PELICAN POINTE HEALTH AND REHABILITATION CENTER

A revisit survey was completed on 8/26/25 for all previous deficiencies cited on 7/15/25. The facility is in compliance with all regulations surveyed.

A survey prompted by complaint #CO1919339 was completed on 7/14/25 to 7/15/25. One deficiency was cited.

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A survey for #CO1919339, Incident #1919340, Incident #1919341, Incident #1919342 and Incident #1919279 was conducted 7/14/25 to 7/15/25. Three deficiencies were cited.

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Based on record review and interviews, the facility failed to ensure professional staff was licensed, certified, or registered in accordance with applicable State laws. Specifically, the facility failed to ensure the acting nursing home administrator's (NHA) license was valid. Findings include:I. Entrance interviewOn 7/14/25 at 9:00 a.m. the entrance conference was conducted with the director of nursing (DON). The DON said she was acting as the NHA at the time of the survey. The DON said there was a nursing home administrator in training who was preparing to become the permanent licensed NHA.II. Record reviewOn 7/14/25 at 9:15 a.m. a review was conducted on the State licensing website. The website showed the DON had applied for a temporary NHA license for emergency situations. The original issue and effective date was 4/2/25 and the expiration date was 7/1/25. The NHA temporary permit for emergency situations was listed as expired. On 7/14/25 at 2:10 p.m. the corporate operations director provided the license invoice information. It was reviewed and revealed the application and payment for the temporary license submission was dated 7/3/25. III. Staff interviewsThe DON was interviewed on 7/14/25 at 1:23 p.m. She said she had applied for the temporary NHA license April 2025 and it had expired on 7/1/25. The DON said she was going to apply again and each time she applied it was good for 90 days. The corporate operations director was interviewed on 7/14/25 at 1:26 p.m. He said he was unable to provide evidence that the State Survey Agency was notified of the change in NHA position because he thought the licensing and regulatory agency would notify the State Survey Agency. IV. Facility follow up On 7/15/25 at 3:39 p.m. the DON provided documentation that the NHA temporary permit for emergency situations became effective on 7/14/25. -There was a lapse in NHA licensing from 7/1/25 to 7/14/25.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome was likely to occur. Findings include:I. Facility policy and procedureThe Quality Assurance Performance Improvement (QAPI) policy and procedure, revised December 2024, was provided by the director of nursing (DON) on 7/15/25 at 1:00 p.m. It read in pertinent part, “It is the policy of this facility to develop, implement, and maintain an ongoing program designed to monitor and evaluate the quality of resident care, and to resolve identified problems.“The primary purposes of the Quality Assessment and Assurance Plan are: To have an ongoing Quality Assessment and Assurance Committee that includes designated key members Director of Nursing Services, a physician, and at least three other members of the facility's staff); to meet at least quarterly; to identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans.“The committee should maintain a record of the dates of all meetings and the names/titles of those attending each meeting.“The primary goals of the QAPI Committee is the identification of quality deficiencies. Include information such as: open and closed record audits; facility logs and tracking forms; incident reports; and, consultant's reports.“The committee responds to quality deficiencies and serves a preventative function by reviewing and improving systems.“The facility's QAPI Committee, having identified the root causes which led to their confirmed quality deficiencies, must develop appropriate corrective plans of action. “Action plans may include: revision of policy and procedures; training for staff concerning changes; plans to purchase or repair equipment; improve the physical plant; standards for evaluating staff performance; implementation of facility's action plans; staff training; deployment of changes to procedures; monitoring and feedback mechanisms; and, process to revise plans that are not achieving or sustaining desired outcomes.”II. Cross-reference citationCross-reference F600: The facility failed to ensure all residents were free from abuse. The facility's failure to protect residents from resident-to-resident physical abuse put residents in a situation where a serious outcome was likely to occur and created an immediate jeopardy situation. III. Staff interviewsThe medical director (MD) was interviewed on 7/15/25 at 11:19 a.m. He said he was in the building about twice per week. The MD said some of the roles he provided included rounding as an attending physician, attending QAPI meetings, psychopharmacology meetings and getting reports from the departments. The MD said he provided education to the staff when needed especially when he noticed something related to the clinical practice such as when monitoring weights or medications. The MD said he received and reviewed many reports such as from the registered dietitian (RD), QAPI reports from different departments and the emergency preparedness manual. The MD said he provided oversight and follow-up to any suggestions by communicating with the DON, who was currently serving as the temporary nursing home administrator (NHA). The MD said he would communicate with the DON and social worker via email regarding resident placements and discharges. The MD said he had not reviewed and made policy changes but was available for thatif needed. The MD said he had been the medical director at the facility for approximately one and a half years. The MD said he was not informed by the facility yet that the survey team had called for immediate jeopardy for failure to prevent abuse. The MD said his thoughts regarding the nature of the immediate jeopardy situation was that the facility needed to better communicate with the staff and thought that was something the facility could fix and improve upon. The MD said he was not sure of his further recommendations for the facility’s next steps since he was just finding out about this and would give it some thought. The MD said he would review the charts and cases and said he was aware that there were some resident altercations but did not realize it rose to this level and was not aware that things were this serious. The DON was interviewed on 7/15/25 at 12:30 p.m. The DON said she had a temporary emergency license as the NHA since April 2025. The DON said she had notified the MD of the potential immediate jeopardy yesterday via email but did not necessarily say it was related to abuse but said it was related to reportable occurrences. The DON said the facility QAPI committee met monthly on the third Tuesday of each month. The DON said the last meeting was 6/17/25. The DON said the QAPI committee included all the required members and they completed a sign in sheet. The DON said for every issue identified the committee would review that. The DON said they had standard items that they reviewed and also obtained information from their tracking and trending, resident council meetings and grievances. The DON said they had worked on one performance improvement plan (PIP) since she started employment at the facility 10/24/24. The DON said the PIP was in regards to falls and there had been some improvements but they were still monitoring it. The DON said standard items were reviewed during QAPI such as admissions, discharges, dietary, weight loss, falls, hospitalizations, infection control, recruitment/hiring and online continuing education. The DON said there was a standard section they reviewed monthly for reportable occurrences and incidents. The DON said they had not implemented a PIP related to the recent occurrences because the interventions that they had in place seemed to be effective. The DON said they had reviewed the medications for Resident #4 and completed the investigations and it appeared it was going to be effective since there were no abuse incidents since the last three, but then another incident happened. The DON said it did not come to their attention to audit the facility since the occurrences were with the same resident. The DON said that abuse had not been identified by the facility as a concern, just the normal and usual review of any reportable occurrences which was looked at monthly.

