HILLCREST CARE CENTER

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/31/2023 and 08/06/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/24/2023 and 07/30/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/17/2023 and 07/23/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit survey was completed form 5/24/23 to 5/25/23 for all previous deficiencies cited on 3/30/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed form 5/24/23 to 5/25/23 for all previous deficiencies cited on 3/30/23. The facility is in compliance with all regulations surveyed.

An onsite revist was completed on 5/24/23 to 5/25/23 with all deficiencies being corrected.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (111) wood framed structure. The facility is protected throughout the first floor by a wet fire sprinkler system and a dry-pipe system in the attic space and is classified as Fully Sprinklered. The facility was constructed in 2000 and is license for 45 beds. This re-certification survey conducted on April 14, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies". The survey outcome was discussed with the Maintenance Director at the end on-site survey. No deficiencies found. No action required.

A licensure survey was completed on 3/27/23 to 3/20/23. Two deficiencies were cited.

Based on record review and interviews, the facility failed to report an occurrence to the State survey agency in accordance with State law for one (#34) of three reviewed out of 29 sample residents. Specifically, the facility failed to report Resident #34's brain injury. Findings include:I. Resident #34A. Resident statusResident #34, age 97, was admitted on 1/31/19. According to the January 2023 computerized physician orders (CPO) diagnoses included type 2 diabetes mellitus, dementia and chronic obstructive pulmonary disease (COPD). According to the 12/28/22 facility assessment revealed the resident was severely cognitively impaired with deficits in long and short term memory. The resident was totally dependent with the assistance of two people for bed mobility, toileting, personal hygiene, totally dependent with the assistance of one person for eating and extensive assistance of two people with transfers and dressing. B. Record reviewThe 12/14/22 nursing progress note documented, "Called to resident room due to resident fall, Observed resident laying on her left side on the floor beside her wheelchair. Her feet were towards her desk and head toward the bathroom, she was between the wheelchair and another chair in her room. Observed bruise with bump to the center of her forehead. Call placed for 911. Notified hospital nurse and daughter/power of attorney. Explained to the daughter that the resident was not responding and that she had hit her head with a bump and bruising noted."Documentation was requested from the facility on 3/30/23 that the brain injury had been reported to the State Agency, however it was not reported (see interviews below). III. Staff interviewsThe director of nursing (DON) was interviewed on 3/30/23 at 3:30 p.m. She said that after a fall with a head injury with loss of consciousness, the process included a charge nurse head to toe assessment, activation of 911, notification family, power of attorney (POA), on-call physician and reported it to the State. The NHA was interviewed on 3/30/23 at 3:50 p.m. She said after a resident fell with a head injury with loss of consciousness, the resident was assessed by the registered nurse, sent to the emergency room, physician family and POA. The DON and NHA would then be notified and they would review the occurrence manual on when to report. She confirmed that there was a breakdown in communication on reporting the occurrence.

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

A recertification survey was completed from 3/27/23 to 3/30/23. Eight deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/27/23 to 3/30/23. Twelve deficiencies were cited.

Based on record review and interviews, the facility failed to establish and maintain a comprehensive emergency preparedness (EP) program that met all of the standards specified within the condition/requirement. To include a comprehensive approach to meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation; and maintain and up to date plan that addressed how the facility would coordinate with other healthcare facilities, as well as the whole community during an emergency or disaster (natural, man-made, facility). This failure had the potential to affect 31 residents. Specifically, the facility failed to maintain the facilities EP program to meet regulatory requirements. The facility failed to:-Review and update their emergency preparedness program annually, and provide documented evidence of the annual review and documentation of required updates made to the elements of the EP program based on the annual review;-Ensure the EP program included and up to date comprehensive approach to meet the health and safety needs of the identified patient population, as identified in the updated facility assessment;-Ensure the EP program included and up to date all hazards approach, for the facility's specific location that was based on an up to date risk assessment; and, -Ensure the EP program addressed the challenges the patient population would face in an emergency. Findings include: The emergency preparedness program binder was reviewed with the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. The binder was incomplete, several required elements were missing and the facility failed to show documented proof that the plan was reviewed, maintained and updated in the last 12 months. An undated document in the EP plan binder read in pertinent part: The purpose of the (facility name) Emergency Operations Plan (EOP) is to improve the capacity to detect, respond to, recover from, and mitigate (ease) the negative outcomes of threats and emergencies. The (facility name) Emergency Operations Plan establishes a basic emergency plan to provide timely, integrated, and coordinated response to the wide range of natural and manmade events that may disrupt normal operations and require pre-planned response to internal and external incidents. The NHA acknowledged the facility had a priority to update the emergency preparedness manual for the previous leadership, but they had not yet had a chance to review and update the emergency preparedness program. The EP program was approved 10/20/2020 and last reviewed and updated on 10/17/21. The EP program had not been maintained since 10/17/21.

Based on record review and interviews, the facility failed to conduct an annual update of the required facility-based and community-based risk assessment, utilizing an all-hazards approach; and include strategies for addressing emergency events identified by the risk assessment. This failure had the potential to affect 31 residents. Specifically, the facility failed to:-Conduct an annual facility based and community based risk assessment; and incorporate the identified risks into the facility emergency preparedness (EP) program; and,-Identify how the identified risk and potential hazards are likely to impact their geographical region, community, facility and patient population. Findings include: The emergency preparedness plan was provided by the nursing home administrator (NHA) on 3/4/21 at 11:56 a.m. The plan was last reviewed and updated by the facility on 10/17/21. The community based risk assessment was last conducted January 2020. I. Facility policy The Emergency Preparedness Plan policy implemented 10/20/2020, documented in pertinent part: "This facility maintains a written emergency preparedness plan that complies with relevant regulations for plan development. The plan is reviewed and updated at least annually.-The plan will be based on and include a documented, facility and community-based risk assessment utilizing an all hazards approach, including missing residents. The plan will include strategies for addressing emergency events identified by the risk assessment.-The plan will consider, among other things, the following:a. All business functions essential to the facility's operations that should be continued during an emergency;b. All risks or emergencies that the facility may reasonably expect to confront;c. All contingencies for which the facility should plan;d. The facility's location;e. Assessment of the extent to which natural or man-made emergencies may cause the facility to cease or limit operations; andf. What arrangements may be necessary with other health care facilities, or other entities that might be needed to ensure that essential services could be provided during an emergency." II. Hazard vulnerability analysis (community based risk assessment) The Community Based Risk Assessment documented, dated 1/28/2020, did not provide assessment or consideration for emerging infectious diseases for epidemic/pandemic outbreaks. Record review and interview during the survey revealed the facility had prior exposure to the Coronavirus disease (COVID-19) pandemic established in 2020; and the facility was just getting over a COVID-19 facility outbreak, at the start of the survey 3/27/23. -The facility did not update their vulnerability assessment to reflect they were at high risk for an epidemic/pandemic or make required annual updates to the EP program.

Based on record review and staff interviews, the facility failed to develop and maintain an emergency preparedness (EP) plan which includes a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials efforts to maintain an integrated response during a disaster or emergency situation. Specifically, the facility failed to:-Identify and define a process for an integrated response documenting how the facility would collaborate efforts with local, State, and Federal emergency preparedness officials and combine efforts to maintain an integrated response during a disaster or emergency situation; and,-Including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. Findings include: I. Facility plan The emergency preparedness plan was provided by the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. II. Facility policy The Emergency Preparedness Plan policy implemented 10/20/2020, documented in pertinent part: "The facility will collaborate with local, tribal, regional State and or Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials." -The policy did not contain a process for how the facility would ensure cooperation and collaboration efforts with local, State and Federal preparedness officials and how the facility planned to maintain an integrated response to a declared emergency. Nor did the plan provide sufficient details to support verification of the process for collaboration with local, State and Federal officials. III. Staff interview The NHA was interviewed on 3/29/23 at 12:30 p.m. The NHA acknowledged the facility did not have an updated policy or procedure that described the facility process for ensuring collaboration with local, State and Federal officials in emergency situations. The NHA was interviewed again on 3/30/23 at 8:23 a.m. The NHA said she looked elsewhere and was still unable to locate an updated policy for this topic.

