State and federal nursing home regulators are required to conduct routine investigations, surveys, and inspections of every facility in Nevada. Their efforts help to identify serious concerns, health violations and deficiencies that affect the level of care provided to residents. When problems are identified, the facility is required to take immediate action to correct serious concerns and revise their policies and procedures to ensure the health and well-being of every resident are protected.
In egregious cases, state surveyors might designate the nursing home a Special Focus Facility (SFF) and add the Center to the federal Medicare watch list. Most these facilities remain under the watchful eye of the government and undergo many more inspections than normal for years. If the Home is unable or unwilling to make necessary corrections, the facility might be required to sell or operation to other companies in good standing or lose their agreement to provide care to Medicaid and Medicare-funded patients.
Nearly two years ago, Highland Manor of Fallon was designated a Special Focus Facility. While the Home has made significant improvements in the level of care they provide, the Center remains on the watch list. Some of the major concerns, safety violations and deficiencies involving this facility are detailed below.
This facility is a ‘not for profit’ 102-certified bed Long-Term Care Center providing cares and services to residents of Fallon and Churchill County, Nevada. The Home is located at:
550 North Sherman Street
Fallon, NV 89406
(775) 423-7800
In addition to providing round the clock skilled nursing care, the Center also offers respite care, hospice care, memory care, and their Bounce Back Rehabilitation Program.
The state of Nevada and the Centers for Medicare and Medicaid Services (CMS) have the legal authority to impose monetary penalties on any nursing facility in the state identified with egregious deficiencies and serious violations. These fines are meant to penalize nursing homes, staff members, and administrators who provide substandard care that causes, or could have caused, significant harm to the residents.
Over the last 36 months, Highland Manor Of Fallon has received numerous monetary penalties including a $10,000 fine on 01/03/2015, a $31,200 fine on 07/22/2015, an $18,005 fine on 02/25/2016, a $12,050 fine on 09/15/2016 and a fine of $21,394 on 03/21/2017. During the same time, Medicare denied payments requested by the facility on multiple occasions including on February 25, 2016, and March 21, 2017, due to substandard care.
The state of Nevada routinely updates their long-term care home database systems to reflect all incident inquiries, safety concerns, health violations, dangerous hazards, filed complaints, and opened investigations. This information can be found on numerous sites including Medicare.gov.
Currently, Highland Manor Of Fallon maintains an overall one out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, four out of five stars for staffing issues, and one star out of five stars for quality measures. Some serious violations and deficiencies involving this facility include:
In a summary statement of deficiencies dated September 15, 2017, the state investigator noted the facility’s failure “to ensure neurological checks were completed after a resident’s fall.” The facility Policy titled Emergencies, revised September 2016, reveals that the facility should “complete neurological checks at least every four hours for 24 hours until stable, or as otherwise ordered by the physician when a head injury occurred.”
The deficiency by the nursing staff involved a resident whose April 27, 2017, Care Plan “documented that the resident was at high-risk for falling related to unsteady gait, dementia, and usage of high-risk medication.” The resident’s August 23, 2017, Nursing Progress Note revealed that “staff noticed the resident on the floor. The Progress Note revealed the resident was lying on his back and was unable to state whether or not there was any pain due to confusion. The Progress Note revealed the fall was unwitnessed.”
Due to the fall, the resident’s January 4, 2017, Nursing Progress Note documented “neuro checks were within normal limits. However, there was no documentary evidence of the medical record that the nursing staff at conducted a minimum six neuro checks and 24 hours.” The investigator interviewed the Director Nursing on September 12, 2017, who “explained when a resident was unable to explain what happened to [them] the expectation was complete neuro checks and a minimum of six neuro checks every 24 hours.” The Director “confirmed neuro checks on August 23, 2017, were not completed per the facility’s protocol.”
In a summary statement of deficiencies dated January 3, 2015, the state investigator noted the facility’s failure “to ensure that staff provides immediate care for [one resident] at the onset of breathing distress.” The incident involved a resident “gasping for breath and turning color.” Documents revealed that during breakfast in the 200 Hall Dining Room a Certified Nursing Assistant notified the Charge Nurse that the resident was in distress.
The surveyor noted that “due to facility staff neglecting to provide immediate care to [the resident’s] change in condition, the resident eventually died. It was determined that there were 36 other residents with [the same medical diagnosis). It was determined the facility had not [guided] staff regarding emergency procedures for choking victims, from the time of the incident (that resulted in [the resident’s] death) through the time of this complaint investigation.” The surveyor identified an Immediate Jeopardy and “facility representatives were notified.”
In a separate summary statement of deficiencies dated September 15, 2016, was noted that the facility had failed to “ensure reference checks were completed [before] employment and training on abuse prohibition practices were provided for [one employee].” The surveyor’s findings included a review of an employee’s personnel records who “was hired on August 5, 2015. The personal record lacked documented evidence that reference checks were completed [before] employment and training on abuse prohibition practices with were provided for [the employee].”
The state investigator interviewed the facility’s Human Resources Director on the morning of September 15, 2016. The Director confirmed that “reference checks were not completed [before] employment and training on abuse prohibition practices was not provided for [the employee, who] was a contract employee and the Human Resources Department did not complete the employee’s pre-employment reference checks. All employees were required to attend the Abuse Prohibition Practices upon hire and at least annually thereafter.”
