Hillcrest Shadow Lake LLC

In the surveyor’s words

From the most serious findings on record at Hillcrest Shadow Lake LLC, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 20, 2026

  Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) & 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to evaluate, monitor, and implement interventions for pressure ulcer prevention and promotion of wound healing for 2 (Resident 1 and 3) of 4 residents sampled. The facility census was 95. Findings are:A. Record review of the facility policy titled Skin integrity, Wound, Ulcer Assessment Prevention Treatment Documentation Policy dated 02-11-2021 revealed all team members are responsible for preventing, caring for, and providing treatment to any guest that has altered skin integrity. A licensed nurse/physician/therapist may stage a wound and determine etiology. Measurement of the wound must be completed upon identification. […]

• Actual harm, isolatedF689Apr 4, 2024

  Licensure Reference Number 175 NAC 12-006.09D7a Based on interview and record review, the facility failed to ensure 1 (Resident 48) of 8 sampled resident's safety belt remain secured during the bathing process and implement interventions to prevent a fall with fracture for 1 (Resident 94) of 8 sampled residents. The facility census was 92. Findings are: A. Record review of the facility's Bathing Procedure dated 05/23/2024 revealed the spa tub procedure was to assist residents out of their clothing and onto the tub chair utilizing appropriate transfer device and ensure the safety belt was on the resident. […]

• Actual harm, isolatedF675Feb 10, 2022

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(5) Based on record review and interview; the facility staff failed to evaluate risk factors and implement interventions to prevent fecal impaction ([NAME] stool that is stuck in the large intestine) for 1( Resident 3) of 1 sampled residents. The facility staff identified a census of 85. Findings are: Record review of Resident 3's Minimum Data Set (MDS: a federally mandate assessment tool use for care planning ) dated 1-3-2022 revealed the facility assessed the following about the resident: -Brief interview of mental status was assessed as a 4. According to the MDS Manuel, a score of 0 to 7 indicates severe impairment. -Required extensive assistance with bed mobility, dressing and toilet use. -Totally dependent for transfers. […]

• No harm, potential for more than minimal, widespreadF812Apr 4, 2024

  Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review, the facility failed to perform hand washing after touching potentially contaminated items during meal prep, place the blade in the puree blender in a sanitary manner, ensure staff did not touch the drinking surfaces of the cups of 12 residents in the E hall dining room to prevent cross-contamination. The facility failed to ensure the main kitchen and the Evergreen/Memory unit kitchen floors and equipment were cleaned and failed to ensure all items in the Evergreen/Memory Care unit refrigerator and freezer were labeled and dated to prevent the potential for food-borne illness. This had the potential to affect all 92 residents in the facility. The facility census was 92. Findings are: A. […]

• No harm, potential for more than minimal, widespreadF880Apr 4, 2024

  Licensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed ensure the facility staff wore surgical masks above the nose and below the chin while in resident care areas, failed to perform hand hygiene when going between 2 residents while assisting with meal, failed to ensure that hand hygiene was performed before and after glove changes during medication administration for Resident 74, and failed to glove and do hand hygiene to prevent cross-contamination during wound care for resident 81 and catheter care for Resident 88 and Resident 1. This had the potential to affect all 92 residents in the facility. The facility census was 92. Findings are: A. […]