-Admission Screening and Resident Review (PASRR) Level II Evaluation, dated 02/02/15, documented the resident met the criteria for a serious mental illness. The PASRR determined Resident #3 could be placed into a nursing facility if the facility was able to provide or arrange for the recommended Specialized Services, including individual, group and/or family psychotherapy, psychiatrist follow-up services, and monitoring and advocacy. Resident #3's clinical record lacked documented evidence of individual, group and/or family psychotherapy and psychiatrist follow-up services for the following PASRR Level II Evaluation quarterly review dates: 12/29/16, 03/28/17, 06/26/17 and 09/12/17. On 10/12/17 at 1:21 PM, the Director of Nursing (DON), confirmed Resident #3 had not attended individual, group and/or family psychotherapy or completed a visit with a psychiatrist for follow-up services per the PASRR Level II Evaluation quarterly review for the dates above. | 2020-09-01 |
| 48 | 48 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 431 | D | 0 | 1 | Z18S11 | Based on observation and interview, the facility failed to ensure 3 of 4 medications were labeled properly. On 10/10/17 in the morning, an inspection of the medication room revealed four vials of a clear liquid substance stored in the refrigerator. The vials had hand written labels with residents names. The labels on 3 of the 4 vials had been placed so that the original label identifying the type of medication was obscured and illegible. A Registered Nurse (RN) present at the time of inspection indicated all of the vials were for a long-acting insulin and could be identified by the size of the vial. The RN agreed it would have been difficult to identify the medication if one did not know the difference in size of the vials. The RN agreed there was potential for the wrong medication to be administered without a proper label. The facility policy titled, Medication Labels 04/1/03, indicated each prescription medication label includes resident's name, specific instructions for use including route of administration, .drug product name, .strength of medication, .physician's name, date medication is dispensed, quantity, expiration date, name, address and telephone number of provider pharmacy, prescription number, .storage requirements, and initials of dispensing pharmacy. | 2020-09-01 |
| 49 | 49 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2017-10-12 | 463 | D | 0 | 1 | Z18S11 | Based on observation, interview and record review the facility failed to ensure the emergency call system was fully functional in Room #10's bathroom. Findings include: On 10/09/17 at 11:22 AM, the call light was not functioning when activated for Room #10. The light outside the resident's room did not light up. The call light system panel at the nursing station representing the resident's room did not light up. The call light panel located in the hallway had a tone but not a light for the Room #10's bathroom. Both panels for call lights (at nursing station and in the hallway) had a label Tone with no light Room 10's bathroom On 10/09/17 at 11:39 AM, a Certified Nursing Assistant (CNA) passed by the audible panel in the hallway and did not check where the sound was coming from. On 10/09/17 at 11:41 AM, a Registered Nurse (RN) passed by the panel and did not look at it. On 10/09/17 at 11:44 AM, another CNA passed by the panel in the hallway and did not check it. On 10/09/17 at 11:50 AM, a CNA looked at the panel at the nursing station and could not figure out where the sound was coming from. The CNA proceeded to check every room. On 10/09/17 at 11:53 AM, the CNA observed the call light had been pushed in the Room #10's bathroom. On 10/11/17 at 2:45 PM, the Maintenance Supervisor verbalized he knew the call light was not working for months. The facility policy #1735 titled Failure of nurse call light, revised 10/11/17 indicated the maintenance department would take the necessary steps to correct any failures of essential equipment or notify the proper service when repair was beyond the capabilities of the Maintenance Department. | 2020-09-01 |
| 50 | 50 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 622 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review and interview, the facility failed to complete a discharge summary to include the required documentation for 2 of 12 sampled residents (Resident #3 and #12). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Nursing Progress Note dated 09/21/19, documented Resident #3 was found to have difficulty breathing and swallowing and was transferred to the Emergency Department that day. Resident #3's clinical record lacked documented evidence of a completed discharge summary, to include the resident's representative and Advance Directive information. Resident #12 Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Nursing Progress Note dated 10/04/19, documented Resident #12 was found to have difficulty swallowing and was unable to focus. The Nursing Progress Note documented the inability to obtain a blood pressure reading and the resident was transferred to the Emergency Department that day. Resident #12's clinical record lacked documented evidence of a completed discharge summary, to include the resident's representative and Advance Directive information. On 10/16/19 at 10:05 AM, the Director of Nursing (DON) confirmed a discharge summary was not completed for the 09/21/19 discharge of Resident #3 or the 10/04/19 discharge of Resident #12. The DON confirmed a discharge summary should have been completed after Resident #3 and #12 were discharged to the Emergency Department. The facility policy titled, Discharge of Resident, revised 11/21/17, documented a discharge summary must be completed within ten days after discharge. | 2020-09-01 |
| 51 | 51 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 623 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to provide a resident, family member, and State Long Term Care Ombudsman's Office with a discharge notification for 1 of 2 sampled closed records (Resident #22). Findings Include: Resident #22 Resident # 22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Resident #22's clinical record lacked documented evidence the resident's discharge was planned. The Psycho-Social Narrative, electronically signed by Social Services, documented the resident had weakness and several falls resulting in the family deciding it was no longer safe for the resident to be at home, as the spouse could no longer manage the resident's care needs. Resident #22's Care Plan for discharge, created and initiated on 07/13/19, documented discharge plans were to be discussed with the resident and/or family during care plan meetings. Resident #22's clinical record lacked documented evidence of a discharge notification and evidence the notification was sent to the State Long Term Care Ombudsman's Office. Resident #22's clinical record lacked documented evidence this was a Resident or Facility Initiated Discharge. Resident #22's Nursing Progress Note, dated 09/26/19, completed by the Director of Nursing (DON), documented the resident discharged home to care of self and wife. On 10/15/19 at 9:33 AM, the Unit Secretary confirmed Resident #22's clinical record lacked documented evidence the discharge notification was completed prior to the resident's discharge. On 10/15/19 at 9:44 AM, the DON verbalized the DON thought it was the DON's responsibility to complete the discharge notification but it might have been the responsibility of a staff member on the acute side of the facility. The DON confirmed the facility had not provided the resident, the resident's family, or the State Long Term Care Ombudsman's Office with a d… | 2020-09-01 |
| 52 | 52 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 655 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a total dependent resident's care needs for positioning were documented on a baseline care plan for 1 of 12 sampled residents (Resident #123). Findings Include: Resident#123 Resident #123 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/13/19 at 6:06 PM, a family member verbalized Resident #123 had a lot of limitations to Range of Motion. The resident had been in bed for nearly a year and had not walked in five to six months. The resident's movements of the body were limited to the ability to kick the legs and move the neck. A Resident Turn Schedule form, dated 10/07/19 - 10/15/19, indicated the facility staff began repositioning the resident on 10/13/19 on a schedule of every two hours between 8:00 AM and 6:00 PM; Three days after admission. Resident #123's Care Plans lacked documented evidence a Baseline Care Plan was initiated for the resident's need for repositioning and the resident's lack of ability to do so alone. On 10/15/19 at 2:48 PM, a Certified Nursing Assistant (CNA) verbalized the Resident #123 was total dependent on staff. The resident was turned every two hours in bed and adjusted frequently in the Geri chair. The CNA explained whenever the CNA changed the resident's clothes, the CNA lifted the resident's arms a few more times then needed to work on Range of Motion. On 10/16/19 at 8:52 AM, the Director of Nursing (DON) explained Resident #123 was not able to walk, could not feed self, and could not turn self in bed. The DON verbalized this was the condition of the resident on the day the resident was admitted . The DON confirmed the resident was a total dependent on staff for assistance and required turning every two hours. The DON explained a care plan for Activities of Daily Living (ADL) would include the resident's total dependence and requirement to turn every two hours. The DON confirmed the Resident did not have an ADL c… | 2020-09-01 |
| 53 | 53 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 656 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review ad document review, the facility failed to ensure a comprehensive care plan was completed for use of antidepressant medication for 1 of 12 sampled residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. Resident #14's annual Minimum Data Set (MDS) 3.0 dated 04/30/19 and Quarterly MDS 3.0 dated 07/31/19, Section D- Mood, revealed the resident had little interest or pleasure in doing things, feeling down, depress or hopeless, feeling tired or having little energy and poor appetite. Resident #14's annual MDS 3.0 dated 04/30/19 and Quarterly MDS dated [DATE], Section I -documented depression as an active diagnosis, and Section N -Medications, indicated resident was taking antidepressant medication. Care Area Assessment (CAA) Summary dated 07/30/19, triggered for [MEDICAL CONDITION] drug use and the care planning decision area documented addressed in the resident's care plan. Resident #14's clinical record lacked documented evidence of a Comprehensive Care Plan for [MEDICAL CONDITION] drug use. On 10/15/19 at 2:00 PM, the Director of nursing (DON) explained the Care Plans were initiated, completed and revised by the DON. The DON confirmed there was no Comprehensive Care Plan developed to address Resident #14's use of antidepressant medication and depression. The Facility policy titled Care Plans, last revised on 03/22/17, documented each resident will have a comprehensive person-centered care plan developed by the interdisciplinary team. These care plans will be updated as the needs of the resident changed. The care plan must include the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care. | 2020-09-01 |
