Hillcrest Shadow Lake LLC

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review, the facility failed to perform hand washing after touching potentially contaminated items during meal prep, place the blade in the puree blender in a sanitary manner, ensure staff did not touch the drinking surfaces of the cups of 12 residents in the E hall dining room to prevent cross-contamination. The facility failed to ensure the main kitchen and the Evergreen/Memory unit kitchen floors and equipment were cleaned and failed to ensure all items in the Evergreen/Memory Care unit refrigerator and freezer were labeled and dated to prevent the potential for food-borne illness. This had the potential to affect all 92 residents in the facility. The facility census was 92. Findings are: A. An observation on 04/02/2024 at 7:04 AM revealed the facility's Chef went to dry storage in the food preparation (prep) process and got 3 cans of green beans, the Chef opened a box of frozen beans and opened the plastic bag inside the box and dumped them into a saucepan with the other green beans. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C. An observation on 04/03/2024 at 7:15 AM of Certified Medication Assistant K (CMA)-K performing blood glucose testing and insulin administration for Resident 74 revealed CMA-K gathered Resident 74's individual glucose monitor, a test strip, a cotton ball, a lancet and a pair of gloves. CMA-K also had 2 insulin flex pens, one of Lantus with 22 units of insulin and one of Humalog 5 units of insulin, both pens were prepared for administration with a safety needle attached. CMA-K entered the resident room and informed Resident 74 that CMA-K was there to test the residents blood glucose and administer insulin. Resident 74 agreed and CMA-K donned gloves without washing their hands or using hand sanitizer. CMA-K opened the alcohol wipe and wiped the forefinger on the right hand. CMA-K used the lancet to pierce the skin producing a drop of blood , placed the test strip in the glucometer and collected the blood drop. CMA-K used the cotton ball to blot the blood on the resident's finger and then gathered the trash and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.18B3 Based on observations and interviews; the facility staff failed to ensure the venting system was functional in 4 (B-004, C-010, C-015 and C-017) room effecting 7 residents who resided in those rooms and failed to ensure the Heating and Cooling unit (commonly called PTAC) was maintained in good repair. This effected 7 of 92 residents. The facility staff identified a census of 92. Findings are: An observation on 04/01/24 at 9:30 AM revealed the vent were not fuctioning in the bathroom of rooms B-004, C-010, C-015, and C-017. An observation on 04/01/2024 at 10:00 AM revealed the front cover of the PTAC has missing pieces in room C-011. On 4/04/2024 at 12:26 PM during a tour of the facility with the Maintenance Director (MD) confirmed the vents in rooms B-004, C-010, C-010, and C-017 were not functional and the PTAC front cover needed replaced in C-011.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(9) Based on record review and interview; the facility staff failed to protect 4 (Resident 32, 92, 342 and 33) residents from abuse. The survey sample was 19 and the facility staff identified a census of 92. Findings are: A. Record review of a Order Summary report sheet printed on 4-04-2024 revealed Resient 32 was admitted to the facility on [DATE]. Record review of Resident 32 Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 2-15-2024 revealed Resident 32 had Brief Interview for Mental Status (BIMS) score of 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. On 4-13-2024 at 11:00 AM the facility Administrator identified Resident 32 had reported of being verbally abused by Nursing Assistant (NA)-EE. On 4-03-2024 at 1:14 PM an interview was conducted with Resident 32. During the interview Resident 32 reported the incident of verbal abuse occurred on 3-30-2024. According to Resident 32…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.04B2b Based on interview and record review, the facility staff failed to ensure competencies in insulin administration were completed for 5 Certified Medication Assistant (CMA) and 3 licensed nurses surveyed. This had the ability to affect 13 residents (Residents 6, 15, 19, 21, 25, 30, 38, 50, 60, 62, 74, 194 and 196) who receive insulin in the facility. The facility claimed a census of 92. Findings are: An interview on 04/03/2024 at 10:32 AM with CMA-K revealed they had not been assessed for competency in administering insulin by the facility. An interview on 04/03/2024 at 1:37 PM with the Director of Nursing (DON) confirmed CMA's have to be assessed for competency before they are allowed to administer insulin in the facility. The DON confirmed they were not aware that MA-K had not been assessed for competency to administer insulin by the facility. An interview with on 04/03/2024 at 1:39 PM with Registered Nurse (RN) B confirmed facility staff are assessed for competency through the facility on boarding and education process. RN-B confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.12B Based on record review and interview; the facility staff failed to have rationale for the continued use of an antianxiety medication for 3( Resident 1,21 and 25), failed to complete behavioral monitoring for 1(Resident 57) and failed to identify the need for a increase in dosage of a antidepressant medication for 1 (Resident) 1 of 5 residents sample size for the medication review. The facility staff identified a census of 92. Findings are: A. A record review of Resident 21's Minimum Data Set (MDS- a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated 1/1/2024 revealed Resident 21 is [AGE] years old and had a Brief Interview of Mental Status (BIMS - a mandatory tool used to screen and identify the cognitive condition of residents) of 5 indicating Resident 21 is severely cognitively impaired. Resident 21 had the following diagnoses: Unspecified dementia, severe with other behavioral disturbance,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.12E1 Licensure Reference Number 175 NAC 12-006.12E7 Based on observation and interview;the facility staff failed to ensure 2 medications in medication cart E were labeled for use, failed to ensure 2 medication carts and medications were secured and failed to ensure the medication refrigerator was secured in the memory care unit. This had the ability to affect 9 ambulatory residents of 22 residents who live on the memory care unit. The facility claimed a census of 92. Findings are: A. An observation on 04/04/2024 at 7:30 AM of the drawers in the medication cart on hall E revealed an open undated, unlabeled generic brand of a 8 oz bottle of Cough DM and a bottle of Neomycin and Polymyxin B Sulfates and Dexamethasone Ophthalmic Suspension On 04/04/2024 at 7:30 AM an interview was conducted with Certified Medication Assistant (CMA). During the interview CMA-K reported not knowing who the medication belonged to or how long the medications had been in the cart. B. An observation on 04/04/24 at 12:45 PM revealed the medication refrigerator on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09C1c Based on observation, interview, and record review, the facility failed review and revise 1 (Resident 77) of 1 resident's Care Plan related to the oxygen order. The facility census was 92. Findings are: A record review of the facility's undated Comprehensive Care Planning policy revealed assessments of residents were ongoing and the care plans were revised as information about the resident and the resident's condition changed. A record of Resident 77's Clinical Census dated 04/02/2024 revealed the resident was admitted to the facility 02/17/2024. A record review of Resident 77's Medical Diagnosis dated 04/02/2024 revealed the resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Hypertension, Unspecified (high pressure in the blood vessels that supply the lungs), Dependance on Supplemental Oxygen, and Solitary Pulmonary Nodule (single mass in lungs). A record review of Resident 77's Minimum Data Set (MDS,a comprehensive assessment used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.10D Based on observations, record review and interview; the facility staff failed to follow practitioners orders for medication administration for 1 (Resident 93) and failed to implement treatment orders for 1 ( Resident 25). The total survey sample was 19. The facility staff identified a census of 92. Findings are: A. Record review of Resident 93's Medical Diagnosis sheet print on 4-04-2024 revealed Resident 93 had the diagnosis of Dementia, Diabetes, Hypertension, Major Depressive disorder and Functional Quadriplegia. Record review of Resident 93's Clinical Physician Orders sheet printed on 4-4-2024 revealed an order for staff to hold insulin if Resident 93 did not eat meals. A record review of Resident 93's Medication Administration Report (MAR) dated 3/16/24 revealed RN-SS administered Resident 93's insulin. A record review of the dietary intake sheet for Resident 93 revealed there was no documentation of food intake for 3/16/2024. A record review of Resident 93's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D6(5) Based on observation, interview, and record review, the facility failed ensure the provider was notified when Resident 77's oxygen level dropped below the ordered parameter. The facility census was 92. Findings are: A record of Resident 77's Clinical Census dated 04/02/2024 revealed the resident was admitted to the facility 02/17/2024. A record review of Resident 77's Medical Diagnosis dated 04/02/2024 revealed the resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Hypertension, Unspecified (high pressure in the blood vessels that supply the lungs), Dependance on Supplemental Oxygen, and Solitary Pulmonary Nodule (single mass in lungs). A record review of Resident 77's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 02/23/2024 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) 4 of 15 which indicated the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview and observation, the facility staff failed to evaluate and implement interventions to manage triggers for 1(Resident 81) of 1 resident reviewed who has a diagnoses of Post Traumatic Stress Disorder (PTSD). The facility staff identified a census of 92. Findings are: Record review of Resident 81's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 1-24-2024 revealed Resident 81 had an active diagnoses of PTSD. Record review of Resident 81's trauma care plan initial date and revised date is 02/06/2024. Care plan interventions are: - Provide reassurance and redirection. -Encourage to express needs/wants. -Encourage to participate in activities of choice. -Provide space if she is upset so long as she and her peers are safe. -Provide female caregivers for toileting/bathing when needed. -Provide comfort when sad. Observation on 04/01/2024 at 7:33 AM revealed Resident 81 was in their room wiping counters and had their belonging packed and placed in the hallway. Observation on 04/01/2024 at 12:33 PM revealed Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.04G Based on observations, record reviews and interviews, the facility failed to ensure staff had functional pagers that alerted staff when residents requested assistance (commonly known as call light). This had the potential to effect all residents