Life Care Center Of Tucson

Based on record review and staff interviews, the facility failed to ensure that two residents (#222 and #223) and/or the resident's representative received an accurate and complete Advanced Beneficiary Notice (ABN) when Medicare services terminated. The deficient practice could result in residents not knowing of their potential liability for payment.

Findings include:

Resident #222 was admitted on December 31, 2023 with diagnosis including urinary tract infection, difficulty walking, muscle weakness, arteritis, hypothyroidism, hyperlipidemia, repeated falls, neuromuscular dysfunction of the bladder, and protein-calorie malnutrition.

A review of the admission MDS (minimum data set) dated January 7, 2024 revealed a BIMS (brief interview of mental status) score of 00, suggesting severe cognitive impairment.

A review of the advanced beneficiary notification for resident #222 revealed the estimated cost for ongoing care effective on February 2, 2024 would be $345.00 a day. The form further revealed that both option 1 and option 3 had been selected in the area that indicated to check one box only. The directions on the form stated to select only one option. Option 1 noted that the care as listed above, outlining the $345.00 a day fee, was wanted, and option 3 noted that the resident does not want the care as listed above. Option 1 and option 3 are in conflict with one another.
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Resident #223 was admitted on November 25, 2023 with diagnosis including knee pain, patella fracture, depression, glaucoma, irregular heartbeat, obesity, osteoarthritis, breast cancer and spinal stenosis.

A review of the 5-day MDS (minimum data set) dated November 29, 2023 revealed a BIMS (brief interview of mental status) score of 15, suggesting that the resident was cognitively intact.

A review of the advanced beneficiary form for resident #223 revealed that the estimated cost, to the resident, beginning December 05, 2024 would be $345.00 a day. The 'options-section' of the form denoting that only one box should be checked revealed that no boxes were checked, leaving ambiguity as to whether resident #223 was opting to continue or not continue with services past December 05, 2023.

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An interview was conducted on July 16, 2024 at 3:13 P.M. with staff #112 (Social Services Director). Staff #112 stated that she believed the advanced beneficiary notification (ABN) was always required for each resident when they are running out of Medicare days of service. Staff #112 stated that only one box should be checked for those sections explicitly stating "check one box" and that this section is required to be completed. Staff #112 reviewed the ABN for resident #223 and stated that a check-box should have been selected, but had not. Staff #112 reviewed the ABN for resident #222 and stated that only one box should have been checked not 2, as observed on the form. Staff #112 stated that the risk would include, that if the form was incorrectly completed, it would make the form invalid. Staff #112 stated that these forms were completed inaccurately and that she takes full responsibility for the errors. Staff #112 stated that going forward one person will be completing the form, another person will audit it for accuracy and it will be documented in point click care (PCC).

An interview was conducted on July 16, 2024 at 3:27 P.M. with staff #110 (administrator). Staff #110 stated that her expectation is that the ABN is given timely and accurately. She stated that the ABN is completed by social services. Staff #110 reviewed the ABN documentation for resident #223 and resident #222 and stated that these should have been completed accurately, but the options section of the ABN was not accurately completed for either resident. Staff #110 stated that the risk could include reimbursement being impacted as well as an impact on resident rights.

A review of the policy entitled Resident Rights with a review date of September 25, 2023 revealed that the resident has the right to request, refuse and or discontinue treatment.

Based on observation, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate and comfortable temperature levels was provided to meet the needs of 14 residents (#4, #5, #8, #11, #20, #25, #34, #35, #41, #42, #43, #48, #56, and #167). The deficient practice could result in the resident's room not having a homelike and comfortable environment. The facility census was 58 and the sample was 14.

Findings include:

On the morning of July 15, 2024, between the hours of 6:45 a.m. to 7:00 a.m., surveyors experienced a notable difference in temperature perceived and felt when entering the facility. The temperature felt uncomfortably warm.

During an interview with the Assistant Maintenance Technician (staff #33) conducted on July 15, 2024 at approximately 6:45 a.m., staff #33 mentioned that the generator did not kick in properly during the power outage yesterday evening. This resulted in the cooling tower (chiller) not activating to cool down the temperature in the facility. Staff #33 stated that the chiller is in the process of kicking in but will take approximately 4 hours to cool down the facility.

An observation of the residents' areas was conducted on July 15, 2024 starting at approximately 7:15 a.m. There was no evidence that rooms were being tested for ambient temperature by the staff. This was despite the residents' areas being noticeably and feeling warm/uncomfortable.


Regarding Resident #4:

-Resident #4 was admitted to the facility on June 9, 2024 with diagnoses that included fracture of the lower end of the right femur, pain in right knee, chronic kidney disease, and osteoarthritis.

Review of the admission Minimum Data Set (MDS) assessment dated June 16, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact. The assessment also revealed that the resident was dependent for transfers. The MDS indicated that the resident uses a walker as a mobility device.

During an interview conducted with the resident on July 15, 2024 at 8:23 a.m., the resident stated that last night they had no power and that she was uncomfortable.

An observation was conducted of the resident's room on July 15, 2024 at 8:23 a.m. There was a notable warm temperature in the room.


Regarding Resident #5:

-Resident #5 was admitted to the facility on June 28, 2023 with diagnoses that included pressure ulcer of sacral region, osteoporosis, hypertension, and gastro-esophageal reflux disease.

Review of the quarterly Minimum Data Set (MDS) assessment dated April 5, 2024 revealed that the resident has modified independence pertaining to decisions regarding tasks of daily life. The assessment also indicated that the resident required substantial assistance for chair to bed transfers, and sit to stand activities. The MDS also noted that the resident uses a wheelchair as a mobility device.

During an interview conducted on June 15, 2024 at 8:19 a.m., the resident responded "Si" when asked if it was warm in their room.

An observation was conducted of the resident's room on June 15, 2024 at 8:19 a.m. The temperature registered 80.7? Fahrenheit. The room felt noticeably warm.

During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:30 a.m., the temperature was taken with a thermometer and registered 76.6 Fahrenheit.


Regarding Resident #8:

- Resident #8 was initially admitted to the facility on November 16, 2012 and readmitted on September 17, 2019 with diagnoses that included dementia, chronic obstructive pulmonary disease, angina pectoris, and peripheral vascular disease.

Review of the annual Minimum Data Set (MDS) assessment dated May 28, 2024 revealed that the resident has modified independence when it came to decisions regarding tasks of daily life. The MDS also indicated that the resident is dependent on assistance with regards to most transfers. The MDS also noted that the resident uses a wheelchair for mobility.

During an observation of the resident's room on July 15, 2024 at 8:17 a.m., the temperature taken with the thermometer registered 81.2? Fahrenheit. Physical inspection of the air conditioner (AC) thermostat located in the room revealed that the controls do not work regardless of the setting. The room felt uncomfortably warm.

An interview with the resident was conducted on July 15, 2024 at 8:17 a.m. Resident #8 confirmed that it is hot in the room.
During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:29 a.m., to check the temperature in the residents' area, resident #8's room temperature registered 81.1 degrees Fahrenheit.


Regarding Resident #11:

-Resident #11 was initially admitted to the facility on June 19, 2017 and readmitted on October 5, 2021 with diagnoses that included paroxysmal atrial fibrillation, antherosclerotic heart disease, dementia, and paralytic syndrome.

Review of the quarterly Minimum Data Set (MDS) dated April 1, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The MDS assessment also indicated that the resident is dependent on assistance for transfers.

An observation of the resident's room was conducted on July 15, 2024 at 8:26 a.m. During the observation, the room felt hot. The temperature taken with a thermometer registered 81.1 Fahrenheit.

During an interview with resident #11 conducted on July 15, 2024 at 8:26 a.m., the resident said that "hell yeah, it's hot" referring to his room.


In a follow-up observation conducted on July 15, 2024 at 9:33 a.m., it was noted that the temperature in the room was finally comfortable. The temperature taken with the thermometer registered 76 Fahrenheit.


Regarding Resident #20:

-Resident #20 was initially admitted to the facility on June 22, 2023 on readmitted on July 3, 2024 with diagnoses that included quadriplegia, chronic obstructive pulmonary disease, heart failure, esophagitis, schizophrenia, and bipolar disorder.

Review of the annual Minimum Data Set (MDS) assessment dated June 26, 2024 revealed Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The assessment noted that the resident is dependent on assistance for transfers. The MDS also indicated that the resident utilizes a wheelchair as a mobility device.

An observation conducted on July 15, 2024 at 8:12 a.m. revealed that the room was uncomfortably hot. The temperature taken with a thermometer registered 83.5 Fahrenheit.

In an interview with resident #20 conducted on July 15, 2024 at 8:12 a.m., the resident stated that they did not have AC (air conditioner) in their room since Friday. The resident said that on Friday, July 12, the AC was fixed just before supper. However, it stopped working through the night Friday into Saturday. The resident noted that maintenance looked at it yesterday and it was still not working.

During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:29 a.m., the room was still felt uncomfortably hot. The temperature was taken with a thermometer and it registered at 82.4 Fahrenheit.


Regarding Resident #25:

-Resident #25 was admitted to the facility on May 20, 2024 with diagnoses that included anemia, heart failure, diabetes, and depression.

Review of the Significant change in status Minimum Data Set (MDS) assessment dated May 27, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that he is cognitively intact. The assessment also indicated that the resident is dependent on assistance for all transfers. The MDS noted that

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to implement and maintain an effective training program for annual training: abuse, resident rights, infection control, dementia training, and emergency preparedness for multiple staff (#50, #26, #43, #54, #38, #59, #32 and #110).

Findings include:

Review of the employee records for a registered nurse (RN/staff #50) revealed that abuse training was completed on June 15, 2022, completed resident rights on February 27, 2023, infection control training on June 15, 2022, and there was no documentation for emergency preparedness.

-Review of the employee records for (RN/staff #26) revealed that abuse training was completed on October 6, 2022, resident rights completed on March 31, 2023, infection control completed on January 27, 2023, and emergency preparedness was competed on January 27, 2023.

-Review of the employee record for Licensed practical nurse (LPN/staff #43) revealed that abuse training was completed March 9, 2022, resident rights completed on May 25, 2022, infection control completed May 31, 2022, and there was no documentation for emergency preparedness.

-Review of the employee record for (LPN/staff #54) revealed that abuse training was completed on January 2, 2023, resident rights was completed on January 2, 2023, infection control was completed on February 20, 2023, dementia care January 3, 2023, and there was no documentation for emergency preparedness.

-Review of the employee record for a Certified nursing assistant (CNA/staff #38) revealed that abuse training completed on October 18, 2022, resident rights October 18, 2022, infection control June 20, 2022, dementia training completed on October 18, 2022, and emergency preparedness was not attempted.

-Review of the employee records for The Director of nursing (DON/staff #59) revealed that abuse training was completed on June 29, 2022, resident rights training was not attempted, infection control was not completed, emergency preparedness was not attempted.

-Review of the employee records for the Maintenance Director (staff #32) revealed that abuse training, resident rights, infection prevention, and dementia care were not attempted.

-Review of the employee records for Administrator (staff #110) revealed no documentation for abuse training, resident rights was not attempted, infection control was not attempted, and emergency preparedness not attempted.

An interview was conducted on July 16, 2024 at 1:56 p.m. with the human resources accounting clerk (staff #73), who stated the corporate office usually sends an email when training needs to be done. She stated that all staff, including the Administrator, are required to complete emergency preparedness, resident rights, abuse, infection control, and dementia training annually and the training are due based on the the staff's date of hire.

An interview was conducted on July 16, 2024 at 3:33 p.m. with (staff #110), who stated that all the staff are required to complete the training annually, but not all the staff had completed emergency preparedness. She stated that they have printed up most of the current training for the ten employees.

An interview was conducted on July 17, 2024 at 11:19 a.m. with (DON/staff #59), who stated that
she has a policy on required annual training for staff: infection control, abuse, resident rights, dementia, emergency preparedness. She stated that the training due date is based on the date of hire and everyone, including the Administrator, are supposed to complete the training.

The facility policy, "Yearly Required Training: states that a facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. Each associate will be provided the following core educational content annually through the learning management software that will be part of a curriculum titled "Annual General Requirements Curriculum." Each associate will need to complete the courses individually by the due date provided in the course assignment page. Core education includes: infection prevention and control, emergency preparedness, resident rights, abuse, but did not include dementia care.

Based on employee records, staff interviews, and the facility policy and procedures, the facility failed to ensure two staff (#110 and #4) had fingerprint clearance cards.

Findings include:

Review of the employee record revealed that staff #110 was hired on January 8, 2024 as the Executive Director. It did not reveal a fingerprint clearance card.

-Review of the employee record revealed that staff #4 was hired on February 29, 2024 for the position of maintenance assistant. It also revealed an application for a fingerprint clearance card dated April 14, 2024.

During an interview conducted on July 16 2024 at 1:56 p.m. with human resource personnel/accounting clerk (staff #73), ten employee records were reviewed. Two (#4 and #110) out of ten employees did not have a fingerprint clearance card. She stated that staff #4 was hired on February 29, 2024 and applied for his fingerprint clearance care on April 14, 2024. She stated that in April 2024, all staff had to have a fingerprint clearance card and prior to that date only only nurses and certified nursing assistants (CNAs) had a fingerprint clearance card to work in the facility. She stated that staff #4's job requires him to go into the residents rooms. She reviewed the employee record for staff #110 and stated that she doesn't have a fingerprint clearance card.

An interview was conducted on July 17, 2024 at 11:19 a.m. with the Director of Nursing (DON.
/staff #59), who stated that the maintenance assistant should probably have a fingerprint clearance card. She stated that he does go into the residents' rooms and comes into contact with the them. She stated that the fingerprint clearance card is to ensure the staff doesn't have anything outstanding and/or and inappropriate background. It is to ensure the safety of the residents.

The facility policy, "Background and Drug Screening Checklist, Addendum - State Specific Requirements " revised September 28, 2023 states that all candidates in Arizona must have a valid fingerprint clearance card or apply for a fingerprint clearance care within twenty working days of employment.

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one staff (#110) was free of tuberculosis (TB) prior to working in the facility.

Findings include:

Staff # was hired as the Administrator (staff #110) for the facility on January 8, 2024,

During an interview conducted on July 16, 2024 at 1:56 p.m. with the accounting clerk/human resources personnel (staff #73), she stated that (staff #110) did not provide a current TB test for herself. She stated that the Executive Director is probably supposed to have a TB test prior to working in the building. She stated that the reason for testing is to prevent the risk of TB spreading throughout the building.

An interview conducted on July 17, 2024 at approximately 9:50 a.m. with the (staff #110), who stated that she did not have a tuberculosis test prior to working in the facility. She stated that she was tested yesterday, July 16, 2024, and the test results had not been read.

An interview was conducted on July 17, 2024 at 11:19 a.m. with the Director of Nursing (DON.
/staff #59), who stated that when a person is hired, he/she is required to show a test result for TB is negative prior to working in the facility. She stated that the administrator (staff #110) walks the floors of the building and should do daily. She doesn't interact directly with residents, but follows up with residents as needed. She stated that staff #110 can come into contact with residents when she is walking the halls.

The facility policy, "Tuberculosis - Testing and Screening" revised June 28, 2024 states that the facility will evaluate each associate and volunteer for tuberculosis in accordance with current CDC guidelines, unless more stringent guidance is provided by local or state regulation. New associates or volunteers who have been made a conditional offer shall be screened for presence of infection through the following measures; pre-placement risk assessment and symptom evaluation and the facility should also perform skin test for M. Tuberculosis using the Mantoux TST skin test.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that initial and ongoing weights were conducted for one resident (Resident #36). The deficient practice could result in a change of condition not being assessed and monitored.

Findings include:

Resident #36 was admitted to the facility on February 8, 2024 with diagnoses that included anoxic brain damage, Parkinson's disease and chronic respiratory disease.

Review of the clinical record revealed that the resident weighed 187 pounds on February 9, 2024.

Review of the nutritional assessment dated February 9, 2024 revealed that the resident was malnourished.

The care plan dated February 22, 2024 revealed that the resident was at risk for weight fluctuation related to dysphagia and anoxic brain injury. Interventions included eternal feeding as ordered and weight as per the facility policy.

The minimum data set (MDS) dated February 27, 2024 included a staff assessment for mental status score of 2 indicating the resident had moderate cognitive impairment.

The clinical record revealed that the resident weighed 168.6 pounds on June 4, 2024 and 167.4 pounds on July 2, 2024.

An interview was conducted on July 17, 2024 at 10:07 a.m. with a Registered Dietician (staff #66), who stated that a nutritional assessment is done when residents are admitted and all residents are supposed to be weighed. He stated that resident #36 was not weighed when he was admitted to the facility and the weight documented in the clinical record was taken from the weight documented in the hospital transfer records. He also stated that the resident should have been weighed monthly as per the facility policy in order to assess and monitor weight loss, fluctuations, fluid shifts, and if a weight change has occurred, so the root cause can be determined. He stated that there is a risk of developing malnutrition and/or congestive heart failure (CHF) fluid retention not being recognized if weights are not being monitored.

An interview conducted on July 17, 2024 at 11:15 a.m. with the Director of Nursing (DON/staff #59), who stated that the facility policy states that all residents are supposed to be weighed weekly for the first four weeks and then monthly. The reason for weighing the resident is to check for significant weight loss or gain. She stated that when the resident was admitted, the certified nursing assistant (CNA) should take the resident's initial weight and should not use the recorded weight from the hospital records because the weight may not be accurate. She stated that they just recently talked about weighing hospice patients, and all residents should be weighed.

The facility addendum to the Lippincott procedure revised August 21, 2023 states that measuring a patient's weight is part of a routine admission to a health care facility. An accurate record of the
patient's weight is essential for calculating dosages of drugs, fluid maintenance, anesthetics, and
contrast agents; calculating tidal volume in patients requiring mechanical ventilation; assessing
the patient's nutritional status; and determining the patient's height-weight ratio, body surface area, and body mass index (BMI).

The facility policy, "Weights and Heights" reviewed August 23, 2023 states that all residents are weighed within 24 hours of admission and weekly for 4 weeks and as needed thereafter or more as determined by the RAR committee and/or physician order.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#6) received assistance with bathing. The deficient practice could result in poor hygiene and skin infections.

Findings include:

Resident #6 was admitted to the facility on June 8, 2022 and readmitted on April 23, 2024 with diagnoses that included a anxiety, depression, unspecified protein-calorie malnutrition, and a personal history of venous thrombosis and embolism.

The care plan for activities of daily living (ADLs) dated March 25, 2024 revealed that the resident has an ADL self-care performance deficit related to weakness and decreased mobility due to acute kidney failure (AKF), pressure ulcer (PU), seizures (s/z) and depressive disorder (d/o). Interventions included that the resident requires assistance by staff with bathing/showering as necessary.

The minimum data set (MDS) dated April 30, 2024 included a brief interview for mental status score of 12 indicating the resident was cognitively intact. It also revealed that the resident was dependent on assistance with showers/bathing.

Review of the shower/bathing task sheet revealed that the resident was schedule to bath on Monday and Thursday evenings.

Review of the shower/bathing task sheet dated April 2024 revealed:
-Thursday, April 4, 2024, bathing was completed.
-Thursday, April 11, 2024, bathing was refused.
-Thursday, April 25, 2024, activity did not occur.

Review of the skin care alert form revealed the following directions: Complete this form dally. While assisting the resident with self-care (bathing, toileting. dressing, Etc.), document the presence of any areas of concern or changes in skin, including: redness, bruising, surgical wounds, drainage. rashes, blisters, etc. Use side two to document detail and indicate current strategies to prevent pressure ulcer/injuries. Review of the skin care alert forms from April 2024 through June 2024 revealed one form dated April 15, 2024 with the documention of a bed bath being completed.

Review of the shower/bathing task sheet dated May 2024 revealed:
-Friday, May 3, 2024, activity did not occur.
-Monday, May 6, 2024, bathing was completed.
-Thursday, May 9, 2024, activity did not occur.
-Monday, May 13, 2024, activity did not occur.
-Monday, May 20, 2024, activity did not occur.
-Thursday, May 23, 2024, activity did not occur.

Review of the shower/bathing task sheet dated June 2024 revealed:
-Friday, June 14, 2024, activity did not occur.
-Monday, June 17, 2024, bathing was completed.
-Thursday, June 20, 2024, bathing was completed.
-Monday, June 24, 2024, bathing was completed.
-Thursday, June 27, 2024, bathing was completed.

