NORTH SHORE HEALTH & REHAB FACILITY

The Initial Comments (ID Tag 0000) are informational only and are a representation of the facility's general characteristics. The survey was conducted under the regulatory requirements of 42 CFR Part 483.70(a)The facility is one story, Type V (000) construction and is protected by an automatic fire sprinkler system. The facility is classified as Fully Sprinklered. The 120 bed facility was surveyed on June 13, 2024 using the National Fire Protection Association, (NFPA) Life Safety Code (2012) Chapter 19, Existing Health Care Occupancies. Life safety features that met the requirements for new construction at the time of licensure or certification shall be maintained and not diminished. The deficiencies cited were discussed with Maintenance staff during the exit conference conducted at the end of the on-site survey. The reported daily census to be 80 residents on the day of the survey.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by the following:1. Fire sprinkler gauge is outdated in the fire sprinkler riser room (2018). 2. Missing fire sprinkler escutcheon plate in the main lobby. 3. A 5-year fire sprinkler internal obstruction testing report was not provided for the wet system. 5.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. 5.3.2.2 Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. NFPA 25, 5.2.1.1.5 Escutcheons and coverplates for recessed, flush, and concealed sprinklers shall be replaced with their listed escutcheon or coverplate if found missing during the inspection. NFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance Director during the exit conference.

A recertification survey was conducted from 5/13/24 to 5/16/24. Six deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/13/24 to 5/16/24. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to assess, accurately document and provide treatment for one (#32) of four residents reviewed for pressure ulcers out of 31 sample residents. Specifically, the facility failed to:-Ensure the progress of Resident #32's pressure ulcers was documented consistently and accurately;-Identify Resident #32 had a pressure wound which had reopened on her coccyx; and,-Obtain appropriate physician's orders for wound care treatment for Resident #32's reopened coccyx pressure ulcer. Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved on 5/23/24 from https://www.internationalguideline.com/guideline, "Pressure ulcer classification is as follows: "Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). "Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. "Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable "Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. "Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment." II. Resident #32Resident statusResident #32, age greater than 65, was admitted on 7/15/21. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, chronic kidney disease Stage II (mild), type II diabetes and a history of a right buttock stage 3 pressure ulcer. The 4/5/24 minimum data set (MDS) assessment revealed the resident had a brief interview for mental status (BIMS) score of three out of 15. She was dependent on help for bed mobility, transfers, and showering, and required maximal assistance with toileting. The assessment indicated Resident #32 was at risk for developing pressure ulcers. She had two unhealed stage 2 pressure ulcers and one unhealed stage 3 pressure ulcers and no unstageable pressure ulcers. The assessment indicated the resident was not on a turning/repositioning program, had no nutritional interventions to manage skin problems and had no diabetic foot ulcers. B. ObservationsOn 5/13/24, the following observations were made:At 12:30 p.m. the resident was observed sitting in her wheelchair and eating in the main dining room. At 1:03 p.m. the resident was observed sitting in her wheelchair across from the nurses' station. At 1:25 p.m. the resident was asleep and sitting in her wheelchair, still across from the nurses' station. At 1:44 p.m. staff was observed bringing the sit-to-stand machine out of the resident's room. The resident was on her back, asleep on a low air loss mattress (a specialty mattress designed to relieve pressure). On 5/14/24, the following observations were made:At 11:41 a.m. Resident #32 was in the dining room sitting in her wheelchair. At 12:08 p.m. the resident was still sitting in her wheelchair in the dining room. At 12:24 p.m. the resident was sitting in her wheelchair by the nurses' station. At 12:34 p.m. the resident's family wheeled her to her room. On 5/15/24 at 9:23 a.m. Resident #32 was observed during incontinence care. A wound about the size of a nickel was observed on the left of the resident's coccyx area. The wound was open and pink. The resident screamed in pain when staff wiped her bottom and put cream on the wound. She yelled, "oh my god it hurts!"C. Record reviewA Braden Scale assessment (a tool used for determining pressure ulcer risk) dated 1/8/24 revealed Resident #1 was at mild risk for developing pressure ulcers.-There were no additional Braden Scale assessments documented following the 1/8/24 assessment. The May 2024 CPO included the following physician's order:Barrier cream to sacrum and peri-areas with brief changes, ordered 1/10/24.-The order failed to reveal that the barrier cream was for treatment or protection of the resident's wound. On 3/29/24, the following wounds were documented At 9:15 a.m. the wound care physician (WCP) documented a resolved stage 3 pressure ulcer on the left buttock, and a Kennedy terminal ulcer on the left buttock with dimensions 0.3 centimeters (cm) by 0.3 cm by 0.2 cm. (A Kennedy terminal ulcer is a wound that can develop in people who are terminally ill or nearing the end of their life. It is a type of pressure ulcer that is characterized by its sudden onset and rapid progression). -No coccyx wound was noted. At 1:55 p.m., an NP/MD documented an evaluation of Resident #32's sacral wounds. The provider documented the resident had three small ulcers, two on the left gluteal cleft region and one on the right (the groove in between the left and right buttocks). The wounds were below the coccyx. The one on the right was a stage 2 that measured 0.3 cm by 0.3 cm. The one on the left was 0.2 cm by 0.4 cm and was consistent with a resolving stage 3. The third was 0.3 cm by 0.4 cm. The wounds were consistent with pressure ulcers and not skin failure and so it was the provider's opinion that the wounds should not be classified as Kennedy ulcers. At 2:36 p.m., a nursing staff member documented a stage 2 pressure wound on the right buttock with an onset date of 3/29/24 and dimensions of 0.3 c.m. by 0.3 c.m. by 0.1 c.m. At 2:50 p.m., a nursing staff member documented a stage 2 pressure wound on the coccyx with an onset date of 3/25/24 and dimensions of 0.5 cm by 0.5 cm by 0.1 cm.-The documentation, including the stage of wound, location and measurements of the wounds, from the WCP and the facility nursing staff did not match. At 2:54 p.m. a nursing staff member documented the resident had a stage 3 pressure wound on the left buttocks with moderate serosanguinous drainage, present since 12/10/24. The wound was cleansed, measured, and a new dressing applied.-The nursing staff member inaccurately documented the date as 12/10/24 instead of 12/10/23. On 4/4/24 at 2:28 p.m. the WCP documented a stage 3 pressure ulcer on the left buttock with dimensions of 1.2 cm by 0.4 cm by 0.2 cm had moderate serosanguinous drainage (a combination of blood, and clear, straw-colored liquid), but was stable. On 4/9/24 at 7:35 p.m., nursing staff documented the resident had no new skin concerns.-The nursing note did not indicate if the previously mentioned pressure wounds were still present. On 4/11/24 at 4:01 p.m. the WCP documented a resolved stage 3 pressure ulcer on the left buttock with prior dimensions of 1.2 cm by 0.4 cm by 0.2 cm and a stage 2 pressure ulcer on the coccyx with dimensions of 0.5 cm by 0.5 cm by 0.2 cm and prior dimensions of 1 cm by 0.5 cm by 0.2 cm. The care plan, revised 4/12/24, documented Resident #32 was to have a gel cushion to her wheelchair, have a low air loss mattress and offload (lay down) between meals. On 4/16/24 at 10:51 p.m. the weekly skin assessment documented the resident had no new skin concerns. On 4/19/24 at 9:01 a.m. the WCP documented a resolved stage 2 pressure ulcer stage on the coccyx. The care plan, revised 4/19/24, identified the resident had the following resolved wounds:-Stage 3 pressure wound on left buttocks - resolved 4/11/24;-Stage 2 pressure wound on coccyx - resolved 4/19/24; and,-Stage 2 pressure wound on right buttocks- resolved 4/3/24. On 4/23/24 at 7:17 a.m. the nursing skin assessment documented the resident had no new skin concerns. On 4/25/24 at 9:33 a.m. the food and nutrition progress note documented the resident had a stage 3 pressure injury on the right buttock.-However, according to the care plan revised 4/19/24, Resident #32's pressure wounds were all resolved as of 4/19/24. The care plan, revised 4/28/24, documented a dietary supplement was to be provided as ordered for wound prevention and healing and staff was to use a barrier cream for Resident #32 as prescribed.-The care plan did not specify where the barrier cream was to be applied. On 5/7/24 at 9:51 a.m. the nursing skin assessment documented the resident had no new skin concerns. On 5/7/24 at 8:28 p.m. RN #5, who was a hospice nurse documented that the resident's skin was intact. On 5/13/24 at 10:50 a.m., RN #6, who was a hospice nurse documented Resident #32 had erythema (redness) of the peri area (private area). On 5/14/24 at 10:58 p.m., a nursing note documented Resident #32 had a new skin concern. The new skin concern was a bruise on the back of the resident's right hand due to hitting the table in the dining room.-The skin assessment did not document any new wounds as skin concerns.-There was no documentation to indicate the facility had identified that Resident #32's wound on her coccyx had reopened and that a physician had been notified (see observations above). D. Staff interviewsThe wound care nurse (WCN) was interviewed on 5/14/24 at 1:05 p.m. The WCN said she mostly cared for pressure, diabetic and vascular (arterial, venous, diabetic) wounds and sometimes skin tears. She said she typically monitored closed wounds, but once they opened up, she said she got the wound care physician (WCP) involved. She said Braden Scale assessments were completed on admission, quarterly and upon any change in condition. She said wounds were not typically measured upon admission, and there usually were not orders for barrier cream because barrier cream was a standard of care for incontinence. The WCN said Resident #32 had two stage 2 pressure wounds that were resolving. The WCN was interviewed again on 5/14/24 at 1:26 p.m. The WCN said the resident had no pressure injuries. The WCN said the resident previously had two pressure wounds, however, she said they were resolved. -However, the WCN said in her interview at 1:05 p.m. that Resident #32 had two stage 2 pressure wounds that were resolving. On 5/15/24 at 9:29 a.m., RN #1 said the wound on Resident #32's coccyx had been present for some time. She said it would heal and open up again repeatedly. She said the wound used to have a dressing but the resident was incontinent of bowel and they had to change the dressing multiple times throughout the day. She said removing dressings frequently was not good for the skin. RN #1 said the barrier cream seemed to work just as well as a dressing. She said the wound team was following Resident #32 and decided the cream was better than a dressing. She said the wound team was not following her anymore because her wounds were healed, and the staff just used zinc barrier cream on the wound. She said the staff had been using the cream without a dressing for at least a month.-However, Resident #32 was observed to have an open wound to her coccyx on 5/15/24 (see observations above). Nurse practitioner (NP) #1 was interviewed on 5/16/24 at 9:14 a.m. NP #1 said she was not notified that Resident #32 had an open wound on her coccyx or that staff were just using barrier cream to treat it. The director of nursing (DON) was interviewed on 5/16/24 at 11:44 a.m. The DON said she believed the coccyx wound was a fragile area. She said for wounds that were shallow, they could potentially be treated with zinc barrier cream, especially if the resident was incontinent. She said the physician should be contacted when there was a new wound or a reopened wound. E. Facility follow-up On 5/17/24 at 5:34 p.m. (after the survey exit) the facility submitted the following documentation:An Interdisciplinary team (IDT) note, dated 5/16/24 at 3:43 p.m. (during the survey) which documented Resident #32 had an open area on the left buttock. Zinc barrier cream was to be applied with each check and change and an order to monitor until resolved was entered.