in the facility. The facility staff identified a census of 105. Findings are: A. Record review of an All Team meeting sign in sheet dated 9-08-2023 revealed part of the team meeting was to review the call light education. According to the All Team meeting information the facility used pagers and a screen in the nursing station. On 12-06-2023 at 12:00 PM an interview was conducted with Resident 62. During the interview Resident 62 reported it would take staff some times an hour or more to answer the call light. B. Record review of Resident 62's Device Activity Report (DAR, a report that identified what time the call light was activated and the time the call light was answer. The DAR also identified location of the call light that had been activated and zone in the facility) revealed the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility staff failed to notify the responsible party of the development of a pressure ulcer for 1(Resident 50) and failed to notify family of significant weight loss for 1 (Resident 4) of 4 sampled residents. The facility staff identified a census of 105. Findings are: A. Record review of Resident 50's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 11-17-2023 revealed the facility staff assessed Resident 50's Brief Interview of Mental Status (BIMS) as a 3. According to the MDS [NAME] a score of 0 to 7 indicates severe cognitive impairment. Record review of a Skin Only Evaluation ([NAME]) sheet dated 9-29-2023 revealed the facility staff identified Resident 50 had a wound the the left heel that measured 3.1 centimeters (CM) by 1.2 cm. Record review of a Practitioner report sheet dated 11-13-2023 revealed the wound to Resident 50 left heel was a pressure ulcer. Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference: 175 NAC 12-006.09D2a Based on record review and interview, the facility failed to ensure pressure sore treatment was initiated for 1 [Resident 4] of 4 sampled residents. The facility had a total census of 105 residents. Findings are: Resident 4 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease according to admission record. Resident 4's admission record identified that Resident 4 discharged from the facility on 11/20/23. A review of Skin Only Evaluation sheet dated 11/4/23 revealed a new issue to left heel with a length of 2 cm [centimeters] and a width of 2 cm and a new issue to right foot with a length of 3 cm and a width of 2 cm. A review of Resident 4's 11.2023 MAR [Medication Administration Record] revealed the following orders: -An order dated 11/6/23 for left heel cleanse with normal saline, pat dry, paint heel with betadine and cover with a merpilex [an absorbent foam dressing] daily. The order was discontinued on 11/7/23. -An order dated 11/7/23 for left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to maintain walls in good and cleanable condition in 15 (resident rooms A 1, A 2, A 7, A 9, B 3, B 4, B 5, B 11, C 6, C 7, E 4, E 5, E 6, E 7, E 10) of 56 occupied rooms. The facility census was 94. Findings are: Observation on 02/14/23 between 8:30 AM and 08:52 AM with the Environmental Services Director [ESD], the Maintenance Director [MD] and the Administrator [ADM] revealed many scraped and gouged areas on the walls behind recliners and next to resident beds in resident rooms A 1, A 2, A 7, A 9, B 3, B 4, B 5, B 11, C 6, C 7, E 4, E 5, E 6, E 7, E 10. Interview on 02/14/23 at 08:57 AM with the ESD confirmed the areas of scrapes and gouges on walls in resident rooms A 1, A 2, A 7, A 9, B 3, B 4, B 5, B 11, C 6, C 7, E 4, E 5, E 6, E 7, E 10 and that they had not been identified prior to the environmental tour of the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number NAC 12-006.17B Based on observation, record review and interview the facility staff failed to ensure catheter cares were performed in a manner to prevent cross contamination for Res 45, failed to ensure Oxygen tubing was stored in a manner to prevent cross contamination for Res 16, and failed to ensure the cleaning and storage for nebulizer masks and tubing was completed to prevent cross contamination for Res 28, 32, and 62. The facility census was 94. The findings are: A. Record review of the Bladder assessment dated [DATE] revealed Resident 45 used an indwelling catheter for obstructive uropathy (occurs when urine cannot drain from the urinary tract) and urinary retention (the inability to completely empty your bladder when urinating). Review of Resident 45's Medication Adminstration Record (MAR) and Treatment Administration Record (TAR) for February 2023 revealed an order dated April 1, 2022 for Foley Catheter Cares twice daily. Review of the Care plan dated April 1, 2022 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide a written notice of transfer to the resident or representative for 4 hospitalizations for one of one sampled residents (Resident 62). The facility identified a census of 94. Findings are: A record review of the census information for Resident 62 revealed in the last 120 days, readmission dates, post hospital stays, of 12/13/22, 12/19/22, 1/7/23 and 1/16/23. A record review of Resident 62's Progress Notes dated 10/20/22 through 2/8/23 revealed Resident 62 had been sent to ER (Emergency Room) and admitted to the hospital related to episodes of hypoxia (low levels of oxygen in your body tissues) surrounding the dates listed above. The record review also noted Resident 62 to be Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus) positive during one of the hospital stays. An interview on 02/14/23 at 2:57 PM with the DON (Director of Nursing) confirmed that no written notice of transfer or signed bed hold policy existed related to Resident 62's hospitalizations and should have been completed.

