Every finding on record at Ponderosa Villa

Licensure Reference Number 175 NAC 12-006.04(B)(ii) Based on record review and interview, the facility failed to ensure 3 of 5 sampled Nurse Aides (NA) completed the required 12 hours of ongoing training per year, including 4 hours of dementia care training, based on their date of hire. The facility census was 27.Findings Are: A record review of an untitled and undated, facility-provided, document revealed the following employee hire dates:-NA-A was hired on 6/7/2024,-NA-B was hired on 4/19/2024, and-NA-C was hired on 9/22/2023. A record review of a document titled NA-A's Training revealed that between 6/7/2024 and 6/7/2025, NA-A completed 7.5 hours of ongoing training, none of which were related to dementia care. A record review of a document titled NA-B's Training revealed that between 4/19/2024 and 4/19/2025, NA-B completed 9.5 hours of ongoing training, none of which were related to dementia care. A record review of a document titled NA-C's Training revealed that between 9/22/2024 and 9/22/2025, NA-C did not complete any ongoing training hours. An interview on 1/13/26 at 7:50 AM with the Administrator confirmed NA-A, NA-B, and NA-C had not completed the required amount of ongoing annual training hours.

Licensure Reference Number 175 NAC 12-006.09(E) Based on record review, observation, and interview; the facility failed to ensure the care plan was comprehensive for 3 (Residents 2, 4 and 18) of 12 sampled residents. The facility census was 27.A. A record review of Resident 2's face sheet revealed they were admitted on [DATE] and had diagnoses including hyponatremia (low sodium levels in the bloodstream), dementia (a progressive loss of memory, language, and other mental abilities), anxiety, and hypertension (high blood pressure). A record review of Resident 2's physician orders revealed they were taking the medication buspirone 5 milligrams (mg) twice daily for, negative statement to self, verbalizes sadness, related to anxiety disorder. A record review of Resident 2's physician orders revealed they were taking the medication citalopram 40 mg daily for, negative statement to self, verbalizes sadness, related to anxiety disorder. A record review of Resident 2's physician orders revealed they were taking the medication quetiapine 50 mg daily for, res displays extreme anxiety about surroundings and self, related to their dementia. A record review of Resident 2's progress notes revealed the following: - In a note dated 11/7/25 at 1:36 PM Resident 2 was verbally fighting with another resident and required redirection by a nurse. - In a note dated 11/12/25 2:23 AM Resident 2 was noted to be more anxious in the evenings and could not do any self-directed activity, with Resident 2 stating they did not know what to do with themself. Resident 2 also used the call light repeatedly and required redirection by staff. - In a note dated 11/17/25 at 8:53 PM Resident 2 was noted to have increased agitation with yelling. - In a note dated 12/2/25 at 8:33 PM Resident 2 had increased agitation and nervousness after supper and used their call light frequently. - In a note dated 12/3/25 at 8:56 PM Resident 2 continued to have increased confusion, anxiety, and agitation after supper, used the call light frequently, and expressed anger with staff. The note also revealed that staff spent time one to one with Resident 2, but it did not help. - In a note dated 12/20/25 9:10 PM Resident 2 was unable to verbalize to the staff what they wanted but stated they felt nervous. - In a note dated 12/22/25 10:49 PM Resident 2 stated they were miserable, and exhibited behaviors including raising the bed to the highest level and swinging the call light around. - In a note dated 12/31/25 8:33 PM Resident 2 used the call light repeatedly after being put to bed and was noted by the nurse to have increased anxiety on other evenings as well. - In a note dated 1/10/26 at 9:52 PM Resident 2 used the call light repeatedly while in bed, then stated they were not sure what they wanted when a staff member responded. An interview on 1/14/26 at 8:17 AM with Registered Nurse-D (RN-D) revealed Resident 2 had dementia and obsessive-compulsive disorder. In addition, Resident 2 frequently yelled out during the night, and argued with their roommate. They required frequent redirection and reassurance from staff, preferred to be in a bed near the window, and wanted the divider curtain open to prevent feeling isolated or having anxiety from being in a small space. A record review of Resident 2's care plan revealed no mention of Resident 2's behaviors as described in the progress notes, or interventions related to dementia or anxiety. An interview on 1/14/2026 at 10:22 AM with the Director of Nursing (DON) confirmed the resident displayed the behaviors described in the progress notes. The interview also revealed the resident frequently woke up during the night and yelled out as if having a bad dream and that a light was left on to help assuage fear. Resident 2 also preferred to have personal items laid out on a bedside table in a particular way and had a specific routine that provided comfort to them. The interview also confirmed that Resident 2's care plan did not contain the goals or interventions to address anxiety or dementia diagnoses, or interventions for negative behaviors exhibited by Resident 2. B. A record review of the facility policy Care Plans, Comprehensive Person-Centered dated March 2022 revealed a policy statement of A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A record review of Resident 4's admission Record dated 1/12/2026 revealed the resident was admitted to the facility on [DATE] with a diagnosis of acquired absence of right leg below knee. A record review of an Office Clinic Note Physician for Resident 4 dated 8/26/2025 revealed documentation of the resident having a history of a below the knee amputation. A record review of a hospital Discharge Summary for Resident 4 dated 10/9/2025 revealed the resident was evaluated by a physician; the documentation included that the resident had a history of a below the knee amputation to the right leg. An interview on 1/11/2026 at 9:29 AM with Resident 4 revealed the resident's right lower leg had been amputated and the resident was unable to walk due to this. The resident stated they would like to have a prosthesis so they could walk again but that they had not received one. A record review of Resident 4's undated Care Plan revealed the following sentence in the activity involvement problem section: (Resident 4) has had an amputation of part of their right leg. There were no goals or interventions in this section related to the amputation. Further review of the remainder of Resident 4's Care Plan revealed no other mention of their amputation or interventions in place related to the amputation. An interview on 1/14/26 at 9:15 AM with the DON revealed Resident 4 had expressed a recurring desire to obtain a prosthesis for their right leg. The DON stated that the resident was not a candidate for the prosthetic because they did not meet the physical strength criteria and because their skin was very fragile and small injuries, such as scratches, were difficult to heal on their lower extremities. The DON revealed that the facility did address the resident's desire for a prosthetic each time the resident brought it up and had the resident re-assessed to confirm their ineligibility, with the most recent time being within the last couple of months. The DON confirmed that the amputation did affect Resident 4's daily life and that this information was currently relevant and should have been in the care plan for staff reference. C. A record review of Resident 18's admission Record dated 1/14/2026 revealed the resident was admitted to the facility on [DATE] and had a diagnosis of Major Depressive Disorder (MDD, a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies). A record review of Resident 18's quarterly MDS dated [DATE] revealed the resident had a diagnosis of depression and was taking antidepressant medication. A record review of Resident 18's physician's orders revealed the resident was taking sertraline (an antidepressant) daily for major depressive disorder. The order had a start date of 11/1/2025. A record review of Resident 18's undated Care Plan revealed no evidence of the resident's MDD diagnosis or their need for interventions related to this diagnosis. An interview on 1/14/2026 at 10:44 AM with the DON confirmed there were no care plan interventions or goals related to their MDD diagnosis.