| 54 | 54 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 657 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to review and update a resident's care to reflect resident's pain management for 1 of 12 sampled residents (Resident #8) and include measures taken to prevent further occurrences of falls after a resident's fall for 1 of 12 sampled residents (Resident #15). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 10/14/19 at 9:53 AM, Resident #8 was in bed in resident's room and verbalized having a headache and pain in the left groin area. Resident #8's physicians orders for pain medication documented: - 09/10/19, [MEDICATION NAME] 50 microgram (mcg)/hour (hr.) 1 patch trans dermally at bedtime every 3 days related to other chronic pain - 09/10/19, [MEDICATION NAME] tablet 50 milligrams (mg), 1 tablet by mouth every 6 hours as needed for headache - 03/21/16, [MEDICATION NAME] capsule 75 mg, 75 mg by mouth three times a day for other chronic pain - [MEDICATION NAME] HCl tablet 10 mg, 10 mg by mouth every 8 hours as needed for pain related to other chronic pain, - Tylenol tablet 325 mg, 2 tablets by mouth every 4 hours as needed for mild pain - [MEDICATION NAME] tablet, 5 mg by mouth every 8 hours as needed for moderate pain related to other muscle spasm - [MEDICATION NAME]-ASA-Caffeine capsule 50-325-40 mg ([MEDICATION NAME]-Aspirin- Caffeine) 1 capsule by mouth every 8 hours as needed for headache Resident 8's Medication Administration Record [REDACTED]. Resident #8's Care Plan for pain medication to include [MEDICATION NAME] and [MEDICATION NAME], was last revised on 07/30/18. Resident #8's Care Plan for acute/chronic pain related to arthritis and depression was revised on 04/06/18. Resident #8's Care Plan for pain lacked documented evidence of a revision or update. On 10/15/19 at 10:30 AM, the Director of Nursing (DON) confirmed the Care Plan had not been updated to r… | 2020-09-01 |
| 55 | 55 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 658 | F | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to have a Standard of Practice available for reference for nursing, follow a Standard of Practice to obtain a physician's orders [REDACTED].#5 and #123). Findings Include: Lack of Standard of Practice On 10/16/19 at 10:29 AM, the Director of Nursing (DON) verbalized she did not know the facility's Standard of Practice. On 10/16/19 at 10:47 AM, the DON verbalized the facility followed American Nursing Association for a Standard of Practice. The material was referenced online. On 10/16/19 at 11:23 AM, the DON explained the facility's Standard of Practice subscription had lapsed. The DON did not know how long it had been lapsed and unavailable for reference. On 10/16/19 at 11:24 AM, the DON in training did not know the Standard of Practice followed for licensed nurses in the facility. On 10/16/19 at 11:27 AM, a Registered Nurse1 (RN) did not know the Standard of Practice followed for licensed nurses in the facility. On 10/16/19 at 11:33 AM, an RN2 verbalized the facility did not have a Standard of Practice. The DON handed down the information when there was not a policy or protocol in place. Resident #5 Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/16/19 at 9:05 AM, the Director of Nursing (DON) confirmed Resident #5 had a PEG tube. The DON verbalized an order was required for a resident with a PEG tube. The DON confirmed Resident #5's clinical record lacked an order for [REDACTED]. On 10/16/19 at 11:47 AM, the RN verbalized the RN had just completed a wound dressing change on Resident #5's PEG tube site. On 10/16/19 at 11:49 AM, the RN explained the RN did a residual check, flushed with 30 milliliters (ml) of water, administered medication, and flushed with 30 ml of water. The RN administers the resident's [MEDICATION NAME] via the PEG tube. The RN flushed with 30 ml of water. On 10/16/19 at 11:54 AM, the RN verbalized the RN did not know … | 2020-09-01 |
| 56 | 56 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 661 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to complete a discharge summary by the primary care provider to include the recapitulation of the resident's stay and the treatment and services obtained at the facility for 1 of 2 sampled closed records (Resident #22). Findings Include: Resident #22 Resident # 22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Resident #22's Discharge Orders and Instructions Sheet lacked evidence of a physician's signature, diagnoses, recapitulation of the admission to include the course of treatment and services provided by the facility. The follow up care instructions documented call for appointment with physician contact information left blank. Resident #22's Nursing Progress Note, dated 09/26/19, documented by the Director of Nursing (DON), indicated the resident was discharged home and was to follow up with the physician. On 10/15/19 at 9:33 AM, the Unit Secretary confirmed Resident #22's clinical record lacked documented evidence of a complete Discharge Summary. On 10/15/19 at 9:44 AM, the Director of Nursing (DON) verbalized the facility lacked documented evidence of a complete Discharge Summary. On 10/16/19 at 9:29 AM, the DON confirmed Resident #22 was not provided a recap of the resident's admission or an explanation of the course of treatments and services provided at the time of discharge. The DON confirmed the family or resident's representative was also not given the documentation regarding the resident's admission. Resident #22's clinical record contained physical therapy notes to include a discharge summary, dated 09/25/19. The summary lacked the primary care provider's signature, follow-up care, and evidence the summary was provided to the resident or family member. On 10/16/19 at 9:31 AM, the DON confirmed the nursing staff did not provide the resident or family the discharge s… | 2020-09-01 |
| 57 | 57 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 684 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure total dependent residents were not pre-charted for their every two hour repositioning for 2 of 12 sampled residents (Resident #123 and #5). Findings Include: Resident#123 Resident #123 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/16/19 at 8:52 AM, the Director of Nursing (DON) explained Resident #123 was not able to walk, could not feed self, and could not turn self in bed. The DON verbalized this was the condition of the resident on the day the resident was admitted . The DON confirmed the resident was a total dependent on staff for assistance and required turning every two hours. The DON explained a Care Plan for Activities of Daily Living (ADL) would include the resident's total dependence and requirement to turn every two hours. The DON confirmed the Resident did not have an ADL care plan completed. Resident #5 Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident # 5's Care Plan for [MEDICAL CONDITION] initiated 01/30/19 documented the resident required frequent turning and repositioning every two hours. On 10/15/19 at 2:40 PM, a Certified Nursing Assistant (CNA) explained Licensed Nurses and CNAs turned residents. There was a turn sheet list for documenting who last turned the residents and when they were turned. The CNA explained Resident #5 was turned every two hours. On 10/15/19 at 2:48 PM, the CNA verbalized Resident #123 was total dependent on staff and was turned every two hours in bed and adjusted frequently when in a Geri-chair. On 10/15/19 at 2:58 PM, a CNA provided a Resident Turn Schedule for Resident #123 and Resident #5. The form documented the CNA positioned Resident #123 on rp right position at 4:00 PM and on back at 6:00 PM on 10/15/19. The form documented the CNA positioned Resident #5 on rp right position at 4:00 PM and lp left position at 6:00 PM on 10/15/19. On 10/15/19 at 2:59 PM, the DON review… | 2020-09-01 |
| 58 | 58 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 690 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review and interview, the facility failed to act on a physician's order for urinalysis for 1 of 12 sampled residents (Resident #12). Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Physician's Progress Note dated 10/10/19, documented the resident reported not feeling well and had a burning sensation over the bladder. A physician's order dated 10/10/19, documented a urinalysis for Resident #12, related to complaint of burning sensation. Resident #12's clinical record lacked documented evidence of the results of the urinalysis. On 10/16/19 at 10:07 AM, the Director of Nursing (DON) confirmed the urinalysis order for Resident #12 was not acted on. The DON confirmed Resident #12's clinical record lacked documented evidence of specimen collection or of laboratory results. The facility policy titled, Physician Visits and Medical Orders, effective 11/2017, documented care, services, and treatments were to have been provided according to the most recent medical orders and standards of practice. On 10/16/19 at 10:29 AM, the DON verbalized the facility's nursing staff did not follow the Nevada Nurse Practice Act. | 2020-09-01 |
| 59 | 59 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 693 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, clinical record review, and document review, the facility failed to obtain a physician's order for maintaining a percutaneous endoscopic gastrostomy (PEG) tube, the amount of water to be administered, and the wound care required of the PEG tube site for 1 of 12 sampled residents (Resident #5). Findings Include: Resident #5 Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/16/19 at 9:05 AM, the Director of Nursing (DON) confirmed Resident #5 had a PEG tube. The DON verbalized an order was required for a resident with a PEG tube. The DON confirmed Resident #5's clinical record lacked an order for [REDACTED]. On 10/16/19 at 11:47 AM, the Registered Nurse (RN) verbalized the RN had just completed a wound dressing change on Resident #5's PEG tube site. On 10/16/19 at 11:49 AM, the RN explained the RN did a residual check, flushed with 30 milliliters (ml) of water, administered medication, and flushed with 30 ml of water. The RN administers the resident's [MEDICATION NAME] via the PEG tube. The RN flushed with 30 ml of water. On 10/16/19 at 11:54 AM, the RN verbalized the RN did not know how often the wound dressing needed to be changed. The RN verbalized there was no order for flushing the PEG tube for Resident #5 and explained the RN just knew the RN had to do it. On 10/16/19 at 12:08 PM, the DON verbalized the facility required an order for [REDACTED].>The facility policy titled Admission Protocol for Nursing, last revised 03/21/14, documented residents were to be admitted with clear orders from a medical provider. The facility policy titled Nasogastric/Gastrostomy Tube Feedings, effective 04/01/03, documented the facility procedure was to obtain an order for [REDACTED].> | 2020-09-01 |
| 60 | 60 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 711 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to ensure the physician completed the progress notes with each visit to reflect the medication review, assessment and plan of care for 1 of 12 sampled residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14 had been seen by the attending physician on 07/05/19 and 09/13/19. Resident #14's physician progress notes [REDACTED]. Chief complaint-none recorded Under vitals- Oxygen saturation level missing allergies [REDACTED]. Medications-not reviewed (last reviewed 08/30/18) History of the present illness (HPI)- see point click care Assessment/Plan -none recorded The encounter was electronically signed by the physician on 07/11/19. Resident #14's physician progress notes [REDACTED]. Chief complaint-none recorded allergies [REDACTED]. Medications-not reviewed (last reviewed 08/30/18) HPI- see point click care Assessment/Plan -none recorded The note was electronically signed by the physician on 09/26/19. On 10/15/19 at 2:45 PM, the Director of Nursing (DON) followed the physician's instruction to retrieve the HPI and additional information from the electronic system and found two blank physician visit notes called draft. The DON verbalized the facility did not have physician's progress notes for Resident #14's visits on 07/05/19 and 09/14/19 reflecting medication review, assessment and plan of care. The facility policy titled, Physician Visits and Medical Orders, effective 11/17, documented physicians had to write, sign and date program notes at each visit. | 2020-09-01 |
