Imperial Manor Nursing Home

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview and record review the facility failed to perform hand hygiene to prevent the potential for cross contamination during meal preparation. This had the potential to affect all residents. The facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B) & (D)Based on Observation, interviews and record review the facility failed to prevent the potential for cross contamination while scooping ice into resident drinking cups. The facility also failed to perform hand hygiene to prevent the potential for cross contamination during hydration preparation in the dining room This had the potential to affect all residents. The facility census was 30.

Inspectors wroteBased on record review and interview, the facility failed to employ a qualified infection preventionist. This had the potential to affect all residents residing within the facility. The facility census was 30. Findings Are: An interview on 9/29/2025 at 10:25 AM with the administrator revealed Licensed Practical Nurse (LPN)-C was the facility's Infection Preventionist. A record review of facility provided documents revealed no evidence that LPN-C had completed specialized training for infection control and prevention. An interview on 9/29/2025 at 11:36 AM with the administrator confirmed LPN-C had not completed specialized training for infection control and prevention and that the facility's Director of Nursing (DON) had been covering the duties of the Infection Preventionist in addition to their DON job duties.

Inspectors wroteBased on record review and interview, the facility failed to notify the ombudsman of 1 (Resident 35) of 1 sample resident's discharge from the facility. The facility census was 30. Findings Are: A record review of Resident 35's admission Record revealed the resident was admitted to the facility on [DATE]. The record also revealed the resident discharged to another nursing facility on 8/19/2025. A record review of Resident 35's electronic medical records revealed no evidence of the Ombudsman being notified of the resident's discharge from the facility. An interview on 9/30/2025 at 2:32 PM with the Director of Nursing (DON) confirmed the resident was discharged from the facility. The DON stated that the Social Services Director (SSD) was responsible for notifications to the ombudsman. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to ensure the care plans were comprehensive for 2 (Residents 17 and 26) of 12 sampled residents. The facility census was 30. Findings Are: A record review of the facility's Comprehensive Care Plans policy with revision date of 9/12/2024 revealed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. A.A record review of Resident 17's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of migraine and polyneuropathy. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record reviews, the facility failed to ensure foods were not stored on the floor and meats were not thawed above fresh vegetables. This had the potential to affect all residents. The facility census was 36.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews and record review, the facility failed to ensure that outdated food items were not available for use, failed to ensure clean and sanitary surfaces were maintained throughout the kitchen, and failed to do proper hand hygiene to prevent cross contamination and prevent the spread of foodborne illness. The facility also failed to use pasteurized eggs when serving over-easy eggs to prevent foodborne illness and failed to follow package directions while preparing stuffing. This had the potential to affect all 32 residents served food out of the kitchen.

Inspectors wroteLicensure Reference 175 NAC 12-00604(B)(ii) Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interview, the facility failed to ensure nurse aides had completed at least 12 hours of continuing education, including Dementia and Abuse training, as required for 4 (Nurse Aide G, F, D, and H) of 5 sampled employees. This had the potential to affect all 32 residents who reside within the facility.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(I)(i)(3) Based on observations, interviews, and record reviews; the facility failed to implement interventions to prevent elopement for 1 resident (Resident 26), ensure fall interventions were in place for 2 residents (Resident 3 and 22), and ensure a call light was within reach for 1 resident (Resident 15). The sample size was 4 out of 4 residents. The facility identified a census of 32.

Inspectors wroteLicensure Reference 175 NAC 1-005.01(G) Based on record reviews and interview, the facility failed to report to the State Agency and submit an investigation within 5 working days of an elopement for 1 (Resident 26) of 1 sampled resident. The facility identified a census of 32.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(c)(ii) Based on interviews and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) within the required 14 days assessment within 14 days of the determination of a significant change for 1 (Resident 11) of 1 sampled resident. The facility identified a census of 32.

Inspectors wroteBased on observation, interview and record review; the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was completed prior to admission for one (Resident 15) of one sampled resident. The facility identified a census of 32.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(F)(i) Based on record review and interview, the facility failed to develop a baseline care plan (a written strategy for how nursing home staff will help a resident receive the care they need) with the required information for 1 (Resident 30) of 1 sampled resident. The facility identified a census of 32.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(H)(vi)(3)(g) Based on observations, interviews, and record review; the facility failed to ensure that nasal cannula tubing was stored in a sanitary condition and failed to ensure oxygen settings were set at the prescribed rate for 2 (Resident 8 and 30) of 2 sampled residents. The facility identified a census of 32.

Inspectors wroteLicensure Reference 175 NAC 12- 006.09(H) Based on record reviews and interview, the facility failed to have a stop date for an antibiotic for 1 (Resident 3) of 5 sampled residents. The facility identified a census of 32.

Inspectors wroteLiscensure Reference Number 175 NAC 12-006.10 (D) Based on observation, interview, and record review; the facility failed to ensure that 1 (Resident 6) of 7 sampled residents received an extended-release medication per manufacturer directions. This resulted in a significant medication error. The facility identified a census of 32.

Inspectors wroteLicensure Reference 175 NAC 12-006.18(B) Licensure Reference 175 NAC 12-006.18(D) Based on observations, interview, and record reviews; the facility failed to don (put on) Personal Protective Equipment (PPE) of a gown during catheter cares and completed hand hygiene between glove use as required for 1 (Resident 26) of 1 sampled resident. The facility identified a census of 32.

Inspectors wroteBased on record reviews and interview, the facility failed to submit data for the third quarter of 2024 for the Payroll Based Journal (PBJ, a collection of staffing information and a requirement of all long-term care facilities.) This had the potential to affect all resident residing within the facility. The facility identified a census of 32.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in a manner that prevents the potential for foodborne illness in residents who consume food from the kitchen. This had the potential to affect all residents residing in the facility who ate from the kitchen. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C1c Based on interviews, and record review, the facility failed to review and revise 4 (Residents 26, 27, 33, and 38) of 4 sampled resident's care plans after a fall. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12A Based on observation, record review, and interviews; the facility and its Contracted Pharmacy failed to ensure that medications were available to be administered as ordered for Resident 241. The facility identified a census of 39 residents at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 27 medication administration opportunities revealed 7 errors that resulted in an error rate of 25.93%. The errors affected Resident 241. The facility staff identified a census of 39 residents at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17D Based on observations, interview, and record review the facility staff failed to perform hand hygiene when preparing and administering medications to 1 (Resident 11) of 1 resident sampled. The facility census was 39. A. Observation of medication administration on 10/3/2023 at 12:40 PM revealed that RN-E had washed their hands with soap and water for five seconds before administering a resident's medications. Prior to administering the medications, RN-E had gone back over to the medication cart, placed their hand in their pockets to retrieve a set of keys, opened drawers on the medication cart, and removed the resident's medications again. Observation at 12:45 PM revealed RN-E washed their hands with soap and water for 10 seconds, put gloves on, and administered the resident's eye drops and nasal spray. [...]