Based on interview and record review, the emergency preparedness (EP) program the facility failed to develop and implement an up to date emergency preparedness policies and procedures, based on the emergency plan risk assessment and the communication plan, where the policies and procedures were reviewed and updated at least annually. Specifically, the facility to ensure the EP plan policies were reviewed annually. Findings include: The emergency preparedness program binder was reviewed with the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. The EP plan failed to show documented proof that all policies and procedures were reviewed, maintained and updated in the last 12 months. The EP program and policies were last reviewed and updated on 10/17/21. The NHA acknowledged the facility had a priority to update the EP program and review the policies and procedures, but they had not yet had a chance to review and update the emergency preparedness program.

Based on record review and interview, the facility failed to develop and implement emergency preparedness policies and procedures based on the emergency plan that identified the provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: Food, water, medical and pharmaceutical supplies. Alternate sources of energy to maintain the following: Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. Emergency lighting, fire detection, extinguishing, and alarm systems; and, sewage and waste disposal. Specifically, the facility failed to:-Have policies and procedures to address all provisions needed for safe sheltering in place and for evacuation to include supplies and resources needed to be on hand for immediate use in the event of an emergency where providers would not be able to deliver regular resources in a timely manner; and,-Have an emergency backup supply of food and water on hand in the event regular supplies cannot be delivered in a timely manner. Findings include: I. Facility plan The emergency preparedness plan was provided by the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. The facility did not have at minimum a policy and procedure to address alternate sources of energy to maintain temperatures to protect resident's health and safety included in the EP program. II. Staff interview The NHA was interviewed on 3/30/23 at 3:45 p.m. The NHA acknowledged the EP program had not been updated in the last 12 months and did not have policy and procedures to meet the current needs of resident and staff in het even of an emergency. Additionally, the facility did not have necessary supplies of food and water on hand in the event that an emergency occurred and the vendors were unable to get to the facility to restock supplies in a timely manner.

Based on record review and staff interviews, the facility failed to develop and maintain an emergency preparedness (EP) program that addressed the following criteria in the event of an emergency. Specifically, the facility failed to develop policies and procedures, for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, during an emergency situation. Findings include: I. Facility plan The emergency preparedness plan was provided by the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. -Review of the EP program revealed the plan failed to include a system that preserved patient information, protected confidentiality of patient information and maintained the availability of records during an emergency situation. II. Staff interview The NHA was interviewed on 3/29/23 at 12:30 p.m. The NHA acknowledged the facility did not have an updated policy or procedure that described the facility process for ensuring confidentiality of resident records in emergency situations.

Based on record review and interviews, the facility failed to have a complete emergency preparedness communication plan to include policies and procedures, for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Specifically, the facility failed to ensure there was a policy and procedure for the use of volunteers in an emergency to include the process and role for the integration of designated health care professionals from both the State and Federal level to address surge needs during an emergency. Findings include: I. Facility plan The emergency preparedness plan was provided by the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. The facility did not have at minimum a policy which addressed their ability to respond to a surge in patients. As required, these policies and procedures must be aligned with a facility's risk assessment, and should include planning for emerging infectious diseases (EID). Concentrated efforts will be required to mobilize all aspects of the healthcare system to reduce transmission of disease, direct people to the right level of care, and decrease the burden on the healthcare system. The EP program revealed the plan had not been reviewed or updated since 10/17/21 and did not have a comprehensive volunteers policy in place to include the process and role for the integration of designated health care professionals from both the State and Federal level to address surge needs during an emergency. The Fire Safety and Disaster Preparedness: Use of Volunteers policy and organizational statement read in pertinent part: "Policy statement: Volunteers from the community shall be used when such becomes necessary during emergency or disaster situations occurring on our premises." -There was no detail of how volunteers would be deployed or utilized; and no procedure for staffing strategies and surge planning surrounding emergencies and disaster situations. III. Staff interviews The NHA was interviewed on 3/29/23 at 12:30 p.m. The NHA acknowledged the facility did not have an updated EP program and was unable to locate a policy to specifically address how volunteers would be utilized and incorporated with additional disaster related staffing strategies.

Based on record review and interview, the facility failed to have a complete emergency preparedness and emergency communication plan to include a policy and procedure outlining the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. Specifically, the facility failed to develop policies and procedures outlining the facility's role and responsibility for providing service at alternate care sites under an 1135 waiver. Findings include: I. Facility plan The emergency preparedness plan was provided by the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. The facility did not have at minimum a policy that addressed their ability to respond to a surge in patients, as required. II. Staff interview The NHA was interviewed on 3/29/23 at 12:30 p.m. The NHA acknowledged the facility did not have an updated EP program and was unable to locate a policy related to providing care to the resident population during a time of a declared waiver in accordance with section 1135 of the Act.

Based on record review and interviews, the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and was reviewed and updated annually. Specifically, the facility failed to an up-to-date written emergency communication plan that:-Documented how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments;-Have a complete communication plan that included an updated key staff and direct care worker list to facilitate quick communication with employees in the event of an emergency; and,-An up-to-date procedure for providing information about the facility's occupancy, needs and its ability to provide assistance to the authority having jurisdiction over a declared emergency. Findings include: I. Facility plan The emergency preparedness (EP) program was provided by the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. The facility did not have an up to date communication plan. II. Staff interviews The NHA was interviewed on 3/29/23 at 12:30 p.m. The NHA acknowledged the facility had a priority to update the emergency preparedness manual for the previous leadership, but they had not yet had a chance to review and update the emergency preparedness program. The EP program was approved 10/20/2020 and last reviewed and updated on 10/17/21. The EP program had not been maintained since 10/17/21.

Based on record review and interview, the facility failed to develop and maintain an up to date emergency preparedness training and testing program that was based on the facility's emergency preparedness (EP) program plan, annual risk assessment, facility EP policies and procedures, and the communication plan that was delivered to all staff annually. Specifically, the facility failed to:-Develop a written training and testing program based on the facility's updated EP program;-Provide education and instruction to staff, contractors, and facility volunteers to ensure all individuals are aware of the facility's EP program;-Ensure the EP training included the facility expected response to the annual risk and all hazards risk assessment; and, -Ensure EP training included, at a minimum, training related to the facility's EP policies and procedures. Findings include: I. Facility plan The emergency preparedness (EP) program was provided by the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. The facility did not have a written training and testing program with provisions to provide all staff, contractors, and facility volunteers received EP training specific to the facility's updated EP program.-Facilities must maintain documentation of the training in order to clearly identify staff training and testing conducted. II. Staff interviews The NHA was interviewed on 3/29/23 at 12:30 p.m. The NHA acknowledged the facility had a priority to update the emergency preparedness manual for the previous leadership, but they had not yet had a chance to review and update the emergency preparedness program.

Based on record review and interview, the facility failed to provide all staff, contracted staff and volunteers received initial and annual emergency preparedness training and testing of the facility's EP program. Specifically, the facility failed to:-Provide initial and annual education and instruction to staff, contractors, and facility volunteers to ensure all individuals are aware of the facility's EP program;-Ensure the EP training encompasses the facility expected response to the annual risk and all hazards risk assessment;-Ensure EP training included, at a minimum, training related to the facility's EP policies and procedures; and,-Ensure staff were knowledgeable of the facility's EP program. .Findings include: I. Facility plan The emergency preparedness (EP) program was provided by the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. The facility did not have documented proof that all staff, contractors, and facility volunteers received EP training specific to the facility's updated EP program. II. Staff interviews The NHA was interviewed on 3/29/23 at 12:30 p.m. The NHA said facility staff took two training titled Basic Fire Prevention and Response and Natural Disasters and Workplace Emergencies: An Overview. Both training were self-paced training developed by an outside vendor and were based on industry standards. -Neither training provided facility specific emergency response for the facility EP program.

Based on record review and interview, the facility failed to conduct two exercises annually to test the facility's emergency plan and maintain documentation of the facility's response to all drills, tabletop exercises, and emergency events, and then revise the facility's emergency plan, as needed. Specifically, the facility failed to:-Conduct two full-scale exercises, individual facility based functional exercises, mock disaster drill, tabletop exercise or workshop in the last year (12-month cycle);-Failed to participate in an annual full-scale exercise that was community-based; or when a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. Either a facility experiences an actual natural or man-made emergency that requires activation of the emergency plan; and,-Document and assess the facility response to an active shooter workshop that was led by a facilitator and document if the facility's EP program needed to be updated based on the facility response. Findings include: I. Testing participation The emergency preparedness (EP) program was provided by the nursing home administrator (NHA) on 3/29/23 at 12:30 p.m. The manual contained a document referencing an active shooter training exercise dated 1/13/23; where 18 of 72 staff were in attendance. -The exercise failed to document that the training discussed the facility's active shooter plan along with the training; and failed to document an assessment of the training and staff response to the training. The facility failed to document if the training led to the discovered relevant information to the effectiveness of the facility's EP program. -Additionally, the facility did not provide evidence of conducting an annual full-scale exercise that was community-based; or when a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. Either a facility experiences an actual natural or man-made emergency that requires activation of the emergency plan. II. Staff interviews The NHA was interviewed on 3/29/23 at 12:30 p.m. The NHA acknowledged the facility had only conducted one tabletop workshop to test the facility's EP program in the last 12 months.