Review of the shower task sheet dated July 2024 revealed bathing only one time during the week of July 4, 2024. No bathing was documented on the task sheet from July 5, 2024 through July 15, 2024 and no refusals were documented.

During an interview conducted on July 16, 2024 at 12:23 p.m. with the Director of Nursing (DON/staff #59), she stated that skin care alert form is being used for the paper shower form and acknowleded that there is nothing on the form to indicate a shower, hair washing, or nail care was done. The form states that it can be used for shower, toileting, dressing, etc. She acknowledged that staff are not identifying which task is being done.

During a second interview conducted on July 17, 2024 at 11:12 a.m. with the (DON/staff #59), she stated that there is a shower schedule for the residents and each resident is scheduled for showers twice a week. It is her expectation that if a resident is not showering, the certified nursing assistant (CNA) should offer a couple of times and report the refusal to the nurse. The nurse should talk to the resident. The nurse could document the refusal on the skin care alert form ask the resident to sign it. She stated that there is a risk of poor hygiene and skin breakdown if a resident is not bathing.

The facility policy, "Activities of Daily Living (ADLs)" revised February 12, 2024 states that the resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be reported to the nurse.

Based on record review and staff interviews, the facility failed to ensure that two residents (#222 and #223) and/or the resident's representative received an accurate and complete Advanced Beneficiary Notice (ABN) when Medicare services terminated.

Findings include:

Resident #222 was admitted on December 31, 2023 with diagnosis including urinary tract infection, difficulty walking, muscle weakness, arteritis, hypothyroidism, hyperlipidemia, repeated falls, neuromuscular dysfunction of the bladder, and protein-calorie malnutrition.

A review of the admission MDS (minimum data set) dated January 7, 2024 revealed a BIMS (brief interview of mental status) score of 00, suggesting severe cognitive impairment.

A review of the advanced beneficiary notification for resident #222 revealed the estimated cost for ongoing care effective on February 2, 2024 would be $345.00 a day. The form further revealed that both option 1 and option 3 had been selected in the area that indicated to check one box only. The directions on the form stated to select only one option. Option 1 noted that the care as listed above, outlining the $345.00 a day fee, was wanted, and option 3 noted that the resident does not want the care as listed above. Option 1 and option 3 are in conflict with one another.
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Resident #223 was admitted on November 25, 2023 with diagnosis including knee pain, patella fracture, depression, glaucoma, irregular heartbeat, obesity, osteoarthritis, breast cancer and spinal stenosis.

A review of the 5-day MDS (minimum data set) dated November 29, 2023 revealed a BIMS (brief interview of mental status) score of 15, suggesting that the resident was cognitively intact.

A review of the advanced beneficiary form for resident #223 revealed that the estimated cost, to the resident, beginning December 05, 2024 would be $345.00 a day. The 'options-section' of the form denoting that only one box should be checked revealed that no boxes were checked, leaving ambiguity as to whether resident #223 was opting to continue or not continue with services past December 05, 2023.

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An interview was conducted on July 16, 2024 at 3:13 P.M. with staff #112 (Social Services Director). Staff #112 stated that she believed the advanced beneficiary notification (ABN) was always required for each resident when they are running out of Medicare days of service. Staff #112 stated that only one box should be checked for those sections explicitly stating "check one box" and that this section is required to be completed. Staff #112 reviewed the ABN for resident #223 and stated that a check-box should have been selected, but had not. Staff #112 reviewed the ABN for resident #222 and stated that only one box should have been checked not 2, as observed on the form. Staff #112 stated that the risk would include, that if the form was incorrectly completed, it would make the form invalid. Staff #112 stated that these forms were completed inaccurately and that she takes full responsibility for the errors. Staff #112 stated that going forward one person will be completing the form, another person will audit it for accuracy and it will be documented in point click care (PCC).

An interview was conducted on July 16, 2024 at 3:27 P.M. with staff #110 (administrator). Staff #110 stated that her expectation is that the ABN is given timely and accurately. She stated that the ABN is completed by social services. Staff #110 reviewed the ABN documentation for resident #223 and resident #222 and stated that these should have been completed accurately, but the options section of the ABN was not accurately completed for either resident. Staff #110 stated that the risk could include reimbursement being impacted as well as an impact on resident rights.

A review of the policy entitled Resident Rights with a review date of September 25, 2023 revealed that the resident has the right to request, refuse and or discontinue treatment.

Based on observation, a staff interview, and the facility policy and procedures, the facility failed to ensure that the daily staff posting included the correct information.

Findings include:

On July 14, 2024 at approximately 9:00 a.m. the daily staff posting was observed hanging on the wall just to the left of the reception desk. The information observed on the posting was:

-July 12, 2024
-census 60
-number of each type of staff for each shift
-the total hours scheduled for each type of staff for each shift
-the actual hours worked was not completed

During this time the Director of Nursing (DON/staff #59) approached and removed the daily staff posting dated July 12, 2024 and stated that she was just about to the change it.

Review of the facility documentation revealed that the census was 58 on July 14, 2024.

An interview was conducted on July 17, 2024 at 11:30 a.m. with the (DON/staff #59), who stated that the Central Supply Director/staffing coordinator (staff #95) is responsible for completing daily staff posting and works Monday through Friday. She stated that staff #95 prepares the daily staff postings for the weekend and the weekend receptionist is supposed to switch them out. She stated that the posting is for visitors and residents to see how many staff are available in the building.

The facility policy, "Facility Staffing Posting" revised December 13, 2023 states that the facility needs to post nurse staffing information in a prominent place where it is accessible to residents and visitors. The data should be clear, readable, up to date and current. When listing the total number of staff and actual hours worked, the facility is required to reflect staff absences on each shift that occur due to callouts or illness. The nurse staffing data needs to be posted on a daily basis at the beginning of each shift. The required information that needs to be posted includes:

I. Facility name
2. Current date
3. Resident census
4. Total number of staff and actual hours worked per shift for:
a. Registered Nurses
b. Licensed Nurses
c. Certified Nurse Aides

Based on observations, staff interviews, and policy, the facility failed to ensure multiple food items were stored at safe temperatures in accordance with professional standards. This deficient practice could result in placing residents at risk for food-borne illnesses. The facility census was 58.

Findings include:

During an initial observation of the kitchen, conducted at 8:25 a.m. on July 14, 2024 with staff #15. In the walk-in refrigerator, the thermometers both inside and out registered a temperature displaying 45 degrees Fahrenheit (F). Inside the refrigerator were various food items including milk, eggs, yogurt, meat, cheese, and dressings. Staff #15 stated the temperatures are recorded on the log twice daily, morning and evening.

Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 14, 2024 was recorded at 36F. The evening temperature was recorded at 40F. The log includes a critical limit (CL) for temperature at 40F on the high end, and revealed that in the event of a temperature not within the required range, to notify the Director of food services or maintenance immediately.

During a kitchen observation conducted on July 15, 2024 at 10:12 a.m. of the same walk-in refrigerator, the external thermometer and internal thermometer registered a temperature displaying 42F.

Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 37F. The evening temperature was recorded at 40F.

During a kitchen observation conducted on July 16, 2024 at 9:30 a.m. of the same walk-in refrigerator, the external thermometer registered a temperature displaying 50F. The internal thermometer registered a temperature displaying 44F. A second observation was made on July 16, 2024 at 11:50 a.m. The external thermometer again showed a temperature displaying 50F, and the internal thermometer displayed a temperature of 44F.

Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 38F. The evening temperature had not been recorded yet.

An interview was conducted on July 16, 2024 at 12:35 p.m. with a cook (kitchen staff #40). The cook stated that most of the foods served for meals are stored in the walk-in refrigerator, including prep stuff for the next day, thawing meat, dairy and milk, as well as cottage cheese. The cook also stated that left overs are also stored in the same walk-in. The cook stated that temps in the walk-in need to be 39F or below, and that temperatures are recorded using the outside thermometer twice daily in the monthly log.

An interview was conducted on July 16, 2024 at 12:44 p.m. with the Registered Dietician and Kitchen Manager (RD/kitchen staff #66). The RD stated that temperatures need to be under 40F in the walk-in or it puts the food at risk of causing food-borne illness such a botulism. The RD stated that all refrigerated items used in the facility are stored in that walk-in, including dairy, cheese, eggs and leftovers. The RD further stated that he was aware of a door being replaced on the freezer for a temperature issue, but was not sure about the walk-in. During this interview the RD removed two random containers of food product from the walk-in refrigerator and took the temperature of them. A single serving yogurt container, and a jar of Mayonnaise. The temperature of both items was measured by the RD at 45F.

An interview was conducted with the Maintenance director (Facility/staff #32) on July 16, at 1:25 p.m. The Maintenance director stated that there was a mistake with what the temperature was set at in the walk-in refrigerator. He stated that the walk-in was accidently set to 40F by mistake when it was being worked on, roughly one month ago. He further stated that the outside thermometer on the walk-in was broken, and does not register temperatures correctly.

However, the facility logs showed multiple entries for the month of July with temperatures ranging from 32F and 40F.

An interview was conducted with the Executive director (ED/staff #110) on July 17, at 11:50 a.m. The ED stated they were aware of the food issue and it was being corrected. The ED further stated that her expectation is that food is stored safely, an that thermometers will be calibrated correctly going forward.

Review of the facility policy titled 'Food Safety' revised April 26, 2023 and reviewed May 1, 2024 revealed that it is the policy of the facility to ensure food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. It further revealed that the "danger zone" means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F allow the rapid growth of pathogenic microorganisms that can cause foodborne illness.

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one staff (#110) was free of tuberculosis (TB) prior to working in the facility. The deficient practice could result in residents being infected with tuberculosis.

Findings include:

Staff # was hired as the Administrator (staff #110) for the facility on January 8, 2024,

During an interview conducted on July 16, 2024 at 1:56 p.m. with the accounting clerk/human resources personnel (staff #73), she stated that (staff #110) did not provide a current TB test for herself. She stated that the Executive Director is probably supposed to have a TB test prior to working in the building. She stated that the reason for testing is to prevent the risk of TB spreading throughout the building.

An interview conducted on July 17, 2024 at approximately 9:50 a.m. with the (staff #110), who stated that she did not have a tuberculosis test prior to working in the facility. She stated that she was tested yesterday, July 16, 2024, and the test results had not been read.

An interview was conducted on July 17, 2024 at 11:19 a.m. with the Director of Nursing (DON.
/staff #59), who stated that when a person is hired, he/she is required to show a test result for TB is negative prior to working in the facility. She stated that the administrator (staff #110) walks the floors of the building and should do daily. She doesn't interact directly with residents, but follows up with residents as needed. She stated that staff #110 can come into contact with residents when she is walking the halls.

The facility policy, "Tuberculosis - Testing and Screening" revised June 28, 2024 states that the facility will evaluate each associate and volunteer for tuberculosis in accordance with current CDC guidelines, unless more stringent guidance is provided by local or state regulation. New associates or volunteers who have been made a conditional offer shall be screened for presence of infection through the following measures; pre-placement risk assessment and symptom evaluation and the facility should also perform skin test for M. Tuberculosis using the Mantoux TST skin test.

Based on record review and staff interview the facility failed to ensure the emergency and standby power systems were functioning properly. Failure to implement an emergency and standby power systems plan during an emergency could lead to harm of the patients and/or staff.

Findings include:

Based on record review and staff interview on July 17-18, 2024, the facility failed to ensure the emergency generator was adequate for the facility needs during an emergency. The facility has had a rental generator since March 2, 2020. On July 14, 2024 the facility experienced a power failure and the temporary generator failed to turn on leaving the facility totally without power. Medical equipment, the elevator and facility walk-in refrigerator and freezer were none functioning during the total outage.

The following are staff interviews:

Monday, July 15, 2024, at approximately 0941 hours an interview was conducted with staff # 32, Maintenance Director. Staff #32 stated that he was notified at 1815 hours on July 14, 2024, that the power was out. Staff #32 stated that he responded to the facility arriving at 1845 hours. Staff # 32 further stated that the facility was dark and the staff were panicking. Staff # 32 stated that he began troubleshooting and found that the main breaker for the facility had popped and that he reset it. Staff #32 further stated that it took approximately one hour to troubleshoot and that the generator was manually started between 1945 and 2000 hours. Staff # 32 stated that the chillers were not active as they drew too much voltage. Staff # 32 stated that When he arrived at the facility on July 15, 2024, he was unaware that the circular pumps were off. Staff # 32 stated that he later learned that staff #33 had bypassed the circular pumps because he had turned the alarm had been turned off. Staff# 32 stated that had the alarm been on he would have known there was an issue with the circular pumps. Staff #32 stated that at 0700 hours on July 15, 2024, they had to go through the facility and reset all of the AC units.

Monday, July 15, 2024, at approximately 1010 hours an interview was conducted with staff # 69, RN unit nurse. Staff # 69 stated that the electricity went out between 1820 and 1830 hours on July 14, 2024. The residents that were on oxygen concentrators had to be switched to O2 tanks due to the electricity being out. Staff #69 stated that the alarm did not go off last night regarding the generator. Staff # 69 further stated that with the electricity being out he knew that the doors needed to be watched to prevent any elopement. Staff # 69 stated that if the resident rooms are hot they should begin moving residents immediately however, if the electricity is out the elevators would not work so they would not be able to move the residents. Staff # 69 stated that he was assuming the generator would kick in right away, but that it did not, and this is why they called maintenance.

Monday, July 15, 2024, at approximately 1048 hours, Staff # 33 was interviewed. Stated that the power had gone out the previous night, July 14, 2024. Staff # 33 stated that he received a telephone call from Staff # 32, Maintenance Director sometime around 1810-1815 hours on July 14, 2024, and asked him to respond to the facility. Staff # 33 stated that he arrived at the facility around 1847 hours and saw that the facility was all dark. Staff # 33 stated that the generator had not kicked on right away and estimated that the generator got going between 1906 and 1910 hours. Staff # 33 further stated that when the power goes off, the gas shuts off for safety reasons and this turns the pumps off to include the chiller system. Staff # 33 stated that he and staff # 32 were in the boiler room around 0500 hours on July 15, 2024, and realized the air conditioning was not cooling. Staff #33 stated that he noticed the heat when he came in at 0500 hours on July 15, 2024, and noticed the kitchen was hot and rechecked the rooms. Stated that he noticed the rooms were hot but did not re-temp them at that time. Stated that he thought the residents should be moved to a place that was more comfortable. The west elevator was working last night when the lights came back. The north elevator was not working. Stated that no discussion of moving residents last night. Stated that residents could have been moved last night. Stated that some units were still functional, but because of auxiliary pump the residual water was allowing for a few units to work. Stated that he did not know at what temp residents should be moved. Stated that extension cords were running into the rooms. All red plugs are in the hallway. There are no red plugs in the rooms. Staff # 33 stated that there is no standard practice to handle a power outage. Stated that in all the time that he has been there, there have been no mock disaster drills. Stated that he had brought concerns up to staff #32 regarding what they would do, especially with the heavier residents.

The findings were confirmed by staff #32 and #110 during the exit conference conducted on July 18, 2024.

The first day the facility was on a temporary generator was March 2, 2020 per the rental contract the facility provided. The life safety code portion of this survey started July 17, 2024. 1598 days is the distance between the two dates. Which is 4 years, 4 months and 15 days.

Based on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents:

Findings include:
Regarding safe environment:
During the initial walk-through observation of the facility conducted on July 14, 2024 at 10:11 a.m., the following was observed:
- Doorway frame missing in room #2100, light brown paint is peeling, exposing the green pain underneath. It felt rough to the touch.
- Corner handrail by room #2117 was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact.
- Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch.
- Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch.
- Second floor nurse's station corner had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch.
- Corner handrail on the second floor by the stairway had 4 screws sticking out. Additionally, the handrail had gouges and was sharp/rough to the touch

In a follow-up wall-through conducted on July 17, 2024 at 8:53 a.m., the following was observed:
- Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch.
- Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. This included shower doorframe.
- Corner handrail by room #2117 was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact.
- Corner rail by soiled utility on the second floor had a metal brace that was slightly sticking out.
- Second floor nurse's station corner still had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch.
- Below the handrail next to linen room on the second floor by room #2133 had a metal brace on the wall corner that is slightly sticking out. That same corner has pieces of the wall corner with severe gouges that is rough/sharp to the touch.
- Corner entry to wall to room #2137 had a metal brace that was coming off the wall and the wall corner had severe gouges that was rough/sharp to the touch.
- Inside entry wall right hand side in room #2133 has long deep gouges on the lower wall above the baseboard.
- Corner handrail on the second floor by the stairway no longer had the 4 screws sticking out. However, the handrail had gouges and was sharp/rough to the touch.

An interview with a Registered Nurse (RN/staff #50) was conducted on July 17, 2024 at 8:29 a.m. Staff #50 stated the process for submitting work orders is that they can either use the book, the app, or call the emergency number for maintenance for whoever is on call. When asked about the overall status of the hallways/residents' living area, the RN noted that the place could use a lot of TLC (tender loving care). Staff #50 noted that to their knowledge maintenance had never asked staff or residents' input regarding what needs to be done. The RN indicated that like the staff, the residents have just come to accept the overall appearance/status of the facility. However, it would be nice to make the area more presentable, a little bit more modern.

An interview with the Maintenance Director (staff #32) was conducted on July 17, 2024 at 9:34 a.m. Staff #32 noted that works orders are submitted by residents by informing the nurses and/or staff who in turn submit work orders via TELS system. The Maintenance Director noted that the turn around time for work orders depends on the required work. Usually the priority are those work orders related to call lights, O2 (oxygen) tanks or anything related to resident safety. For work orders tagged as priority, maintenance resolves them no more than 24-hours. Other work orders such as painting, normally takes 2-3 days to close out. Staff #32 stated that there are no current plans for updates to halls or rooms per corporate. The Maintenance Director indicated that they conduct walk-throughs on Mondays and take care of the issues.

A walk-through with the Maintenance Director (staff #32) was conducted on July 17, 2024 at approximately 9:56 a.m. to look at the identified observations above. Below are staff #32's comments:
- room 2133's long deep gouges on the lower wall above the baseboard-noted that it is not very homelike
- handrail by room #2133 with a metal brace on the wall corner - indicated that it was not noticed before but is a concern since it is metal
- shower doorframe on second floor - noted that it is a concern since there are metal components
- room #2137 - indicated that it is a concern since the metal brace came off as we were inspecting it
- nail sticking out at nurse's station was no longer there, a photo from the entrance day and earlier in the morning sticking out was shown to staff #32 - he noted that it is a concern since someone could get hurt with it.

A follow-up interview was conducted with the Maintenance Director (staff #32) on July 17, 2024 at approximately 10:15 a.m. Staff #32 stated that in their opinion, the facility is livable, but some of the identified harm during our walk-through puts it at "75% homelike." Whether they gets all the things fixed, "it is a routine and it will get messed up again." The Maintenance Director said that it is hard to maintain but it is livable and that if residents were asked, the residents would say it is okay. Staff #32 said that during their walk-through, they identify what can damage residents and staff, prioritize it and fix it. However, if nobody says anything, and they are not aware, they it cannot be fixed. The Maintenance Director said that it is important for the facility to be safe and comfortable so residents and their families are happy and to make it better for the residents.

An interview with the Administrator (staff #110) was conducted on July 17, 2024 at 1:09 p.m. Staff #110 stated that the expectation is that the living area for resident are clean, free of obstruction and without significant odors. The facility is to be clean and safe from hazards. Staff #110 stated that repairs should be maintained to have a homelike environment such as paint and upkeep. The Administrator stated that this is important since this is the home for people living here and they deserve a good quality of life. It has to be safe so that residents are not put at risk for accidents or injuries. Staff #110 stated that the impact if the facility is not homelike and safe is that residents might feel discomfort, might reduce the homelike environment feel until things were repaired, it could provide a risk for some type of injury i.e. if legs extend beyond the wheelchair there could be a risk of injury.

Review of the open work order report generated on July 15, 2024 did not reveal any work order pertaining to any of the issues identified during the walk-through observations.

Review of the facility policy titled "Preventive Maintenance Program" revised January 11, 2023 and reviewed January 22, 2024 indicated that the facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public.

The facility policy titled "Work Request System" revised May 14, 2019 and reviewed January 15, 2024 indicated that the work order request system was designed to provide an established and effective means of requesting, coordinating, and completing maintenance of a corrective nature.

A facility policy titled "Resident Rights" issued June 8, 2020 and reviewed September 25, 2023 indicated that resident has a right to safe, clean, comfortable, and homelike environment.

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to implement and maintain an effective training program for annual training: abuse, resident rights, infection control, dementia training, and emergency preparedness for multiple staff (#50, #26, #43, #54, #38, #59, #32 and #110). The deficient practice could impact the safety, rights, and care provided to residents.

Findings include:

Review of the employee records for a registered nurse (RN/staff #50) revealed that abuse training was completed on June 15, 2022, completed resident rights on February 27, 2023, infection control training on June 15, 2022, and there was no documentation for emergency preparedness.

-Review of the employee records for (RN/staff #26) revealed that abuse training was completed on October 6, 2022, resident rights completed on March 31, 2023, infection control completed on January 27, 2023, and emergency preparedness was competed on January 27, 2023.

-Review of the employee record for Licensed practical nurse (LPN/staff #43) revealed that abuse training was completed March 9, 2022, resident rights completed on May 25, 2022, infection control completed May 31, 2022, and there was no documentation for emergency preparedness.

-Review of the employee record for (LPN/staff #54) revealed that abuse training was completed on January 2, 2023, resident rights was completed on January 2, 2023, infection control was completed on February 20, 2023, dementia care January 3, 2023, and there was no documentation for emergency preparedness.

-Review of the employee record for a Certified nursing assistant (CNA/staff #38) revealed that abuse training completed on October 18, 2022, resident rights October 18, 2022, infection control June 20, 2022, dementia training completed on October 18, 2022, and emergency preparedness was not attempted.

-Review of the employee records for The Director of nursing (DON/staff #59) revealed that abuse training was completed on June 29, 2022, resident rights training was not attempted, infection control was not completed, emergency preparedness was not attempted.

-Review of the employee records for the Maintenance Director (staff #32) revealed that abuse training, resident rights, infection prevention, and dementia care were not attempted.

-Review of the employee records for Administrator (staff #110) revealed no documentation for abuse training, resident rights was not attempted, infection control was not attempted, and emergency preparedness not attempted.

An interview was conducted on July 16, 2024 at 1:56 p.m. with the human resources accounting clerk (staff #73), who stated the corporate office usually sends an email when training needs to be done. She stated that all staff, including the Administrator, are required to complete emergency preparedness, resident rights, abuse, infection control, and dementia training annually and the training are due based on the the staff's date of hire.

An interview was conducted on July 16, 2024 at 3:33 p.m. with (staff #110), who stated that all the staff are required to complete the training annually, but not all the staff had completed emergency preparedness. She stated that they have printed up most of the current training for the ten employees.

An interview was conducted on July 17, 2024 at 11:19 a.m. with (DON/staff #59), who stated that
she has a policy on required annual training for staff: infection control, abuse, resident rights, dementia, emergency preparedness. She stated that the training due date is based on the date of hire and everyone, including the Administrator, are supposed to complete the training.

The facility policy, "Yearly Required Training: states that a facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. Each associate will be provided the following core educational content annually through the learning management software that will be part of a curriculum titled "Annual General Requirements Curriculum." Each associate will need to complete the courses individually by the due date provided in the course assignment page. Core education includes: infection prevention and control, emergency preparedness, resident rights, abuse, but did not include dementia care.

Based on observation, a staff interview, and the facility policy and procedures, the facility failed to ensure that the daily staff posting included the correct information.

Findings include:

On July 14, 2024 at approximately 9:00 a.m. the daily staff posting was observed hanging on the wall just to the left of the reception desk. The information observed on the posting was:

-July 12, 2024
-census 60
-number of each type of staff for each shift
-the total hours scheduled for each type of staff for each shift
-the actual hours worked was not completed

During this time the Director of Nursing (DON/staff #59) approached and removed the daily staff posting dated July 12, 2024 and stated that she was just about to the change it.

Review of the facility documentation revealed that the census was 58 on July 14, 2024.

An interview was conducted on July 17, 2024 at 11:30 a.m. with the (DON/staff #59), who stated that the Central Supply Director/staffing coordinator (staff #95) is responsible for completing daily staff posting and works Monday through Friday. She stated that staff #95 prepares the daily staff postings for the weekend and the weekend receptionist is supposed to switch them out. She stated that the posting is for visitors and residents to see how many staff are available in the building.

The facility policy, "Facility Staffing Posting" revised December 13, 2023 states that the facility needs to post nurse staffing information in a prominent place where it is accessible to residents and visitors. The data should be clear, readable, up to date and current. When listing the total number of staff and actual hours worked, the facility is required to reflect staff absences on each shift that occur due to callouts or illness. The nurse staffing data needs to be posted on a daily basis at the beginning of each shift. The required information that needs to be posted includes:

I. Facility name
2. Current date
3. Resident census
4. Total number of staff and actual hours worked per shift for:
a. Registered Nurses
b. Licensed Nurses
c. Certified Nurse Aides

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that initial and ongoing weights were conducted for one resident (Resident #36).

Findings include:

Resident #36 was admitted to the facility on February 8, 2024 with diagnoses that included anoxic brain damage, Parkinson's disease and chronic respiratory disease.

Review of the clinical record revealed that the resident weighed 187 pounds on February 9, 2024.

Review of the nutritional assessment dated February 9, 2024 revealed that the resident was malnourished.

The care plan dated February 22, 2024 revealed that the resident was at risk for weight fluctuation related to dysphagia and anoxic brain injury. Interventions included eternal feeding as ordered and weight as per the facility policy.

The minimum data set (MDS) dated February 27, 2024 included a staff assessment for mental status score of 2 indicating the resident had moderate cognitive impairment.

The clinical record revealed that the resident weighed 168.6 pounds on June 4, 2024 and 167.4 pounds on July 2, 2024.

An interview was conducted on July 17, 2024 at 10:07 a.m. with a Registered Dietician (staff #66), who stated that a nutritional assessment is done when residents are admitted and all residents are supposed to be weighed. He stated that resident #36 was not weighed when he was admitted to the facility and the weight documented in the clinical record was taken from the weight documented in the hospital transfer records. He also stated that the resident should have been weighed monthly as per the facility policy in order to assess and monitor weight loss, fluctuations, fluid shifts, and if a weight change has occurred, so the root cause can be determined. He stated that there is a risk of developing malnutrition and/or congestive heart failure (CHF) fluid retention not being recognized if weights are not being monitored.

An interview conducted on July 17, 2024 at 11:15 a.m. with the Director of Nursing (DON/staff #59), who stated that the facility policy states that all residents are supposed to be weighed weekly for the first four weeks and then monthly. The reason for weighing the resident is to check for significant weight loss or gain. She stated that when the resident was admitted, the certified nursing assistant (CNA) should take the resident's initial weight and should not use the recorded weight from the hospital records because the weight may not be accurate. She stated that they just recently talked about weighing hospice patients, and all residents should be weighed.

The facility addendum to the Lippincott procedure revised August 21, 2023 states that measuring a patient's weight is part of a routine admission to a health care facility. An accurate record of the
patient's weight is essential for calculating dosages of drugs, fluid maintenance, anesthetics, and
contrast agents; calculating tidal volume in patients requiring mechanical ventilation; assessing
the patient's nutritional status; and determining the patient's height-weight ratio, body surface area, and body mass index (BMI).

The facility policy, "Weights and Heights" reviewed August 23, 2023 states that all residents are weighed within 24 hours of admission and weekly for 4 weeks and as needed thereafter or more as determined by the RAR committee and/or physician order.

Based on observations, staff interviews, and policy, the facility failed to ensure multiple food items were stored at safe temperatures in accordance with professional standards. The facility census was 58.

Findings include:

During an initial observation of the kitchen, conducted at 8:25 a.m. on July 14, 2024 with staff #15. In the walk-in refrigerator, the thermometers both inside and out registered a temperature displaying 45 degrees Fahrenheit (F). Inside the refrigerator were various food items including milk, eggs, yogurt, meat, cheese, and dressings. Staff #15 stated the temperatures are recorded on the log twice daily, morning and evening.

Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 14, 2024 was recorded at 36F. The evening temperature was recorded at 40F. The log includes a critical limit (CL) for temperature at 40F on the high end, and revealed that in the event of a temperature not within the required range, to notify the Director of food services or maintenance immediately.

During a kitchen observation conducted on July 15, 2024 at 10:12 a.m. of the same walk-in refrigerator, the external thermometer and internal thermometer registered a temperature displaying 42F.

Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 37F. The evening temperature was recorded at 40F.

During a kitchen observation conducted on July 16, 2024 at 9:30 a.m. of the same walk-in refrigerator, the external thermometer registered a temperature displaying 50F. The internal thermometer registered a temperature displaying 44F. A second observation was made on July 16, 2024 at 11:50 a.m. The external thermometer again showed a temperature displaying 50F, and the internal thermometer displayed a temperature of 44F.

Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 38F. The evening temperature had not been recorded yet.

An interview was conducted on July 16, 2024 at 12:35 p.m. with a cook (kitchen staff #40). The cook stated that most of the foods served for meals are stored in the walk-in refrigerator, including prep stuff for the next day, thawing meat, dairy and milk, as well as cottage cheese. The cook also stated that left overs are also stored in the same walk-in. The cook stated that temps in the walk-in need to be 39F or below, and that temperatures are recorded using the outside thermometer twice daily in the monthly log.

An interview was conducted on July 16, 2024 at 12:44 p.m. with the Registered Dietician and Kitchen Manager (RD/kitchen staff #66). The RD stated that temperatures need to be under 40F in the walk-in or it puts the food at risk of causing food-borne illness such a botulism. The RD stated that all refrigerated items used in the facility are stored in that walk-in, including dairy, cheese, eggs and leftovers. The RD further stated that he was aware of a door being replaced on the freezer for a temperature issue, but was not sure about the walk-in. During this interview the RD removed two random containers of food product from the walk-in refrigerator and took the temperature of them. A single serving yogurt container, and a jar of Mayonnaise. The temperature of both items was measured by the RD at 45F.

An interview was conducted with the Maintenance director (Facility/staff #32) on July 16, at 1:25 p.m. The Maintenance director stated that there was a mistake with what the temperature was set at in the walk-in refrigerator. He stated that the walk-in was accidently set to 40F by mistake when it was being worked on, roughly one month ago. He further stated that the outside thermometer on the walk-in was broken, and does not register temperatures correctly.

However, the facility logs showed multiple entries for the month of July with temperatures ranging from 32F and 40F.

An interview was conducted with the Executive director (ED/staff #110) on July 17, at 11:50 a.m. The ED stated they were aware of the food issue and it was being corrected. The ED further stated that her expectation is that food is stored safely, an that thermometers will be calibrated correctly going forward.

Review of the facility policy titled 'Food Safety' revised April 26, 2023 and reviewed May 1, 2024 revealed that it is the policy of the facility to ensure food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. It further revealed that the "danger zone" means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F allow the rapid growth of pathogenic microorganisms that can cause foodborne illness.

Based on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents.

Findings include:
Regarding safe environment:
During the initial walk-through observation of the facility conducted on July 14, 2024 at 10:11 a.m., the following was observed:
- Doorway frame missing in room #2100, light brown paint is peeling, exposing the green pain underneath. It felt rough to the touch.
- Corner handrail by room #2117 was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact.
- Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch.
- Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch.
- Second floor nurse's station corner had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch.
- Corner handrail on the second floor by the stairway had 4 screws sticking out. Additionally, the handrail had gouges and was sharp/rough to the touch

In a follow-up wall-through conducted on July 17, 2024 at 8:53 a.m., the following was observed:
- Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch.
- Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. This included shower doorframe.
- Corner handrail by room #2117 was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact.
- Corner rail by soiled utility on the second floor had a metal brace that was slightly sticking out.
- Second floor nurse's station corner still had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch.
- Below the handrail next to linen room on the second floor by room #2133 had a metal brace on the wall corner that is slightly sticking out. That same corner has pieces of the wall corner with severe gouges that is rough/sharp to the touch.
- Corner entry to wall to room #2137 had a metal brace that was coming off the wall and the wall corner had severe gouges that was rough/sharp to the touch.
- Inside entry wall right hand side in room #2133 has long deep gouges on the lower wall above the baseboard.
- Corner handrail on the second floor by the stairway no longer had the 4 screws sticking out. However, the handrail had gouges and was sharp/rough to the touch.
An interview with a Registered Nurse (RN/staff #50) was conducted on July 17, 2024 at 8:29 a.m. Staff #50 stated the process for submitting work orders is that they can either use the book, the app, or call the emergency number for maintenance for whoever is on call. When asked about the overall status of the hallways/residents' living area, the RN noted that the place could use a lot of TLC (tender loving care). Staff #50 noted that to their knowledge maintenance had never asked staff or residents' input regarding what needs to be done. The RN indicated that like the staff, the residents have just come to accept the overall appearance/status of the facility. However, it would be nice to make the area more presentable, a little bit more modern.

An interview with the Maintenance Director (staff #32) was conducted on July 17, 2024 at 9:34 a.m. Staff #32 noted that works orders are submitted by residents by informing the nurses and/or staff who in turn submit work orders via TELS system. The Maintenance Director noted that the turn around time for work orders depends on the required work. Usually the priority are those work orders related to call lights, O2 (oxygen) tanks or anything related to resident safety. For work orders tagged as priority, maintenance resolves them no more than 24-hours. Other work orders such as painting, normally takes 2-3 days to close out. Staff #32 stated that there are no current plans for updates to halls or rooms per corporate. The Maintenance Director indicated that they conduct walk-throughs on Mondays and take care of the issues.

A walk-through with the Maintenance Director (staff #32) was conducted on July 17, 2024 at approximately 9:56 a.m. to look at the identified observations above. Below are staff #32's comments:
- room 2133's long deep gouges on the lower wall above the baseboard-noted that it is not very homelike
- handrail by room #2133 with a metal brace on the wall corner - indicated that it was not noticed before but is a concern since it is metal
- shower doorframe on second floor - noted that it is a concern since there are metal components
- room #2137 - indicated that it is a concern since the metal brace came off as we were inspecting it
- nail sticking out at nurse's station was no longer there, a photo from the entrance day and earlier in the morning sticking out was shown to staff #32 - he noted that it is a concern since someone could get hurt with it.

A follow-up interview was conducted with the Maintenance Director (staff #32) on July 17, 2024 at approximately 10:15 a.m. Staff #32 stated that in their opinion, the facility is livable, but some of the identified harm during our walk-through puts it at "75% homelike." Whether they gets all the things fixed, "it is a routine and it will get messed up again." The Maintenance Director said that it is hard to maintain but it is livable and that if residents were asked, the residents would say it is okay. Staff #32 said that during their walk-through, they identify what can damage residents and staff, prioritize it and fix it. However, if nobody says anything, and they are not aware, they it cannot be fixed. The Maintenance Director said that it is important for the facility to be safe and comfortable so residents and their families are happy and to make it better for the residents.

An interview with the Administrator (staff #110) was conducted on July 17, 2024 at 1:09 p.m. Staff #110 stated that the expectation is that the living area for resident are clean, free of obstruction and without significant odors. The facility is to be clean and safe from hazards. Staff #110 stated that repairs should be maintained to have a homelike environment such as paint and upkeep. The Administrator stated that this is important since this is the home for people living here and they deserve a good quality of life. It has to be safe so that residents are not put at risk for accidents or injuries. Staff #110 stated that the impact if the facility is not homelike and safe is that residents might feel discomfort, might reduce the homelike environment feel until things were repaired, it could provide a risk for some type of injury i.e. if legs extend beyond the wheelchair there could be a risk of injury.

Review of the open work order report generated on July 15, 2024 did not reveal any work order pertaining to any of the issues identified during the walk-through observations.

Review of the facility policy titled "Preventive Maintenance Program" revised January 11, 2023 and reviewed January 22, 2024 indicated that the facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public.

The facility policy titled "Work Request System" revised May 14, 2019 and reviewed January 15, 2024 indicated that the work order request system was designed to provide an established and effective means of requesting, coordinating, and completing maintenance of a corrective nature.

A facility policy titled "Resident Rights" issued June 8, 2020 and reviewed September 25, 2023 indicated that resident has a right to safe, clean, comfortable, and homelike environment.

Based on observation, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate and comfortable temperature levels was provided to meet the needs of 14 residents (#4, #5, #8, #11, #20, #25, #34, #35, #41, #42, #43, #48, #56, and #167). The facility census was 58 and the sample was 13.

Findings include:

On the morning of July 15, 2024, between the hours of 6:45 a.m. to 7:00 a.m., surveyors experienced a notable difference in temperature perceived and felt when entering the facility. The temperature felt uncomfortably warm.

During an interview with the Assistant Maintenance Technician (staff #33) conducted on July 15, 2024 at approximately 6:45 a.m., staff #33 mentioned that the generator did not kick in properly during the power outage yesterday evening. This resulted in the cooling tower (chiller) not activating to cool down the temperature in the facility. Staff #33 stated that the chiller is in the process of kicking in but will take approximately 4 hours to cool down the facility.

An observation of the residents' areas was conducted on July 15, 2024 starting at approximately 7:15 a.m. There was no evidence that rooms were being tested for ambient temperature by the staff. This was despite the residents' areas being noticeably and feeling warm/uncomfortable.


Regarding Resident #4:

-Resident #4 was admitted to the facility on June 9, 2024 with diagnoses that included fracture of the lower end of the right femur, pain in right knee, chronic kidney disease, and osteoarthritis.

Review of the admission Minimum Data Set (MDS) assessment dated June 16, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact. The assessment also revealed that the resident was dependent for transfers. The MDS indicated that the resident uses a walker as a mobility device.

During an interview conducted with the resident on July 15, 2024 at 8:23 a.m., the resident stated that last night they had no power and that she was uncomfortable.

An observation was conducted of the resident's room on July 15, 2024 at 8:23 a.m. There was a notable warm temperature in the room.


Regarding Resident #5:

-Resident #5 was admitted to the facility on June 28, 2023 with diagnoses that included pressure ulcer of sacral region, osteoporosis, hypertension, and gastro-esophageal reflux disease.

Review of the quarterly Minimum Data Set (MDS) assessment dated April 5, 2024 revealed that the resident has modified independence pertaining to decisions regarding tasks of daily life. The assessment also indicated that the resident required substantial assistance for chair to bed transfers, and sit to stand activities. The MDS also noted that the resident uses a wheelchair as a mobility device.

During an interview conducted on June 15, 2024 at 8:19 a.m., the resident responded "Si" when asked if it was warm in their room.

An observation was conducted of the resident's room on June 15, 2024 at 8:19 a.m. The temperature registered 80.7? Fahrenheit. The room felt noticeably warm.

During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:30 a.m., the temperature was taken with a thermometer and registered 76.6? Fahrenheit.


Regarding Resident #8:

- Resident #8 was initially admitted to the facility on November 16, 2012 and readmitted on September 17, 2019 with diagnoses that included dementia, chronic obstructive pulmonary disease, angina pectoris, and peripheral vascular disease.

Review of the annual Minimum Data Set (MDS) assessment dated May 28, 2024 revealed that the resident has modified independence when it came to decisions regarding tasks of daily life. The MDS also indicated that the resident is dependent on assistance with regards to most transfers. The MDS also noted that the resident uses a wheelchair for mobility.

During an observation of the resident's room on July 15, 2024 at 8:17 a.m., the temperature taken with the thermometer registered 81.2? Fahrenheit. Physical inspection of the air conditioner (AC) thermostat located in the room revealed that the controls do not work regardless of the setting. The room felt uncomfortably warm.

An interview with the resident was conducted on July 15, 2024 at 8:17 a.m. Resident #8 confirmed that it is hot in the room.
During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:29 a.m., to check the temperature in the residents' area, resident #8's room temperature registered 81.1? degrees Fahrenheit.


Regarding Resident #11:

-Resident #11 was initially admitted to the facility on June 19, 2017 and readmitted on October 5, 2021 with diagnoses that included paroxysmal atrial fibrillation, antherosclerotic heart disease, dementia, and paralytic syndrome.

Review of the quarterly Minimum Data Set (MDS) dated April 1, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The MDS assessment also indicated that the resident is dependent on assistance for transfers.

An observation of the resident's room was conducted on July 15, 2024 at 8:26 a.m. During the observation, the room felt hot. The temperature taken with a thermometer registered 81.1? Fahrenheit.

