Ponderosa Villa

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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. [...]

Inspectors wroteBased 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.

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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. [...]

Inspectors wroteLICENSURE 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.