Based on observations, record review and interviews, the facility failed to ensure two (#32 and #1) of five residents reviewed for pain management out of 31 sample residents received timely, adequate pain control. Specifically, the facility failed to:-Ensure pain was effectively managed during incontinence care for Resident #32;-Ensure Resident #32 was provided as needed (PRN) pain medication prior to brief changes per physician's orders;-Ensure staff consistently documented Resident #32's pain levels every shift; and,-Ensure individualized non-pharmacological interventions were documented for Resident #32 and Resident #1. Findings include:Facility PolicyThe Pain Management policy, revised on 5/3/23, was provided by the director of nursing (DON) on 5/17/24 at 5:36 p.m. It read in pertinent part:"Pain is subjective and is what the resident says it is, existing when and where the resident says it does. "All residents will be evaluated for pain by utilizing a pain evaluation tool in the electronic medical record (EMR). The pain evaluation will be completed upon admission, readmission, quarterly, and with any significant change in condition. The pain evaluation includes the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness."All subsequent pain evaluations will be documented on the Pain Evaluation in the EMR and/or the MAR (medication administration record) as applicable to include location, intensity rating, and response to pain management interventions. When a resident complains of pain, ask the resident to rate the level of pain using the numerical Scale using a pain level of zero (none) to ten (severe)."Cognitively impaired residents or residents unable to respond verbally may not be able to rate their pain using a numeric scale. Non-verbal indicators of pain include: increased agitation, crying, grimacing, holding the area where the pain is located, calling out, decreased appetite, and any other behaviors which are unusual for the resident. Cognitively impaired residents have pain evaluated using the PAINAD (Pain Assessment in Advanced Dementia) Scale."Around the clock (ATC) dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management. Intermittent pain can be managed with intermittent (PRN) analgesic administration. (Every shift pain checks on the MAR should be completed after the resident receives the routine medication.)"Do not forget the non pharmacological interventions such as repositioning, relaxation, aromatherapy, visualization, desensitization, massage, and humor therapy etc. Non-pharmacological interventions should be documented in progress notes and included on the individual resident care plan."II. Resident #32Resident statusResident #32, age greater than 65, was admitted on 7/15/21. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia, chronic kidney disease, type two diabetes and a history of a right buttock stage 3 pressure injury. The 4/5/24 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. She was dependent on two staff members for assistance with bed mobility, transfers and showering. She required maximal assistance of two staff members with toileting. B. Resident observations and interviewOn 5/13/24 at 10:36 a.m. moaning and yelling was heard from behind the closed door to Resident #32's room. At 10:42 a.m. certified nurse aide (CNA) #5 exited the room. CNA #5 said the resident was in a lot of pain during the transfer. She said the resident was in such pain that she did not feel comfortable proceeding with incontinence care and was on the way to inform the nurse about the pain. She said it was herfirst encounter with the resident as the resident was recently admitted to hospice care. At 10:44 a.m. registered nurse (RN) #1 entered the resident's room where the Resident #32 was lying in bed. RN #1 touched the resident's right foot and heel and the resident cried out in pain. RN #1 left the room and returned to give the resident pain medication. -RN #1 did not ask the resident where her pain was or what her level of pain was. On 5/15/24 Resident #32 was observed during a continuous observation, beginning at 9:03 a.m. and ending at 9:40 a.m. The following observations were made:At 9:08 a.m., Resident #32 was moaning while she waited for CNA #1 to return to help her transfer to bed. The resident said her whole right leg hurt. The resident was unable to describe her pain further or give a pain level for the right leg pain. At 9:23 a.m., after the resident was transferred to bed by RN #1 and CNA #1, RN#1 told CNA #1 the resident's brief should be changed. RN #1 told Resident #32 she needed to change her brief and started taking the resident's pants down. The resident started yelling "No" and hit RN #1 several times. The resident continuously yelled out, "No" while RN #1 and CNA #1 moved and changed her. Resident #32 yelled "oh my god it hurts" and hit RN #1 several times on her back. RN #1 asked the resident what hurt but the resident did not answer. The resident was breathing heavily and grimacing. During the incontinence care, an open wound was observed on the resident's left buttock. Resident #32 screamed in pain when the staff was wiping and putting cream on the wound. After incontinence care was completed, Resident #32 was positioned on her back, she stopped yelling and fell asleep. Resident #32 was hyperventilating, moaning loudly, groaning, crying, showed facial grimacing and was pulling and pushing away from the staff during the incontinence care. She was only able to be momentarily distracted by reassurances from RN#1 and CNA #1. C. Record reviewThe care plan for pain, initiated 7/21/23 and revised 5/7/24, identified the resident had the potential for pain related to a wound and a history of a fracture. Pertinent interventions included the following:-Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition;-Monitor/document for probable cause of each pain episode. Remove/limit causes where possible;-Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting, dizziness and falls. Report occurrences to the physician;-Monitor/record pain characteristics: including quality (sharp, burning), severity (1 to 10 pain scale) anatomical location, onset duration (continuous, intermittent) aggravating factors and relieving factors;-Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain;-Observe resident closely for signs of pain, administer pain medications as ordered, and notify hospice nurse timely if there is breakthrough or uncontrolled pain; and,-Offer non-pharmacological interventions for pain prior to administering medication and PRN (as needed).-However, the care plan did not document what individualized non-pharmacological interventions were effective for Resident #32. The May 2024 CPO included the following physician's orders:Monitor pain every shift using the PAINAD scale, ordered 3/29/24. Tramadol HCl oral tablet (medication used to treat pain) 50 milligrams (mg), give 50 mg orally two times a day for pain, ordered 4/16/24. Acetaminophen (analgesic) 325 mg, give two tablets by mouth four times a day for pain, ordered 6/22/23. Tramadol HCl oral tablet 50 mg, give 50 mg orally for pain level of 6-10 on a pain scale of 1-10 twice daily as needed (PRN) before wound care and brief changes, ordered 4/19/24. Review of Resident #32's medication administration record (MAR) and treatment administration record (TAR) from 5/1/24 through 5/14/24 revealed Resident #32 received 13 out of 14 doses of scheduled, with one refusal. She received 52 out of 60 doses of scheduled acetaminophen, with three refusals and the resident was documented as sleeping for five administrations.-Resident #32 did not receive any doses of PRN Tramadol from 5/1/24 through 5/14/24, despite the resident having a physician's order to administer PRN Tramadol prior to wound care and brief changes.-The required monitoring of Resident #32's pain every shift was documented as completed on the TAR, however, the documentation did not include a pain score or description of the pain.-A pain score was documented six times in the first 14 days of May and was noted to be zero out of 10 for each.-No pain score was documented on 5/13/24, after the resident was observed yelling in pain and was given pain medication. A nursing pain evaluation, dated 4/12/24 at 10:38 a.m. by RN #1, revealed the resident had a chronic wound to the coccyx that contributed to pain. The resident was unable to describe what the pain felt like but additional symptoms associated with pain included decreased appetite, non-verbal signs including facial grimacing and moaning and verbal indications. The evaluation documented the resident's preferred pain scale was PAINAD but she was unable to state her acceptable level of pain. Measures that helped relieve pain were medication and relaxation. A progress note, documented on 3/17/24 at 7:00 p.m., revealed Resident #32 had yelled out in pain during incontinence care and resisted care when wipes touched her buttocks region. D. Staff interviewsRN #1 was interviewed on 5/15/24 at 9:24 a.m. RN #1 said the resident's reaction during the incontinence care was typical for the resident during incontinence care. She said sometimes the resident hit her when she was providing incontinence care. RN #1 said she assumed, based on the resident's reaction, that her pain was a 10 out of 10. RN #1 said she did not notify a physician of the resident's pain and did not document it in the progress notes. Nurse practitioner (NP) #1 and the director of nursing (DON) were interviewed together on 5/16/24 at 9:14 am. NP #1 said she had seen Resident #32 during cares before and she had assessed her with catheter care the other day. She said even when there was no open wound, the resident would still complain of pain during incontinence care. NP #1 said the resident was very good about telling her that she was in pain. She said when staff was doing wound care in the past (when she had a documented open wound), the staff would pre-medicate the resident but that had not been the case for a while so she was not aware if her pain had gotten worse.-NP #1 was unaware the resident had a current open wound observed on the resident's buttocks (see observations above). NP #1 said the resident's family was somewhat resistant to medication changes. She said she did not think all of Resident #32's reaction during incontinence care was pain related. She said she thought some of it had been the transition to long-term care. She said the resident was used to being at home with her large family. She said she had a phone call with hospice later that day and they would also do another pain assessment to see if there was a change in the resident's condition. NP #1 said the resident's family had requested hospice services when the resident's decline started a few weeks ago. She said the last pain assessment documented on 4/12/24 was probably when the resident's decline started. NP #1 said she felt that the resident's dementia was part of what was contributing to her resisting care. She said she thought when the nurse heard the resident yelling in pain that the nurses might collaborate with social services and look at the care plan. The DON said nurses should document something in theprogress notes which said what happened during the incontinence care and that the resident complained of pain. E. Facility follow-upOn 5/17/24 at 5:34 p.m. (after the survey exit) the facility submitted the following documentation:1. Record of pain audit performed 5/17/24 at 3:53 pm: 88 residents were audited for pain orders and documentation of pain level, and orders were in place. The audit was signed by the DON. An Interdisciplinary team (IDT) note, dated 5/16/24 at 3:43 p.m. documented the IDT was in collaboration regarding pain/anxiety/skin with the DON, social services director (SSD), RN #3, NP #2 and Resident #32's representative/power of attorney (POA). The IDT note read, in pertinent part,"Pain management: pain is well controlled at this time, no need for changes identified. POA declined any changes to medications/pain plan of care for pain."-However, per the observations and RN #1's interview during the survey, Resident #32's pain was not well controlled during incontinence care (see observations and interviews above). III. Resident #1 A. Resident status Resident #1, over 65 years old, was readmitted on 11/16/23. According to the May 2024 CPO, diagnoses included hemiplegia (paralysis on one side) and hemiparesis (weakness or inability to move one side of the body) post cerebrovascular disease affecting the left non-dominant side, a psychotic disorder with delusions, peripheral vascular disease (reduction in blood circulation), insomnia and depression. The 2/20/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of three out of 15. She had an impairment to the lower extremity on one side and used a wheelchair. She was dependent for oral hygiene, toileting hygiene, showering, dressing and personal hygiene. The resident was on a scheduled pain medication regimen, received as needed pain medication and non-pharmacological interventions for pain. The assessment revealed the resident was almost constantly in pain which frequently affected her sleep and the pain intensity was severe. B. Resident observation and resident representative interview The resident's representative was interviewed on 5/15/24 at 2:10 p.m. He said the resident complained to him a lot about pain on her right buttock from a wound. He said it was difficult visiting with the resident today (5/15/24) because the facility had just administered morphine and she was pretty drowsy. He said the facility had not found the right balance of medication so she could be awake to participate in her daily activities. -During the interview, Resident #1 was sitting in her wheelchair with two family members present. The resident's eyes were closed. C. Record review The pain care plan, revised 8/23/23, revealed the resident had pain related to arthritis, hemiplegia and contractures. Interventions included administering pain medication per orders, evaluating the pain intervention's effectiveness, monitoring and documenting the probable cause of each pain episode and monitoring and recording pain characteristics. -The care plan did not identify the location of the resident's pain or what non-pharmacological interventions were being provided to help alleviate the resident's pain. A pain assessment, dated 2/16/24, revealed the resident had pain due to cerebral vascular disease and cancer. She had pain in the past five days. She said the pain was sharp and throbbing. She said she could not sit up in a wheelchair for an extended period because it caused pain. She said the pain was worse mid day. Her acceptable level of pain was three out of ten. She said pain medication and position change relieved her pain. -The onset and duration of pain was not identified. The May 2024 CPO revealed the following physician's orders: Morphine sulfate 15 milligrams (mg). Administer 15 mg by mouth two times a day for pain, ordered2/20/24. Tylenol 500 mg. Administer two tablets by mouth three times a day for pain, ordered 2/20/24. Morphine sulfate 20 mg/ml (milliliter). Administer 0.5 ml by mouth every two hours as needed for pain and shortness of breath, ordered 4/12/24. Monitor pain every shift using a zero to ten pain scale. Acceptable level of pain is two, ordered 11/16/23. -The orders did not specify where the resident had pain and did not identify any non-pharmacological interventions for pain. Review of the May 2024 medication administration record (MAR) from 5/1/24 through 5/13/24 revealed the following: -The as needed morphine sulfate was administered at least once a day on 5/2/24 through 5/5/24 and 5/10/24 through 5/13/24. -The May 2024 MAR did not document where the resident had pain and did not identify if non-pharmacological interventions were offered when the as needed morphine sulfate was administered. A 5/13/24 nurse progress note said morphine sulfate 20 mg/ml was administered for pain. -The progress note did not document where the resident had pain and did not identify if non-pharmacological interventions were offered when the as needed morphine sulfate was administered. A 5/12/24 nurse progress note revealed the resident was yelling out all night. The nurse stayed with the resident and gave juice and water. The resident kept asking for her sister and complained of pain. At 1:15 a.m. the resident was administered as needed morphine and it was effective.-The progress note did not document where the resident had pain and did not identify if non-pharmacological interventions were offered when the as needed morphine sulfate was administered. A 5/4/24 nurse note revealed the resident complained of pain and was restless. As needed morphine and scheduled ativan was administered. -The progress note did not document where the resident had pain and did not identify if non-pharmacological interventions were offered when the as needed morphine sulfate was administered. A 5/5/24 nurse progress note revealed the resident had an elevated blood pressure and pulse due to increased pain and fearfulness of being alone. As needed morphine was administered with scheduled ativan. Resident #1 was tearful and wanted her family to stay with her. The nurseried to provide comfort yet the resident was forgetful.-The progress note did not document where the resident had pain and did not identify if non-pharmacological interventions were offered when the as needed morphine sulfate was administered. D. Staff interviews Certified nurses aide (CNA) #4 was interviewed on 5/16/24 at 1:18 p.m. CNA #4 said she was familiar with Resident #1. She said the resident had pain in her leg, her back and her head. She said when she moved from her bed to her wheelchair it was one intervention that alleviated the resident's pain. CNA #4 said talking to the resident about her family also helped distract her from her pain. Licensed practical nurse (LPN) #1 was interviewed on 5/16/24 at 11:12 a.m. LPN #1 said pain assessments were completed for residents at admission and quarterly. She said the pain assessment addressed if the resident had any pain and if the resident had a diagnosis which caused pain. She said the pain assessment also addressed if the resident had scheduled or as needed pain medications and the location and severity of the pain. She said non-pharmacological interventions included redirection, reassurance and a calm environment. LPN #1 said she was familiar with Resident #1. She said she had pain on her coccyx, her left leg, back pain and generalized pain. She said repositioning helped minimize her pain. She said the minimum was to reposition the resident every two hours. LPN #1 said the resident was unable to shift her weight on her own so staff should reposition her to help with her pain. Nurse practitioner (NP) #1 was interviewed on 5/16/24 at 9:42 a.m. NP #1 said she was unsure if Resident #1 had pain. She said she was unable to identify the location of the resident's pain. NP #1 said it was possible when the resident's anxiety was high, the resident could be saying she was in pain. She said the lack ofdocumentation by the nursing staff regarding Resident #1's pain made it difficult for her to provide direction to the facility on the best way to manage the resident's pain. She said hospice, the facility and the resident's representative needed to meet so everyone could be on the same page on what the goals were for her pain. The DON was interviewed on 5/16/24 at 11:44 a.m. The DON said pain assessments were completed at admission, quarterly and every shift. She said the pain assessment covered where the pain was located, what the pain management goal was and what non-pharmacological interventions helped alleviate the pain. She said the pain interventions were documented in the care plan and in the progress notes. She said she was familiar with Resident #1. She said the resident had pain but was unable to verbalize where the pain was. The DON said, in the past, the resident's pain was from her contractures and arthritis. She said she could check with the resident. She said the resident's care plan and orders needed to be updated to reflect what helped alleviate her pain besides pain medication.