Based on record review and interview, the facility failed to issue the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123 as required for 2 (Residents 10 and 33) of 3 sampled residents. Findings:A.Record review of a facility-completed document titled, SNF Beneficiary Notification Review for Residents who received Medicare Part A services, revealed the following:Resident 10's Medicare Part A skilled services started on 8/2/25.Their last covered day of Part A services was 10/16/25.The facility initiated Resident 10's discharge from Part A services when benefit days were not exhausted.The same document also revealed that a NOMNC, Form CMS-10123 was not provided and should have been. B.Record review of a facility-completed document titled, SNF Beneficiary Notification Review for Residents who received Medicare Part A services, revealed the following:Resident 33's Medicare Part A skilled services started on 10/27/25.Their last covered day of Part A services was 11/12/25.The facility initiated Resident 33's discharge from Part A services when benefit days were not exhausted.The same document also revealed that a NOMNC, Form CMS-10123 was not provided and should have been.An interview with the Business Office Manager on 1/13/26 at 8:30 AM confirmed that Resident 10 and 33 did not receive the NOMNC, Form CMS-10123, and should have.

Licensure Reference Number 175 NAC 12-006.09(B)Based on record review and interview, the facility failed to accurately code an active diagnosis on the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 1 (Resident 4) of 12 sampled residents. The facility census was 27.Findings Are: A record review of the facility policy MDS Assessment Coordinator dated November 2019 revealed each individual who completes a portion of the assessment must certify the accuracy of that portion of the MDS. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated October 2025 revealed that active diagnoses are defined as Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. A record review of Resident 4's admission Record dated 1/12/2026 revealed the resident was admitted to the facility on [DATE] with a diagnosis of acquired absence of right leg below knee. An interview on 1/11/2026 at 9:29 AM with Resident 4 revealed the resident's right lower leg had been amputated and the resident was unable to walk due to this. A record review of an Office Clinic Note Physician for Resident 4 dated 8/26/2025 revealed documentation of the resident having a history of a below the knee amputation. A record review of Resident 4's quarterly MDS dated [DATE] revealed no evidence of an active diagnosis related to their below the knee amputation. A record review of a hospital Discharge Summary for Resident 4 dated 10/9/2025 revealed the resident was evaluated by a physician; the documentation included that the resident had a history of a below the knee amputation to the right leg. A record review of Resident 4's quarterly MDS dated [DATE] revealed no evidence of an active diagnosis related to their below the knee amputation. An interview on 1/14/26 at 9:15 AM with the Director of Nursing confirmed that Resident 4's amputation was not included in their active diagnoses on their MDS's despite it affecting their daily activities.

Licensure Reference Number 175 NAC 12-006.19(C)(i) Licensure Reference NUMBER 175 NAC 12-006.18(D) Based on observation, interview, and record the facility failed to ensure that staff performed hand hygiene between resident rooms during laundry delivery to prevent the potential for cross-contamination. This affected 10 residents (Residents 2, 4, 6, 8, 12, 13, 15, 17, 20, and 21), and the facility failed to ensure nursing staff changed gloves and performed hand hygiene during wound care for 1 resident (Resident 17). The facility identified a census of 24. Findings are: A. An observation on 11/18/2024 at 12:45 PM revealed that Laundry Aide (LA)-G pushed a covered laundry cart into the 100 hallway. LA-G removed some folded clothing from a bin in the laundry cart and delivered the clothing into the room of Resident 13 and then exited the room. LA-G pulled back the cover on the laundry cart and removed some clothing on hangers and clothing from a bin in the cart, then re-covered the cart. LA-G carried the clothing into the room of Resident 6 and Resident 2 (roommates sharing the same room), left the laundry in the room and then exited the room. LA-G then pushed the cart in front of the room of Resident 8 and Resident 15 (roommates sharing the same room), opened the cover on the cart, removed some folded clothing from a bin in the cart, and some clothing on hangers in the cart. LA-G closed the cover on the cart and delivered the clothing into the room of Resident 8 and Resident 15. LA-G hung the clothes in the resident closet in the resident room and removed an empty hanger from inside the closet and carried the empty hangers out of the resident room and hung it on the rack inside the laundry cart. LA-G removed some folded clothing from a bin inside the laundry cart and some clothing on hangers from the cart and delivered them into the room of Resident 21 and placed the folded clothing into a drawer of the freestanding dresser in the resident's room and then hung the clothing on hangers in the resident's closet. LA-G removed 2 empty hangers from the resident closet and exited the resident room and placed the empty hangers on the rack inside the laundry cart. LA-G did not perform hand hygiene as required while delivering laundry to these resident rooms. An observation on 11/19/2024 at 1:36 PM revealed that LA-G pushed the covered laundry cart into the 100 hallway. LA-G uncovered the side of the cart and removed some clothing on hangers from the cart. LA-G put the cover back in place and delivered the clothes into the room of Resident 20 and hung the clothes in the closet. LA-G removed some empty hangers from the closet in the resident's room and carried the hangers to the laundry cart and placed the hangers on the rack in the laundry cart. LA-G did not perform hand hygiene. LA-G then pushed the covered laundry cart into the 200 hallway. LA-G removed some folded clothing from a bin in the laundry cart and delivered the clothing into the room of Resident 12 and then exited the room. LA-G did not perform hand hygiene as required while delivering laundry to these resident rooms. Interview on 11/19/2024 at 1:49 PM with LA-G revealed that the facility provided education on washing hands, Alcohol Based Hand Rub (ABHR), and when to complete each. LA-G revealed that hand hygiene should be performed after leaving each resident room with hand sanitizer (ABHR). Record review of the undated facility policy titled, Monitoring Compliance with Infection Control revealed in section 3, Monitoring includes hand hygiene practices and availability of hand hygiene supplies. Interview on 11/21/2024 at 9:54 AM with the facility Director of Nursing (DON) revealed that the facility had an open Performance Improvement Plan (PIP) which included monthly audits of hand hygiene and hand sanitization, however, the PIP did not include the delivery of laundry. The DON stated that the facility had failed to audit the process of delivering laundry, hanging clothes in closet or placing in dresser and keeping laundry away from staff clothes, and well as hand sanitizing between room delivery. Interview on 11/21/23 at 10:00 AM with the facility DON confirmed that staff were expected to perform hand sanitization when going between resident rooms, including during laundry delivery. 51122 B. A record review of a facility policy titled, Wound Care, last revised in October 2010, revealed the procedure for changing a wound dressing. According to the policy, after discarding a soiled dressing with used gloves, the nurse is instructed to, Wash and dry your hands thoroughly, then put on new gloves prior to handling new dressings. A record review of Resident 17's physician's orders revealed that the resident had an active physician's order dated 11/15/24 which read, Nursing order: Clean both buttocks with wound cleanser, pat dry. Apply A&D ointment. Cover with ABD dressing twice a day. An observation of wound care on 11/19/24 at 2:20 PM for Resident 17 revealed that Licensed Practical Nurse (LPN)-H wore a gown and gloves while performing wound care for Resident 17. LPN-H removed a soiled dressing from the sacrum of Resident 17 while the resident was lying on their left side, cleansed the wound with a cleansing spray, applied A&D ointment, and put a new dressing on the resident while wearing the same pair of gloves throughout the procedure. No hand hygiene was performed and gloves were not changed between the removal of the soiled dressing and application of the new dressing. An interview with LPN-H on 11/19/24 at 2:30 PM confirmed the nurse did not change their gloves or perform hand hygiene between removing the soiled dressing and applying a new one for Resident 17.

Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interview, the facility failed to ensure 4 of 4 sampled nurse aides had at least 12 hours of ongoing training including dementia and abuse training. This had the potential to affect all residents residing at the facility. The facility identified a census of 24. Findings are: A record review of a Facility Assessment for Ponderosa Villa with a date of 7/30/2024 revealed ongoing training is provided for all existing staff and includes topics of abuse and dementia. A record review of City of [NAME] dba Ponderosa Villa, a document that included a list of employees, their job titles, department, hire date, and license number revealed the following employee hire dates: -Medication Aide (MA)-B was hired on 3/6/1998. -Nurse Aide (NA)-E was hired on 10/17/2022. -NA-A was hired on 9/1/2008. -NA-C was hired on 9/13/2023. A record review of a document, User Learning with a date of 11/20/2024 for MA-B revealed a total of 5.25 training hours and no training regarding abuse or dementia over the prior 12 months. A record review of a document, User Learning with a date of 11/20/2024 for NA-E revealed a total of 6.75 training hours over the prior 12 months. A record review of a document, User Learning with a date of 11/20/2024 for NA-A revealed no training regarding abuse in the prior 12 months. A record review of a document, User Learning with a date of 11/20/2024 for NA-C revealed a total of 8.5 training hours over the prior 12 months. An interview on 11/21/2024 at 9:20 AM with the Office Manager (OM) confirmed the nurse aides should have at least 12 hours of training each year, including on the topics of abuse and dementia. The interview also confirmed MA-B, NA-E, NA-A, and NA-C had not met these requirements.

Licensure Reference 175 NAC 12-006.09(H)(iv)(5) Based on record reviews and interviews, the facility failed to ensure bowel management was provided for 3 (Resident 12, 17, and 18) of 3 sampled residents. The facility identified a census of 24. Findings are: A record review of a facility policy, Constipation Management Policy with a date of 1/1/2024 revealed steps would be taken when a resident is experiencing constipation. The steps identified were: on day 2 - give prune juice, day 3 - give milk of magnesia, day 4 - give suppository, and day 5 - give an enema. The policy also revealed the facility was to monitor residents for changes in bowel habits, all bowel movements are to be charted, and interventions to treat constipation are to be charted. A. A record review of a Face Sheet revealed Resident 18 was admitted to the facility on [DATE] for acute cholecystitis (inflammation of the gallbladder). A record review of Resident 18's quarterly Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) with an Assessment Reference Date of 10/10/2024 revealed Resident 18 had short- and long-term memory impairment. It also revealed Resident 18 was dependent for toileting. A record review of Resident 18's Care Plan with a date of 9/17/2024 revealed a problem area stating that Resident 18 was terminally ill and had been admitted to hospice care on 7/12/2024. Interventions in this section stated to assess bowel function and administer medications, evaluating efficacy and adverse effects. A record review of Resident 18's physician's orders with a date of 11/19/2024 revealed Resident 18 was currently taking Senokot-S (a laxative) daily, Miralax (a laxative) daily as needed, and Morphine Sulfate (a pain medication) every hour as needed. A record review of Resident 18's bowel documentation from 7/12/2024 to 11/14/2024 revealed the following: -Resident 18 had no bowel movement from 7/18/2024-7/23/2024 (6 days), -Resident 18 had no bowel movement from 8/12/2024-8/18/2024 (7 days), -Resident 18 had no bowel movement from 9/2/2024-9/4/2024 (3 days), -Resident 18 had no bowel movement from 9/27/2024-9/29/2024 (3 days), -Resident 18 had no bowel movement from 10/7/2024-10/9/2024 (3 days), -Resident 18 had no bowel movement from 10/27/2024-11/8/2024 (13 days), and -Resident 18 had no bowel movement from 11/10/2024-11/14/2024 (5 days). A record review of Resident 18's Medication Administration Records from 7/12/2024 to 11/14/2024 revealed the following interventions: -Resident 18 was documented as being given as needed Miralax on 7/23/2024. -Resident 18 was not given any medications to relieve constipation between 8/12/2024-8/18/2024. -Resident 18 was not given any medications to relieve constipation between 9/2/2024-9/4/2024. -Resident 18 was not given any medications to relieve constipation between 9/27/2024-9/29/2024. -Resident 18 was not given any medications to relieve constipation between 10/7/2024-10/9/2024. -Resident 18 was not given any medication to relieve constipation between 10/27/2024-11/8/2024. -Resident 18 was given as needed Miralax on 11/14/2024. A record review of Resident 18's Nurses Notes from 7/12/2024-11/18/2024 revealed the following: -On 7/23/2024, it was documented that Resident 18 had no bowel movement in five days, was offered milk of magnesia and MiraLAX. Resident 18 refused both. -On 7/24/2024, Resident 18 was started on the Senokot-S. -There was no documentation of bowel interventions between 8/12/2024-8/18/2024. -There was no documentation of bowel interventions between 9/2/2024-9/4/2024. -There was no documentation of bowel interventions between 9/27/2024-9/29/2024. -There was no documentation of bowel interventions between 10/7/2024-10/9/2024. -There was no documentation of bowel interventions between 10/27/2024-11/8/2024. -There was no documentation of bowel interventions between 11/10/2024-11/13/2024. An interview on 11/21/2024 at 9:05 AM with the Director of Nursing (DON) confirmed Resident 18 had not had a documented bowel movement on 7/18/2024-7/23/2024, 8/12/2024-8/18/2024, 9/2/2024-9/4/2024, 9/27/2024-9/29/2024, 10/7/2024-10/9/2024, 10/27/2024-11/8/2024, and 11/10/2024-11/14/2024. The DON also confirmed there were no documented interventions for Resident 18's constipation for 7/18/2024-7/22/2024, 8/12/2024-8/18/2024, 9/2/2024-9/4/2024, 9/27/2024-9/29/2024, 10/7/2024-10/9/2024, 10/27/2024-11/8/2024, and 11/10/2024-11/13/2024. The interview with the DON also revealed that staff should be implementing the bowel management policy and implementing residents' care planned and physician ordered interventions. 51122 B. A record review of Resident 17's care plan revealed the following statements: -Problem, End of Life decline in ADLs, manifested by, Unable to ambulate. One of the approaches listed was, Nurses - Assess bowel function. The problem and approach were dated 8/22/24. -Problem, Indwelling urinary catheter, related to pressure ulcer of sacral region. One of the approaches listed was, Nurse aide - Record bowel movements. The problem and approach were dated 8/22/24. -Problem, Potential for adverse side effects, related to use of hypnotic medication. One approach listed was, Nurses - Monitor for adverse effects, one of the adverse effects listed was constipation. The problem and approach were dated 8/22/24. A record review of Resident 17's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 10/29/24, in Section GG revealed that Resident 12 was dependent on staff for toileting hygiene. Section H revealed that Resident 12 was always incontinent of bowel, that they did not have a toileting program, and that the resident had constipation. A record review of Resident 17's physician's orders revealed the following active as needed medication orders to treat constipation: -Bisacodyl (a laxative) 10 milligrams (mg) rectal suppository daily as needed for constipation, the order start date was 5/8/24. -Milk of Magnesia 30 milliliters (ml) suspension by mouth daily as needed for 3 days of no BM, the order start date was 5/28/24. -Senokot S (sennosides-Docusate 8.6 mg/50 mg) 1 tablet by mouth daily as needed for constipation, the order start date was 5/8/24. -Senokot (sennosides 8.6 mg) tablet by mouth twice a day as needed for constipation, the order start date was 6/24/24. A record review of Resident 17's untitled bowel output report from 8/2/24 to 11/20/24 revealed the resident had the following time periods without a bowel movement: -8/6/24 through 8/11/24 (6 days), -9/10/24 through 9/16/24 (7 days), -9/30/24 through 10/5/24 (6 days), -10/23/24 through 10/28/24 (6 days), and -10/30/24 through 11/4/24 (6 days). A record review of Resident 17's medication administration record (MAR) for the period between 8/1/24 and 11/20/24 revealed the following: -The as needed Milk of Magnesia had not been administered. -The as needed Senokot had not been administered. -The as needed Bisacodyl was given once on 10/29/24 at 9:00 PM. -The as needed Senokot S was administered once on 11/16/24 at 9:05 AM. An interview on 11/21/24 at 9:06 AM with the Director of Nursing (DON) confirmed there was no documentation of a bowel movement or any additional bowel interventions for Resident 17, (pharmaceutical or non-pharmaceutical), assessments, or notifications to the resident's provider during the identified time periods. C. A record review of Resident 12's care plan revealed the following: -Problem and description, Functional incontinence - (Resident 12) is frequently incontinent of bladder and always continent of bowel, related to cognitive deficit. Approaches listed included, Nurses - Assist with toilet hygiene and toilet transfer as needed, and Nurses - Record bowel movements. The problem and approaches were dated 8/17/22. -Problem, Potential for Bleeding, related to anticoagulant therapy. One of the approaches listed was, Evaluate for constipation and employ preventative measures. The problem and approach were dated 8/18/22. -Problem and description, Potential for fluid volume deficit, manifested by, concentrated urine, and constipation. One approach listed was, Nurses - Monitor indicators of hydration, with an indicator listed of, stool output. All items were dated 8/18/22. -Problem, Potential for adverse side effects, related to use of antidepressant medication. One approach listed was, Nurses - Monitor for adverse effects, with an effect listed of constipation. The problem and approach were dated 8/18/22. A record review of Resident 12's MDS dated [DATE], in Section GG revealed that Resident 12 was dependent on staff for toileting hygiene and toilet transfer. Section H revealed that Resident 12 was always continent of bowel, and that they did not have a toileting program. Section I revealed the resident had a diagnosis of constipation. A record review of Resident 12's active physician's orders revealed the following medications to treat constipation: -Polyethylene glycol (Miralax) 17 grams by mouth daily, with an order start date of 5/7/24. -Senna Plus (sennosides-Docusate 8.6 mg/50 mg) 1 tablet by mouth daily for constipation, with an order start date of 12/15/23. -Bisacodyl 10 mg rectal suppository daily as needed for constipation, if no results from MOM daily prn (as needed), for 4 days of no BM, with an order start date of 2/14/23. -Milk of Magnesia 30 ml suspension by mouth daily as needed for 3 days of no BM standing order, with an order start date of 2/14/23. -Hydrocil/Psyllium powder 1.7 gram by mouth daily as needed for diverticulosis, with an order start date of 5/16/23. A record review of Resident 12's untitled stool output report from 8/2/24 to 11/20/24 revealed Resident 12 had no documented bowel movements from 10/26/24 through 11/2/24, which was 8 days. A record review of Resident 12's medication administration record (MAR) for the period between 8/1/24 and 11/20/24 revealed none of the resident's as needed bowel management medications had been administered. An interview on 11/21/24 at 9:30 AM with the Director of Nursing (DON) confirmed that Resident 12 had no documentation of assessments, notifications, bowel movement, or bowel interventions, (pharmaceutical or non-pharmaceutical) between 10/26/24 and 11/2/24, when the resident had no documentation of having had a bowel movement.