During an interview with resident #11 conducted on July 15, 2024 at 8:26 a.m., the resident said that "hell yeah, it's hot" referring to his room.


In a follow-up observation conducted on July 15, 2024 at 9:33 a.m., it was noted that the temperature in the room was finally comfortable. The temperature taken with the thermometer registered 76? Fahrenheit.


Regarding Resident #20:

-Resident #20 was initially admitted to the facility on June 22, 2023 on readmitted on July 3, 2024 with diagnoses that included quadriplegia, chronic obstructive pulmonary disease, heart failure, esophagitis, schizophrenia, and bipolar disorder.

Review of the annual Minimum Data Set (MDS) assessment dated June 26, 2024 revealed Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The assessment noted that the resident is dependent on assistance for transfers. The MDS also indicated that the resident utilizes a wheelchair as a mobility device.

An observation conducted on July 15, 2024 at 8:12 a.m. revealed that the room was uncomfortably hot. The temperature taken with a thermometer registered 83.5? Fahrenheit.

In an interview with resident #20 conducted on July 15, 2024 at 8:12 a.m., the resident stated that they did not have AC (air conditioner) in their room since Friday. The resident said that on Friday, July 12, the AC was fixed just before supper. However, it stopped working through the night Friday into Saturday. The resident noted that maintenance looked at it yesterday and it was still not working.

During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:29 a.m., the room was still felt uncomfortably hot. The temperature was taken with a thermometer and it registered at 82.4? Fahrenheit.


Regarding Resident #25:

-Resident #25 was admitted to the facility on May 20, 2024 with diagnoses that included anemia, heart failure, diabetes, and depression.

Review of the Significant change in status Minimum Data Set (MDS) assessment dated May 27, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that he is cognitively intact. The assessment also indicated that the resident is dependent on assistance for all transfers. The MDS noted that the resident uses a wheelchair as a mobility device.

A CNA (Certified Nursing Assistant/staff #9) was o

Based on record review and staff interview the facility failed to ensure the emergency and standby power systems were functioning properly. Failure to implement an emergency and standby power systems plan during an emergency could lead to harm of the patients and/or staff.

Findings include:

Based on record review and staff interview on July 17-18, 2024, the facility failed to ensure the emergency generator was adequate for the facility needs during an emergency. The facility has had a rental generator since March 2, 2020. On July 14, 2024 the facility experienced a power failure and the temporary generator failed to turn on leaving the facility totally without power. Medical equipment, the elevator and facility walk-in refrigerator and freezer were none functioning during the total outage.

The following are staff interviews:

Monday, July 15, 2024, at approximately 0941 hours an interview was conducted with staff # 32, Maintenance Director. Staff #32 stated that he was notified at 1815 hours on July 14, 2024, that the power was out. Staff #32 stated that he responded to the facility arriving at 1845 hours. Staff # 32 further stated that the facility was dark and the staff were panicking. Staff # 32 stated that he began troubleshooting and found that the main breaker for the facility had popped and that he reset it. Staff #32 further stated that it took approximately one hour to troubleshoot and that the generator was manually started between 1945 and 2000 hours. Staff # 32 stated that the chillers were not active as they drew too much voltage. Staff # 32 stated that When he arrived at the facility on July 15, 2024, he was unaware that the circular pumps were off. Staff # 32 stated that he later learned that staff #33 had bypassed the circular pumps because he had turned the alarm had been turned off. Staff# 32 stated that had the alarm been on he would have known there was an issue with the circular pumps. Staff #32 stated that at 0700 hours on July 15, 2024, they had to go through the facility and reset all of the AC units.

Monday, July 15, 2024, at approximately 1010 hours an interview was conducted with staff # 69, RN unit nurse. Staff # 69 stated that the electricity went out between 1820 and 1830 hours on July 14, 2024. The residents that were on oxygen concentrators had to be switched to O2 tanks due to the electricity being out. Staff #69 stated that the alarm did not go off last night regarding the generator. Staff # 69 further stated that with the electricity being out he knew that the doors needed to be watched to prevent any elopement. Staff # 69 stated that if the resident rooms are hot they should begin moving residents immediately however, if the electricity is out the elevators would not work so they would not be able to move the residents. Staff # 69 stated that he was assuming the generator would kick in right away, but that it did not, and this is why they called maintenance.

Monday, July 15, 2024, at approximately 1048 hours, Staff # 33 was interviewed. Stated that the power had gone out the previous night, July 14, 2024. Staff # 33 stated that he received a telephone call from Staff # 32, Maintenance Director sometime around 1810-1815 hours on July 14, 2024, and asked him to respond to the facility. Staff # 33 stated that he arrived at the facility around 1847 hours and saw that the facility was all dark. Staff # 33 stated that the generator had not kicked on right away and estimated that the generator got going between 1906 and 1910 hours. Staff # 33 further stated that when the power goes off, the gas shuts off for safety reasons and this turns the pumps off to include the chiller system. Staff # 33 stated that he and staff # 32 were in the boiler room around 0500 hours on July 15, 2024, and realized the air conditioning was not cooling. Staff #33 stated that he noticed the heat when he came in at 0500 hours on July 15, 2024, and noticed the kitchen was hot and rechecked the rooms. Stated that he noticed the rooms were hot but did not re-temp them at that time. Stated that he thought the residents should be moved to a place that was more comfortable. The west elevator was working last night when the lights came back. The north elevator was not working. Stated that no discussion of moving residents last night. Stated that residents could have been moved last night. Stated that some units were still functional, but because of auxiliary pump the residual water was allowing for a few units to work. Stated that he did not know at what temp residents should be moved. Stated that extension cords were running into the rooms. All red plugs are in the hallway. There are no red plugs in the rooms. Staff # 33 stated that there is no standard practice to handle a power outage. Stated that in all the time that he has been there, there have been no mock disaster drills. Stated that he had brought concerns up to staff #32 regarding what they would do, especially with the heavier residents.

The findings were confirmed by staff #32 and #110 during the exit conference conducted on July 18, 2024.

The first day the facility was on a temporary generator was March 2, 2020 per the rental contract the facility provided. The life safety code portion of this survey started July 17, 2024. 1598 days is the distance between the two dates. Which is 4 years, 4 months and 15 days.

Based on record review and staff interview the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on community-based risk assessment poses a potential risk and may cause harm to the patients and/or staff during an emergency.

Findings include:

Based on record review and staff interview on July 17-18, 2024, revealed the facility failed to provide proof on a community-based risk assessment was used prior to developing the facility's emergency plan

During the exit conference on July 18, 2024, the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to ensure the Emergency Preparedness plan included the needs of the patient population they serve and a delegation of authority as part of the continuity of operations. Failure to develop a continuity plan involving the patient population may cause disruption of services to patients during an emergency which could lead to harm.

Findings include:

Based on record review and staff interview on July 17-18, 2024, revealed the facility failed to develop a plan addressing the needs of the patient population within the current written plan or a delegation of authority as part of the community operations.

During the exit conference on July 18, 2024 the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to provide a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on a community and facility-based risk assessment may cause harm to the patients and/or staff during an emergency.

Findings include:

Based on observation and staff interview on July 17-18, 2024, revealed the facilities policies, were not based on a current risk assessment. CFR 494.62 requires both facility and community hazard assessments but is used to develop the policy and procedures. The assessment provided listed hazards that do not occur in Arizona and the policies don't match the identified hazards.

During the exit conference on July 18, 2024, the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to develop and maintain policies to ensure that refrigerated foods were stored at or below 41 degrees. Failure to maintain the appropriate food temperatures could result in bacterial growth resulting in harm to the patients.

Finding include

Based on observation and staff interview on July 17-18, revealed that problems developed with the refrigerated food storage compartment, and temperatures exceeded 41 degrees for an extended period of time resulting in food having to be thrown out. On July 14, 2024 the facility experienced as power outage and temperatures were documented at 50 degrees fahrenheit.

During the exit interview on July 18, 2024, the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to have policies and procedures for safe evacuation from the facility that contains all of the required elements. Failure to provide all of the required elements in the evacuation plan could lead to harm serious injury or death to patients and/or staff.

Findings include:

Based on record review and staff interview on July 17-18, 2024 revealed, the facility failed to have written policies and procedures regarding the safe evacuation of residents from the second floor in the event of an emergency. On July 14, 2024 the facility experienced a power failure. Because of the total power outage, the facility did not work. Survey team members asked facility staff how they would evacuate the second floor and the staff responded they would wait for the fire department.

During the exit interview on July 18, 2024, the above finding was again acknowledged by the management team.

Based on record review and staff interview, the facility failed to develop a facility-based emergency planning, training, and testing program. Failure to provide facility-based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients and/or staff during an emergency.

Finding include:

Based on record review and staff interview on July 17-18, 2024, revealed the facility failed to establish a facility-based training and testing for staff based on the Emergency Plan, and facility risk assessment.

During the exit conference conducted on July 18, 2024, the above finding was acknowledged by the management team.

Based on record review and staff interview the facility failed to provide training for new and existing staff which include a review of the facility emergency preparedness plan. Failure to have staff review the emergency preparedness plan consistent with their expected roles may cause harm to the patients and/or staff during an emergency.

Findings include:

Based on record review and staff interview on July 17-18, 2024, revealed the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures. In addition, the staff was questioned nobody was able to find the emergency preparedness policies or phone numbers of required numbers. The staff was not familiar the emergency Preparedness program and didn't recall receiving any training. The management was able to find their EP program.

During the exit interview on July 18, 2024, the above finding was again acknowledged by the management team.

Based on record review and staff interview the facility failed to ensure the emergency and standby power systems were functioning properly. Failure to implement an emergency and standby power systems plan during an emergency could lead to harm of the patients and/or staff.

Findings include:

Based on record review and staff interview on July 17-18, 2024, the facility failed to ensure the emergency generator was adequate for the facility needs during an emergency. The facility has had a rental generator since March 2, 2020. On July 14, 2024 the facility experienced a power failure and the temporary generator failed to turn on leaving the facility totally without power. Medical equipment, the elevator and facility walk-in refrigerator and freezer were none functioning during the total outage.

The following are staff interviews:

Monday, July 15, 2024, at approximately 0941 hours an interview was conducted with staff # 32, Maintenance Director. Staff #32 stated that he was notified at 1815 hours on July 14, 2024, that the power was out. Staff #32 stated that he responded to the facility arriving at 1845 hours. Staff # 32 further stated that the facility was dark and the staff were panicking. Staff # 32 stated that he began troubleshooting and found that the main breaker for the facility had popped and that he reset it. Staff #32 further stated that it took approximately one hour to troubleshoot and that the generator was manually started between 1945 and 2000 hours. Staff # 32 stated that the chillers were not active as they drew too much voltage. Staff # 32 stated that When he arrived at the facility on July 15, 2024, he was unaware that the circular pumps were off. Staff # 32 stated that he later learned that staff #33 had bypassed the circular pumps because he had turned the alarm had been turned off. Staff# 32 stated that had the alarm been on he would have known there was an issue with the circular pumps. Staff #32 stated that at 0700 hours on July 15, 2024, they had to go through the facility and reset all of the AC units.

Monday, July 15, 2024, at approximately 1010 hours an interview was conducted with staff # 69, RN unit nurse. Staff # 69 stated that the electricity went out between 1820 and 1830 hours on July 14, 2024. The residents that were on oxygen concentrators had to be switched to O2 tanks due to the electricity being out. Staff #69 stated that the alarm did not go off last night regarding the generator. Staff # 69 further stated that with the electricity being out he knew that the doors needed to be watched to prevent any elopement. Staff # 69 stated that if the resident rooms are hot they should begin moving residents immediately however, if the electricity is out the elevators would not work so they would not be able to move the residents. Staff # 69 stated that he was assuming the generator would kick in right away, but that it did not, and this is why they called maintenance.

Monday, July 15, 2024, at approximately 1048 hours, Staff # 33 was interviewed. Stated that the power had gone out the previous night, July 14, 2024. Staff # 33 stated that he received a telephone call from Staff # 32, Maintenance Director sometime around 1810-1815 hours on July 14, 2024, and asked him to respond to the facility. Staff # 33 stated that he arrived at the facility around 1847 hours and saw that the facility was all dark. Staff # 33 stated that the generator had not kicked on right away and estimated that the generator got going between 1906 and 1910 hours. Staff # 33 further stated that when the power goes off, the gas shuts off for safety reasons and this turns the pumps off to include the chiller system. Staff # 33 stated that he and staff # 32 were in the boiler room around 0500 hours on July 15, 2024, and realized the air conditioning was not cooling. Staff #33 stated that he noticed the heat when he came in at 0500 hours on July 15, 2024, and noticed the kitchen was hot and rechecked the rooms. Stated that he noticed the rooms were hot but did not re-temp them at that time. Stated that he thought the residents should be moved to a place that was more comfortable. The west elevator was working last night when the lights came back. The north elevator was not working. Stated that no discussion of moving residents last night. Stated that residents could have been moved last night. Stated that some units were still functional, but because of auxiliary pump the residual water was allowing for a few units to work. Stated that he did not know at what temp residents should be moved. Stated that extension cords were running into the rooms. All red plugs are in the hallway. There are no red plugs in the rooms. Staff # 33 stated that there is no standard practice to handle a power outage. Stated that in all the time that he has been there, there have been no mock disaster drills. Stated that he had brought concerns up to staff #32 regarding what they would do, especially with the heavier residents.

The findings were confirmed by staff #32 and #110 during the exit conference conducted on July 18, 2024.

The first day the facility was on a temporary generator was March 2, 2020 per the rental contract the facility provided. The life safety code portion of this survey started July 17, 2024. 1598 days is the distance between the two dates. Which is 4 years, 4 months and 15 days.

Based on observation and interview the facility failed to provide a safe means of egress out of the soiled laundry room. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and/or staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof."

Findings include:

During a facility tour conducted on July 17-18, 2024, observations made revealed:

1) The entry/exit to the soiled laundry room was blocked by a laundry cart.
2) a medication cart was blocking the fire doors in the 1200 hall.

These findings were acknowledged during the exit conference on July 18, 2024, by the management team.

Based on observation the facility failed to ensure proper rated doors were protecting hazardous area. Failing to have proper rated doors and maintain the the self-closing hardware on the door and frame to a hazardous room could cause harm to patients in time of a fire if the door does not close and latch secure.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Chapter 8, 8.7.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: 1. Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3 2. Protecting the area with automatic extinguishing systems in accordance with Section 9.7 3. Applying both 8.7.1.1 (1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43. Section 8.7.1.3 Doors in barriers required to have a fire resistance rating shall have a minimum 3/4-hour fire protecting rating and shall be self or automatic closing in accordance with 7.2.1.8. Section 7.2.1.8.1 A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self or automatic closing in accordance with 7.2.1.8.2.
..
Findings include:

Observations made while on tour on July 17-18, 2024, revealed the following;

1) Fire door leading to laundry had holes in the upper left portion of the door indicating self closing hardware had been removed.
2) A door was removed from soiled laundry into clean laundry.
3) Laminate chipped on the upper left hinge side of the door entering/exiting the clean laundry room and the door closure was not functioning as the door was propped open.

During the exit conference on July 18, 2024,2, the above findings were again acknowledged by the management team.

Based on observation and interview, the facility failed to protect cooking equipment per the requirements of NFPA 101 - 2012 edition, Section 19.3.2.5.3 (9). This deficient practice could affect patients and/or staff causing a fire in the facility.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... "Chapter 4, Section 4.1.1 "Cooking equipment used in processes producing smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard." Section 4.1.2 "All such equipment and its performance shall be maintained in accordance with the requirements of this standard during all periods of operation of the cooking equipment." Chapter 10, Section 10.1.2 "Cooking equipment that produces grease-laden vapors and that might be a source of ignition of grease in the hood, grease removal device, or duct shall be protected by fire extinguishing equipment."

Findings include:

During a facility tour conducted on July 17-18, 2024, revealed no approved hood system installed in the therapy room of the facility and that the cooking range was plugged in a functioning.

During the exit conference on July 18, 2024, the above findings were again acknowledged by the management staff.

Based on observation the facility failed to assure that all parts of the facility were provided sprinkler system coverage. Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads could result in harm to patients and/or staff in time of a fire. Failure to ensure the plate is present could cause the sprinkler calculation to be inaccurate during a system modification.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7."Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 8, Section 8.5.6 Clearance to Storage. Section 8.5.6.1 Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4. or 8.5.6.5 are met a clearance between the deflector and the storage shall be 18 inches. (457mm) or greater.

NFPA 25: Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition - Chapter 5 Sprinkler Systems 5.2.6 * Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

Findings include:

Observations made while on tour on July 17-18, 2024, revealed multiple areas within the facility where items were stored within 18 inches of the ceiling. These areas included the following:

1- The maintenance room.
2- The housekeeping room next to the maintenance room.
3- The linen closest outside room 2123

Observations made in the sprinkler riser room revealed the hydraulic plate was missing.

During the exit conference on July 18, 2024, the above findings were again acknowledged by the management staff.

Based on observation the facility failed to provide a protective guards on light bulbs located inside building. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage."In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

Findings include:

Observations made while on tour on July 17-18, 2024, revealed several light bulbs in the facility were exposed:

1) the records room off the 1100 hall.
2) the housekeeping closet outside room 1226
3) the area behind the clothes dryers in the laundry

During the exit conference on July 18, 2024, the above findings were again acknowledged by the management staff.

Based on record review and interview the facility failed to provide all required fire drills per NFPA 101. Failing to conduct fire drills in accordance with the life safety code one per shift per quarter to familiarize staff with conditions under an actual fire can result in harm to patients and/or staff during a an actual fire or emergency situation.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.7.1.4* "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions." Section 19.7.1.6 "Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." Section 19.7.1.7 "When drills are conducted between 9:00 PM and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms."

Findings include:

Based on record review and interview on July 17-18, 2024 revealed that the facility failed to conduct fire drills during the first shift of the first quarter of 2024 as well as the third shift of the second quarter.

During the exit conference on July 18, 2024, the above findings were again acknowledged by the Administrator and Director of Maintenance.

Based on observations and staff interview the facility failed to ensure the generator was permanently mounted. Failing to have the emergency generator permanently mounted could cause harm to patients and/or staff during an emergency.

NFPA 110 2010 edition Section 4.4* Level. This standard recognizes two levels of equipment installation, performance, and maintenance. 4.4.2* Level 2 system shall be installed where the failure of the Emergency Power Supply System (EPSS) is less critical to human life and safety. 4.4.3 All equipment shall be permanently installed. NFPA 110 2010 edition Section 7.4 Mounting.
7.4.1 Rotating energy converters shall be installed on solid foundations to prohibit sagging of fuel, exhaust, or lubricating-oil piping and damage to parts resulting in leakage at joints. 7.4.1.1 Such foundations or structural bases shall raise the engine at least 150 mm (6 in.) above the floor or grade level and be of sufficient elevation to facilitate lubricating-oil drainage and ease of maintenance.
7.4.2 Foundations shall be of the size (mass) and type recommended by the energy converter manufacturer. 7.4.3 Where required to prevent transmission of vibration during operation, the foundation shall be isolated from the surrounding floor or other foundations, or both, in accordance with the manufacturer's recommendations and accepted structural engineering practices. 7.4.4 The EPS shall be mounted on a fabricated metal skid base of the type that shall resist damage during shipping and handling. After installation, the base shall maintain alignment of the unit during operation.

Finding include:

Based on observation and interview on July 17-18, 2024, revealed the facility has had a rental emergency generator for over (4) four years. The facility provided a rental agreement from Power Plus dated March 2, 2020. On July 14, 2024, sometime before 1810 hours, the facility sustained a power outage. The rented portable generator failed to operate as required resulting in a total power loss greater than 30 minutes. Medical equipment such as bilevel positive airway pressure machine (BiPap), oxygen concentrators failed to be utilized for the patients. The facility walk-in refrigerator and walk-in freezer did not have power to them. The facility elevator failed to operate because of no electricity.

During the exit conference on July 18, 2024, the above finding was again acknowledged by the management staff.

Based staff interview and record review the facility failed to ensure the emergency generator transferred to emergency power in 10 seconds or under. Failure maintain the facility emergency generator transfer time from normal power to emergency power could result in harm to patients and/or staff during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 7.9.1 Emergency Lighting. 7.9.1.3 Where maintenance of illumination depends on changing from one energy source to another, delay of not more than 10 seconds shall be permitted.

