Clark County Nursing Home

Inspectors wroteBased on interview and record review, the facility failed to document in one resident's record (Resident #5), or notify the physician, when the resident had a large fecal impaction digitally removed by staff on 1/11/26 of seven sampled residents. The resident had a history of constipation and hemorrhoids with medication to treat. On 1/13/26, the resident experienced bleeding from his/her hemorrhoids. On 1/14/26, the Director of Nursing notified the physician of the resident's bleeding hemorrhoids. The physician ordered a complete blood count (CBC, a blood test used to look at overall health including the number of red blood cells to carry oxygen throughout the body). On 1/16/26 the resident passed a large amount of blood from his/her/rectum, began vomiting and was pale, tired and weak. Staff did not obtain the ordered blood work until 1/17/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide for the rights of one resident (Resident #1), in a review of five sampled residents, when the facility performed a urinary catheterization (a procedure that involves inserting a flexible tube called a catheter into the bladder to drain urine) and obtained a urine drug screen (used to detect illegal and some prescription drugs in the urine) without notification and permission from the resident or his/her emergency contact. The facility census was 54. Review of the facility policy, Resident Rights, undated, showed the following: -It is the goal of the facility to promote and protect the rights as a resident in the facility. The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. Therefore, as a resident, you have: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label food items, discard food that was past the expiration/remove by date in dry storage, and discard prepared food after the labeled use by date in the walk-in cooler. The facility also failed to ensure food service equipment and surfaces were appropriately cleaned and maintained. The facility census was 59. Review of the facility's policy, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, showed the following: -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current infection control standards for three residents (Residents #25, #17, and #21), in a review of 22 sampled residents, and for two additional residents (Resident #20 and #55). The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for three residents (Resident #25, #20, and #17) when staff failed to appropriately sanitize the glucometer (a machine that tests a drop of blood for the amount of sugar it contains) after use and use a barrier to protect against contamination. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for four residents (Residents #18, #8, #13 and #28), in a review of 22 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 59. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper technique for medication administration of insulin pens and eye drops for three residents (Resident #2, #58, and #21), in a review of 22 sampled residents. The facility census was 59. 1. Review of resident #58's Continuity of Care Document (CCD) showed a diagnosis of diabetes mellitus (too much sugar in the blood stream). Review of the resident's care plan, dated 12/26/24, showed the following: -The resident had diabetes; -Administer insulin as ordered. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 01/22/25, showed the resident received seven insulin injections in the last seven days. Observation on 01/23/25 at 7:00 A.M., showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to propel three residents (Resident 28, #17, and #11), in wheelchairs equipped with foot pedals, in a review of 22 sampled residents. The facility census was 59. 1. Review of Resident #28's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/14/24, showed the following: -Severe cognitive impairment; -Diagnoses included new dementia and contractures (muscle tightening restricting range of motion due to non use) right knee and left knee, -Dependent on wheelchair mobility; -Two or more non injury falls. Review of the resident's Social Services progress note, dated 12/03/2024, at 8:24 A.M., shoed the Social Services Director documented when up in his/her wheelchair, the resident will at times propel himself/herself. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a side rail assessment for one resident, (Resident #17) or assess three residents' (Resident #17, #54 and #18) risk for entrapment prior to use of side rails, in a review of 22 sampled residents. The facility failed to obtain consent from one resident (Resident #54) or his/her family for use of the side rails prior to use. The facility census was 59. Review of the undated facility policy, Quarter Side Rail Policy, showed the following: -The purpose is to ensure the appropriate use of quarter bed rails and to ensure the safety for a resident who requests quarter bed rails. -Any resident who is admitted to the facility, that has a history of using bed rails, fall risks and compromised mobility, shall be reassessed for appropriate use; -Bed rails are used for: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure insulin (a medication used to treat diabetes) vials/pens for two residents (Residents #2 and #58), were dated when opened or discarded within the designated time frame after opening. The facility failed to secure a schedule IV controlled substance (a medication subject to abuse) in a separately locked compartment, failed to timely destroy expired medications, and failed to destroy one expired resident's (Resident #300's) medications. The facility census was 59. 