Based on record review, observations and interviews, the facility failed to ensure one (#1) of five residents reviewed for unnecessary medications out of 31 sample residents were free from unnecessary medications. Specifically the facility failed to: -Ensure Resident #1 had appropriate non-pharmacological interventions for behaviors initiated; -Ensure Resident #1 was monitored for side effects of a psychotropic medications; and, -Ensure Resident #1 was monitored consistently for behaviors to justify the use of psychotropic medications. Findings include: I. Facility policy The Psychopharmacological policy, revised 3/10/23, was provided by the director of nursing (DON) on 5/16/24 at 1:44 p.m. It read in pertinent part, "Licensed nurses and additional staff will monitor and document any targeted behaviors that occur."The care plan will include the resident's focus and target behaviors for the medication. Realistic and measurable goals will be utilized and approaches will include alternatives to psychopharmacological drug use." II. Resident #1A. Resident status Resident #1, age greater than 65, was admitted on7/9/99 and readmitted on 11/16/23. According to the May 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis on one side) and hemiparesis (weakness or inability to move one side of the body) post cerebrovascular disease affecting the left non-dominant side, a psychotic disorder with delusions, peripheral vascular disease (reduction in blood circulation), insomnia and depression. The 2/20/24 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for a mental status (BIMS) score of three out of 15. She had an impairment to one lower extremity and used a wheelchair. She was dependent on staff assistance for oral hygiene, toileting hygiene, showering, dressing and personal hygiene. B. Observations Resident #1 was observed during a continuous observation on 5/13/24, beginning at 11:15 a.m. and ending at 11:33 a.m. The following observations were made:Resident #1 was lying in bed and had her legs bent to her right side at 45 degrees. The sheets and blankets were pushed to the end of the bed. She yelled "nurse" thirteen times between 11:15 a.m until 11:27 a.m. At 11:22 a.m. an unidentified certified nurse aide (CNA) walked into the room across from Resident #1's room when the resident was asking for a nurse.-The unidentified CNA did not acknowledge Resident #1 when she was calling out for a nurse and the resident continued to call out. At 11:27 a.m. the unidentified CNA entered Resident #1's room and asked if she wanted to get out of bed for lunch. -However, the CNA proceeded to leave Resident #1's room without getting the resident out of bed and the resident continued to call out. From 11:27 a.m until 11:33 a.m. the resident yelled "nurse and "I need help" ten times. At 11:33 a.m. CNA #4 walked into the resident's room (five minutes after the previous CNA had initially entered the room) and asked Resident #1 if she wanted to get out of bed for lunch. C. Record review The 2/16/24 care plan revealed the resident used hypnotic, sedative and sleep disorder medications related to anxiety and agitation with expressed difficulty sleeping as evidenced by calling out at night. Interventions included a gradual dose reduction of Restoril (initiated 5/15/24), review medications with the interdisciplinary team (IDT) quarterly and as needed and attempt gradual dose reduction when clinically indicated (initiated 2/16/24). The 6/29/23 care plan, revised 9/15/23, revealed the resident used an antidepressant medication related to generalized anxiety. Interventions included to monitor, document and report adverse reactions to antidepressant therapy, changes in behavior and to review medications with IDT quarterly. The 8/28/23 care plan revealed the resident used an antipsychotic medication for symptoms and behaviors associated with psychotic disorders with delusions. Interventions initiated on 8/28/23 included to monitor for side effects and effectiveness, behavior monitoring and to review medications with the IDT quarterly. The May 2024 CPO revealed the following physician's orders: -Duloxetine (medication used to treat depression and anxiety) 60 milligrams (mg). Administer 60 mg by mouth in the morning for anxiety, ordered 1/15/24. -Mirtazapine (medication used to treat depression) 15mg. Administer 15 mg by mouth at bedtime for anxiety and depression, ordered 2/5/24. -Restoril (medication used to treat insomnia) 15 mg. Administer 7.5 mg by mouth in the evening for sleep for 14 days, ordered 5/11/24. -Lorazepam (medication used to treat anxiety) 2mg/ml (milliliters). Administer 0.5 ml by mouth three times a day for anxiety, ordered 5/10/24. -Review of the May 2024 medication administration record (MAR) revealed there was no documentation the medications were monitored for effectiveness and side effects. -The May 2024 MAR revealed there was no documentation Resident #1's behaviors were consistently monitored.-The May 2024 MAR revealed there no documentation non-pharmacological interventions were attempted with Resident #1 when she was exhibiting behaviors, such as calling out. -There was no documentation in Resident #1's electronic medical record (EMR) to indicate the facility was monitoring the resident for the effectiveness of the medications or potential side effects of the medications. -There was no documentation in the resident's EMR to indicate the facility was consistently monitoring the resident for behaviors or that staff were attempting non-pharmacological interventions to address the resident's behaviors. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/16/24 at 11:10 a.m. LPN #1 said she continuously monitored for resident's for behaviors. She said it was not consistent where she documented the behaviors. She said some residents had an order to monitor behaviors so she documented the behavior in the treatment administration record (TAR). LPN #1 said the resident did not have an order to document behaviors in the TAR then she documented in a progress note. She said she monitored residents for side effects of psychotropic medications based on if the resident was sleepy, had agitation or if there was a change in the dose of the medication. She said she documented side effects in the TAR. LPN #1 said non-pharmacological interventions included companionship, social service intervention, room changes, contacting the family and activities. She said she was familiar with Resident #1. She said she monitored the resident's behavior. She said the resident's behavior included she did not want to get out of bed. She said sitting with the resident helped the resident's behavior and the family helped too. LPN #1 said one on one care would be helpful for Resident #1. She said she monitored side effects of her medications. She said the resident's Duloxetine was decreased a while ago and the resident yelled more, had agitation, confusion and helplessness. She said the resident was very lonely. LPN #1 said she had not documented Resident #1's behavior, if non-pharmacological interventions were offered or if there were side effects. She said the medication was given to reduce fearfulness, loneliness, pain and agitation. She said Resident #1 responded well to music, a stuffed monkey was comforting, putting a pillow between her legs, doing her hair and offering fluids. Nurse practitioner (NP) #1 was interviewed on 5/16/24 at 9:42 a.m. NP #1 said Resident #1's anxiety was not managed. She said hospice, the facility and the resident's representative needed to meet so everyone could be on the same page on what the goals were for her anxiety. She said without the behaviors documented it was hard to provide direction to reduce the resident's anxiety. The DON was interviewed on 5/16/24 at 11:44 a.m. The DON said the facility did not document medications were monitored for effectiveness and side effects. She said the facility did not document that behaviors were monitored and if non-pharmacological interventions were offered. She said it was important to document because it helped determine if gradual dose reduction was an option for a medication, if the resident needed the medication and if the resident should continue to have the medication. IV. Facility follow up The DON sent a physician's progress note on 5/20/24 (after the survey). The 5/17/24 physician progress note revealed Resident #1 continued to have periods of restlessness, that in the past, were managed with antipsychotics. The medications were no longer appropriate but her anxiety and sleep issues were being addressed with benzodiazepines (depressant medications). The resident was non-ambulatory and the benefit of these medications for quality of life outweighed the potential risks that would occur if she were ambulatory. There would continue to be a collaborative and interdisciplinary approach to the care of the resident.-However, the physician's progress note was dated on 5/17/24, the day after the survey exit, and failed to address the monitoring of medication side effects, behavior monitoring or non-pharmacological interventions.

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet order of level six soft and bite-sized texture as indicated on their meal tray cards. Findings include:I. Professional referenceThe International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) (a tool to standardize mechanically altered diets and liquids) (January 2019), was retrieved on 5/21/24, from https://iddsi.org/Resources/Patient-Handouts read in pertinent part, "Level six soft and bite-sized, for safety avoid these food textures that pose a choking risk for adults who need level six soft and bite-sized food: "-Bread (no regular dry bread, sandwiches or toast of any kind). Use IDDSI level five minced and moist sandwich recipe to prepare bread; use pre-gelled 'soaked' breads that are very moist and gelled through the entire thickness;"-Food with skins or outer shell foods with husks such as peas, grapes, chicken skin, salmon skin, and sausage skin."II. Record reviewThe diet spreadsheet for level six (soft and bite-size) mechanically altered diets was provided by the consulting registered dietitian (CRD) on 5/15/24 at 4:30 p.m. The soft and bite-size texture spreadsheet documented the following modifications for menu items served during the lunch meal on 5/15/24:-The green peas were to be omitted and sliced cooked carrots served instead; and,-The wheat dinner roll was to be omitted and a slice of puree bread produced from a commercially prepared mix was to be served instead.-The facility failed to ensure the residents who were prescribed a soft and bite-size mechanically altered diet received foods that were altered to the correct texture for the lunch meal on 5/15/24. -Residents prescribed the level six soft and bite-size diet were served a regular wheat roll for lunch and green peas. III. Meal service observation and staff interviewsDuring a continuous observation of the lunch meal service on 5/15/24, beginning at 11:30 a.m. and ending at 12:55 p.m., the following was observed:The posted menu in the dining room documented the lunch meal consisted of baked chicken, peas, baked potatoes, wheat roll, and fruit crisp. -According to the diet spreadsheets (see above), the level six soft and bite-size restricted regular wheat rolls and peas. The diet spreadsheets indicated a sliced puree bread made with a commercial mix and cooked sliced carrots were to be served instead of a regular wheat roll and peas. At 11:45 a.m. service for the lunch meal began. Between 11:30 a.m. and 12:15 p.m., nine meal plates were assembled and delivered to residents who were prescribed a level six soft and bite-size mechanically altered diet. -The nine plates included a regular roll and peas instead of the puree bread slice and cooked sliced carrots.-At 12:00 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll;-At 12:01 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll;-At 12:15 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll;-At 12:16 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll;-At 12:18 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll;and,-At 12:22 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll. The dietary manager (DM) was interviewed on 5/15/24 at 12:23 p.m. during the lunch meal. The DM said the facility served a regular wheat roll and peas to the residents who were prescribed a soft and bite size texture and had done so in the past. The DM said recipes and menu spreadsheets for the level six soft and bite size texture were in the kitchen and kept in binders. At 12:24 p.m. the DM reviewed the recipes for wheat rolls and peas in the binders in the kitchen. -Neither the recipe for the peas or the wheat roll listed a modification for mechanically altered diets on the recipe. -The DM did not review a diet spreadsheet (see above) after reviewing the wheat roll and pea recipes and dietary staff continued to serve residents prescribed the soft and bite-size texture diet a regular wheat roll and peas. -At 12:26 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll;-At 12:44 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll; and,-At 12:46 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll. The DM was interviewed again on 5/15/24 at 12:50 p.m., during the lunch meal service. The DM said the facility had not yet switched to using a commercially prepared puree bread mix to offer at meals. The DM said the puree mix was for residents on the level five mince and moist texture diet and not the level six soft and bite-size texture diet. IV. Additional staff interviewsThe DM was interviewed a third time on 5/16/24 at 9:00 a.m. The DM said the facility had offered the IDDSI diet textures for approximately a year. The DM said the diet spreadsheets were in the kitchen for the lunch meal served on 5/15/24, however, she said cook (CK) #2 did not refer to the spreadsheet to prepare the modified textures. She said the cooks tried to use the spreadsheets as much as possible. The DM said she was concerned the residents would not like the commercially prepared puree bread mix. The DM said the facility had been offering regular rolls to residents on the level six soft and bite-sized mechanically altered diet, however, the DM said she had scheduled an inservice for the following week to begin using the puree bread mix. The DM said she started a plan and put together staff education because further training was needed for the dietary staff on mechanically altered diet production.-The DM initiated the date for the inservice and the action plan during the survey. The registered dietitian (RD) was interviewed on 5/16/24 at 9:00 a.m. The RD said she audited the diets in the residents' electronic medical records (EMR) to ensure the prescribed diets matched what was on the residents' meal tickets. The RD said there had been no recent changes to many of the residents' diet orders. Dietary aide (DA) #2 was interviewed on 5/16/24 at 10:20 a.m. DA #2 said she did not cook but helped assemble and plate residents' meals. DA #2 said she knew the diet spreadsheets were located in the binders in the kitchen. DA #2 said the diet spreadsheets used to be posted near the back preperation table but were no longer posted so she asked the cooks which diet modifications were to be served during meals. The executive chef (EC) was interviewed on 5/16/24 at 10:30 a.m. The EC said he was not fully trained on how to use the diet spreadsheets and had not used the spreadsheets previously to prepare the mechanically altered diets. The EC said the modifications on the spreadsheets were to help reduce the risk of choking and swallowing issues for the residents. V. Facility follow upThe quality mentor (QM) provided additional information on 5/18/24 (after the survey) at 9:00 a.m. An action plan with an identified concern of following portions, extensions and diets was identified and created on 5/15/24 (during the survey). The plan included for staff to follow portion sizes, diet extensions and changes as listed on the diet spreadsheets with bimonthly meal observations to occur.

