DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
295041
NAME OF PROVIDER OF SUPPLIER
DELMAR GARDENS OF GREEN VALLEY
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
F 0309
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
F 0311
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99)
Previous Versions Obsolete
PRINTED:03/12/2020
FORM APPROVED
OMB NO. 0938-0391
(X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
/ CLIA A. BUILDING ______ COMPLETED
IDENNTIFICATION B. WING _____ 03/22/2017
NUMBER
STREET ADDRESS, CITY, STATE, ZIP
100 DELMAR GARDENS DRIVE
HENDERSON, NV 89074
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
Provide necessary care and services to maintain the highest well being of each resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, interview and document review, the facility failed schedule a neurology appointment for 1 of 29
sampled residents (Resident #8); and to follow physician orders [REDACTED].#33.
Finding include:
Resident #33
Resident #33 was admitted on [DATE], with [DIAGNOSES REDACTED].
The Physician order [REDACTED].
The Medications Flowsheet for the month of (MONTH) (YEAR), indicated the administration of [MEDICATION NAME] 20 mg was
scheduled at 6:30 AM.
On 3/15/17 at 8:31 AM, during the Medication Administration Pass observation, a Licensed Practical Nurse (LPN) prepared and
administered the resident's medication including [MEDICATION NAME] 20 mg one capsule.
On 3/15/17 at 12:10 PM, the LPN confirmed the observation and acknowledged [MEDICATION NAME] 20 mg should have been
administered to the resident at 6:30 AM per the physician's orders [REDACTED].
The LPN provided a copy of Nursing 2011 Drug Handbook copyright in 2011 by Lippincott[NAME] and Wilkins. The Drug
Handbook
was kept inside the medication cart and used as a reference in medication administration. The LPN indicated the medication
should have been given 30 minutes before meals per the Drug Handbook. The LPN confirmed the resident had breakfast prior to the
administration of [MEDICATION NAME] 20 mg.
On 3/16/17 at 10:40 AM, the Director of Nursing (DON) confirmed the physician's orders [REDACTED].
On 3/16/17 at 11:30 AM, the DON provided a copy of PharMerica (name of pharmacy) 2014 Nursing Drug Handbook copyright in
2013 by Lexi-Comp, Incorporated. The Drug Handbook indicated the administration of [MEDICATION NAME] by mouth was best
before breakfast. The facility used the current Drug Handbook as a reference in medication administration.
The facility's policy titled Medication Administration dated (MONTH) 2007, indicated medications were to be given at the
time ordered, within 60 minutes before or after designated time.
Resident #8
Resident #8 was admitted on [DATE] with a [DIAGNOSES REDACTED].
The Physician order [REDACTED].
On 3/15/17 at 3:40 PM, the Director of Activities explained the physician ordered the consultation. The nurses would fill
out a consultation form which indicated the resident's name, the physician who made the referral and the information about
the type of consultation. The nurses would place the consultation form in a folder at the nurses station. The scheduler
would check the folder daily for consultation forms. The scheduler would make the appointments for the consultations and
document the appointments in a calendar with the resident's name, date, the time of the appointment and the physician's
name.
The Director of Activities reviewed the calendar for (MONTH) (YEAR) and (MONTH) (YEAR) and was unable to locate the
appointment for Resident #8's Neurology consultation.
On 3/15/17 at 3:50 PM, a Certified Nursing Assistant (CNA)/Scheduler, explained the nurses obtained the referrals for
consultations from the physician. The nurses would fill out a Consultation form and place the form in a folder at the
nurses station. The scheduler would check the folder daily and make the consultation appointments. The CNA/Scheduler could
not locate the Consultation form for the Neurology consultation dated 2/23/17, for Resident #8. The CNA/Scheduler explained if the
Consultation form was not in the folder, the nurses did not fill out the consultation form and the appointment was
not made.
On 3/16/17 at 11:30 AM, a family member of Resident #8 explained the appointment was not made by the facility. The family
member spoke to the facility several times and asked if the appointment was made.
On 3/17/17 at 9:55 AM, the Director of Nursing (DON) explained the nurses filled out the consultation form for the referrals and
submitted them to the scheduling staff who would schedule the appointment immediately. The DON was unaware the
Neurology appointment was not set for Resident #8.
The Director of Nursing explained the facility lacked a policy regarding how consultations were scheduled.
Make sure that residents receive treatment/services to not only continue, but improve the
ability to care for themselves.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to ensure a resident was informed on the risks and benefits of the
refusal of the restorative program and notify the physician of a resident's refusal to participate in the program for 1 of
29 sampled residents (Resident #7).