| 61 | 61 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 730 | D | 0 | 1 | LI3Z11 | Based on personnel record review and interview, the facility failed to complete annual performance reviews of a nurse aide for 1 of 12 sampled staff. Findings include: The personnel record for a Certified Nursing Assistant (CNA) with a start date of 08/15/16, lacked documented evidence a performance review was completed in (YEAR), (YEAR), or 2019. On 10/15/19 at 2:34 PM, the Human Resources/Payroll Manager confirmed the personnel record for the CNA with a start date of 08/15/16, lacked a completed performance review for (YEAR), (YEAR), or 2019. | 2020-09-01 |
| 62 | 62 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 756 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review and interview, the facility's attending physician failed to document a review and/or a course of action rationale of the monthly pharmacy medication regimens reviews for 2 of 12 sampled residents (Resident #7 and #14). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. A Pharmacist Progress Note dated 08/10/19, documented a recommendation to discontinue [MEDICATION NAME] and initiate [MEDICATION NAME] due to chronic use of [MEDICATION NAME] increasing the risk of infections. Resident #7's physician visit dated 09/13/19, documented the resident's medications were last reviewed 05/20/19. Resident #7's clinical record lacked documented evidence the facility's attending physician reviewed and/or acted upon the pharmacist's recommendations dated 08/10/19. On 10/16/19 at 11:51 AM, the Director of Nursing (DON) confirmed Resident #7's clinical record lacked documented evidence the attending physician documented a review and/or a course of action rationale for the monthly pharmacist medication regimen review dated 08/10/19. The DON confirmed the facility policy, requiring the attending physician to document a review of the monthly medication reviews, had not been followed. Resident #14 Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Pharmacist Progress Note dated 07/30/19, documented Resident #14 was taking [MEDICATION NAME] 150 microgram (mcg) daily for [MEDICAL CONDITION]. Most recent labs, dated 07/23/19, revealed low [MEDICAL CONDITION] Stimulating Hormone (TSH) (0.302, normal 0.340-4.820 milli-International units/milliliter (uiu/ml). The recommendation was to consider reducing [MEDICATION NAME] to 125mcg daily with a follow up TSH /Free T 4 test in six weeks. Resident had [MEDICATION NAME] 5 mg daily for [MEDICAL CONDITION] since 10/2018. Per GOLD (YEAR) guidelines (Global Initia… | 2020-09-01 |
| 63 | 63 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 761 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure expired medications were disposed of and a medication cart was locked while unattended. Findings include: On 10/14/19 at 4:30 PM, the medication cart for skilled nursing facility contained the following medications: [REDACTED] -[MEDICATION NAME] ([MEDICATION NAME] (rDNA origin) for injection) 1 milligram per vial, containing 2 vials, expired on 03/2019 -One a day women multivitamin expired on 05/2019. On 10/14/19 at 4:30 PM, the Registered Nurse confirmed the two medications were expired and should have been discarded. On 10/15/19 at 10:20 AM, the Director of Nursing acknowledged the expired medications should have been disposed of. The facility policy titled, Administration of medication, revised on 10/30/08, documented medication past the expiration date will be destroyed. Medication Cart On 10/16/19 at 10:32 AM, a medication cart was located against the wall, in the hallway, between rooms [ROOM NUMBERS]. The Registered Nurse (RN) was standing in front of the medication cart. The RN turned away from the medication cart and walked down the corridor connecting the adjacent hallway. The RN was no longer in view of the medication cart. The medication cart's lock was in the out position and unlocked. On 10/16/19 at 10:33 AM, the RN returned to the medication cart located between rooms [ROOM NUMBERS]. The RN confirmed stepping away from the medication cart and walking down the corridor to room nine without locking the medication cart. The RN confirmed the medication cart contained opened medications. The RN verbalized the medication cart should have been locked to prevent harm to the residents if the medications were accessed. The facility policy titled, Administration of Medication, revised 10/30/08, documented the medication cart was to remain locked at all times and was to remain with the nurse during the medication pass. | 2020-09-01 |
| 64 | 64 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 868 | D | 0 | 1 | LI3Z11 | Based on interview the facility failed to maintain the required quality and assurance committee members to include the Medical Director. Findings include: On 10/16/19 at 9:02 AM, the Safety Manager verbalized the quality and assurance committee meetings for (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 did not include the facility's Medical Director. The Safety Manager verbalized it was not clear if the Medical Director provided any recommendations, comments, or feedback of the quality and assurance committee meetings for those months. The Safety Manager confirmed the requirement for the quality and assurance committee to include the Medical Director was not met. The facility plan titled, Lefa [MI] Seran Skilled Nursing Facility Quality Assessment Performance Improvement Plan, dated 07/28/17, lacked language identifying the Medical Director as a required member of the quality and assurance committee. | 2020-09-01 |
| 65 | 65 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 943 | D | 0 | 1 | LI3Z11 | Based on personnel record review and interview, the facility failed to ensure 1 of 14 sampled staff was provided training on dementia management and resident abuse prevention. Findings include: The personnel record for a Registered Nurse (RN) with a start date of 06/03/19, lacked documented evidence dementia or resident abuse prevention training had been completed. On 10/15/19 at 2:27 PM, the Human Resources/Payroll Manager confirmed the RN with a start date of 06/03/19, had not completed the dementia management or the resident abuse prevention training. The Human Resources/Payroll Manager confirmed dementia and abuse training should have been completed prior to providing care to the residents. | 2020-09-01 |
| 66 | 66 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-01-24 | 684 | D | 1 | 0 | V7CS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and document review, the facility failed to ensure 2 of 6 sampled residents received a shower as scheduled and according to the care plan (Resident #2 and Resident #3). Findings include: Resident #2 Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 1/24/18 at 8:29 AM, the resident's family member indicated the resident had not had a shower in over a week. The resident confirmed he had not received a shower in over a week. The resident explained he had a schedule to receive showers two times a week on Mondays and Thursdays on the day shift. The resident's family member indicated the resident had not received a shower on Monday, 1/22/18. The resident's family member explained a staff member was busy and told the family member that they had to attend to another issue and would be back to give the resident a shower, but the staff member had not returned. The family member expressed when the resident received a shower, a staff member would shave the resident's face. The family member explained she had to shave the resident's face on 1/24/18 because the resident had not received a shower and a shave on 1/22/18. On 1/24/18 at 9:50 AM, a Certified Nursing Assistant (CNA) indicated residents received a shower according to a schedule and 2-3 times per week on different shifts. The CNA explained residents could receive a bed bath if they refused a shower. The CNA explained residents should have received a shower unless they refused. The CNA explained the documentation of showers and bed baths, as well as resident refusals was kept in the Activities of Daily Living (ADL) binder, on the ADL flow sheet. Review of the care plan, dated 2/3/17 revealed the resident required skilled nursing care for medical management and the approach was to provide showers per the schedule. Review of the day shift shower schedule revealed the resident was to receive a shower on Mondays and Thursdays. Review of the ADL Supplem… | 2020-09-01 |
| 67 | 67 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2019-02-08 | 551 | D | 1 | 0 | YZ1W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to obtain a resident representative for a resident for 1 of 5 sampled residents (Resident #2). Findings include: Resident #2 Resident #2 (R2) was admitted on [DATE], with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. A Social Worker note dated 09/16/17, revealed R2 cognition was severely impaired and Brief Interview for Mental Status score was 3. R2 had no relative sources available. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented R2 had no guardian or legally authorized representative. 1) A physician order [REDACTED]. The admission orders [REDACTED]. A Resident Care Plan, Flu Vaccine dated 01/12/18, documented to administer Influenza vaccine per physician order [REDACTED]. The Immunization Record for R2 revealed the Influenza vaccine was administered to R2 on 11/17/18. The medical record lacked documented evidence an informed consent had been obtained prior to the administration of the Influenza vaccine to R2. 2) A physician order [REDACTED]. [MEDICATION NAME] 25 milligrams (mg) by oral route daily in the morning for [MEDICAL CONDITION], yelling every shift; [MEDICATION NAME] 50 mg by oral route daily in the evening for [MEDICAL CONDITION], yelling every shift; [MEDICATION NAME] 250 mg by oral route twice daily for [MEDICAL CONDITION] and mood swings. The Medication Administration Record [REDACTED]. The medical record lacked documented evidence an Acknowledgment of Psychoactive Medication Use explaining the potential benefits and risks of using the above psychoactive medications had been signed by a resident representative for R2. 3) The Comprehensive Care Plan for Resident Code Status revised (MONTH) (YEAR), documented a code status was signed by the resident or resident representative in the active medical record. The Do Not Resuscitate (DNR)/Full Code Request Form indicated R2 was a full code. The form had been signed by the Physician but did not… | 2020-09-01 |
