Hillcrest Health & Rehab

Inspectors wroteLicensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to ensure all food stored in the facility's kitchen was labeled, dated, and/or sealed, ensure kitchen was maintained in a clean and sanitary manner, ensure food holding temperatures (temps) were completed prior to food service all to prevent foodborne illness. The facility failed to ensure food temperature probes were sanitized between product usage, ensure staff washed hands between glove changes, and failed to ensure tongs were stored in a manner to prevent cross contamination. This had the potential to affect 118 residents that consumed food prepared in the facility kitchen. The total facility census was 120.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.07(C) Based on record review and staff interviews; the facility Quality Assessment Performance Improvement Plan (QAPI) failed to identify issues relevant to F 553, F 578, F 580, F 628, F 641, F 656, F 684, F689, F692, F 695, F 698, F 757, F 812, F 842, F 880 and implement plans of action to identify and correct the deficient practice. This deficient practice had the potential to affect all residents who reside in the facility. The facility sample size was 51. The facility staff identified a census of 120.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on interview and record review the facility failed to notify the provider of blood sugars outside of parameters for 1 resident (Resident 151), medications provided outside of parameters for 3 residents (Resident 2, 146 and 151), failed to notify provider of a change in an Abnormal Involuntary Movement Scale (AIMS, a clinical tool used to detect and measure involuntary muscle movements, primarily Tardive Dyskinesia in patients taking neuroleptic or antipsychotic medications) score for 1 (Resident 30) and no Continuous Positive Airway Pressure (CPAP, a device primarily used to treat obstructive sleep apnea) available for 1 resident (Resident 32) of 6 sampled residents. The facility identified a census of 120.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(E)Licensure Reference Number 175 NAC 12-006.09(F) Based on interview and record review, the facility failed to ensure comprehensive care plan (documents that outlined a resident's medical, emotional, and daily living needs) meetings and invitations to the residents and families were completed quarterly for 3 (Residents 14, 9, and 130) of 6 sampled residents. The facility census was 120.

Inspectors wroteBased on interview and record review the facility staff failed to obtain a signed code status prior to changing the code status in the electronic health record for 1 (Resident 16) of 32 sampled residents. The facility identified a census of 120.

Inspectors wroteBased on record review and interview, the facility failed to complete a recapitulation of stay (the clinical story of a person's time in a care facility) for 1 (Resident 148) of 2 sampled residents. The facility staff identified a census of 120.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview, the facility failed to accurately code 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) for 2 (Resident 32 and Resident 70) of 46 sampled residents. The facility staff identified a census of 120.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to develop 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) for 2 ( Resident 12, related to seizures, and did not develop a CCP for identified care areas for Resident 11) of 51 sampled residents reviewed for CCP's. The facility census was 120.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)Based on record reviews, observations, and interviews, the facility failed to complete a recliner chair safety evaluation for 2 (Resident 79 and Resident 70) of 8 sampled residents; and the facility failed to turn off an oxygen concentrator when not in use for 1 (Resident 20) of 2 sampled residents. The facility staff identified a census of 120.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J) Based on record reviews, observations, and interviews, the facility staff failed to follow ordered fluid restrictions for 1 (Resident 32) of 1 sampled resident. The facility identified a census of 120.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to have valid Positive Airway Pressure (PAP)(a machine used to treat sleep apnea) device orders for 2 (Residents 7 and 14) of 2 sampled residents, and failed to have and follow valid oxygen orders for 3 (Residents 14, 13, and 9) of 3 sampled residents. The facility census was 120.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate meals and transportation for dialysis for 1 (Resident 7) of 1 sampled resident. The facility identified a census of 120.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review the facility failed to ensure residents were not provided medications outside of ordered parameters for 3 (Residents 2, 146 and 151) of 8 sample residents. The facility identified a census of 120.