Findings include:
Resident #7
Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED].
The History and Physical dated 12/29/16, indicated the resident's goals while at the facility would have been to achieve
safety, ambulation, independence, and range of motion. The primary goal would have been to achieve the resident's previous
functional status and discharged to the resident's previous living facility safely.
The Care Plan dated 1/9/17, revealed the resident had a decrease in functional status related to recent hospitalization
secondary to [DIAGNOSES REDACTED]. The resident currently needed extensive to moderate assistance with all ADL (activities
of daily living) care.
The physician's orders [REDACTED].
The Therapy Communication Form to RNA dated 1/23/17, indicated the resident was at risk for decreased range of
motion/contractures and at risk for decline in transfers. The RNA program for the resident included:
- Stretch bilateral knees into extension/bilateral hips to neutral rotation
- Sit to stand exercises
The Nursing Rehab (rehabilitation)/Restorative Care Plan for the month of (MONTH) (YEAR) and (MONTH) (YEAR), documented
the
resident refused the RNA services on the following dates:
- 1/25/17, 1/27/17, and 1/31/17 or a total of three refusals
- 2/2/17, 2/3/17, 2/6/17, 2/9/17, 2/10/17, 2/14/17, 2/16/17, 2/17/17, 2/20/17, 2/22/17, 2/23/17, 2/27/17, and 2/28/17 or a
total of 13 refusals.
TITLE (X6) DATE
Event ID: YL1O11 Facility ID: 295041 If continuation sheet
Page 1 of 4
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
295041
NAME OF PROVIDER OF SUPPLIER
DELMAR GARDENS OF GREEN VALLEY
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
F 0311
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
F 0312
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
F 0328
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
FORM CMS-2567(02-99)
Previous Versions Obsolete
PRINTED:03/12/2020
FORM APPROVED
OMB NO. 0938-0391
(X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
/ CLIA A. BUILDING ______ COMPLETED
IDENNTIFICATION B. WING _____ 03/22/2017
NUMBER
STREET ADDRESS, CITY, STATE, ZIP
100 DELMAR GARDENS DRIVE
HENDERSON, NV 89074
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
(continued... from page 1)
The resident's clinical record lacked documented evidence the resident was informed on the risks and benefits of the refusal of the
restorative program and the physician was notified of the resident's refusal to participate in the program.
On 3/14/17 in the morning, during the initial tour, the resident was laying in bed and was alert, oriented, and able to make needs
known. The resident indicated he did not get enough exercise and stopped having therapy. The resident was not
informed whether the resident would get more therapy.
On 3/16/17 at 8:20 AM, the Licensed Practical Nurse (LPN)/RNA Coordinator confirmed the resident refused the RNA treatment
on the above-mentioned dates. The RNA was discontinued on 2/28/17 due to frequent refusals. The LPN/RNA Coordinator
acknowledged the resident was not informed of the risks and benefits of the refusal of the restorative program and the
physician was not notified of the resident's refusal to participate in the program. The LPN/RNA Coordinator should have
talked to the resident after two weeks of refusal or the resident could have been referred back to therapy. The physician
should have been notified of the resident's refusal of the RNA program.
On 3/16/17 at 9:00 AM, the resident revealed he needed the RNA or therapy at least three times a week for exercises. The
resident refused the RNA before because he could not stand up for two to five minutes due to pain on his right foot. The
resident indicated he fell yesterday because he wanted to go to the bathroom. The resident tried to stand and sit on the
wheelchair but the resident slid on the floor and fell .
Assist those residents who need total help with eating/drinking, grooming and personal
and oral hygiene.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to ensure a shower was provided as scheduled to one unsampled
resident (Resident #34).
Findings include:
Resident #34
Resident #34 was readmitted on [DATE], with [DIAGNOSES REDACTED].
On 3/14/17 in the morning, during the initial tour, the resident indicated she missed a shower on Saturday, 3/11/17. The
resident was scheduled to have a shower every Wednesday and Saturday morning. The resident revealed she had a [MEDICAL
CONDITION] and needed assistance with shower. The resident asked a Certified Nurse Assistant (CNA) to give the resident a
shower at 8:30 AM on Saturday. The CNA came back at 11:30 AM but the resident refused to have a shower because it was lunch
time. The resident asked to CNA to give her a shower after lunch but the CNA did not come back.
The Care Plan dated 11/1/16, documented the resident was extensive to total assist with activities of daily living (ADL)
functions due to [MEDICAL CONDITION].