Based on observations, record review, and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to:-Ongoing food and pest control concerns; and,-Grievances brought up in the resident council. Findings include: I. Facility policyThe Grievance policy, undated, was provided by the nursing home administrator (NHA) on 3/30/23 at 11:02 a.m. It read it pertinent part,"The social services director is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion."Grievances may be voiced by verbal complaint during resident or family council meetings."The social services director or designee will keep the resident appropriately apprised of progress towards the resolution of the grievance." II. Resident interviewsAll residents were identified by facility and assessment as interviewable. Resident #4 was interviewed on 3/27/23 at 9:55 a.m. The resident stated she had observed mice running across the floor of the room, in and out of the bathroom, and in and out of the closet for the last two weeks. The resident stated she had voiced this to the floor staff and the housekeepers but was not aware if a grievance had been written. The resident stated the cold food was not cold enough and the hot food was not hot enough. Resident #1 was interviewed on 3/27/23 at 11:12 a.m. The resident stated the food temperatures were not right sometimes and the food was not desirable in appearance. Resident #20 was interviewed on 3/27/23 at 2:17 p.m. The resident stated the facility food had no flavor, did not look appealing, the temperature was not usually hot enough. III. Observations On 3/28/23 at 1:40 p.m. in resident room #108 an exposed rodent glue trap behind the resident's recliner. It was visible from the hallway and had a piece of corn chip on it. At 3:43 p.m. in resident room #112 an exposed rodent glue trap behind the resident's recliner with a corn chip in it. In resident room #111 an exposed rodent glue trap behind the resident's recliner with a corn chip in it. Cross-reference F925 for pest controlOn 3/29/23 at 5:00 p.m. the temperature was taken of the chicken served with dinner and it was 172 degrees F. The temperature was taken again after the last resident was served at 5:35 p.m. and it had dropped to 107 degrees F.The meal was nachos and consisted of a plate full of chips, a small amount of nacho cheese, meat, beans, and sour cream on the top. The toppings could only sustain approximately 25% of the chips leaving the rest of the chips to be eaten plain. The dessert was to be churros, but it was not provided to the residents and there was no alternative for dessert. IV. Record reviewResident council meeting minutes dated 11/8/22 revealed concerns voiced to nutrition services director (NSD) regarding drink temperatures (of the hot beverages). The NSD responded "there had been a break in the chain between a couple departments, but they were working on it."Resident council meeting minutes dated 1/10/23 revealed concerns voiced to NSD regarding drink temperatures not being hot enough. NSD responded "one of the boilers that controlled the kitchen water temperature had been down but it was being worked on and drinks could be microwaved."Resident council meeting minutes dated 2/14/23 revealed concerns voiced to NSD regarding drinks, soups, and oatmeal not being hot enough. It was also voiced that the presentation of the food appeared "sloppy." -There was no response from NSD on meeting minutes. Facility grievances for the last six months were reviewed on 3/30/23 at 9:00 a.m. There were no written grievances for food or rodents. In addition, there also were no grievances for 2023. V. Staff interviews Registered nurse (RN) #1 was interviewed on 3/28/23 at 2:50 p.m. She stated in the last two weeks residents have started to report to her seeing mice in their rooms. She had reported these concerns to the housekeeping and maintenance departments. Housekeeper (HSKP) #2 was interviewed on 3/29/23 at 9:07 a.m. She stated she had been receiving complaints from staff and residents regarding rodents for the last month. The NSD was interviewed on 3/29/23 at 5:10 p.m. He stated he had not received grievances regarding food temperatures or appearance. He said he attended resident council meetings. The social services director was interviewed on 3/30/23 at 9:00 a.m. She stated she only wrote a grievance form when the resident concern was very serious. Examples might be theft or abuse. She tried to resolve concerns when they came to her and would write a progress note in the resident's chart. The SSD said she did not ever write a grievance form for a complaint brought up in resident council. She depended on the department head to address concerns for their department. She acknowledged she did not have a way to track if the department head resolved it, how long it took them, and if they followed up with the resident with a resolution. If a resident said a complaint had not been addressed, without a grievance form, the SSD would have to go through the resident's progress notes to show if she had addressed it or not. The NHA was interviewed on 3/30/23 at 10:25 a.m. She stated if there was a grievance, it was referred to the SSD. The grievance process was to try to resolve grievances right away and not write a grievance form. The NHA acknowledged that this process did not guarantee a grievance was addressed and not ignored, and did not provide documentation of trends. The NSD was interviewed on 3/30/23 at 1:25 p.m. He stated in regards to the resident council concerns, he had addressed them in resident council and no grievance form had been completed. The 11/8/22 concern was regarding the coffee being brewed too long before service and then cooling down so the kitchen started to wait closer to time of service to brew coffee. The 1/10/23 concern was resolved by a new water heater being purchased for the kitchen. The staff had to use the microwave to heat drinks but took the temperature of the drinks before serving to the residents. He could not explain what had been done for the 2/14/23 resident council concerns. VI. Facility follow-upAn email was received from the NHA on 3/30/23 at 10:16 a.m. documenting the glue traps had been removed from all the resident rooms. The NHA provided the prior two months pest control invoices. Invoice dated 2/22/23 charged the facility for interior inspection of pests and external service of baited traps. Invoiced dated 1/12/23 charged the facility for interior inspection of pests and external service of baited traps. The NHA provided invoices on 3/30/23 at 2:15 p.m. for kitchen repairs made by the facility's heating, ventilation, and air conditioning (HVAC) service provider. Invoice dated 1/30/23 showed a 1/3/23 service call to replace a boiler combustion fan. Invoiced dated 2/27/23 showed a 1/10/23 service call to replace heat exchanger for boiler.