Based on record review and interview, the facility failed to provide a signed bed-hold policy from the resident or representative related to 4 hospitalizations for one of one sampled residents (Resident 62). The facility identified a census of 94. Findings are: A record review of the census information for Resident 62 revealed in the last 120 days Resident 62 re-admission dates following hospital stay, of 12/13/22, 12/19/22, 1/7/23 and 1/16/23. A record review of Resident 62's Progress Notes dated 10/20/22 through 2/8/23 revealed Resident 62 had been sent to ER (Emergency Room) and admitted to the hospital related to episodes of hypoxia (low levels of oxygen in your body tissues) surrounding the dates listed above. The record review also noted Resident 62 to be Covid (a mild to severe respiratory illness that is caused by a coronavirus) positive during one of the hospital stays. An interview on 02/14/23 at 02:57 PM with the DON (Director of Nursing) confirmed that no written notice of transfer or signed bed hold policy existed related to Resident 62's hospitalizations and should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

LICENSURE REFERENCE NUMBER 12-006.09D Based on record review and interview, the facility failed to follow physician's orders related to medications given outside of physician ordered parameters for 2 sampled residents (Resident 52 and Resident 62) and failed to prevent constipation for 1of 1 sampled residents (Resident 52). The facility census was 94. Findings are: A. A record review of the MAR (Medication Administration Record) dated February 2023 revealed Resident 52 had the following routine medication orders: Lisinopril (a medication used to treat high blood pressure) 40mg orally every morning Metoprolol Succinate (a medication classified as a beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure) tab 1000mg ER (Extended Release) orally every morning for hypertension, *hold for SBP <90 or HR <60 A record review of the MAR dated February 2023 revealed Resident 52 had a documented blood pressure of 150/68 and heart rate of 56 on 2/8/23 with the Metoprolol being given instead of held as ordered. A record review of the MAR dated January 2023 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18 Based on observation, record review and interview; the facility staff failed to ensure fall interventions were implemented for Resident 19. The facility staff identified a census of 94. The findings are: Record review of Resident 19's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 01/05/23 revealed Resident 19 requires extensive assist with bed mobility and is total dependence with transfers and toilet use. Additionally the MDS revealed Resident 19 had 2 falls with injury. Review of the Huddle Report dated 11/5/22 revealed Resident 19 was observed by the nurse tech to be sitting on the floor next to bed. According to the Huddle report Resident 19 reported having pain in left lower leg. Resident 19 was transported by the Emergency Medical Staff to the Hospital. Review of the Huddle Report dated 11/7/22 revealed Resident 19 may have rolled to the side of the bed and slid off the bed. Resident 19 had a previous broken hip and was sitting on the floor at a diagnol. Resident 19 was sent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview the facility staff failed to administer medications as ordered before dialysis for 1 (Resident 16) of 1 sampled resident. The facility staff identified a census of 94. The findings are: Record review of current physician orders printed on 02/13/23 revealed Resident 16 receives dialysis treatments on Monday, Wednesday and Friday and Resident 16 was to be woken up at 5 AM. An interview on 02/10/23 at 02:38 PM with Resident 16 revealed that (gender) takes about 3 or 4 medications before leaving for dialysis and then takes the rest with (gender) to the dialysis center. A record review of Resident 16's physician orders for February 2023 revealed an order dated May 6, 2020 for Pre-Dialysis Meds: Azelastine & Fluticason Nasal Sprays ( Medications to relieve nasal congestion), Gabapentin (a medication used to prevent seizures and relieve nerve pain), Pantoprazole (a medication used to reduce the amount of acid in the stomach), Loperamide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.12E1 Based on observation, record review and interview the facility failed to ensure medications for 1 out of 6 residents sampled (Resident 16 ) were secured and stored safely. The facility census was 94 at the time of survey. Findings are: An observation on 02/08/23 at 10:19 AM of a plastic medication cup with white powder was noted in Resident 16's room next to the sink. An observation on 02/09/23 at 10:08 AM of a plastic medication cup with white powder noted in Resident 16's room next to the sink. Resident stated it was Nystatin (used to treat fungal skin infections). Nystatin bottle was noted to be on top of the resident's refrigerator in room with label on, it did not say may keep at bedside or resident may self administer the medication. A review of the Medication Integrity and Labeling policy, dated 6/1/2017 stated the facility will ensure that nursing staff will follow pharmacy recommendations for storage of medications. A review of Medication Storage in the Facility undated policy stated Medications and biological's are stored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.