Licensure Reference 175 NAC 1-009.04(D)(i)(2) Based on observations, record review, and interview; the facility failed to ensure that 3 (Residents 5, 14, and 21) of 3 sampled residents' bathroom sinks maintained a water temperature of 120 degrees Fahrenheit or less. The facility identified a census of 24. Findings are: A record review of an undated facility policy titled Safe Water Temperatures revealed water temperatures will be set to a temperature of no more than 120 degrees Fahrenheit or the state's allowable maximum water temperature in resident rooms. A. An observation on 11/18/24 at 08:10 AM revealed a water temperature reading of 140 degrees Fahrenheit in Resident 5's bathroom sink. 49766 B. An observation on 11/18/2024 at 8:14 AM revealed a water temperature reading of 136 degrees Fahrenheit in Resident 14's bathroom sink. C. An observation on 11/18/2024 at 8:20 AM revealed a water temperature reading of 135 degrees Fahrenheit in Resident 21's bathroom sink. On 11/18/2024 from 10:42 AM to 10:54 AM, a walk through with the Administrator and the Maintenance Director was completed to confirm facility water temperatures. -Resident 5's bathroom sink water temperature was confirmed to be 141 degrees Fahrenheit. -Resident 14's bathroom sink water temperature was confirmed to be 139.4 degrees Fahrenheit. -Resident 21's bathroom sink water temperature was confirmed to be 139.6 degrees Fahrenheit. An interview conducted during the facility walk through on 11/18/24 with the Administrator and the Maintenance Director confirmed the water temperatures in the residents' bathroom sinks should not exceed 120 degrees Fahrenheit.

Licensure Reference Number 175 NAC 12-006.17(D) Based on record review and interview, the facility failed to ensure that quarterly statements of Resident Trust Accounts were sent to residents/residents' representatives as required for 1 (Resident 9) of 1 sampled resident. The facility identified a census of 24. Findings are: An interview on 11/18/2024 at 11:25 AM with Resident 9 revealed they had a resident trust account, and they were not receiving quarterly statements. A record review of an undated facility policy titled; Resident Personal Funds revealed the following: Accounting and Records: 3. The individual financial record must be available to the resident through quarterly statement and upon request. An interview on 11/21/2024 at 8:06 AM with the Office Manager (OM) revealed they did not provided residents with accounting statements on a quarterly rotation. An interview on 11/21/2024 at 9:11 AM with the Administrator revealed they were aware that personal fund accounting statements were not being provided to residents.

Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on observation, record review, and interviews; the facility failed to provide dietitian services and ensure nutritional interventions were implemented to prevent further weight loss for 1 sampled resident (Resident 10). The facility identified a census of 24. Findings are: Record review of Resident 10's admission record revealed the resident was admitted to the facility on [DATE] with a diagnosis of heart failure, unspecified. Record review of Resident 10's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 5/03/2023 revealed a problem indicating that the resident was at nutritional risk. The care plan also revealed that the resident had been on Hospice and had since been discharged from Hospice services on 5/15/2024. The care plan identified nutritional strengths of the resident which revealed the resident could sometimes tell staff what they wanted to eat and that the resident was able to self-feed. Goals of the resident revealed that the resident would have foods they enjoyed. Approaches identified on the care plan revealed to monitor and record food intake, offer food substitutions as needed, and to provide small portions at lunch and supper. Another approach identified revealed for all staff to encourage the resident to eat and drink. Record review of Resident 10's weights in the medical record revealed the following weights: -On 12/14/2023 the resident's weight was 183.8 pounds. -On 03/08/2024 the resident's weight was 171 pounds. -On 05/10/2024 the resident's weight was 174 pounds. -On 07/29/2024 the resident's weight was 169 pounds. -On 10/27/2024 the resident's weight was 161.5 pounds. -On 11/18/2024 the resident's weight was 158.8 pounds. There were no other weights recorded for Resident 10 for the year 2024. Record review of Resident 10's dietician note on 04/04/2024 revealed that the resident has had a significant weight loss in the prior 90 days and that the resident had shown an insidious weight loss in the prior year. There was no evidence of any additional dietitian's notes since that date. Record review of Resident 10's 60-day physician review on 09/20/2024 revealed that resident's sleeping had increased, intake had decreased, and that weight loss was identified as a 10 pound loss in 90 days. There were no new physician orders or interventions related to the resident's weight loss. Record review of Resident 10's 60-day physician review on 11/05/2024 revealed that the resident was not eating and weight continued to decline. There were no new physician orders or interventions related to the resident's weight loss. Record review of Resident 10's progress notes on 10/28/2024 revealed a quarterly review of dietary intakes at an average of 13% for breakfast, 42% for lunch and 71% for supper. An observation conducted on 11/18/2024 from 8:00 AM until 12:15 PM revealed Resident 10 was in bed during breakfast and mid-morning snack pass and was not offered a meal or a snack. Resident 10 was observed to be up at 12:15 PM at the lunch table waiting for lunch to be served, sleeping off and on. No assistance from staff was observed during the meal. A record review of Resident 10's intake on 11/18/24 for breakfast was documented at 0%, snack at 0%, and lunch was documented at 25%. An observation on 11/19/2024 at 8:00 AM revealed Resident 10 to be up and sitting at the table for breakfast. No assistance from staff was observed during the meal. A record review of Resident 10's intake on 11/19/24 was documented at 15% of their meal and 0% for their morning snack. Further observation on 11/19/24 from 12:30 PM until 1:30 PM revealed Resident 10 had remained up for lunch where a meal was provided, no assistance from staff was observed during the meal, and intake was documented at 5%. An observation on 11/20/2024 from 8:00 AM until 12:05 PM revealed Resident 10 was in bed during breakfast and mid-morning snack pass and was not offered a meal or snack during this time. Resident was observed to be up at 12:05 PM coming out to visit with family. Resident was observed at the lunch table eating, staying awake while family was nearby. A record review of Resident 10's intake on 11/20/24 for breakfast was documented at 0%, morning snack at 0%, and lunch was documented at 25%. An interview with the Dietary Manager (DM) on 11/20/2024 at 11:30 AM revealed that the Registered Dietician (RD) comes into the facility monthly and is alerted to review a set number of identified residents that require interventions, weight loss or gains, or who've had a change a condition. The DM also revealed that the amount of intake for all meals and snacks are documented daily by the Certified Nursing Assistant (CNA) in the CNA documentation portal on the Electronic Medical Record system, and that that this information was reviewed by the facility at quarterly conferences. The DM confirmed that they did not alert the RD that Resident 10 had not been receiving Hospice services since 05/15/2024 and that the resident was last seen by the RD on 04/04/2024. The DM confirmed that the RD was not made aware of the resident's weight loss and decrease of intakes.

Licensure Reference Number 175 NAC 12-006.17 Based on observations, interviews, and record review, the facility staff failed to utilize Personal Protective Equipment (PPE) as required to prevent the spread of infection during a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak. This had the potential to affect all residents who resided within the facility. The facility identified a census of 19 residents at the time of the survey. Findings are: A. Observation upon arrival at the facility on 11/2/2023 at 7:30 AM revealed a staff member at the main entrance door of the facility was wearing an N 95 respirator mask. The staff member reported that the facility was in a COVID-19 outbreak and N 95 masks were recommended. An interview with the Administrator on 11/2/2023 at 7:59 AM confirmed they were in a COVID-19 outbreak as they had three residents and one staff member who had tested positive for COVID and that N 95 respirator masks were recommended. The facility Administrator further reported the facility staff are required to wear N 95 respirator masks during an outbreak. An observation in the hallway cattycorner from the nurse's station on 11/2/2023 at 8:47 AM revealed the Activity Director (AD)-A working on a bulletin board with the activity calendars and was wearing a cloth mask underneath their N 95 mask. An observation in the commons area on 11/2/2023 revealed the AD-A sitting on a couch next to a resident and was wearing a cloth mask underneath their N 95 mask. An observation in the 100-resident hallway on 11/2/2023 at 2:35 PM revealed Nursing Assistant/Medication Assistant (NA/MA)-B was wearing a N 95 mask and goggles. Further observation revealed NA/MA-B put on a gown and gloves and entered a COVID-positive precaution room, room [ROOM NUMBER]-D, to deliver a water pitcher. NA/MA-B exited the room and took off their gown and gloves and continued to wear the same N 95 respirator mask as they walked down the hallway. An observation at the nurse's station on 11/2/2023 at 2:43 P.M. revealed Licensed Practical Nurse (LPN)-D standing at a medication cart that was parked behind the counter without a mask on their face. An observation on 11/2/2023 at 2:51 P.M. in the hallway at the nurse's station revealed LPN-D had walked across the hall into the activity room and back to the nurse's station without a mask on. An observation at the nurse's station on 11/2/2023 at 2:52 P.M. revealed LPN-D and the DON had walked into the medication room. LPN-D did not placed a N 95 mask on their face. LPN-D and the DON had exited the medication room and LPN-D did not have a mask on. An observation at the nurse's station on 11/2/2023 at 2:54 P.M. revealed LPN-D did not have a mask on and had walked down the hallway, through the dining room, through the back hallway, back up to a storage room off the dining room, and back to the nurse's station without a face covering. LPN-D had gathered wound care supplies and placed them on a black-wheeled cart. LPN-D had not placed an N 95 mask on and started walking toward the 200-resident hallway. LPN-D stopped at room [ROOM NUMBER] and knocked on the door. LPN-D had not placed a mask/N 95 mask on their face. LPN-D was stopped prior to entering the resident's room without a mask. An interview with LPN-D on 11/2/2023 at 2:54 P.M. confirmed they did not have a N 95 mask on and explained they had taken it off earlier when they went into the medication room to get some air and had forgotten to put it back on. LPN-D confirmed they had not been wearing a mask during the observation times on 11/2/2023 from 2:43 PM to 2:54 P.M. An interview with the DON on 11/2/2023 at 4:03 P.M. revealed their expectation for masks/PPE use is the facility staff is to wear an N 95 mask, gloves, gown, and goggles/a face shield when in a COVID-positive room. The DON said staff are to take the gown, gloves, face shield/goggles off upon exiting a COVID-19 isolation room, and hand sanitize or wash their hands with soap and water. The DON said staff could continue wearing the same N 95 mask they had worn in a COVID-positive room unless it were to get soiled, then they would need to change their mask. An interview with the Administrator on 11/6/2023 at 8:45 AM revealed there was one more COVID-19-positive resident. An observation in the dining room on 11/6/2023 at 10:11 AM revealed AD-A sitting at a table with two residents. AD-A was wearing a cloth mask underneath their N 95 mask. The N 95 mask was not covering their nose. An interview with the Administrator on 11/6/2023 at 10:15 A.M. confirmed AD-A does and was wearing a cloth mask underneath an N 95 respirator mask because AD-A had reported to them that the N 95 masks the facility provides bother them. The Administrator also confirmed that the masks did not fit tightly around AD-A's nose and mouth, so there was not a good seal. A record review of the facility's policy, Personal Protective Equipment-Using Face Masks Level I with a revised date of September 2010 revealed a Purpose to guide the use of masks. The section, Objectives Number 1. To prevent transmission of infectious agents through air; number 2. To prevent the wearer from inhaling droplets; and number 3. To prevent the transmission of some infections that are spread by direct contact with mucous membranes. Under the section Miscellaneous Number 2. Be sure the face mask covers the nose and mouth while performing treatment or services for the patient. Number 7. Use a mask only once and then discard it. Number 9. Never touch the mask while it is in use. A record review of the facility's policy, Coronavirus Prevention and Response with an implemented date of 10/5/2022 revealed the following information: -Policy: revealed the facility will respond promptly upon suspicion of illness associated with SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus. -9. Source Control measures include: -b. Source control options for HCP (Health Care Providers) include a National Institute for Occupational Safety & Health (NIOSH)-approved particulate respirator with N 95 filters or higher. A respirator approved under standards used in other countries that are similar to NIOSH-approved N 95 filtering face piece respirators. A barrier face covering that meets ASTM F3502-21 (is a barrier face mask covering standard created to address a lack of community-focused source control mask/respirator standards) requirements including Workplace Performance and Workplace Performance Plus Masks, a well-fitting facemask. -d. If source control is used during the care of a resident for which NIOSH-approved particulate respirator or face mask is indicated for PPE, they should be removed and discarded after the resident care encounter and a new one donned (put on).