| 68 | 68 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2019-02-08 | 553 | D | 1 | 0 | YZ1W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to involve the resident and/or resident representative in the resident's care planning process for 1 of 5 sampled residents (Resident #1). Findings include : Resident #1 (R1) R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], documented R1 had a Brief Interview of Mental Status (BIMS) score of two (reflective of impaired cognition). The MDS revealed triggered care areas for [MEDICAL CONDITION], cognitive loss, visual function, urinary incontinence, nutritional status, falls and pressure ulcers. A General Power of Attorney dated 10/04/18, identified R1's brother as R1's appointed representative. The medical records lacked documented evidence the facility attempted to involve R1's representative in the development and implementation of R1's care planning process. On 01/10/19 at 3:00 PM, the Social Services Director (SSD) indicated utilizing a form to invite residents and/or resident representatives to care plan conferences. The SSD explained if the invitation is made by telephone, Social Services staff documented on the form whether the resident representative declined or accepted the invitation, the form is placed in the resident's chart. On 01/10/19 at 3:10 PM, the SSD acknowledged there was no evidence R1's representative was invited to participate in R1's care planning process and could not provide the date when R1's care plan conference occurred. On 01/10/19 at 3:15 PM, the DON explained since R1 was cognitively impaired R1's representative should have been involved in the care planning process. The DON acknowledged there should have been evidence of R1's representative's involvement in the medical records. On 01/10/19 a 3:21 PM, R1's representative confirmed not receiving an invitation from facility staff to attend any care conferences for R1 and was not provided a copy of R1's plan of care. | 2020-09-01 |
| 69 | 69 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2019-02-08 | 609 | D | 1 | 0 | YZ1W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and document review, the facility failed to report resident to resident altercations for 3 of 5 sampled residents (Residents #1 (R1), #2 (R2) and #3 (R3)). Findings include : 1) R1 and R3 R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. R3 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 01/10/19 at 1:35 PM, R1 was propelling wheelchair along the 100-hall. R1 turned head away and did not respond to questions. On 01/10/19 at 1:55 PM, R3 was seated on wheelchair and was alert, pleasant and cooperative. R3 recalled on 12/16/18 R1 was blocking the pathway to R3's room and when R1 was asked to move away, R1 grabbed R3 by the arm and hit R3 leaving a bruise on R3's arm. R3 recalled another resident stopped the fight by separating the two residents. R3 indicated the Registered Nurse was made aware and eventually the Director of Nursing (DON). R3 recalled being offered to notify law the police but R3 declined indicating it was unnecessary. A nurses note dated 12/16/18, documented R1 had an altercation with R3. R1 was blocking R3's door when R3 asked R1 to move away. R1 grabbed the left arm of R3 and hit R3 leaving a bruise on R3's arm. The residents were separated by staff and residents. On 01/10/19 at 2:25 PM, the DON indicated being aware of the altercation between R1 and R3 on 12/16/18. The DON narrated visiting R3 after the incident and offered to call the police but R3 declined. The DON acknowledged the resident altercation was a reportable incident and confirmed it was not reported to the State agency. On 01/10/19 at 2:30 PM, the Administrator indicated the facility should report incidences of resident to resident abuse to appropriate agencies and it is not up to the resident to decide whether the incident should be reported or not. 2) R2 and R3 R2 was admitted on [DATE], with [DIAGNOSES REDACTED]. R3 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 11/18/18 at 7:30 AM, R2 entered R3's room and… | 2020-09-01 |
| 70 | 70 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2019-02-08 | 610 | D | 1 | 0 | YZ1W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and document review, the facility failed to investigate a resident to resident altercation in a timely manner for 2 of 5 sampled residents (Resident #2 and #3). Findings include: Resident #2 (R2) R2 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #3 (R3) R3 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 11/18/18 at 7:30 AM, R2 entered R3's room and started pulling R3's bed and clothing. On 01/10/19 at 2:00 PM, R3 revealed having been attacked by R2 on 11/18/18 and indicated R3 would try to stay away from R2 because of the previous incident. There was no facility reported incident submitted to the State Regulatory Agencies regarding the altercation between R2 and R3. On 01/10/19 at 2:37 PM, the Director of Nursing (DON) revealed being aware of the altercation between R2 and R3. The DON had informed the previous Administrator regarding the incident but the Administrator informed the DON the incident was not considered abuse and decided not to report the incident to the State Agencies. On 01/10/19 at 2:40 PM, the current Administrator indicated the incident on 11/18/18 between R2 and R3 should have been reported to the State Agencies and should have been investigated. The facility policy Abuse Investigation (undated), documented the Administrator would investigate and alleged incident or suspected incident of resident abuse. The results of the investigation would be recorded on the approved documentation forms. | 2020-09-01 |
| 71 | 71 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-03-22 | 580 | D | 1 | 0 | 5VNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and document review, the facility failed to notify 1 of 5 resident's authorized representative of a transfer to a hospital (Resident #2). Findings include: Resident #2 Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Resident Authorization Consent Form dated 2/19/18, was signed by the resident identifying the resident's family member as the authorized representative to receive information regarding the resident's condition, scheduled appointments and/or meetings regarding resident's care. The Resident Transfer Form dated 2/21/18, reflected a transfer to a local hospital for [DIAGNOSES REDACTED]. The Document entitled Discharge census listed the resident as being transferred to a local hospital on [DATE] at 4:25 PM. On 3/15/18 at 1:36 PM, a Social Worker explained the facility's process was to contact the next of kin or authorized representative when a resident was transferred to the hospital and staff would be document in nurse's notes. On 3/15/18 at 1:45 PM, a Licensed Practical Nurse (LPN) explained the facility process was staff would inform next of kin or authorized representative in an event of a transfer to a hospital. The LPN explained this was documented in the nurse's notes. The nursing notes lacked documented evidence the family member was notified of the hospital transfer. On 3/15/18 at 3:45 PM, the Director of Nursing (DON) verified the family was not notified of the resident's transfer to the hospital. | 2020-09-01 |
| 72 | 72 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-03-22 | 623 | C | 1 | 0 | 5VNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and document review, the facility failed to provide the Ombudsman the required notice of discharge within the required period of time for two of five sampled residents (Resident #3 and #4). Findings include: Resident #3 Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged to home on 03/08/18. A Discharge Notification Form with no date, documented the resident's planned discharge date was 03/08/18. The Discharge Notice with no date and signed by the resident, documented the resident would be discharged from the facility effective 30 days after the date of this notice, on 02/27/18. The resident would be discharged to home with family as the resident's health has improved sufficiently and would no longer need the services provided by the facility. The discharge notice was sent by the Assistant Administrator to the Ombudsman via electronic mail on 03/08/18, the same day the resident was discharged from the facility. Resident #4 Resident #4 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged to home on 03/02/18. A Discharge Notification Form with no date, documented the resident's planned discharge date was 03/02/18. A Discharge Notice with no date and signed by the resident, documented the resident would be discharged from the facility effective 30 days after the date of this notice, on 02/27/18. The resident would be discharged to home with family as the resident's health has improved sufficiently and would no longer need the services provided by the facility. The discharge notice was sent by the Administrator to the Ombudsman via electronic mail on 03/05/18, three days after the resident was discharged from the facility. On 03/15/18 at 1:36 PM, the Social Worker revealed not understanding the new regulations on notification of the Ombudsman for transfers and discharge. The Social Worker indicated not understanding how to differentiate between fa… | 2020-09-01 |
| 73 | 73 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-03-22 | 684 | D | 1 | 0 | 5VNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Interview and record review, the facility failed to ensure medications were administered per Physicians' orders for 1 of 5 sampled residents (Resident #1). Findings Include: Resident #1 Resident #1 was admitted to on 1/3/18, discharged to the hospital on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. 0-149= 0 units 150-200= 2 units 201-250= 4 units 251-300= 6 units 301-350= 8 units 351-400 = 10 units > (greater than) 400 call physician (MD) The care plan dated 1/10/18, documented the resident is a diabetic and had accucheck sliding scale per order. The Medication Administration Record [REDACTED]. On 3/22/18 at 1:25 PM, the Director of Nursing (DON) verified the MAR indicated [REDACTED]. On 3/22/18 at 1:40 PM, a Licensed Practical Nurse (LPN), explained if the MAR indicated [REDACTED]. | 2020-09-01 |
| 74 | 74 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2017-05-04 | 202 | D | 1 | 1 | XLYQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and document review, the facility failed to maintain complete discharge documentation in 1 of 15 resident's clinical records (Resident #15). Findings include: Resident #15 Resident #15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to an unlicensed group home. The resident's clinical record lacked documented evidence of a completed discharge summary and a copy of the post discharge plan and summary. A nurses note dated 9/27/16 documented the resident was discharged to a group home, discharge instructions were given and verbalized understanding. Left facility not in distress. On 5/4/17 at 9:40 AM, the Director of Nursing (DON) explained any discharge planning and discharge summary documentation should be in the resident's closed clinical record. On 5/4/17 at 10:45 AM, the Social Worker explained the discharge summary documents would be in a binder in the office. All discharge planning should be documented in the resident's clinical record. The Social Worker could not produce completed documentation of the resident's discharge including: -A recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge. -The post discharge plan developed by the care planning/interdisciplinary team with the assistance of the resident and family, including the resident's preferences, how care should be coordinated if continuing treatment involves multiple caregivers, identify specific needs after discharge (ex. personal care, sterile dressings and physical therapy etc) and how the resident needs to prepare for the discharge. On 5/4/17 at 12:30 PM, the Medical Records Assistant could not locate completed discharge documentation for the resident. The policy, Discharge Summary and Plan, dated 11/2014, documented a copy of the post-discharge plan and summary will be filed in the resident's medical records. Com… | 2020-09-01 |
