Douglas County Health Center

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D). Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 3 (Resident 1, 4 and 5) of 5 residents sampled. The facility census was 233.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review the facility failed to administer pain medication according to the practitioner's orders for 2 (Resident 4 and 5) of 5 residents sampled. The facility census was 233.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview and record review the facility failed to utilize beard restraints while preparing food in facility kitchen. This had the potential to affect 231 of the 235 residents in the facility. The facility census was 240.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview, the facility failed to identify and monitor target behaviors for the use of an antipsychotic medication for 1 (Resident 97) of 2 sampled residents. The facility identified a census of 240.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) St 28-372 Based on record reviews and interviews, the facility failed to report to Adult Protective Services and the Department of Health and Human Services an alleged verbal altercation between 2 residents within the prescribed time frame. This had the potential to affect 1 (Resident 218) out of 2 residents sampled. The facility census was 240.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record reviews, interviews and observations, the facility failed to investigate an alleged verbal altercation between Resident 218 and an unnamed resident. This had the potential to affect 1 (Resident 218) out of 2 residents sampled. The facility census was 240.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record reviews and interviews, the facility failed to ensure that the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) comprehensive assessment identified Post Traumatic Stress Disorder (PTSD) for 1 (Resident 135) of 2 sampled residents. The facility census was 240.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E)(i) Based on record reviews and interviews, the facility failed to develop a person-centered comprehensive care plan to meet the mental and psychological needs of 1 resident (135) out of 2 sampled. The facility census was 240.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(3). Based on observation, interview and record review, the facility failed to evaluate and monitor open lesions for 1 (Resident 65) of 4 residents sampled. The facility census was 240. Findings Are: Record review of Resident 65's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-24-2025 revealed the facility staff assessed the following about the resident: -A Brief Interview of Mental Status (BIMS) was not scored for this resident. -The resident required extensive assistance with lower body dressing, bed mobility and transfers. -The resident required total assistance with toileting and bathing. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Based on observation, interview and record review the facility failed to implement interventions to offload heels to prevent the potential for pressure ulcer development for 1 (Resident 236) of 3 sampled residents. The facility census was 235.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(v) Based on observation, record review and interview; the facility failed to reevaluate wheelchair positioning, ensure foot pedals were in place and head rest was positioned to support the head for 1 (Resident 164) of 2 sampled residents. The facility census was 240.

Inspectors wroteLicensure Reference Number 12-006.09(H)(vi)(3)(g) Based on observation, interview and record review, the facility failed to obtain and implement orders for a non-invasive ventilator including settings and daily, weekly, and monthly cleaning for 1 (Resident 55) of 4 sampled residents. The facility census was 235.

Inspectors wroteBased on record review and interview, the facility failed to assess for pain prior to administering scheduled pain medication and failed to monitor for the effectiveness of pain medication for 1 (Resident 19) of 2 sampled residents. The facility had a census of 240.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure trauma survivors received trauma-informed care to eliminate triggers that may cause re-traumatization for 1 (Resident 135) of 2 sampled residents. The facility census was 240.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure 3 (Resident 218, 135, 226) of 7 residents had a physician conduct a face-to-face visit within the first 30 days after admission. The facility census was 240.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B) & 1-005.06 Based on observation, interview and record review the facility failed to secure a catheter bag for 1 (Resident 221) of 2 residents and failed to secure oxygen tubing with cannula for 1 (Resident 108) of 5 residents sampled in a manner to prevent the potential for cross contamination. The facility census was 240.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(f)(i)(5) Based on observation, record review and interview; the facility failed to ensure follow up was completed with the physician to obtain x-rays after complaints of pain were made by Resident 1 and failed to ensure x-ray recommendations were followed timely for Resident 1. X-rays showed that Resident 1 sustained a fracture of the right shoulder. The facility census was 239.

Inspectors wroteBased on interview, and record review; the facility failed to implement a care planned intervention for 1 (Resident #2) of 6 residents whose care plans were reviewed. Specifically, following an incident on 04/22/2023 involving Resident #2 and another resident, the facility implemented a new intervention consisting of a magnetic barrier attached to Resident #2's door frame to deter other residents from entering Resident #2's room. This intervention was never discontinued, but the barrier was removed, and additional resident to resident altercations involving Resident #2 and Resident #3 occurred on 10/17/2023 and 11/22/2023, when Resident #3 entered Resident #2's room.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure staff stored foods for residents in a sanitary manner. Specifically, staff failed to label and date resident foods brought in by visitors, clear the nourishment refrigerators of spoiled foods, and maintain the temperature logs for the nourishment refrigerators. This had the potential to affect 153 residents who resided in 6 neighborhoods (Wind Song Way, Field of Dreams, [NAME] Way, Tranquility Road, Sunshine Gardens, and Safe Harbor) of 10 total neighborhoods in the facility.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to invite 1 (Resident #45) of 39 sampled residents whose care plans were reviewed to attend their care conferences.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to promptly notify a resident's hospice service provider of a change in condition for 1 (Resident #231) of 2 sampled residents reviewed for change in condition. Specifically, Resident #231's hospice and primary care provider were not notified of an abnormal culture and sensitivity (C&S) lab result until a week after it was reported to the facility. As a result of this delayed notification, the hospice provider did not order an antibiotic to treat Resident #231 until a week after the abnormal C&S lab result was reported to the facility.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure call lights were within reach for 2 (Resident #101 and Resident #487) of 2 residents observed for the use of call lights.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure new Level I Preadmission and Resident Reviews (PASRRs) were completed after residents were diagnosed with new mental illness diagnoses and prescribed psychotropic medications for 2 (Resident #12 and Resident #74) of 5 sampled residents reviewed for PASRR requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside of 1 (Resident #102) of 20 residents that resided in the Field of Dreams neighborhood, which was a locked behavioral unit.

Inspectors wroteBased on observations, interviews, review of medical records, and facility policy review, the facility failed to ensure staff performed hand hygiene and did not touch medications with their bare hands when administering medication for 1 (Resident #160) of 3 residents observed during medication pass.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure the most recent survey results were readily accessible to all residents to review and that posted notices of the availability of the survey results were in an area of the facility that was prominent and accessible to the public. This had the potential to affect all residents that resided in the facility.

Inspectors wroteBased on record review and interview; the facility failed to provide a written investigation to the state agency within the required five working days for 1 (Resident 1) of 3 sampled residents. The facility census was 231.

Inspectors wroteLicensure reference: 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure glove changes were completed during food preparation and service to prevent potential food borne illness. This has the potential to affect 208 residents who eat meals prepared in the kitchen. The facility had a total census of 216 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-004.c3a(6) Based on observation, interview, and record review, the facility failed to notify the provider and resident representative of a change in condition for Resident 175. Total facility census was 216.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18B Based on observation and interview, the facility failed to ensure 1 (Resident 129) of 1 sampled resident's water faucet was operational to allow the flow of hot water. Total facility census was 216.

Inspectors wroteBased on record review and interview, the facility failed to reevaluate resident status and provide notice of discharge for 1 [Resident 265] of 1 sampled resident following transfer to the hospital in an emergency status. The facility had a total census of 216 residents.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.14 Based on record review, interview, and observation, the facility failed to ensure Resident 176 received follow up dental services. The facility staff identified a census of 216.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene (cleaning) between resident contact. This had the potential to affect 3 residents (Resident 80, 131, and 146). Total facility census was 216.