Srmc Long Term Care, LLC Dba Pole Creek Estates

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 12-006.18(D) Based on record reviews, observations, and interviews; the facility failed to ensure staff followed proper glove use practices by changing gloves when contaminated or between tasks in accordance with facility policy and Center for Disease Control (CDC) guidelines during meal service to prevent the potential for cross-contamination. This had the potential to affect all 15 residents who reside within the Memory Care Unit (MCU). The facility identified a census of 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record review, observation, and interview, the facility failed to identify and address potential adverse side effects of psychotropic (drug that affects brain activities associated with mental processes and behavior) medications for 1 (Resident 7) of 5 sampled residents. The facility identified a census of 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(C)(ii) Based on record reviews and interviews, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS, a federally mandated assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) within 14 days of determining there had been a significant change (major decline in a resident's status that will usually not resolve) in the condition for 1 (Resident 7) of 1 sample resident. The facility identified a census of 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(v)Based on record review, observation, and interview, the facility failed to provide care, treatment, and ensure services were obtained for a hand contracture (a condition where the fingers bend towards the palm and cannot be straightened due to tightened tissues in the hand) for 1 (Resident 40) of 2 sampled residents. The facility identified a census of 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi) and 175 NAC 12-006.14Based on record review, observation, and interview, the facility failed to provide assistance with eating and administration of medications that was consistent with the needs of an individual with a diagnosis of dementia for (a progressive disorder that primarily affects cognition, memory, and behaviors that includes agitation) 1 (Resident 40) of 4 sampled residents. The facility identified a census of 60.

Inspectors wroteLicensure Reference 12-006.11E Based on observations, interviews, and record review; the facility failed to a) ensure food products were disposed of prior to expiration dates, b) utilize handwashing as required to prevent potential food contamination during food preparation, and c) ensure food temperatures were maintained at least 135 degrees on the steam table as required during serving of meals. This had the potential to affect all residents who resided at the facility. The facility census was 43.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17D Based on observations, interviews, and record review the facility failed to implement hand hygiene as required while passing water pitchers to resident rooms, during medication administration, and during dining room services. This had the potential to affect all residents who resided within the facility. The facility census was 43. The Findings Are: A. An observation on 5/23/24 at 10:55 AM revealed Domestic Aide (DA)-H collecting old water pitchers and passing out new water pitchers to resident rooms. DA-H went into Resident 31's room and carried a water pitcher out of the room, sat it on the lower shelf of a rolling cart, and wrote down the total amount drank on a piece of paper. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C Based on observations, record reviews and interviews the facility failed to develop and implement a comprehensive care plan for 2 (Residents 29, and 30) of 12 sampled residents. The facility census was 43. The Findings Are: A. A record review of facility policy Care Plan dated 5/15/24 revealed that the comprehensive care plan would describe the services that were being furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy also revealed the comprehensive care plan would describe care provided related to high-risk medications including, but not limited to psychotropics, anticoagulants, and antibiotics. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on observation, interviews, and record review the facility failed to provide ongoing care and services to address 1 (Resident 42) of 1 sampled resident's lower extremity edema (swelling). The facility census was 43. Findings Are: A record review of Resident 42's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 3/4/2024 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 2/15, which indicated the resident had severe cognitive impairment. Section I revealed the resident had a diagnosis of non-Alzheimer's dementia, and Section K revealed the resident had not had any significant weight changes in the prior 6 months. An observation on 5/21/24 at 12:23 PM revealed Resident 42 sitting in a chair in the dining room with their lower legs visible. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from unnecessary antibiotic use for 2 (Resident 1 and 29) of 3 sampled residents. The facility census was 43.

Inspectors wroteLicensure Reference 175 NAC 12-006.10D Based on observations, interviews, and record reviews; the facility failed to administer medications at the right time for 2 (Resident 6 and 33) out of 9 sampled residents and ensure the medication error rate was less than 5%. There were 25 medication opportunities observed and there were 2 errors, this resulted in a medication errors rate of 8%. The facility census was 43.

Inspectors wroteLicensure reference number 175 NAC 12-006.09D Based on observation, interview, and record review, the facility failed to obtain a supporting diagnosis for the use of an antipsychotic medication (a medication utilized in the control of hallucinations, delusions, and disordered thinking) for one current sampled resident (Resident #33) out of 12 sampled Residents. The facility census was 44.