A complaint survey, prompted by #CO39911 was conducted on 4/28/25. No deficiencies were cited.

A complaint survey, prompted by #CO39621 was conducted 4/9/25. No deficiencies were cited.

A complaint survey, prompted by #CO39258 was conducted on 3/5/25 to 3/6/25. No deficiencies were cited.

A revisit survey was completed on 2/27/25 for all previous deficiencies cited on 2/4/25. The facility is in compliance with all regulations surveyed.

A survey prompted by #CO37380, #CO37418, #CO38757, Incident #37547, Incident #38374 and Incident #38375 was conducted 2/3/25 to 2/4/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure residents and their representatives were provided prompt efforts by the facility to resolve grievances for one (#3) of eight residents reviewed for grievances out of 14 sample residents. Specifically, the facility failed to document and follow-up on grievances reported by Resident #3 regarding a missing cell phone and eye glasses. Findings include:I. Facility policy and procedureThe Grievances policy, dated December 2024, was provided by the nursing home administrator (NHA) on 2/4/25 at 2:07 p.m. It read in pertinent part,"It is the policy of this facility to establish a grievance process that allows residents a way to execute their right to voice concerns or grievances to the facility without fear of discrimination or reprisal. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the residents may have. "The facility's grievance official is responsible for overseeing the grievance process and for receiving and tracking grievances and leading necessary investigations by the facility."The grievance official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations."The grievance official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, and misappropriation of resident property to the administrator and as required by state law."The grievance official responds to the individual expressing the concern within three working days of the initial concern to acknowledge receipt and describe steps taken towards resolution."I. Resident statusResident #3, age 85, was admitted on 11/30/22. According to the February 2025 computerized physician orders (CPO), diagnoses included chronic kidney disease, dementia, hypertension (high blood pressure) and depression. The 10/25/24 minimum data set (MDS) assessment revealed Resident #3 had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. Resident #3 required partial to moderate assistance with personal hygiene and substantial to maximal assistance with transfers and walking short distances. He used a manual wheelchair for longer distances with partial assistance from staff. II. Resident and representative interviewResident #3 was interviewed on 2/3/25 at 10:15 a.m. Resident #3 said he wore his eye glasses when he could find them. He said they had been missing for a while. Resident #3's representative was interviewed on 2/3/25 at 9:46 a.m. The representative said Resident #3 had lost five cell phones and five pairs of eye glasses at the facility. She said she had tethered his last cell phone in his room so it could not be taken or lost. She said she did take the cell phone home a few months ago because Resident #3 did not understand how to use it anymore. She said the most recent pair of Resident #3's eye glasses were lost in December 2024 and replaced in early January 2025. She said the eye glasses went missing again two days after they were replaced and were still missing. She said she reported his missing items to the staff at the facility. III. Record reviewOn 2/3/25 at 3:37 p.m. the social services director (SSD) provided the following grievance forms related to missing items for Resident #3:A grievance concern form, dated 1/31/24, was completed by the SSD and documented Resident #3 was missing a cellular phone, a television, a recliner, several items of clothing and a red blanket. It was noted on the form that the recliner was located and was missing again and the television was replaced by the facility. -There was no follow-up on the form for the other alleged missing items or what the facility was doing to safeguard the resident's items in the future. A grievance concern form, dated 12/5/24, was completed by the SSD and documented Resident #3's representative informed the facility that the resident was missing a pair of eye glasses that were delivered to the resident two weeks prior. The SSD documented a search of the resident's room was conducted on 12/6/24 and laundry/housekeeping staff were alerted to watch for the missing glasses. The glasses were confirmed to be lost, and on 12/12/24, the SSD requested the glasses be replaced. On 1/3/25 the grievance was resolved when new glasses were provided to Resident #3. -There was no documentation on the grievance form or in the progress notes indicating the resident representative was notified of the resolution or what measures were put in place to safeguard the resident's eye glasses. -There was no grievance form documented for the eye glasses that were currently missing at the time of survey (2/3/25). IV. Staff interviewsThe SSD was interviewed on 2/3/25 at 2:47 p.m. The SSD said she was in charge of the grievances at the facility. The SSD said she was aware Resident #3's eye glasses were currently missing and she had called his insurance to get approval for new ones. The SSD said she did not complete a grievance because did not think the glasses were stolen. The SSD said the eye glasses that were currently missing were the second pair of glasses that had been replaced in the past few months for Resident #3. The SSD said Resident #3 was also missing two cell phones. She said one was replaced and then it went missing and had been missing for quite some time. The SSD said she should have completed a grievance form on the second missing pair of eye glasses and cell phones. She said she did not have any follow-up documentation on the missing eye glasses or cell phones. The SSD said the recliner from the 1/31/24 grievance form for Resident #3 was found in another resident's room and the television was replaced. She said there was no follow-up documented on the form, but the facility offered to replace the other items. She said she was not in charge of grievances in January 2024. The NHA was interviewed on 2/3/25 1:50 p.m. The NHA said he was aware Resident #3's eye glasses were missing again. He said he did not know if a new grievance form had been completed because the SSD was in charge of the grievances. The SSD was interviewed again on 2/4/25 at 10:50 a.m. The SSD said when a resident reported a missing item, a concern form should be completed and it should be reported to the NHA or designee. She said the facility reviewed grievance concerns during the morning meeting. The SSD said if an item was reported missing, the facility conducted a search right away for the missing item(s). The SSD said the facility would document the investigation and follow-up on the concern form or in a progress note. The SSD said the facility had tried different things to safeguard Resident #3's items but he had not been agreeable. She said the facility offered to lock up his eye glasses at night but he did not want the staff to take them. The SSD said Resident #3 did not want a chain or cord on his eye glasses. The SSD said the family decided not to provide another cell phone and staff were to take the resident a facility phone if he wanted to call his family. The SSD said the facility had educated staff to check the trash and the laundry for personal items. -However, the SSD was unable to locate documentation regarding the current missing items, investigation or follow-up. The NHA provided an email on 2/5/25 at 3:39 p.m.,the day after the survey exit. In the email, the NHA said the facility held a care conference with Resident #3 and his representative on 2/5/25 at 1:30 p.m. The facility reviewed the concerns of lost glasses and the cell phone. The facility said the eye glasses would be replaced and when they were received, Resident #3 would be provided an eye glasses string holder so the eye glasses would be secure and not fall off his person. Staff would also monitor the eye glasses at night when the resident went to bed by putting the glasses in a case. The facility offered to replace the lost cell phone but the representative said Resident #3 was no longer physically able to use it so it was not necessary to replace it.-However, the facility did not address the above missing items for Resident #3 until after the missing items were identified during the survey (2/3/25 to 2/4/25).

