Archstone Care Center

Based on documentation, staff and resident interviews, and policy and procedures the facility failed to ensure that one resident (#1) received adequate supervision and care, during perineal care, to prevent accidents.

Findings include:

Resident #1 was most recently admitted on December 14, 2023 with diagnosis including: encephalopathy, extended spectrum beta lactamase resistance, unspecified fracture of the right ilium, subsequent encounter for fracture with routine healing, acute kidney failure, anemia in chronic kidney disease, acute embolism and thrombosis of unspecified deep veins of right lower extremity, type 2 diabetes, non-pressure chronic ulcer of other part of right lower leg with unspecified severity, muscle weakness, need for assistance with personal care, polyneuropathy, pressure ulcers of left heel-unstageable, chronic pain syndrome, retention of urine, chronic kidney disease stage 2, poly-osteoarthritis, essential hypertension, diastolic congestive heart failure, and morbid obesity. It was noted that the resident was discharged to the hospital on January 04, 2024.

A review of the admission MDS (minimum data set) dated December 20, 2023 revealed a BIMS (brief interview of mental status) score of 10, indicating moderate cognitive impairment. The MDS further revealed that the resident had no noted behaviors, was totally dependent for toileting needs and personal hygiene. It was further noted that the resident had falls in the last 2-6 months prior to admission.

A review of the care plan revealed a focus area for falls initiated on September 27, 2023, noting that the resident was at risk for falls. Interventions included to anticipate and meet the resident's needs, placing the call light within reach and educating on use thereof and safety, encouraging good footwear usage, following facility fall protocol and reviewing past falls to determine root cause. The care plan noted to assist with ADL's (activities of daily living) as needed but did not specify a 2-person assist.

A review of the facility's fall assessment dated January 4. 2024 revealed that the resident was a moderate fall risk. It further noted that the bed was placed in the lowest position, that call light and water were in place and within reach.

A review of the progress notes revealed that the resident had a witnessed fall on January 4, 2024. A, post fall, nursing assessment revealed no outwardly noted injuries and that the appropriate notifications transpired. The incident note in the progress notes further stated that that the CNA (certified nursing assistant) was performing peri care on the resident and proceeded to turn the resident to the left when the resident rolled out of bed and landed on her knees. It was noted that the resident did not hit her head and had been assessed for injuries. Notes stated that the resident was alert and oriented. It was documented that the physician and POA (power of attorney) were notified and that x-rays had been ordered. However, x-rays not able to be completed at the facility; therefore, the resident was sent to the hospital, per the progress notes.

A review of the fall and fall prevention training documentation, revealed that a training was conducted on April 16, 2023; however, there was no evidence that staff #87 had participated in the training.

Hospital records were requested, but had not been received.

An interview was conducted on October 9, 2024 at 11:50 A.M. with staff #64 RN (registered nurse). Staff #64 stated that she recalled the incident of when resident #1 had rolled off the bed, but had not observed it. She stated that a post-fall incident assessment had been conducted and that notifications had transpired. She stated that she had later assisted with calling the hospital as the resident had been yelling out in pain. Staff #64 stated that she recalled having had peri care training and fall prevention training when she had initially started as a CNA in November of 2017 and a few thereafter but was unable to recall if she had either training last year.

An interview was conducted on October 9, 2024 at 12:15 A.M with staff #106, DON (director of nursing), who provided fall and fall prevention in-service documentation. When asked about missing signatures on the sign-off, she stated that either staff did not attend or forgot to sign-off. She stated that oversight of the training documentation, at the time, was conducted by another staff member who is no longer at the facility. She stated that the risk would include staff not having received the necessary training. She further stated that she is now tracking all training and verify for completeness as well as conducting audits to ensure and verify understanding of the required trainings.

Another interview was conducted with staff #106 DON regarding skills training for staff #87. Staff #106 stated that no skills training or annual performance review was conducted for staff #87 in 2023. A further review of the staff file revealed that although there was no evidence of an annual performance review a skills checklist was evident with a completion date of December 5, 2023; however individual topics did not denote a completion date-only the overall date was indicated.

