REHABILITATION AND NURSING CENTER OF THE ROCKIES

A revisit survey was completed on 12/3/24 for all previous deficiencies cited on 10/23/24. The facility is in compliance with all regulations surveyed.

A complaint survey prompted by complaint #CO35456 was conducted on 10/21/24 to 10/23/24. No deficiencies were cited.

A complaint survey prompted by #CO36990 and #CO37755 was conducted on 10/21/24 to 10/23/24. Two deficiences were cited.

Based on observations, record review and interview, the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life for three (#3, #12 and #9) of four residents out of 20 sample residents. Specifically, the facility failed to ensure Resident #3, #12 and #9 received timely person-centered assistance with meal set up and/or eating. Findings include:I. Facility policy and procedureThe Activity of Daily Living policy, reviewed September 2023, was received from the director of nursing (DON) on 10/23/24 at 11:30 a.m. The policy read in pertinent part, "It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support from staff to maintain eating, grooming, personal hygiene, communication, oral hygiene, transfers and ambulation. ADLs will be care planned to reflect the residents' specific needs." II. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 10/9/24. According to the October 2024 computerized physician orders (CPO), diagnoses included dysphagia (difficulty swallowing), Alzheimer's disease with late onset (disease that impacts memory and thinking), dementia with agitation (condition which causes a gradual decline in cognitive abilities) and macular degeneration (disease that causes vision loss). The 10/15/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. She required substantial/maximum assistance with eating. B. ObservationsDuring a continuous observation on 10/21/24, beginning at 5:20 p.m. and ending at 6:13 p.m., the following was observed:Certified nurse aide (CNA) #3 and an unidentified CNA each had three residents who required assistance with eating. At 5:28 p.m. Resident #3 had not received her meal and began to repeatedly hit the table, her chest and her head with her hand. Resident #3 continued to hit the table, her chest and her head until CNA #1 moved the resident to another table at 5:39 p.m. CNA #1 proceeded to stand between Resident #3 and another resident who required assistance with eating. CNA #1 provided eating assistance to Resident #3 while simultaneously providing redirection and occasional assistance to the other resident who required assistance with eating, who kept trying to scoot himself away from the table. During a continuous observation on 10/22/24, beginning at 11:08 a.m. and ending at 12:47 p.m., the following was observed:CNA #6 was seated between Resident #3 and another resident who required assistance with eating. At 11:42 a.m. CNA #6 began to assist the other resident with eatingAt 11:44 a.m. Resident #3's lunch was delivered to the table and placed out of her reach due to her need for assistance with eating. Resident #3 made a repeated motion of reaching for the food on her plate, which was not within her reach, and then bring her hand to her mouth without any food and suck on her fingers. Resident #3 began to hit the table with her hand in between her attempts to retrieve food off of her plate.-CNA #6 did not attempt to distract Resident #3 from hitting the table or making any attempt to offer the resident a bite of food from her plate. At 12:08 p.m., after assisting the other resident with their entire meal, CNA #6 began to assist Resident #3 with eating her meal (24 minutes after the resident's plate had been served). During a continuous observation on 10/22/24, beginning at 5:03 p.m. and ending at 6:18 p.m., the following was observed:At 5:47 p.m. Resident #3's dinner plate was placed on the table in front of her and out of reach. At 5:49 p.m. Resident #3 began to hit her hand on the table. At 5:50 p.m. another resident who required assistance with eating was served her meal and CNA #3 began to assist her with eating, even though the other resident's food had been served after Resident #3's meal. At 5:54 p.m. Resident #3 was redirected to stop hitting the table.-CNA #3 did not attempt to assist Resident #3 with eating and continued to only assist the other resident with eating. At 5:55 p.m. CNA #3 began to provide assistance with eating to Resident #3 while continuing to provide eating assistance to the other resident simultaneously. -Resident #3 was not provided with eating assistance until almost ten minutes after her meal was served. C. Record ReviewThe care plan, initiated 10/9/24 and revised 10/16/24, revealed Resident #3 had a nutritional risk related to Alzheimer's and dementia. Pertinent interventions included, providing the resident's diet as ordered by the physician, providing meals in the dining room if the resident was in agreement and providing full staff assistance with meals. III. Resident #12A. Resident statusResident #12, age less than 65, was admitted on 8/16/24. According to the October 2024 CPO, diagnoses included cognitive communication deficit. The 8/21/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of one out of 15. She required supervision or touching assistance with eating. B. ObservationsDuring a continuous observation on 10/22/24, beginning at 11:08 a.m. and ending at 12:47 p.m., the following was observed:The meal consisted of a piece of chicken with gravy, rice, mixed vegetables, peach cobbler. At 11:40 a.m. Resident #12's meal was served to her. The resident did not make any attempts to begin eating her mealAt 12:23 p.m. CNA #4 noticed that Resident #12 had not eaten any food and offered to cut up the resident's chicken for her. After the chicken had been cut up, Resident #12 began to eat lunch, 43 minutes after her meal had initially been served. C. Record ReviewThe care plan, initiated 8/16/24, revealed Resident #12 required set up and clean up assistance with eating. Resident #12 had a weak left arm and required assistance with meals as needed. IV. Staff interviewsCNA #8 was interviewed on 10/23/24 at 11:40 a.m. CNA # 8 said CNAs were supposed to only be assigned two residents at a time that required assistance with eating. CNA #8 said the facility had recently admitted additional residents that required eating assistance and staff had been assigned three or four residents at one time to assist with meals. CNA #8 said she would assist two residents at the beginning of the meal and two more residents at the end of the meal. CNA # 8 said she would sit in between two residents and use both her hands to feed the residents simultaneously. CNA #8 said it was important to prevent one resident's food from becoming cold while another resident was being assisted. CNA #8 said Resident #3 was dependent on staff and required full assistance with eating during meals. CNA #8 said that Resident #3 usually ate the majority of her meals if she was assisted. CNA #8 said Resident #12 required minimal assistance with eating but needed assistance with cutting up her food so she could eat it herself. CNA #8 said Resident #12 should have had her food cut up by staff when her tray was served. CNA #8 said Resident #12 would become agitated if her hands became dirty or sticky. CNA #8 said Resident #12 had the capability to cut up soft foods but she would not cut them up because of her dislike of having potentially dirty hands. CNA #8 said Resident #12 would not have been unable to cut up a piece of chicken without assistance. CNA #9 was interviewed on 10/23/24 at 11:40 a.m. CNA #9 said CNAs should not be assigned more than two residents at a time to assist with eating. CNA #9 said she would sit in the middle of two residents and use both of her hands to assist the residents with eating so both residents were able to eat at the same time. CNA #9 said the facility admitted more residents that required eating assistance during meals. CNA #9 said Resident #3 required full eating assistanceat each meal. CNA #9 said Resident #3 should have been assisted to eat at the same time as the other resident, not after the other resident was finished eating. CNA #9 said any CNA assisting other residents to eat should know that both residents should be assisted at the same time. CNA #9 said there may have been staff brought in to help with assisting the residents with eating who were not aware of the process. CNA #9 said Resident #12 did not require assistance with eating but she did require help to cut up food, such as chicken. CNA #9 said even though Resident #12 was able to cut up some foods, such as a burrito, the resident would not do it for fear of getting her hands messy. CNA #9 said Resident #12's food should be cut up for her at the time the meal was served. The DON, the assistant director of nursing (ADON), the clinical resource nurse (CRN) and registered nurse (RN) #1 were interviewed together on 10/23/24 at 12:01 p.m. The DON said a CNA could only assist two residents with eating at one time. The DON said a CNA needed to be seated while they were providing residents with eating assistance. The ADON said a nurse should be pulled from a medication cart to help with assisting residents with eating if needed. RN #1 said dining tables should be served at the same time so staff could assist the residents at the table with eating at the same time. V. Resident #9A. Resident statusResident #9, age 79, was admitted on 8/9/23. According to the October 2024 CPO, diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbances. The 8/15/24, minimum data set (MDS) assessment revealed the resident was cognitively impaired based on the staff assessment for mental status. She had poor long term and short term memory. Decision making skills were moderately impaired. She required set up assistance with meals. B. ObservationsOn 10/22/24 during the breakfast meal, the following observations were mad:At 8:16 a.m. Resident #9 was lying in bed and was served her breakfast tray which consisted of a pancake. The pancake was not cut up and the resident was not eating her breakfast. At 8:38 a.m. Resident #9 still had not eaten her meal and had not received any meal assistance from staff. At 10:35 a.m. Resident #9 still lying in bed and her breakfast meal had not been touched. On 10/22/24 during a continuous observation of the lunch meal, beginning at 12:11 p.m. and ending at 1:08 p.m., the following observations were made:At 12:11 p.m. Resident #9 received her lunch meal. She received pork, rice, a blend of vegetables and apple crisp. At 12:22 p.m. Resident #9 was not eating her lunch and she had not received any assistance with eating from staff. She had not touched her meal since it had been served. At 12:39 p.m. Resident #9 had not eaten anything and no staff had checked on or encouraged her to eat. At 12:50 p.m. Resident #9 was picking at her food with her fingers. She ate the vegetables and the whipped cream off the top of the apple crisp, however, no staff had assisted her with eating the other items on her plate. At 1:08 p.m. an unidentified CNA removed Resident #9's food tray. She was not offered any encouragement to eat or another alternative for food. The resident had only consumed approximately 20 percent (%) of her meal. On 10/23/24 during a continuous observation of the breakfast meal, beginning at 8:14 a.m. and ending at 8:43 a.m., the following observations were made:At 8:14 a.m. CNA #10 delivered a breakfast room tray to Resident #9 while she was lying in bed. She was served scrambled eggs, hashbrowns, toast, oatmeal and some potato chips. At 8:18 a.m. Resident #9 was awake and was picking at her meal with her fingers. At 8:27 a.m. Resident #9 was still picking at her food with her fingers. She had not received any assistance to eat from staff. At 8:28 a.m. RN #1 went in to Resident #9's room, told the resident she was not eating her oatmeal and the resident responded no. Resident #9 had eaten the eggs but had not touched the hashbrowns or the oatmeal. -RN #1 did not offer Resident #9 an alternative to the oatmeal or offer to assist the resident with eating it. At 8:29 a.m. RN #1 left the resident's room. At 8:40 a.m. Resident #9 still had her toast in her hands. She had not eaten any more of it (half eaten). She had not touched the hashbrowns or the oatmeal. She took the potato chips off of the tray and did not eat them. She had not drunk any of her grape juice. At 8:43 a.m. CNA #8 went into Resident #9's room and removed the meal tray. -CNA #8 did not provide any encouragement to eat to the resident or offer her any substitutes to the meal. Resident #9 had only eaten the eggs and half of her toast. C. Record reviewThe care plan, revised 10/12/23, identified Resident #9 was a nutritional risk due to a dementia diagnosis. Pertinent interventions included a regular diet, including thinned liquids, providing meals in the dining room if the resident was in agreement, offering and encouraging snacks/fluids between meals, offering the resident portable meal options if she was not eating in the dining room and offering soft foods when the resident's dentures were not in use. D. Staff interviewsCNA #8 was interviewed on 10/23/24 at 10:15 a.m. CNA #8 said Resident #9 had cognitive impairments. She said the resident was able to feed herself but she required meal set up and encouragement to eat. She said the resident ate much better when she could pick the food up with her fingers. CNA #8 said Resident #9 did not do well eating in the dining room and she liked to eat in bed. RN#1 was interviewed on 10/23/24 at 10:35 a.m. RN # 1 said Resident #9 preferred to eat in her room and was anxious when she was out in the dining room. RN#1 said Resident #9 was able to feed herself but she required encouragement to eat and set up assistance. RN #1 said Resident #9 preferred little bowls and finger foods.