1. Review of the Drugs.com showed the following: -Use Humalog (a rapid acting injectable insulin used to treat diabetes) within 28 days of opening; -Use Basaglar (a long-acting injectable insulin used to treat diabetes) within 28 days of opening. Observation of the east hall medication room and east hall nurse's medication and treatment cart on 01/23/25 at 5:16 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the use of pressure alarms used in a resident's bed and chair as a restraint for one resident (Resident #48), in a review of 22 sampled residents. The facility implemented the pressure alarms upon the resident's admission to the facility as an intervention to prevent falls. Staff documented the alarms caused the resident to become agitated. The resident expressed he/she hated the alarms and felt restrained to his/her chair and trapped. The facility census was 59. 1. Review of Resident #48's undated Continuity of Care Document (CCD), showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Resident #42 and #1), a review of 22 sampled residents, received care and treatment to promote healing and prevent new pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) from developing. Facility staff failed to update Resident #42's care plan, implement identified interventions needed to promote healing and prevent worsening of a wound, prevent direct pressure to a pressure wound, or provide pressure reducing surfaces to promote healing of his/her unstageable pressure ulcer to his/her right heel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative nursing services to assist one resident (Resident #28), in a review of 22 sampled residents to attain or maintain his/her their highest level of functioning. The resident admitted to the facility free of contractures and had no limits in range of motion. The facility did not have a system to identify residents at risk for a decrease in range of motion or prevent development of contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The facility failed to develop restorative nursing plans with goals to prevent the development of contractures, improve or maintain functional range of motion, or direction to staff to meet the resident's needs. Resident #28 had a decrease in her range of motion abilities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to ensure residents, including one resident (Resident #13), with diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event, either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), were assessed and received trauma informed care to mitigate or eliminate triggers that may cause retraumatization of the resident. The facility's census was 59. Review of email communication, dated 02/05/25 at 4:52 P.M., showed the Director of Nursing (DON) wrote the facility did not have a policy for trauma informed care or care for residents with PTSD. 1. Review of the resident's face sheet showed the following: -Current admission date of 08/08/22; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of discharge with required information to the resident and/or resident representative for two residents (Residents #13 and #48), in a review of 22 sampled residents, when the facility initiated a transfer to the hospital. The facility did not provide any other written documentation to the resident or resident representative of the reason and date for transfer/discharge, where the resident was transferred/discharged , ombudsman contact information, information on how to appeal a transfer/discharge, or how to contact the mental health advocacy group for residents with intellectual disabilities or mental illness. The facility census was 59. Review of the undated facility policy, Discharges, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold policy with required information to the resident and/or resident representative for three residents (Resident #13, #61, and #48), in a review of 22 sampled residents, when the residents were transferred to the hospital for medical evaluation and treatment. The facility census was 59. 1. Review of Resident #13's undated Face Sheet showed the resident had emergency contacts that were his/her family members. Review of the resident's annual Minimum Data Set (MDS), a federally required assessment completed by staff, dated 1/26/24, showed the resident had moderate cognitive impairment. Review of the resident's Nursing Progress Notes, dated 04/05/24 at 8:00 P.M., showed the resident had a temperature of 101-102 degrees Fahrenheit (normal 98.6 degrees) and was sent to the hospital for evaluation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure food items were labeled, dated, covered or discarded when expired; failed to ensure staff utilized sanitary practices when handling ready to eat food items; and failed to ensure staff wore hair restraints to cover exposed hair. The facility census was 59. 1. Review of the undated facility policy, Food Labeling and Dating and Closure, showed the following: -All foods placed in dry storage, refrigerated and freezer units must be dated with date opened/placed, use by date (UBD) and initials and sealed with an approved tie; -Dietary staff and/or any staff member placing items for dietary or resident must follow this procedure; -Dietary staff and/or any staff member receiving food from family for a resident must follow this procedure and inform the family that the item will only be kept for three days; [...]