Licensure Reference Number 175 NAC 12-006.09C1c Based on record review and interview; the facility staff failed to review and revise care plans for 4 (Resident 4,14,1 and 15) of 5 sampled residents. The facility identified a census of 19 residents at the time of the survey. The Findings Are: A. Record Review of Resident's 4 Face Sheet revealed Resident 4 was admitted on [DATE] with a diagnosis of Localization -related idiopathic epilepsy with seizures of localized onset. Record Review of incident reports reveal Resident 4 had falls on 3/15/2023, 4/10/2023, 5/25/2023, 8/4/2023, 8/8/2023 and 9/13/2023. Record review of Resident 4's Care Plan (CP) dated 3-10-2023 revealed Resident 4's CP had not been updated to reflect the falls on 4-10-2023, 5-25-2023, 8-4-2023 and 8-8-2023. An interview with Director of Nursing( DON) on 11/7/2023 at 1:15 PM revealed no interventions or dates of falls for Resident 4's falls on 4/10/2023, 5/25/2023,8/4/2023 and 8/8/2023. DON confirmed that the care plan is not being updated to reflect the falls. B. Record Review of Resident's 14's Face Sheet revealed Resident 14 was admitted on [DATE] with a diagnosis of Spinal Stenosis, lumbar region without neurogenic claudication. Record Review of Current Physician Orders as of 11-07-2023 revealed Resident 14 has an order for Quetiapine Fumarate ( an antipsychotic medication) 25mg tablet by mouth daily in the HS for Major Depressive Disorder, single episode. Record Review of Resident 14's CP dated 10/22/2023 revealed that Quetiapine Fumarate 25mg daily was not listed on the care plan. An interview with the DON on 11/7/2023 at 1:15 PM revealed that the Care Plans are not being updated as needed. 49263 C. Record review of Resident 1's undated facesheet revealed Resident 1 was admitted to the facility on [DATE] with an admitting diagnosis of Alzheimer's disease, unspecified (A progressive disease that destroys memory and other important mental functions). A record review of Resident 1's physician's orders revealed Resident 1's medication order for DULoxetine HCl (an antidepreasnt medication) 30MG Capsule Delayed Release Particles dose ordered: (1 capsule / 30mg) by mouth daily AM for Major Depressive Disorder was discontinued on 9/26/2023. Record review of Resident 1's CP with a handwritten date on top of Page 1 of 8/9/23 revealed the following: -Page 2 Problem dated 2/23/2023 RELATED TO: Depression Resident 1 takes DULoxetine HCl by mouth daily FOR: Major Depressive Disorder F32.9. -Page 1 Problems dated 2/26/2023 PROBLEM (PSYCHOTROPIC MED USE): Potential for Adverse side effects, RELATED TO: Use of antidepressant medication Resident 1 takes DULoxetine HCl by mouth daily. Resident 1 has Dx: Major depressive disorder, single episode, unspecified CODE: F32.9. & MANIFESTED BY: Side effects of DULoxetine HCll: Drowsiness, nausea, constipation, loss of appetite, dry mouth, or increased sweating. Goals dated 2/26/2023 Res will receive the lowest possible dosage of the prescribed psychotropic drugs to ensure maximum functional ability both mentally and physically Three months, & no adverse effects Three months, Three months,. Handwritten in the Problems section was 3/14/23- GDR- clinically contraindicated. -Page 1 Problem dated 2/26/2023 RELATED TO: Psychiatric or Cognitive: depression Resident 1 has Dx: Major Depressive Disorder, single episode, unspecified CODE: F32.9 takes DULoxetine HCl by mouth daily. An interview on 11/6/23 at 2:50 PM with DON revealed each department updates their own sections of the resident's care plan. The DON further reported care plans are updated at each care plan meeting as well as at the time of any changes that occur, such as with falls or medication changes. The DON confirmed Resident 1's care plan should have been updated when the resident's Duloxetine was discontinued 9/26/23. D. Record review of Resident 15's undated face sheet revealed Resident 15 was admitted to the facility on [DATE] with an admitting diagnosis of Fx unsp part of nk of r femr, subs for [NAME] fx w routn heal (a fracture of an unspecified part of the neck of the right femur, a bone in the leg with routine healing). A record review of Resident 15's Nursing Home Hospice Admission/Transfer Orders form revealed Resident 15 was admitted to Hospice Services on 10/24/23 with Medical Conditions Related to Hospice Diagnosis: Abnormal Wt Loss, A Fib, HTN, OA, Neuropathy, Osteoporosis, Diverticulitis, Polymyalgia, Basal Cell CA of face. A record review of Resident 15's Nursing Home Hospice Admission/Transfer Orders form dated 10/24/23 revealed documentation of Discontinue the following medication: Cephalexin, Apixaban, Omeprazole, Ketamin-GABA-[NAME] cream, Furosemide. A record review of Resident 15's Medication Administration Record (MAR) revealed Resident 15's Eliquis (apixaban) order and Lasix (furosemide) order were discontinued on 10/24/23. A record review of Resident 15's CP with a date at bottom of all pages of 10/22/23, revealed the following: -Page 2 Problem 10/22/23 RELATED TO: Medications Cardiovascular medications Resident 15 has Dx: Unspecified atrial fibrillation CODE: I48.91, (gender) takes [Eliquis] Apixaban by mouth twice a day. -Page 2 Problem 10/22/23 RELATED TO: Edema Resident 15 has edema on BLE, (gender) takes [Lasix] Furosemide by mouth daily. -Page 1 Problem 10/22/23 RELATED TO: Anticoagulant therapy Resident 15 takes [Eliquis] Apixaban FOR: Unspecified atrial fibrillation CODE: I48.91. - Page 1 Problem 10/22/23 RELATED TO: Medications Resident 15 takes [Lasix] Furosemide by mouth daily FOR: Edema, unspecified CODE: R60.9. An interview on 11/6/23 at 2:50 PM with DON revealed each department updates their own sections of the resident's care plan and that care plans are updated at each care plan meeting as well as at the time of any changes that occur, such as with falls or medication changes. A Record review of the facility policy Care Plans, Comprehensive Person-Centered, last revised March 2022, Section 11 revealed Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (5) Based on interview and record review, the facility staff failed to notify a resident and/or their Power of Attorney (POA- a person/representative authorized to make decisions regarding care in the event the individual is unable to make decisions for themselves) when 1(Resident 17) of 1 resident was transferred to the hospital. The facility identified a census of 19 residents at the time of the survey. Findings are: Record review of Resident 17's Nurses Notes (NN) dated 11/01/2023 revealed Resident 17 would awaken to verbal stimuli, was unable to follow commands or respond verbally, was unable to drink from a cup or straw, and was unable to take oral medications. According to Resident 17's NN dated 11/01-2023 Resident 17's practitioners office was contacted with instructions to to send Resident 17 to the emergency room with 911 being called. An interview with the Administrator on 11/1/2023 at 3:45 PM revealed Resident 17 had been transported to the Hospital at 3:30 PM due to not eating or drinking, not responding verbally, and was a change for Resident 17. An interview with the Administrator on 11/6/2023 at 4:35 PM confirmed they had not notified Resident 17's POA in writing of their transfer from the facility to the hospital. A record review of the facility's policy, Transfer or Discharge Documentation with a revised date of December 2016, revealed Number 4. When a resident is discharged from the facility, the following information will be documented in the medical record: a. The basis of transfer or discharge; (1) If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: (a) the specific resident needs that cannot be met; (b) this facility's attempt to meet those needs; and (c) the receiving facility's service(s) that are available to meet those needs. B. That an appropriate notice was provided to the resident and/or their legal representative.