Based on observations, interventions and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically the facility failed to:-Ensure the high temperature dish washing machine functioned at the proper temperatures for one of two facility dish washing machines;-Ensure, for a high temperature dish washing machine, an irreversible registering surface temperature indicator (test strip) was present at the facility and readily accessible for measuring the utensil surface temperature; and-Ensure staff performed proper hand hygiene while plating and serving resident meals. Findings include:I. High temperature dish washing machine not at proper temperature and failure to monitor with an irreversible registering temperature indicator (test strip)A. Professional referenceThe Colorado Retail Food Regulations, (3/16/24), retrieved on 5/20/24 from https://cdphe.colorado.gov/environment/food-regulations, read in pertinent part,"A warewashing machine and its auxiliary components shall be operated in accordance with the machine's data plate (label) and other manufacturer's instructions. The temperature of the hot water sanitizing rinse as it enters the manifold (dish washing compartment) may not be less than 180 degrees fahrenheit (F). In hot water mechanical warewashing operations, an irreversible registering temperature indicator (test strip) shall be provided and readily accessible for measuring the utensil surface temperature. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: Hot water mechanical operations by being cycled through equipment achieving a utensil surface temperature of 160 degrees fahrenheit (F) as measured by an irreversible registering temperature indicator; chemical, manual or mechanical operations, including the application of sanitizing chemicals by immersion with a contact time of at least 10 seconds for a chlorine solution. "Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria specified under sanitizers, criteria, shall be used in accordance with the EPA- registered label use instructions, and shall be used as follows: a chlorine solution shall have a minimum temperature based on the concentration and ph of the solution as listed in the following chart concentration range (mg/l). Mg/L means milligrams per liter, which is the metric equivalent of parts per million (ppm)."B. Observations and interviewsOn 5/13/24 the following observations were made in main kitchen:At 9:15 a.m. the high temperature dish machine completed a dish washing and rinse cycle in the main kitchen. The label on the dish machine front panel listed these instructions: The rinse temperature should be 180 degrees F for a minimum of 10 seconds. -However, the dish machine gauges showed the rinse temperature was 170 degrees F.At 9:18 a.m. the high temperature dish machine completed another dish washing and rinse cycle. The dish machine gauges showed the rinse temperature was 172 degrees F.At 9:20 a.m. the May 2024 high temperature dish machine log was reviewed. The log instructions documented the wash and rinse cycle temperatures for the high temperature dish machine were to be recorded once during each meal period and the rinse temperature requirement was 180 degrees F. -However, observations of the high temperature dish machine gauge failed to show the rinse temperature reached 180 degrees F to adequately sanitize the dishes in the dish machine. The May 2024 dish machine log also failed to show documentation the rinse cycle reached 180 degrees F for the first 12 days or list any corrective actions. The facility also failed to have back up temperature indicator strips to monitor that the surface temperature of dishes in the machine reached 160 degrees F.Dietary aide (DA) #1, who was washing dishes during the observation of the dish machine, was interviewed on 5/13/24 at 9:20 a.m. DA #1 said the proper rinse temperature for the dish machine needed to be between 170 degrees and 180 degrees F to sanitize the dishes (However, the dish machine needed to reach 180 degrees F to properly sanitize the dishes using heat). DA #1 said if the dish machine was not operating at the correct rinse temperature a staff member should inform the dietary manager (DM). DA #1 said she was not aware the operating instructions for the dish machine were on the dish machine's label. The DM was interviewed on 5/13/24 at 9:25 a.m. The DM said the dish machine rinse temperatures should be between 170 degrees and 180 degrees F (However, the dish machine needed to reach 180 degrees F to properly sanitize the dishes using heat). The DM said the dish machine was connected to a chemical sanitizer to sanitize the dishes. The DM said she would tell the nursing home administrator (NHA) if the dish machine rinse temperature was not reaching the minimum temperature. The DM said she did not have any temperature indicator strips to measure the surface temperature of the utensils and dishes inside the dish machine. The DM said she was unable to determine if the dishes washed on 5/13/24 were sanitized. The DM said she was unaware that the label on the dish machine front panel provided operating instructions.-The chemical connected to the dish machine was not a chemical sanitizer but a rinse aid which expedited the dishes drying and did not function as a sanitizing agent. The DM was interviewed again on 5/13/24 at 10:10 a.m. The DM said the facility placed a call to their contracted kitchen repair vendor to check the dish machine. The DM said the facility would utilize paper products for lunch. The contracted kitchen repair vendor was interviewed on 5/13/24 at 10:55 a.m. The vendor said he tested the high temperature dish machine in the main kitchen. The vendor said he used temperature indicator strips and the strips showed dishes in the dish machine reached the required 160 degrees F during three separate cycles. The vendor said he left temperature indicator strips with the dietary manager and instructed the dietary staff to run temperature indicator strips through the dish machine once every eight dish washing cycles. He said the dish machine would also be connected to a chemical sanitizer should the rinse cycle not meet the minimum temperature of 180 degrees F. The DM was interviewed again at 5:00 p.m. The DM said the dish machine worked properly throughout the day after the kitchen repair vendor checked the machine and washed the dishes. The DM said she used the temperature indicator strips as instructed by the kitchen repair vendor to monitor the surface temperature of the dishes and the indicator strips turned black, which meant the surface temperature of the dishes in the machine reached the minimum requirement of 160 degrees F. The DM said she found registering temperature indicator strips in her desk previously and did not know what the strips were for and had never used them. The DM said a chemical sanitizer was also now connected to the dish machine. At 5:05 p.m. additional cycles of the high temperature dish washing machine were observed. The dish machine ran for six cycles and temperature indicator strips and chemical sanitizing strips were used to test the sanitation levels in the dish machine. The first two dish machine cycles operated with a temperature indicator strip on a dish in the machine. The temperature gauge on the gauge showed a maximum rinse cycle temperature of 166 degrees F during both cycles. The temperature indicator strips on the dish inside the machine did not indicate the dishes had reached a minimum 160 degrees F surface temperature. The DM used a chlorine sanitizer test strip at the end of the rinse cycle to test the strength of the chemical sanitizer solution in the dish machine. The test strip read 10 parts per million (ppm) instead of the minimum of 50 ppm. A temperature indicator strip was placed on a different dish in the machine and the dish machine ran for two more cycles. The temperature gauge at the end of each cycle showed a maximum rinse temperature of 170 degrees F. The temperature indicator strips on the dish inside the machine did not indicate the dish had reached a minimum 160 degrees F surface temperature. The DM used a new chlorine sanitizer test strip at the end of the rinse cycle to test the strength of the chemical sanitizer solution in the dish machine. The test strip read 10 ppm instead of the minimum of 50 ppm. A temperature indicator strip was placed on a different dish in the machine and the dish machine ran for a total of two more cycles. The temperature gauge at the end of each cycle showed a maximum rinse temperature of 172 degrees F. The temperature indicator strips on the dish inside the machine did not turn black to indicate the dish had reached a minimum 160 degrees F surface temperature. The DM used a new chlorine sanitizer test strip at the end of the rinse cycle to test the strength of the chemical sanitizer solution. The test strip read 10 ppm instead of the minimum of 50 ppm. The NHA was notified at 5:30 p.m. the dish machine did not reach the minimum internal rinse temperature and the temperature indicator strips did not show the surface temperature of dishes in the machine reached a minimum of 160 degrees F and the chemical sanitizer test strips did not reach 50 ppm. -The NHA said the facility would utilize paper products for resident meals going forward and rewash any dishes that needed to be sanitized in the dish machine in the rehabilitation unit dishwasher. The NHA and the environmental services director (ESD) were interviewed on 5/14/24 at 9:30 a.m. The ESD said the facility called the kitchen repair vendor who came to the facility again on 5/14/24. The ESD said the kitchen repair vendor instructed the staff to test the sanitizer concentration in the dish machine. The ESD said the staff needed to use the test strip in pooled water in a utensil for a correct reading. The ESD said the facility would continue to test the chemical sanitizer concentration for 24 hours and ensure the sanitizer was at the correct concentration prior to transitioning back to reusable dishes for residents' meal service. The NHA said the facility would use paper products for the next 24 hours while continuing to monitor the dish machine in the main kitchen for proper sanitization prior to transitioning back to china. The NHA said dietary staff were provided additional education on how to test the dish machine to ensure it was sanitizing properly (see facility follow up). C. Record reviewThe dishwashing machine temperature logs were reviewed from December 2023 to April 2024. The log listed the rinse temperature requirement for the dish machine was 180 degrees F and wash and rinse temperatures were to be recorded once each meal. Any temperatures outside of the acceptable range should be reported to a supervisor or maintenance person immediately. The logs revealed the following:-In December 2023 the rinse temperature was recorded as being below 180 degrees F for 21 meals.-In January 2024 the rinse temperature was recorded as being below 180 degrees F for 53 meals, and no temperatures were recorded for 25 meals.-In February 2024 the rinse temperature was recorded as being below 180 degrees F every meal.-In March 2024 the rinse temperature was recorded as being below 180 degrees F every dinner meal and at three lunch meals-In April 2024 the rinse temperature was recorded as being below 180 degrees F every breakfast meal and four dinner meals.-The dish machine temperature logs documented the dish machine rinse temperature as below the recommended 180 degrees F and failed to list a corrective action for rinse temperatures below 180 degrees F.D. Staff interviewsThe DM was interviewed on 5/16/24 at 9:00 a.m. The DM said she did not think staff knew during the dishwashing cycle when to check the rinse temperature. The DM said she was not aware if staff had previously reported the incorrect dish machine temperatures to anyone in the facility. The DM said she had long term dietary staff and those staff members assisted training the new staff how to wash dishes and monitor the dish machine temperatures. The DM said all dietary staff washed dishes in the dish machine except for the cooks. The DM said she had not yet followed up the training staff (during the survey) since the issue with the dish machine was identified. The DM said she was not aware of the dish machine instructions on the label prior to the survey, but she began showing the staff the label (during the survey) and planned to incorporate the label instructions as part of staff training on the dish machine. The DM said staff were now to notify her, the chef, the ESD, or the administrator if the dish machine was not working correctly. The DM said she planned to change how she monitored the functionality of the dish machine and how the staff monitored the dish machine temperatures, and would check the dish machine every morning to verify staff monitored and recorded the sanitizer ppm properly and require that staff demonstrate how to monitor the sanitizer ppm. The consulting registered dietitian (CRD) was interviewed on 5/16/24 at 9:10 a.m. The CRD said the gauge on the dish machine had been replaced (during the survey) and the booster heater for the dish machine was faulty so the facility would continue with a chemical sanitizer for the dish machine. Dietary aide (DA) #2 was interviewed on 5/13/24 at 10:20 a.m. DA #2 said the dish machine in the kitchen had been adjusted (during the survey) to be used with a chemical sanitizer instead of high temperature sanitizing. She said she used the machine to wash dishes on occasion and the temperature for rinse sanitizing should be 180 degrees and temperature indicator strips could be used to test the temperature during the rinse cycle. She said if the dish machine temperatures were below the minimum standard she would stop washing dishes and tell a supervisor immediately. She said she had not identified any temperature issues with the dish machine prior to the survey. E. Facility follow upThe quality mentor (QM) provided additional information on 5/18/24 (after the survey) at 9:00 a.m. A kitchen education was provided to the dietary staff on 5/13/24 at 6:30 p.m. by the NHA. The inservice provided instructions (below) on how to test the chemical sanitizer concentration of the dish machine and corrective action. The dish machine sanitizes by using correct sanitizer measured with sanitizing test strips. Sanitizing strips should measure 50 ppm for proper sanitizing of dishes and utensils. If the strip did not turn the correct color, measure using another test strip. Make sure the strips were not expired and did not show signs of wetness and contamination. Measure the water immediately after the rinse cycle by collecting a drip from the door. Record ppm measured and temperature of the machine on the proper recording sheet. If the machine test (verification) was not correct, contact a supervisor and/or kitchen repair vendor. If in doubt, serve food on disposable products until the dish machine was repaired. An inservice covering how to properly record dish machine chemical sanitizer ppm was provided to the dietary staff on 5/14/24. The updated dish machine log listed the updated minimum temperature standards for the dish machine as 120 degrees F and the minimum sanitizer concentration as 50 ppm and staff were to report inappropriate temperatures or sanitizing issues to the supervisor immediately for corrective action. An action plan with an identified concern of the dish machine not at optimal temperature of 180 degrees F (rinse temperature) was identified and created on 5/14/24. The plan included the following steps: Call for repair for machine and evaluation for booster (heater); the high temperature dish machine was converted to a chemical sanitizing machine and reviewed with the chemical company; appropriate test steps were in place for checking sanitizing levels; and, an inservice was created for staff on recording sanitation levels, checking temperature and proper test strips; director/chef was to check recording daily and verify as needed. II. Ensure staff performed proper hand hygiene while plating and serving resident mealsA. Professional reference The Colorado Retail Food Regulations, (3/16/24), retrieved on 5/20/24 from https://cdphe.colorado.gov/environment/food-regulations, read in pertinent part, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: After touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; after handling soiled equipment or utensils; During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; When switching between working with raw food and working with ready-to-eat food; Before donning gloves to initiate a task that involves working with food; After engaging in other activities that contaminate the hands."B. ObservationsDuring a continuous observation of the lunch meal service on 5/13/24, beginning at 11:30 a.m. and ending at 12:50 p.m., cook (CK) #1 was observed touching her mask and hair with her hands and then handing clean dishes throughout resident meal service:At 11:47 a.m. while standing at the steam table where the lunch meal was held hot for the lunch meal service, CK #1 touched her mask with both hands. Without performing hand hygiene CK #1 picked up a plate with one hand and a serving utensil with her other hand and dished food onto the plate. CK #1 placed the plate of food in the serving window to be served to a resident. CK #1 picked up a soup bowl with one hand and with her other hand picked up a utensil to scoop food into the soup bowl. CK #1 then touched her mask, picked up a lid and placed the lid on the soup bowl. At 11:50 a.m. CK #1 touched her hair with her bare hand, then walked to the back of the kitchen and touched her hair again. CK #1 returned to the steam table in front of the serving window and touched her hair again. Without performing hand hygiene, CK #1 picked up a plate with the same hand she touched her hair with, picked up a utensil with her other hand and scooped food onto the plate. CK #1 then touched her surgical mask, picked up a disposable wipe, wiped off the steam table and threw the wipe away. CK #1 touched her mask again, picked up a disposable towel to wipe off her steam table and threw the towel away. At 11:53 a.m. CK #1 exited the kitchen into the dining room. After returning to the kitchen, CK #1 did not perform hand hygiene before she picked up a utensil and stirred food in the steam table. At 11:55 a.m. CK #1 touched her mask with both hands and touched her cheeks with both hands. CK #1 turned around, touched a shelf on the food preparation table and walked through the kitchen with her hands on her hips before she returned to the steam table. CK #1 touched the front of her shirt and pants with her right hand, failed to hand hygiene, picked up a plate with her right hand and a utensil with her other hand and scooped food onto a plate to be placed in the serving window to be served to a resident. CK #1 then touched her mask, picked up tongs and a plate and scooped food on a plate, placed the plate in the serving window. CK #1 then prepared another plate and placed the plate in the serving window. Both plates were served to a resident. At 12:00 p.m. CK #1 put anoven mitt on her left hand. CK #1 picked up a hot pan, placed the hot pan on a preparation table and removed the oven mitt from her left hand. Without performing hand hygiene, CK #1 then put on single use gloves. At 12:05 p.m. CK #1 adjusted her name tag on the front of her shirt with both hands. Without performing hand hygiene, CK #1 picked up a plate and utensil and scooped food onto the plate and set the plate in the serving window and then touched her mask with both hands. At 12:07 p.m. CK #1 picked up a hot pad and used the hot pad to place a pan of hot rolls on a food preparation table and then returned to the steam table to continue to assemble meal plates. At 12:11 p.m. without performing hand hygiene, CK #1 put on single use gloves and picked up a food item with her hand. CK #1 cut the food item and placed it on a plate to be served to a resident. CK #1 discarded the gloves and returned to the steam table. At 12:12 p.m. CK #1 adjusted her shirt and pants with both hands, touched her face with her right hand and picked up a scoop with her right hand and a plate with her left hand. CK #1 scooped food onto the plate and then placed the plate in the serving window to be served to a resident. Without performing hand hygiene, CK #1 picked up a plate with her bare hand and brushed her hand over the center of the plate. CK #1 scooped food onto the plate and placed the plate in the serving window to be served to a resident. At 12:15 p.m. CK #1 touched her hair and then touched her mask with both hands. CK #1 picked up a bowl and scooped food into a bowl. CK #1 walked to the back of the kitchen into dry storage. As she returned to the steam table CK #1 touched her hair then picked up a plate with a dessert covered with plastic wrap, placed it in the serving window and an unidentified staff member served the dessert to a resident. At 12:22 p.m CK #1 touched her nose with her left hand and then donned (put on) single use gloves without washing her hands. CK #1 used a knife to cut a food item on the steam table and used the knife and her gloved hand to place the food item on a plate. CK #1 discarded her gloves then touched her mask with both hands. CK #1 then picked up a plate and a serving utensil and continued to assemble meal plates to be served to residents. At 12:30 p.m CK #1 picked up a styrofoam cup and filled the cup at a juice machine in the kitchen. CK #1 pulled her mask down below her mouth and drank from the cup while walking through the kitchen and into the break room. CK #1 returned to the steam table, did not perform hand hygiene and placed a four ounce dish of food in the window. CK #1 continued to assemble resident meal plates to be served to residents. D. Staff interviewsDA #2 was interviewed on 5/16/24 at 10:20 a.m. DA #2 said she had received hand hygiene education from the facility's infection preventionist (IP). She said staff should wash their hands anytime the staff changed tasks in the kitchen and wash their hands in between glove changes. DA #2 said gloves should be worn to handle raw meat. She said hand hygiene needed to be performed anytime someone entered the kitchen. DA #2 said hand hygiene needed to be performed after touching a face mask or hair. The DM was interviewed on 5/16/24 at 9:00 a.m. The DM said the facility's IP provided education to the dietary staff that included how to properly wash hands and when to perform hand hygiene. The DM said the IP included in the education that staff needed to wash their hands after touching their mask. The DM said if a staff member touched their mask or hair during food preparation the staff member should wash their hands..E. Facility follow-upThe QM provided a hand washing inservice on 5/18/24 (after the survey) at 9:00 a.m. The hand washing in-service was provided to dietary staff on 5/15/24 and included the following topics:education for food and nutrition staff on the proper usage of masks and gloves and hand washing. Staff must wash their hands after touching face masks, face or any part of the body before returning to serve (meals) or prepping foods. The inservice included a demonstration with return demonstration from the staff.

Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one of three units. Specifically, the facility failed to:-Follow proper infection control processes for cleaning and disinfecting lifts and vital signs equipment on the Parkview unit; and,-Use proper infection control procedures during a vaccination clinic. Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Healthcare Facilities (2019), retrieved on 5/25/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/index.html, read in pertinent part, "Careful cleaning of patient rooms and medical equipment contributes substantially to the overall control of Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-intermediate Staphylococcus aureus (VISA) and Vancomycin-resistant Enterococci (VRE) transmission. "Direct patient-care items (blood pressure cuffs) should be disposable whenever possible when used in contact isolation settings for patients with multiply resistant microorganisms."Non-critical items (those that come in contact with intact skin but not mucous membranes), are divided into noncritical resident care items (blood pressure cuffs, stethoscopes, wheelchairs, therapy equipment) and noncritical environmental surfaces (bed rails, bedside tables). They require cleaning followed by either low or intermediate level disinfection following manufacturers' instructions. Disinfection should be performed with an Environmental Protection Agency (EPA)-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA-registered disinfectant products must be followed (use-dilution, shelf life, storage, material compatibility, safe use and disposal). II. Mechanical lifts (sit-to-stand machine) and vital signs equipment A. ObservationsOn 5/13/24 at 1:44 p.m. certified nurse aide (CNA) #1 was observed bringing the sit-to-stand mechanical lift out of a resident's room on the Parkview unit. CNA #1 took the equipment to a holding area with other lifts and left the lift. -CNA #1 failed to disinfect the sit-to-stand mechanical lift after using the lift with the resident. On 5/15/24 during a continuous observation, beginning at 11:06 a.m. and ending at 11:20 a.m., an unidentified CNA was observed using a vital signs machine. The unidentified CNA was observed leaving a room on the Parkview unit with the vital signs machine and equipment, including blood pressure cuffs, a pulse oximeter, and a thermometer. -There were no cleaning wipes stored with the equipment. -The unidentified CNA wheeled the equipment down the hall and placed it next to the nurses' station. The CNA failed to disinfect the vital signs machine and equipment C. Interviews The infection preventionist (IP) was interviewed on 5/15/24 at 4:06 p.m. The IP said she had been working at the facility since 2020. She said the cleaning policy for vital signs equipment depended on if there was an outbreak. She said hydrogen peroxide was readily available and more gentle on skin and the equipment. The IP said the dwell time for hydrogen peroxide was about 30 seconds. She said if there was a range for the dwell time, she usually recommended the longer time listed, but she did not usually see a range. She said disinfection of the equipment depended on what was going on in the building. The IP said it was okay to clean all the equipment with the same wipe, however, she said it should be done after each use with a resident. She said CNAs were responsible for cleaning the equipment after every use with the hydrogen peroxide wipes. III. Hand hygiene during vaccination administrationA. ObservationsOn 5/15/24 a contract pharmacist (CP) was administering vaccinations to the residents in the presence of the infection preventionist (IP). At 11:28 a.m. the CP was observed standing next to room #5. She put clean gloves on, took band aids, peeled them on one end and stuck them to a sharps container. She used her gloved hands to adjust her skirt, took paper records from the cart and went into room #5. She exited the room holding paper records and wearing the same gloves. -Without changing her gloves or performing hand hygiene, the CP proceeded to take two prefilled vaccine syringes from the cart, stuck one band aid on her watch and one bandaid on her gloved hand and approached the resident in room #5 to administer the vaccination. After administering the vaccination, the CP removed her gloves and exited room #5 holding both syringes in her hands. She placed the syringes into the sharps container on the cart.-The CP did not perform hand hygiene before documenting the vaccination in the resident's record and pushing the cart to the next roomAt 11:31 a.m. the CP approached room #22. She put clean gloves on, without performing hand hygiene, stuck band aids to her glove and entered room #22 with two syringes. After administering the vaccinations to the residents, the CP exited the room with gloves on, threw the syringes into a sharps container and took her gloves off. -The CP did not perform hand hygiene prior to putting clean gloves on. -With the new pair of clean gloves on, she adjusted her shirt, organized paper records and pushed the cart to the next room still wearing the gloves. At 11:38 a.m. the CP approached room #18. She put clean gloves on, without performing hand hygiene, stuck band aids to her glove and entered room #18 with two syringes. After administering the vaccinations to the residents, the CP exited the room wearing gloves, put the two syringes into a sharps container and removed her gloves. -The CP did not perform hand hygiene after she removed the gloves. B. Staff interviewsThe IP was interviewed on 5/6/24 at 4:15 p.m. The IP said the pharmacist that was administering vaccinations was from the contracted company. She said the CP was not an employee of the facility. The IP said band aids should not be placed on the sharps container as the sharps container was considered to be unclean from contact with syringes and blood products. The IP said once the CP had applied clean gloves, other potentially unclean surfaces such as the cart, paper records, personal clothes and pens should not have been touched. She said once gloves were removed after administering the vaccinations, the CP should have performed hand hygiene prior to reapplying clean gloves.

A complaint survey, prompted by #CO35318 was conducted on 3/27/24 to 4/2/24. No deficiencies were cited.

A health survey with complaint #CO34197 was completed 3/27/24 to 4/2/24. No response necessary.

A complaint survey, prompted by #CO34051 was conducted on 11/2/23. No deficiencies were cited.

A revisit survey was completed on 8/30/23 for all previous deficiencies cited on 6/26/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO29967 and #CO32491 was completed on 6/22/23 to 6/26/23. Four deficiencies were cited.