The facility was reminded of their October 2015 Abuse Prohibition Policy that reads in part:
“Screening of potential employees would have been conducted and hiring would have been dependent upon screening result. Screening should have included two reference checks with a previous employer and current employer or personal references if no prior employer. New employee orientation should have included training on abuse and neglect prohibition.”
In a third summary statement of deficiencies dated March 21, 2017, the state investigator identified a deficiency. It was noted that the facility’s failed “to implement and facility policy and procedure for abuse prevention went to [residents] were physically or verbally abused by [a third resident] and ensure adequate measures to protect residents from potential further abuse by [the abusive resident] were put into place.”
The state investigator identified an Immediate Jeopardy at the facility on the afternoon of March 15, 2017 “due to the lack of protection for residents to prevent physical abuse from a resident.” The allegedly abusive resident’s Quarterly Minimum Data Set Assessment dated January 24, 2017, indicated that the resident “exhibited behaviors including verbal and physical aggression [and] was unable to walk independently and needed limited assistance from one person for locomotion on the unit in a wheelchair.
The investigator reviewed the Nursing and Interdisciplinary Team Progress Notes that revealed that “a Certified Nursing Assistant (CNA) reported that the aggressive resident hit “the female resident on the face, first with two fingers, then with an open hand, in the hallway of the facility. The victim was [the allegedly aggressive resident’s] roommate. No injuries to the victim were noted. [The aggressive resident] gave no explanation and stated she did not do it.”
In a summary statement of deficiencies dated March 21, 2017, the state investigator noted the facility had failed to “ensure a physician’s Progress Notes” were completed. The surveyor reviewed numerous resident’s medical records and physician’s orders that did not reveal that the resident’s physician had visited the resident.
As a part of the investigation, the surveyor interviewed the facility’s Director of Nursing on the morning of March 16, 2017. The Director “explained the physician’s orders for [two residents] was evidence of a physician visit and verbalize the physician would not write an order at the facility without examining the resident.” The Director “confirmed the facility lacked documented evidence [that] a physician’s examination was completed for [two residents].”
The Director further explained that “the physicians use a transcription service to document their exams [and] explained the Medical Records Department was responsible for printing the exam notes from the Internet.” The Director “confirmed the Medical Records Office and the physician’s office lacked documented evidence of the rest of the physical exam portion of the visit.” The Director “explained that the facility’s expectation was a physician was to document evidence of a physical exam from a visit.”
The facility’s Nursing Home and Subject: Physician Services revised on August 2010 “lacked the required documentation [that] a physician is to provide on a physician visit to include a review of the resident’s program of care.”
In a summary statement of deficiencies dated September 15, 2016, the State surveyor noted that the facility had failed to “ensure behavior monitoring for the use of an anti-anxiety medication was initiated and completed for [a resident].” The state investigator reviewed a resident’s March 2016, April 2016, July 2016, August 2016, and September 2016 Anti-Anxiety Monthly Flow Record. The document revealed “the number of episodes per shift of target behaviors including pacing, scratching, self-continuously and obsessive-compulsive episodes.
However, “the resident’s medical record lacked documented evidence of an Anti-Anxiety Monthly Flow Chart for May 2016, and June 2016 was initiated and completed.” A Licensed Practical Nurse providing the resident care “confirmed the findings and indicated target behaviors for the use of an anti-anxiety medication should have been monitored and documented on every shift. The documentation should have been completed in the [monthly records]. The Director of Nursing was then interviewed and revealed that “nurses were expected to monitor the target behaviors for the use of an anti-anxiety medication every shift.”
In a summary statement of deficiencies dated September 15, 2016, the state investigator noted that the facility “failed to store its ice scooper in a sanitary manner.” The ice scooper was observed on the morning of September 12, 2016 “resting directly in the ice bed of the ice machine adjacent to the kitchen area.
The Kitchen Director pointed to a sign posted on the machine to wear gloves and not leave the ice scooper on the ice bed.” The Director also indicated that “employees never left the ice scooper on the ice bed before” and then “removed the ice scooper and placed it on the mounted holder on the side of the ice machine.”
In a summary statement of deficiencies dated March 21, 2017, the state investigator noted the facility’s failure “to ensure residents were free from abuse.” The incident involved multiple residents who were hit by another resident “who had a recent prior history of altercations with other residents.”
A review of the resident’s February 7, 2017, Progress Note revealed that a resident “was hit by another resident in the face.” The assaulting resident sustained injuries including “a small amount of blood under the skin and swelling.” The assaulting resident’s Progress Notes dated February 8, 2017, revealed that the resident “was backing up from the resident who hit her earlier. The note indicated that [the resident] was backing up in the hallway when [another resident] saw the aggressor.”
If you suspect your loved one has suffered harm through abuse, neglect or mistreatment while a patient at Highland Manor Of Fallon, or any nursing home, contact a personal injury law office now. Your lawyer can take over your compensation case and file documents, investigate your claim, present evidence to the jury and negotiate with the defendant’s attorney to obtain an adequate out of court settlement.
A personal injury attorney will provide immediate legal representation without any upfront payment or fee. All legal fees are paid only after the law firm has successfully resolved your case and obtained financial compensation on your behalf.
Sources:
Chicago Nursing Home Injury Attorney Nursing Home Law Center LLC Home