| 75 | 75 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2017-05-04 | 204 | D | 1 | 1 | XLYQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and document review, the facility failed to ensure a resident was prepared for a safe discharge to another facility for 1 of 15 sampled residents (Resident #15). Findings include: Resident #15 Resident #15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A physician order [REDACTED]. A nurses note dated 9/27/16, documented the resident was discharged and transported to a group home. The clinical record lacked documented evidence of the address for the group home. The Minimum Data Set (MDS), dated [DATE], documented the resident was total dependence for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene and bathing. The resident's weighed 305 lbs. The dimensions of unhealed stage 3 and stage 4 pressure ulcer was 18.0 pressure ulcer length and 18.0 pressure ulcer depth. Resident #15's clinical record contained an Interdisciplinary Discharge Summary form dated 9/27/17. The following areas were not completed on the form or were blank: The treatment provided. The progress and the reason for discharge/discharge diagnoses. Assistive devices the resident required The drug therapy required. On 5/2/17, in the afternoon, the Social Worker explained an independent group home was a not licensed. Resident's who were discharged to this type of home were fully ambulatory, administer their own medications and toilet independently. The Social Worker explained to determine if group home was licensed the Social Worker would request the group homes current license faxed to the facility. On 5/4/17 at 10:45 AM, the Social Worker explained the expectations of discharging a resident to a group home involved the following: Finding the appropriate place to care for the resident's needs Notify the resident of the transfer Take them to the group home to make sure the resident was comfortable at the facility Set up any home health required Make sure the finances were suitable. The Social Worker… | 2020-09-01 |
| 76 | 76 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2017-05-04 | 250 | D | 1 | 1 | XLYQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and document review, the facility failed to provide necessary Social Services to 1 of 15 sampled residents for a Public Guardian (Resident #5); failed to provide appropriate discharge planning for 1 of 15 residents (Resident #15); and failed to ensure a referral was completed per a physician's orders [REDACTED].#16). Findings include: Resident #5 Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Record of Admission documented the resident had no next of kin and the resident was the responsible party. A Neuropsychological consultation dated 12/20/16, documented the resident's performance on the Mini-Mental State Exam (MMSE), a measure of basic cognitive functioning, was in the moderately impaired range. The resident was diagnosed with [REDACTED]. The Minimum Data Set (MDS)Annual Resident Assessment and Care Screening dated 12/26/16 documented the resident scored 1 on the Brief Interview for Mental Status (BIMS) Summary Score. On 5/3/17 at 2:00 PM, the Director of Social Services explained a BIMS score of 1 meant the resident was alert and oriented times 1 and had poor short and long term memory. An evaluation by the Director of Social Services dated 12/26/16, documented the resident's cognition was severely impaired as evidenced by a BIMS score of 1. A Psychiatric consultation dated 1/2/17 documented the resident's memory appeared significantly impaired. The resident was alert and oriented times 1 to person, but not to place, time or situation. The resident was diagnosed with [REDACTED]. The resident's clinical record lacked documented evidence of a Public Guardianship referral. A consent for admission and treatment form revealed two facility staff members signed as witnesses for the resident on 12/19/16. The resident's signed the consent form on 12/28/16. On 5/4/17 at 11:30 AM, the Director of Nursing (DON) confirmed the resident was cognitively impaired on admission. The DON confirmed the … | 2020-09-01 |
| 77 | 77 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2017-05-04 | 309 | D | 0 | 1 | XLYQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review the facility failed to ensure a physician's order for a medication was followed for one unsampled resident (Resident #17). Findings include: Resident #17 Resident #17 was admitted on [DATE], with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. On 5/3/17 at 9:16 AM, during a Medication Administration Pass observation, a Licensed Practical Nurse (LPN) prepared and administered the resident's medications including Vitamin D 400 units two tablets by mouth. On 5/3/17 at 10:55 AM, the LPN confirmed the observation and acknowledged the resident should have received Vitamin D3 2,000 units per the physician's order. The LPN indicated the physician's order was not followed. On 5/3/17 at 12:25 PM, the Director of Nursing (DON) explained the nurses were expected to administer the medication per the physician's order. The facility's policy titled Administering Medications revised on (MONTH) 2012, indicated medications must be administered in accordance with the orders. | 2020-09-01 |
| 78 | 78 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2017-05-04 | 371 | E | 0 | 1 | XLYQ11 | Based on observation and interview, the facility failed to ensure proper sanitation and food handling practices were maintained. Findings include: On 5/2/17 at 8:20 AM, an inspection was conducted in the kitchen with a Dietary staff member. The following issues were identified: -An opened bottle of Italian dressing lacked a use by date. -An opened bottle of homestyle ranch dressing lacked a use by date. -An opened container of chocolate chip cookie dough lacked a use by date. -An opened box of plastic spoons, knives and forks were not covered. On 5/2/17 at 8:30 AM, a dietary staff member was not aware opened bottle of dressing and cookie dough did not have labels. On 5/3/17 at 12:00 PM, an inspection was conducted with the Registered Dietician (RD) who confirmed the following issues were identified: -Sides of the toaster located in the serving area had a brown substance on the side. The RD acknowledged the toaster needed to be cleaned. -The serving pans on the steam table had aluminum foil covering the food. The RD questioned the cook about the aluminum foil. The Cook explained the facility did not provide lids for the pans on the steam table, so aluminum foil was used to cover the food before serving a meal. The RD instructed the Cook to remove all the aluminum foil from the pans to prevent pieces of aluminum foil from falling in the food. -Crumbs and dirt were located under the stove, oven, steamer, refrigerators and steam table in the kitchen. -An oven mitt was found behind the stove. A dietary staff member explained the oven mitt must have fallen during cleaning. -The hoses behind the stove were caked with a brown coating with dust on it. -The rubber seal on the back door was broken and coming off the door. -The metal screen door on the back door had grime and dust on it. -A box of plastic knives, forks and spoons were not covered. The RD explained the utensils should be covered. | 2020-09-01 |
| 79 | 79 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2017-05-04 | 406 | D | 1 | 1 | XLYQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and document review the facility failed to ensure specialized rehabilitative services specifically Applied Behavior Analysis (ABA) therapy was provided per the physician's orders [REDACTED].#14). Findings include: Resident #14 Resident #14 was admitted on [DATE] and discharged on [DATE], with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The resident's clinical record lacked documented evidence the resident received ABA therapy per the physician's orders [REDACTED].>On 5/3/17 at 4:35 PM, the Director of Rehabilitation revealed the resident had a physical and occupational therapy evaluation. The resident's functional mobility was appropriate for age and current medical diagnosis. The treatment for [REDACTED]. The resident needed more ABA therapy which was provided by outside healthcare practitioners. On 5/4/17 at 11:00 AM, a Licensed Practical Nurse (LPN) showed a copy of a typewritten note signed by the Director of Social Services which read: 10-22-16 Received an order from (name of physician) for ABA therapy for (name of Resident #14). Spoke with DFS (Department of Family Services) worker, (name of worker) and she indicated that (name of Resident #14) has been referred with Early Childhood Services through Southern Nevada Regional Center since 9-15-16. Will contact to re-initiate services . The LPN explained the Early Childhood Services included ABA therapy which the resident had received since 9/15/16. The LPN acknowledged the typewritten note was not filed in the resident's clinical record. The LPN could not provide documentation the resident received the ABA therapy per the physician's orders [REDACTED]. On 5/4/17 at 11:13 AM, the LPN provided a copy of a typewritten note signed by the Director of Social Services with the same information from the note previously shown by the LPN, but the date was changed from 10/22/16 to 9/22/16. The LPN indicated the note dated 10/22/16 was shredded. The… | 2020-09-01 |
| 80 | 80 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2017-05-04 | 431 | D | 0 | 1 | XLYQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, , interview, record review and document review, the facility failed to ensure medications were securely stored for one of 15 sampled residents (Resident #9) and one unsampled resident (Resident #18). Findings include: Resident #9 Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 05/02/17 at 11:42 AM, 12 packets of Vitamin A and D ointment weighing 5 grams each, two packets of Derma Septin ointment weighing five grams each and one packet of Peri Guard ointment weighing five grams were on Resident #9's bedside nightstand. A Licensed Practical Nurse confirmed the findings and indicated the packets of ointment should not have been left there. Resident #18 Resident #18 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 5/2/17 at 8:20 AM, during the initial tour, the resident had a bottle of prescription Artificial Tears laying in the middle of the bed. On 5/2/17 at 8:25 AM, a Licensed Practical Nurse (LPN), explained the artificial tears came from the hospital and the facility was not aware the resident had them in their position. The LPN reported the medications should not be in the resident's room. On 5/4/17 at 9:40 AM, the Director of Nursing (DON), explained the Artificial Tears came from the hospital. When the residents are discharged from the hospital they were sent home with a discharge package, any medications located in the package should be destroyed. Prescription medications should not be in the resident rooms. The facility's undated policy titled Storage of Medications documented the facility shall store all drugs and biological's in a safe, secure and orderly manner and shall be locked when not in use and not be left unattended if open or otherwise potentially available to others. | 2020-09-01 |
