Holmes Lake Rehabilitation & Care Center

Inspectors wroteThe facility failed to ensure food was served in a safe and timely manner to prevent potential food born illnesses. This had the potential to affect all residents who ate from the kitchen. The facility census was 52. Licensure Reference Number 175 NAC 12-006.11 (E) A record review of the kitchen menu revealed the mealtimes were: 8:00 AM for breakfast, noon for lunch and 6:00 PM for supper. An interview on 4/8/26 with the Dietary Manager confirmed that the mealtimes were: 8:00 AM for breakfast, noon for lunch and 6:00 PM for supper. An observation on 4/9/26 at 7:00 AM with the Dietary Manager and the Cook-A who was preparing the lunch meal revealed, Cook-A opened two bags of chicken breast and placed them in two greased pans. Cook-A did not count how many chicken breast had been placed in the two greased pans. [...]

Inspectors wroteThe facility failed to ensure Enhanced Barrier Precautions (EBP, refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) were used during G-tube (surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach) feeding and medication administration for 1 sampled resident (Resident 5). The facility census was 52. Licensure Reference Number 175 NAC 12.006.18(B)

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(E) Based on interviews and record reviews, the facility failed to provide notification to Department of Health and Human Servcies (DHHS) within 5 working days of a change in Director of Nursing (DON) position. This had the potential to affect all the residents that reside in the facility. The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on observations, interviews and record reviews, the facility failed to ensure prompt response to call lights to ensure resident needs were being met for 4 (Residents 1, 3, 7, and 8) out of 4 sampled residents. The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on interviews and record reviews, the facility failed to complete and send a 5-day written investigation of an alleged abuse to the Department of Health and Human Services (DHHS) as required for 1 (Resident 8) of 3 sampled residents. The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04C3a(5) Based on interview and record review the facility failed to have a nursing services representative present during the care plan conferences for 4 (Residents 1, 4 and 6) of 4 sampled residents. The facility identified a census of 52.

Inspectors wroteLicensure Reference Number 175 NAC 12.00610(D) Based on observation, record review and interview, the facility failed to ensure1 resident (Resident 3) of 5 sampled residents were free from significant medication errors. The facility census is 52.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17D Based on observation, interview and record review the facility failed to ensure infection control procedures were followed and maintained during peri cares (the process of washing the genitals and anal area) for one (Resident 11) of two residents sampled. The facility identified a census of 52.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observations, interviews, and record reviews, the facility failed to ensure staff was wearing N-95 mask for Resident 1, wear the N-95 mask appropriately, not placing the Covid sample on clean surface, and washing hands between gloves changes to prevent potential for cross contamination. The facility census is 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview and record review; the facility failed to maintain the cleanliness of the kitchen to prevent the potential for food-borne illness and failed to ensure fluids were provided that were maintained within the required temperature range. This had the potential to affect all 47 residents that ate food prepared in the facility kitchen. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19(C)(i) Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, interview, and record review, the facility failed to ensure staff handled contaminated and clean laundry and linens to prevent cross contamination, failed to ensure Enhanced Barrier Precautions (EBP) signage was posted and Personal Protective Equipment (PPE) was available for staff use in 3 (Residents 23, 31, and 40) of 4 sampled resident's rooms, failed to ensure 1 (Resident 5) of 2 sampled resident's Positive Airway Pressure (PAP, a machine use to treat sleep apnea) device contained a filter, and failed to clean and store PAP supplies for 1 (Resident 2) of 2 sampled residents. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview; the facility failed to ensure current staff were completing the required 12 hours of continuing education annually. This had the potential to affect all residents in the facility. The facility identified a census of 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on interview and record review the facility failed to provide bathing services as required for four (Residents 2, 31, 35 and 38) of eight sampled residents. The facility identified a census of 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.04(F)(i)(5) Based on interview and record review, the facility failed to ensure 2 (Residents 23 and 38) of 4 sampled resident's representative was notified following all falls. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on interview and record review, the facility failed to ensure interventions were implemented to prevent falls for 1 (Resident 23) of 5 sampled residents. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to ensure rationale was provided and the provider's order was followed for 1 (Resident 26) of 5 sampled resident's as needed (PRN) Lorazepam (an antianxiety medication used to treat anxiety). The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7b Based on record review and interview; the facility staff failed to implement and re-evaluate interventions to prevent ongoing falls for 1 (Resident 1) of 3 sampled residents. The facility staff identifed a census of 50.

Inspectors wroteBased on observation and interview, the facility failed to ensure daily nurse staffing was posted. This had the potential to affect all 50 residents in the facility.

Inspectors wroteB. A record review of the Policy Hand Hygiene Effective date 4/30/2018 Guideline revealed, hand hygiene will be completed and is indicated after touching blood, body fluids, secretions, excretions, and contaminated items whether gloves or not are worn. Wash hands immediately after gloves are removed. It may be necessary to wash hands between tasks and procedures on the same resident to prevent cross contamination to different body sites. Alcohol based sanitizer if soap and water are no readily available use hand sanitizer that contains at least 60% alcohol. A waterless antiseptic may be used to supplement routine hand washing. Regular hand washing must be performed on a routine basis. A record review of Resident 14's Medical Diagnosis dated 11/29/2023 revealed, the resident had diagnoses of: [...]

Inspectors wroteLicensure Reference Number 175 NAC 12.006.04B2a Based on interview and record review, the facility failed to complete 12 hours of on ongoing education for nursing assistants. This had the potential to affect all 50 residents in the facility. The total facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D6(5) Based on observation, interview, and record review, the facility failed to ensure 4 (Residents 14, 16, 2, and 4) of 4 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 50.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D2 Based on observation, interview and record review, the facility failed to follow provider wound orders for 1 (Resident 14) of 1 sampled. The total facility census was 50.

Inspectors wroteLicense Reference Number 175 NAC 12-006.09D2a Based on record review and interview, the facility failed to monitor pressure injuries weekly with measurements and wound appearance for 1 resident (Resident 4) of 3 sampled residents. The facility identified a census of 50 at time of survey.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observation, interview and record review, the facility failed to identify and implement new interventions related to fall prevention for 3 of 3 (Resident 1, Resident 2, and Resident 3) residents reviewed. The facility identified a census of 43. Findings Are: A record review of the facility policy titled Fall Prevention Program, dated October 2021, revealed the following: 4. All resident's identified at risk for falls will have deficits and interventions care planned. 5. Reassess risk factors following a fall in order to evaluate and identify the root cause of fall and care plan interventions. 7. Updates of fall prevention interventions will be communicated to staff. A. [...]