Based on observation, interview and record review the facility failed to provide adequate supervision during use of assistive devices to keep residents free from safety hazards for two (#10 and #11) of three residents out of 20 sample residents. Specifically, the facility failed to ensure wheelchair pedals were attached to Resident #10's and Resident #11's wheelchairs prior to pushing the residents within the facility. I. Facility policy and procedureThe Fall Management System policy, reviewedNovember 2023, was received from the director of nursing (DON) on 10/22/24 at 4:55 p.m. The policy read in pertinent part, " It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs."II. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on 4/25/24. According to the October 2024 computerized physician orders (CPO), diagnoses included cognitive communication deficit, generalized muscle weakness, repeated falls and dementia. The 8/1/24 minimum data set (MDS) assessment revealed the resident had short term and long term memory impairment with moderate impairment in making decisions regarding daily life. The resident had both short and long term memory problems. He required physical assistance with activities of daily living (ADL). B. ObservationsDuring a continuous observation on 10/22/24, beginning at 11:08 a.m. and ending at 12:47 p.m., the following was observed:At 11:13 a.m. Resident #10 was pushed into the dining room by an unidentified staff member without foot pedals on his wheelchair which caused the resident to hold his feet up off the floor. At 12:13 p.m. Resident #10 was pushed out of the dining room by an unidentified staff member. The resident's wheelchair did not have foot pedals on it. On 10/23/24 at 11:30 a.m., the physical therapist (PT) was observed asking Resident #10 to lift his feet while he pushed the resident in his wheelchair from the dining room to his room. C. Record reviewThe fall risk care plan, initiated 4/25/24 and revised 4/30/24, revealed Resident #10 was at risk for falls related to weakness and impaired mobility. Interventions included encouraging activities and time in the common area for increased supervision, anticipating and meeting the resident's needs and keeping the resident's call light within reach. The fall care plan, 5/6/24 and revised 5/21/24, revealed that Resident #10 had sustained previous falls without injury related to a history of falls, dementia, weakness, lack of safety awareness, and impulsivity. Interventions included placing a "call don't fall" sign in the resident's room and bright colored tape on the resident's call light.-The care plans did not include an intervention to ensure Resident #10's foot pedals were in place in order to prevent potential falls when the resident was being pushed in his wheelchair. The fall risk assessment dated 9/14/24 revealed Resident #10 as a high fall risk. III. Resident #11A. Resident statusResident #11, age greater than 65, was admitted on 2/27/24. According to the October 2024 CPO, diagnoses included spastic hemiplegia (paralysis or severe loss of strength on one side of the body) affecting the right dominant side, abnormal involuntary movements, generalized muscle weakness, lack of coordination, encephalopathy (brain syndrome that can cause confusion, memory loss, twitching), cognitive communication deficit, and non-traumatic intracranial hemorrhage (a type of stroke that cause blood to pool between the brain and skull preventing oxygen from reaching the brain tissue). The 6/27/24 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. The MDS assessment revealed he required minimal assistance with use of a manual wheelchair. B. ObservationsOn 10/22/24 at 11:49 a.m. Resident #11 was assisted to the dining room by an unidentified staff member. The resident did not have foot pedals on his wheelchair which caused the resident to hold his feet up off the floor. On 10/22/24 at 5:39 p.m. Resident #11 was observed being wheeled into the dining room without foot pedals on his wheelchair which caused the resident to have to hold his feet up off the floor. C. Record reviewThe October 2024 Kardex (a tool utilized to provide consistent resident care) revealed Resident #1 was a high fall risk, required frequent rounding and staff was to encourage activities in the common area for increased supervision. IV. Staff InterviewsThe DON was interviewed on 10/23/24 at 1:34 p.m. The DON said some residents refused to have foot pedals on their wheelchairs. The DON said staff education regarding ensuring foot pedals were in place on residents' wheelchairs when they were being pushed was frequently provided in daily huddles on every shift. The DON said the foot pedals could be placed on the chair and then removed once the resident has been transported to the location. She said there was no system in place as to where the foot pedals were kept so they were easily accessible to staff for transportation of residents. The director of rehabilitation (DOR) was interviewed on 10/23/24 at 2:44 p.m. The DOR said wheelchair pedals were kept in a residents' closet if they were not attached to the wheelchair. The DOR said he provided education to residents on an as needed basis about wheelchair foot pedal importance and safety. He said if a resident dropped their feet suddenly to the floor when they were being transported in a wheelchair without foot pedals attached, it could cause the resident to be propelled forward out of the wheelchair and sustain a fall.

A revisit survey was completed on 6/10/24 for all previous deficiencies cited on 5/1/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO35842 was conducted on 4/30/24 to 5/1/24. Two deficiences were cited.

Based on observations, record review and interviews, the facility failed to ensure one (#2) of three residents out of nine sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure identified person-centered fall interventions, which were care planned, were implemented consistently for Resident #2 following a fall with a left wrist fracture. Findings include:I. Facility policy and procedureThe Fall Management System policy policy, dated 11/2023, was provided by the director of nursing (DON) on 5/1/24 at 11:26 a.m. It read in pertinent part, "It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls."Care plan interventions will be developed to prevent falls." II. Resident #2 statusResident #2, age under 65, was admitted on 4/8/24. According to the April 2024 computerized physician orders (CPO), diagnoses included paraplegia, contractures to ankles, pressure ulcer and type I diabetes mellitus. The 4/14/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required substantial/maximal assistance with transfers. The assessment indicated the resident did not have a history of falls. A. Resident interviewResident #2 was interviewed on 4/30/24 at 4:28 p.m. Resident #2 said she fell a few weeks prior. She said she had been in bed, was reaching for something and fell out of the bed. She said she did not ask for help from the facility staff. She said she had fractured her wrist. B. ObservationsOn 4/30/24 at 4:45 p.m., Resident #2 was lying in bed. There was an air mattress on the bed with no bolsters (foam raised edges) present. A fall mat was in front of the dresser, across the room, and not beside the bed.-Resident #2 said she did not know where her reacher was. The reacher was observed in the wheelchair, behind the bed, out of reach of the resident. On 5/1/24 at 9:13 a.m. Resident #2 was lying in bed. There were no bolsters on the air mattress and the fall mat was across the room in front of the dresser and not beside the bed. At 9:58 a.m., the resident continued to lie in bed. Certified nurse aide (CNA) #1 was interviewed and confirmed the fall mat was in front of the dresser and not in front of the bed. He said he would move it to its proper location. He confirmed there were no bolsters on the mattress. At 10:10 a.m. Resident #2 was laying in bed and the fall mat was beside the bed. -There were no bolsters on the mattress. At 3:30 p.m. the resident was laying in bed, the fall mat was beside the bed and the bolsters were now present on the mattress. C. Record reviewThe admission fall risk assessment for Resident #2, dated 4/8/24, indicated she was at a medium fall risk. A progress note, dated 4/15/24, documented Resident #2 had a fall on 4/13/24 when she was reaching for the bed controls. It documented the resident sustained a contusion to the midline of the forehead and complained of pain to the left forearm. An x-ray, dated 4/14/24, revealed the resident sustained a fracture of the left wrist. The fall intervention implemented was to provide the resident with a reacher. The post-fall interview with Resident #2, dated 4/15/24, documented staff offered the resident a bolster to the air mattress and a fall mat next to the bed. It indicated that the resident was agreeable to the new interventions. The fall care plan, initiated 4/8/24 and revised 4/15/24, identified Resident #2 had an actual fall. It indicated Resident #2 was at risk for falls. The interventions, updated on 4/14/24 and 4/15/24, included providing bolsters on the air mattress, providing a floor mat beside the bed, providing a reacher to the resident and rearranging the resident's room for better ergonomics and resident preference. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 5/1/24 at 9:58 a.m. CNA #1 said he provided care for Resident #2 on a regular basis. He said he did not know the meaning of the falling star sticker that was placed on the name plate outside of the resident ' s room. He said Resident #2 had sustained a recent fall but he was not aware of any fall interventions for the resident. CNA #1 observed the fall mat in front of the dresser. He said he did not know the fall mat needed to be by the bed. He said the resident did not have any bolsters on the mattress. Registered nurse (RN) #1 was interviewed on 5/1/24 at 10:10 a.m. RN #1 said the falling star program was an awareness program for residents who were at risk for falls. She said Resident #2 was at risk for falls. She said it was everyone's responsibility to ensure the fall risk interventions were in place. RN #1 said fall mats should be placed next to the bedside. She said she could not recall where the fall mats were when she went into Resident #2' room that morning when she administered the resident' medications. RN #1 said the current mattress Resident #2 was using did not have bolsters, which was identified as an intervention in the resident ' s comprehensive care plan. She said the bolsters should be on the mattress. She said the reacher should be within reach of the resident. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 5/1/24 at 2:15 p.m. The ADON said the interdisciplinary team (IDT) reviewed all falls. The ADON said all interventions were discussed during the IDT meeting, documented in the comprehensive care plan and put into place following the meeting. The DON said the falling star sticker indicated a particular resident was considered a high fall risk. She said it was an internal system and was not part of the facility policy. Both the DON and the ADON said they did not check to ensure Resident #2's interventions were put into place following the IDT meeting. The ADON said the facility did not follow through on Resident #2's fall interventions to ensure they were in place.

Based on record review and interviews, the facility failed to manage the pain of two (#7 and #8) of three residents out of nine sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the facility failed to ensure pain medication had documented parameters for Resident #7 and Resident #8. Findings include:I. Professional reference The American Medical Directors Association (AMDA) The Society for Post-Acute and Long-Term Care Medicine Pain in the Post-Acute and Long-Term Care Setting Clinical Practice Guideline. Columbia, MD (2021), retrieved on 5/8/24 from www.paltc.org, read in pertinent part, "When several options for administering analgesics are ordered for a patient, nursing staff need adequately detailed guidance concerning how and when to select a PRN medication from among the several options that have been ordered." II. Facility policy and procedureThe Pain Recognition and Management policy and procedure, dated 12/2023, was provided by the director of nursing (DON) on 5/1/24 at 3:50 p.m. It read in pertinent part, "It is the policy of this facility that pain management is provided to residents who require such services, consistent with professional standards of practice."III. Resident #7A. Resident statusResident #7, age 69, was admitted on 4/20/23. According to the April 2024 computerized physician orders (CPO), diagnoses included left sided-paralysis (hemiplegia) and left sided weakness (hemiparesis) following a stroke (cerebral infarction), contracture of muscle in left upper arm, pain in joints of left ankle and left foot and arthritis of many joints (polyosteoarthritis). The 4/25/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. It indicated that the resident was on a scheduled pain regimen and received as needed pain medication. The assessment revealed the resident had frequent pain which frequently interfered with daily activities. B. Resident interviewResident # 7 was interviewed on 5/1/24 at 1:45 p.m. Resident #7 said he had pain in his left foot, left elbow and shoulder. He said it was a stabbing pain. Resident #7 said he received both Tylenol and Norco pain medications on an as needed (PRN) basis. He said when he received the PRN Tylenol it did not address his pain effectively. He said he lost sleep at night due to the pain. C. Record reviewThe April 2024 CPO documented the following physician orders:Acetaminophen (Tylenol) 325 mg (milligrams) two tablets every six hours as needed for general discomfort/pain/fever, not to exceed 3 gm (grams) from all sources, ordered on 2/13/24. Norco (hydrocodone-acetaminophen) 5-325 mg one tablet every eight hours as needed for pain. ordered on 4/16/24. -The physician's orders for the acetaminophen and Norco pain medications did not indicate the pain level parameters for which to administer each of the medications. -The Norco physician's order did not indicate to not exceed 3 gm of Acetaminophen. D. Staff interviewsRegistered nurse (RN) #1 was interviewed on 5/1/24 at 2:00 p.m. RN #1 said parameters around pain medications were important to have documented on the physician's orders to ensure the resident's pain was adequately addressed. She confirmed Resident #7 had pain in his left foot, elbow and shoulder. She confirmed that Resident #7's pain medications (Tylenol and Norco) did not have parameters for when to administer the medications. IV. Resident #8 A. Resident statusResident #8, age under 65, was admitted on 7/27/22. According to the April 2024 CPO, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and chronic post-traumatic headache. The 3/7/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. The assessment revealedthe resident had frequent pain which interfered with daily activities. B. Record reviewThe April 2024 CPO documented the following physician order:Norco (hydrocodone-acetaminophen) 5-325 mg one tablet every eight hours as needed for oral pain, ordered on 5/18/23. Tylenol 325 MG (acetaminophen) 650 mg by mouth every six hours as needed for mild pain/fever, do not exceed 3 gm within 24 hours, ordered 12/6/23. -The physician's order for the acetaminophen and Norco pain medications did not indicate the pain level parameters for when to administer each of the medications. -The Norco physician's order did not indicate to not exceed 3 gm of acetaminophen. The March 2024 and April 2024 medication administration record (MAR) listed the pain scale utilized for administration of the PRN Norco as a numerical 1-10 scale.-It did not specify what pain levels on the scale of 1-10 the medication should be administered for. -The MAR did not specify what type of pain scale was utilized for Tylenol or what specific pain levels the medication should be administered for.-According to the March 2024 and April 2024 MAR, Norco had been administered when the resident had a pain level ranging from 2-7. C. Staff interviewsCharge nurse (CN) #1 was interviewed on 5/1/24 at 2:00 p.m. CN #1 said Resident #8 was able to ask for pain medications. She said the resident had an order for Norco and Tylenol. She said Resident #8 typically asked for pain medications around 2:00 p.m. She said for mild pain, a pain level of 1 to 5 on a pain scale of 1-10, she would administer Tylenol to the resident. RN#1 was interviewed on 5/1/24 at 3:20 p.m. RN #1 confirmed pain parameters were not indicated on the physician's orders for Resident #8's Tylenol or Norco. She said the pain medications needed to have parameters indicated for what pain levels the medications should be administered for.

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

A revisit survey was completed on 2/27/24 for all previous deficiencies cited on 12/12/23. The facility is in compliance with all regulations surveyed.

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). This survey was conducted on January 9, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a one (1) story, Type V (000) construction. This original facility was constructed in 1963. The facility is licensed for 106 beds and the census on the date of the survey was 75. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and anti-freeze fire sprinkler systems. This facility is classified as fully sprinklered. The results of this survey were discussed with the Administrator and the Maintenance Director during the exit conference.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with NFPA 101, Life Safety Code Sections 21.2.9 and 7.9.3.1.1. This was evidenced by the following:1. No records or inadequate documentation for emergency lighting 30 second monthly and 90-minute annual testing. 2. Missing required emergency lighting at the generator transfer switch. NFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. (3) An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.2.3. The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting. This deficient practice could affect occupants and staff if emergency lighting is needed during a power loss. This was discussed during the exit conference.

Based record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the NFPA 101, Life Safety Code Section 19.3.4.1 and NFPA 72. This was evidenced by:1. No records or documentation for 2-year smoke detector sensitivity testing. NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, 14.2.1.1.2 Inspection, testing, and maintenance programs shall verify correct operation of the system. NFPA 72, 14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. NFPA 72, 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. NFPA 72, 14.4.5.3.2 Sensitivity shall be checked every alternate year. This deficiency was discussed during the exit conference.

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 01/01/2024 and 01/07/2024, 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 recertification survey with complaints #CO34070, #CO34332, #CO34333 and #CO34380 was complerted on 12/6/23 to 12/12/23. Two deficeincies were cited.

An Emergency Preparedness survey was conducted from 12/6/23 to 12/12/23. No deficiencies were cited.

Based on observations, interviews and record review, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#65) of one resident reviewed for respect and dignity out of 40 sample residents. Specifically, the facility failed to:-Ensure Resident #65 was treated with respect and dignity from facility staff after she reported concerns;-Ensure Resident #65 was offered alternative activities when facility administration requested she not enter the activities hallway;-Ensure Resident 65's care plan was updated to with her involvement, included accurate resident needs and interventions; and,-Ensure Resident #65's concerns and interventions were documented in her medical record. Findings include: I. Facility policiesThe Promoting/Maintaining Resident Self-Determination, revised March 2023, was received by the nursing home administrator (NHA) on 12/12/23 at 8:50 a.m. and read in pertinent part,"It is the policy of this facility to protect and promote rights by promoting and facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences."Procedure:-All staff members involved in providing care to residents will promote and facilitate resident self-determination;-It is the resident's right to determine what, if anything, they would prefer to do or not to do each day in accordance with physician orders and resident's abilities;-Each resident has the right to choose their schedules consistent with their interests, assessments, and plan of care;-Each resident has the right to make to choices about aspects of his or her life in the facility that are significant to the resident;-All aspects of care and services will be discussed in the care plan meeting and documented as such;-The care plan will reflect resident choices when applicable;-Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident;-All aspects of care and services will be discussed in the care plan meeting and documented as such;-The care plan will reflect resident choices when applicable;-Each resident has the right to participate in activities, including social, religious, and community activities that do not interfere with the rights of other residents on the facility;-The facility will accommodate for the resident preference to the extent possible and as agreed upon by the resident sponsor and physician."B.The Care Planning policy, revised in June 2023, was received by the NHA on 12/11/23 at 7:14 p.m. and read in pertinent part,"It is the policy of this facility that the interdisciplinary (IDT) shall develop a comprehensive care plan for each resident."Procedure-The care plan is developed by the IDT which includes, but is not limited to social service staff members, registered nurses (RN) and others as necessary.-To the extent possible, the resident should participate in the development of the care plan."II. Resident #65A. Resident statusResident #65, age 87, was admitted on 4/6/23. According to the December 2023 computerized physician's orders (CPO), diagnoses included muscle weakness, orthopedic aftercare, unsteady on feet, back pain and hypertension. The 10/12/23 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a score 15 out of 15 on the brief interview for the mental status (BIMS) exam. The resident did not walk but used a manual wheelchair to get around the unit with limited assistance. She needed extensive assistance from staff to complete activities of daily living for bed mobility, transfers, bathing, dressing, toileting and personal hygiene. The resident had no behavior psychosis and had no history of physical or behavioral symptoms directed at others and the resident was not on any antipsychotic medication at the time of the assessment. The staff assessment of the resident's mood was not completed but indicated the resident never felt lonely or isolated from those around her. The resident had no wandering behaviors. The resident had no behavioral symptoms. B. Resident observation and interviewsResident #65 was interviewed on 12/7/23 at 9:50 a.m. Resident #65 was observed in her room, with the door closed. She sat in her wheelchair next to her bed. The resident's hair was dyed purple. Resident #65 said she had a problem with one male resident (#74). She said that he resided on hallway four, across the hallway from the activities room. She said since Resident #74 a few months ago approached her several times in the facility's common areas. She said he reached out to touch her on the arms or shoulders and talked to her like she was his wife. She said Resident #74 made her feel uncomfortable and it "gave her the creeps" that he sought her. Resident #65 said a few weeks ago Resident #74 wandered into her room while she was in bed and she yelled at Resident #74 to "go away" and he left her doorway. She said he wandered into her room just once but she has noticed him in the hallway outside her room at other times. Resident #65 said she normally went to activities but she noticed the DON helping Resident #74 to the activity and she said felt she had no choice but to stay in her room to avoid him. Resident #65 said the NHA was aware of her concern because he told her last week they could not send him away. Resident #65 said the NHA told her last week he would ask staff to monitor Resident #74. Resident #65 said after speaking with the NHA she noticed staff had Resident #74 sat at a table in the dining room across the room from her but once he was seated, they did not monitor him. She said a few weeks ago the social services director (SSD) told her that she resembled Resident 74's wife. She said changing her hair color maybe worked because he stopped wandering to her room. Resident #65 said she used to keep her door open and now she kept it closed and it was in an attempt to hide herself from Resident #74. Resident 65 was interviewed again on 12/11/23 at 10:40 a.m. Resident #65 said she was frustrated and said no staff from the facility had followed up with her to let her know what was being done for her. She said they keep offering me counseling and she asked, "why am I the one that needs counseling? I have done nothing wrong." She said they offered to help her move to another facility but she had many friends where she was and did not want to leave. She said in November 2023 staff tried using the stop sign across her doorway but she wanted it removed because it had acted like a target. She said at that time she was the resident on the hallway with a stop sign and it let Resident #74 know right where to find her. She said, "but they keep asking me to put the stop sign back up." The resident said the NHA met with her earlier on 12/11/23 and he told her she was the problem. She said The NHA told her she needed to understand that Resident #74 did not know where he was or what he was doing. Resident #65 said that made her especially mad because she knows very well some residents did not think clearly. -The facility had updated the resident's behavior care plan (see below) that she could perseverate on the intent of other wandering residents and making unfounded allegations (see care plan below). The resident denied she had neither perseverated on wandering residents nor made unfounded allegations. She said no staff members spoke with her about updating her care plan interventions and did not understand why the facility made that statement. She denied that she was triggered by wandering males of lower cognitive functioning in her space and said it was really the opposite. She referred to another male resident that walked in the hallways and said she understood he was lost. Resident #65 said the difference was Resident #74 thought she was his wife and kept seeking her out. The resident was interviewed again on 12/12/23 at 11:00 a.m. She said the SSD met with her again on 12/12/23 and she agreed to counseling. Resident #65 said she agreed to counseling because she felt it was pushed on her. She said the NHA met with her again on 12/12/23 and asked her to stay off hallway four, where Resident #74 resided. She said the NHA told her if Resident #74 could not enter hallway two it was fair that she stay off hallway four. Resident #65 was visibly upset as she spoke. She said she now felt the NHA was not being fair to her. . Tears formed in the resident's eyes and she said she attended many activities on hallway four. She said the NHA did not offer her any alternatives and she now felt he told her to stay in her room. Cross-reference F744: the facility failed to provide dementia care and services to Resident #74. C. Record reviewResident #65's comprehensive care plan imitated 8/11/23 included a care focus for potential to have adjustment issues due to admission. The care plan documented a care focus to address a resident-to-resident physical altercation. The care focus initiated 8/11/23 with a target completion date of 10/30/23. The care focus revealed the goal was to receive daily opportunities for social contact through the review date. The goal specific interventions for Resident #65 included: -Encourage to participate in conversation with staff, other residents daily;-Learn to recognize/help to identify stressors which may be early warning signs of problem behavior. Intervene and remove stressors where possible;-Needs the opportunity to communicate feelings regarding attended activities;-Needs the opportunity to communicate feelings regarding nursing home admission;-Provide with as many situations as possible which give control over environment and care delivery.-The facility identified and planned care for Resident 65's need for daily conversation with staff, to attend regular activities and her need to be provided with control over her environment. However, after the occurrences in November and December 2023, the resident said staff have made her feel that she needs to stay in her room and to stay off the activities hallway. The behavior care plan, initiated 12/7/23 (during the survey), identified Resident #65 could have the potential for a behavior problem with a history of perseverating on the intent of other wandering residents and a history of making unfounded allegations. Interventions to meet the resident needs included (in part):-Approach in a calm manner;-Anticipate and meet needs;-Caregivers to provide opportunity for positive interaction;-Stop and talk with him/her passing by;-Counseling offered, but declined on 11/2023 and accepted 12/7/23;-Discuss behavior, explain why behavior is inappropriate and/or unacceptable;-Intervene as necessary to protect the rights and safety of others;-Approach/speak in a calm manner, divert attention, remove from the situation and take to alternate location as needed, reassure resident that she is safe;-Offer resident to participate in bingo, exercise class;-Report any allegation per facility protocol;-Praise any indication of progress/improvement in behavior;-Provide a program of activities that is of interest and accommodated resident's status; and,-Triggers: wandering males of lower cognitive functioning in her space.-Review of the resident's progress note revealed the resident had no documented concerns or altercations with residents in the facility prior to 12/7/23. On 12/7/23 at 2:53 p.m., the SSD had a conversation with Resident #65 and documented in pertinent part: "Resident #65 said she was having discomfort with Resident #74. Resident #65 agreed to try counseling services to address psychosocial effects. Resident #65 declined to moverooms within the facility and declined to have a stop sign put back up on her door. Resident #65 reported that she may be interested in moving to a different facility. At the conclusion of the interview Resident #65 appeared at baseline mood and functioning." IV. Staff interviewsThe SSD was interviewed on 12/7/23 at 11:45 a.m. The SSD said she offered Resident #65 counseling, to replace the stop sign across her doorway and to help her move to another facility and the resident declined all offers. The SSD said she had previously offered counseling to Resident #65, around 11/22/23. She said she did not have any documentation of the conversations with Resident #65. The SSD said she knew about one time Resident #74 confused Resident #65 for his wife. The SSD said the stop sign was used as a deterrent to direct wandering residents in another direction. She did not recall when that occurred and it was around 11/22/23. -However, this was not documented in Resident #65's record. The SSD said when the stop signs were implemented in November 2023 the resident's care plan should have been updated. She said it was her responsibility to update care areas of resident behavior needs. She said she did not update the care plan for Resident #65 because the situation in November 2023 was not a big issue. She said she regularly offered counseling to residents in response when concerns were reported to her. The SSD was interviewed again on 12/12/23 at 12:10 p.m. She said the medical record entry she made on 12/7/23 at 2:48 p.m. was the first documentation she had on the resident's concern. She said 2:48 p.m. reflected the actual time of her interview with the resident on 12/7/23 because she was delayed due to other matters. The SSD said she did not report the resident concerns from November 2023 to the NHA because Resident #65 was not distressed. She said the resident was "just telling me something." The SSD said Resident #65 talked to her following the incident in November 2023 and then she stopped talking to about and said the issue was exacerbated only this week, after the start of the survey. The SSD said to her knowledge Resident #65 did not have a paranoid diagnosis, had made no other allegations towards staff, residents or visitors. The SSD was aware Resident #65 had dyed her hair green and then purple. The SSD said the resident dyed her hair because Resident #74 was seeking Resident #65. She said dying hair could be an emotional or mental thing which prompted her to offer Resident #65 counseling. The SSD said she had follow up interviews with the Resident on 12/11/23 and 12/12/23 and Resident #65 continued to decline to place a stop sign across her doorway. She said on 12/12/23 Resident #65 agreed to be referred for counseling. Certified nurse aide (CNA) #6 was interviewed on 12/7/23 at 10:55 a.m. She said she was familiar with Residents #65 and #74. She said she has worked the hallways where Resident #65 and #74 resided. She said she was aware of the situation with Resident #74 approaching and seeking out Resident #65 "now and then" because she looked like his wife. CNA #6 said she and other staff members thought it was funny and they laughed about it, sometimes with Resident #65. CNA #6 said she was unaware when Resident #65 dyed her hair but she received the hair dye from the activities assistant sometime last week. Restorative nurse aide (RNA) #1 was interviewed on 12/7/23 at 1:40 p.m. She said she was familiar with Residents #65 and #74. She said the resident attended activities regularly in group activities in the dining room, enjoyed outings for shopping with the group and attended smaller group activities in the activity room. RNA #1 said Resident #65 told her about Resident #74 mistaking her for his wife. She said Resident #65 discussed dying her hair as a disguise, to confuse Resident #74. RNA #1 said she did not think it was a serious concern and the resident never told her she was afraid. She said the resident talked about him seeking her out and staff thought that was cute and funny. She said she provided the hair dye for Resident #65 and suggested the resident first try a spray on (temporary) dye that was green, in case she did not like the change. RNA #1 said in the previous week, the resident wanted permanent hair dye and she provided the resident with purple, permanent hair dye. The RNA could not recall the dates she spoke with Resident #65 about Resident #74, provided the hair dye and said did not keep documentation about the concern. RNA #1 was interviewed again on 12/12/23 at 11:30 a.m. She said she was aware Resident #65 was told to stay off hallway four. She said that would probably upset Resident #65 because she attended group activities in the activities room located on hallway four. RNA #1 said in the room on hallway four, she held group Bible studies, had question and answer sessions about other readings and Resident #65 visited individually regularly just to talk and say hello. RNA #1 said she had no immediate activities replacement options for Resident #65 but she would see what could be offered off hallway four. Registered nurse (RN) #3 was interviewed on 12/7/23 at 2:05 p.m. She said she was aware Resident #74 confused Resident #65 for his wife and that Resident #74 followed her around the facility sometimes. RN #3 said Resident #65 told her Resident #74 went into her room and it made her feel uncomfortable. She said Resident #65 told her she told Resident #74 to get away from her and he left her alone so she did not see it as an issue. RN #3 said Resident #65 agreed to try placing a stop sign across her doorway. RN #3 said she could not remember when the stop sign was placed but thought it was around the middle of November 2023. She recalled around Thanksgiving Resident #65 wanted the stop sign removed from her doorway when Resident #65 realized her room was the only room on hallway two that had a stop sign and thought it would act as a target and help Resident #74 locate her room. RN #3 said she did not believe Resident #65 was bothered very much by Resident #74 because staff joked and laughed with Resident #65 when they realized she resembled the wife of Resident #74. RN #3 said she not tell anyone about Resident #65 being uncomfortable because she and other staff thought it was cute and harmless that Resident #74 confused Resident #65 for his wife. RN#3 said she thought the situation changed when she noticed in late November 2023 Resident #65 dyed her hair in the previous week. RN #3 said around the time the stop sign was placed across Resident #65's doorway, the DON told staff in a huddle meeting they needed to watch Resident #74 and keep him off hallway two. RN #3 said when a resident had a stop sign placed across their doorway, the nurse should write a progress note and notify DON, the physician and obtain an order to use the stop sign. She said she was unaware of physician orders for the stop sign or any monitoring or tracking behavior for Resident #65. The DON and NHA were interviewed together on 12/12/23 at 2:39 p.m. The DON said she was aware of one time in November 2023 Resident #65 had a concern that she resembled Resident #74's wife. The DON said she did not remember how she found out about the resident's concern. She said she was told by someone and did not remember by whom. She said in November 2023 the SSD spoke with her after she talked with Resident #65 and said the concern was not a problem. The DON said she did not recall telling staff specifically to keep Resident #74 off hallway two. She said when residents wander without supervision staff redirect off every hallway as needed, it was not official supervision to redirect a wandering resident. The DON said she held huddle meetings twice a day for staff education and care plan updates. She said she did not keep huddle notes. The NHA said the DON did not have detailed information for Resident #65 because what occurred in November 2023 was not an issue. He said it was a minor incident a few weeks ago. The NHA said Resident #65 dyed her hair a couple of different colors maybe to make a fashion statement. The NHA said Resident #74 had not been observed wandering and was currently asleep in his room, which was his baseline. The NHA said he had not interviewed Resident #65 regarding her concerns. He said the SSD completed the interviews. The NHA said Resident #65 asked yesterday or today about the possibility of Resident #74 be moved to another facility. The NHA said he was unaware what trauma Resident #65 had previously suffered. He said he thought she had some trauma to make her want to stay in her room. He said he did not ask her to stay in her room. The NHA said Resident #65 had previously been offered a stop sign to place across her doorway and had declined offers for counseling. The NHA said he did not want Resident #65 to be uncomfortable or scared. The NHA said earlier in the day he requested Resident #65 to stay off hallway four. He said she had not abided by the agreement to stay off hallway four. He said he watched her enter the hallway but he did not confront her or say anything. The NHA said he had not seen anything that indicated there was a problem between Residents #65 and #74. The DON agreed with the NHA and said there was not a problem identified.

Based on observation, interview and record review, the facility failed to ensure one (#74) of one resident reviewed for dementia care out of 40 sample residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to develop a comprehensive plan of care, to include person-centered interventions to engage Resident #74 and address his wandering behaviors. Findings include:I. Facility policy and procedureThe Dementia care policy and procedure, not dated, was provided by the nursing home administrator (NHA) on 12/7/23 at 4:05 p.m. The policy read in pertinent part: "It is the policy of this facility that all residents will have an individualized plan of care and have the least restrictive approaches to care;"The staff are offered specialized training in the care of the dementia population, appropriate approaches to care and managing behaviors;"The interdisciplinary staff will initiate a thorough clinical assessment; "The monitoring of mood, behavior, and/or any psychosocial related issues to identify possible underlying medical problems which may be causing the behavior problems;"The interdisciplinary team will review findings of evaluations and develop a plan of care addressing the resident's needs."II. Resident statusResident #74, over age 65, was admitted to the facility on 10/10/23. According to the December 2023 computerized physician orders (CPO), diagnoses included severe vascular dementia with anxiety, cognitive impairment, depression, bilateral (in both ears) hearing loss and difficulty walking. The 10/10/23 minimum data set (MDS) assessment documented the resident had a severe cognitive deficit with a brief interview for mental status (BIMS) score of six out of 15. The resident required a walker or wheelchair for mobility and supervision with walking 10 feet and walking 50 feet and no wandering behavior exhibited. III. Observations During continuous observations on 12/11/23 from 8:47 a.m. to 9:16 a.m. Resident #74 was sitting in the living room/common area watching television. During continuous observation from 10:30 a.m. to 11:51 a.m. Resident #74 was in the living room watching television. Resident #74 was taken to his room at 10:48 a.m. At 11:44 a.m. the resident was in bed asleep. During continuous observation from 2:20 p.m. to 3:00 p.m. activities staff were preparing for Bingo. Resident #74 was in bed asleep. During continuous observation on 12/12/23 from 11:30 a.m. to 12:11 p.m. Resident #74 finished the lunch meal and was taken back to his room at 12:11 p.m. -The observations revealed the resident was not engaged and according to the resident's family (see record review below) the resident was social and liked to be around people. IV. Record reviewThe care plan for impaired cognitive function, initiated 10/10/23, documented the resident was at risk for impaired thought processes related to cognitive impairments. The interventions included engaging in simple, structured activities that avoid overly demanding tasks. The care plan for activities, initiated 10/13/23, documented the resident enjoyed listening to all types of music, reading the daily chronicles, watching tv and playing bingo. The resident needed cues and prompting while playing bingo. The resident was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. Interventions included encouraging attendance at special events, activities and meals, helping the resident get to and from activities, inviting the resident to scheduled activities, offer animal visits, opportunities to go outside, providing alternative activities, and to provide the resident with that were of interest and empower the resident by encouraging/allowing choice, self-expression and responsibility. -The facility failed to develop and implement wandering and mood/behavior care plans prior to the survey from 12/6-12/12/23. Nursing note dated 10/12/23 at 5:57 a.m. documented the resident had needed redirection at time and was up and down through the night with confusion. Nursing note dated 10/13/23 at 12:32 a.m. documented the resident had been up through the night. Nursing note dated 10/13/23 at 9:19 p.m. documented the resident needed frequent reminders to use his walker during the shift. Social services summary note dated 10/18/23 at 6:30 p.m. documented the resident had cognitive impairment related to the diagnosis and needed frequent reorientation and cueing. The resident's family reported the resident liked to be social and around people. Social services assessment evaluation, cognitive patterns, moods and behavior section, dated 10/18/23 at 6:30 p.m. documented the resident had a BIMS of six and was generally confused and needed frequent reorientation and cueing in the facility. V. Staff interviewsRegistered nurse (RN) #3 was interviewed on 12/7/23 at 2:05 p.m. She said Resident #74 confused another female for his wife and Resident #74 followed her around the facility sometimes. Registered nurse (RN) #4 was interviewed on 12/7/23 at 2:55 p.m. She said she was assigned as the MDS nurse. She said when a resident was admitted to the facility, each discipline completed required assessments and identified care areas of need for the resident. She said after the resident needs were identified, the responsible discipline initiated an individualized care plan that included a care area for focus, a specific goal and interventions for goal achievement. Certified nurse aide (CNA) #8 and CNA #9 were interviewed on 12/12/23 at 8:57 a.m. The CNAs said the resident liked to walk around rather than use his wheelchair and he needed to be redirected to use the chair. The CNAs said the resident was redirected with naps, snacks or drinks. -None of the strategies used for redirection were indicated on his care plan (see above). The SSD was interviewed on 12/12/23 at 9:01 a.m. She said Resident #74 wandered in the halls, lobby and dining room. She said she had seen the resident appear to be looking for something; however, he did not remember what he was looking for. She said dementia care plans should specifically identify triggers and interventions. She said there should be interventions put into place for a resident who believed another resident was their spouse. She said those interventions should include redirection if the staff were observing interactions or behaviors. She said the staff had some training on the interventions and they were specific to residents. The NHA said was interviewed on 12/12/23 and 12:18 p.m. He said there was one time when Resident #74 confused another female resident for his wife but that was the only time and it had not happened again. -However, staff interviews revealed the resident did confuse another resident for his wife and followed her around sometimes. The SSD was interviewed again on 12/12/23 at 1:48 p.m. The SSD said Resident #74 confused a female resident for his wife sometime around 11/20/23. She said the female resident had seen Resident #74 was coming toward her room and had told him to stop and go away. She said the interdisciplinary team (IDT) discuss interventions to keep Resident #74 away from the female resident. The director of nursing (DON) and NHA were interviewed on 12/12/23 at 2:39 p.m. The DON said Resident #74 thought a female resident looked like his wife and he was walking toward her room. When residents wandered, the staff worked to keep the residents off other halls but it was not official supervision. The NHA said there was an incident a few weeks ago when Resident #74 followed a female resident to her room. The NHA said the staff did not feel it was an issue. The NHA said it was not reported by staff because they did not think it was a big deal. The DON said the staff hold huddle meetings twice a day. The DON said she could not remember if Resident #74's wandering had been discussed in the huddle meetings. The DON said she did not keep notes about huddle meetings. VI. Facility follow-upOn 12/13/23 following the survey the facility provided:"-Dementia care plan, initiated on 10/10/23 and revised on 12/6/23 with additional interventions.-Elopement/wandering care plan initiated on 12/6/23. The care plan for elopement risk/ wandering, initiated 12/6/23 during the survey, documented the resident wanders aimlessly within the facility. Interventions included distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books and to document wandering behaviors and attempted diversional interventions.-Mood and behavior care plan initiated on 12/7/23. The mood/behavior care plan, initiated 12/7/23 during the survey, documented the potential for a mood/behavior problem related to dementia diagnosis. The resident can wander without intent at times and mistaken other residents for his wife. He lacks some awareness of personal space. The resident is at risk for restlessness, agitation, and altered perceptions of reality and hallucinations and wandering. Interventions included anticipate and meet needs, approach in a calm manner, assist to develop more appropriate methods of coping and interacting, encourage to express feelings appropriately, and intervene as necessary to protect the rights and safety of others. -Huddle summary notes dated 10/25/23 to 11/19/23 listing residents who wandered including Resident #74. -Huddle summary notes dated 11/20/23 -?? Listing residents who wandered including Resident #74."-However, the huddle notes did not document interventions for the residents who wandered or personalized interventions for those residents. In addition, the DON said she did not keep notes of what was discussed in the huddles (see above).