Based on record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#3, #7, #11 and #18) of five residents out of eight sample residents. Specifically, the facility failed to:-Address continued call light complaints voiced during resident council for several months; and,-Ensure Resident #3, Resident #7, Resident #11 and Resident #18 experienced a dignified living experience by answering the residents' call lights in a timely manner. Findings include:I. Facility policy and proceduresThe Answering the Call Light policy, revised September 2022, was provided by the nursing home administrator (NHA) via email on 6/28/23 at 3:08 p.m. It read in pertinent part, "The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Answer the resident call system immediately. If the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident's request requires another staff member, notify the individual. If the resident's request is something you can fulfill, complete the task within five minutes if possible."II. Resident council minutesReview of the 2/17/23 resident council minutes revealed the residents reported call lights were taking too long to get answered or nursing staff went into resident rooms and turned off the call lights and said they would be back but never returned.-There was no follow-up response to address the resident's call light concerns documented in the resident council minutes. Review of the 3/9/23 resident council minutes revealed call lights taking too long to be answered was a continued concern for residents. The minutes documented nurse managers were completing call light audits and there was an ongoing process improvement plan for call light times. Review of the 4/14/23 resident council minutes revealed the residents reported call lights were taking too long to be answered. The minutes documented the NHA said he was getting the manager pagers fixed so that the facility could monitor call lights better. Review of the 5/12/23 resident council minutes revealed the residents reported call lights were taking too long to be answered. The minutes documented the NHA said he was getting the manager pagers fixed so that the facility could monitor call lights better.-The NHA response documented in the resident council minutes was the same response that had been provided in the 4/14/23 resident council minutes. Review of the 6/9/23 resident council minutes revealed the residents reported call lights were taking too long to be answered. The minutes documented the NHA said pagers were in place for call lights and they were being monitored by all the nursing managers including the NHA and the social services director. III. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 12/4/2020 and readmitted on 8/19/22. According to the June 2023 computerized physician orders (CPO), diagnoses included congestive heart failure, age-related osteoporosis (weak, brittle bones), pain in left and right hips, low back pain and glaucoma. The 2/20/23 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers and toilet use. She required one-person limited assistance for dressing and personal hygiene. B. Resident interviewResident #3 was interviewed on 6/26/23 at 2:59 p.m. Resident #3 said she sometimes had to wait for a long time for staff to come assist her when she put her call light on. She said she had waited for longer than 30 minutes at times for staff to answer her call light. Resident #3 said she was not supposed to go to the bathroom without assistance, however, she said she sometimes had to take herself to the bathroom because she could not wait any longer for a staff member to answer her call light and assist her. C. Record reviewReview of Resident #3's activities of daily living (ADL) care plan, initiated 12/4/2020 and revised 4/4/23, revealed that the resident needed limited to extensive assistance withsome ADL activities related to weakness and deconditioning. Pertinent interventions included ensuring the call light was within reach and staff was to respond promptly to requests for help. If the resident was unable to use or was inconsistent with call light use, staff was to monitor the resident every one to two hours for needs and safety and anticipate the resident's needs as able. Review of Resident #3's call light log report from 6/1/23 to 6/25/23 revealed the following:-6/1/23 at 4:29 a.m: the call light was on for 31 minutes;-6/2/23 at 4:33 p.m: the call light was on for 23 minutes;-6/5/23 at 7:17 p.m: the call light was on for 26 minutes;-6/8/23 at 11:21 a.m: the call light was on for 25 minutes;-6/8/23 at 11:47 a.m: the call light was on for 33 minutes;-6/10/23 at 4:28 p.m: the call light was on for 21 minutes;-6/12/23 at 7:23 p.m: the call light was on for one hour and 38 minutes;-6/17/23 at 12:17 p.m: the call light was on for one hour and 20 minutes;-6/17/23 at 7:37 p.m: the call light was on for 20 minutes;-6/18/23 at 10:36 a.m: the call light was on for 21 minutes;-6/19/23 at 7:16 a.m: the call light was on for 47 minutes;-6/19/23 at 8:59 a.m: the call light was on for one hour and 41 minutes;-6/19/23 at 7:12 p.m: the call light was on for 21 minutes;-6/19/23 at 9:00 p.m: the call light was on for one hour and 33 minutes;-6/22/23 at 7:32 p.m: the call light was on for 21 minutes; and,-6/26/23 at 6:09 a.m: the call light was on for one hour and 15 minutes. IV. Resident #7A. Resident statusResident #7, age 66, was admitted on 8/27/2020 and readmitted on 5/23/23. According to the June CPO, diagnoses included hemiplegia (complete paralysis of an extremity on one side of the body) and hemiparesis (weakness of an extremity on one side of the body) following cerebral infarction (stroke) affecting the right dominant side, muscle weakness and muscle spasms. The 6/5/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. He required two-person extensive assistance for bed mobility, transfers and toilet use. He required one-person extensive assistance for dressing and personal hygiene. B. Resident interviewResident #7 was interviewed on 6/26/23 at 11:38 a.m. Resident #7 said he sometimes had to wait 30 minutes or longer for his call light to be answered. He said he required two people to transfer him with the mechanical lift. He said staff would answer his call light quickly at times, however, he said they would turn off his call light and tell him they would return with another staff member to assist with his transfer. Resident #7 said it would often take the initial staff member who answered his call light 15 minutes or more to return to assist him. He said sometimes they did not return and he would have to put his call light back on. C. Record reviewReview of Resident #7's ADL care plan, initiated 8/28/2020 and last revised 12/20/22, revealed the resident needed limited to extensive to total assistance with some ADL activities related to weakness and pain. Pertinent interventions included ensuring the call light was within reach and staff was to respond promptly to requests for help. If the resident was unable to use or wasinconsistent with call light use, staff was to monitor the resident every one to two hours for needs and safety and anticipate the resident's needs as able. Review of Resident #7's call light log report from 6/1/23 to 6/25/23 revealed the following:-6/1/23 at 11:32 a.m: the call light was on for 23 minutes;-6/1/23 at 1:03 p.m: the call light was on for 29 minutes;-6/2/23 at 6:11 a.m: the call light was on for 32 minutes;-6/2/23 at 7:48 a.m: the call light was on for 54 minutes;-6/2/23 at 11:22 a.m: the call light was on for 24 minutes;-6/3/23 at 6:19 a.m: the call light was onfor 49 minutes;-6/3/23 at 8:23 a.m: the call light was on for 36 minutes;-6/5/23 at 7:47 a.m: the call light was on for 58 minutes;-6/6/23 at 6:11 a.m: the call light was on for 23 minutes;-6/6/23 at 7:47 a.m: the call light was on for 29 minutes;-6/6/23 at 11:33 a.m: the call light was on for 24 minutes;-6/7/23 at 6:11 a.m: the call light was on for 24 minutes;-6/7/23 at 7:36 a.m: the call light was on for 40 minutes;-6/8/23 at 7:27 a.m: the call light was on for one hour and 10 minutes;-6/8/23 at 11:23 a.m: the call light was on for 28 minutes;-6/8/23 at 12:27 p.m: the call light was on for 24 minutes;-6/9/23 at 7:44 a.m: the call light was on for one hour and 15 minutes;-6/9/23 at 7:20 p.m: the call light was on for 45 minutes;-6/10/23 at 11:21 a.m: the call light was on for 25 minutes;-6/11/23 at 6:15 a.m: the call light was on for 45 minutes;-6/11/23 at 8:02 a.m: the call light was on for 52 minutes;-6/12/23 at 7:44 a.m: the call light was on for 27 minutes;-6/12/23 at 7:13 p.m: the call light was on for 31 minutes;-6/13/23 at 7:45 a.m: the call light was on for 51 minutes;-6/13/23 at 12:35 p.m: the call light was on for 33 minutes;-6/14/23 at 7:42 a.m: the call light was on for 29 minutes;-6/22/23 at 6:18 a.m: the call light was on for 28 minutes;-6/22/23 at 10:05 a.m: the call light was on for 24 minutes;-6/22/23 at 8:39 p.m: the call light was on for 31 minutes;-6/23/23 at 5:27 a.m: the call light was on for 23 minutes;-6/23/23 at 12:35 p.m: the call light was on for 37 minutes;-6/24/23 at 5:37 a.m: the call light was on for 37 minutes; and,-6/24/23 at 6:31 a.m: the call light was on for one hour and 21 minutes. V. Resident #11A. Resident statusResident #11, age 74, was admitted on 7/12/18 and readmitted on 2/8/23. According to the June 2023 CPO, diagnoses included shortness of breath, lack of coordination, fatigue and weakness. The 5/10/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. She required two-person extensive assistance for bed mobility and transfers. She required one-person limited assistance for dressing. She required one-person extensive assistance for personal hygiene. She was totally dependent on one staff person for toilet use. B. Resident interviewResident #11 was interviewed on 6/26/23 at 11:01 a.m. Resident #11 said she had experienced long wait times for staff to respond to her call light. She said it usually happened when she needed her brief changed or she wanted to get into or out of her bed. She said it did not happen all the time, however, she said it happened often enough that it was very frustrating. She said she had to wait 20 minutes or longer at times. Resident #11 said 20 minutes was too long to have to wait for her to get the assistance she needed. C. Record reviewReview of Resident #11's ADL care plan, initiated 7/12/18 and revised 5/24/23, revealed that the resident needed limited to extensive to total assistance with some ADL activities. Pertinent interventions included providing assistance for ADLs and mobility as needed. Review of Resident #11's call light log report from 6/1/23 to 6/25/23 revealed the following:-6/1/23 at 6:37 a.m: the call light was on for 49 minutes;-6/1/23 at 8:19 a.m: the call light was on for 28 minutes;-6/1/23 at 10:57 a.m: the call light was on for 46 minutes;-6/1/23 at 12:34 p.m: the call light was on for 34 minutes;-6/1/23 at 9:26 p.m: the call light was on for one hour;-6/4/23 at 10:14 a.m: the call light was on for 25 minutes;-6/4/23 at 11:26 a.m: the call light was on for 27 minutes;-6/5/23 at 9:52 a.m: the call light was on for 26 minutes;-6/8/23 at 5:55 a.m: the call light was on for 40 minutes;-6/8/23 at 12:29 p.m: the call light was on for 22 minutes;-6/8/23 at 4:04 p.m: the call light was on for 51 minutes;-6/8/23 at 7:03 p.m: the call light was on for 24 minutes;-6/9/23 at 7:44 p.m: the call light was on for 25 minutes;-6/10/23 at 2:08 p.m: the call light was on for 37 minutes;-6/10/23 at 7:06 p.m: thecall light was on for 40 minutes;-6/12/23 at 8:12 a.m: the call light was on for 55 minutes;-6/14/23 at 8:04 a.m: the call light was on for 33 minutes;-6/15/23 at 8:52 p.m: the call light was on for 25 minutes;-6/15/23 at 5:51 p.m: the call light was on for 47 minutes;-6/17/23 at 3:51 a.m: the call light was on for 21 minutes;-6/17/23 at 7:52 a.m: the call light was on for two hours and two minutes;-6/17/23 at 10:36 a.m: the call light was on for 45 minutes;-6/17/23 at 1:13 p.m: the call light was on for 43 minutes;-6/17/23 at 4:18 p.m: the call light was on for 57 minutes;-6/18/23 at 6:46 a.m: the call light was on for 49 minutes;-6/18/23 at 8:33 a.m: the call light was on for 33 minutes;-6/19/23 at 12:44 p.m: the call light was on for 23 minutes;-6/20/23 at 7:25 p.m: the call light was on for 38 minutes;-6/20/23 at 9:46 p.m: the call light was on for 24 minutes;-6/21/23 at 6:58 p.m: the call light was on for 47 minutes;-6/22/23 at 4:16 p.m: the call light was on for 23 minutes;-6/22/23 at 8:38 p.m: the call light was on for 39 minutes;-6/23/23 at 8:51 a.m: the call light was on for 31 minutes;-6/23/23 at 6:09 p.m: the call light was on for 48 minutes;-6/24/23 at 8:05 a.m: the call light was on for 26 minutes;-6/24/23 at 8:39 a.m: the call light was on for 21 minutes;-6/24/23 at 11:27 a.m: the call light was on for 24 minutes;-6/24/23 at 12:43 p.m: the call light was on for 33 minutes;-6/24/23 at 3:58 p.m: the call light was on for 30 minutes; and,-6/24/23 at 9:20 p.m: the call light was on for 39 minutes. VI. Resident #18A. Resident statusResident #18, age 84 was admitted on 5/12/18. According to the June 2023 CPO, diagnoses included pain, lack of coordination, muscle weakness and contracture (a fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the associated body part) of the left elbow. The 4/5/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. B. Resident interviewResident #18 was interviewed on 6/26/23 at 2:30 p.m. Resident #18 said she sometimes had to wait at least 30 minutes to get her call light answered. She said she put her call light on when she needed to have her brief changed or she wanted to get up or go back to bed. Resident #18 said she understood staff were very busy, however, she said it was frustrating to have to wait so long to receive assistance from staff. C. Record reviewReview of Resident #18's ADL care plan, initiated 5/12/18 and revised 4/10/23, revealed that the resident had experienced a decline in function from baseline with increased weakness, deconditioning and/or functional limitations. Review of Resident #18's call light log report from 6/1/23 to 6/25/23 revealed the following:-6/1/23 at 12:56 p.m: the call light was on for 24 minutes;-6/2/23 at 6:45 a.m: the call light was on for 49 minutes;-6/3/23 at 9:16 a.m: the call light was on for 39 minutes;-6/4/23 at 8:56 a.m: the call light was on for 20 minutes;-6/7/23 at 1:02 p.m: the call light was on for 25 minutes;-6/8/23 at 1:00 p.m: the call light was on for 29 minutes;-6/8/23 at 2:17 p.m: the call light was on for 25 minutes;-6/8/23 at 4:31 p.m: the call light was on for 21 minutes;-6/9/23 at 8:18 a.m: the call light was on for one hour and seven minutes;-6/9/23 at 10:58 a.m: the call light was on for 36 minutes;-6/10/23 at 4:42 p.m: the call light was on for 21 minutes;-6/13/23 at 6:28 a.m: the call light was on for one hour and 26 minutes;-6/14/23 at 6:33 a.m: the call light was on for 29 minutes;-6/15/23 at 7:13 a.m: the call light was on for 55 minutes;-6/16/23 at 7:10 a.m: the call light was on for 30 minutes;-6/16/23 at 1:12 p.m: the call light was on for 20 minutes;-6/17/23 at 10:10 a.m: the call light was on for 58 minutes;-6/18/23 at 1:38 p.m: the call light was on for 25 minutes;-6/19/23 at 6:37 a.m: the call light was on for one hour and six minutes;-6/19/23 at 10:04 a.m: the call light was on for 55 minutes;-6/20/23 at 9:20 a.m: the call light was on for 42 minutes;-6/20/23 at 12:59 p.m: the call light was on for 28 minutes;-6/23/23 at 9:04 a.m: the call light was on for 26 minutes;-6/25/23 at 5:58 p.m: the call light was on for 30 minutes; and,-6/26/23 at 7:26 a.m: the call light was on for 47 minutes. VII. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 6/22/23 at 12:56 p.m. CNA #1 said resident call lights should be answered by staff as quickly as possible. She said residents' call lights should not be turned off until the resident had been assisted. She said if a second person was needed for a transfer, the call light should be turned off to acknowledge that the resident's request had been noted. CNA #1 said the call light should then be turned back on until that staff person found a second staff member to help with the transfer. CNA #3 was interviewed on 6/26/23 at 2:50 p.m. CNA #3 said call lights should not be on longer than 20 minutes if possible. She said call lights should be answered as quickly as possible. CNA #3 said staff should not turn off call lights until the resident's need had been met. The nursing home administrator (NHA) was interviewed on 6/26/23 at 4:20 p.m. The NHA said call lights should be answered as quickly as possible. She said call lights should be answered in under 20 minutes whenever it was possible. She said a mechanical lift or a second staff person to help with a resident transfer might not be available at times and the wait time for the resident might have to wait a little longer. The NHA said if a mechanical lift and a second person was needed for a transfer, the CNA should acknowledge the resident's request and turn off the call light. She said the CNA should explain to the resident that they would return after they obtained the lift and another staff member. She said the CNA should make every effort to return to finish assisting the resident as soon as possible.