Based on observations, record review and interviews, the facility failed to provide appropriate treatment and services to maintain or improve the ability to perform activities of daily living (ADLs) for for one (#32) of two residents reviewed for ADLs out of 29 residents. Specifically, the facility failed to provide supervision, oversight, encouragement and cueing with eating for Resident #32. Findings include:I. Resident statusResident #32, age of 93, was admitted on 1/27/23. According to the March 2023 computerized physician orders (CPO) diagnoses included unspecified dementia and diabetes. The 2/2/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required one-person assistance with transfers, dressing, walking, toilet use, bathing, and personal hygiene. The resident required supervision, oversight, encouragement and cueing with eating. II. ObservationsThe resident was observed on 3/28/23 at 11:45 a.m. in the resident's room for lunch. The resident refused to come to the dining room and refused food. A meal tray was brought to the room and put next to the resident's recliner. At 11:51 a.m. the director of nursing (DON) went into the resident's room to assist with encouragement but the resident refused to eat. At 11:54 a.m. certified nursing aide (CNA) #1 went into the resident's room to assist with encouragement but the resident refused to eat. At 12:00 p.m. the resident's spouse, whom the resident shared a room with, returned from the dining room and did not encourage the resident to eat. The meal tray was removed from the room at 12:10 p.m. The resident was not offered an alternative. The resident was observed on 3/29/23 at 11:25 a.m. sitting in the dining room with spouse for lunch. When the lunch plate arrived, the resident first ate the dessert cup, then ate a few bites of the entree. After 10 minutes of picking at the entree, the resident went back to the dessert cup and used the spoon to scrape the sides of the bowl to eat any remaining dessert. The resident then drank coffee until 11:45 a.m. The resident again tried to scrap the dessert cup but there was no dessert left. The resident went back to drinking coffee until the spouse was ready to leave at 11:52 a.m. At no point did nursing staff come to the resident's table to check on the meal intake or if the resident wanted something different to eat. The resident was observed on 3/29/23 at 5:25 p.m. arriving at the dining room for dinner. From 5:25 p.m. through 6:00 p.m, the resident picked at dinner, which was nacho chips. The resident was attempting to eat the nacho chips with a fork and having difficulty. At 5:35 p.m., a dietary staff member stopped by the resident's table to ask if the resident needed anything and then left. No other staff checked on the resident and the spouse did not encourage the resident to eat dinner. The resident left the dining room at 6:00 p.m. At no point did nursing staff come to the resident's table to check on the meal intake or if the resident was having difficulty eating. III. Record reviewThe comprehensive care plan nutrition focus initiated on 2/20/23, revealed the resident had the potential for nutritional risk due to diagnosis of diabetes, dementia, and hypertension. Interventions initiated on 2/22/23 were to encourage fluids, follow physician diet order of low calorie sweetener and remind the resident of mealtimes and location. The activities of daily living focus initiated on 2/10/23 revealed the resident had a self-care deficit due to dementia. Interventions initiated 2/21/23 revealed the resident was independent with eating. Nutrition progress notes from 2/24/23 through 3/21/23 revealed the registered dietitian (RD) had been monitoring the resident for weight loss related to poor intake. The resident would refuse one to two meals a week and intakes were between 10%-60%. The RD documented the resident as independent with eating until 3/21/23 than documented independent with the need for supervision. The resident intake log for food and fluids revealed:30% intake for lunch on 3/28/23;95% intake for lunch on 3/29/23; and, 15% intake for dinner on 3/29/23. Facility tasks for CNAs for recording meals revealed:-Lunch on 3/28/23 the resident received supervision, oversight, and encouragement; -Lunch on 3/29/23 the resident was independent and did not require any supervision to eat; and, -Dinner on 3/29/23 the resident was independent and did not require any supervision to eat. IV. Staff interviewsRestorative aide (RA) #1 was interviewed on 3/28/23 at 1:58 p.m. She stated she had never seen the resident for restorative therapy for dining. Registered nurse (RN) #1 was interviewed on 3/28/23 at 2:50 p.m. She stated the resident did not eat very much due to advancing dementia. She said the resident did not associate what they were supposed to do with food anymore. The resident needed supervision, cues, and food cut up by staff. Certified nursing assistant (CNA) #2 was interviewed at 3/28/23 at 11:46 a.m. She stated the CNAs have to provide the resident eating assistance. The resident needs supervision, cues, and prompts or else the resident would not eat the meal. The director of nursing (DON) was interviewed on 3/29/23 at 10:27 a.m. The DON stated the resident had come from assisted living due to cognitive and functional decline. The staff would give the resident encouragement to eat. The resident liked sweets and the kitchen would provide dessert with meals. The resident enjoyed coffee so the kitchen provided snacks to be kept in the room for the resident to eat with coffee. The resident's spouse also provided cues and prompted the resident during meal times to eat. The activities director (AD) was interviewed on 3/29/23 at 1:40 p.m. She stated she had been a CNA and could determine meal intake. After looking at Resident #32's lunch plate, she determined the intake was 15%. CNA #3 was interviewed on 3/29/23 at 4:11 p.m. She stated the CNA working in the dining room records the meal intakes on a sheet of paper and gives it to the floor CNAs to record in the resident's medical record. She normally worked on Resident #32's hallway and it was not typical for the resident to eat 95% (as indicated on 3/29/23). The meal intake was usually less than 40% for Resident #32. The AD was interviewed again on 3/29/23 at 5:15 p.m. She stated she did not usually record the meal intakes, the CNAs in the dining room did that. She acknowledged that 95% intake for Resident #32 at lunch time on 3/29/23 was not accurate. The nutrition services director (NSD) was interviewed on 3/29/23 at 5:22 p.m. He stated if a resident in the dining room needed assistance with dining, there was an area of tables in the corner where CNA staff would assist residents with eating. . If the resident needed to be cued and prompted to eat, the nursing staff would come by the residents table in the main part of the dining room. CNA #4 was interviewed on 3/29/23 at 6:00 p.m. After looking at Resident #32's dinner plate, she determined the intake was 10%. She usually helped with the residents who needed help to be assisted with their meal. She acknowledged that Resident #32 needed cues and prompts to eat meals or the resident would just pick at the food. The DON was interviewed on 3/30/23 at 12:55 p.m. She was not aware that the CNAs were leaving cueing and prompting of meal intake to the resident's spouse and not encouraging the resident in the dining room. She said that the spouse encouragement was not to replace the care provided by the CNAs. The DON acknowledged the resident needed to be reminded to eat and encouraged at every meal.