A complaint survey, prompted by #CO36908, #CO36917, #CO36943, #CO36971 & #CO36974 was conducted on 8/7/24 to 8/12/24. No deficiencies were cited.

A revisit survey was completed on 7/25/24 for all previous deficiencies cited on 6/10/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO36311 and #CO36338 was conducted on 6/10/24. Three deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#1, #3 and #5) of three residents reviewed out of 10 sample residents. Specifically, the facility failed to:-Ensure Resident #1, Resident #3 and Resident #5, who were dependent on staff for bathing, received their scheduled showers; and,-Ensure resident #5, who was dependent on staff for ADL care, received assistance with shaving. Findings include:I. Facility policy and procedureThe Supporting Activities of Daily Living (ADL) policy, revised March 2018, was received from the regional director of operations (RDO) on 6/10/24 at 4:53 p.m. The policy documented in pertinent part, "Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care)."II. Resident #1A. Resident statusResident #1, age 65, was admitted on 5/21/24 and discharged on 6/8/24. According to the June 2024 computerized physician orders (CPO), diagnoses included debility, congestive heart failure, peripheral vascular disease (poor circulation to extremities), and surgical incision to the right groin. The 5/24/24 MDS assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. She required maximal, substantial assistance with bathing. B. Record reviewReview of Resident #1's June 2024 CPO revealed the following physician's order:Wound Care for the right groin incision, daily showers, clothing and bedding changes, ordered 5/23/24. The bathing records from the electronic medical record (EMR) were provided by the director of nursing (DON) on 6/10/24 at 1:00 p.m. -The documentation revealed the resident had not received showers on 5/28/24, 5/29/24, 6/3/24, 6/4/24, 6/5/24, 6/7/24 or 6/8/24 as ordered. The showers on those days were documented with a "N" or "NA." III. Resident #3A. Resident statusResident #3, age 84, was admitted on 2/29/24 and readmitted on 4/15/24. According to the June 2024 CPO, diagnoses included debility, congestive heart failure, diabetes mellitus and obesity. The 4/15/24 MDS assessment revealed the resident had mild cognitive impairment with a BIMS score of 13 out of 15. She required maximal, substantial assistance with bathing. B. Resident interviewResident #3 was interviewed on 6/10/24 at 12:34 p.m. Resident #3 said she was supposed to get bed baths during the day shift on Tuesdays and Fridays. She said she was too big to go in the shower or bath and therefore she had to have bed baths. Resident #3 said she frequently did not get a bed bath because the staff told her they were too busy or did not have enough staff. C. Record review The certified nurse aide (CNA) bathing record tasks for the last 30 days (from 5/11/24 through 6/10/24) was reviewed in the EMR on 6/10/24 at 12:45 p.m. The bathing task record documented the resident preferred baths on Tuesdays and Fridays. -There was no documentation in the CNA task record to indicate Resident #3 had received a bed bath from 5/11/24 through 6/10/24. Paper records of baths for Resident #3 from 5/11/24 through 6/10/24 were requested from the DON on 6/10/24 at 1:00 p.m. The records were provided at 1:30 p.m. The paper bathing records documented the following:Resident #3 received a bed bath on 5/16/24 (Thursday), 5/28/24 (Tuesday), 5/31/24 (Friday), 6/4/24 (Tuesday) and 6/10/24 (Monday).-There was no shower documentation for the week of 5/19/24 through 5/25/24.-The resident did not have a bed bath on 6/7/24. The paper shower record documented "could not shower due to short staffing."The paper record documentation provided by the DON indicated Resident #3 received a bed bath, was shaved, and had no skin concerns on 6/17/24 and 6/23/24. -However, the information was provided on 6/10/24 and 6/17/24 and 6/23/24 had not occurred yet. IV. Resident #5A. Resident statusResident #5, age 84, was admitted on 8/18/24 and readmitted on 4/6/24. According to the June 2024 CPO, diagnoses included diabetes mellitus, cerebral vascular accident (stroke) and multi drug resistant organism (MDRO). The 4/25/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. She required maximal, substantial assistance with personal hygiene including shaving. B. Observation and interviewResident #5 was observed in her room on 6/10/24 at 11:24 a.m. She had long, thick, white facial hair across her entire upper lip, chin and below her chin. She said she would like to be shaved. C. Record reviewThe resident's bathing records were reviewed in the EMR. The CNA task bath record documented the resident preferred baths on Wednesdays and Saturdays.-There was no documentation in the CNA task record to indicate Resident #5 had received a bed bath from 5/11/24 through 6/10/24. Paper records of baths for Resident #5 from 5/11/24 through 6/10/24 were requested from the DON on 6/10/24 at 1:00 p.m. The records were provided at 1:30 p.m. The paper bathing records documented the following:-The resident had a shower on 5/1/24 (Wednesday), 5/8/24 (Wednesday), 5/11/24 (Saturday), 5/15/24 (Wednesday), 5/18/24 (Saturday), 5/22/24 (Wednesday), 5/25/24 (Saturday), 5/27/24 (Monday) and 5/29/24 (Wednesday).-The resident did not receive a shower on 5/4/24. -The resident received a shower on 6/5/24, seven days after her last shower on 5/29/24. -The paper bathing records documented Resident #5 was not shaved on 5/29/24 or 6/5/24. V. InterviewsThe DON was interviewed on 6/10/24 at 1:40 p.m. She said when the CNAs documented "N" in the CNA bathing task record it meant the care was not done. She said "NA" meant not applicable. She said if a resident refused a bath or shower, the CNA would document "RR" for the resident refused. The DON said she did not know why the showers were not done daily as ordered by the physician for Resident #1 to prevent infection of her groin incision. She said she was not aware the showers had not been done. The DON said showers were documented in the residents' EMR and on paper. She said she had provided the EMR record (as above) and had no further paper records of showers for Resident #1, #3 or #5. The DON said the orders for Resident #3's baths had been put in the EMR incorrectly and therefore there was no documentation of her bed baths. She said she was not aware the resident had no record of baths the week of 5/19/24 through 5/25/24 or that she had not received a bath due to short staffing. The DON said residents were supposed to be shaved on bath days and as needed. She said did not have any further bathing records for June 2024 for Resident #5 or documentation to indicate why she had not been shaved. She said she would have the resident shaved. The DON was interviewed again on 6/10/24 at 4:18 p.m. The DON said she had provided education to the nursing staff in the past about ensuring showers and baths were given and documented. She said she had no current system for monitoring to ensure showers and baths were given and documented.

Based on observations, record review and interviews, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for four (#4, #7, #8 and #9) of five residents reviewed for accident hazards out of 10 sample residents. Specifically, the facility failed to:-Provide supervision to prevent the elopement of Resident #4;-Investigate how Resident #4, who had a wander prevention device, eloped from the facility in order to prevent a recurrence; -Complete accurate elopement risk assessments for Resident #7 and Resident #8; -Ensure Resident #8 and Resident #9's care plans were updated to include their wander risk and wanderguards; and,-Routinely check the function of wander prevention devices for Resident #7, Resident #8 and Resident #9. Findings include:I. Facility policy and procedureThe Wandering and Elopement policy, dated 2/29/24, was received from the regional director of operations (RDO) on 6/10/24 at 4:53 p.m. The policy documented in pertinent part, "A Wander/Elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the interdisciplinary team (IDT) during the initial care conference, or earlier if the elopement risk is of immediate concern. The elopement risk is assessed quarterly or as needed with change of condition. "Nursing staff will address initial elopement risk concerns in the baseline care plan. If the resident is identified as an elopement risk, the following will be maintained: Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder. Implementing and care planning interventions to address safety and decrease risk of elopement. "A Physical Restraint Use Consent shall be obtained from the resident's responsible party if an electronic device is utilized. A Physician order will be required for the use of monitoring the device. The order will include checking placement of the device every shift and checking function of the device daily. The care plan will be updated to include that an electronic alarm system is used for resident's safety."II. Resident #4A. Resident statusResident #4, age 79, was admitted on 4/27/24. According to the June 2024 computerized physician orders (CPO), diagnoses included dementia and diabetes mellitus. The 5/1/24 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. He was independent with transfers and ambulation. Resident #4 required partial to moderate assistance with dressing and personal hygiene, and supervision with toileting. The assessment documented the resident wandered. B. Record reviewOn 4/27/24 the Wander Elopement Risk Evaluation documented the Resident #4 ambulated independently, routinely wandered or paced, wandered or paced in a manner that placed his safety at risk and had a diagnosis of dementia impacting his decision making. The assessment further documented the resident was confused and wandered in halls independently but did not appear to be at risk for exit seeking. On 4/27/24 at 2:06 p.m. a nurse progress note documented the resident had a diagnosis of dementia and ambulated with a walker. A wanderguard was placed. On 5/19/24 at 1:03 p.m. a nurse progress note documented Resident #4 went out the front door without the wanderguard going off. He was redirected back to the building. He walked out when another resident opened the door. His wanderguard was replaced. On 5/22/24 a Special Care Unit Criteria (secure unit) review documented the resident met the criteria for the special unit due to dementia with exit seeking, walking in halls naked, and wandering. On 5/25/24 at 12:57 p.m. a nurse progress note documented the resident was found walking two blocks away from the facility. His wanderguard did not go off when the resident exited. It did go off when the resident came back to the building. There were no injuries. The family was notified and said they would come in and move him to the secure unit that afternoon (5/25/24).-The physician's orders were reviewed. There were no orders for a wanderguard or checking the function of a wanderguard. -There was no documentation the physician was notified of Resident #4's elopement on 5/25/24. A physician's order, dated 5/28/24, documented Resident #4 was to move to the men's secure unit. The elopement risk care plan, initiated 4/27/24, documented the resident's risk for leaving the facility unattended would be minimized through the review date. Interventions included identifying patterns of wandering, intervening as appropriate, distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. The resident used a wanderguard for safety and staff were to check placement of the wanderguard every shift. The care plan indicated Resident #4 was moved to the secure unit on 5/25/24. C. Interviews and observationThe nursing home administrator (NHA) was interviewed on 6/10/24 at 1:00 p.m. The NHA said Resident #4 had eloped on a weekend. He said he was informed in a group chat text. He said he did not have an investigation of how the resident eloped with a wanderguard bracelet on. The NHA said he thought maybe the maintenance director checked the doors to make sure they were working the following Monday, but he was not sure. He said he had not interviewed any of the staff and did not know who was involved. The NHA said he was not aware there were no physician's orders for the wanderguard device or documentation the bracelet was checked to ensure it functioned routinely. The NHA said maybe the door was already open and Resident #4 followed someone out. He said he did not know how long the resident had been gone from the facility or who found him. The NHA said he had not reported the elopement to the state agency. The director of nursing (DON) was interviewed on 6/10/24 at 1:07 p.m. She said she was notified Resident #4 eloped via a group text chat on the weekend from social services. She said she thought the NHA investigated the elopement. The DON said she did not know how long the resident was gone or who found him. She said social services could provide more information. The DON said Resident #4 did have a wanderguard but she did not see a physician's order for it or to check the placement and function of the device routinely. The DON said the wanderguard device should be checked every 24 hours for placement and function. She said there was no increased supervision or monitoring of the resident but there should have been prior to his elopement on 5/25/24. The regional vice president (RVP) was interviewed on 6/10/24 at 1:28 p.m . The RVP said an investigation should have been done of the elopement to determine the cause. The RVP said the facility was doing a house sweep (during the survey) of all residents and verifying all residents with wander guards had physician's orders to include routine checks of the wanderguard function and a care plan. She said she would provide a copy of the facility's plan to correct the issue with elopement and lack of investigation as to cause and IDT education. The maintenance director (MTD) was interviewed on 6/10/24 at 1:45 p.m. The MTD said he heard about Resident #4's elopement over the weekend from a group text chat. He said he did not come in to check the function of the doors over the weekend. He said he routinely checked the function of the alarms on doors Monday through Friday and the manager on duty (MOD) checked them on the weekends. He said the MOD did not document the door checks on the weekends but he documented his door checks Monday through Friday. The MTD said the nursing staff had reported concerns with the doors not alarming when a wanderguard device was in range but each time he checked the doors, they worked. The front door was checked for function with the MTD on 6/10/24 1:45 p.m.. The MTD put a wanderguard device in his pocket. The alarm sounded and the door locked when the MTD was about eight feet from the door. The door was then placed in the open position. The door alarmed when the MTD approached with the wanderguard device at approximately eight to nine feet.-Copies of the door checks for Monday through Friday were requested twice from the MTD and not received by the end of the survey on 6/10/24. Registered nurse (RN) #3 was interviewed on 6/10/24 at 2:44 p.m. RN #3 said she was on duty on 5/25/24 when Resident #4 eloped. RN #3 said she came out of the bathroom and a couple of certified nurse aides (CNAs) told her a man in a white van came to the door and said he thought one of the facility's residents was seen down the road a couple of blocks away. She said the CNs got in the white van and went with the man. RN #3 said the CNAs walked the resident back to the facility. RN #3 said she did not know how long the resident had been gone or when he had last been seen at the facility. She said she was notified by the CNAs sometime after lunch. RN #3 said she did not recall who the CNAs were who notified her. She said she notified the family but did not notify the physician. RN #3 said she did not see any injuries on Resident #4. RN #3 said she assumed Resident #4's wanderguard did not alarm when he went out of the building but she did not know. RN #3 said she thought social services notified the NHA.The social service assistant (SSA) was interviewed via phone on 6/10/24 at 3:10 P.M. The SSA said she was helping serve lunch on 5/25/24 and she saw CNAs walking with Resident #4 outside. The CNA's said he had been way down the street. The SSA said she assumed the door did not alarm when the resident went out. She said sometimes it did not alarm when a wanderguard went through the door. She said the door had not alarmed in the past when a wanderguard was near it. She said the maintenance director had been notified. The SSA said she did not know who the CNAs were or who notified the NHA of the elopement. She said the resident already had an assessment done that indicated he needed secure unit placement due to his exit seeking. She said the facility had not moved the resident yet because they were waiting for the family to come in and assist with the move. She said the family had requested to be present for the move to decrease the resident's anxiety. CNA #1 was interviewed on 6/10/24 at 3:18 p.m. CNA #1 said she was providing incontinence care on a resident and saw a man walking outside the window. She said she thought it looked like Resident #4. CNA #1 said she finished what she was doing with the other resident, which took about 15 minutes, and then notified the nurse that she thought she saw a man who looked like Resident #4 walking outside. CNA #1 said she went to see who the resident was. CNA #1 said he was not aware of Resident #4's elopement risk. She said he must have been a "good walker" because she found him a couple of blocks down the street near a school. CNA #1 said she walked him back to the facility. She said she did not know anything about a white van with a man who had seen the resident. III. Other residents with wanderguardsOn 6/10/24 at 1:07 p.m. the director of nursing (DON) provided a list of residents with wanderguard needs due to risk of elopement. The list included Resident #7, #8 and #9. A. Resident #71. Resident statusResident #7, age less than 65 years old, was admitted on 6/6/13. According to the June 2024 CPO, diagnoses included vascular dementia and multiple sclerosis (nerves become damaged and communication with the brain and other body parts is lost). The 4/25/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with transfers, ambulation, dressing, personal hygiene and toileting. The assessment documented he used a wander elopement device. 2. Record reviewOn 4/24/24 the Wonder Elopement Risk Evaluation documented the resident was not at risk for elopement. -However, the resident had a wanderguard device. On 4/25/24 at 12:41 p.m. the social services summary documented the resident had a wanderguard. The care plan, initiated 8/24/22, documented the resident was at risk of elopement related to cognitive status, mobility status and assessment indicating risk for wandering and elopement. He had a wanderguard. The wanderguard was to be checked for proper function daily and placement every shift. On 5/31/24 at 4:15 p.m. the provider documented the resident displayed impaired thought production and problem solving. He had moderate deficits in memory complex attention concentration, word finding and orientation. He had dementia with behavioral disturbance including defecating in the hallways, sexually inappropriateness and poor impulse control. On 6/5/24 at 10:40 a.m. social services documented the resident was going to his wife's funeral with his family. The family was advised that the resident needed constant supervision during the time out of the facility. The June 2024 CPO was reviewed. The resident had a physician's order dated 6/7/24 for a wanderguard, check the placement visually daily. -However, there were no physician's orders to check the function of the device. B. Resident #81. Resident statusResident #8, age greater than 65, was admitted on 5/1/24. According to the June 2024 CPO, diagnoses included loss of cognitive function and awareness and mental disorder due to physiological condition. The 5/7/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. He required limited assistance with bed mobility, transfers, dressing, toileting and personal hygiene.-The assessment documented he did not use a wander/elopement alarm. 2. Record reviewThe June 2024 CPO was reviewed. The resident had an order dated 5/15/24 to apply a wanderguard to prevent the resident from going out of the facility unassisted. Monitor the presence of the wanderguard every shift. -The order did not include checking the function of the wanderguard device.-The nursing progress notes were reviewed for May 2024 and June 2024. There was no documentation as to why the wanderguard was ordered on 5/15/24.-The care plan was reviewed. There was no care plan for elopement or wandering. C. Resident #91. Resident statusResident #9, age 84, was admitted on 11/30/22. According to the June 2024 CPO, diagnoses included dementia and obesity. The 6/5/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. He required substantial to maximal assistance with transfers, toileting, dressing, and personal hygiene. The assessment documented he used a wander/elopement alarm daily. 2. Record reviewThe June 2024 CPO was reviewed. On 6/10/24 (during the survey) a physician's order was written for a wanderguard device for Resident #9. The Wander Elopement Assessment dated 6/4/24 documented the resident was at low risk for wandering or elopement. -However the assessment inaccurately documented the resident did not have dementia or a condition impacting decision making.-The care plan was reviewed. There was no care plan for wandering or elopement. On 6/10/24, during the survey, a wandering elopement care plan was initiated. The care plan documented risk for wandering and elopement was identified. The resident would not leave thefacility unattended. The resident's safety would be maintained. Interventions included clearly identifying the resident's room and bathroom, providing care in a calm and reassuring manner, providing clear, simple instructions and Providing reorientation to surroundings and the environment. D. DON interviewThe DON was interviewed again on 6/10/24 at 3:08 p.m. The DON said Resident #7, #8 and #9 all required wander guards due to their risk of elopement. Shesaid she was not aware the function of the wander guards was not being checked routinely. IV. Facility follow upOn 6/10/24 at 2:35 p.m. (during the survey) the RVP provided an action plan titled Elopement Actions items. The plan documented in pertinent part, "Wanderguard audit:-An audit will be completed on 6/10/24 to ensure all residents are accounted for and to check if they have a Wanderguard in place, where it is located, and if it is functional; and,-Once the Wanderguard is confirmed, an audit will be conducted to ensure all appropriate orders and care plans are in place. Completed 6/10/24 for Resident #7, #8, #9."Admission Process to identify Wandering/Elopement Risk-Ensure you have a solid process for new admissions deemed to be at risk to be kept safe in the event WanderGuards are not accessible; -Referrals to be reviewed for risk of wandering/elopement prior to facility acceptance;-Residents identified of risk prior per Elopement to admission staff education to be completed on specific resident to ensure education on wandering/elopement and processes in place for:-15 minutes checks first 24 hours after admission;-Interventions to engage residents in purposeful activities;-IDT to review new admissions the next day to review orders, diagnosis, assessments at the clinical meeting;-Comprehensive, accurate assessment of each resident's needs to be completed "no later than 14 days after the admission" and "at least every three months thereafter, unless there is "a significant change" in the resident's physical or mental condition;-If significant change resident to be placed on 15-minute checks; and,-If identified as exit seeking to be placed on one and one with IDT review for changes/updates to care plan "After admission, facility will follow Elopements and Wandering Residents Policy."The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary."Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering-Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team;-The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan; - Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff;-Adequate supervision will be provided to help prevent accidents or elopements;-Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly; and,-The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff."Wandering/Elopement Binders-Ensure information for all residents identified to be at risk are placed in an elopement binder at every nurse's station and front desk in the lobby to include a current photo, their room number, and face sheet, and Elopements and Wandering Residents Policy."Maintenance Assessment of WanderGuard and Egress Doors-If not already in place, ensure Maintenance is assessing every egress door accessible to a resident for either the WanderGuard or alarming functionality daily;-The Maintenance Director tested all WanderGuard doors, and egress exit doors to ensure they were functioning properly and alarmed when opened. All exit doors are currently functioning properly as of 6/10/25;-Maintenance Director to assess every egress door accessible to residents Monday - Friday; and, -Manager on Duty to assess every egress door accessible to residents Saturday - Sunday. "All Staff Education in Wandering/Elopement Conduct All Staff education on Elopement. Education should include:-What makes a resident at risk;-Actions to take if a resident is exit-seeking;-The locations of your elopement binders;-The process for a missing resident (refer to the Disaster Plan); and,-If a resident does not come out for meals, is not available for medications, is not in usual activities, validate their location;"What to do if a door alarm sounds:-Do not just deactivate the alarm;-Look for the resident outside;-Refer to the elopement book to ensure all residents who are at risk are accounted for; and,-Staff training has been initiated 6/10/24 and is ongoing till all staff has received training."All Staff Meeting meeting to be conducted in June and Wandering/Elopement Education to be reviewed. "RDO (regional director of operations) completed education with NHA and DON on 6/10/24 regarding expectation for notifying the RDO and Nurse Quality Mentor (NQM) immediately for an elopement event. In case of an elopement event, the RDO, NQM will give guidance on investigation steps and documentation."Conduct Quarterly Elopement DrillsMaintenance is responsible for conducting the drills. Facility to use as validation of staff education. Can include setting off a door alarm and seeing if staff respond appropriately on every shift. Elopement drill to be conducted by 6/30/24."

Based on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure staff performed hand hygiene with blood glucose checks; and,-Ensure glucometers were cleaned and disinfected with appropriate disinfectant contact time between uses. Findings include: I. Facility policy and procedureThe Handwashing Hand Hygiene policy, revised August 2019, was received from the regional director of operations (RDO) on 6/10/24 at 4:53 p.m. The policy documented in pertinent part, "Use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents, before performing any non-surgical invasive procedures, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or bodily fluids, after contact with objects (such as medical equipment) in the immediate vicinity of the resident and aAfter removing gloves."The Cleaning and Disinfecting of Resident Care Equipment Items and Equipment policy, revised September 2022, was received from the regional director of operations (RDO) on 6/10/24 at 4:53 p.m. The policy documented in pertinent part, "Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (such as respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. Semi-critical items are sterilized or disinfected in a central processing location and stored appropriately until use."II. Manufacturer's instructions for Sani-Cloth Germicidal Disposable Wipes The directions on the side of the purple top Sani-Cloth Germicidal Disposable Wipes container used by the facility for disinfecting glucometers read in pertinent part, "Disinfects after two minutes. Ensure the surface remains visibly wet for at least two minutes for complete disinfection."III. Observations and interviewsOn 6/10/24 at 11:01 a.m. licensed practical nurse (LPN) #1 was observed as she checked the blood glucose level of Resident #3. After obtaining Resident #3's blood glucose level, LPN #1 wiped the glucometer with a purple top Sani-Cloth Germicidal Disposable wipe. LPN #1 wiped the front and back of the glucometer with the wipe. The surfaces of the glucometer remained wet for approximately nine seconds.-LPN #1 failed to allow the surfaces of the glucometer to remain wet for the two minutes recommended on the container label as the appropriate amount of time for proper disinfection. LPN #1 said she did not know what the dwell time for the wipes was. She said she had just been given the wipe this morning (6/10/24) and she had previously been cleaning the glucometers with an alcohol wipe. On 6/10/24 at 11:24 a.m. LPN #2 was observed as she checked the blood glucose level of Resident #5. At the medication cart down the hall from the resident's room, LPN #2 donned a pair of gloves. -LPN #2 did not perform hand hygiene before applying the gloves. LPN #2 took a glucometer, a test strip, an alcohol pad and two lancets to Resident #5's room. She placed the supplies on the resident's bedside table. She checked the resident's blood glucose level and then pulled the test strip, with blood on it, out of the glucometer. The test strip with blood on it fell on the floor. LPN #2 attempted for several seconds to pick up the test strip off the floor but said it was sticking. She retrieved the test strip off the floor, grabbed the glucometer and headed back to her medication cart, wearing the same gloves she had on to obtain the resident's blood glucose level and pick up the used test strip from the floor.-After returning to her medication cart, LPN #2 proceeded to open a container of purple top Sani-Cloth Germicidal Disposable wipes, without removing her gloves or performing hand hygiene. -The lid to the disposable wipes came off and, without removing her soiled gloves or performing hand hygiene, LPN #2 reached into the canister and pulled out several wipes. -LPN #2 proceeded to clean the front and back of the glucometer with the same soiled gloves and placed the glucometer on a paper towel to dry. The glucometer surfaces remained wet for approximately 10 seconds.-LPN #2 removed her gloves but did not perform hand hygiene. LPN #2 said the glucometer dried quickly. LPN #2 said she did not know what the dwell time was on the Sani-Cloth wipes. She said she had just been given the purple top Sani-Cloth Germicidal Disposable wipes this morning (6/10/24). LPN #2 said she had been using Sani-Hand Cloth wipes to clean the glucometers. She said it was "better than nothing."On 6/10/24 at 11:38 p.m. registered nurse (RN) #1 was observed as he checked the blood glucose level of Resident #2. RN #1 went to the resident's room. He said the resident's glucometer was in his room. RN #1 said he did not know why Resident #2's glucometer was kept in his room and other residents' glucometers were kept in the medication cart. RN #1 applied gloves and checked the resident's blood glucose level. -RN #1 did not perform hand hygiene before donning gloves. -RN #1 did not disinfect Resident #2's glucometer after use. RN #1 removed his gloves and went back to his medication cart. -He did not perform hand hygiene after removing his gloves. RN #1 said he had been using the Sani-Hand wipes and not the purple top Sani-Cloth Germicidal Disposable wipes to clean the glucometers. IV. Director of nursing (DON) interviewThe DON was interviewed on 6/10/24 at 12:57 p.m. The DON said nurses should complete hand hygiene before and after donning gloves to check residents' blood glucose levels. The DON said the glucometers should be disinfected after each use. She said the nurses used to have the purple top Sani-Cloth disinfectant wipes to clean the glucometers. She said she did not know what happened to them but she said she gave the nurses new canisters of the wipes to use this morning (6/10/24). She said she had not provided education on the dwell time or contact time for the Sani-Cloth Germicidal Disposable wipes.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/29/2024 and 02/04/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit survey was completed on 2/1/24 for all previous deficiencies cited on 12/11/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 2/1/24 for all previous deficiencies cited on 12/11/24. The facility is in compliance with all regulations surveyed.