Findings include:

Based staff interview and record review on July 17-18, 2024, revealed the facility emergency generator failed to transfer to emergency power in 10 seconds or less during a power outage on July 14, 2024. The entire facility was without power in excess of 30 minutes before the generator as manually started.

During the exit conference conducted on July 18, 2024 the above findings were again acknowledged by the management team.

Based on observation and staff interview the facility failed to ensure that appliances are directly plugged into wall outlet receptacles and not power strips. Appliances plugged into power strips could create an overload of the electrical system and could cause a fire which could harm patients and/or staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 "The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code." Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters."

Findings include:

During a facility tour conducted on July 17-18, 2024, revealed a refrigerator and microwave plugged into a power strip in the maintenance room.

During the exit conference on July 18, 2024, the above findings were again acknowledged by the management team.

Based on observation the facility allowed oxygen cylinders to be stored within five feet of combustibles. Allowing oxygen cylinders to be stored near combustible materials could cause harm to the patients and/or staff during a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.3 Cylinder and Container Storage Requirements. 11.3.2 Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3.11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1? 2 hour
Findings include:

Observations made while on tour on July 17-18, 2024, a single unsecured oxygen cylinder being stored next to a rack containing combustible material in a linen closet outside of room 1124.

During the exit conference on July 18, 2024, the above findings were again acknowledged by the management staff.

Based on resident and staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure a residents' care was not neglected. Neglected care could result in increased morbidity for residents.

Findings include:

Resident #48 was admitted on 5/15/23 with diagnoses of depression, anxiety disorder, generalized muscle weakness and difficulty in walking.

A 5 day Minimum Data Set (MDS) dated 12/21/23 included that this resident was cognitively intact and needed partial/moderate assistance with toileting hygiene.

A care plan dated 5/16/23 included that this resident requires Activities of Daily Living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Interventions include to assist with mobility and ADL's as needed.

However, a complaint/Incident Investigation Report dated 2/1/24 included that a resident ".. is stating that on Saturday, January 20, at approximately 9:00 PM, a Certified Nursing Assistant (CNA) came into the room to provider patient care, but was "refusing to change her brief". The resident stated that the Aide was trying to force her to stand up and when patient expressed that she couldn't do it, the CNA threw the brief at the patient and told her to change it herself."

A 5 day facility investigation included an interview with a Licensed Practical Nurse (LPN/#105) dated 1/26/24 at 7:07 AM, which included, "Upon entering residents room, to administer evening medications, the resident was upset and kept asking me why does that CNA hate me. She was very loud and just kept repeating that she could not stand and that they don't believe me when I tell them I can not stand for long and they insist that I stand for them to change my brief. She just kept repeating that and that she had been in the hospital and was bleeding inside and that is why she is weak. I explained to her that no one hates her and that I would talk to them. She was still upset so I informed her that the CNA would be told not to come back in her room and that I would change her brief and assist her with whatever she needed."

This 5 day facility investigation also included an interview that was conducted on 1/22/24 with the Director of Nursing (DON/staff #16) " ...(resident #48) stated that she had the call light on to ask to have her "diaper" changed because she was wet. (resident #48) stated that when the CNA did come in to provide care, the CNA kept demanding her to stand saying, "You're able to stand. I've seen you stand before." Resident #48 said that she kept trying to tell the CNA that her legs were bothering her and she couldn't stand. She further stated that the CNA then threw a diaper at her and said to change herself before walking out of the room. After speaking with resident #48, I met with the roommate. The roommate states that she watched the CNA throw the brief at the patient. This writer asked if the CNA could have been trying to toss the brief onto the bed to gather their supplies in one area, and the roommate denied this as a possibility"

An interview was conducted on February 7, 2023 at 1:23 P.M. with resident #27 who said that about a month ago, her roommate (resident #11) was complaining about the aid not changing her. She said that the aid just handed a brief to her and said you can change herself.

An interview was conducted on February 7, 2023 at 1:55 P.M. with a Certified Nursing Assistant (CNA/staff #55) who said that when checking if a resident needs a brief change, she would ask them if they need help and to check them every 2 hours to see if they need assistance with transferring or hygiene. She said that it is abuse if a resident asks for assistance with brief care and staff refuse.

An interview was conducted on February 7, 2023 at 2:00 P.M. with a Registered Nurse (RN/staff #32) who said that if a resident asks for help, staff have to help them. This nurse said that refusing to help a resident is 100% abuse.

An interview was conducted on February 7, 2023 at 2:09 P.M. with the Executive Director (staff #6) who said that our staff should be responding to residents' requests for help, and checking on them if they have a need for assistance. She said that staff should respond with promptness and assist residents according to their ability, need and care plan. She said that it is not her expectation that the staff would refuse to assist the resident as it would be neglect of care.

A policy titled Abuse - Identification of Types dated 7/18/23 revealed that abuse includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This policy included that in these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s).

Resident #48 was admitted on 5/15/23 with diagnoses of depression, anxiety disorder, generalized muscle weakness and difficulty in walking.

A 5 day Minimum Data Set (MDS) dated 12/21/23 included that this resident was cognitively intact and needed partial/moderate assistance with toileting hygiene.

A care plan dated 5/16/23 included that this resident requires Activities of Daily Living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Interventions include to assist with mobility and ADL's as needed.

However, a complaint/Incident Investigation Report dated 2/1/24 included that a resident ".. is stating that on Saturday, January 20, at approximately 9:00 PM, a Certified Nursing Assistant (CNA) came into the room to provider patient care, but was "refusing to change her brief". The resident stated that the Aide was trying to force her to stand up and when patient expressed that she couldn't do it, the CNA threw the brief at the patient and told her to change it herself."

A 5 day facility investigation included an interview with a Licensed Practical Nurse (LPN/#105) dated 1/26/24 at 7:07 AM, which included, "Upon entering residents room, to administer evening medications, the resident was upset and kept asking me why does that CNA hate me. She was very loud and just kept repeating that she could not stand and that they don't believe me when I tell them I can not stand for long and they insist that I stand for them to change my brief. She just kept repeating that and that she had been in the hospital and was bleeding inside and that is why she is weak. I explained to her that no one hates her and that I would talk to them. She was still upset so I informed her that the CNA would be told not to come back in her room and that I would change her brief and assist her with whatever she needed."

This 5 day facility investigation also included an interview that was conducted on 1/22/24 with the Director of Nursing (DON/staff #16) " ...(resident #48) stated that she had the call light on to ask to have her "diaper" changed because she was wet. (resident #48) stated that when the CNA did come in to provide care, the CNA kept demanding her to stand saying, "You're able to stand. I've seen you stand before." Resident #48 said that she kept trying to tell the CNA that her legs were bothering her and she couldn't stand. She further stated that the CNA then threw a diaper at her and said to change herself before walking out of the room. After speaking with resident #48, I met with the roommate. The roommate states that she watched the CNA throw the brief at the patient. This writer asked if the CNA could have been trying to toss the brief onto the bed to gather their supplies in one area, and the roommate denied this as a possibility"

An interview was conducted on February 7, 2023 at 1:23 P.M. with resident #27 who said that about a month ago, her roommate (resident #11) was complaining about the aid not changing her. She said that the aid just handed a brief to her and said you can change herself.

An interview was conducted on February 7, 2023 at 1:55 P.M. with a Certified Nursing Assistant (CNA/staff #55) who said that when checking if a resident needs a brief change, she would ask them if they need help and to check them every 2 hours to see if they need assistance with transferring or hygiene. She said that it is abuse if a resident asks for assistance with brief care and staff refuse.

An interview was conducted on February 7, 2023 at 2:00 P.M. with a Registered Nurse (RN/staff #32) who said that if a resident asks for help, staff have to help them. This nurse said that refusing to help a resident is 100% abuse.

An interview was conducted on February 7, 2023 at 2:09 P.M. with the Executive Director (staff #6) who said that our staff should be responding to residents' requests for help, and checking on them if they have a need for assistance. She said that staff should respond with promptness and assist residents according to their ability, need and care plan. She said that it is not her expectation that the staff would refuse to assist the resident as it would be neglect of care.

A policy titled Abuse - Identification of Types dated 7/18/23 revealed that abuse includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This policy included that in these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s).

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an injury of unknown origin was reported to the Administrator, and state agency within 24 hours.

Findings include:

Resident #4 was admitted to the facility on December 12, 2023, with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation.

Review of the 5-day Minimum Data Set (MDS) assessment dated December 12, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment.

Review of the facility's investigation report revealed that on December 24, at approximately 12:00 PM, the Resident's daughter approached the nursing station expressing that there was a large bruiser to her mother's face that was not present during her visit the day prior.

Review of State agency documentation revealed the report for this incident was received by the agency on December 27, 2023 at 10:30 AM.

An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON further stated that the facility had 24 hours to report an injury of unknown origin.

A review of facility policy titled 'Abuse - Protection of residents' reviewed July 18, 2023 revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, or not later than 24 hours of the events that caused the allegation do not involve abuse to the Administrator and to other officials including the State survey agency in accordance with State law through established procedures.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident's representative (#4) was able to exercise her rights regarding decisions about the resident's care. This deficient practice could result in resident's or their representatives not being able to make their own healthcare decisions.

Findings include:

Resident #4 was admitted to the facility on December 12, 2023, with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation.

Review of the 5-day Minimum Data Set (MDS) assessment dated December 12, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment.

Review of the facility's investigation report revealed that on December 24, at approximately 12:00 p.m. the Resident's daughter approached the nursing station expressing that there was a large bruiser to her mother's face that was not present during her visit the day prior.

Review of progress notes revealed a nurse's note that detailed the daughter of the resident visiting on Sunday December 24, 2023 and had requested the nurse send the resident to the hospital related to the hematoma that was discovered.

However, review of progress notes further revealed that on December 25, 2023 the daughter was again present at the facility and upset with the facility staff because the resident was still in the facility. A progress note dated December 25, 2023 at 1:18 p.m. detailed the staff called 911 and had the resident sent with emergency services to the hospital. The note further reveals the daughter followed the resident to the hospital.

An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 p.m. The LPN stated that the daughter of the resident had requested her mother be sent to the hospital but "for some reason the nurse didn't do it". The LPN further stated that she was the one who sent the resident to the hospital, and it was on December 25, 2023 after noon.

An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 p.m. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON also stated that she can't speak to why they didn't send her out, and further stated that "we have done in-services on whether the residents have rights to be sent out and how our opinions don't matter." The DON concluded that her expectation is that the staff would follow facility policy.

A review of facility policy titled 'Area of Focus, Resident rights' Reviewed November 27, 2023 revealed that the facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was free from neglect by staff. The deficient practice could result in further incidents of neglect of the residents.

Findings include:

Resident #4 was admitted to the facility on December 12, 2023, with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation.

An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising.

Review of the 5-day Minimum Data Set (MDS) assessment dated December 12, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment.

A review of progress notes revealed that during direct care two staff members had identified a "medium sized hematoma" on the right side of the resident's forehead, and that no report was given to the writer from day shift of any incidents that had occurred that day.

An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 PM. The LPN stated that at the beginning of the shift on the morning of December 25, 2023, it was reported that the resident had a hematoma on the right side of her face. The LPN also stated that "nobody did neuros because nobody knew when it happened".

An interview with a Certified Nursing Assistant (CNA/staff #13) was conducted on January 4, 2024 at 9:15 AM. The CNA stated that the resident was normally very pleasant but confused, and not aggressive. The CNA stated that during rounds at the end of the shift, approximately 6:00 p.m. on Saturday December 23, 2023 no bruising was seen on resident #4.

An interview was conducted with a Registered Nurse (RN/staff #82) on January 4, 2024 at 9:55 AM. The RN stated that when she got the report of the hematoma, she notified the doctor and started a neurological assessment. The RN also stated that the resident was on three separate blood thinners.

However, a review of the clinical record revealed no change of condition assessment and no neurological assessment.

An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON further stated that no neurological assessment was done for this incident. The DON also stated that her expectation of her staff is to follow the facility policies and that there should have been no delay in treatment.

A review of facility policy titled 'Preventing, Reporting, and Investigating Abuse' revised July 2022 revealed that Neglect is a failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an injury of unknown origin was reported to the Administrator, and state agency within 24 hours.

Findings include:

Resident #4 was admitted to the facility on December 12, 2023, with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation.

Review of the 5-day Minimum Data Set (MDS) assessment dated December 12, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment.

Review of the facility's investigation report revealed that on December 24, at approximately 12:00 PM, the Resident's daughter approached the nursing station expressing that there was a large bruiser to her mother's face that was not present during her visit the day prior.

Review of State agency documentation revealed the report for this incident was received by the agency on December 27, 2023 at 10:30 AM.

An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON further stated that the facility had 24 hours to report an injury of unknown origin.

A review of facility policy titled 'Abuse - Protection of residents' reviewed July 18, 2023 revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, or not later than 24 hours of the events that caused the allegation do not involve abuse to the Administrator and to other officials including the State survey agency in accordance with State law through established procedures.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was assessed according to professional standards. The deficient practice could result in a delay of clinically necessary treatment.

Findings include:

Resident #4 was admitted to the facility on December 12, 2023, with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation.

An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising.

Review of the 5-day Minimum Data Set (MDS) assessment dated December 12, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment.

A review of progress notes revealed that during direct care two staff members had identified a "medium sized hematoma" on the right side of the resident's forehead, and that no report was given to the writer from day shift of any incidents that had occurred that day.

An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 PM. The LPN stated that at the beginning of the shift on the morning of December 25, 2023, it was reported that the resident had a hematoma on the right side of her face. The LPN also stated that "nobody did neuros because nobody knew when it happened".

An interview with a Certified Nursing Assistant (CNA/staff #13) was conducted on January 4, 2024 at 9:15 AM. The CNA stated that the resident was normally very pleasant but confused, and not aggressive. The CNA stated that during rounds at the end of the shift, approximately 6:00 p.m. on Saturday December 23, 2023 no bruising was seen on resident #4.

An interview was conducted with a Registered Nurse (RN/staff #82) on January 4, 2024 at 9:55 AM. The RN stated that when she got the report of the hematoma, she notified the doctor and started a neurological assessment.

However, a review of the clinical record revealed no change of condition assessment and no neurological assessment.

An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that no neurological assessment was done for this incident. The DON also stated that her expectation of her staff is to follow the facility policies and that there should have been no delay in treatment.

Review of facility policy titled 'Abuse, Neglect, and Exploitation' reviewed July 18, 2023 revealed Neglect of goods or services may occur when staff are aware, or should be aware of resident's care needs, based on assessment and care planning.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was free from neglect by staff.

Findings include:

Resident #4 was admitted to the facility on December 12, 2023, with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation.

An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising.

Review of the 5-day Minimum Data Set (MDS) assessment dated December 12, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment.

A review of progress notes revealed that during direct care two staff members had identified a "medium sized hematoma" on the right side of the resident's forehead, and that no report was given to the writer from day shift of any incidents that had occurred that day.

An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 PM. The LPN stated that at the beginning of the shift on the morning of December 25, 2023, it was reported that the resident had a hematoma on the right side of her face. The LPN also stated that "nobody did neuros because nobody knew when it happened".

An interview with a Certified Nursing Assistant (CNA/staff #13) was conducted on January 4, 2024 at 9:15 AM. The CNA stated that the resident was normally very pleasant but confused, and not aggressive. The CNA stated that during rounds at the end of the shift, approximately 6:00 p.m. on Saturday December 23, 2023 no bruising was seen on resident #4.

An interview was conducted with a Registered Nurse (RN/staff #82) on January 4, 2024 at 9:55 AM. The RN stated that when she got the report of the hematoma, she notified the doctor and started a neurological assessment. The RN also stated that the resident was on three separate blood thinners.

However, a review of the clinical record revealed no change of condition assessment and no neurological assessment.

An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON further stated that no neurological assessment was done for this incident. The DON also stated that her expectation of her staff is to follow the facility policies and that there should have been no delay in treatment.

A review of facility policy titled 'Preventing, Reporting, and Investigating Abuse' revised July 2022 revealed that Neglect is a failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident's representative (#4) was able to exercise her rights regarding decisions about the resident's care.

Findings include:

Resident #4 was admitted to the facility on December 12, 2023, with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation.

Review of the 5-day Minimum Data Set (MDS) assessment dated December 12, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment.

Review of the facility's investigation report revealed that on December 24, at approximately 12:00 p.m. the Resident's daughter approached the nursing station expressing that there was a large bruiser to her mother's face that was not present during her visit the day prior.

Review of progress notes revealed a nurse's note that detailed the daughter of the resident visiting on Sunday December 24, 2023 and had requested the nurse send the resident to the hospital related to the hematoma that was discovered.

However, review of progress notes further revealed that on December 25, 2023 the daughter was again present at the facility and upset with the facility staff because the resident was still in the facility. A progress note dated December 25, 2023 at 1:18 p.m. detailed the staff called 911 and had the resident sent with emergency services to the hospital. The note further reveals the daughter followed the resident to the hospital.

An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 p.m. The LPN stated that the daughter of the resident had requested her mother be sent to the hospital but "for some reason the nurse didn't do it". The LPN further stated that she was the one who sent the resident to the hospital, and it was on December 25, 2023 after noon.

An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 p.m. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON also stated that she can't speak to why they didn't send her out, and further stated that "we have done in-services on whether the residents have rights to be sent out and how our opinions don't matter." The DON concluded that her expectation is that the staff would follow facility policy.

A review of facility policy titled 'Area of Focus, Resident rights' Reviewed November 27, 2023 revealed that the facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was assessed according to professional standards.

Findings include:

Resident #4 was admitted to the facility on December 12, 2023, with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation.

An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising.

Review of the 5-day Minimum Data Set (MDS) assessment dated December 12, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment.

A review of progress notes revealed that during direct care two staff members had identified a "medium sized hematoma" on the right side of the resident's forehead, and that no report was given to the writer from day shift of any incidents that had occurred that day.

An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 PM. The LPN stated that at the beginning of the shift on the morning of December 25, 2023, it was reported that the resident had a hematoma on the right side of her face. The LPN also stated that "nobody did neuros because nobody knew when it happened".

An interview with a Certified Nursing Assistant (CNA/staff #13) was conducted on January 4, 2024 at 9:15 AM. The CNA stated that the resident was normally very pleasant but confused, and not aggressive. The CNA stated that during rounds at the end of the shift, approximately 6:00 p.m. on Saturday December 23, 2023 no bruising was seen on resident #4.

An interview was conducted with a Registered Nurse (RN/staff #82) on January 4, 2024 at 9:55 AM. The RN stated that when she got the report of the hematoma, she notified the doctor and started a neurological assessment.

However, a review of the clinical record revealed no change of condition assessment and no neurological assessment.

An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that no neurological assessment was done for this incident. The DON also stated that her expectation of her staff is to follow the facility policies and that there should have been no delay in treatment.

Review of facility policy titled 'Abuse, Neglect, and Exploitation' reviewed July 18, 2023 revealed Neglect of goods or services may occur when staff are aware, or should be aware of resident's care needs, based on assessment and care planning.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#10) was free from physical abuse by staff. The deficient practice could result in further incidents of staff to resident abuse.

Findings include:

-Resident #10 was admitted to the facility on March 20, 2020, with diagnoses that include Alzheimer's disease, weakness, aphasia, Bipolar disorder, depression, and anxiety.

A behavioral care plan revised February 6, 2023 revealed the resident was at risk for mobility performance deficit related to Alzheimer's dementia. The goal was to maintain a current level of functional mobility through the next review period, and a noted intervention that staff are to assist her turn and reposition in bed as necessary.

Review of the Quarterly Minimum Data Set (MDS) assessment dated August 22, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had significant cognitive impairment.

A review of the facilities reported incident reports detailed an altercation between a Certified Nursing Assistant (CNA/staff #50), and resident #10 as witnessed by another CNA (CNA/staff #16), stating that when CNA #16 entered the room she witnessed CNA #50 push the patient into the wall, and was yelling at her. When asked what she was doing, CNA #50 stated "you weren't here and didn't hear what she called me. She called me an asshole."

However, a review of the clinical record revealed a progress note detailing the incident dated December 4, 2023 revealed no mention of the previously reported incident, and only noted that the resident stated she didn't remember the incident.

An interview was conducted with a resident (#77) on December 6, 2023 3:20 p.m. The resident stated that CNA #50 has always had an attitude, and can be very rude.

An interview with a CNA (CNA/staff #1) was conducted on December 6, 2023 at 4:25 p.m. The CNA stated that CNA #50 was having a lot of problems working the floor, needed a lot of help, and stated she feels CNA #50 was overwhelmed.

An interview with a CNA (CNA/staff #16) was conducted on December 6, 2023 at 4:37 p.m. The CNA stated that the witnessed statement provided above was accurate. She stated that when she went to answer the call light, she entered the room to see CNA #50 behind the patient with her hands on her back and was pushing her into the window, and then CNA #50 stated it was because the resident had called her a name. CNA #16 then stated she reported the incident to the nurse and then to the Director of Nursing.

An interview with the Director of Nursing (DON/staff #80) was conducted on December, 2023 at 5:05 p.m. The DON stated that CNA #16 had reported the incident appropriately, and that CNA #50 was suspended immediately. The DON also confirmed she is the abuse coordinator and that it was reported timely per state guidelines. She stated her expectation is that her residents are not abused and that any suspicion of abuse is reported timely.

A review of facility policy titled 'Abuse: Protection of residents' reviewed July 18, 2023 revealed that the facility will ensure that all residents are protected from physical and psychosocial harm.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#10) was free from physical abuse by staff. The deficient practice could result in further incidents of staff to resident abuse.

Findings include:

-Resident #10 was admitted to the facility on March 20, 2020, with diagnoses that include Alzheimer's disease, weakness, aphasia, Bipolar disorder, depression, and anxiety.

A behavioral care plan revised February 6, 2023 revealed the resident was at risk for mobility performance deficit related to Alzheimer's dementia. The goal was to maintain a current level of functional mobility through the next review period, and a noted intervention that staff are to assist her turn and reposition in bed as necessary.

Review of the Quarterly Minimum Data Set (MDS) assessment dated August 22, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had significant cognitive impairment.

A review of the facilities reported incident reports detailed an altercation between a Certified Nursing Assistant (CNA/staff #50), and resident #10 as witnessed by another CNA (CNA/staff #16), stating that when CNA #16 entered the room she witnessed CNA #50 push the patient into the wall, and was yelling at her. When asked what she was doing, CNA #50 stated "you weren't here and didn't hear what she called me. She called me an asshole."

However, a review of the clinical record revealed a progress note detailing the incident dated December 4, 2023 revealed no mention of the previously reported incident, and only noted that the resident stated she didn't remember the incident.

An interview was conducted with a resident (#77) on December 6, 2023 3:20 p.m. The resident stated that CNA #50 has always had an attitude, and can be very rude.

An interview with a CNA (CNA/staff #1) was conducted on December 6, 2023 at 4:25 p.m. The CNA stated that CNA #50 was having a lot of problems working the floor, needed a lot of help, and stated she feels CNA #50 was overwhelmed.

An interview with a CNA (CNA/staff #16) was conducted on December 6, 2023 at 4:37 p.m. The CNA stated that the witnessed statement provided above was accurate. She stated that when she went to answer the call light, she entered the room to see CNA #50 behind the patient with her hands on her back and was pushing her into the window, and then CNA #50 stated it was because the resident had called her a name. CNA #16 then stated she reported the incident to the nurse and then to the Director of Nursing.

An interview with the Director of Nursing (DON/staff #80) was conducted on December, 2023 at 5:05 p.m. The DON stated that CNA #16 had reported the incident appropriately, and that CNA #50 was suspended immediately. The DON also confirmed she is the abuse coordinator and that it was reported timely per state guidelines. She stated her expectation is that her residents are not abused and that any suspicion of abuse is reported timely.

A review of facility policy titled 'Abuse: Protection of residents' reviewed July 18, 2023 revealed that the facility will ensure that all residents are protected from physical and psychosocial harm.

Based on clinical record review, staff interviews, review of facility policy and the Lippincott Procedure, the facility failed to ensure assistance with eating was provided for 2 out of 3 sampled residents (#12 and #14). The deficient practice could result in residents having inadequate nutritional status and weight loss.

Findings include:

-Resident #12 admitted on March 7, 2023 with diagnoses of nontraumatic intracranial hemorrhage, dysphagia following cerebral infarction and acute respiratory failure with hypoxia.

The admission/readmission collection tool dated March 7, 2023 revealed the resident had no chewing or swallowing issued evident at this time.

A physician orders dated March 7, 2023 included for the following:
-Regular diet, puree texture, thin consistency diet, condiments with 1:1 supervision for small bites and sips;
-Enteral feeding at 80 ml (milliliters)/hour x 24 hours via pump and to flush with [no specified amount] mL water every [no specified time] hours; and,
-Speech Therapy evaluation and treatment as indicated, one time only for 7 days.

The Cognitive/BIMS (brief interview for mental status) note dated March 8, 2023 revealed the resident was aphasic and cannot answer all questions

The Weight Summary revealed that on March 8, 2023 the resident had a weight of 193.0 lbs. (pounds).

An ADL (activities of daily living) care plan dated March 8, 2023 revealed the resident had performance deficit related to limited mobility, shortness of breath and recent CVA (cerebrovascular accident). The goal was that the resident to improve her current level of function in ADLs. Interventions included the resident was totally dependent on staff for eating and required assistance by staff to eat.

A care plan dated March 8, 2023 revealed the resident at was risk for weight fluctuation related to intracerebral hemorrhage, CVA and dysphagia. Goal was to maintain the resident's current weight. Interventions included assistance with meals as needed.

A physician order dated March 8, 2023 revealed an order to hold enteral feeding beginning 03/10/23.

The skin/wound note dated March 8, 2023 included the resident had right-sided weakness, difficulty verbalizing needs, was working with speech therapy and was on puree diet with enteral feeding orders on hold.

The skilled note dated March 9, 2023 revealed the resident was alert and oriented but was unable to make needs known.

An encounter note dated March 12, 2023 revealed the resident was alert and oriented x 2.

The Weight Summary included that on March 13, 2023 the resident's weight was 199.3 lbs.

The physician order dated March 14, 2023 included an enteral feed order for formula at 60 mL/hr. for 12 hours via pump and to flush with 45 ml water every 1-hour times 20 hours per day.

The Nutrition/Dietary progress note dated March 14, 2023 revealed the resident had a 6-pound weight gain that week; and that, speech therapy felt the resident would consume more if tube feeding were off more. Per the documentation, the resident was encouraged to increase her intake by mouth.

The admission MDS (Minimum Data Set) assessment dated March 17, 2023 revealed that the resident was rarely/never understood, had modified independence with some difficulty in new situations only for cognitive skills for daily decision making; and, required extensive assistance for most ADLs including eating.

A nutrition/dietary note dated March 21, 2023 included the resident had 5 lbs. weight loss this week following a 6 lbs. weight gain the week prior. Further, the documentation included the resident was tolerating tube feeding at night and may consider tube feeding back to 20 hours per day.

The weight recorded for March 27, 2023 was 197.2 lbs.

Review of the March 8 through 31, 2023 MAR (Medication Administration Record) revealed enteral feeding was provided as ordered.

Despite documentation that the resident required assistance with eating, the CNA (certified nursing assistant) documentation from March 8 through April 10, 2023 revealed multiple dates with no documentation to indicate whether or not the resident received assistance with eating. It also revealed multiple dates that identified the resident was independent and/or required setup help only with eating.

There was no evidence found in the clinical record of a reason why the resident was not provided with assistance with eating on dates not marked in the CNA documentation.

-Resident #14 admitted on March 4, 2023 with diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and unspecified protein-calorie malnutrition.

The weight record dated March 4, 2023 was 103.6 lbs.

An ADL care plan dated March 5, 2023 revealed the resident had self-care performance deficit related to disease process, limited range of motion and pain. The goal was that the resident will maintain her current level of function. Interventions included total dependence on 1 staff for eating.

The alert note dated March 5, 2023 included that the resident no longer tolerated tube feeding; and that, G-tube (gastrostomy tube) feeding was stopped per family's request.

The skin/wound note dated March 6, 2023 revealed the resident was suffering from malnutrition and PEG (percutaneous endoscopic gastrostomy) was placed on February 13. Per the documentation the resident was more alert so the NP (nurse practitioner) ordered oral diet and to hold tube feeding.

A Health Status Note dated March 6, 2023 included the resident had been seen by the NP and an order to discontinue tube feeding was received. Per the documentation, the resident had mechanical soft diet with thin liquid; and that, the resident was doing pretty well eating by mouth.

A health status note dated March 8, 2023 revealed the resident was eating better and was more alert than before.

The skilled note dated March 10, 2023 revealed the resident was alert, able to make needs known and required one-person assistance with ADL cares, mobility and transfers.

The admission MDS assessment dated March 11, 2023 revealed the resident had severe cognitive impairment; required extensive assistance for ADLs, including eating; and, received nutritional approaches such as feeding tube and a mechanically altered diet while she was a resident at the facility.

The health status note dated March 13, 2023 included the resident will no longer be under hospice; and that, the resident would be under skilled nursing.

A physician order dated March 14, 2023 included for regular diet puree texture, thin consistency.

The nutrition/dietary note dated March 20, 2023 revealed the resident was on regular puree diet and was on daily nutritional shake.

The skilled note dated March 21, 2023 revealed the resident was alert with increased confusion and required one-person assistance with cares and transfers.

The weight record dated March 22, 2023 was 98.4 lbs. which was 5.01% weight loss since admission.

The nutrition/dietary note dated March 22, 2023 included that NP was informed of the resident's weight loss; and that, resident's family declined hospice.

The skilled note dated March 26, 2023 included that resident was alert with good appetite. According to the documentation, resident pulled out her PEG tube.

The nutrition/dietary note dated March 28, 2023 revealed the resident had a 2 lbs. weight loss this week, PEG tube was "pilled out" and was on daily nutritional shakes. It also included that increased oral intake was encouraged.

The CNA documentation for March 2023 revealed multiple dates with no documentation to indicate whether or not the resident received assistance with eating; there were multiple dates that documented the resident as independent and/or required setup help only with eating.

There was no evidence found in the clinical

Based on clinical record review, staff interviews, review of facility policy and the Lippincott Procedure, the facility failed to ensure assistance with eating was provided for 2 out of 3 sampled residents (#12 and #14).

Findings include:

-Resident #12 admitted on March 7, 2023 with diagnoses of nontraumatic intracranial hemorrhage, dysphagia following cerebral infarction and acute respiratory failure with hypoxia.

The admission/readmission collection tool dated March 7, 2023 revealed the resident had no chewing or swallowing issued evident at this time.

A physician orders dated March 7, 2023 included for the following:
-Regular diet, puree texture, thin consistency diet, condiments with 1:1 supervision for small bites and sips;
-Enteral feeding at 80 ml (milliliters)/hour x 24 hours via pump and to flush with [no specified amount] mL water every [no specified time] hours; and,
-Speech Therapy evaluation and treatment as indicated, one time only for 7 days.

The Cognitive/BIMS (brief interview for mental status) note dated March 8, 2023 revealed the resident was aphasic and cannot answer all questions

The Weight Summary revealed that on March 8, 2023 the resident had a weight of 193.0 lbs. (pounds).

An ADL (activities of daily living) care plan dated March 8, 2023 revealed the resident had performance deficit related to limited mobility, shortness of breath and recent CVA (cerebrovascular accident). The goal was that the resident to improve her current level of function in ADLs. Interventions included the resident was totally dependent on staff for eating and required assistance by staff to eat.

A care plan dated March 8, 2023 revealed the resident at was risk for weight fluctuation related to intracerebral hemorrhage, CVA and dysphagia. Goal was to maintain the resident's current weight. Interventions included assistance with meals as needed.

A physician order dated March 8, 2023 revealed an order to hold enteral feeding beginning 03/10/23.

The skin/wound note dated March 8, 2023 included the resident had right-sided weakness, difficulty verbalizing needs, was working with speech therapy and was on puree diet with enteral feeding orders on hold.

The skilled note dated March 9, 2023 revealed the resident was alert and oriented but was unable to make needs known.

An encounter note dated March 12, 2023 revealed the resident was alert and oriented x 2.

The Weight Summary included that on March 13, 2023 the resident's weight was 199.3 lbs.

The physician order dated March 14, 2023 included an enteral feed order for formula at 60 mL/hr. for 12 hours via pump and to flush with 45 ml water every 1-hour times 20 hours per day.

The Nutrition/Dietary progress note dated March 14, 2023 revealed the resident had a 6-pound weight gain that week; and that, speech therapy felt the resident would consume more if tube feeding were off more. Per the documentation, the resident was encouraged to increase her intake by mouth.

The admission MDS (Minimum Data Set) assessment dated March 17, 2023 revealed that the resident was rarely/never understood, had modified independence with some difficulty in new situations only for cognitive skills for daily decision making; and, required extensive assistance for most ADLs including eating.

A nutrition/dietary note dated March 21, 2023 included the resident had 5 lbs. weight loss this week following a 6 lbs. weight gain the week prior. Further, the documentation included the resident was tolerating tube feeding at night and may consider tube feeding back to 20 hours per day.

The weight recorded for March 27, 2023 was 197.2 lbs.

Review of the March 8 through 31, 2023 MAR (Medication Administration Record) revealed enteral feeding was provided as ordered.

Despite documentation that the resident required assistance with eating, the CNA (certified nursing assistant) documentation from March 8 through April 10, 2023 revealed multiple dates with no documentation to indicate whether or not the resident received assistance with eating. It also revealed multiple dates that identified the resident was independent and/or required setup help only with eating.

There was no evidence found in the clinical record of a reason why the resident was not provided with assistance with eating on dates not marked in the CNA documentation.

-Resident #14 admitted on March 4, 2023 with diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and unspecified protein-calorie malnutrition.

The weight record dated March 4, 2023 was 103.6 lbs.

An ADL care plan dated March 5, 2023 revealed the resident had self-care performance deficit related to disease process, limited range of motion and pain. The goal was that the resident will maintain her current level of function. Interventions included total dependence on 1 staff for eating.

The alert note dated March 5, 2023 included that the resident no longer tolerated tube feeding; and that, G-tube (gastrostomy tube) feeding was stopped per family's request.

The skin/wound note dated March 6, 2023 revealed the resident was suffering from malnutrition and PEG (percutaneous endoscopic gastrostomy) was placed on February 13. Per the documentation the resident was more alert so the NP (nurse practitioner) ordered oral diet and to hold tube feeding.

A Health Status Note dated March 6, 2023 included the resident had been seen by the NP and an order to discontinue tube feeding was received. Per the documentation, the resident had mechanical soft diet with thin liquid; and that, the resident was doing pretty well eating by mouth.

A health status note dated March 8, 2023 revealed the resident was eating better and was more alert than before.

The skilled note dated March 10, 2023 revealed the resident was alert, able to make needs known and required one-person assistance with ADL cares, mobility and transfers.

The admission MDS assessment dated March 11, 2023 revealed the resident had severe cognitive impairment; required extensive assistance for ADLs, including eating; and, received nutritional approaches such as feeding tube and a mechanically altered diet while she was a resident at the facility.

The health status note dated March 13, 2023 included the resident will no longer be under hospice; and that, the resident would be under skilled nursing.

A physician order dated March 14, 2023 included for regular diet puree texture, thin consistency.

The nutrition/dietary note dated March 20, 2023 revealed the resident was on regular puree diet and was on daily nutritional shake.

The skilled note dated March 21, 2023 revealed the resident was alert with increased confusion and required one-person assistance with cares and transfers.

The weight record dated March 22, 2023 was 98.4 lbs. which was 5.01% weight loss since admission.

The nutrition/dietary note dated March 22, 2023 included that NP was informed of the resident's weight loss; and that, resident's family declined hospice.

The skilled note dated March 26, 2023 included that resident was alert with good appetite. According to the documentation, resident pulled out her PEG tube.

The nutrition/dietary note dated March 28, 2023 revealed the resident had a 2 lbs. weight loss this week, PEG tube was "pilled out" and was on daily nutritional shakes. It also included that increased oral intake was encouraged.

The CNA documentation for March 2023 revealed multiple dates with no documentation to indicate whether or not the resident received assistance with eating; there were multiple dates that documented the resident as independent and/or required setup help only with eating.

There was no evidence found in the clinical record of a reason why the resident was not provided with assistance with eating on dates not marked i

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure medication was obtained and available to meet the needs of one resident (#43). The sample size was 5. The deficient practice may result in residents not receiving medications necessary to treat their medical conditions.

Findings include:

Resident #43 readmitted to the facility on 02/08/23 with diagnoses including atherosclerosis of coronary artery bypass graft(s) without angina pectoris, type 2 diabetes mellitus with diabetic neuropathy and hyperlipidemia.

A history of nonrheumatic aortic valve disorder care plan dated 02/01/23 related to a history of myocardial infarction had a goal for the resident to verbalize less difficulty breathing. Interventions included to give medications as ordered.

Review of a physician's order dated 02/08/23 included rosuvastatin calcium (HMG-CoA reductase inhibitor) 40 milligrams (mg) at bedtime for hyperlipidemia.

The admission Minimum Data Set assessment dated 02/12/23 revealed the resident scored 3 on the Brief Interview for Mental Status, indicating severe cognitive impairment. He required extensive 2-person physical assistance for most activities of daily living.

Review of the February 8 - 28, 2023 Medication Administration Record (MAR) revealed 17 out of 21 opportunities for medication administration included the codes "9" or "10" in the space provided for nursing documentation.

Per the Chart Codes key located on the last page of the MAR, code "9" meant the resident was sleeping. Code "10" was an indication of "Other/See Progress Note".

A review of the resident's progress notes revealed documentation including: medication ordered, medication not available, awaiting pharmacy and on order.

According to the MAR, rosuvastatin calcium was administered on 4 out of 21 days in the month: 02/22, 02/23, 02/24 and 02/26.

On 03/13/23 at 8:58 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #45). He stated that the pharmacy will deliver once per shift or 3 times a day. He stated that if he put an order in now, he would typically get the medication that same day or evening. He stated that if the medication did not arrive, the facility has an automated medication dispensing machine (OMNICEL) and usually anything they need will be there. He stated that if a resident's medication was not available in his cart, he would check to make sure it had been ordered, check the bottom of the medication cart where overflow medications are kept, then he would get the medication from the OMNICEL. He stated that if the pharmacy reported that the medication was not available, he would call the provider and ask for an alternate medication. He stated that unless there was a crazy backorder, there would be no reason for the medication not to be available.

An interview was conducted on 03/14/23 at 10:10 a.m. with the Director of Nursing (DON/staff #4). She stated that if the residents' medications were not delivered right away, she would expect nurses to get it from the OMNICEL. She stated that usually medications are delivered within 12 hours. She stated that it did not meet her expectations for resident #43 not to have received his medication. She stated that the nurses should have called the doctor, pharmacy, and/or should have notified her.

The Pharmacy Services and Procedures Manual, revised 01/01/22, included that facility staff should monitor pharmacy communications to address or correct all orders that require clarification before the next scheduled medication delivery, when possible. Facility staff should notify the physician/prescriber of any identified discrepancies in electronically prescribed orders received from the pharmacy and orders entered into the resident's medical record for resolution.

The Administration of Medications policy, revised 02/13/23, included the facility will ensure medications are administered safely and appropriately per physician orders to address residents' diagnoses, signs and symptoms.

Based on clinical record review and staff interviews, the facility failed to ensure that three residents (#17, #67, #275 ) and/or the resident's representative received the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when Medicare services terminated. The sample size was 3. The deficient practice could result in residents not being informed of their potential liability for payment.

Findings include:
Resident #17 was admitted January 27, 2023 with diagnosis including congestive heart failure, metabolic encephalopathy, chronic kidney disease-stage 4, unspecified dementia, and type 2 diabetes mellitus. The resident was discharged to home with home health services on March 6, 2023.

However, review of the clinical record for resident #17 did not reveal the resident and/or the resident's representative had been provided the SNFABN.

Resident #67 was admitted February 10, 2023 with diagnosis including intracapsular fracture of the left femur, severe protein-calorie malnutrition, and pressure ulcer of the sacral region-stage 1. The resident remained in the facility.

However, review of the clinical record for resident #67 did not reveal the resident and/or the resident's representative had been provided the SNFABN.

Resident #275 was admitted September 13, 2022 with diagnosis including cellulitis of buttock, cutaneous abscess of buttock, and type 2 diabetes mellitus. The resident was discharged home on October 11, 2022.