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Based on interviews and record review, the facility failed to establish parameters for pain medication for one (#29) of three residents in a manner consistent with professional standards of practice out of 29 sample residents. Specifically, the facility failed to:-Pain parameters and assessments were established and implemented for a physician ordered scheduled and as needed (PRN) pain medication; and, -Non-pharmacological interventions were established or implemented. Findings include:I. Facility policy and procedureThe Pain Management policy and procedure, reviewed March 2018, was provided by the nursing home administrator (NHA) on 3/30/23 at 4:50 p.m. It revealed in pertinent part,"An assessment or an evaluation of pain based on clinical standards of practice may necessitate gathering the following information, as applicable to the resident: history of pain and its treatments (including non-pharmacological and pharmacological treatment), characteristics of pain such as intensity of pain (as measured on a standardized pain scale); descriptors of pain (burning, stabbing, tingling, aching); pattern of pain (constant or intermittent); location and radiation of pain; frequency, timing and duration of pain; impact of pain on quality of life (sleeping, functioning, papetitis, an mood); factors such as activities, care, or treatment that precipitate or exacerbate pain; strategies an factors that reduce pain; additional symptoms associated with pain (nausea and anxiety); physical, psychological and cognitive status); current medical conditions and medications;or the resident ' s goals for pain management and his or her satisfaction with the current level of pain control."II. Resident statusResident #29, age 92, was admitted on 2/17/23. According to the March 2023 computerized physician orders (CPO), the diagnoses included multiple fractures of ribs and pain in the right hip. The 2/26/23 minimum data set MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required extensive assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene and supervision with setup for eating. It indicated the resident was on a scheduled pain medication program, received PRN medications and did not receive non pharmacological interventions for pain management. III. Record reviewThe pain management care plan, initiated on 3/4/23, documented the resident was at risk for pain and was able to request assistance and pain medication when in pain. Interventions included monitor and document for side effects of pain medication, monitor and record pain characteristics, administer pain medication per order if non medication interventions were ineffective.-A review of Resident #29 ' s comprehensive care plan did not reveal a person-centered approach with identification of location, type or intensity of pain the resident experienced. It did not include personalized non pharmacological interventions to address the resident ' s pain. It did not identify a baseline assessment of pain or person-centered pain management goals. The February 2023 and March 2023 medication administration record (MAR) documented the resident was prescribed the following medications:-Norco 10/325 milligrams (mg) tablet-one tablet twice a day ordered 2/17/23, discontinued 3/15/23.-Norco 5/325 mg tablet- one tablet twice a day ordered 3/15/23.-Norco 5/325 mg tablet-one tablet every six hours for pain as needed for breakthrough pain ordered 2/17/23.-Morphine sulfate 20 mg/ml solution-0.25 ml every two hours as needed if unable to swallow Norco ordered 2/17/23.-Acetaminophen 500 mg tablet-one tablet at bedtime for pain ordered 2/17/23. A comprehensive review of February and March 2023 MAR failed to document location and type of resident ' s pain being treated for Acetaminophen, Norco and Morphine Sulfate. The physician orders did not include specific pain scale parameters for the PRN Norco and Morphine sulfate. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 3/30/23 at 10:00 a.m. LPN #1 said a pain assessment was done prior to administration of a pain medication. A pain assessment scale was used if the resident was cognitively intact or a behavioral assessment if the resident was not cognitively intact. LPN #1 said there were no parameters ordered and clinical judgment was used prior to administration. The director of nursing (DON) was interviewed on 3/30/23 at 3:15 p.m. The DON said that when a PRN or routine pain medication was administered, clinical judgment was used before giving the pain medication. The DON confirmed that parameters based on a pain assessment should be in place before administration of a pain medication.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to:-Ensure professional standards of infection control were followed while cleaning resident rooms;-Ensure that different cleaning cloths were used to clean and disinfect different potentially contaminated surfaces;-Ensure housekeeping staff changed gloves and performed hand hygiene consistently when moving from a task where the staffs hand became contaminated form cleaning and or touching a contaminated surface within a resident's room before cleaning the next surface;-Ensure housekeeping staff cleaned and thoroughly cleaned all high-touch surfaces in resident rooms and followed manufacturer directions for thorough cleaning of a potentially contaminated surface during routine daily cleaning;-Ensure housekeeping staff followed the appropriate procedure when cleaning resident room bathrooms, so they did not contaminate surfaces with water from the inside of the toilet bowl;-Ensure the facility had a water monitoring program to prevent the potential spreads of Legionella and other waterborne pathogen infections;-Ensure residents were offered hand hygiene before meals in both the dining rooms and room trays; and,-Ensure nursing staff administered medications in a hygienic manner and wearing proper personal protective equipment when coming into contact with bodily fluids. Findings include: I. Routine cleaning in resident rooms A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Infection control: Guidelines for Environmental Infection Control in Health-Care Facilities, last reviewed 5/14/19, was retrieved on 4/3/23 from https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/services.html: "Cleaning is the necessary first step of any sterilization or disinfection process. Cleaning is a form of decontamination that renders the environmental surface safe to handle or use by removing organic matter, salts, and visible soils, all of which interfere with microbial inactivation. The physical action of scrubbing with detergents and surfactants and rinsing with water removes large numbers of microorganisms from surfaces. "Housekeeping surfaces can be divided into two groups - those with minimal hand-contact (floors, and ceilings) and those with frequent hand-contact ( 'high touch surfaces' ). The methods, thoroughness, and frequency of cleaning and the products used are determined by health-care facility policy. However, high-touch housekeeping surfaces in patient-care areas (doorknobs, bed rails, light switches, wall areas around the toilet in the patient's room, and the edges of privacy curtains) should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact. Infection-control practitioners typically use a risk-assessment approach to identify high-touch surfaces and then coordinate an appropriate cleaning and disinfecting strategy and schedule with the housekeeping staff. "Part of the cleaning strategy is to minimize contamination of cleaning solutions and cleaning tools. Bucket solutions become contaminated almost immediately during cleaning, and continued use of the solution transfers increasing numbers of microorganisms to each subsequent surface to be cleaned. -A simplified approach to cleaning involves replacing soiled cloths and mop heads with clean items. "Application of contaminated cleaning solutions, particularly from small-quantity aerosol spray bottles or with equipment that might generate aerosols during operation, should be avoided, especially in high-risk patient areas. Making sufficient fresh cleaning solution for daily cleaning, discarding any remaining solution, and drying out the container will help tominimize the degree of bacterial contamination. Containers that dispense liquid as opposed to spray-nozzle dispensers (quart-sized dishwashing liquid bottles) can be used to apply detergent/disinfectants to surfaces and then to cleaning cloths with minimal aerosol generation. A pre-mixed, 'ready-to-use' detergent/disinfectant solution may be used if available." B. Facility policy The Routine Cleaning and Disinfection policy, undated, was provided by the nursing home administrator (NHA) on 3/30/23 at 3:35 p.m. It read: "It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.-Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge;-Use standard precautions, including appropriate personal protective equipment, for all rooms;-Clean from areas that are visibly clean and least likely to be contaminated to areas usually visibly dirty;-Clean from top to bottom (bring dirt from high levels down to floor levels);-Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: Toilet flush handles; bed rails; tray tables, call buttons; TV (television) remote; light switches; door knobs and levers;-Clean prior to disinfection as recommended by the manufacturer of the product(s) being used;-Disinfectant solution will be prepared fresh daily and changed frequently in order to ensure effectiveness. Follow manufacturer recommendations for dilution and frequency of changing of disinfectant solution. Follow manufacturer recommendations regarding appropriate contact time to ensure adequate disinfection;-Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine resident-care areas should be cleaned: On a regular basis." C. Observations On 3/28/23 at 1:45 p.m. housekeeper (HSKP) #1 was observed cleaning room #102. HSKP #1 gathered supplies to clean the resident's room. The HSKP removed a small plastic container from the housekeeping cart and put cleaning supplies in the container including a toilet bowl brush, a small hand scrub brush, a very small pumice stone, and two "clean" cloths. The container was packed so the items were touching including the clean cloths being right next to the previously used toilet brush. The HSKP did not apply gloves for cleaning and did not perform hand hygiene prior to starting the cleaning process. With bare hands, HSKP #1 went to the resident bathroom first and poured a moderate amount of a cream cleanser inside the toilet bowl and inside the sink. The creamy cleanser was labeled as a bleach type toilet bowl cleaner. HSKP #1 used the toilet bowl brush to clean the inside of the toilet bowl, rim, and underside then top of the toilet seat in that order. The HSKP rinsed the toilet brush in the toilet and returned it to the small plastic container it was brought into the resident room inside. After cleaning the toilet bowl and seat; HSKP #1 without performing any hand hygiene; picked up the small scrub brush to clean the sink, rinsed the sink and brush and put that back into the small container with the toilet brush and cleaning cloths. Next HSKP #1 picked up a bottle of disinfectant spray and a cleaning cloths form the container that also contained the used toilet brush; sprayed a small amount of disinfectant onto the contaminated cloth to clean the base of the toilet, the tank; the top of the toilet tanks and then the flushing handle in that order. There was insufficient amount of disinfectant on the cleaning cloth to cover or saturate the surfaces cleaned and no waiting for the surface disinfectant time while the surfaces were properly disinfected. The HSKP then returned the used cloth to the small plastic container with the used toilet brush. HSKP #1 next took the small pumice stone out of the small plastic container and cleaned inside the toilet bowl. HSKP #1 said this was to remove any rust or hard water stains for the toilet. After use of the pumice stone, the stone was placed back into the small plastic container. HSKP #1 then took another cleaning cloth out of the small plastic container that also contained the used toilet brush; scrub brush; the used pumice stone; and used (toilet) cleaning cloth were placed. This cleaning cloth was sprayed with a small amount of disinfectant cleaner so that only a small spot on the cloth was dampened with the disinfectant solution. HSKP #1 used the cleaning cloth to clean the grab bars, soap dispenser, paper towel holder, sink countertop, and sink handles in the bathroom. After cleaning those items with the contaminated cloth, the HSKP used that same cloth and unwashed hands to handle and wipe down the entire surface (inside and outside) of the resident's denture cup. -HSKP #1 only perform hand hygiene once at the start of the cleaning process and did not put on any gloves to clean the resident's room;-HSKP #1 did not clean any of the high touch surfaces in the resident's room including the bed controller, the call light, or the television remote;-HSKP #1 did not clean the resident's bedside table, where the resident had drinks and other food items throughout the day;-HSKP #1 did not clean any vertical surfaces such as the windowsills or resident dresser, which were visibly dusty. D. Interview HSKP #1 was interviewed on 3/28/23 at 1:55 p.m. There was a language barrier between HSKP #1 and the interviewer. HSK P#1 said she was done and the room was clean. HSKP #1 shrugged and was unable to explain how she was to use any of the chemicals for cleaning and following prescribed surface disinfectant times. The NHA was interviewed on 3/28/23 at 2:00 p.m. When informed that the housekeeper was using a contaminated cloth to wipe down a resident's denture cup, the NHA was not aware that any of the HSKPs were cleaning resident denture cups. The NHA said the correct procedure was for the certified nurse aides (CNAs) to maintain and clean any of the residents personal care items, not the HSKPs. The NHA said she would educate HSKP#1 again on proper housekeeping procedure and that no HSKP was to clean residents' denture cups or any other personal care items. In addition, all resident denture cups would be replaced. The NHA said the HSKP should be using a clean cloth on each surface thought-out the resident's room; cleaning from top to bottom or cleanest to dirtiest and most importantly the HSKPs were not to clean nursing supplies or resident care items. HSKP #2 was interviewed on 3/30/23 at 11:58 p.m. HSKP #2 said the creamy cleanser was a bleach based product to be used in the toilet and the disinfectant spray was to be sprayed directly on high touch surfaces to saturate the surface and let it sit to kill pathogens for a period of three minutes. The HSKP identified the disinfectant cleaner as QT3 disinfectant with a surface disinfectant time of three to five minutes. The infection preventionist (IP),who was also the housekeeping supervisor, was interviewed on 3/30/23 at 4:06 p.m. The IP said housekeeping staff received training on orientation that included the expectations and procedure for routine resident room cleaning; but was considering providing each HSKP with an annual retraining on infection control measures for routine housekeeping. The IP said each HSKP should start the room cleaning process through hand hygiene and putting on a pair of gloves; using other personal protective equipment as indicated by imposed precautions individualized to each resident. The HSKPs were to clean from top to bottom or clean to dirty. The bathroom was to be cleaned last. The housekeeper was to enter the resident's room and spray all high touch surfaces and let the chemical sit to disinfect the surfaces for three minutes. While they waited for the surface disinfectant time, the HSKP was to sweep and take out the trash. Cleaning cloths were to be changed frequently for different surfaces throughout the resident's room and when soiled. Cleaning cloths used to clean the bathroom were not to be used in any other part of the resident room, especially not on the resident bedside table, remotes and the HSKP should never have cleaned the resident's denture cup. Surfaces that come into contact with food or eating utensils need to be cleaned daily with a separate clean cloth. The IP said the toilet should be cleaned from top to base then inside; the cleaning cloth used to clean the toilet were not to be used on any other surface. HSKPs were expected to perform hand hygiene after cleaning the toilet before moving to touch or clean any other surface. The HSKP should be wearing clean gloves throughout the cleaning process and changing the gloves frequently when moving from contaminated surfaces. II. Facility had no water management plan to prevent Legionella disease A. Professional reference According to CDC, "Legionella (Legionnaires Disease and Pontiac fever), last reviewed 3/25/21, retrieved from on 4/4/23: https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html. It read in pertinent part, "Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. "Legionella bacteria are typically found naturally in freshwater environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. "Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. "The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. "Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. "Seven key elements of a Legionella water management program are to:-Establish a water management program team-Describe the building water systems using text and flow diagrams-Identify areas where Legionella could grow and spread-Decide where control measures should be applied and how to monitor them-Establish ways to intervene when control limits are not met-Make sure the program is running as designed (verification) and is effective (validation)-Document and communicate all the activities. "Principles: In general, the principles of effective water management include:-Maintaining water temperatures outside the ideal range for Legionella growth- Preventing water stagnation-Ensuring adequate disinfection-Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. "Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. "A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs." B. Facility Legionella plan A request was made on 3/29/23 for the facility's plan to address Legionella. The facility was unable to provide a written water management plan/program that would reduce the risk for Legionella growing and spreading within their water system and devices. The NHA confirmed the facility did not have a written plan to document procedures and monitoring efforts the facility would take to prevent water related health care associated infections. The NHA was interviewed on 3/30/23 at 3:33 p.m. The NHA was familiar with Legionella but acknowledged she was unable to locate a written facility water management plan to address Legionella. The NHA said she spoke to the maintenance director (MTD) that day and the MTD confirmed the facility did not have a written water management plan for Legionella. The NHA said the facility paid for an outside vendor to test the facility's water quality. The vendor tested the facility's water quality for Legionella and other potential pathogens. The test found that the flushing surveillance monitors in vacant rooms were all "red" indicating stagnation for greater than one month. Although test results found no healthcare-acquired infections suspected by waterborne pathogens, the company recommended the facility continue to monitor and track the facility's water quality. It was also recommended that the facility flush the water in the pipes in vacant rooms and use a water (flushing) monitor. The NHA contacted the MTD by phone during the interview. The MTD acknowledged there were no written records that documented the facility's efforts to monitor water quality, assess water temperatures or usage of the recommended flushing monitors. -The facility's plan addressing Legionella was not provided by exit on 3/30/23. III. Failure to ensure residents were offered hand hygiene before meals A. Professional reference According to the CDC Hand Hygiene in Healthcare settings, last reviewed 22/7/23, retrieved from https://www.cdc.gov/handhygiene/index.html on 4/4/23, "Hand hygiene protects you and those receiving the care you provide. The simple act of cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics. "Clean your hands: Before preparing or eating food." B. Observations On 3/27/23 from 10:40 a.m. to 12:10 p.m. residents arrived for lunch in the main dining room, some walking in, some self-propelling themselves in manual wheelchairs and some escorted in by staff. Residents in wheelchairs were observed to be handing the large wheel on their manual wheelchairs to wheel into the dining room; some who walked in were observed using the hand rails in the halls. Residents were assisted to sit at their tables and staff in the dining room approached to take resident meal orders. Each table was full with one resident per table. Of all the residents in the dining room waiting for lunch only one resident was offered and assisted with hand hygiene.-At 11:00 a.m., certified nurse aide (CNA) #1 was observed serving lunch to a resident in room #106. CNA #1 delivered the resident's meal, set up the meal but did not encourage the resident to perform hand hygiene or offer to assist the resident with hand hygiene prior to the resident eating the meal. -At 11:06 a.m., CNA #1 delivered a lunch tray to the resident in room #108. CNA #1 set up the meal for the resident but did not offer the resident a method of hand hygiene or encourage the resident to perform hand hygiene prior to eating the meal. Neither resident trays had hand wipes for the resident use. -At 11:10 a.m., staff walked around to each resident to assist the resident to put on a clothing protector; but did not offer hand hygiene assistance; -At 11:10 a.m., staff started to deliver resident meals but did offer hand hygiene;-At 11:33 a.m. a male resident who had received his meal but not offered any method of hand hygiene was observed eating his meal with his hands, putting his fingers in his food and then putting his fingers in his mouth. -At 11:46 a.m., a female resident who was not offered hand hygiene was observed eating her meal after picking her nose for several minutes. Lunch service in the main dining room was observed on 3/28/23 and 3/29/23 starting at 10:45 a.m. Residents were observed coming in in the same manner. No residents were offered hand hygiene or assistance with hand hygiene during these to lunch services.-In all dining room observations staff greeted resident as they arrived to the dining room; applied clothing protectors to all residents; delivered preferred drinks; and outlook meal order; but except for one observation did not offer any resident a method of hand hygiene or ask the resident if they needed assistance with hand hygiene D. Interview The dining manager (DM) was interviewed on 3/29/23 at 4:50 p.m. The DM said it was the nursing staff's responsibility to assist residents with hand hygiene. The kitchen did not provide antibacterial hand rub (ABHR) or hand wipes on resident trays. The DM acknowledged hand wipes would be a good ideal for more independent residents wanting to wash their hands prior to eating. The infection control preventionist (IP) was interviewed on 3/30/23 at 2:13 p.m. The IP said hand hygiene was to be offered to the residents prior to the meal service. If the resident needed assistance, staff were to provide the resident hand hygiene assistance. Residents could use the sink with soap and water or antibacterial hand hygiene to clean their hands prior to eating a meal. IV. Administering medication in hygenic mannerA. Professional referenceCenters for Disease Control and Prevention. (2019). Part III: Precautions to Prevent Transmission of Infectious Agents. https://www.cdc.gov/handhygiene/providers/guideline.html. Retrieved on 4/3/23. "Standard Precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions, except sweat, non intact skin and mucous membranes may contain transmissible infectious agents. "These include: hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluid must be handled in a manner to prevent transmission of infectious agents (wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient)."B. Observations 1. Certified nurse aide with medication authority (CNA_Med) #1 obtained a blood glucose from Resident #24 on 3/29/23 at 4:00 p.m. CNA_Med #1 performed hand hygiene with alcohol based sanitizer and obtained Resident #24's dedicated blood glucose monitor. CNA_Med #1 then placed a sterile lancet into the resident's lancet pen. CNA_Med #1 entered Resident #24's room placed a testing strip in the glucose monitor and swabbed Resident #24's finger with alcohol and stuck resident's finger with lancet pen. CNA_Med #1 took Resident #24's finger with the drop of blood and touched it to the testing strip in the blood glucose monitor and swabbed the resident's finger with a dry cotton ball. CNA_Med #1 took the glucose monitor with the used testing strip, alcohol pad and used cotton ball to the medication cart and placed the used lancet, alcohol swab and cotton ball into the sharps container. CNA_Med #1 cleaned the end of Resident #24's blood glucose monitor with an alcohol swab, placed into the designated bag and returned it back to the medication cart. CNA_Med #1 obtained Resident #24's humalog insulin pen and cleaned hub off with alcohol and applied sterile needle. CNA_Med #1 dialed two units into the pen and primed the pen. CNA_Med #1 then dialed six units in per sliding scale order. CNA_Med #1 did not use gloves during handling of the used test strip, alcohol swab, cotton ball, lancet and injection needle. CNA_Med #1 entered Resident #24's room, and administered the insulin into the resident's left arm. CNA_Med #1 left the resident's room and dispensed the used needle in the sharps container at the medication cart, placed the resident's pen into the dedicated bag and performed hand hygiene. CNA_Med #1 did not use gloves during handling of the used test strip, alcohol swab, cotton ball, lancet and injection needle. 2. CNA_Med #1 obtained a blood glucose and administered an injection for Resident #6 at 4:10 p.m. CNA_Med #1 performed hand hygiene with alcohol based sanitizer and obtained Resident #6's designated blood glucose monitor. CNA_Med #1 placed a new sterile lancet into the lancet pen and obtained an alcohol swab and dry cotton ball. CNA_Med #1 entered Resident #6's room, placed a test strip into the glucose monitor and swabbed resident's finger with alcohol swab and stuck Resident #6's finger with lancet pen. CNA_Med #1 took Resident #6's finger with the drop of blood and touched it to the testing strip in the blood glucose monitor and swabbed the resident's finger with a dry cotton ball. CNA_Med #1 took the glucose monitor with the used testing strip, alcohol pad and cotton ball to the medication cart and placed the used lancet, alcohol swab and cotton ball into the sharps container. CNA_Med#1 cleaned the end of Resident #6's blood glucose monitor with an alcohol swab, placed into the designated bag and returned it back to the medication cart. CNA_Med #1 obtained Resident #6's Novalog insulin pen and cleaned hub with an alcohol swab and placed a new sterile needle. CNA_Med #1 then dialed two units and primed the insulin pen. CNA_Med #1 dialed 11 units into the insulin pen per physician ordered sliding scale. CNA_Med #1 entered Resident #6's room, swabbed Resident #6's right lower abdomen and administered insulin. CNA_Med #1 left the resident's room and dispensed the used needle in the sharps container at the medication cart, placed the resident's pen into the dedicated bag and performed hand hygiene with alcohol based sanitizer. CNA_Med #1 did not use gloves during handling of the used test strip, alcohol swab, cotton ball, lancet and injection needle. 3. CNA_Med #1 obtained a blood glucose and administered an injection for Resident #25 at 4:15 p.m. CNA_Med #1 performed hand hygiene with alcohol based sanitizer and obtained Resident #25's designated blood glucose monitor. CNA_Med #1 placed a new sterile lancet into the lancet pen and obtained an alcohol swab and dry cotton ball. CNA_Med #1 entered Resident #25's room, placed a test strip into the glucose monitor and swabbed resident's finger with alcohol swab and stuck Resident #25's finger with lancet pen. CNA_Med #1 took Resident #25's finger with the drop of blood and touched it to the testing strip in the blood glucose monitor and swabbed the resident's finger with a dry cotton ball. CNA_Med #1 took the glucose monitor with the used testing strip, alcohol pad and cotton ball to the medication cart and placed the used lancet, alcohol swab and cotton ball into the sharps container. CNA_Med #1 cleaned the end of Resident #25's blood glucose monitor with an alcohol swab, placed into the designated bag and returned it back to the medication cart. CNA_Med #1 performed hand hygiene with alcohol based sanitizer. CNA_Med #1 did not use gloves during handling of the used test strip, alcohol swab, cotton ball, lancet and injection needle. 4. CNA_Med #1 obtained blood glucose for Resident #32 at 4:25 p.m. CNA_Med #1 performed hand hygiene with alcohol based sanitizer and obtained Resident #32's designated blood glucose monitor. CNA_Med #1 placed a new sterile lancet into the lancet pen and obtained an alcohol swab and dry cotton ball. CNA_Med #1 entered Resident #32's room, placed a test strip into the glucosemonitor. Resident #32 CNA_Med #1 took Resident #32's finger with the drop of blood and touched it to the testing strip in the blood glucose monitor and swabbed the resident's finger with a dry cotton ball. CNA_Med #1 took the glucose monitor with the used testing strip, alcohol pad and cotton ball to the medication cart and placed the used lancet, alcohol swab and cotton ball into the sharps container. CNA_Med #1 cleaned the end of Resident #32's blood glucose monitor with an alcohol swab, placed into the designated bag and returned it back to the medication cart. CNA_Med #1 performed hand hygiene with alcohol based sanitizer. CNA_Med #1 did not use gloves during handling of the used test strip, alcohol swab, cotton ball and lancet. 5. CNA_Med #1 administered an injection for Resident #22 at 4:30 p.m. CNA_Med #1 performed hand hygiene with alcohol based sanitizer and obtained Resident #22's designated blood glucose monitor. CNA_Med #1 placed a new sterile lancet into the lancet pen and obtained an alcohol swab and dry cotton ball. CNA_Med #1 entered Resident #22's room, placed a test strip into the glucose monitor. Resident #22 took the lancet pen and stuck their own finger and placed a drop of blood onto the test strip. CNA_Med #1 took the glucose monitor with the used testing strip, alcohol pad and cotton ball to the medication cart and placed the used lancet, alcohol swab and cotton ball into the sharps container. CNA_Med #1 cleaned the end of Resident #22's blood glucose monitor with an alcohol swab, placed into the designated bag and returned it back to the medication cart. CNA_Med #1 performed hand hygiene with alcohol based sanitizer. CNA_Med #1 obtained Resident #22's insulin pen cleaned off the hub with an alcohol swab and applied a new sterile needle. CNA_Med #1 primed pen with two units and dialed in five units of scheduled Humalog insulin. CNA_Med #1 entered Resident #22's room and administered insulin into the left arm. Returned to the medication cart and dispensed the used needle into the sharps container. CNA_Med #1 did not use gloves during handling of the used test strip, alcohol swab, lancet, cotton ball or injection needle. C. Staff interviewsRegistered nurse #2 was interviewed on 3/30/23 at 9:00 a.m. RN #2 said that when obtaining resident blood glucoses, administering insulin injections or coming into contact with blood or bodily fluids standard precautions should be followed. RN #2 said gloves were worn and hand hygiene was performed before donning gloves and after doffing gloves. The infection preventionist (IP) was interviewed on 3/30/23 at 4:10 p.m. The IP said standard precautions should be followed prior to resident care that had the potential for blood or bodily fluid exposure which included finger sticks for blood glucose monitoring, giving injections and handling items contaminated by blood or bodily fluids. The director of nursing (DON) was interviewed on 3/30/23 at 4:20 p.m. The DON said that before obtaining resident blood sugars, administering insulin injections and handling any item contaminated with blood or bodily fluids, standard precautions were followed which included hand hygiene and the use of gloves.

Based on observations and interviews, the facility failed to ensure mechanical equipment was in safe, operational condition. Specifically, the facility failed to ensure necessary kitchen equipment was maintained in safe, working condition. Findings include: I. Observations On 3/27/23 at 9:15 a.m., a kitchen inspection revealed a three compartment sink with one faucet handle dripping into the left hand side sink compartment. On 3/29/23 at 5:00 a.m. the faucet on the three compartment sink dripping into the sink still. Underneath the sink, a valve handle was dripping water into a seven quart rectangular wash basin and overflowing onto the floor under the sink. On 3/30/23 at 8:30 a.m. the faucet and valve had still not been repaired. II. Staff interviews The nutrition services director (NSD) was interviewed on 3/27/23 at 9:30 a.m. He stated he had reported the dripping sink to the maintenance director two days prior and was told that once the maintenance assistant returned to work from being sick, it would be taken care of. The NSD was interviewed again on 3/29/23 at 5:10 p.m. He stated the faucet and valve had both been dripping for a week and the maintenance director had been informed of both leaks. Dietary cook (DC) #2 was interviewed on 3/30/23 at 8:45 a.m. She stated both leaks had been going on for a month but recently had become worse. DC #1 was interviewed on 3/30/23 at 10:10 a.m. She stated the faucet and the valve had both been dripping for a month but in the last two weeks it had become worse. In the last two weeks, the container underneath filled up again right after being emptied. The container had begun overflowing more often and the staff had to mop water off the floor to prevent from slipping. The maintenance director (MTD) was interviewed with the nursing home administrator (NHA) present on 3/30/23 at 10:20 a.m. The MTD stated the NSD had let him know about the leaks in the kitchen a week prior and he had provided them with the seven quart rectangular wash basin as a short term remedy until his assistant returned from being out sick. The assistant had still not returned to work. He stated the repair was on his list of things to do and should only require a few parts to be fixed when he got the chance. The NHA was interviewed on 3/20/23 at 10:25 a.m. She stated the leaks in the kitchen would be addressed immediately and a plumber would be contacted. III. Facility follow-up On 3/30/23 at 11:02 a.m. an email from the NHA documented a plumber had arrived at the facility. At 2:12 p.m. an email from the NHA documented a purchase order receipt from a plumbing company showing a replacement of a SharkBite fitting by the plumber to the kitchen sink.

