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.

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

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

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. 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.

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 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.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 12-006.09C1c 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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).