However, review of the clinical record for resident #275 did not reveal the resident and/or the resident's representative had been provided the SNFABN.

An interview was conducted on March 10, 2023 at 8:32 a.m. with the Social Services Director, staff #93. She stated that all residents should be given an ABN (advanced beneficiary notice) in conjunction with the NOMNC (notice of Medicare non-coverage). She stated she is working with the business office to streamline the process and ensure that all applicable residents receive the appropriate notifications. She stated that residents #17, #67 and #275 did not receive an ABN.

An interview was conducted on March 10, 2023 at 8:51 a.m. with the Business Office Manager, staff #57. The business office manager stated that her understanding is that every resident should receive an ABN along with a NOMNC when Medicare Part A services terminate, but is aware that this has not been happening.

An interview was conducted on March 10, 2023 at 1:34 p.m. with the facility administrator, staff #125. The administrator stated that he thought the ABN's were being completed, but found out they had not been when they were requested during the survey. He is stated that his expectation is for each resident, as applicable, to have a signed ABN and NOMNC in place.

Based on observations, staff interviews, and policy review, the facility failed to maintain an environment for residents that was free of pervasive odors. The deficient practice could result in residents not having a homelike environment.

Findings include:

During a facility observation conducted on March 13, 2023 at 09:11 AM, a strong urine odor was noted in the vicinity of resident #38's room. It was noted again at 12:10 PM, and 3:27 PM the same day. On March 14, 2023 the same strong urine odor was noted outside resident #38's room at 9:23 AM, 12:04 PM, and 2:38 PM the same day.

An interview was conducted on March 13, 2023 with the Resident #38 at 12:15 PM. The resident stated that the room always smells of urine and that it comes from her bathroom which is regularly cleaned but the smell remains. She stated that the smell is of urine and stated that it always smells that way.

An interview was conducted on March 15, 2023 at 11:53 AM with a Certified Nursing Assistant (CNA/staff #67), who stated that she has noticed a urine odor this morning but that typically it doesn't smell. She then stated that her nose was clogged and didn't really notice the smell but would get housekeeping. She stated that housekeeping is who they would contact for odors.

An interview was conducted on March 15 at 2:00 PM with the Administrator (staff #125) who stated that he was not aware of the odor in the hallway or the resident's bathroom. He stated he would have housekeeping check the room again and that they try to keep the building free of odors.

Review of the facility policy titled, "Resident Belongings and Home Like Environment' issued January 26, 2023 defines a homelike environment should include the resident's opinion of the living environment. It further states that It is the responsibility of all facility staff to create a "homelike" environment and promptly address any cleaning needs.

Based on review of clinical record review, resident interview, staff interviews, observation, and review of facility policy and procedure, the facility failed to ensure nail care was provided for one resident (#18). The deficient practice could result in residents not receiving necessary care and services to maintain good grooming and personal hygiene

Findings include:

Resident #18 was admitted on November 17, 2014 with diagnosis that included cerebrovascular disease, type 2 diabetes, long term use of insulin, polyneuropathy, neuralgia, neuritis and other symptoms and signs involving the circulatory system.

The MDS (minimum data set) dated December 29, 2022 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. The MDS further did not reveal psychosis or behaviors.

Review of the care plan goal dated February 11, 2023 included that resident #18 has an ADL (activities of daily living) self-care deficit due to left-sided hemiparesis. The noted intervention included that staff will continue to assist and encourage the resident in participation. It further noted that the resident requires assistance with personal hygiene.

A review of the progress notes from February 12, 2023 through March 10, 2023 did not reveal any notation of nail care need or treatment.

A review of the skin care alert forms dated February 20, 2023 through March 9, 2023 revealed no documentation of skin or nail concerns.

An observation on March 9, 2023 at 9:33 a.m. revealed the thumb nail, of resident #18, to be yellowing and long (1/2 inch) above the nail bed. The other nails on both hands were jagged, appearing rough, uneven and splitting.

During an interview with resident #18 on March 9, 2023 at 9:33 a.m. the resident stated that he had asked to have his nails trimmed and staff stated that they don't have time.

During a wound care observation on March 10, 2023 at 10:34 a.m. with a Registered Nurse (RN/staff #126) and the Nurse Practitioner (NP/staff #127), the resident stated that his fingernails still needed to be cut. The NP stated that he would bring it up to the Certified Nursing Assistants (CNA).

However, an observation of resident #18 on March 13, 2023 at 10:11 a.m. revealed that the fingernails had still not been trimmed.

An interview was conducted on March 13, 2023 at 10:21 a.m. with staff #71, a CNA. Staff # 71 stated that the need for nail care is observed at all times, but more specifically during shower time. She stated that if a resident is not diabetic then a CNA can conduct the nail care. If a patient is diabetic then then the CNA would alert the nurse, who would then see the patient and document it. However, there is no documentation of nail care need or treatment evident in the medical record for resident #18.

An interview was conducted with staff #80, an RN, on March 13, 2023 at 11:48 a.m. Staff # 80 stated that generally CNA's identify nail care concerns and either conduct the nail care if the resident is not diabetic or alert the nurse if the resident is diabetic. If it is a more complex case, the RN stated that the DON would be alerted. The RN stated that turn around for nail care is less than a week. The RN stated that if a resident refuses nail care, it would be documented in the progress notes.

An interview conducted on March 13, 2023 with the director of nursing (DON/staff #4). The DON stated that the expectations are that nails are clipped and well-maintained. She stated that refusals for nail care are documented, documentation for the need of nail care should be found in progress notes or the skin care alert forms. She stated the risk of not conducting nail care include the potential for the nails to tear or infection.

The nail care policy dated August 25, 2021 and reviewed August 22, 2022, included the following: Any concerns with skin or nails identified during the completion of nail care should be reported to the nurse who will document and report to the practitioner as needed. Additionally, the policy revealed that fingernails are to be clean and trimmed to avoid injury and infection.

Based on clinical record review, staff interviews and review of policy, the facility failed to ensure one resident (#60) received care and services in accordance with physician's orders, professional standards of practice and his person-centered care plan. The sample size was 23. The deficient practice could increase the risk for complications and/or rehospitalization.

Findings include:

Resident #60 readmitted to the facility on 02/26/23 with diagnoses including urinary tract infection, acute respiratory failure with hypoxia and heart failure.

A physician's order dated 02/24/23 included monitoring for edema every shift for congestive heart failure (CHF).

A physician's order dated 02/25/23 revealed for furosemide (diuretic) 20 milligrams (mg); give one tablet a day for fluid retention for 14 days.

The Admission/Readmission Collection Tool dated 02/26/23 included the resident's most recent weight at 298.2 pounds (lbs).

A physician's order dated 02/26/23 included weight every night shift for CHF before breakfast. Report 3 lb weight gain in a day or 5 lb weight gain in a week to MD.

Review of the Weight Summary dated 02/28/23 revealed the resident weighed 302.4 lbs.

Review of the February 2023 MAR revealed furosemide was administered per orders.

A congestive heart failure care plan initiated 03/02/23 related to weight fluctuations associated with diuretic medications had a goal to have no complications related to peripheral edema. Interventions included to observe and report any signs or symptoms of CHF, including dependent edema of the legs and feet, shortness of breath upon exertion and weight gain.

The March 2023 Medication Administration Record (MAR) revealed that on 03/03 the resident had 1+ edema on day shift and 4+ edema on the night shift. On 03/04 the resident had 4+ edema on both the day and the night shifts. However, review of the clinical record did not indicate that the provider had been notified.

Review of the March 2023 MAR, the resident received daily weights from 03/02 to 03/04.

However, according to the Weight Summary, the resident's weight was not recorded again until 03/05/23.

An orders administration note dated 03/05/23 at 5:33 a.m. included Cardiac/CHF Protocol - Weight every night shift for CHF, before breakfast. Report 3 lb weight gain in a day or 5 lb weight gain in a week to MD. 317.4 lbs.

However, further review of the clinical record did not include documented evidence that the provider had been notified of the 14.8 lb gain within the 5 day period.

Review of the Weight Summary dated 03/06/23 revealed the resident's weight was documented at 317.2 lbs. However, the clinical record gave no indication that the provider had been notified.

On 03/07/23 at 11:39 a.m. a health status note indicated that the resident's right lower leg had increased edema, the weight gain was noted and new orders for furosemide 40 mg twice daily for 3 days were obtained.

A skilled note dated 03/08/23 at 4:00 a.m. included that weight gain was noted with the resident's weight at 320.6 lbs that morning. The note indicated that the provider had been made aware.

On 03/14/23 at 2:04 p.m. an interview was conducted with a Registered Nurse (RN/staff #39). He stated that the resident should be weighed daily per orders. He stated that it would be kind of like a medication error not to weigh the resident. He stated that the Certified Nursing Assistants weigh the residents, then they report to the nurse. He stated that the nurses should have been aware of the changes in the resident's weights and that it should have been reported to the physician.

An interview was conducted on 03/14/23 at 2:19 p.m. with the Director of Nursing (DON/staff #4). She stated that her expectation was that the physician's orders would be followed. She stated that a resident with CHF could go into CHF exacerbation and have complications related to his diagnosis.

The Heart Failure, Long-Term Care policy/procedure, revised January 9, 2023 included that treatment in the older adult should focus on reducing symptoms, reducing hospitalizations and preventing acute exacerbations. Monitoring includes daily and/or weekly weight and monitoring extremities for peripheral edema and other signs and symptoms of fluid overload.

The Change in Status, Identifying and Communicating, Long-Term Care policy/procedure, reviewed 08/19/2022, included that in the long-term care setting, any change from baseline in a resident's status must be identified and addressed. A resident is more likely to return to baseline status and avoid complications when a condition is recognized early so that it can be treated. When a nurse recognizes a potentially life-threatening condition or significant change in a resident's status, the nurse must communicate with other health care providers to meet the resident's needs. The care plan should address the resident's risk factors, allow for rapid identification of a change in status, and define baseline assessment findings. A nursing assistant who notices [changes in a resident's condition] should immediately report them to a nurse. The nurse, in turn, must communicate a resident's change in status, including assessment findings, to the practitioner.

Based on observation, resident and staff interviews, clinical record review, and review of facility policy, the facility failed to ensure one resident (#4) received appropriate catheter care and services in accordance with professional standards. Two residents were reviewed for urinary catheter/Urinary Tract Infection (UTI). The deficient practice could result in complications with indwelling urinary catheters, including infection.

Findings include:

Resident #4 admitted to the facility on 02/20/23 with diagnoses including displaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for routine healing, acute kidney failure with tubular necrosis and a UTI.

An indwelling Foley catheter care plan dated 02/21/23 related to obstructive uropathy had a goal for no complications related to indwelling catheter use. Interventions included catheter care every shift.

A skilled nursing note dated 02/26/23 at 10:36 a.m. included that the resident's Foley catheter was intact and patent and draining yellow urine.

The skilled nursing note dated 02/27/23 at 11:16 a.m. revealed that the resident's urine was positive for klebsiella pneumoniae greater than 1000,000. The note indicated that the results were sent to the provider.

A physician's order dated 02/27/23 included cephalexin (antibiotic) 500 milligrams (mg); give one capsule every 6 hours for UTI for 5 days.

The 5-day Admission Minimum Data Set assessment dated 02/27/23 revealed the resident scored 15 on the brief interview for mental status, indicating intact cognition. She required extensive 1-2 person physical assistance for most activities of daily living and she had an indwelling urinary catheter.

Review of the February 28, 2023 MAR revealed the medication was administered as ordered.

The March 2023 MAR revealed the resident was provided antibiotic medication as ordered, with the exception of 03/04 at 6:00 a.m. when no documentation was provided to indicate whether or not the resident had received the medication.

On 03/05/23 at 10:23 a.m. a skilled nursing note included that the resident's Foley was intact and draining yellow [urine].

A physician's order dated 03/07/23 included for a urinalysis and culture and sensitivity for elevated blood sugars. Review of the MAR indicated the order was completed by night shift on that date.

On 03/09/23 at 1:24 p.m. an interview was conducted with resident #4. She stated that she thinks she has UTIs due to improper cleaning of her catheter. The resident gave permission for observation of catheter care. An observation of her urinary catheter bag revealed a small amount of very cloudy/turbid urine.

An observation of the resident's catheter bag was conducted on 03/10/23 at 10:50 a.m. The urine in the resident's bag was noted to be dark orange with turbidity.

On 03/10/23 at 10:51 a.m. an observation of catheter care was conducted with a Certified Nursing Assistant (CNA/staff #47). The CNA was not observed to perform hand hygiene. She donned clean gloves. The resident's brief was opened for the procedure. The CNA used wipes to clean inside the resident's upper thighs, moving to the labia and finally cleaning the insertion site of the tube. She did not use clean wipes during the process. Once at the insertion site, she held the catheter tubing with one hand and cleaned the tubing with the hand holding the wipes. She was observed to use approximately 4-6 passes up and down the tube to clean. During this process, the CNA identified a medium bowel movement in the resident's brief. She had the resident turn to her side and proceeded to clean the resident's anus and buttocks and removed the soiled brief. The CNA doffed her soiled gloves then applied clean ones without performing hand hygiene. She applied a clean brief to the resident, pulled up the bedding and gathered the trash.

On 03/10/23 at approximately 11:00 a.m. an interview was conducted with CNA staff #47. She stated that another CNA had trained her on how to do catheter care. She stated that this was the way she had been taught and the way she does catheter care each time.

An interview was conducted on 03/10/23 at 11:07 a.m. with a Licensed Practical Nurse (LPN/staff #62). She stated that her process for providing catheter care began with washing her hands and applying clean gloves. She stated that she was taught to use soap and water for the procedure. She stated that she would clean the upper thighs and ensure there was no stool in the resident's brief. She stated that using a clean cloth, she would separate the resident's labia and using a down and out motion she would clean the area. She stated that using a clean cloth, she would clean the insertion site and the tube using a downward motion only. She stated that if an upward motion was used, it could introduce bacteria into the resident's urethra. She stated that the resident would absolutely be at a higher risk for UTI. She stated that utilizing an inappropriate technique for catheter care could additionally place the resident at risk for pain, antibiotic use and rehospitalization.

On 03/10/2023 at 1:57 p.m. a Lab report included the results of the culture and sensitivity. According to the documentation, the resident's urine was positive for klebsiella pneumoniae of greater than 100,000 colony forming units per milliliter.

An infection note dated 03/11/23 at 7:39 a.m. included that the results of the culture and sensitivity were reported to the provider.

An interview was conducted on 03/14/23 at 10:20 a.m. with the Director of Nursing (DON/staff #4). She stated that either nurses or CNAs may complete catheter care. She stated that the CNA will provide peri care prior to catheter care. She stated that either wipes or perineal cleansing spray with wipes would be appropriate, according to preference. She stated that her expectation of the process would include hand hygiene, changing the resident's brief, washing hands with soap and water and donning clean gloves. She stated the performance of catheter care included cleaning the labia, holding the resident with one hand and cleaning with the other. She stated that the expectation is to begin at the "dirty" area and clean away from the body. She stated that the process should be repeated until there is no visible soiling. She stated that when the process is completed, the individual providing care should take off their soiled gloves and wash their hands. She stated that it would not meet her expectations for the caregiver to clean the catheter tubing in an up and down motion.

The Indwelling Urinary Catheter (Foley) Management policy, reviewed 08/22/2022, included that the facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed, including insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures.

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure medication was obtained and available to meet the needs of one resident (#43). The sample size was 5. The deficient practice may result in residents not receiving medications necessary to treat their medical conditions.

Findings include:

Resident #43 readmitted to the facility on 02/08/23 with diagnoses including atherosclerosis of coronary artery bypass graft(s) without angina pectoris, type 2 diabetes mellitus with diabetic neuropathy and hyperlipidemia.

A history of nonrheumatic aortic valve disorder care plan dated 02/01/23 related to a history of myocardial infarction had a goal for the resident to verbalize less difficulty breathing. Interventions included to give medications as ordered.

Review of a physician's order dated 02/08/23 included rosuvastatin calcium (HMG-CoA reductase inhibitor) 40 milligrams (mg) at bedtime for hyperlipidemia.

The admission Minimum Data Set assessment dated 02/12/23 revealed the resident scored 3 on the Brief Interview for Mental Status, indicating severe cognitive impairment. He required extensive 2-person physical assistance for most activities of daily living.

Review of the February 8 - 28, 2023 Medication Administration Record (MAR) revealed 17 out of 21 opportunities for medication administration included the codes "9" or "10" in the space provided for nursing documentation.

Per the Chart Codes key located on the last page of the MAR, code "9" meant the resident was sleeping. Code "10" was an indication of "Other/See Progress Note".

A review of the resident's progress notes revealed documentation including: medication ordered, medication not available, awaiting pharmacy and on order.

According to the MAR, rosuvastatin calcium was administered on 4 out of 21 days in the month: 02/22, 02/23, 02/24 and 02/26.

On 03/13/23 at 8:58 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #45). He stated that the pharmacy will deliver once per shift or 3 times a day. He stated that if he put an order in now, he would typically get the medication that same day or evening. He stated that if the medication did not arrive, the facility has an automated medication dispensing machine (OMNICEL) and usually anything they need will be there. He stated that if a resident's medication was not available in his cart, he would check to make sure it had been ordered, check the bottom of the medication cart where overflow medications are kept, then he would get the medication from the OMNICEL. He stated that if the pharmacy reported that the medication was not available, he would call the provider and ask for an alternate medication. He stated that unless there was a crazy backorder, there would be no reason for the medication not to be available.

An interview was conducted on 03/14/23 at 10:10 a.m. with the Director of Nursing (DON/staff #4). She stated that if the residents' medications were not delivered right away, she would expect nurses to get it from the OMNICEL. She stated that usually medications are delivered within 12 hours. She stated that it did not meet her expectations for resident #43 not to have received his medication. She stated that the nurses should have called the doctor, pharmacy, and/or should have notified her.

The Pharmacy Services and Procedures Manual, revised 01/01/22, included that facility staff should monitor pharmacy communications to address or correct all orders that require clarification before the next scheduled medication delivery, when possible. Facility staff should notify the physician/prescriber of any identified discrepancies in electronically prescribed orders received from the pharmacy and orders entered into the resident's medical record for resolution.

The Administration of Medications policy, revised 02/13/23, included the facility will ensure medications are administered safely and appropriately per physician orders to address residents' diagnoses, signs and symptoms.

Based on observations, staff interviews, clinical record reviews, and policy, the facility failed to ensure the medication error rate was not 5% or greater by failing to administer a medication as ordered for two of three sampled residents (#26 and #48). The medication error rate was 10.71%. The deficient practice could result in additional medication errors.

Findings include:

-Resident #26 readmitted to the facility on 09/08/20 with diagnoses which included primary hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease and major depressive disorder, single episode.

A physician's order dated 12/04/22 included duloxetine HCl (antidepressant) capsule delayed release sprinkle 60 milligrams (mg); give one capsule once daily for depression as evidenced by verbalizing sadness.

On 03/13/23 at approximately 8:56 a.m. an observation of medication administration was conducted with a Licensed Practical Nurse (LPN/staff #45). Per review of the resident's duloxetine medication card, the dose per capsule was identified as 20 mg. Per observation, staff #45 popped two capsules into the medication cup for administration. Staff #45 administered the medication to the resident and documented that the dose was given as ordered.

An interview was conducted on 03/14/23 at 8:58 a.m. with an LPN (staff #41). She reviewed resident #26's medication card containing duloxetine HCl 20 mg. She read the order from the card which stated to give 60 mg or 3 capsules per day. She stated that she had not passed medications to resident #26 yet. Per her review, she stated that she could see that 8 capsules were missing from the card; two correct doses of 60 mg and one dose of 40 mg.

-Resident #48 was readmitted to the facility on 01/24/23 with diagnoses including respiratory failure, atrial fibrillation and type 2 diabetes mellitus without complications.

Review of a physician's order dated 01/20/23 included:
-Folic acid (supplement) 1 mg; give 1 tablet daily for supplement.
-Vitamin D (supplement) 25 micrograms (mcg) (1000 Units); give one tablet daily for supplement.

On 03/14/23 at 8:08 a.m. an observation of medication administration was performed with an LPN (staff #41). During the observation, it was noted that in lieu of folic acid 1 mg, staff #41 obtained the folic acid from a bottle which was identified as 400 mcg and to place it into the medication cup. Later in the observation, staff #41 was noted to pull 50 mcg/2,000 Units of Vitamin D3 instead of 25 mcg/1,000 Units of Vitamin D and place it into the medication cup. Staff #41 administered the medications and supplements to the resident.