Inspectors wroteBased on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for six residents (Residents #9, #18, #34, #44, #57, and #162), in a review of 19 sampled residents. The facility census was 59. 1. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for care plans timing and revisions. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and/or revise interventions to prevent falls for four residents (Residents #9, #25, #47, and #54), in a review of 19 sampled residents. The facility failed to use proper technique when transferring one resident (Resident #13) when staff lifted under the resident's armpits during transfer and did not use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers). The facility failed to safely transport three residents (Residents #9, #13, and #34) in wheelchairs with footrests. The facility census was 59. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for transporting residents in wheelchairs. Review of facility's policy for management of falls, dated December 2007, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to obtain informed consent and educate residents and their responsible parties about the risks of bed rail use prior to use, and failed to assess for continued safe use of bed rails for five residents (Resident #9, #13, #18, #34, #162), in a review of 19 sampled residents. The facility census was 59. 1. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for bed rail assessments or use. 2. Review of the Food and Drug Administration (FDA) Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff performed acceptable infection control practices to prevent contamination when staff failed to protect nebulizer masks while not in use for two residents (Residents #22 and #54), in a review of 19 sampled residents. The facility failed to follow the facility's policy for hand washing and gloving during perineal care for one sampled resident (Resident #13) and for three additional residents (Residents #11, #19 and #163). The facility census was 59. Review of facility's undated handwashing policy showed the following: -Handwashing remained the single most effective means of preventing disease transmission; -Washing hands often and well, paying particular attention to around and under fingernails and between the fingers; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop policies and procedures regarding the provisions of pneumococcal (lung inflammation caused by bacterial or viral infection) vaccinations in accordance with the Centers for Disease Control and Prevention (CDC) recommendations. The facility failed to provide pneumococcal vaccine for one additional resident (Resident #163), who had a signed consent requesting the vaccine, and failed to follow CDC recommendations to administer the PCV15 (15-valent pneumococcal conjugate vaccine) or PCV20 (20-valent pneumococcal conjugate vaccine) when one resident's (Resident #8's), vaccination history was unknown. The facility failed to provide five residents (Resident #2, #8, #22, #54, and #57) in a sample of 19 residents and one additional resident (Resident #59), education of risks and benefits of receiving a pneumococcal vaccine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for five residents (Resident #9, #13, #18, #34 and #162), who used bed rails, in a review of 19 sampled residents. The facility census was 59. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for measuring the entrapment zones or a regular maintenance program to identify areas of possible entrapment. Review of the Food and Drug Administration's (FDA) Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #54) with a diagnosis of severe coronary obstructive pulmonary disease (COPD), a chronic lung disease that caused hypoxia (low oxygen levels), in a review of 19 residents wore his/her oxygen continuously as ordered. Staff failed to ensure the resident had supplemental oxygen when staff transported the resident from his/her room to the dining room, and back to his/her room. The resident had increased respiratory effort and critically low oxygen saturation levels after staff transported the resident without oxygen. The facility census was 59. During an interview on 5/5/2 at 1:00 P.M., Registered Nurse (RN) A said the facility did not have a policy regarding oxygen use. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs and risks that provide effective person-centered care that met professional standards of quality care within 48 hours of admission to the facility for one resident (Resident #164), in a review of 19 sampled residents. The facility census was 59. During interview on 05/04/23 at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for completing baseline care plans. 1. Review of Resident #164's face sheet showed the following: -admitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services based on professional standards of practice for three residents (Residents #35, #33 and #62), in a review of 13 sampled residents, to maintain or improve their highest practicable physical and mental well-being, by failing to monitor and document bowel movements and administer medications as appropriate to prevent constipation. The facility census was 65. 1. Review of an email received by the facility's assistant administrator on 9/24/19, regarding the facility's Bowel Protocol, showed the following: -Day three without a bowel movement: Milk of Magnesia (laxative to relieve occasional constipation); -Day four without a bowel movement: Suppository; -Day five without a bowel movement: Enema. 2. Review of Resident #35's Care Plan, with an onset date of 11/7/18, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer insulin according to the manufacturer's recommendations for one resident (Resident #4), in a review of 13 sampled resident. The failure had the potential to result in the resident not receiving the full dose of ordered insulin. The facility census was 65. 1. Review of the Novolog FlexPen information, provided by the director of nursing (DON), showed the following: -For prefilled pen injectors, prime the needle before each injection with two units of insulin; -Once injected, hold the pen device in the skin for a count of six after the dose dial has returned to zero units before the needle is removed to ensure the full dose has been administered. 2. Review of Resident #4's physician orders for September 2019, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), by failing to implement their policy or to complete a risk assessment to determine susceptible locations for the growth of such organisms. The facility census was 65. 1. Review of the facility's Legionella Prevention Policy, dated 2017, showed the following: -Legionnaire's disease is a bacterial disease commonly associated with water-based aerosols and often a result of poorly maintained air conditioning cooling towers and potable water systems; -Only those who are directly exposed to the contaminated aerolized water source can get the disease; [...]