| 81 | 81 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2017-05-04 | 441 | D | 0 | 1 | XLYQ11 | Based on observation, interview, and document review the facility failed to ensure staff would performed hand hygiene in between residents during Medication Administration Pass. Findings include: On 5/3/17 at 8:25 AM, during a Medication Administration Pass observation, a Licensed Practical Nurse (LPN) administered the medications to Resident #19. The LPN then went to the medication cart and prepared the medication of Resident #20. The LPN did not perform hand hygiene after the medications were administered to Resident #19 and before the medication of Resident #20 was prepared. On 5/3/17 at 8:40 AM, the LPN confirmed the observation and indicated he should have performed hand hygiene prior to preparing and administering Resident #20's medication. On 5/3/17 at 2:25 PM, the Director of Nursing (DON) explained the nurses were expected to perform hand hygiene before and after the administration of medications to each resident to prevent cross-contamination. The facility's policy titled Administering Medications revised on (MONTH) 2012, documented staff should have followed established facility infection control procedures such as hand washing for the administration of medications, as applicable. | 2020-09-01 |
| 82 | 82 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2017-05-04 | 465 | D | 0 | 1 | XLYQ11 | Based on observation, interview and document review, the facility failed to ensure two sinks were functional. Findings include: Review of facility policy entitled Work Order Requests, Maintenance revised (MONTH) 2010, documented work order requests must be filled out in the maintenance log. The Maintenance Supervisor will check the log at least once daily for any requests. On 5/2/17 at 8:15 AM, the bathroom door in room 301 displayed a sign which read Do not use the sink. The sink in the bathroom, which connected rooms 301 and room 302, was filled half-way with standing water. On 5/2/17 at 8:50 AM, a Licensed Practical Nurse (LPN) indicated the sink had been clogged for a week. Maintenance had attempted to fix the sink and it continued to be clogged. On 5/2/17 at 2:25 PM, the sink in the bathroom which connected rooms 301 and room 302 was filled half-way with standing water. On 5/2/17 at 2:25 PM, an Activities Aide reported the sink had been clogged since last week. On 5/2/17 at 2:30 PM, a Certified Nurse Assistant (CNA) revealed the sink in the bathroom had been reported to maintenance. The CNA explained the facility's process for work order requests was to report it to the LPN, Maintenance, and complete a document kept at the receptionist desk. On 5/2/17 at 2:35 PM, a Receptionist explained a maintenance log was kept at the nurse's station and not at the receptionist desk. On 5/2/17 at 2:37 PM, an LPN explained the maintenance log was where work order requests were documented. Review of the facility's maintenance log revealed no evidence a work order request had been submitted for the clogged sink in the bathroom which connected rooms 301 and room 302. The latest work order request was dated 4/27/17. On 5/2/17 at 2:40 PM, the Director of Maintenance explained work order requests were documented in the maintenance log. The Director indicated it was possible for a work order to be verbally reported to the Director instead of documenting the work order in the maintenance log. The Director reported being aware of a… | 2020-09-01 |
| 83 | 83 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2017-05-04 | 518 | D | 0 | 1 | XLYQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure exit doors of a locked unit were supervised during a fire drill. Findings include: On 5/2/17 at 3:10 PM, the fire alarm sounded. The exit doors of a locked unit near room [ROOM NUMBER] and room [ROOM NUMBER] were not supervised by a staff member. The staff members on the unit were gathered at the fire alarm pull in the middle of the unit hallway. On 5/2/17 at 3:15 PM, a Licensed Practical Nurse (LPN) indicated the exit doors near room [ROOM NUMBER] and room [ROOM NUMBER] should have been supervised with a staff member standing at the door. The LPN indicated she was aware the exit door's locking mechanism released when the fire alarm sounded. | 2020-09-01 |
| 84 | 84 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 644 | D | 1 | 1 | QB3511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to refer 2 out of 18 residents for pre-admission screening and resident review (PASARR) level two (Residents #19 and #59). Findings include: Resident #19 Resident #19 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 05/10/18 at 8:30 AM, the resident indicated chronic pain issues and debility from [MEDICAL CONDITION] contributed to depression and anxiety. The resident indicated refusing activities and preferred to remain in bed. The resident verbalized being totally dependent on staff for activities of daily living (ADL). The clinical records documented the resident's PASARR level one screening completed on 05/18/18, did not require a PASSAR level two. Section I (Active Diagnoses) of the resident's Minimum Data Set ((MDS) dated [DATE], identified anxiety disorder ( ) and depression ( ) with no additional active psychiatric [DIAGNOSES REDACTED]. Section I (Active Diagnoses) of the resident's Minimum Data Set ((MDS) dated [DATE], identified anxiety disorder ( ), depression ( ) and major [MEDICAL CONDITION], single episode, severe with psychotic features (1800). Section I (Active Diagnoses) of the resident's Minimum Data Set ((MDS) dated [DATE], identified anxiety disorder ( ) and depression ( ) with no additional active psychiatric [DIAGNOSES REDACTED]. Section I (Active Diagnoses) of the resident's Minimum Data Set ((MDS) dated [DATE], identified anxiety disorder ( ) and depression ( ) and major [MEDICAL CONDITION], single episode, unspecified (1800). The [MEDICAL CONDITION] Summary Sheet for [MEDICATION NAME] 25 milligrams (mg) for [MEDICAL CONDITION], documented the number of behavior episodes of yelling: - 32 for the month of (MONTH) (YEAR) -90 for the month of (MONTH) (YEAR) -27 for the month of (MONTH) (YEAR) -9 for the month of (MONTH) (YEAR) -41 for the month of (MONTH) (YEAR) The [MEDICAL CONDITION] Summary Sheet for [MEDICATION NAME] 1.0 mg. for anxiety, docu… | 2020-09-01 |
| 85 | 85 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 658 | D | 0 | 1 | QB3511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to clarify physician orders [REDACTED].#8), and 1 unsampled resident (Resident #6). Findings include: The facility policy and procedure titled Crushing Medications, revised 11/11, indicated medications would be crushed only when consistent with physician's orders [REDACTED]. The nursing staff or Consultant Pharmacist would notify any attending physician who gives an to order to crush a drug that the manufacturer states hould not be crushed (for example, long acting or [MEDICATION NAME] coated medication). The attending physician or Consultant Pharmacist must identify an alternative, or the attending physici8an must document why crushing the medication would not adversely affect the resident. Resident #8 Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 05/10/18 at 08:08 AM, the Licensed Practical Nurse (LPN) administered the following oral medication tablets crushed and then mixed with applesauce to the resident: [MEDICATION NAME] 50 milligrams (mg) Levitiracetam 250 mg and Chewable aspirin 81 mg. The record lacked a physician's orders [REDACTED]. There was no documentation on the Medication Administration Record (MAR) why it was necessary to crush the medication. On 05/10/18 at 08:42 AM, the LPN revealed the medications were crushed because the resident was unable to safely swallow whole pills or tablets. The LPN verified the record and MAR lacked a physician's orders [REDACTED]. The LPN stated she wasn't sure if a physician's orders [REDACTED]. The LPN stated nursing staff discussed which resident's needed crushed medications during change of shift meetings. Resident #6: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. 05/10/18 at 08:46 AM, the Registered Nurse (RN), administered the following oral medications crushed and mixed with pudding to the resident: [MEDICATION NAME] 10 mg 81 mg aspirin chewable [MEDICATION NAME] 20 mg [MEDICATION NA… | 2020-09-01 |
| 86 | 86 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 677 | D | 0 | 1 | QB3511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide assist with trimming and cleaning the finger nails for 1 of 18 sampled residenst (Resident #22). Findings include: Resident #22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 05/08/18 at 10:29 AM, the resident was in bed and answered some questions appropriately. The resident's finger nails, on both hands, were about 1/2 inch long and had dark colored material lodged underneath the nails. The resident stated he was unable to bathe or groom himself and relied on staff to provide all of his care. The resident reported he could not see well. On 05/11/18 at 12:17 PM, the Licensed Practical Nurse (LPN) checked the resident's fingernails and reported they were overly long and and had debris underneath, and should have been kept trimmed and clean. The LPN did not know why the nails were not kept trimmed and clean on the resident. The LPN stated sometimes residents will refuse, but did not recall the resident refusing care. The LPN asked the resident if he would like to have the finger nails trimmed, and the resident replied yes. The LPN revealed toe nails were trimmed by a podiatrist who made monthly visits. The LPN wasn't sure if resident fingernails should be clipped by licensed nurses or by the nursing assistants, or by a podiatrist. The facility policy and procedure titled Shower/Tub Bath, revised 10/10, indicated staff should not trim finger nails unless otherwise instructed by your supervisor. | 2020-09-01 |
| 87 | 87 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 679 | D | 0 | 1 | QB3511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility provided inaccurate documentation related to activities for 1 out of 18 sampled residents (Resident #11). Resident #11 Resident #11 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 05/10/18 at 8:07 AM, the resident was asleep in bed. On 05/10/18 at 8:10 AM, the Certified Nursing Assistant (CNA) indicated the resident was bed-bound, non-verbal and required extensive assistance with all activities of daily living (ADL's). On 05/10/18 at 1:30 PM, the resident was asleep in bed. On 05/10/18 at 2:45 PM, the resident's eyes were open but did not respond to simple questions answerable by yes or no. On 05/10/18 at 3:40 PM, the resident's eyes were open but did not respond to simple questions answerable by yes or no. On 05/11/18 at 8:30 AM, the Medication Nurse indicated the resident remained in bed at all times and daily activities were limited to passive range of motion (PROM) exercises performed by the Restorative Nursing Assistant (RNA), as ordered. The Medication Nurse indicated the resident was non-verbal and was unable to signify a Yes response by nodding or signify a No response by turning head from side to side. On 05/11/18 at 10:00 AM, the resident's eyes were open but did not respond to simple questions answerable by yes or no. Section B0600 (Speech Clarity) of the resident's Minimum Data Set ((MDS) dated [DATE], documented resident's speech as no speech-absence of spoken words. Section G0110 (Functional Status-ADL's) of the MDS dated [DATE], documented the resident was totally dependent for ADL's. A physician's orders [REDACTED]. The Activity Attendance Record and Response Record for the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) and the Individual Patient Daily Group Activity for (MONTH) (YEAR) had the following entries : - The resident refused a puzzle activity on 01/06/18. - The resident refused Bingo on 01/06/18, 01/08/18, 01/13/18, 0… | 2020-09-01 |
