Mitchell Care Center

Inspectors wroteLicensure reference number 175 NAC 12-006.11(E) Based on observation, record review, and interviews, the facility failed to ensure cold foods were maintained at a temperature below 41 degrees Fahrenheit, and hot foods were maintained at a temperature above 135 degrees Fahrenheit to prevent the potential for foodborne illness. This had the potential to affect all residents. The facility showed a census of 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview, the facility failed to ensure 2 of 5 sampled nurse aides (NA) completed the required 12 hours of ongoing training annually and failed to ensure 5 of 5 sampled NAs had completed 4 hours of Alzheimer's care and dementia care training annually. This had the potential to affect all residents who reside within the facility. The facility census was 42. Findings Are: A record review of a facility document [NAME] Care Center Employee Hire and Release Dates dated 9/7/2025 revealed the following:-NA-C was hired on 6/25/2024,-NA-D was hired on 5/9/2024,-NA-E was hired on 8/10/2023,-NA-F was hired on 7/17/2023, and -NA-G was hired on 7/10/2019. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv) Based on record review and interview, the facility failed to implement an effective bowel management program to prevent constipation for 2 (Residents 4 and 9) of 5 sampled residents. The facility census was 42. Findings Are: A record review of the facility's undated Policy and Procedure for Bowel Care Program revealed in the Steps section: 1) If no BM (Bowel Movement) for 3 days, perform full GI (gastrointestinal) assessment and document in progress note. Administer Milk of Magnesia 30 milliliters (ML) by mouth. Document effectiveness. 2) If no BM for 4 days, perform full GI assessment and document in progress note. Administer Dulcolax suppository rectally. Document effectiveness. 3) If no BM for 5 days, perform full GI assessment, contact provider for recommendations, and document in progress note. A. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(A)(iii)(2)(a) Based on record review and interview, the facility failed to ensure a nurse aide registry check was completed as required for two of five sampled employees. This had the potential to affect all residents who resided within the facility. The facility census was 42. Findings Are: A record review of the facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy with a review date of 6/17/2025 revealed in the Screening Components section that board registrations and certifications will be verified regarding the prospective employee's background. A record review of the [NAME] Care Center Employee Hire and Release Dates document dated 9/7/2025 revealed Licensed Practical Nurse (LPN)-A was hired on 7/11/2025 and Maintenance (Maint)-B was hired on 8/5/2025 as a Maintenance Assistant. [...]

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures to prevent the potential for further abuse to occur during the investigation of abuse allegations. This had the potential to affect all residents. The facility identified a census of 45. Findings Are: A record review of an undated facility Abuse Policy revealed no documented evidence regarding procedures for how residents would be protected from further abuse while allegations of abuse were investigated, as per regulatory requirements. The policy revealed the facility was to include how the residents were protected in the report to the State Agency. A record review of an Investigative Summary dated 4/25/25 revealed no documented evidence of how residents were protected during investigative process. [...]

Inspectors wroteLicensure Reference Number 175 12-006.02(H) Based on record review and interviews, the facility failed to protect residents from further potential abuse during an investigation of alleged violations of abuse as per regulatory requirements. This had the potential to affect all residents. The facility identified a census of 45. Findings Are: A record review of a facility undated Abuse Policy revealed the following: The facility must include the following investigative components- -Have evidence that all investigative components have been thoroghly investigated. -Prevent further abuse, neglect, exploitation, or mistreatment while the investigation is in progress. An interview with the Director of Nursing (DON) on 06/16/2025 at 2:30 PM revealed they were aware of an incident involving a nurse and a resident that occurred on 04/19/2025. [...]

Inspectors wroteLicensure Reference Number 175 12-006.02(H) Based on record review and interviews, the facility failed to report an allegation of abuse as per regulatory requirements. This had the potential to affect all residents. The facility identified a census of 45. Findings Are: A record review of the facility's undated Abuse Policy revealed the following: External Reporting: -Intitial reporting of allegations: If an incident or allegation is considered reportable the Administratior or designee will make initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within 5 working days. A record review of an Investigative Summary that concluded on 04/28/2025 revealed no documented evidence of abuse allegations being reported to the State Agency. [...]