Licensure Reference Number: 175 NAC 12-006.04D2a Based on record review and interview, the facility failed to ensure the Dietary Manager met the required qualifications. This failure could affect all residents receiving meals from the facility kitchen. The facility census was 17. Findings are: Staff interview on 6/16/21 at 9:25 AM with Cook-A reported that Cook-B had retired as the Dietary Manager and that a new Dietary Manager had been hired and this person did not have Certification for a Dietary Manager. Record review of the Dietary Manager's employee record verified the Dietary Manager did not have the regulatory required training to meet the required credentials. Staff interview on 6-21-21 at 2:19 PM with the Administrator verified that the newly hired Dietary Manager did not have the required credentials for the Dietary Manager portion of the job.

Licensure Reference Number: 175-NAC 12-006.11E Based on observations and interviews, the facility failed to: 1) Date and label an open bag of frozen pees and frozen mixed vegetables, and 2) Failed to keep a box of frozen diced chicken and hot dogs off the walk in freezer floor. These failures had the potential to affect all residents. Facility census was 17. Findings are: A. Kitchen observation upon entry on 6/16/21 at 9:25 AM revealed an open bag of frozen pees and an open bag of mixed vegetables in the white upright freezer located in the kitchen that had not been labeled or dated. Staff interview on 6/16/21 at 9:30 AM with Cook-A verified there was an open bag of pees and an open bag of mixed vegetables in the white upright freezer located in the kitchen. Staff interview on 6/21/21 at 2:19 PM with the Administrator verified there was an open bag of pees and an open bag of mixed vegetables located in the white upright freezer that had not been labeled or dated. Review of the 07/21/16 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices, revealed the following: 3-201.11)C) Packaged Food shall be labeled as specified by law, including 21 CFR 101 Food labeling, 9 CFR 317 labeling, Marking Devices and Containers and 9 CFR 381 Subpart Labeling and Containers, and as specified under 3-202.17 and 3-202.18. B. Kitchen observation on 6-21-21 at 9:35 AM revealed a box with frozen diced chicken and hot dogs on the floor of the walk in freezer located in the kitchen. Kitchen observation on 6-21-21 at 2:19 PM revealed a box with frozen diced chicken and hot dogs on the floor of the walk in freezer located in the kitchen. Staff interview on 6-21-21 at 2:25 PM with the Administrator verified that a box with frozen hot dogs and diced chicken was located on the floor of the walk in freezer. The Administrator reported that these items would be disposed of immediately as items should not be stored on the floor due to cross contamination. Review of the 7/21/16 Version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritive reference for the food service sanitation practices, revealed the following: 305.11 (B) Food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling equipment as specified under 4-204.122.

Licensure Reference Number: 175 NAC 12-006.05(4) Based on record reviews and interviews; the facility failed to ensure that routine bathing was provided as requested for three current sampled residents (Residents 3, 11 and 13). The facility census was 17 with 12 current sampled residents. Findings are: A. Interview with Resident 3 on 6/16/21 at 11:00 AM revealed that routine bathing was requested at least three times a week which was not consistently provided. Review of the resident's bathing record, dated 5/1/21 through 6/17/21, revealed that the resident was bathed on 5/10/21 and 5 /14/21 ( two times that week), 5/17/21, 5/21/21 ( two times that week), 5/24/21, 5/26/21, 5/28/21 (three times that week), 6/1/21 and 6/2/21 (two times that week), 6/8/21 and 6/10/21 (two times that week) and 6/14/21, 6/15/21 and 6/16/21 ( three times that week). Review of the facility bathing schedule revealed that the resident was scheduled for a bath on Mondays, Wednesdays and Fridays. Interview with the Administrator on 6/21/21 at 11:00 AM confirmed that the resident did not receive a bath as requested three times a week. B. Interview with Resident 11 on 6/16/21 at 3:45 PM revealed that routine bathing was requested at least two times a week which was not consistently provided. Review of the resident's bathing record, dated 5/11/21 through 6/15/21, revealed that the resident received a bath two times a week in May, 2021. Further review revealed that the resident received a bath on 6/1/21 (one time that week), 6/10/21 (one time that week) and on 6/15/21. Review of the facility bathing schedule revealed that the resident was scheduled to receive a bath on Tuesdays and Fridays. Interview with the Administrator on 6/21/21 at 11:00 AM confirmed that the resident did not receive a bath at least two times a week as requested. C. Interview with Resident 13 on 6/16/21 at 2:28 PM revealed that routine bathing was requested at least 2 times a week which was not consistently provided. Review of the resident's bathing record, dated 5/6/21 through 6/17/21, revealed that the resident was bathed on 5/6/21 (one time that week), 5/13/21 and 5/14/21 (two times that week), 5/18/21 (one time that week), 5/25/21 and 5/27/21 (two times that week), 6/1/21 and 6/2/21 (two times that week), 6/8/21 and 6/10/21 (Two times that week), 6/15/21 and 6/17/21 (two times that week). Review of the facility bathing schedule revealed that the resident was scheduled for a bath on Tuesdays and Thursdays. Interview with the Administrator on 6/21/21 at 11:10 AM confirmed that the resident did not receive a bath as request two times a week.