| 88 | 88 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 686 | D | 0 | 1 | QB3511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review and document review, the facility failed to implement interventions to prevent skin break down and promote the healing of existing pressure ulcers for a bedfast resident per resident's care plan for 1 out of 18 sampled residents (Resident #11). Resident #11 Resident #11 was admitted on [DATE], with [DIAGNOSES REDACTED]. A comprehensive care plan dated 12/27/17, documented an intervention to reposition the resident every two hours using positioning devices. The resident's history and physical dated 01/02/18, documented the resident was bed-bound with existing sacral decubitus. On 05/10/18 at 8:07 AM the resident was supine (flat on back facing upwards), bed elevated approximately 20 to 30 degrees. The Certified Nursing Assistant (CNA) #1 indicated the resident was bed-bound, non-verbal and required extensive assistance with all activities of daily living (ADL's). On 05/10/18 at 1:30 PM, the resident was on her right side with pillow underneath left side of the back for support. The bed was elevated approximately 20 to 30 degrees. On 05/10/18 at 2:45 PM, the resident was on her right side with pillow underneath left side of the back for support. The bed was elevated 20 to 30 degrees. On 05/10/18 at 3:40 PM, the resident was on her right side with pillow underneath left side of the back for support. The bed was elevated 20 to 30 degrees. On 05/10/18 at 3:45 PM, CNA #2 indicated the resident should have been repositioned earlier. CNA #2 acknowledged the resident had not been turned. CNA #2 verbalized staff should document on the ADL Flow Record each time a resident is turned. CNA #2 acknowledged staff did not document consistently each time a bed-bound resident is turned. CNA #2 indicated seeking another staff member to reposition the resident. On 05/10/18 at 4:00 PM, the resident was on her right side with pillow underneath left side of the back for support. The bed was elevated 20 to 30 degrees.… | 2020-09-01 |
| 89 | 89 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 690 | D | 0 | 1 | QB3511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician's order for changing a Foley catheter and failed to provide accurate and consistent documentation regarding Foley catheter care for 1 out of 18 sampled residents (Resident #19). Findings include: Resident #19 Resident #19 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 05/10/18 at 8:30 AM, the resident indicated being admitted with a Foley catheter due to a stage four pressure ulcer on his sacrum. The resident verbalized having a history of urinary tract infections [MEDICAL CONDITION] due to prolonged Foley catheter use. The resident communicated needing a Foley catheter due to being a quadriplegic. The resident verbalized the original order for the Foley catheter was french 16 with 10 cubic centimeter (cc) balloon. The resident confirmed having a french 20 Foley catheter due to clogging from sediments. A physician's order dated 08/11/17, documented Foley catheter size french 16 with 10 cubic centimeter (cc) balloon to gravity drainage with justification sacral wound. The Foley Catheter Flowsheet (August (YEAR)) documented the Foley catheter was changed on 08/20/18, using french 18 with 5cc balloon. A nurses note dated 08/20/17, documented Foley catheter changed, inserted french 18 with 5 cc balloon. The Foley Catheter Flowsheet (September (YEAR)) documented catheter care every shift on a Foley catheter french 18 with 5 cc balloon. The Foley Catheter Flowsheet (October (YEAR)) documented catheter care every shift on a Foley catheter french 18 with 10 cc balloon. The Foley Catheter Flowsheet (December (YEAR)) documented catheter care every shift on an unspecified Foley catheter. A physician's order dated 02/22/18, documented indwelling catheter french 16 with 10 cc balloon. Physician orders dated (MONTH) 1, (YEAR) to (MONTH) 31, (YEAR), documented indwelling catheter french 16 with 10 cc balloon. The Foley Catheter Flowsheet (March (YEAR)) document… | 2020-09-01 |
| 90 | 90 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 697 | D | 0 | 1 | QB3511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure pain assessments were completed accurately for 2 of 18 sampled residents (Residents #40 and #59). Findings include: Resident #40 Resident #40 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Care Plan dated 03/2018, revealed the resident was at risk for pain. The approach was to assess the resident's level of pain using the pain rating scale. The Medication Administration Record (MAR) dated (MONTH) (YEAR), revealed the resident was administered [MEDICATION NAME] 325 mg - 7.5 mg on 05/09/18. The Pain Assessment Flow Sheet dated (MONTH) (YEAR), lacked documented evidence the resident's post-[MEDICATION NAME] pain rating and sedation level was assessed on 05/09/18. On 05/10/18 in the morning, a Licensed Practical Nurse (LPN) indicated when PRN pain medication was administered to a resident, the pain assessment flow sheet was completed and the MAR was signed. The LPN explained the pain assessment was completed by adding the resident's post-[MEDICATION NAME] pain rating and sedation level. The LPN acknowledged the pain assessment was not completed accurately with the resident's post-[MEDICATION NAME] pain rating and sedation level on 05/09/18. On 05/10/18 in the morning, the Director of Nursing (DON) indicated pain assessments should be completed accurately. The DON explained when PRN pain medication was administered, the resident's post-[MEDICATION NAME] pain rating and sedation level should be completed. The DON acknowledged the pain assessment was not completed accurately with the resident's post-[MEDICATION NAME] pain rating and sedation level on 05/09/18. Resident #59 Resident #59 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The MAR dated (MONTH) (YEAR), revealed the resident was administered [MEDICATION NAME] 2 mg on 05/07/18. The Pain Assessment Flow Sheet dated (MONTH) (YEAR), lack… | 2020-09-01 |
| 91 | 91 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 698 | D | 0 | 1 | QB3511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to secure written contracts and/or agreements with [MEDICAL TREATMENT] providers, ensure a physician's orders [REDACTED].#40) and post [MEDICAL TREATMENT] assessments were completed for 1 of 18 sampled residents (Resident #57). Findings include: The facility's policy titled Policy and Procedure on [MEDICAL TREATMENT] Care (dated 09/27/18), documented: 1) The Administrator shall secure written contracts and/or agreements with [MEDICAL TREATMENT] Care Centers providing services to residents on [MEDICAL TREATMENT] care and, 2) Written contracts and/or agreements shall contain provisions on how to maintain communication by and between facility and [MEDICAL TREATMENT] centers to ensure proper care is provided to residents e.g. dietary recommendations (from [MEDICAL TREATMENT] center), physician orders, etc. On 05/10/18 at 11:00 AM, the Administrator indicated he could not provide documented evidence of contracts and/or agreements with any [MEDICAL TREATMENT] provider. On 05/11/18 in the morning, the Director of Nursing confirmed the facility currently had two residents receiving [MEDICAL TREATMENT] from [MEDICAL TREATMENT] provider #1 and three residents receiving [MEDICAL TREATMENT] from [MEDICAL TREATMENT] provider #2. Resident #57 Resident #57 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 05/08/18 at 3:28 PM, the resident verified [MEDICAL TREATMENT] treatments were scheduled on Mondays, Wednesdays and Fridays at a nearby [MEDICAL TREATMENT] facility. The resident indicated not missing [MEDICAL TREATMENT] treatments since admission. The facility's policy titled Policy and Procedure on [MEDICAL TREATMENT] Care (dated 09/27/12), documented a licensed nurse shall monitor and document on pre and post [MEDICAL TREATMENT] observations, such as vital signs, bruits, shunt area for color, warmth, redness or [MEDICAL CONDITION], etc. A physician's orders [REDACTED]. On 05/… | 2020-09-01 |
| 92 | 92 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 755 | D | 1 | 1 | QB3511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide a medication as ordered by the prescriber to meet the resident's needs for 1 of 18 sampled residents (Resident #19). Findings include: Resident #19 Resident # 19 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 05/10/18 at 8:30 AM, the resident indicated not receiving [MEDICATION NAME] 0.5 milligrams (mg) from 04/05/18 to 04/09/18 due to the medication being unavailable. The resident verbalized difficulty managing anxiety issues even without missed doses. A physician's orders [REDACTED]. by mouth (PO) every eight hours (Q8h) for anxiety. The Nurses Medication Notes documented the following: - 04/05/18 at 10:00 AM [MEDICATION NAME] not available. - 04/06/18 at 10:00 AM [MEDICATION NAME] not available. MD (Medical Doctor) notified. - 04/06/18 at 6:00 PM [MEDICATION NAME] not available. Called MD again and left message. - 04/07/18 at 10:00 AM [MEDICATION NAME] not available. Called MD and left message. - 04/08/18 at 2:00 AM [MEDICATION NAME] not available. Waiting for MD to sign script. - 04/08/18 at 10:00 AM [MEDICATION NAME] not available. New prescription. - 04/09/18 at 6:00 AM [MEDICATION NAME] not available. MD to sign script. - 04/09/18 at 10:00 AM [MEDICATION NAME] not available. MD aware. On 05/09/18 at 2:16 PM, a Licensed Practical Nurse (LPN) #1 verbalized filling out a Refill Reorder Form if a medication was running low. LPN #1 indicated she would also verbally inform the next shift nurse. On 05/09/18 at 3:54 PM, LPN #2 clarified the psychiatric doctor came once or twice a week to renew orders for narcotics and controlled substances. LPN #2 indicated not being certain on whether the psychiatric doctor came the week of 04/05/18 to 04/09/18. On 05/11/18 at 11:20 AM, the Director of Nursing (DON) verbalized pharmacy required a five-day notification when a medication was running low. The DON confirmed not being informed by nursing staff regarding the resident not … | 2020-09-01 |
| 93 | 93 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 759 | D | 0 | 1 | QB3511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% during medication pass. The facility scored a 6.67 % medication error rate. Findings include: The policy and procedure titled Administering Medications, revised 12/12, indicated medications must be administered in accordance with the physician's orders [REDACTED]. A resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician order, dated 05/9/17, documented Aspirin 81 milligrams (mg) [MEDICATION NAME] Coated Tablet (ECT) per oral route daily. A physician order, dated 05/18/17, documented [MEDICATION NAME] Extended Release (ER) 60 mg by oral route daily, to hold if systolic blood pressure (the top number) was less than 110, and if the heart rate was less than 60 beats per minute. On 05/10/18 08:46 AM, a medication pass observation was performed with the Registered Nurse (RN). The RN administered an Aspirin 81 mg chewable tablet, and administered [MEDICATION NAME] ER 60 mg. Both medications were crushed and mixed with applesauce prior to giving them to the resident by mouth. On 05/10/11, in the morning, the RN stated the [MEDICATION NAME] 60 mg ER was an extended release tablet and should not be crushed, because the medication had the potential to release too fast with possible adverse effect. The RN acknowledged she had not noticed or acted on her knowledge regarding this medication, which was an error. The RN verified a physician's orders [REDACTED]. On 05/10/18 at 02:45 PM, the Consultant Pharmacist (CP) stated [MEDICATION NAME] ER tablet should never be crushed, because the medication was designed to be released slowly. If crushed, the medication could enter the resident's blood stream faster than desired and cause the blood pressure to go too low, which could be unsafe. | 2020-09-01 |