Based on record review and interviews, the facility failed to ensure residents had a right to make choices about aspects of their life in the facility that were significant to the resident for three (#6, #7 and #11) of four residents reviewed for choices out of eight sample residents. Specifically, the facility failed to identify and honor resident preferences regarding wake up times for Resident #6, Resident #7 and Resident #11. Findings include:I. Facility policy and proceduresThe Dignity policy, revised February 2021, was provided by the nursing home administrator (NHA) on 6/29/23 at 10:38 a.m. It read in pertinent part, "Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. Individual needs and preferences of the resident are identified through the assessment process. When assisting with care, residents are supported in exercising their rights. For example, residents are allowed to choose when to sleep, eat and conduct activities of daily living."II. Resident #6A. Resident statusResident #6, age 83, was admitted on 12/30/21. According to the June 2023 computerized physician orders (CPO), diagnoses included hemiplegia (complete paralysis of an extremity on one side of the body) and hemiparesis (weakness of an extremity on one side of the body) following cerebral infarction (stroke) affecting the left dominant side, lack of coordination and muscle weakness. The 3/22/23 minimum date set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The 10/7/22 annual MDS assessment revealed that it was very important to the resident to choose her own bedtimes. Wakeup times were not included in the MDS preferences assessment. B. Resident interviewResident #6 was interviewed on 6/26/23 at 11:13 a.m. Resident #6 said she liked to get up at 8:00 a.m. She said staff frequently did not get her up at her preferred wake up time. She said staff would often come into her room to get her up at 7:30 a.m. Resident #6 said she did not want to get up at 7:30 a.m. and staff would tell her they would return to get her up at 8:00 a.m. She said staff did not always come back at 8:00 a.m. and there had been many mornings when she did not get up until 9:00 a.m. or after. Resident #6 said not getting up at her preferred wake up time occurred at least three times per week. C. Record review-Review of Resident #6's comprehensive care plan, initiated 12/2/2020 and last revised 6/16/23, did not include specific preferences.-Review of Resident #6's resident information sheet, which was a tool used by staff to provide consistent care for the resident, did not include the resident's preferences for wake up times. -There was no documentation of preferences in the resident's medical record, other than the MDS assessments. III. Resident #7A. Resident statusResident #7, age 66, was admitted on 8/27/2020 and readmitted on 5/23/23. According to the June CPO, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, muscle weakness and muscle spasms. The 6/5/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. He required two-person extensive assistance for bed mobility, transfers and toilet use. He required one-person extensive assistance for dressing and personal hygiene. The 7/5/22 annual MDS assessment revealed that it was somewhat important to the resident to choose his own bedtimes. Wakeup times were not included in the MDS preferences assessment. B. Resident interviewResident #7 was interviewed on 6/26/23 at 11:38 a.m. Resident #7 said he liked to get up at 6:30 a.m. every day. He said he had always been an early resident information sheeter. He said he liked to eat breakfast around 7:00 a.m. in the dining room. He said he pushed his call light at 6:30 a.m. and a certified nurse aide (CNA) would often come into his room and tell him they needed to go find someone to help with his mechanical lift transfer and they would be back. He said the CNAs would turn off his call light and not return until 7:00 a.m. or later. Resident #7 said it did not happen every day, however, he said it happened often enough that it was frustrating. He said on the days he did not get up at his preferred time of 6:30 a.m. he did not get to the dining room for breakfast until at least 8:00 a.m. C. Record review-Review of Resident #7's comprehensive care plan, initiated 8/27/2020 and last revised 5/31/23, did not include specific preferences.-Review of Resident #7's resident information sheet did not include the resident's preferences for wake up times. -There was no documentation of preferences in the resident's medical record, other than the MDS assessments. IV. Resident #11A. Resident statusResident #11, age 74, was admitted on 7/12/18 and readmitted on 2/8/23. According to the June 2023 CPO, diagnoses included shortness of breath, lack of coordination, fatigue and weakness. The 5/10/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. She required two-person extensive assistance for bed mobility and transfers. She required one-person limited assistance for dressing. She required one-person extensive assistance for personal hygiene. She was totally dependent on one staff person for toilet use. It was very important to the resident to choose her own bedtimes. Wakeup times were not included in the MDS preferences assessment. B. Resident interviewResident #11 was interviewed on 6/26/23 at 11:01 a.m. Resident #11 said she liked to get up at 6:00 a.m. every day because she liked to eat breakfast early. She said staff often did not come to get her up until 7:00 a.m. She said it was frustrating to not be able to get up at the time she would like to get up every morning. C. Record review-Review of Resident #11's comprehensive care plan, initiated 7/21/18 and last revised 5/24/23, did not include specific preferences.-Review of Resident #11's resident information sheet did not include the resident's preferences for wake up times. -There was no documentation of preferences in the resident's medical record, other than the MDS assessments. V. Staff interviewsCNA #2 was interviewed on 6/22/23 at 1:10 p.m. CNA #2 said residents were asked what time they wanted to get up in the morning and their preferences were supposed to be documented on the resident information sheet so CNAs knew what time each resident preferred to get up for the day. CNA #3 was interviewed on 6/26/23 at 2:50 p.m. CNA #3 said resident preferences, such as wake up times were documented on the resident information sheet. She said CNAs used the resident information sheet to provide consistent care for each resident, including their preferences.-After looking at the resident information sheet which she was carrying in her pocket, CNA #3 said the resident information sheet did not document the residents' preferences. She said the preferences used to be on the resident information sheet and she was not aware that they were no longer on the sheet. CNA #4 was interviewed on 6/26/23 at 3:43 p.m. CNA #4 said preferences for each resident were documented on the resident information sheet. He said the resident information sheet was supposed to contain preferences such as when each resident liked to get up in the morning so CNAs knew how to care consistently for each resident. The NHA was interviewed on 6/26/23 at 4:20 p.m. The NHA said she had only been the administrator at the facility since March 2023, so she was not sure exactly where resident preferences were documented. She said she would think if a resident expressed a preference for wake up times their preference should be documented on the resident information sheet so CNAs would know when to get the resident up in the morning. She said preferences should be documented on the resident's care plan. The NHA said resident preferences should be followed because the facility was their home and staff should do everything possible to honor their choices and create the best homelike environment for each resident.