The CNA ADL Documentation for the month of (MONTH) (YEAR), lacked documented evidence a shower or bath was provided to
the
resident on 3/11/17.
On 3/14/17 at 9:45 AM, a Licensed Practical Nurse (LPN) and a CNA confirmed the findings and revealed the resident was
scheduled to have a shower every Wednesday and Saturday on day shift, from 6:00 AM to 2:00 PM. A shower should have been
provided to the resident on 3/11/17. The CNA indicated the resident needed an extensive assist in shower or bathing.
On 3/16/17 at 11:30 AM, the Director of Nursing (DON) explained the CNA's were expected to provide a shower to the residents as
scheduled then document in the CNA ADL Documentation. The DON confirmed there was no documentation Resident #34 received a
shower on 3/11/17.
Properly care for residents needing special services, including: injections, colostomy,
ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot
care, and prostheses
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, interview and document review, the facility failed to clarify Oxygen therapy orders and monitor
use for 1 of 29 sampled residents (Resident #13); obtain a physician order [REDACTED].
Finding include:
Resident #13
Resident #13 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED].
On 03/14/17 at 8:55 AM, the resident was in bed and did not have oxygen in use.
The Physician admission orders [REDACTED]. The Treatment Flowsheet indicated inconsistent documentation regarding oxygen use
on 2/7/17- 2/9/17 and 2/27/17-2/28/17.
On 03/14/17 at 3:30 PM, the LPN explained the nurses were supposed to initial or circle if they rendered treatment or not
and document the reason on the back of the Medication Administration Record, [REDACTED].
The facility's policy titled,Oxygen Administration revised date: (MONTH) 5, 2009 documented
To provide higher concentration of oxygen than is available in room air. Note resident tolerance to the treatment and all
pertinent observation.
Resident #6
Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED].
The physician's orders [REDACTED].
The physician's orders [REDACTED].
The Nurse's Notes documented:
- 1/17/17 at 10:00 AM, a Registered Nurse (RN) inserted heplock (IV line) at right hand and started 1/2 NS at 60 cc per hour times
two liters.
- 1/21/17 at 10:00 AM, continue IV fluid 1/2 NS at 60 cc per hour fourth bag and last bag.
The resident's clinical record lacked documented evidence a physician's orders [REDACTED].
On 3/16/17 at 9:20 AM, the Director of Nursing (DON) confirmed the findings and acknowledged a physician's orders
[REDACTED]. The DON explained the date, time, and IV site assessment when the heplock was discontinued should have been
documented in the Nurse's Notes. The facility had no policy on heplock care and maintenance.
On 3/16/17 at 2:15 PM, an RN revealed a physician's orders [REDACTED]. The nurses should have documented in the Nurse's
Notes the date, time, and IV site assessment when the heplock was discontinued.
Resident #2
Resident #2 was admitted to the facility on [DATE] and re admitted on [DATE] with a [DIAGNOSES REDACTED].
On 3/14/17, in the morning, during the initial tour, the resident had a PICC (peripherally inserted central catheter) line
inserted on the left upper arm.
The resident's clinical record lacked documented evidence a physician's orders [REDACTED].
On 3/15/17 at 1:30 PM, the resident's PICC line had a gauze dressing. The gauze dressing lacked a date to indicate when the
dressing was changed.
A Registered Nurse (RN) confirmed the observation of the gauze dressing and indicated the current PICC line's dressing was
done at the hospital. The RN explained the dressing would not be changed upon admission, however would be changed weekly.
The PICC line would be flushed daily with 7 cubic centimeters (cc's) of saline solution and 3 cc's of [MEDICATION NAME].
The RN explained a physician order [REDACTED].
The flushes and site monitoring were documented on the Intravenous (IV) sheets and nurses notes.
The resident's IV Medication flow sheet documented the resident's PICC line was flushed with 10 cc normal saline IV after
medication on 3/14/17 and 3/15/17.
The Medication Administration Record [REDACTED].
On 3/16/17 at 3:40 PM, an RN explained when a resident was admitted from the hospital with a PICC line,the hospital nurse
would inform the facility of when the PICC line was inserted and when the dressing was changed. If the dressing was a gauze
Event ID: YL1O11 Facility ID: 295041 If continuation sheet
Page 2 of 4
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
295041
NAME OF PROVIDER OF SUPPLIER
DELMAR GARDENS OF GREEN VALLEY
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
F 0328
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
F 0329
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
F 0406
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
F 0431
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
FORM CMS-2567(02-99)
Previous Versions Obsolete
PRINTED:03/12/2020
FORM APPROVED
OMB NO. 0938-0391
(X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
/ CLIA A. BUILDING ______ COMPLETED
IDENNTIFICATION B. WING _____ 03/22/2017
NUMBER
STREET ADDRESS, CITY, STATE, ZIP
100 DELMAR GARDENS DRIVE
HENDERSON, NV 89074
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
(continued... from page 2)
dressing, the dressing would be changed upon admission, dated and changed weekly. The PICC line would be flushed with 7
cc's or 10 cc's of saline solution and 3 cc's of [MEDICATION NAME]. The RN explained a physician order [REDACTED].
