Trellis Paradise

within 15 minutes and reported the findings back to the nurse.On 11/18/2025 at 1:20 PM, a Registered Nurse (RN), explained that vital signs were checked in the morning and again later in the day if needed before medications were administered. A temperature above 100.3 F was considered high, and interventions would have been done, including giving Tylenol, applying a cold compress, wiping the resident down, providing hydration, removing blankets, lowering the room temperature, and rechecking the temperature in one hour.

The physician would have been notified initially, and if the interventions did not work, the nurse would have contacted the physician again for further orders such as Tylenol or laboratory bloodwork.

The situation would have been documented as a change of condition, the resident's family notified, and the temperature rechecked within the hour.

The RN added that a high temperature raised concern for infection and possible sepsis, which was why laboratory bloodwork would be needed.On 11/18/2025 at 2:55 PM, the Director of Nursing (DON) explained a temperature above 99.1 degrees (F) was considered high, and a physician would have been notified. A change of condition would be completed, and the facility would get a physician order and place it in the system.

The resident's family would have been notified but if the resident was alert and oriented the resident would be told to contact the family with their information.

While waiting on the physician's order, interventions and cooling measures would have been done.

The temperature would be rechecked within the hour.

The DON stated there was no facility standing order for temperature medications.On 11/18/2025 at 3:43 PM, a Physician explained, documenting Tylenol as needed in a physician progress note should not be considered a Tylenol order, because an order must include the type, route, dosage, frequency and strength of the medication.

The physician stated the facility nurses called directly or contacted the answering service after hours to make physician notifications for changes in conditions.

Physicians would have given verbal orders over the phone or placed the orders themselves. In a change-of-condition event, the expectation was to document the fever and the nursing interventions, and the temperature rechecked.On 11/18/2025 at 4:08 PM, the DON confirmed R1's medical record lacked a change of condition for the high temperature, nursing progress notes regarding interventions, and physician notification.The facility's Change in a Resident's Condition or Status policy dated 02/2021 documented the facility promptly notified the resident, the attending physician, and the resident representative of any changes in the resident's medical or mental condition.

The nurse notified the physician or on-call physician when there was a significant change in the resident's physical condition or a need to significantly alter medical treatment.

The policy indicated nurses made detailed observations, gathered relevant information for the provider, and, except in emergencies, made notifications within 24 hours of the change.

Regardless of the residents' condition, staff informed the resident of changes in care and documented all related information in the medical record.

Complaint #2591137

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trellis Paradise

4375 S.

Eastern Avenue Las Vegas, NV 89119

SUMMARY STATEMENT OF DEFICIENCIES