An interview was conducted on 03/14/23 at 8:58 a.m. with LPN/staff #41. She reviewed the bottles of supplements and verbalized that she had given the wrong doses of each. She stated that she had not noticed the difference before and would go to Central Supply to get the correct supplements for the resident.

On 03/14/23 at 9:08 a.m. an interview was conducted with the Director of Nursing (DON/staff #4). She stated that her expectation was for medications to be administered as ordered by the physician.

The Administration of Medications policy, revised 02/13/23, included that the facility must ensure that its medication error rates are not 5 percent or greater and that residents are free of any significant medication errors. Staff who are responsible for medication administration will adhere to the 10 rights of medication administration, including the right drug. Every drug administered must have an order from the provider. Compare the order with the medication administration record (MAR) for accuracy. Compare the label on the drug to the information on the MAR three times: before removing the container from the drawer, as the drug is removed from the container, and at the bedside before administering it to the resident. The right dose should be ensured by checking the MAR and the doctor's order before medicating. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering.

Based on observation, staff interviews, and policy, the facility failed to ensure that medications were stored safely and secured in the medication cart. The deficient practice could increase the risk for unsecured medications, including/and/or schedule II - V medications, to be unsecured.

Findings include:

Prior to a medication administration observation conducted on 03/13/23 at 8:31 a.m. a medication cart was identified on the Esperanza hallway near room 2121. A medication cup containing approximately 8 pills was noted on top of the cart. The medication cart was unlocked. The computer on top of the cart had been left open and a resident's private health care information was visible. There were no residents identified in the hallway. The nurse returned to the cart within approximately 3 minutes.

An interview was conducted on 03/13/23 at 8:58 a.m. with a Licensed Practical Nurse (LPN/staff #45). He stated that the earlier situation was not normal. He stated that typically, he does keep his cart locked. He stated that he was supposed to lock his cart with the medications inside and lock the screen on his computer before he stepped away. He stated that he knew the protocol. He stated that he left the cart because a Hospice nurse called him urgently stating her resident was having pain.

On 03/14/23 at 9:08 a.m. an interview was conducted with the Director of Nursing (DON/staff #4). She stated that when a nurse is called urgently for assistance, the nurse should ask the aide to let the resident know that they will be there in a minute. She stated that it would not meet her expectations for nurses to leave medications on top of the cart, leave the cart unlocked and/or leave the screen to their computers open and visible. She stated that doing so would not meet expectations for resident safety and/or could be a HIPAA violation. She stated that the nurses have all been trained.

Based on review of clinical record review, resident interview, staff interviews, observation, and review of facility policy and procedure, the facility failed to ensure care and services were provided for three residents (#18, #60, #4) for nail care assistance, weight monitoring, and catheter care.

Findings include:

Regarding ADL assistance:

Resident #18 was admitted on November 17, 2014 with diagnosis that included cerebrovascular disease, type 2 diabetes, long term use of insulin, polyneuropathy, neuralgia, neuritis and other symptoms and signs involving the circulatory system.

The MDS (minimum data set) dated December 29, 2022 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. The MDS further did not reveal psychosis or behaviors.

Review of the care plan goal dated February 11, 2023 included that resident #18 has an ADL (activities of daily living) self-care deficit due to left-sided hemiparesis. The noted intervention included that staff will continue to assist and encourage the resident in participation. It further noted that the resident requires assistance with personal hygiene.

A review of the progress notes from February 12, 2023 through March 10, 2023 did not reveal any notation of nail care need or treatment.

A review of the skin care alert forms dated February 20, 2023 through March 9, 2023 revealed no documentation of skin or nail concerns.

An observation on March 9, 2023 at 9:33 a.m. revealed the thumb nail, of resident #18, to be yellowing and long (1/2 inch) above the nail bed. The other nails on both hands were jagged, appearing rough, uneven and splitting.

During an interview with resident #18 on March 9, 2023 at 9:33 a.m. the resident stated that he had asked to have his nails trimmed and staff stated that they don't have time.

During a wound care observation on March 10, 2023 at 10:34 a.m. with a Registered Nurse (RN/staff #126) and the Nurse Practitioner (NP/staff #127), the resident stated that his fingernails still needed to be cut. The NP stated that he would bring it up to the Certified Nursing Assistants (CNA).

However, an observation of resident #18 on March 13, 2023 at 10:11 a.m. revealed that the fingernails had still not been trimmed.

An interview was conducted on March 13, 2023 at 10:21 a.m. with staff #71, a CNA. Staff # 71 stated that the need for nail care is observed at all times, but more specifically during shower time. She stated that if a resident is not diabetic then a CNA can conduct the nail care. If a patient is diabetic then then the CNA would alert the nurse, who would then see the patient and document it. However, there is no documentation of nail care need or treatment evident in the medical record for resident #18.

An interview was conducted with staff #80, an RN, on March 13, 2023 at 11:48 a.m. Staff # 80 stated that generally CNA's identify nail care concerns and either conduct the nail care if the resident is not diabetic or alert the nurse if the resident is diabetic. If it is a more complex case, the RN stated that the DON would be alerted. The RN stated that turn around for nail care is less than a week. The RN stated that if a resident refuses nail care, it would be documented in the progress notes.

An interview conducted on March 13, 2023 with the director of nursing (DON/staff #4). The DON stated that the expectations are that nails are clipped and well-maintained. She stated that refusals for nail care are documented, documentation for the need of nail care should be found in progress notes or the skin care alert forms. She stated the risk of not conducting nail care include the potential for the nails to tear or infection.

The nail care policy dated August 25, 2021 and reviewed August 22, 2022, included the following: Any concerns with skin or nails identified during the completion of nail care should be reported to the nurse who will document and report to the practitioner as needed. Additionally, the policy revealed that fingernails are to be clean and trimmed to avoid injury and infection.

Regarding weight monitoring:

Resident #60 readmitted to the facility on 02/26/23 with diagnoses including urinary tract infection, acute respiratory failure with hypoxia and heart failure.

A physician's order dated 02/24/23 included monitoring for edema every shift for congestive heart failure (CHF).

A physician's order dated 02/25/23 revealed for furosemide (diuretic) 20 milligrams (mg); give one tablet a day for fluid retention for 14 days.

The Admission/Readmission Collection Tool dated 02/26/23 included the resident's most recent weight at 298.2 pounds (lbs).

A physician's order dated 02/26/23 included weight every night shift for CHF before breakfast. Report 3 lb weight gain in a day or 5 lb weight gain in a week to MD.

Review of the Weight Summary dated 02/28/23 revealed the resident weighed 302.4 lbs.

Review of the February 2023 MAR revealed furosemide was administered per orders.

A congestive heart failure care plan initiated 03/02/23 related to weight fluctuations associated with diuretic medications had a goal to have no complications related to peripheral edema. Interventions included to observe and report any signs or symptoms of CHF, including dependent edema of the legs and feet, shortness of breath upon exertion and weight gain.

The March 2023 Medication Administration Record (MAR) revealed that on 03/03 the resident had 1+ edema on day shift and 4+ edema on the night shift. On 03/04 the resident had 4+ edema on both the day and the night shifts. However, review of the clinical record did not indicate that the provider had been notified.

Review of the March 2023 MAR, the resident received daily weights from 03/02 to 03/04.

However, according to the Weight Summary, the resident's weight was not recorded again until 03/05/23.

An orders administration note dated 03/05/23 at 5:33 a.m. included Cardiac/CHF Protocol - Weight every night shift for CHF, before breakfast. Report 3 lb weight gain in a day or 5 lb weight gain in a week to MD. 317.4 lbs.

However, further review of the clinical record did not include documented evidence that the provider had been notified of the 14.8 lb gain within the 5 day period.

Review of the Weight Summary dated 03/06/23 revealed the resident's weight was documented at 317.2 lbs. However, the clinical record gave no indication that the provider had been notified.

On 03/07/23 at 11:39 a.m. a health status note indicated that the resident's right lower leg had increased edema, the weight gain was noted and new orders for furosemide 40 mg twice daily for 3 days were obtained.

A skilled note dated 03/08/23 at 4:00 a.m. included that weight gain was noted with the resident's weight at 320.6 lbs that morning. The note indicated that the provider had been made aware.

On 03/14/23 at 2:04 p.m. an interview was conducted with a Registered Nurse (RN/staff #39). He stated that the resident should be weighed daily per orders. He stated that it would be kind of like a medication error not to weigh the resident. He stated that the Certified Nursing Assistants weigh the residents, then they report to the nurse. He stated that the nurses should have been aware of the changes in the resident's weights and that it should have been reported to the physician.

An interview was conducted on 03/14/23 at 2:19 p.m. with the Director of Nursing (DON/staff #4). She stated that her expectation was that the physician's orders would be followed. She stated that a resident with CHF could go into CHF exacerbation and have complications related to his diagnosis.

The Heart Failure, Long-Term Care policy/procedure, revised January 9, 2023 included that treatment in the older adult should focus on reducing sympto

Based on observations, staff interviews, clinical record reviews, and policy, the facility failed to ensure the medication error rate was not 5% or greater by failing to administer a medication as ordered for two of three sampled residents (#26 and #48). The medication error rate was 10.71%. The deficient practice could result in additional medication errors.

Findings include:

-Resident #26 readmitted to the facility on 09/08/20 with diagnoses which included primary hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease and major depressive disorder, single episode.

A physician's order dated 12/04/22 included duloxetine HCl (antidepressant) capsule delayed release sprinkle 60 milligrams (mg); give one capsule once daily for depression as evidenced by verbalizing sadness.

On 03/13/23 at approximately 8:56 a.m. an observation of medication administration was conducted with a Licensed Practical Nurse (LPN/staff #45). Per review of the resident's duloxetine medication card, the dose per capsule was identified as 20 mg. Per observation, staff #45 popped two capsules into the medication cup for administration. Staff #45 administered the medication to the resident and documented that the dose was given as ordered.

An interview was conducted on 03/14/23 at 8:58 a.m. with an LPN (staff #41). She reviewed resident #26's medication card containing duloxetine HCl 20 mg. She read the order from the card which stated to give 60 mg or 3 capsules per day. She stated that she had not passed medications to resident #26 yet. Per her review, she stated that she could see that 8 capsules were missing from the card; two correct doses of 60 mg and one dose of 40 mg.

-Resident #48 was readmitted to the facility on 01/24/23 with diagnoses including respiratory failure, atrial fibrillation and type 2 diabetes mellitus without complications.

Review of a physician's order dated 01/20/23 included:
-Folic acid (supplement) 1 mg; give 1 tablet daily for supplement.
-Vitamin D (supplement) 25 micrograms (mcg) (1000 Units); give one tablet daily for supplement.

On 03/14/23 at 8:08 a.m. an observation of medication administration was performed with an LPN (staff #41). During the observation, it was noted that in lieu of folic acid 1 mg, staff #41 obtained the folic acid from a bottle which was identified as 400 mcg and to place it into the medication cup. Later in the observation, staff #41 was noted to pull 50 mcg/2,000 Units of Vitamin D3 instead of 25 mcg/1,000 Units of Vitamin D and place it into the medication cup. Staff #41 administered the medications and supplements to the resident.

An interview was conducted on 03/14/23 at 8:58 a.m. with LPN/staff #41. She reviewed the bottles of supplements and verbalized that she had given the wrong doses of each. She stated that she had not noticed the difference before and would go to Central Supply to get the correct supplements for the resident.

On 03/14/23 at 9:08 a.m. an interview was conducted with the Director of Nursing (DON/staff #4). She stated that her expectation was for medications to be administered as ordered by the physician.

The Administration of Medications policy, revised 02/13/23, included that the facility must ensure that its medication error rates are not 5 percent or greater and that residents are free of any significant medication errors. Staff who are responsible for medication administration will adhere to the 10 rights of medication administration, including the right drug. Every drug administered must have an order from the provider. Compare the order with the medication administration record (MAR) for accuracy. Compare the label on the drug to the information on the MAR three times: before removing the container from the drawer, as the drug is removed from the container, and at the bedside before administering it to the resident. The right dose should be ensured by checking the MAR and the doctor's order before medicating. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering.

Based on observations, staff interviews, and policy review, the facility failed to maintain an environment for residents that was free of pervasive odors. The deficient practice could result in residents not having a homelike environment.

Findings include:

During a facility observation conducted on March 13, 2023 at 09:11 AM, a strong urine odor was noted in the vicinity of resident #38's room. It was noted again at 12:10 PM, and 3:27 PM the same day. On March 14, 2023 the same strong urine odor was noted outside resident #38's room at 9:23 AM, 12:04 PM, and 2:38 PM the same day.

An interview was conducted on March 13, 2023 with the Resident #38 at 12:15 PM. The resident stated that the room always smells of urine and that it comes from her bathroom which is regularly cleaned but the smell remains. She stated that the smell is of urine and stated that it always smells that way.

An interview was conducted on March 15, 2023 at 11:53 AM with a Certified Nursing Assistant (CNA/staff #67), who stated that she has noticed a urine odor this morning but that typically it doesn't smell. She then stated that her nose was clogged and didn't really notice the smell but would get housekeeping. She stated that housekeeping is who they would contact for odors.

An interview was conducted on March 15 at 2:00 PM with the Administrator (staff #125) who stated that he was not aware of the odor in the hallway or the resident's bathroom. He stated he would have housekeeping check the room again and that they try to keep the building free of odors.

Review of the facility policy titled, "Resident Belongings and Home Like Environment' issued January 26, 2023 defines a homelike environment should include the resident's opinion of the living environment. It further states that It is the responsibility of all facility staff to create a "homelike" environment and promptly address any cleaning needs.

Based on document review and interview, the facility failed to maintain, review and update the Emergency Preparedness (EP) Plan annually. Failure to develop an emergency plan may cause harm to the patients and staff during an emergency.

Findings include;

Based on document review and interview on March 15, 2023, revealed the facility failed to update their EP books at the nurses stations. The north nurses station was last updated on February 7, 2007. The south nurses station was last updated on September 2016. The second floor Esparanza unit nurses station was last updated September 2016.

During the exit conference on March 15, 2023 the above findings were again acknowledged by the management team.

Based on observation and document review the facility failed to ensure the generator was able to switch to emergency power within 10 seconds. Failing to have the emergency generator switch to emergency power within 10 seconds could cause harm to patients and/or staff during a power outage in an emergency egress.
NFPA 99 2012 edition. 6.4.3.1 Source.
The life safety and critical branches shall be installed and connected to the alternate power source specified in 6.4.1.1.4 and 6.4.1.1.5 so that all functions specified herein for the life safety and critical branches are automatically restored to operation within 10 seconds after interruption of the normal source.

Finding include:
Based on observation and document review on March 15, 2023, revealed the facility rental emergency generator failed to transfer to emergency power within 10 seconds in September 2022, October 2022 and November 2022. The transfer times was 15 seconds.

During the exit conference on March 15, 2023, the above finding was again acknowledged by the management staff.

Based on observation the facility failed to have proper signage the special locking exit door located in the facility. Failing to provide manual release of the exit doors could cause harm to patients and/or staff in an emergency

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only." (4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1? 8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:
PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS

Findings include:

Observations made while on tour on March 15, 2023, revealed the south exit door was missing the 15 second delay egress signage.

During the exit conference on March 15, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to conduct a visual inspection of several ABC fire extinguishers and document the visual inspection. Failing to inspect and document on a monthly basis, all the ABC fire extinguishers in the facility could result in harm to the patients and/or staff in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 7, Section 7.2.1 Frequency Section 7.2.1.2 Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30 day intervals. Section 7.2.4 Inspection Record keeping Section 7.2.4.1 Personnel, making the manual inspections shall keep records of all fire extinguishers inspected, including those found to corrective action.

Findings include:

Observations while on tour on March 15, 2023, revealed the facility failed to complete monthly visual inspections of the following fire extinguishers;

one (1) ABC fire extinguisher in the elevator room last dated 11/28/2022
one (1) ABC fire extinguisher outside the boiler room last dated 10/2022
one (1) ABC fire extinguisher at the business office exit door last dated 12/2022
one (1) ABC fire extinguisher in the electrical room in the service hall last dated 12/2022
one (1) ABC fire extinguisher in the outdoor courtyard last dated 12/30/2022

During the exit conference on March 15, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on March 15, 2023, revealed the following;

1) the rated door for the dining room failed to latch when testes 3 of 3 times
2) the rated door for the first floor north elevator had excessive gap on the lower handle side
3) the rate door for the north hall janitor closet next to 1218 had excessive gap on the lower handle side

During the exit conference conducted on March 15, 2023, the above findings were again acknowledged by the management team.

Based on record review and interview the facility failed to provide documentation for (3) three fire drills for 2022. Failing to conducted the fire drills in accordance with the life safety code to familiarize staff with conditions under an actual fire can result in harm to patients and/or staff during a an actual fire or emergency situation.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

Findings include:

Based on record review and interview on March 15, 2023, revealed the facility was missing the following fire drills;

1) third quarter third shift 2022
2) fourth quarter first shift 2022
3) third quarter third shift 2022

During the exit conference conducted on March 15, 2023, the above findings were again acknowledged by the management team. .

Based on interview and document review the facility failed to conduct, maintain and document electrical receptacle testing in patient care areas specifically to the patient care rooms throughout the facility. Failing to test the receptacles could lead to an ignition hazard in a patient care area resulting in fire and/or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction. NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

Findings include:

Based on interview and document review on March 15, 2023, revealed the facility failed to provide documentation on the annual receptacle testing. The facility was unable to provide documentation for 2022.

During the exit conference on March 15, 2023, the above finding was again acknowledged by the management team.

Based on observation and document review the facility failed to ensure the generator was permanently mounted. Failing to have the emergency generator permanently mounted could cause harm to patients and/or staff during an emergency.
NFPA 110 2010 edition Section 7.4 Mounting.
7.4.1 Rotating energy converters shall be installed on solid foundations to prohibit sagging of fuel, exhaust, or lubricating-oil piping and damage to parts resulting in leakage at joints.
7.4.1.1 Such foundations or structural bases shall raise the engine at least 150 mm (6 in.) above the floor or grade level and be of sufficient elevation to facilitate lubricating-oil drainage and ease of maintenance.
7.4.2 Foundations shall be of the size (mass) and type recommended by the energy converter manufacturer.
7.4.3 Where required to prevent transmission of vibration during operation, the foundation shall be isolated from the surrounding floor or other foundations, or both, in accordance with the manufacturer's recommendations and accepted structural engineering practices.
7.4.4 The EPS shall be mounted on a fabricated metal skid base of the type that shall resist damage during shipping and handling. After installation, the base shall maintain alignment of the unit during operation.

Finding include;
Based on observation and document review on March 15, 2023, revealed the facility has had a rental emergency generator for over (3) three years. The facility provided a rental agreement from Power Plus dated March 2, 2020. The facility said their corporate office was looking at purchasing a new generator. Last year there was a rental generator at the facility. The staff said they received the rental just prior to last survey on March 2, 2022.

During the exit conference on March 15, 2023, the above finding was again acknowledged by the management staff.

Based on record review and staff interview the facility failed to provide documentation upon request the required annual load bank test of the emergency generator. Failure to test the emergency generator as required could result in harm to patients during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 8, Section 8.4.2.3 "Diesel powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 20 continuous minutes and at not less than 75 percent of the EPS kW rating for 1 continuous hour for a total test duration of not less the 1.5 continuous hours.

Findings include:

Based on record review and staff interview on March 15, 2023, revealed the following;

1) the facility failed to provide documentation for the rental generator annual inspection upon request
2) the facility was missing (3) three monthly load transfers (December 2022, January 2023, and February 2023)

During the exit conference conducted on March 15, 2023, the above findings were again acknowledged by the management team.

Based on observation, the facility failed to ensure that staff did not use daisy chain power strips (power strip plugged into power strip). The use of daisy chained power strips could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area.

Findings include:

Observations made while on tour on March 15, 2023, revealed the following;

1) two (2) power strips plugged into one another in the facility central supply
2) a refrigerator plugged into a power strip in the wound care office
3) a microwave oven was plugged into a power strip in the second floor (Esperanza) nurses station

During the exit conference conducted on March 15, 2023, the above findings were again acknowledged by the management team.