On 3/16/17 at 4:02 PM, the Regional Nurse Supervisor explained the dressing should have been changed within 24 hours of the
PICC line being inserted. A physician order [REDACTED].
The final report from the hospital dated, 3/7/17, documented the resident's PICC line was inserted on 3/7/17 at 3:03 PM.
On 3/17/17 in the morning, the Regional Nurse Supervisor explained the resident's dressing should have been changed on
3/14/17 which was seven days after the PICC line was inserted. The order for PICC line dressing changes was not obtained
until 3/16/17.
On 3/17/17 in the morning, the Director of Nursing (DON) confirmed the resident's PICC line dressing should have been
changed on 3/14/17 which was seven days after the PICC line was inserted.
The skilled daily nursing notes for 3/14/17 lacked documented evidence of dressing changes.
The facility policy entitled, Invasive Lines Dressing Change, revised 09/03/2009, documented dressings on PICC lines would
be changed 24 hours after insertion. After initial dressing changes, all dressings would be changed every seven days and as needed.
Resident #30 was admitted on [DATE] with a [DIAGNOSES REDACTED].
On 3/14/17 during the tour, a suction machine and an Oxygen concentrator's tubing lacked a date to indicate when the tubings were
changed.
A physician order [REDACTED].
On 3/14/17 at 11:15, a Licensed Practical Nurse (LPN), confirmed the lack of dates on the suction machine and the O2 tubing. The
LPN explained the tubing was changed on Sunday and the tubing should be dated.
Resident #31
Resident #31 was admitted on [DATE] with a [DIAGNOSES REDACTED].
On 3/14/17 during the tour, an oxygen concentrator's tubing lacked a date to indicate when the tubing was changed.
A physician order [REDACTED].
Resident #32
Resident #32 was admitted on [DATE] with a [DIAGNOSES REDACTED].
On 3/14/17 during the tour, an oxygen concentrator's tubing lacked a date to indicate when the tubing was changed.
A physician order [REDACTED].
On 3/14/17 at 9:40 AM, a Certified Nursing Assistant (CNA), confirmed the dates were not on the tubing. The CNA was unaware
the dates were needed on the tubing.
On 3/17/17 at 10:20 AM, an Infection Control Nurse explained the tubing on the suction machines and O2 concentrators was
changed on Sundays by the nursing staff. The tubing should be dated to show the last time the tubing had been changed.
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each
resident's entire drug/medication is managed and monitored to achieve highest well being.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to monitor responses to or effects of a
psychotherapeutic medication and follow up on the Pharmacist's recommendation to discontinue a controlled medication for 1
of 29 sampled residents, (Resident #9).
Findings include:
Resident #9
Resident #9 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED].
Resident #9 was prescribed [MEDICATION NAME] 50 milligrams (mg) once a day for depression. The resident received
[MEDICATION NAME] 50 mg once a day from 3/01/17 to 3/16/17. The facility lacked documented evidence of the resident's
behavioral
monitoring flow sheet for (MONTH) (YEAR).
On 03/16/17 at 2:00 PM, the Licensed Practical Nurse (LPN) verified there was no behavioral monitoring flow sheet in the
medication administration record (MAR) and not in the medical record for Resident #9.
On 03/16/17 at 2:00 PM, the LPN acknowledged there should have been a behavioral monitoring flow sheet to document the
effects of the medication for the resident.
On 03/17/17 at 8:30 AM, the Director of Nursing (DON) conveyed there should have been a behavioral monitoring flow sheet to
monitor signs and symptoms for the pharmacy consultant to review monthly to possibly reduce the dosage of the medication.
On 03/17/17 at 9:08 AM, the DON verified the behavioral monitoring flow sheet was not with the resident's MAR and it should
have been.
The facility's policy, Accommodating Behaviors Using Person-Centered Care, dated 09/2013, revealed targeted harmful
behaviors should have been defined and the occurrence of the behavior should have been documented quantitatively every
shift on a flow sheet. The occurrence of any side effects should have been charted every shift on a flow sheet.