A subsequent interview was conducted on January 4, 2024 at 1:48 P.M. with staff #106 DON (director of nursing). Staff #106 stated that peri-care for a resident with a diagnosis of morbid obesity should always be a 2-person assist; however resident #1 was noted to have only been assisted by 1 CNA on January 4, 2024. She further stated that resident #1 was designated as a Hoyer lift transfer and therefore should have been a 2-person assist for peri care. She stated that the risk for not utilizing 2-staff members for peri care could include potential injuries or falls. Staff #106 further stated that fall management training is conducted annually. However, in reviewing the documentation of training, was unable to initially find documentation for fall management training in 2023. When the sign-off documentation was found it did not contain signatures or sign-off documentation for staff #87. Staff #106 stated that the risk for incomplete training could include not knowing about a change of condition and when to refer forward to therapy when that does happen. She stated that a change of condition might also be the cause a fall and without fall management training might not be recognized by staff. She further stated that her expectation was that policy was followed at all times when providing resident care and the risk for not doing so could result in resident injury.

A telephonic interview was conducted on October 9, 2024 at 2:33 P.M. with staff #87 CNA. Staff #87 stated that on January 4, 2024 she had been performing peri care on resident #1. She stated that the resident was in bed on her left side and she was standing behind her on the other side of the bed. She stated that she made sure that the resident was secure. She stated that the resident's legs were stacked above each other, when the right leg slipped and dropped. She stated that the resident had her enabler bars in place and she was still behind her, when the resident's lower half of the body slipped from the bed, but upper half of the body remained on the bed. She stated that the resident landed on her knees and that she called out for help. Staff #87 stated that that the criteria for assisting residents with a diagnosis of morbid obesity includes having 2 -staff present if you can, but thought it was okay to do it by herself. She stated that in hind-sight having had another person there to assist would have been helpful, but stated that she couldn't find anyone. When asked if there were staffing concerns that day, she stated that she thought they were fully staffed that day with 3 CNA on that unit a

Based on personnel record reviews, staff interviews, and policy and procedures, the facility failed to ensure that one out of two Certified Nursing Assistants, (CNA/#106), sampled received in-services and training for at least 12 hours per year. The deficient practice failed to ensure the continuing competence of the CNA.

Based on personnel record reviews, staff interviews, and policy and procedures, the facility failed to ensure that one out of two Registered Nurses (RN/#33) sampled received in-services and training for at least 12 hours per year. The deficient practice failed to ensure the continuing competence of the RN.

Findings include:

Review of the personnel file for CNA, (staff #106), revealed a hire date of October 11, 2022. Further review of the training from October 2022 to October 2023, revealed no evidence of in-service training for Communication and Dementia. The review did reveal completed in-service training for Abuse and Neglect and Resident Rights.

Review of the personnel file for RN, (staff #33), revealed a hire date of October 7, 2022. Further review of the training from October 2022 to October 2023 revealed no training had been completed.

An interview was conducted on October 12, 2023 at 09:35 AM, with Director of Nursing, (DON staff #12). He stated that orientation and training for skills is provided upon hire. He also stated that in-services are provided monthly at staff meetings and that CNA (staff #106), did not have documentation that dementia training was completed since hire date. He did provide an in-service sign in sheet dated February 12, 2023, with CNA (staff #106) signature, but the in-service was for Abuse, Neglect, Misappropriation of Property, Elder Justice and Resident Rights. He stated he did not have documentation for any dementia in-service training for her.

An interview was conducted on October 12, 2023 with DON (staff #12). He stated an employee audit revealed
RN (staff #33), had not completed training, TB testing or fingerprint clearance. He stated he had a phone conversation with her on October 11, 2023. He stated she refused to obtain her fingerprint clearance card. As a direct result of this refusal, her employment was terminated on October 11, 2023.

Review of the facility's Sufficient and Competent Nurse Staffing revealed licensed nurses and nursing assistants are trained and monitored by nursing leadership to ensure programming for staff training results in nursing competency and gaps in education are identified and addressed. Skills in the following areas but not limited to: Resident Rights, Behavioral Health, Psychosocial Care, Dementia Care, Person Centered Care, Communication, Basic Nursing Skills, Basic Restorative Services, Skin and Wound Care, Medication Management, Pain Management, Infection Control, Identification of Changes in Condition, and Cultural Competency.