Inspectors wroteLicensure Reference number 175 NAC 12-006.17(A)(v)Licensure Reference Number 175 NAC 1-008(xii)Based on record review and interview, the facility staff failed to accurately document the use of a continuous positive airway pressure device (CPAP, a small bedside device that pumps a steady stream of gentle, pressurized air through a mask which keeps the throat open to prevent blockage) for 1 (Resident 32) of 3 sampled residents and failed to document restorative (services provided to maintain range of motion ability] services provided for 1 (Resident 67) of 1 reviewed. The facility staff identified a census of 120.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observations, record reviews and interviews, the facility staff failed to apply gloves prior to administering an injectable medication, discard the nasal cannula (oxygen tubing) that was lying on the floor for 1 (Resident 20) of 1 sampled residents and failed to perform hand hygiene between taking off and putting on new gloves during medication administration for 1 (Resident 14) of 6 sampled residents. The facility identified a census of 120.

Inspectors wroteLicensure Reference Number NAC 175 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to implement interventions for the prevention of pressure ulcers for 2 (Resident 2 and 4) of 4 residents sampled and failed to provide practitioner ordered wound care to promote healing of pressure ulcers for 1 (Resident 4) of 4 residents sampled. The facility census was 121.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.18(B) Based on observation, interview, and record review, the facility failed to ensure staff donned (put on) masks during a COVID-19 outbreak, ensure Enhanced Barrier Precautions (EBP) were followed for Resident 2, and maintain vinyl coverings on six recliners to reduce the potential for cross contamination in the Magnolia Trail commons area. The facility census was 121.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 and 12-006.09(H)(iv)(5). Based on observation, interview, and record review, the facility failed to implement neurological checks for an unwitnessed fall for 2 (Residents 1 and 2) of 3 sampled residents, and failed to monitor bowel movements and provider ordered interventions to prevent the potential for constipation for 1 (Resident 2) of 1 sampled resident. The facility staff identified a census of 121.

Inspectors wroteB. Record review of Resident 1's admission Record revealed the facility admitted the resident on 9/11/2025. Further review of the admission record identified the resident had diagnoses that included infection and inflammatory reaction due to internal left knee prosthesis, bacteremia (a blood stream infection of bacteria in the blood), myasthenia gravis (a chronic autoimmune disease causing fluctuating weakness in voluntary muscles such as the eyes, face, throat, and limbs due to nerve-muscle communication breakdown, where antibodies block signals, worsening with activity and improving with rest), essential tremors, abnormalities of gait, and unsteadiness on feet. [...]

Inspectors wroteBased on record review and interview, the facility failed to evaluate change of condition for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 119.

Inspectors wroteLicensure reference: 175 NAC 12-006.09(I)(i)(1) Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were implemented for 2 [Residents 4 and 7] of 4 sampled residents with falls. The facility had a total census of 142 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(A) Based on record review and interview the facility failed to ensure a psychotropic (a medication that affects how the brain works) PRN ( PRN - as needed) order had a rationale (a reason) for continued use and failed to identify target behaviors (specific actions) for an antipsychotic (a class of drug that treats psychotic symptoms and disorders) medication and an antianxiety (a drug that reduces anxiety) medication for 1 (Resident 50) of 5 residents. The facility had a census of 117.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview the facility failed to ensure the facility's Medication Regimen Review (MRR) Policy included the required procedural steps.

Inspectors wroteLicensure reference: 12-007.01A Based on observation, interview, and record review, the facility failed to ensure food temperatures were maintained and failed to ensure handwashing and glove changes were completed to protect from food borne illness. The facility had a total census of 113 of 113 residents that could be affected by the practice.

Inspectors wroteLicensure Reference Number 175 NAC 12-007.04D Based on observation and interview, the facility failed to ensure a working ventilation system in 17 resident bathrooms (room [ROOM NUMBER], 12, 13, 14, 15, 16, 85, 86, 88, 91, 93, 95, 103, 105, 107, 111 and 113) of 99 occupied resident rooms. The facility census was 113.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure blood pressures were taken in accordance with pharmacy recommendations for 1 [Resident 91] 5 residents sampled for unnecessary medications. The facility had a total census of 113 residents.