Based on observations and interviews, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and vermin. Specifically, the facility failed to utilize a method for pest control that was effective and sanitary. Findings include: I. Professional references According to the Centers for Disease Control and Prevention, How to Trap and Remove Rodent Infestations, retrieved from https://www.cdc.gov/healthypets/pets/wildlife/trap on 4/4/23, "Glue traps (small board made of cardboard, fiberboard, or plastic that's coated with a sticky adhesive that ensnares any small animal who wanders across or lands on its surface) can increase a human's risk to exposure of diseases. Do not use glue traps or live traps. These traps can scare the rodents causing them to urinate, which can increase a human's chances of getting sick."In addition, glue traps were not included in the Environmental Protection Agency (EPA) list of registered and recommended products to treat rodent infestations. II. Facility Policy The Pest Control policy, undated, was provided by the nursing home administrator (NHA) on 3/28/23 at 5:03 p.m. It read in pertinent part, "The facility will ensure that appropriate chemicals are used to control pests but can be used safely inside of the building without compromising resident health." III. Observations On 3/28/23 at 1:40 p.m. in resident room #108 an exposed rodent glue trap was behind the resident's recliner. It was visible from the hallway and had a piece of corn chip on it. At 3:43 p.m. in resident room #112 an exposed rodent glue trap was behind the resident's recliner with a corn chip in it. In resident room #111 an exposed rodent glue trap was behind the resident's recliner with a corn chip in it. IV. Resident interviewsThe resident in room #108 was interviewed on 3/27/23 at 9:55 a.m. The resident was aware of the trap in the room but did not believe it was effective. The resident had observed mice running across the floor of the room, in and out of the bathroom, and in and out of the closet for the last two weeks. The resident in room #108 was interviewed again on 3/29/23 at 10:11 a.m. The resident stated there was a rodent problem on that hallway and the resident had observed mice in the room daily. V. Interviews Registered nurse (RN) #1 was interviewed on 3/28/23 at 2:50 p.m. She stated in the last two weeks the residents have started to report to her seeing mice in their rooms. She had not seen mice herself but the residents making the reports were cognitively intact. She was aware of the glue traps being put out. Certified nursing aide (CNA) #2 was interviewed on 3/28/23 at 3:47 p.m. She had not seen any mice in the facility personally but stated she had heard rumors from other staff there was an infestation in the last week. Housekeeper (HSKP) #2 was interviewed on 3/29/23 at 9:07 a.m. The rodents had only recently become a problem in the last month. She knew the maintenance department was using glue traps and residents had reported to her seeing mice. She stated sometimes the traps would stay out for a few days with a mouse in them before they were disposed of. HSKP #2 said she personally has disposed of two mice in the last month. The NHA was interviewed on 3/29/23 at 9:56 a.m. She said the pest control company the facility used was scheduled to come out for the regular monthly visit today. The maintenance director (MTD) was interviewed on 3/29/23 at 10:14 a.m. with the NHA present. The MTD stated the facility had a pest control company that came out monthly. The company would spray around the outside of the building and set up baited box traps (traps that once the mouse went inside, they could not get back out) outside and in the facility's boiler room. He said several months ago, he had been given the glue traps by the pest control company on one of their visits to the facility. The maintenance department was putting the corn chips on the glue traps as bait. He acknowledged he had not considered whether having a rodent stuck to a glue trap behind a resident's chair was sanitary or disturbing for the resident. A representative with the pest control agency was interviewed on 3/29/23 at 11:30 a.m. He stated his company had been coming to the facility for approximately six months and he had been to the facility four times personally. The company had set out twelve external baited box traps and serviced those traps monthly. The agent said about four months ago, the maintenance department asked him for interior bait traps and he sold those to the facility. Interior bait traps include poisoned bait inside and once a mouse went inside and ate the bait, they left the trap and went elsewhere in the building to die. The agent said the pest control company could sell or provide interior bait traps or glue traps by request but those were not recommended methods. He did not recommend interior bait traps because finding the deceased rodent and disposing of them could be difficult. He did not recommend glue traps because rodents could sometimes get off of the trap and this process could be very messy. A rodent's body may not be intact when they get themselves free from the glue. IV. Facility follow-upAn email was received from the NHA on 3/30/23 at 10:16 a.m. documenting the glue traps had been removed from all the resident rooms. The NHA provided the prior two months pest control invoices. Invoice dated 2/22/23 charged the facility for interior inspection of pests and external service of baited traps. Invoiced dated 1/12/23 charged the facility for interior inspection of pests and external service of baited traps.