Based on personnel record review, staff interviews, and policy review, the facility failed to provide evidence that two employees (staff #119 and staff #83) were free from infectious tuberculosis (TB).

Findings include:

Review of the personnel record for Licensed Practical Nurse (LPN/staff #119), on October 12, 2023, revealed a hire date of September 4, 2023. Review of the file did not include verification that the LPN had been screened and deemed free from infectious TB. Review of the file further showed that that the LPN was scheduled to have her screening done on October 12, 2023.

Review of the personnel record for LPN (staff #83), on October 12, 2023, revealed a hire date of November 15,2018. Review of the file did not include verification that the LPN had been screened and deemed free from infectious TB. Review of the file further showed that the LPN was scheduled to have her screening done on
October 10, 2023.

An interview with Director of Nursing, (DON staff #12), was conducted on October 12, 2023 at 09:35 AM. He stated he is aware of the regulation that new employees need to have a baseline TB/two step test done, and an annual questionnaire. Previous to the change in January 2023, the facility's policy was to have the two step test completed before start date. However, he cannot explain why LPN (staff #119), had not had her testing completed previously. He also stated staff #119 is scheduled to have a blood draw on October 12, 2023.

An interview was conducted with DON (staff #12) on October 12, 2023, He stated that LPN (staff #83) had stated she needs a chest x-ray for her TB screening. He knows she had an x-ray in the 1970's, but can't explain why other x-rays have not been completed. He stated they had scheduled her for a blood draw on October 10, 2023.

Based on employee personnel record review, staff interviews, and policy and procedures, the administrator failed to ensure that documentation of a fingerprint clearance card was maintained in the personnel record for two employees (staff #33 and staff # 106).

Findings include:

Review of the personnel file for a Registered Nurse, (RN staff # 33), revealed a hire date of October 7, 2022. Further review of the personnel file revealed no evidence of fingerprint clearance card.

Review of the personnel file for a Certified Nursing Assistant, (CNA staff #106), revealed a hire date of
October 11, 2022. Further review of the personnel file revealed no evidence of fingerprint clearance card.

An interview was conducted on October 12, 2023, with Director of Nursing, (DON staff #12). He stated that staff who have direct contact with residents are required to have a fingerprint clearance. He stated that RN (staff #33) required a fingerprint clearance in her current position and she had refused. He stated that RN (staff #33) had been terminated on October 11, 2023 for refusal to complete fingerprint clearance. He stated regarding
CNA (staff #106), he did not know why she did not have a fingerprint clearance card. He stated she loses things easily, so that could be the reason why, but he would follow up with her.

The facility's policy, Background Screening Investigations, revised March 2019, stated the Director of Personnel, or other designee, will conduct background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment.

Based on personnel record reviews, staff interviews, and policy and procedures, the facility failed to ensure that one out of two Certified Nursing Assistants, (CNA/#106), sampled received in-services and training for at least 12 hours per year. The deficient practice failed to ensure the continuing competence of the CNA.

Based on personnel record reviews, staff interviews, and policy and procedures, the facility failed to ensure that one out of two Registered Nurses (RN/#33) sampled received in-services and training for at least 12 hours per year. The deficient practice failed to ensure the continuing competence of the RN.

Findings include:

Review of the personnel file for CNA, (staff #106), revealed a hire date of October 11, 2022. Further review of the training from October 2022 to October 2023, revealed no evidence of in-service training for Communication and Dementia. The review did reveal completed in-service training for Abuse and Neglect and Resident Rights.

Review of the personnel file for RN, (staff #33), revealed a hire date of October 7, 2022. Further review of the training from October 2022 to October 2023 revealed no training had been completed.

An interview was conducted on October 12, 2023 at 09:35 AM, with Director of Nursing, (DON staff #12). He stated that orientation and training for skills is provided upon hire. He also stated that in-services are provided monthly at staff meetings and that CNA (staff #106), did not have documentation that dementia training was completed since hire date. He did provide an in-service sign in sheet dated February 12, 2023, with CNA (staff #106) signature, but the in-service was for Abuse, Neglect, Misappropriation of Property, Elder Justice and Resident Rights. He stated he did not have documentation for any dementia in-service training for her.