| 94 | 94 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-05-11 | 908 | D | 0 | 1 | QB3511 | Based on observation and interview, the facility failed to ensure equipment used to store the meal tray dome lids was safe for storage next to hot food service equipment. Findings Include: On 05/10/18 at 12:47 PM, the white plastic cart holding the dome lids for meal trays was blackened and melted on the third shelf up from the bottom. The top rung of the cart was melted and bowed out but it was not discolored. On 05/10/18 at 12:50 PM, The Dietary Manager explained that the kitchen is small and that there is not another location to store the cart with the lids. The Dietary Manger was unsure of how the damage had occurred but did note that the location of the cart is next to the ovens. On 05/11/18 at 12:30 PM, a maintenance employee confirmed the cart holding the dome lids was melted and explained the kitchen was not large enough for this piece of equipment to be stored elsewhere. | 2020-09-01 |
| 95 | 95 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-07-10 | 684 | D | 1 | 0 | 1YJV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and document review, the facility failed to document missed medications, transcribe physician orders [REDACTED].#1 and #2). Resident #1 Findings include: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 07/10/18 at 8:55 AM, the resident was alert, cooperative and able to express needs. A Sitter was observed by the door. 1) The admission orders [REDACTED]. The Antipsychotic Monthly Flow Record for (MONTH) (YEAR), documented to give [MEDICATION NAME] 600 mg. one tablet by mouth at hour of sleep. The document revealed the following: -06/13/18 to 06/17/18 were blank (no initials, no notes, no monitoring of behavior and side effects) -06/18/18 encircled initials with nurses notes awaiting pharmacy to deliver, monitoring for behavior and side effects documented. On 07/10/18 at 10:40 AM, a Licensed Practical Nurse (LPN) indicated the resident did not receive [MEDICATION NAME] for a few days after admission due to unavailability. The LPN indicated if the medication was not available the nurse should encircle his/her initials and document why it was not given. On 07/10/18 at 12:35 PM, the DON indicated expecting nursing staff to document on the Antipsychotic Flow Record whether or not the medication was administered. The DON indicated if the medication was not administered, the nurse encircled their initials and documented the reason for non-administration. The DON verbalized not being informed sooner of [MEDICATION NAME] not being available. The DON indicated not being familiar with [MEDICATION NAME] side effects and consequences of not being administered as prescribed. On 07/10/18 at 12:45 PM, the DON confirmed the resident did not receive [MEDICATION NAME] for six days, on 06/13/18, 06/14/18, 06/15/18, 06/16/18, 06/17/18 and 06/18/18. The DON confirmed this was not acceptable. The facility policy titled Administering Medications (revised (MONTH) 2012), documented the individual who d… | 2020-09-01 |
| 96 | 96 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-07-10 | 755 | D | 1 | 0 | 1YJV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide the resident's anti-psychotic medication for six days for 1 of 7 sampled residents (Resident #1). Findings include: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 07/10/18 at 8:55 AM, the resident was alert, cooperative and able to express needs. A Sitter was observed by the door. The admission orders [REDACTED]. The Antipsychotic Monthly Flow Record for (MONTH) (YEAR), documented to give [MEDICATION NAME] 600 mg. one tablet by mouth at hour of sleep. The document revealed the following: -06/13/18 to 7/17/18 were blank (no initials, no notes, no monitoring of behavior and side effects) -06/18/18 encircled initials with nurses notes awaiting pharmacy to deliver, monitoring for behavior and side effects documented. On 07/10/18 at 10:40 AM, a Licensed Practical Nurse (LPN) indicated the resident did not receive [MEDICATION NAME] for a few days after admission due to miscommunication regarding how the medication would be obtained. The LPN indicated the Veterans Affair (VA) case manager informed the facility if the resident did not receive the medication by 06/19/18, the resident would have to start from a low dose and slowly build up to the current dose of 600 mg since the resident had already missed six days. On 07/10/18 at 12:05 PM, the Social Worker (SW) indicated coordinating care with the VA case manager who was familiar with the resident's mental health care. The SW indicated the VA case manager informed the facility the resident needed to be registered through the Risk Evaluation and Mitigation Strategy (REMS) program and required routine blood draw in order for the medication to be dispensed by the manufacturer. On 07/10/18 at 12:35 PM, the DON indicated the facility terminated services with Pharmacy provider #1 on 06/15/18 and started using the services of Pharmacy provider #2 on 06/16/18. The DON indicated the transition contributed to… | 2020-09-01 |
| 97 | 97 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2018-07-10 | 773 | D | 1 | 0 | 1YJV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to perform blood work in accordance to physician's order for 1 of 7 sampled residents (Resident 1). Resident #1 Findings include: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 07/10/18 at 8:55 AM, the resident was alert, cooperative and able to express needs. A Sitter was observed by the door. The resident's hospital discharge instructions dated 06/13/18, documented Resident #1 needed a complete blood count (CBC) once a week for the next three months and every other week thereafter. The resident's admission orders [REDACTED]. The clinical records reflected a CBC was done on 06/14/18, 06/26/18, 07/03/18 and 07/09/18. There was no documented evidence a CBC was drawn between 06/14/18 and 06/26/18 (12 days). On 07/10/1 at 1:05 PM, the DON confirmed hospital discharge instructions to draw a CBC weekly should have been transcribed into the admission orders [REDACTED]. The facility policy titled Admission Criteria (revised (MONTH) 2012), documented medication orders and problems/conditions associated with each medication should be included in the admission orders [REDACTED] | 2020-09-01 |
| 98 | 98 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2019-07-12 | 604 | D | 0 | 1 | MXY711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to properly assess a resident and obtain a physician order [REDACTED].#36). Findings include: Resident #36 (R36) R36 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 07/10/19 at 10:38 AM, R36 was sleeping with full side rails up on both sides of bed. On 07/10/19 at 12:12 PM and 4:12 PM, the side rails remained up in same position. On 07/11/19 at 12:07 PM, full side rails remained up on both sides of bed throughout day A Nurses Note dated 07/05/19 at 11:40 PM, indicated the resident fell out of bed. The Nurses Note documented the side rails were up for safety and the bed was in low position. On 07/12/19 at 3:40 PM, both full side rails were up. A Registered Nurse (RN) explained the side rails were used for safety with some residents. The RN verbalized an assessment would be performed and a physician's orders [REDACTED]. On 07/12/19 at 1:50 PM, the Assistant Administrator indicated the facility was restraint free and there was no restraint policy. On 07/12/19 at 3:45 PM, the Director of Nursing (DON) confirmed the expectation when a resident had side rails was for the staff to complete a assessment, obtain a physician order [REDACTED]. The DON verified the lack of documentation and physician order [REDACTED].>The facility policy titled Bed Siderails (undated) documented the need for an assessment of the resident and review with physician for any other reasonable alternatives. The resident and family must be informed of the benefits/hazards before application of bed siderails. | 2020-09-01 |
| 99 | 99 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2019-07-12 | 640 | D | 0 | 1 | MXY711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based document review and interview the facility failed to ensure a resident's quarterly assessment was submitted within 14 day timeline. Findings include: Resident #1 (R1) R1 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 07/12/19 at 2:41 PM, the Minimum Data Set (MDS) Coordinator verified the R1 was still residing in the facility. The MDS Coordinator indicated an initial assessment was completed on 11/20/18, and quarterly assessments were completed on 03/02/19 and 06/02/19. The MDS Coordinator indicated the last quarterly assessment was closed on 06/15/19. The MDS Coordinator explained the facility had 14 days to complete the assessments and 14 days to submit the assessments according to the Resident Assessment Instrument (RAI) instructions. The MDS Coordinator indicated the assessments were submitted before the 92nd day. On 07/12/19 at 3:04 PM, the MDS Coordinator provided a copy of the CMS Submission Report/MDS 3.0 Nursing Home Final Validation Report for R1. The report revealed the last quarterly assessment was submitted on 07/09/19. The report documented the target date for submission was 06/02/19 and a message indicated the record was submitted late. The MDS Coordinator acknowledged the quarterly assessment was submitted late. The MDS Coordinator verbalized the assessment was closed and not submitted. On 07/12/19 at 3:43 PM, the MDS Coordinator provided a copy of the RAI Omnibus Budget Reconciliation Act (OBRA)required Assessment Summary CMS Version 3.0 Manual Chapter 2: Assessments for RAI (MONTH) (YEAR). The MDS Coordinator verbalized using the Assessment Summary as the guideline for submission of the quarterly assessments. The Assessment Summary documented the Quarterly (Non Comprehensive) Transmission date was no later than 14 calendar days. | 2020-09-01 |
| 100 | 100 | LAS VEGAS POST ACUTE & REHABILITATION | 295006 | 2832 S. MARYLAND PARKWAY | LAS VEGAS | NV | 89109 | 2019-07-12 | 641 | D | 0 | 1 | MXY711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and document review the facility failed to ensure a resident's Insulin and Antidepressant was documented on the Comprehensive Assessment for 1 of 18 sampled residents (Resident #55). Findings include: Resident #55 (R55) R55 was admitted [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Minimal Data Set ((MDS) dated [DATE], documented diabetes under additional diagnoses. The MDS lacked documented evidence the resident received insulin. The MDS lacked documented evidence of the Antidepressant ([MEDICATION NAME] 20 mg daily) had been administered. On 07/12/19 at 03:59 PM, the MDS Coordinator acknowledged the coding for diabetes had been placed under additional [DIAGNOSES REDACTED]. The MDS coordinator verified the orders for insulin and the antidepressant had been given as ordered by the physician and had not been coded in the Comprehensive MDS. The Policy titled Care Plans - Comprehensive (no date) documented a comprehensive care plan was based on a thorough assessment including information from the MDS assessment. | 2020-09-01 |
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CREATE TABLE [cms_NV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );