Tlc Care Center

F 0676

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review, interview and document review the facility failed to provide bathing as scheduled for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to negatively impact the resident's overall well-being. Findings include:Based on observation, record review, interview and document review the facility failed to provide bathing as scheduled for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for skin breakdown, rashes, and overall poor hygiene. Findings include:Resident 1 (Resident R1) was admitted on [DATE REDACTED] with diagnoses including dysphagia following cerebral infarction, type 2 diabetes mellitus, and essential hypertension.On 12/30/2025 at 9:30 AM, Resident R1 explained they had a rash, experienced itching, and staff did not bathe or shower them regularly.On 12/30/2025 at 9:40 AM, a Certified Nurse Assistant (CNA) explained that resident bathing was scheduled according to room numbers, with residents bathed twice weekly and as needed. Bathing was documented in the medical record. After reviewing the schedule, the CNA confirmed that Resident R1's baths were assigned to the evening shift on Wednesdays and Saturdays.The Quarterly Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident R1 was dependent on staff for showering and bathing, including washing, rinsing, and drying (excluding washing of the back and hair). This did not include assistance with transferring in or out of the tub/shower. Resident R1's shower/bathing tasks documented the following bathing activity:-Tuesday, 09/30/2025 a bed bath-Saturday, 10/11/2025 a shower-Wednesday, 10/22/2025 a bed bath-Wednesday, 10/29/2025 a bed bath-Wednesday, 11/19/2025 a bed bath-Wednesday, 12/10/2025 a shower-Wednesday, 12/17/2025 a bed bath-Saturday, 12/20/2205 a bed bath-Sunday, 12/21/2025 a showerOn 12/30/2025 at 10:31 AM, the Director of Nursing (DON) explained resident showers or bed baths were to be performed as scheduled. After reviewing Resident R1's bathing schedule and documentation, the DON confirmed showers were scheduled for Wednesday and Saturday evening but were not provided as scheduled. The DON explained when a resident did not receive routing bathing, they were at risk for skin breakdown, rashes, and overall poor hygiene. The facility policy titled Shower/Tub Bath, undated, documented qualified nursing staff would provide a bed bath to the resident as needed, at a minimum, the resident would be offered at least two full baths or shower per week. Complaint #2651495

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Tlc Care Center

1500 W Warm Springs Rd Henderson, NV 89014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interviews, the facility failed to ensure physician orders for monthly weights were followed for 1 of 6 sample residents (Resident 6). This deficient had the potential to impact monitoring of the resident's changes in weight (loss or gain), nutritional assessment, and delay dietary interventions. Findings Include: Resident 6 (Resident R6) was admitted to the facility on [DATE REDACTED] with diagnoses including Parkinson's disease without dyskinesia, dementia, and major depressive disorder.A physician order summary dated 07/03/2025, documented monthly weight one time a day starting on the 1st and ending on the 7th every month for monitoring.A physician/nurse practitioner progress note dated 12/11/2025 documented Resident R6 had

an eight-pound weight loss from August of 2025.Resident R6's weight record documented the following:12/10/202592.3 pounds (weight chair) 08/07/2025 -100.00 pounds (weight chair)The medical record lacked documented evidence of weights for September 2025, October 2025 and November 2025. On 12/30/2025 at 1:25 PM, the Director of Nursing (DON) stated obtaining resident weights had been an ongoing issue.

Certified Nurse Assistants (CNA) had not consistently obtained monthly weights, which could have resulted

in inaccurate care planning and delayed or inappropriate interventions for residents who experienced weight loss.On 12/30/2025 at 2:30 PM, the Unit Manager stated that CNAs were expected to obtain resident weights monthly. The Unit Manager acknowledged ongoing challenges in obtaining consistent and accurate measurements and indicated that missing or inaccurate weights had negatively impacted care planning and delayed timely interventions for residents experiencing weight loss or significant changes.On 12/30/2025 at 2:45 PM, the Assistant Director of Nursing (ADON), revealed obtaining accurate weights by CNAs had been challenging. Weights were obtained upon admission, monthly, and as needed. Inconsistent weight measurements could have negatively impacted resident care plans and overall health outcomes.On 12/30/2025 at 3:15 PM, the Registered Dietitian (RD) acknowledged ongoing challenges in obtaining accurate and consistent weight measurements, noting missing or inconsistent data made it difficult to track true weight changes. The RD stated that consistent weight monitoring would have allowed timely dietary interventions and more effective nutritional planning, ensuring better alignment of Resident R6's dietary needs with

the care plan.The facility's policy titled Weight Assessment and Intervention, dated 10/01/2021, stated the nursing staff or designee will measure resident weight as ordered by the physician/practitioner and weights will be measured monthly. Complaint #2675657

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet