Adept Nursing & Rehab of Sutherland

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observations, interviews, and record review; the facility failed to ensure water temperatures in resident restroom sinks and a resident accessible dining room sink were 120 degrees or below, placing 6 (Residents 9, 15, 26, 29, 38, and 40) of 6 sampled residents at risk for burns. The facility census was 42. Findings Are: The facility was notified on 3/2/2026 at 2:30 PM of an Immediate Jeopardy (IJ) which began on 4/15/2025. The IJ was removed on 3/2/2026, as confirmed by surveyor onsite verification. A record review of facility policy Safe Water Temperatures with a revision date of 4/2/2025 revealed water temperatures will be set to a temperature of no more than 120 degrees Fahrenheit (F). Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. [...]

Inspectors wroteThe facility failed to prepare foods according to the recipe, including pureed foods, to ensure the nutritive value was maintained. This had the potential to affect all 42 residents. Pureed residents were 1, 5, 22Licensure Reference Number 175 NAC 12-006.09(J)(i) Based on observation, record review, and interviews, the facility failed to prepare foods according to the recipe, including pureed foods for Residents 1, 5, and 22, to ensure nutritive value was maintained. This had the potential to affect all residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the freezers were maintained at 0 degrees or below, failed to prevent the potential for cross contamination when handling raw meat, and failed to use or dispose of foods prior to expiration date, This had the potential to affect all 42 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05Based on record review and interview, the facility failed to ensure informed consent was obtained for 1 (Resident 1) of 5 sampled residents' psychotropic medications. The facility identified a census of 42.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 (G)Based on record review and interview, the facility failed to ensure there was a duration for psychotropic medication for 1 (Resident 1) of 5 sampled residents. The facility identified a census of 42. Resident 1 was admitted on [DATE] and had diagnoses of chronic obstructive pulmonary disease (a progressive lung disease that restricts breathing, often caused by smoking), Type 2 diabetes mellitus (a metabolic disorder when the body cannot regulate levels of sugar in the blood), schizophrenia (a mental disorder that affects how a person thinks, feels, and behaves), bipolar disorder (a mental illness with episodes of extreme mood changes), depression, and anxiety. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv) Based on record review and interview, the facility failed to follow their bowel protocol to prevent constipation for 1 (Resident 29) of 5 sampled residents. The facility census was 42. Findings Are: A record review of a facility document BM (bowel movement) List revealed Bowel Routine as per facility protocol with the following guidance:-Give Prune Juice if no BM in 2 days.-Give MOM (milk of magnesia) if no BM in 3 days -Must document bowel sounds daily starting day 3 until BM occurs.-Give suppository if no BM in 4 days.-Notify MD (physician) if refused or no results from suppository on day 4. A record review of Resident 29's admission Record revealed the resident was admitted to the facility on [DATE] and had a diagnosis of chronic idiopathic constipation. [...]

Inspectors wroteBased on record review and interview; the facility failed to ensure the attending physician reviewed and acted upon, or provided rationale for not acting upon, recommendations made by the pharmacist during their monthly medication regimen reviews for 1 (Resident 33) out of 5 sampled residents. The facility census was 42.

Inspectors wroteBased on record review and interviews, the facility failed to evaluate resources related to decision-making for 1 sampled resident (Resident 1) with cognitive impairment. The facility identified a census of 42. A record review of Resident 1's face sheet revealed that Resident 1 was admitted on [DATE] and had diagnoses of chronic obstructive pulmonary disease (a progressive lung disease that restricts breathing, often caused by smoking), Type 2 diabetes mellitus (a metabolic disorder when the body cannot regulate levels of sugar in the blood), schizophrenia (a mental disorder that affects how a person thinks, feels, and behaves), bipolar disorder (a mental illness with episodes of extreme mood changes), depression, and anxiety. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)Based on record review and interviews, the facility failed to accurately assess a resident for elopement, failed to provide interventions to prevent elopements, and failed to implement interventions to prevent further elopement for 1 resident (Resident 1) of 3 sampled residents. The facility census was 41.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04Based on record review and interview, the facility failed to complete competencies to ensure proficiency for 8 of 9 sampled staff which had the potential to affect all of the residents residing in the facility. The facility census was 41.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H)Based on record review and interviews, the facility failed to investigate and report to the regulatory agencies possible incident of abuse and or neglect for 1 residents (Resident 1) of 3 sampled residents. The facility census was 41.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record reviews and interviews, the facility failed to assess non-verbal indications of pain, and implement, monitor and revise interventions to manage pain for 1 (Resident 3) of 3 sampled residents. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number 175 NAC 12--006.04(F)(i)(5) Based on record reviews and interview, the facility failed to notify the physician of ongoing pain for 1 (Resident 3) of 3 sampled residents. The facility identified a census of 45.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to develop and implement a comprehensive care plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) regarding pain for 1 (Resident 1) of 3 sampled residents. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to assess and evaluate underlying causes of behavior to prevent the unnecessary use of a psychotropic (medications that affect the mind, emotions, or behavior, often used to treat mental health disorders) medication for 1 (Resident 3) of 1 sampled resident. The facility identified a census of 45.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.11(E) Based on observations, interview, and record review, the facility failed to store, label, cover, and use or discard food and drink items to prevent the potential for foodborne illness. This had the potential to affect all 39 residents that resided at the facility and consumed foods from the kitchen.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the Minimum Data Set (MDS, a federally mandated assessment used for Care Planning purpose) was not coded correctly for pressure ulcer of 1 (Resident 34) out of 10 sampled residents' pressure sores. The facility census was 39.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(F)(i) Based on record reviews and interview, the facility failed to develop baseline care plans (a document that outlines a resident's healthcare needs and safety concerns when they are first admitted to a nursing home) within 48 hours of admission as required for 2 (Residents 9 and 96) of 2 sampled residents. The facility identified a census of 39.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(E)(iii) Based on record reviews and interview, the facility failed to develop a comprehensive care plan (CCP, a document that outlines a resident's needs and the services that are to be provided to meet these needs) regarding activities of daily living (ADLs) for 1 (Resident 97) of 12 sampled residents. The facility identified a census of 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review, and interview, the facility failed to identify and update the comprehensive care plan with interventions after a fall for one (Resident 39) of one sampled resident. The facility identified a census of 39. Findings Are: A record review on 12/16/24 of Resident 39's Minimum Data Set (MDS, a federally mandated process that helps to standardize assessments, improve the accuracy of care, and facilitate care management) dated 11/18/24 reveals in Section GG: Resident 39 was independent with eating. They required set up assistance with oral hygiene. They were total dependence with transfers and toileting. They required moderate assistance with upper body dressing and maximum assistance with lower body dressing. A record review on 12/16/24 of Resident 39's diagnosis revealed diagnoses of: [...]

Inspectors wroteLicensure Reference 175 NAC 12-00609(H)(iv)(5) Based on record reviews and interviews, the facility failed to provide interventions for constipation for 1 (Resident 15) of 1 sampled resident. The facility identified a census of 39.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(H)(vi)(3)(g) Based on observations, interviews, and record reviews; the facility failed to administer oxygen following the prescriber's orders for 1 (Resident 9) of 4 sampled residents. The facility identified a census of 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observations, record review and interviews; the facility failed to ensure a medication error rate of less than 5%. Observations of 26 medications opportunities revealed 4 errors resulting in a medication error rate 16%. The errors affected 1 (Residents 2) of 3 sampled residents. The facility census was 39.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(D) Based on observations, interviews, and record review, the facility failed to perform hand hygiene and change gloves while performing catheter care for one (Resident 39) of one sampled resident. The facility identified a census of 39. Findings Are: A record review of a policy titled Enhanced Barrier Precautions dated 3/20/24 stated on page 1, number 3b: PPE (personal protection equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities. Page 2 number 4 stated high-contact care activities include: d) providing hygiene, f) changing briefs, g) device care including urinary catheters. An observation on 12/18/24 at 7:19 PM of Nurse Aide (NA)-C and NA-D performing foley catheter care on Resident 39. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement safety checks, education, or hazard assessments to ensure resident saftey for use of a bath chair, this affected 1 (Resident 4) of 1 resident sampled. Facility identified a census of 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D1c Based on observation, interview, and record review, the facility failed to provide assistance with grooming to 3 (Residents 1, 12, and 15) of 3 sampled residents. The facility census was 48. A. A record review of Resident 1's admission Record revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Minimum Data Set (MDS), a federally mandated assessment tool utilized to develop resident care plans, dated 1/23/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 4/15, which indicated the resident had moderate cognitive impairment. Section GG revealed the resident required partial or moderate assistance for toileting, personal hygiene, and transfers. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to code dialysis on the Minimum Data Set (MDS a federally mandated assessment tool utilized to develop resident care plans) assessment for 1 (Resident 1) of 1 sampled resident. The facility census was 48. The Findings Are: A record review of facility policy MDS 3.0 Completion dated 8/1/2023, revealed Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. A record review of Resident 1's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and Dependence on Renal Dialysis. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C1c Based on record review and interview, the facility failed to revise a Care Plan for a provider order 1 (Resident 1) of 1 sampled resident. The facility census was 48. The Findings Are: A record review of Resident 1's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease (ESRD) and Dependence on Renal Dialysis. A record review conducted on 2/14/24 of Resident 1's undated Care Plan revealed The resident needs hemodialysis related to (r/t) ESRD. Presence of right subclavian catheter (removed on 12/20/2023). Stitches in place: Daily Dressing Change. A record review conducted on 2/14/2024 of Resident 1's current Physician's Orders revealed the resident did not have an order for a daily dressing change related to stitches being in place post-removal of a right subclavian catheter. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to remove a dressing per the physician's order and failed to document in the Treatment Administration Record that the AV fistula dressing was being removed and the site was being monitored as required. This affected 1 (Resident 1) of 1 sampled resident. The facility census was 48. The Findings Are: A. A record review of Resident 1's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and Dependence on Renal Dialysis. A record review of Resident 1's progress note dated 1/15/2024 at 9:08 AM by the Director of Nursing (DON) revealed the DON, Administrator, resident's child, and a social worker from the dialysis center had a meeting to discuss how the resident was tolerating dialysis and concerns from the dialysis center. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observations, interviews, and record reviews; the facility staff failed to perform wound care to prevent the potential for cross-contamination and infection. This failure had the potential to affect 2 (Resident 2 and 9) of 2 sampled residents. The facility census was 48.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC12-006.04D2 Based on interview and record review, the facility failed to have a qualified Dietary Manager. This had the potential to affect all of the residents who consumed food from the kitchen. The facility staff identified a census of 42. An interview with the Food Service Supervisor (FSS) on 11/14/23 from 11:00 AM to 11:12 AM revealed that the FSS was enrolled in dietary manager classes and will graduate in the Spring of 2024 and was currently not certified as a dietary manager. The interview also revealed the FSS splits their time with this facility and a second facility. The FSS verbalized there is a Consultant Registered Dietician who comes to the facility monthly. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observations, interviews, and record review, the facility failed to maintain cleanliness of equipment, floors, walls, stove, oven and storage areas, failed to ensure puree foods were temped prior to serving, failed to perform hand hygiene and gloving during meal prep and service, failed to prepare food in a sanitary condition to prevent cross contamination and food borne illness. This had the potential to affect all residents that ate foods prepared in the facility kitchen. The facility census was 42.

Inspectors wroteLicensure Reference Number NAC 175 12-006.17 AND 12-006.17D The facility staff failed to perform hand hygiene and gloving during personal hygiene cares and failed to complete personal hygiene cares in a manner to prevent the potential for cross contamination for 2 (Residents 13 and 19) of 2 sampled residents and failed to perform hand hygiene correctly after leaving a Enhanced Barrier Precaution room. The facility identified a census of 42.

Inspectors wroteBased on record review and interview, the facility failed to ensure their Infection Control Nurse completed specialized training in infection prevention and control prior to assuming the role of the Infection Preventionist. This had the potential to affect all residents residing in the facility. The facility census was 42. The Findings Are: An interview on 11/15/23 at 11:10 AM with Licensed Practical Nurse (LPN)-C confirmed LPN-C was the facility's Infection Control Nurse. LPN-C revealed they have not completed all of the CDC Nursing Home Infection Preventionist Training Course but has Modules 1-12A done. An interview on 11/15/23 at 6:50 AM with the facility Administrator revealed LPN-C was currently enrolled in the CDC Nursing Home Infection Preventionist Training Course. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 (21) Based on observations, interview, and record review, the facility failed to maintain 1 (Resident 3) of 3 sampled resident's dignity as evidenced by placing Resident 3 to face the wall during dining and in their room. The facility census was 42.

Inspectors wroteLicensure Reference Number NAC 17512-006.09D4 Based on observations, interviews, and record reviews, the facility failed to implement interventions to maintain range of motion for 1 (Resident 13) of 2 sampled residents. The facility staff identified a census of 42.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on observations, interviews, and record reviews, the facility failed to implement interventions for pain management, failed to evaluate the effectiveness and failed to re-evaluate interventions to manage 1 (Resident 13) of 2 sampled resident's pain. The facility identified a census of 42.