Inspectors wroteLICENSURE REFERENCE NUMBER NAC 175 12-006.11(E) Based on observations, interviews, and record review; the facility failed to ensure foods were date-marked or labeled with their common names and failed to dispose of or consume foods within seven days as required to prevent the potential for food-borne illness. This had the potential to affect all 43 residents who resided within the facility and were served out of the kitchen.

Inspectors wroteLicensure Reference Number 175 NAC 12-007.04D Based on record review, observation, and interview; the facility failed to ensure that the ventilation system was operational in resident's bathrooms on 100, 200, and 300 wings. This had the potential to affect all 43 residents who resided within the facility.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observations, interviews, and record review; the facility failed to utilize enhanced barrier precautions as required when assisting with personal cares for Residents 3 and 40, and failed to ensure staff did not continue to utilize gloves after they were contaminated during medication administration for Resident 12. The facility census was 43. The Findings Are: A. A record review of an undated facility policy Infection Control-Enhanced Barrier Precautions revealed that the facility would implement enhanced barrier precautions (EBP) during high-contact resident care activities when caring for residents that had an increased risk for acquiring a multi-drug resistant organism, such as residents with wounds. The policy stated that high contact care activities included dressing, transferring, changing briefs, and wound care. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility failed to monitor 1 (Resident 2) of 2 sampled resident's blood pressure while the resident was taking medications used to treat hypertension (elevated blood pressure). The facility census was 43. The Findings Are: A record review of a facility document provided by the Director of Nursing (DON) titled admission Check Off List revealed that if a resident was taking a blood pressure medication, staff must put an order in for weekly vital signs and medications must have parameters. A record review of Resident 2's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 6/27/24 revealed Resident 2 had a diagnosis of hypertension. A record review of Resident 2's Physician's Orders revealed the following medications: [...]

Inspectors wroteLicensure Reference 12-006.12(A)(vi) Based on record reviews and an interview; the facility failed to ensure the pharmacist had identified irregularities during their monthly medication regimen review (MRR, a monthly review of a resident's medications by a licensed pharmacist to minimize or prevent adverse consequences or to prevent residents from receiving unnecessary medications) for 1 (Resident 37) of 5 sampled residents. The facility identified a census of 43.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(H)(vi) Based on record reviews and interview; the facility failed to ensure a PRN (as needed) psychotropic medication (a medication to treat mental illnesses) had a stop date for 1 (Resident 37) of 5 sampled residents. The facility identified a census of 43.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observations, interview and record reviews, the facility failed to utilize proper hand hygiene practices during the preparation and serving of food to prevent the potential for foodborne illness. This had the potential to affect 46 of 47 residents who ate from the kitchen.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(5) Based on interviews and record reviews, the facility failed to provide notice to the residents and/or their Representatives of the Facility's Bed Holding Policy before facility-initiated transfers to the hospital. This failure affected 4 of 4 sampled residents (Resident 29, Resident 36, Resident 40, and Resident 51). The facility census was 47 at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.06B Based on observations, interviews, and record review, the facility failed to follow up on a complaint regarding wheelchair equiptment for 1 (Resident 4) of 1 sampled residents. The facility identified a census of 48 residents at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(8) Based on observations, record review, and interviews; the facility failed to identify a body pillow secured under a fitted sheet and placed along the edge of the bed as a potential restraint for 1 resident (Resident 12). The facility staff identified a census of 47 at the time of the survey.

Inspectors wroteLicensure Referene Number: 175 NAC 12-006.05 (5) Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a facility initiated transfer to the hospital for 1 (Resident 29) of 1 sampled residents. The facility identified a census of 47 residents at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.17 Based on observations, interviews and record review, the facility failed to perform hand hygiene while providing direct resident care to 1(Resident 12) of 1 sampled residents. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C1c Based on observations, interviews, and record review the facility failed to review and revise 1 (Resident 23) of 1 sampled resident's care plan to meet the resident's needs. The facility census was 47.