Based on observation, record review, and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and hygiene for four (#3, #6, #11 and #18) of eight residents out of eight sample residents. Specifically, the facility failed to ensure Resident #3, Resident #6, Resident #11 and Resident #18 were provided consistent baths according to their plan of care. Findings include:I. Facility policy and proceduresThe Activities of Daily Living policy, revised 2/9/22, was provided by the nursing home administrator (NHA) via email on 6/28/23 at 3:08 p.m. It read in pertinent part, "The facility will provide necessary care and services for residents based upon the comprehensive assessment of each resident and consistent with each resident's needs and choices. A resident who is unable to carry out activities of daily living (ADLs) will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Upon admission each resident is assessed to determine ADL ability. Resident's are encouraged to participate in ADLs to maintain the highest level of independence. If it is determined that a resident is unable to adequately perform an ADL, the facility will assist the resident to the extent necessary as stated in the plan of care."II. Resident council minutesReview of the monthly resident council minutes revealed the following:-4/14/23: residents had concerns regarding bath schedules not being followed;-5/12/23: residents continued to have concerns regarding bath schedules not being followed; and,-6/9/23: residents again indicated bath schedules continued to be an issue for some residents. III. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 12/4/2020 and readmitted on 8/19/22. According to the June 2023 computerized physician orders (CPO), diagnoses included congestive heart failure, age-related osteoporosis (weak, brittle bones), pain in left and right hips, low back pain and glaucoma. The 2/20/23 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers and toilet use. She required one-person limited assistance for dressing and personal hygiene. She required one-person physical help in part of her bathing activity. B. Resident interviewResident #3 was interviewed on 6/26/23 at 2:59 p.m. Resident #3 said she only received one bath per week. She said she would prefer at least two baths and would be happier if she could have three baths per week. Resident #3 said sometimes she did not even receive one bath per week. She said she had gone at least two weeks on occasion without receiving a bath. C. Record reviewReview of Resident #3's activities of daily living (ADL) care plan, initiated 12/4/2020 and revised 4/4/23, revealed that the resident needed limited to extensive assistance withsome ADL activities related to weakness and deconditioning. Pertinent interventions included assisting the resident as needed with bathing; encouraging independence as much as possible; bathing frequency per resident's request; utilizing resident's preferences for bathing products and individualized bathing schedule and providing the resident with two baths a week unlessotherwise indicated.-The care plan did not document how many baths per week the resident preferred. Review of the preprinted weekly bath schedule revealed Resident #3 was scheduled for one bath per week on Friday evenings.-Despite the care plan documenting the resident was to be provided with two baths per week unless otherwise indicated, Resident #3 was only scheduled to receive one bath per week on the bath schedule. Review of Resident #3's weekly bath schedules from 5/1/23 to 6/23/23 revealed the following:-5/1/23 to 5/7/23: The resident received one bath on 5/3/23;-5/8/23 to 5/14/23: The resident received one bath on 5/10/23;-5/15/23 to 5/21/23: There was no bath documented for the resident;-5/22/23 to 5/28/23: The resident received one bath on 5/26/23 (16 days after her last bath on 5/10/23;-5/29/23 to 6/4/23: The resident received one bath on 6/2/23;-6/5/23 to 6/11/23: The resident received one bath on 6/8/23;-6/12/23 to 6/18/23: The resident received one bath on 6/16/23 (eight days after her last bath on 6/8/23; and,-6/19/23 to 6/25/23: The resident received one bath on 6/23/23.-The weekly bath schedules had no documentation to indicate Resident #3 had refused any baths. IV. Resident #6A. Resident statusResident #6, age 83, was admitted on 12/30/21. According to the June 2023 CPO, diagnoses included hemiplegia (complete paralysis of an extremity on one side of the body) and hemiparesis (weakness of an extremity on one side of the body) following cerebral infarction (stroke) affecting the left dominant side, lack of coordination and muscle weakness. The 3/22/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. She required one-person physical help in part of her bathing activity. B. Resident interviewResident #6 was interviewed on 6/26/23 at 11:13 a.m. Resident #6 said she received one bath per week. She said one bath was okay, however, she said it would be nice to have two baths per week. Resident #6 said she did not always get her bath every week. She said she had gone two weeks without a bath before and she felt dirty and smelly. She said she was very particular about her baths and would occasionally refuse a bath if she did not like how the certified nurse aide (CNA) gave her a shower. She said she usually took her baths when they were offered. C. Record reviewReview of Resident #6's ADL care plan, initiated 12/2/2020 and revised 3/27/23, revealed that the resident needed limited to extensive assistance with some ADL activities. Pertinent interventions included assisting the resident as needed with bathing; encouraging independence as much as possible; bathing frequency per resident's request; utilizing resident's preferences for bathing products and individualized bathing schedule and providing the resident with two baths a week unless otherwise indicated.-The care plan did not document how many baths per week the resident preferred. Review of the preprinted weekly bath schedule revealed Resident #6 was scheduled for one bath per week on Tuesday evenings.-Despite the care plan documenting the resident was to be provided with two baths per week unless otherwise indicated, Resident #6 was only scheduled to receive one bath per week on the bath schedule. Review of Resident #6's weekly bath schedules from 5/1/23 to 6/23/23 revealed the following:-5/1/23 to 5/7/23: The resident received one bath on 5/2/23; -5/8/23 to 5/14/23: The resident received one bath on 5/9/23; -5/15/23 to 5/21/23: The resident received one bath on 5/16/23;-5/22/23 to 5/28/23: The resident received one bath on 5/26/23 (10 days after her last bath on 5/16/23); -5/29/23 to 6/4/23: The resident received one bath on 5/31/23; -6/5/23 to 6/11/23: There was no bath documented for the resident; -6/12/23 to 6/18/23: There was no bath documented for the resident; and,-6/19/23 to 6/25/23: There was no bath documented for the resident (the resident's last documented bath was 5/31/23 and she had not had a bath in over 21 days).-The weekly bath schedules had no documentation to indicate Resident #6 had refused any baths. V. Resident #11A. Resident statusResident #11, age 74, was admitted on 7/12/18 and readmitted on 2/8/23. According to the June 2023 CPO, diagnoses included shortness of breath, lack of coordination, fatigue and weakness. The 5/10/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. She required two-person extensive assistance for bed mobility and transfers. She required one-person limited assistance for dressing. She required one-person extensive assistance for personal hygiene. She was totally dependent on one staff person for toilet use. The MDS assessment documented that bathing activity had not occurred during the seven day look back period. B. Resident interviewResident #11 was interviewed on 6/26/23 at 11:01 a.m. Resident #11 said she received one bath per week. She said she would like to have two baths per week. She said there were weeks when she did not receive a bath at all. She said she had gone two weeks without a bath. Resident #11 said she felt unclean when she did not receive her baths. C. Record reviewReview of Resident #11's ADL care plan, initiated 7/12/18 and revised 5/24/23, revealed that the resident needed limited to extensive to total assistance with some ADL activities. Pertinent interventions included assisting the resident as needed with bathing; encouraging independence as much as possible; bathing frequency per resident's request of two per week and utilizing resident's preferences for bathing products and individualized bathing schedule. Review of the preprinted weekly bath schedule revealed Resident #11 was scheduled for one bath per week on Friday evenings.-Despite the care plan documenting the resident was to be provided with two baths per week, Resident #11 was only scheduled to receive one bath per week on the bath schedule. Review of Resident #11's weekly bath schedules from 5/1/23 to 6/23/23 revealed the following:-5/1/23 to 5/7/23: The resident received one bath on 5/6/23; -5/8/23 to 5/14/23: The resident received one bath on 5/13/23;-5/15/23 to 5/21/23: There was no bath documented for the resident; -5/22/23 to 5/28/23: The resident received a bath on 5/26/23 (13 days after her last bath on 5/13/23);-5/29/23 to 6/4/23: There was no bath documented for the resident; -6/5/23 to 6/11/23: The resident received a bath on 6/9/23 (14 days after her last bath on 5/26/23); -6/12/23 to 6/18/23: The resident refused her bath on 6/16/23. There were no documented attempts to offer the resident another bath this week; and, -6/19/23 to 6/25/23: There was no bath documented for the resident (the resident's last documented bath was 6/9/23 and she had not had a bath in over 14 days).-The weekly bath schedules documented Resident #11 had refused one bath on 5/16/23. There was no other documentation to indicate the resident had refused any of her other baths. VI. Resident #18A. Resident statusResident #18, age 84, was admitted on 5/12/18. According to the June 2023 CPO, diagnoses included pain, lack of coordination, muscle weakness and contracture (a fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the associated body part) of the left elbow. The 4/5/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. She was totally dependent on one staff person for bathing activity. B. Resident interviewResident #18 was interviewed on 6/26/23 at 2:30 p.m. Resident #18 said she received one bath per week. She said one bath per week was enough for her, however, she said she did not always receive her one bath. She said she sometimes went two weeks without a bath. C. Record reviewReview of Resident #18's ADL care plan, initiated 5/12/18 and revised 4/10/23, revealed that the resident had experienced a decline in function from baseline with increased weakness, deconditioning and/or functional limitations. Pertinent interventions included assisting the resident as needed with bathing; encouraging independence as much as possible; bathing frequency per resident's request; utilizing resident's preferences for bathing products and individualized bathing schedule and providing the resident with two baths per her preference. Review of the preprinted weekly bath schedule revealed Resident #18 was scheduled for one bath per week on Fridays during the day.-Despite the care plan documenting the resident was to be provided with two baths per week, Resident #18 was only scheduled to receive one bath per week on the bath schedule. Review of Resident #18's weekly bath schedules from 5/1/23 to 6/23/23 revealed the following:-5/1/23 to 5/7/23: The resident one bath on 5/4/23; -5/8/23 to 5/14/23: The resident one bath on 5/12/23; -5/15/23 to 5/21/23: There was no bath documented for the resident;-5/22/23 to 5/28/23: The resident received one bath on 5/26/23 (14 days since her last bath on 5/12/23); -5/29/23 to 6/4/23: There was no bath documented for the resident; -6/5/23 to 6/11/23: The resident received one bath on 6/9/23 (14 days since her last bath on 5/26/23); -6/12/23 to 6/18/23: The resident received one bath on 6/16/23; and, -6/19/23 to 6/25/23: The resident received one bath on 6/23/23.-The weekly bath schedules had no documentation to indicate Resident #18 had refused any baths. VII. Staff interviewsCNA #2 was interviewed on 6/22/23 at 1:10 p.m. CNA #2 said the Mountain View unit was staffed with four to five CNAs for 45 residents. He said there was not a designated bath aide. He said the CNAs on the floor completed the baths for the residents on their individual hall assignments. CNA #2 said residents were supposed to receive two baths per week. He said sometimes the CNAs were not able to complete all of the baths for the day. He said if a resident refused a bath or it was not completed, attempts were made to complete the bath on a different day that same week. CNA #3 was interviewed on 6/26/23 at 2:50 p.m. CNA #3 said residents were scheduled for one bath per week. She said floor CNAs were responsible for completing the baths scheduled for their own hall assignments. She said the CNAs did the best they could, however, she said there were days that not all of the resident baths were completed. CNA #3 said if a bath was not completed attempts were made to complete the bath on a different day. The NHA and the director of nursing (DON) were interviewed together on 6/26/23 at 4:20 p.m. The NHA said she had been at the facility since March 2023. The DON said she had been at the facility for less than one week. The NHA said when she became the NHA at the facility in March 2023 residents were receiving one bath per week. She said the facility had recently identified that residents would prefer more than one bath per week. She said the facility had started a performance improvement plan the week of 6/19/23 to update residents' bathing preferences and work on ensuring residents received their preferred number of baths per week. She said the facility did not have designated bath aides. The NHA said that each CNA was assigned to complete the baths each day for the residents on their hall assignment. She said the facility was staffed so that each CNA could reasonably complete their resident baths each day. VIII. Facility follow-upOn 6/29/23 at 10:38 a.m., after the survey exit, the NHA sent a copy via email of a Personal Bathing Preferences form. The form included questions for residents' preferred type of bath, number of baths preferred per week, preferred days of the week for bathing and preferred time of day for bathing.-The NHA did not provide a copy of the facility's performance improvement plan which the NHA said was started the week of 6/19/23.

Based on observations and interviews the facility failed to ensure residents resided in a sanitary and comfortable environment for five of 15 rooms observed for cleanliness. Specifically the facility failed to ensure resident rooms were free from dirty clothes/linens and trash and debris on the floor. Findings include:I. Facility policy and proceduresThe Homelike Environment policy, last revised February 2021, was provided by the nursing home administrator (NHA) via email on 6/28/23 at 3:08 p.m. It read in pertinent part, "Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment."II. ObservationsA. Room 21On 6/22/23 at 12:59 p.m., a wadded up facial tissue was on the floor just inside the entrance to the room by the door. There were several small bits of trash debris on the floor. A small decorative pillow was on the floor underneath the resident's bed. At 5:08 p.m., the wadded up facial tissue was still on the floor near the door of the room and the small bits of trash debris on the floor were still present. The decorative pillow was still on the floor underneath the bed.-No staff members had picked up the trash on the floor of the room in over four hours. On 6/26/23 at 2:59 p.m. the small decorative pillow was still on the floor underneath the resident's bed.-No staff member had picked up the decorative pillow in four days. B. Room 18On 6/22/23 at 1:02 p.m., there were several bits of small trash debris on the floor throughout the entire room. An empty brown sugar instant oatmeal packet was on the floor on the window side of the room near the half full trash can. A small pillow covered in a pillow case was on the floor by the bed on the window side of the room and a red square sticky note was on the floor in the middle of the room. At 5:03 p.m., the small trash debris including the red sticky note and the empty oatmeal packet had been picked up, however, the small pillow remained on the floor by the bed on the window side of the room.-No staff members had picked up the pillow on the floor of the room in over four hours. C. Room 58On 6/22/23 at 1:35 p.m., there were several small pieces of trash debris observed on the floor of the room. There was a pair of wadded up red pants on the floor in front of a large grandfather clock in the room. At 4:42 p.m., the small pieces of trash debris were no longer on the floor, however, the wadded up red pants were still on the floor in front of the clock.-No staff members had picked up the wadded up red pants on the floor of the room in over three hours. D. Room 22On 6/22/23 at 5:11 p.m., the resident's bed was stripped of all bed coverings. There was a white plastic spoon and a wadded up facial tissue on the floor under the bed. There was a pillowcase on the floor at the foot of the bed. At 5:12 pm, two certified nurse aides (CNAs) looked into the room and commented about the bed not being made. The CNAs proceeded down the hall after looking in the resident's room.-Neither CNA attempted to pick up the spoon, facial tissue or pillowcase that were on the floor in the room. E. Room 54On 6/26/23 at 10:56 a.m., a folded up piece of paper was on the floor under a small table by the window. There was a blouse on the floor of the room by a desk chair. At 3:30 p.m., the folded up piece of paper and the blouse were still on the floor in the room.-No staff member had picked up the folded piece of paper or the blouse in over four hours. III. InterviewsThe housekeeping supervisor (HSKS) was interviewed on 6/26/23 at 1:20 p.m. The HSKS said all resident rooms were cleaned one time daily. She said all high touch areas were cleaned daily. She said the floors were swept and mopped daily. The HSKS said if trash or clothing/linens were observed on the floor after the room had been cleaned by the housekeeper, it was the duty of all staff to pick it up. CNA #3 was interviewed on 6/26/23 at 2:50 p.m. CNA #3 said if any staff member observed trash, clothes, linens or pillows on the floor of a resident's room the staff member should pick the items up. She said it was not just the housekeeper's job. CNA #4 was interviewed on 6/26/23 at 3:43 p.m. CNA #4 said picking up trash on the floor of resident rooms was any staff's responsibility. He said dirty clothes and pillows should not be on the floor and should be picked up if they were noticed by a staff member. The nursing home administrator (NHA) was interviewed on 6/26/23 at 4:20 p.m. The NHA said resident rooms were cleaned every day by the housekeeping staff. She said picking up trash or other items off the floor of a resident's room was not just a housekeeper's job. The NHA said every staff member was responsible for picking up items off the floor when they noticed them. She said most people would not leave trash or clothes/linens lying on the floor of their homes. The NHA said the facility had a responsibility to provide the residents with an environment that was as homelike as possible, which included keeping their rooms clean and picked up.

A complaint survey, prompted by #CO31999 was completed on 5/11/23 to 5/15/23. No deficiencies were cited.

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 05/08/2023 and 05/14/2023, 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 05/01/2023 and 05/07/2023, 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 04/24/2023 and 04/30/2023, 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.