Give or get specialized rehabilitative services per the patient's assessment or plan of
care.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to ensure a therapy evaluation for the use of a
walker was performed for 1 of 29 sampled residents (Resident #7).
Findings include:
Resident #7
Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED].
Section G Functional Status of Minimum Data Set (MDS) - Version 3.0 dated 1/9/17, documented the resident required extensive
assistance with one person physical assist on transfer and locomotion (ambulation).
The Care Plan dated 1/9/17, revealed the resident had a decrease in functional status related to recent hospitalization
secondary to [DIAGNOSES REDACTED]. The resident currently needed extensive to moderate assistance with all ADL (activities
of daily living) care.
The PT (Physical Therapy) - Therapist Progress and Discharge Summary dated 1/23/17, documented the long term goals on bed
mobility-transfers-ambulation were not met. The resident was unable to ambulate due to the resident unable to tolerate
weight acceptance on right lower extremity, limited by pain.
On 3/14/17 in the morning, during the initial tour, the resident was laying in bed and was alert, oriented, and able to make needs
known. There was a walker beside the resident's bed. The resident revealed his family brought the walker to the
facility. The resident used the walker to ambulate.
On 3/16/17 at 8:40 AM, a Physical Therapist (PT) indicated the resident was discharged from therapy on 1/23/17 because the
resident did not make any progress in therapy. The resident was unable to ambulate and had poor safety awareness. The PT
acknowledged there was no therapy evaluation for the resident's use of a walker. The resident should have been evaluated
first to determine if the resident could use a walker.
On 3/16/17 at 9:00 AM, the resident revealed his family just took the walker because the resident was not allowed to use the walker.
The resident indicated he fell yesterday because he wanted to go to the bathroom. The resident tried to stand and
sit on the wheelchair but the resident slid on the floor and fell .
On 3/16/17 at 9:05 AM, a Restorative Aide (RA) confirmed the resident used a walker last week to ambulate. The RA saw the
resident used the walker as the resident walked in the hallway.
Maintain drug records and properly mark/label drugs and other similar products according
to accepted professional standards.
Event ID: YL1O11 Facility ID: 295041 If continuation sheet
Page 3 of 4
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
295041
NAME OF PROVIDER OF SUPPLIER
DELMAR GARDENS OF GREEN VALLEY
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
F 0431
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
F 0441
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Few
FORM CMS-2567(02-99)
Previous Versions Obsolete
PRINTED:03/12/2020
FORM APPROVED
OMB NO. 0938-0391
(X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
/ CLIA A. BUILDING ______ COMPLETED
IDENNTIFICATION B. WING _____ 03/22/2017
NUMBER
STREET ADDRESS, CITY, STATE, ZIP
100 DELMAR GARDENS DRIVE
HENDERSON, NV 89074
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
(continued... from page 3)
Based on observation and interview the facility failed to ensure medications were secured.
Finding include:
On 3/14/17 at 9:10 AM, during the initial tour a half full bottle of fish oil capsule/ 1200 milligram (mg) was on the top of bed side
table. Under the television stand were seven normal saline solution (NSS)/100 milliliter bottles, one tube of
Mupirocin antibiotic ointment, one tube of Calmoseptine ointment and approximately 10 gauze rolls, and 20 packets of clean
dry dressing.
On 3/14/17 at 9: 17 AM, the Licensed Practical Nurse (LPN) explained the fish oil supplement was to be kept in the
medication cart and wound care items in the treatment cart.
On 3/14/17 at 2:15 PM, a medication cart was unlocked located in the right corner of 400 hall, approximately 13 feet away
from the LPN in the nurses station.
On 3/14/17 at 2:45 PM, an LPN, explained the medication cart must be locked at all times if not in use.
Have a program that investigates, controls and keeps infection from spreading.
Based on observation, interview and document review, the facility failed to ensure proper infection control during a
medication administration.
Finding included:
On 3/15/17 at 8:20 AM, a medication pass observation was conducted in Unit 900 with a Licensed Practical Nurse (LPN). The
LPN prepared several medications for an unsampled resident. The LPN used one of her fingers to pull out athe capsule from
the medication container. The LPN did not wear gloves during the preparation of the medication.
The LPN acknowledged the medications could not be touched with bare hands.
Facility policy titled Medication Administration dated (MONTH) 2007, indicated that tablets or capsules should be
transferred from a bottle using the bottle cap directly into the souffle cup.
Event ID: YL1O11 Facility ID: 295041 If continuation sheet
Page 4 of 4