Heartland Ridge Care Center

Inspectors wroteLicensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to complete hand hygiene (the practice of keeping your hands clean) between glove changes and after hands were soiled while preparing food in the kitchen. The facility failed to wash dirty vegetables prior to use. The facility failed to ensure facial hair was completely covered. This had the potential to affect 30 of 30 residents that resided at the facility. The total facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 1-005.06(D) Based on observations, record reviews, and interviews, the facility failed to ensure that staff followed principles of infection control and prevention related to hand hygiene, use of personal protection equipment (PPE), and cleaning and storage of respiratory equipment. This affected 6 residents (Residents 13, 14, 20, 21, 129, and 136) of 9 sampled for infection control practices. The facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.19(A)(i) Based on observation, interview, and record review the facility failed to ensure that the ventilation (the provision of fresh air to a room, building, etc.) systems were operational in 7 resident bathrooms (rooms 501, 502, 503, 507, 508, 509, and 510) of the occupied resident bathrooms. The facility census was 30.

Inspectors wroteBased on interview and record review, the facility failed to ensure a notice of transfer was provided to 1 (Resident 27) of 1 sampled resident and the resident's representative in a language they could understand upon emergent transfer from the facility. The total facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09(B)(iii) Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 05/06/2025 included 1 (Resident 6) of 1's documented behaviors. The total facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09(H)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to ensure 2 (Residents 129 and 13) of 2 sampled residents had a valid non-invasive ventilator (a machine used to deliver positive pressure to the airway) provider order. The total facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on observation, interview, and record review, the facility failed to assess the resident's fistula (A port used for dialysis -a process of filtering the blood), and obtain vital signs following dialysis for 2 (Resident 7 and 9) of 2 sampled residents. The total facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10 (D) Based on observation, record review and interviews, the facility failed to ensure they had a medication error rate of less than 5%. Observations of 36 medications administrations revealed 3 errors, for a medication error rate of 8.33%. This affected 2 residents (Resident 20 and Resident 13) of 5 residents sampled. The facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii) Based on record review and interviews, the facility failed to ensure 3 nurse aides (NA) and 1 medication aide (MA)(NA-C, NA-E, NA-F, MA-D) of 6 sampled have the competencies required to care for residents' needs. The facility census was 34.

Inspectors wrote175 NAC 12-006.04(H)(ii)(1) Based on record review and interview, the facility failed to ensure the Dietary Manager (DM) had the required credentials. This had the potential to affect 33 of 34 residents who ate food prepared in the kitchen. The facility census was 34.

Inspectors wroteLiscensure Reference Number 175 NAC 12-006.11E Based on observations, record review and interview, the facility failed to ensure hair was covered during food preparation and cooking. This had the potential to affect 33 or 34 residents who ate food prepared in the dining room. The facility census was 34.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04B(ii) Based on record review and interviews, the facility failed to ensure 3 nurse aides(NA) and medication aide (MA) (NA-C, MA-D, NA-F) of 6 sampled had at least 12 hours of continuing education in a year. The facility census was 34.

Inspectors wroteBased on record review and interview, the facility failed to provide a written notice of transfer to Resident 20 and/or their representative upon transfer to the hospital. This affected 1 of 2 residents sampled for hospitalizations. The facility census was 34.

Inspectors wroteBased on record review and interview, the facility failed to provide a notification of the facility policy for bed hold to Resident 20 and/or their representative upon transfer to the hospital. This affected 1 of 2 residents sampled for hospitalizations. The facility census was 34.

Inspectors wroteBased on record review and interview, the facility failed to offer the COVID-19 vaccination and failed to provide education regarding the risks and benefits of receiving the COVID-19 vaccination to Resident 5 and Resident 16 and/or their representatives. This affected 2 of 5 residents sampled for COVID-19 vaccination status. The facility census was 34.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interviews; the facility failed to notify the resident's physician of discharge to another facility for 1 (Resident 1) of 1 resident sampled. The facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to notify APS (Adult Protective Services ) within 2 hours of serious bodily injury from a fall for 1 (Resident 3) of 3 sampled residents and failed to submit an investigation to the State Agency within 5 working days of a serious bodily injury from a fall for 1 (Resident 3) of 3 sampled residents and an investigation for an injury of Unknown Origin for 1 (Resident 2) of 3 sampled residents. The facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(5) Based on record review and interviews the facility failed to complete a discharge summary for 1 (Resident 1) of 3 sampled residents. The facility census was 30.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.11C Based on observation, interview, and record review; the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, the facility failed to ensure hair restraints were being worn, and facility failed to ensure hand washing was being completed by facility staff to prevent potential cross contamination. This had the potential to affect all 35 residents who received food from the facility kitchen. The facility identified a census of 35 at the time of survey.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(5) LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D9 Based on interview, observation, and record review, the facility failed to ensure bowel care was monitored and protocol provided for Resident 6, 13 and 22; in addition, the facility failed to follow fluid restriction for Resident 29. The sample size was 4. The facility identified a census of 35. Findings Are: A. Record review of the facility policy titled Order Summary related to bowel care revealed facility staff are to chart bowel movements and initiate bowel protocol as applicable for no bowel movement (BM) in 3 or more days. The policy revealed the facility staff were to document any refusal of protocol and/or use of alternate intervention(s). The policy revealed the following was the BM protocol (if a resident has not had a BM in the given days); [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from unnecessary medications related to antibiotic use for Resident 13. The sample size was 1. The facility identified a census of 35. Findings Are: Record review revealed Resident 13 had an order for Cephalexin 500mg qid (4 times daily) x 7 days for possible infection ordered on 6/11/23. Record review of the Progress Notes dated 6/11/23 for Resident 13 read as follows; Resident 13 had a medium emesis this AM and had several loose stools. Resident 13 refused to work with therapy and was shivering when PTA (Physical Therapy Aide) was talking to [gender]. Resident 13 had a tachy (elevated pace) pulse. Resident's 13 daughter came to the faciltiy prior to dinner and was concerned about Resident 13 not feeling well and inquired if Resident 13 could have a urinary tract infection. [...]