An interview was conducted on October 12, 2023 with DON (staff #12). He stated an employee audit revealed
RN (staff #33), had not completed training, TB testing or fingerprint clearance. He stated he had a phone conversation with her on October 11, 2023. He stated she refused to obtain her fingerprint clearance card. As a direct result of this refusal, her employment was terminated on October 11, 2023.

Review of the facility's Sufficient and Competent Nurse Staffing revealed licensed nurses and nursing assistants are trained and monitored by nursing leadership to ensure programming for staff training results in nursing competency and gaps in education are identified and addressed. Skills in the following areas but not limited to: Resident Rights, Behavioral Health, Psychosocial Care, Dementia Care, Person Centered Care, Communication, Basic Nursing Skills, Basic Restorative Services, Skin and Wound Care, Medication Management, Pain Management, Infection Control, Identification of Changes in Condition, and Cultural Competency.

Based on observation and staff interview the facility failed to have a kitchen hood system and a fire suppression system for a deep fat fryer in the kitchen, in accordance with NFPA 96. Failing to install a kitchen hood system increases the build-up of grease and could provide fuel for a fire. A fire in the kitchen has potential to harm the patients and/or staff.

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."

Observations made while on tour on October 18, 2023, revealed a deep fat fryer on a table in the kitchen. The deep fat fryer was not under the commercial kitchen hood and was not protected by a suppression system.

During the exit conference on October 18, 2023, the above findings were acknowledged by the management staff.

Based on observation the facility failed to maintain rated fire 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 8, Section 8.3.3.1 Fire Doors and Windows, "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code."

NFPA 80, Fire Doors and Other Opening Protectives Section 5.1.5 Repairs and Field Modifications. 5.1.5.1 Repairs shall be made, and defects that could interfere with operation shall be corrected without delay. Section 5.1.5.2.1, "In cases where a field modification to a fire door or a fire door assembly is desired, the laboratory with which the product or component being modified is listed shall be contacted and a description of the modifications shall be presented to that laboratory." Section 5.1.5.2.2 "If the laboratory finds that the modifications will not compromise the integrity and fire resistance capabilities of the assembly, the modifications shall be permitted to be authorized by the laboratory with a field visit from the laboratory."

Findings include:

Observations made while on tour on October 18, 2023, revealed the following;

1) the rated fire door identified as "House Keeping, Dietary, Maintenance" for the service hall had been damaged and had a field repair bottom hinge. The door had other damaged areas on it
2) the rated fire door in the corridor near the beauty salon was missing the latching hardware on one of the leafs

During the exit conference conducted on October 18, 2023, the above findings were again acknowledged by the management team.

Based on interview and record review the facility failed to inspect and maintain the facilities smoke dampers or fusible links. Failing to inspect and maintain the facility smoke dampers may cause harm to the residents and/or staff during an emergency.

NFPA 101 Life Safety Code, 2012 Edition Chapter 21, section 21.5.2.1 "Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications" Section 9.2.1 " Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90 A." "Standard for Installation of Air Conditioning and Ventilating Systems, NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 90 A 2012 Edition Section 5.4.8 Maintenance Section 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80 Standard for Fire Doors and Other opening Protective's. Section 5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 80 Standard for Fire Doors and Other opening Protective's Chapter 19 Installation, Testing, and Maintenance of Fire Dampers, Section 19.4* Periodic Inspection and Testing The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every six years. Section 19.4.4 if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. Section 19.4.5 The operational test of the fire damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. Section 19.4.6 The damper frame shall not b penetrated by any foreign objects that would effect fire damper operations. Section 19.4.7 The fusible link shall be reinstalled after testing is complete. Section 19.4.8.1 if the link is damaged or painted, it shall be replaced with a link of the same size, temperature and rating. Section 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's. NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's Chapter 6 Installation, Testing and Maintenance smoke dampers. Section 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except hospitals, where the frequency shall be every 6 years. Section 6.5 Periodic Inspection and Testing. Section 6.5.11 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 6.5.11

Findings include:

Based on interview and record review on October 18, 2023, the facility was unable to provide documentation the smoke dampers had been inspected. The last documented inspection was in January 2017.

During the exit conference conducted on October 18, 2023, the above findings were again acknowledged by the management staff.