The Laurels of Carson City

Inspectors wroteThis citation pertains to Incident 3042858Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of an allegation of abuse in accordance with section 1150B of the Act for one (R18) of four residents reviewed for abuse. Findings Include:R26Review of the Minimum Data Set (MDS) dated [DATE] revealed R26 was admitted to the facility 5/22/2026 with diagnosis that included Alzheimer's disease and Dementia. The MDS Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which indicated the Resident was severely cognitively impaired. The MDS reflected R26 was independently ambulatory. R18Review of the MDS date reflected R18 admitted to the facility 5/5/2024 with diagnoses that included Dementia. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the development of a pressure ulcer for one resident (R7) of two residents reviewed for treatment of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for a continuous positive airway pressure (CPAP) machine and schedule cleaning for a CPAP machine for one resident (R88) of three residents reviewed for respiratory care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician reviewed monthly drug regimen review recommendations for 1 resident (R20) of 5 residents reviewed for unnecessary medications.

Inspectors wroteThis citation pertains to Complaint 2975929Based on interview and record review, the facility failed to ensure appropriate caregiver/support availability for an incapacitated resident who did not have a guardian/Power of Attorney and implement a safe discharge plan for one resident (Resident #1) out of 4 residents reviewed for discharge planning.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1) use Personal Protective Equipment (PPE) according to Transmission Based Precaution (TBP) orders for 1 resident (R61) of two residents reviewed for TBP, 2) implement the facility water management policy/procedure, and 3) dispose of soiled linens in a sanitary manner for 1 resident (R25) of 18 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignified care for four residents (R50, R11, R4, R75) of six reviewed for dignity.

Inspectors wroteBased on interview and record review, the facility failed to hold blood pressure medication according to the physician's order for 1 resident (R69) of 18 residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to utilize an intervention to enhance the comfort and functionality for one of three residents (Resident #25) reviewed for range of motion.

Inspectors wroteBased on observation and record review, the facility failed to follow a safety intervention for one of three resident's (Resident #25) reviewed for falls and accidents.

Inspectors wroteThis Citation pertains to Intake Number MI00145232. Based on interview and record review the facility failed to ensure adequate assessment and monitoring of a resident having chest pain and using nitroglycerin for one resident (Resident #101) of 3 residents reviewed for change of condition, resulting in incomplete information being communicated to the medical practitioner, the potential for unnoticed cardiovascular compromise, and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess, provide treatments as ordered, and ensure physician oversite for wounds for 2 residents (Resident #276 and #64) out of 18 residents reviewed for alterations in skin integrity/pressure injuries, resulting in an immediate jeopardy when on 12/21/23, an alteration in skin integrity was identified on R276's left heel. R276 was not provided care in accordance with professional standards of practice and facility policy to treat and prevent the deterioration pressure injuries, did not have an accurate assessment of the pressure injury, and was not provided the necessary treatment for a deteriorating pressure injury resulting in the development of osteomyelitis. [...]

Inspectors wroteThis citation is related to intake #MI00140932 Based on interview and record review, the facility failed to 1.) promptly identify an outbreak of acute respiratory illness and implement facility infection prevention and control policies and procedures, 2.) implement transmission-based precautions for residents with signs and symptoms of acute respiratory illness to prevent the spread of infection, 3.) ensure prompt testing for residents with signs and symptoms of acute respiratory illness, 4.) investigate the outbreak and document the surveillance of respiratory infections, and 5.) follow transmission based precautions for suspected Clostridum difficle (C-diff). This deficient practice resulted in the widespread transmission and infection of residents and staff with COVID-19, Influenza, and Respiratory Syncytial Virus.

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal immunization per consent and the recommendation by the Centers for Disease Control and Prevention (CDC) for 1 (Resident #287) out of 5 reviewed for immunizations, resulting in residents not receiving the pneumococcal immunization.

Inspectors wroteThis citation relates to intake #MI00-140932 Based on observation, interview, and record review the facility failed to 1.) administer controlled medications following a physician order and professional standards of practice, 2.) ensure medications were administered following nursing professional standards of practice, and 3.) ensure medications were administered follow the physician ordered parameters for 6 residents (R13, R25, R58, R11, R275, R225), resulting in the lack of assessment, monitoring, and documentation, medication errors, and the withholding of medications without a physician order.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse in a facility with a daily average census of more than 60 residents resulting in a lack of consistent clinical services oversight and negative resident outcomes when the DON was a charge nurse for over 110 hours since January 2024.

Inspectors wroteThis citation is related to intake #MI00140932 Based on observation, interview, and record review, the facility failed to ensure call lights were within sight and reach for 1 of 3 residents (Resident #70) reviewed for call light placement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe water temperatures, resulting in the potential for scalding residents, affecting residents using the 200 hall spa, and Room #'s 214 and 204.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatments and orders were in place to prevent catheter associated urinary tract infections for 1 resident (Resident #64) out of 3 residents reviewed for catheters and urinary tract infections, resulting in the potential for complications from cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure best practice standards were followed for residents receiving supplemental oxygen, for 2 of 3 residents reviewed (Resident #67 and Resident #70).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that intravenous (IV) medications were administered by licensed nurses who had demonstrated proficiency with IV medication administration through training and monitoring in accordance with State professional standards of practice. This failure, of administering intravenous medications outside their scope of practice, increased the potential for adverse complications for one resident (R35), from a sample of 18 residents, who was observed receiving IV antibiotics administered by a Licensed Practical Nurse (LPN), untrained in intravenous medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clean ventilation filters, resulting in reduced air quality and reduced air circulation, affecting resident rooms 204, 214, 326, and 327.

Inspectors wroteBased on observation, interview, and record review, the facility failed to operationalize policies and procedures to appropriately evaluate and assess for pain and implement pharmacological and nonpharmacological interventions for pain control for 1 of 18 sampled residents (Resident #27) reviewed for pain management, resulting in the absence of pain assessments and an increased perception of pain and unmet pain needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received medications as ordered for 1 resident (Resident #64) out of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who required an antibiotic was prescribed the appropriate antibiotic for 1 of 10 residents (Resident #43) reviewed for antibiotic use, resulting in inappropriate antibiotic utilization and the potential for antibiotic resistance.

Inspectors wroteThis citation pertains to intake number MI00138689 Based on interview and record review, the facility failed to notify the physician and assess a resident with an elevated potassium level (critical laboratory level) for 1 Resident (R2) of 3 Residents reviewed for quality of care, resulting in the potential for medical complications and harm.

Inspectors wroteThis citation pertains to intake number MI00138689 Based on interview and record review the facility failed to have 1 Resident (R2) of 3 residents reviewed for physician visits, be seen by her physician every 60 days, resulting in the potential for unmet medical needs.