Based on record reviews and interviews; the facility failed to request further PASARR (Pre- Admission Screening and Resident Review) assessments as required for three current sampled residents (Residents 10, 12 and 8) with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 17 with 12 current sampled residents. Findings are: A. Review of Resident 10s medication Summary Report, dated June 2021, revealed an order dated, 2/15/21, for [MEDICATION(S)] (antipsychotic) every bedtime for [CONDITION(S)]. Review of the medical record revealed that a PASARR Level 1 was completed on 6/4/19. Further review revealed no documentation that further assessments were completed. B. Review of Resident 12's medication Summary Report, dated June 2021, revealed an order, dated 2/25/21, for [MEDICATION(S)] (antipsychotic) daily for Unspecified [CONDITION(S)]. Review of the medical record revealed that a PASARR Level 1 was completed on admission, 12/9/20. Further review revealed no documentation that further assessments were completed. Interview with the Administrator on 6/21/21 at 11:10 AM confirmed that further PASARR assessments were not completed as required for these residents with new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Review of Resient 8's medication Summary Report, dated June 2021, revealed an order, dated 5/5/21, for [MEDICATION(S)] (antipsychotic) daily for Unspecified [CONDITION(S)]. Review of the Medical Record revealed that a PASARR Level 1 was completed on admission 2/21/19. Further review revealed no documentation that further assessments were completed. Interview with the Administrator on 6/22/21 at 11:47 AM confirmed that further PASARR assessments were not completed as required for this resident with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Licensure Reference Number: 175 NAC 12-006.02 (8) Based on record reviews and interview, the facility failed to ensure that an investigation report was sent to the State Agency (SA) within five working days. The facility census was 17 with 12 current sampled residents. Findings are: Review of the facility Abuse, Neglect or Misappropriation report, dated 6/1/20, revealed that an investigation related to alleged staff to resident abuse was investigated. Review of the facility investigation file revealed no documentation that the report was sent to the SA as required. Review of the facility policy Abuse Investigation and Reporting, dated 2001, revealed the following including: Reporting . 5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. Interview with the Administrator on 6/22/21 at 11:00 AM confirmed that there was no documentation that the investigation report was sent to the SA as required.

Based on employee file record reviews and interview, the facility failed to ensure 4 of 4 sampled Nurse Aides (Nurse Aides-B, C, D, and E) received annual performance evaluations. The failure could potentially affect direct care delivery to all residents. Facility census was 25. Findings are: [NAME] Record review of NA (Nurse Aide)-B's employee file revealed the nurse aide was hired on 9/8/2010. Review of the employee's file revealed no annual performance evaluation was done for the employee between 1/1/2019 and 2/20/2020. B. Record review of NA (Nurse Aide)-C's employee file revealed the nurse aide was hired on 12/13/2018. Review of the employee's file revealed no annual performance evaluation was done for the employee between 1/1/2019 and 2/20/2020. C. Record review of NA (Nurse Aide)-D's employee file revealed the nurse aide was hired on 11/15/2005. Review of the employee's file revealed no annual performance evaluation was done for the employee between 1/1/2019 and 2/20/2020. D. Record review of NA (Nurse Aide)-E's employee file revealed the nurse aide was hired on 12/1/2015. Review of the employee's file revealed no annual performance evaluation was done for the employee between 1/1/2019 and 2/20/2020. Interview with the facility's Administrator on 2/20/2020 at 1:45 p.m. confirmed Nurse Aides B, C, D, and [NAME] had been employed to provide direct care to residents and had not received an annual performance evaluation between 1/1/2019 and 2/20/2020.

Licensure Reference Number: 175 NAC 12-006.18E3a Based on observations and interviews, the facility failed to ensure the bathing whirlpool room was equipped with a thermometer to ensure bathing water temperatures were monitored to prevent potential burning incidents from excessive water temperature. The failure could have affected excessive water bathing temperatures for baths provided to six non-sampled residents (Residents 1, 2, 4, 7, 8, and 23). Facility census was 25. Sample included 13 current residents. Findings are. Observation on 2/20/20 at 11 a.m. revealed NA (Nurse-Aide)-A was assigned to providing resident bathing in the whirlpool tub room. NA-A was asked how water temperatures are monitored for the bathing water. NA-A indicated the tub dials were referenced. Demonstration of direct hot water into the tub revealed the dials on the tub fluctuated rapidly from 122 degrees F (Fahrenheit) to 130 degrees F. A check with the surveyor thermometer indicated the water temperature read 125.9 degrees F. NA-A confirmed there was no thermometer in the tub room and that the tub water was not checked directly with a thermometer. NA-A verified hand-testing water and having residents hand test water but there was no way of determining exact water temperatures provided to ensure bathing temperatures did not exceed 110 degrees. NA-A confirmed 6 baths were provided on 2/20/20 without being able to check temperatures and identified the residents given baths as Residents 1, 2, 4, 7, 8, and 23. Interview and observation with the Administrator on 2/20/20 at 11:10 a.m. revealed the Administrator monitored tub temperatures and kept a log of temps ranging 112-114 degrees with full hot water. A check of the direct hot water in the whirlpool tub with the administrator showed the Administrator's un-calibrated thermometer read 120 degrees F while the surveyor's read 125 degrees F while the dials on the tub jumped between 122 and 133 degrees F. The Administrator verified the facility thermometer could not be calibrated. The Administrator verified the dial reading on the tub was not a source to monitor accurate bathing water temperatures and a new thermometer was needed and should be placed in the facility's whirlpool tub room to ensure accurate bathing water temperatures were being checked before resident's were bathed. Source: American Burn Association Scald Injury Prevention Educator's Guide (YEAR): Older adults . have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred . Time for a third degree burn to occur was identified in the guide as: 3 minute exposure at 124 degrees F; 5 minute exposure at 120 degrees F. The guide indicated 100 degrees F is the safe temperature for bathing.

Licensure Reference Number 175 NAC 12-006.09D7 Based on record reviews and staff interview, the facility failed to ensure that residents at high risk for falls are safe before leaving the residents alone to reduce the risk for a fall and fracture for one sampled resident (Resident 1). The facility census was 27. Findings are: Review of the "Face Sheet", printed 2/25/15, revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Care Plan", dated 2/4/15, revealed that the resident had a [DIAGNOSES REDACTED]. Further review revealed that the resident had several falls as follows: 12/9/14 - Resident transferred self without assistance in the room, with no injury noted. 12/20/14 - Resident transferred self without assistance and sustained skin tear to the finger and hematoma to the occipital area (side of head). 1/5/15 - Resident fell in hallway after standing up from wheelchair. Personal alarm sounded and there was no injury; 1/15/15 - Resident walked into the activity room without an assistive device. Staff left the resident to get the walker which was just outside the activity room. As the staff member was bringing in the walker, the resident turned to reach the walker, lost balance, and fell . The resident complained of pain and swelling was noted at left side. The resident was transferred to the hospital per ambulance and subsequently had surgery for [REDACTED]. Review of the "Care Plan", dated 2/4/15, revealed approaches before the fractured hip included place a personal alarm on person when in wheelchair and provide one on one staff when ambulating with walker. Interview on 2/25/15 at 1:30 PM with the DON (Director of Nursing) confirmed that the resident was a high risk for falls, had short term memory problems, was to have assistance when ambulating with walker, and should not have been left alone to retrieve the walker.