A focused infection control survey with complaint #CO29996 was conducted 8/22/23. No deficiencies were cited.

An Emergency Preparedness focused infection control survey was conducted 8/22/23. No deficiencies were cited.

A revisit survey was completed on 5/1/23 for all previous deficiencies cited on 2/16/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO30838 was conducted on 2/14/23 to 2/16/23. One deficiency was cited.

Based on interviews and record review, the facility failed to provide services by qualified persons for two (#21 and #9) out of two residents reviewed out of 23 sample residents. Specifically, the facility failed to ensure for Resident #21 and Resident #9:-Staff who were licensed practical nurses (LPN) did not perform duties outside of their scope of practice including performing intravenous/peripherally inserted central catheter (IV/PICC) line flushes and procedures without qualifications or certification; and,-LPN's did not chart under the registered nurse (RN) designated orders on the medication and treatment administration record (MAR/TAR) and in the progress notes for a procedure that was to be completed by an RN. Findings include:I. Professional referenceThe Code of Colorado Regulations, Chapter 1 licensure, undated, viewed on 2/23/23, https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=695 , read in pertinent part, "Historical Note: Prior to January 1, 2006, Chapter IX rules required LPNs in Colorado to obtain separate IV certification, which was then attached to their licenses. LPNs were granted either an IV or IV-2 certification status after completion of a Board-approved IV course. IV-2 status included education in central line IV therapy. LPNs without IV-2 status, as of January 1, 2006, were ruled to no longer have IV certification. LPNs without IV-2 status, including any LPN/LVN endorsing into Colorado from another jurisdiction, must bear the responsibility, with their employer, of acquiring the necessary education, training and experience to safely perform within the IV scope of practice pursuant to section 3 of these rules. The approval process for IV Therapy and venous blood sampling authority contained in these rules replaces the previously applicable bi-level certification."II. Facility policy and proceduresThe Documentation of Medication Administration policy and procedure, revised April 2007, was provided by the nursing home administrator (NHA) on 2/17/23 at 3:12 p.m. It read in pertinent part, "The facility shall maintain a medication administration record to document all medications administered. A nurse or certified medication aide shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it is given. Documentation must include, as a minimum: name and strength of the drug; dosage; method of administration (oral, injection and site); date and time of administration; reason(s) why a medication was withheld, not administered, or refused (as applicable); Signature and title of the person administering the medication; and resident response to the medication."III. Resident #21A. Resident statusResident #21, age 62, was admitted on 1/13/23. According to the February 2023 computerized physician orders (CPO), diagnoses included infection and inflammatory reaction due to internal left knee prosthesis (knee replacement), diabetes, and sepsis (infection). The 1/16/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required extensive assistance with one person for transfers, dressing and toilet use. He required limited assistance with one person for bed mobility, locomotion on/off unit, and personal hygiene. B. Record reviewReview of the January 2023 CPO revealed the following order to be completed by an RN:RN to flush PICC line with 10 cubic centimeters (cc) normal saline (NS) evert shift for IV therapy. PICC lumen flushes, positive blood return, dressing dry and intact, site without signs/symptoms of infection. Discontinue this order when the PICC line is removed/discontinued. Start date 1/13/23. Review of the January 2023 MAR/TAR revealed the following:On 1/14/23 (day) LPN #2 documented the RN procedure was administered by her. On 1/19/23 (evening) LPN #4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/19/23 at 9:17 p.m. revealed, "completed by RN" and signed by LPN #4. -However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress notes on 1/19/23 for that treatment. On 1/19/23 (night) LPN # 1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress note dated 1/20/23 at 3:43 a.m. revealed, "completed by RN" and signed by LPN #1. -However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 1/20/23 for that treatment. On 1/23/23 (night) LPN # 4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/24/23 at 2:35 a.m. revealed, "to be completed by RN" and signed by LPN #4. -However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/24/23 for that treatment. On 1/25/23 (day) LPN #2 documented the RN procedure was administered by her. On 1/27/23 (day) LPN #2 documented the RN procedure was administered by her. On 1/27/23 (evening) LPN #4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/27/23 at 9:05 p.m. revealed, "completed by RN" and signed by LPN #4. -However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/27/23 for that treatment. On 1/27/23 (night) LPN #4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/28/23 at 3:14 a.m. revealed, "to be completed by RN" and signed by LPN #4.-However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/28/23 for that treatment. On 1/28/23 (day) LPN #2 documented the RN procedure was administered by her. On 1/28/23 (evening) LPN #4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/28/23 at 9:02 p.m. revealed, "To be completed by RN" and signed by LPN #4.-However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/28/23 for that treatment. Review of the February 2023 MAR/TAR revealed the following:On 2/1/23 (night) LPN #1 documented the RN procedure was administered by her. On 2/4/23 (evening) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress noted dated 2/4/23 at 7:54 p.m. revealed "Completed by RN" and signed by LPN #1.-However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/4/23 for that treatment. On 2/7/23 (evening) the documentation was blank, there was no documentation that the physician orders had been followed. On 2/8/23 (night) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress noted dated 2/9/23 at 3:52 a.m. revealed "completed by RN" and signed by LPN #1.-However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/9/23 for that treatment. On 2/9/23 (evening) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress noted dated 2/9/23 at 9:36 p.m. revealed "completed by RN" and signed by LPN #1.-However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/9/23 for that treatment. On 2/12/23 (evening) the documentation was blank, there was no documentation that the physician orders had been followed. On 2/15/23 (night) the documentation was blank, there was no documentation that the physician orders had been followed. Review of the February 2023 CPO revealed the following order to be completed by an RN:Obtain complete blood count (CBC), comprehensive metabolic panel (CMP) and C-reactive protein (CRP) (night shift nurse to have lab requisition completed) RN to draw via PICC every day shift, every Tuesday, for septic arthritis and bacteremia. Start date 1/17/23. Review of the February 2023 MAR/TAR revealed the following:On 2/7/23 (day) LPN # 2 documented the RN procedure was administered by her. -LPN #1, LPN #2 and LPN #4 did not have intravenous certifications. IV. Resident #9A. Resident statusResident #9, age 82, was initially admitted on 6/10/22, and readmitted on 2/7/23. According to the February 2023 computerized physician orders (CPO), diagnoses included left foot chronic ulcer (sore) non-pressure, chronic atrial fibrillation (heart disorder), and hemiplegia (paralysis on one side after a stroke). The 12/28/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with one person for transfers and limited assistance with one person for bed mobility, locomotion on/off unit, dressing, toilet use, and personal hygiene. B. Record reviewReview of the February 2023 CPO revealed the following order to be completed by an RN:RN to flush PICC with 10 cc NS every shift for IV therapy. D/C this order when PICC is removed/discontinued. Start date 2/7/23. Review of the February 2023 MAR/TAR revealed the following:On 2/10/23 (night) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress note dated 2/11/23 at 1:35 a.m. revealed "completed by RN" and signed by LPN #1.-However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/11/23 for that treatment.-LPN #1 did not have an intravenous certification. V. Staff interviewsLPN #2 was interviewed on 2/16/23 at 3:24 pm. She said she charted any treatments or procedures that she completed as ordered for residents. LPN #2 said she did chart on Resident #21 for the IV treatments but she did not do the IV and PICC treatments. LPN #2 said that each nurse should chart what treatments they do and she regretted charting for the RN, but the RN did it. LPN #2 said the RN should have done the charting for themselves. The director of nursing (DON), assistant director of nursing (ADON), and infection preventionist (IP) were Interviewed on 2/16/23 at 4:35 pm. They said it was the practice and standard at the facility to have nurses chart what procedures and medication administration they completed. They said the nurse staff should chart for themselves what they did. They said other nurses cannot chart and sign for them. They said on the MAR/TAR the nurse who completed the treatment should chart and document that they completed the treatment. They said a check mark on the MAR/TAR indicated that the treatment was administered. They said if a box on the MAR/TAR was completely empty it meant the dose or treatment was not done or missed. They said if there was not a check mark and there was a number nine, the nurse should do a progress note. They said the progress note would usually indicate if the resident was in the hospital, the resident refused, or medications were held for parameters. They said the progress noted should clarify the reason why the treatment or medication were not checked and administered. They said if the MAR/TAR said other/see progress note, that means the nurse who signed it was the nurse who administered it. They said they would expect the name of the nurse who administered it and they should chart that they administered a medication or treatment. They said it was not okay for an LPN to draw blood via a PICC line for a lab, or flush the PICC line if the order says it should be done by an RN. They said they completed education with LPN #2. They said the LPNs should not perform duties and procedures outside their scope of practice because it was not safe to do so. VI. Facility follow-upOn 2/16/23 at 1:10 p.m. the DON provided the IV certification of the one LPN who had her certification. Of the eight LPNs employed by the facility including the contract LPNs, one had her IV certification, which was LPN #3. -LPN #3 did not chart on Resident #21 or Resident #9 (see above).