Based on record review and interview, the facility failed to provide training to their staff that at a minimum educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically the facility failed to:-Provide annual abuse identification and prevention training for one of out of six certified nurse aides (CNA) reviewed; and,-Provide initial hire orientation and/or annual dementia management training for four out of six CNAs. Findings include: I. Facility policy and procedures The Abuse, Neglect and Exploitation policy, revised 2/27/2020, was provided by the nursing home administrator (NHA) on 3/27/23 at 11:12 a.m., read in part: "The facility will develop and implement written policies and procedures that:-Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention. "Employee Training: New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. Existing staff will receive annual education through planned in-services and as needed. Training topics will include:-Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation;-Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property;-Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators;-Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources;-Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: Aggressive and/or catastrophic reactions of residents; Wandering or elopement-type behaviors; Resistance to care; Outbursts and yelling out; and Difficulty in adjusting to new routines or staff." II. Training records A request was made for training records for the past 12 months (3/29/22 to 3/29/23) for six randomly selected CNAs showing proof of participation in orientation (new hire) or annual abuse identification, prevention, and reporting; and dementia management training. The facility staff development coordinator (SDC) provided employee records. The training records revealed not all reviewed employees were up to date with annual and new hire abuse identification, prevention, and reporting; and dementia management training Training records revealed -CNA #11 was hired on 8/16/19. CNA #11's training records revealed the CNA had no documented training in the last 12 months. CNA #11 was not provided either annual abuse identification, prevention, and reporting; and dementia management training. -CNA #1 was hired on 8/21/2020. CNA #1's training records revealed CNA #1 was not provided annual dementia management training. -CNA #9 was hired on 12/28/22. CNA #9's training records revealed CNA #9 was not provided initial new hire dementia management training prior to working with residents diagnosed with dementia; CNA #9 had been working in the facility for 93 days at the completion of the survey. -CNA #10 was hired on 12/28/22. CNA #10's training records revealed CNA #10 was not provided initial new hire dementia management training prior to working with residents diagnosed with dementia; CNA #9 had been working in the facility for 93 days at the completion of the survey. III. Staff interviews The SDC was interviewed on 3/30/23 at 2:13 p.m. The SDC said both abuse identification, prevention, and reporting; and dementia management training were mandatory for all newly hired staff provided during employee orientation and the training was to be repeated annually. The SDC said she maintained the staff training records and had provided the most up to date records for review. All facility staff were assigned the required training topic on a monthly basis and were expected to come into the facility to complete the required training sessions independently. The staff had access to computers in the facility library and were permitted to come in off scheduled work hours to complete the training; staff were paid for their training time. All staff were required to complete the assigned training. The SDC said the online training was developed by a health care professional organization (organization name provided) (each training was based on industry standards). The SDC said if staff failed to complete the assigned training the employee's manager was notified. The manager was responsible to provide appropriate disciplinary action to ensure the employee completed any missing training session to maintain compliance with training recommendations. If the employee remained out of compliance with training requirements after one additional month, the SDC was to provide a report to the NHA for next step actions. The SDC said a recent review of staff compliance with training requirements revealed several staff were out of compliance with the facility's training expectations; based on these findings facility leadership determined it was necessary to give all staff a list of uncompleted training with an expected completion deadline of 5/30/23. If a staff failed to catch up on uncompleted training by the deadline that staff member would face unpaid suspension. The SDC was not sure why CNA #11 had not completed any of the facility assigned required trainings; CNA #11's lack of compliance with training assignments was somehow overlooked and no staff recognized that CNA #11 had not completed any of the assigned training in the last 17 months. It was not until the CNA's training records were requested during the survey that it was realized that CNA #11 had not been completing the assigned training. The NHA was interviewed on 3/30/23 at 2:25 p.m. The NHA acknowledged the importance of employee education particularly when staff were newly hired to ensure staff had the knowledge and skills necessary to perform the job. The NHA said there was no reason that any staff should not be in compliance with new hire and annual training requirements. Staff were provided paid time to complete training and were given dedicated time to complete the assigned training modules.