A revist survey for Emergency Preparednes was conducted from 1/31/24 to 2/1/24. The facility is in substantial compliance with all deficiencies cited on 12/11/23.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

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 12/25/2023 and 12/31/2023, 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.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one-story, Type V (000) (VB) slab on grade construction without a basement. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet and dry fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1968 and is licensed for 104 beds. This re-certification survey conducted on December 27, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19," Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Director of Maintenance during the exit conference conducted at the end of the on-site survey.

Based on observation during the survey, it was determined the facility failed to maintain proper access to portable fire extinguishers in accordance with NFPA 10. Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 1. Blocked fire extinguisher on women's patio (outside). NFPA 101 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. NFPA 10, 6.1.3 6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. This deficiency has the potential to affect occupants, who might include residents and staff located in the women ' s outdoor patio area. Deficient items were identified during the survey and discussed with the Administrator and Maintenance Director at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:1. No testing and written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents and staff throughout patient care rooms in the entire facility. Deficient items were identified during the survey and discussed with the Administrator and Maintenance Director at the exit conference.

A recertification survey with complaints #CO34085 and #CO34338 was conducted from 12/4/23 to 12/11/23. Seventeen deficiencies were cited.

An Emergency Preparedness survey was conducted from 12/4/23 to 12/11/23. Four deficiencies were cited.

Based on record review and interviews, the facility failed to develop, establish and maintain a comprehensive emergency preparedness (EP) program that met all of the required components taking into account a contingency plan in the event that essential resources were not available; and the EP program was reviewed annually and updated annually. Specifically, the facility to ensure the EP plan policies were updated when the facility changed ownership. Findings include: I. Record reviewThe emergency preparedness program binder was provided by the maintenance director (MTD) on 12/6/23 at 8:45 a.m. The EP program binder failed to contain an EP program plan was updated annually and updated to the new corporate owner's policies for emergency preparedness specific to the facility's community and location. The facility provided an EP program policy that was specific to the corporate ownership that owned the facility community more than two owners past; the facility was under new corporate ownership as of 2023. The EP plan binder contained the following policies: The Emergency Preparedness Management Plan revised in June 2015; and, the Nursing Home Incident Command System was revised in April 2019. The policies throughout the EP plan binder instructed staff to contact the (city name in another State) Field Support Office for further instructions in the event of a resident evacuation. The policies directed staff to fax pertinent information to the field office for further guidance. -The current ownership was not connected with the (city name in another State) field office and the number contained in the document was out of order. Another number identified for corporate support in the event of an emergency in the EP policies was not a number offering the caller a list of special offer purchases. A review of the EP plan binders at each of the facility's nurses' stations contained the same EP policies plan and guidance as the binder provided for the survey review on 12/6/23 by the MTD. II. InterviewsThe MTD was interviewed on 12/6/23 at 12:33 p.m. The MTD said the policies continued in the facility's EP program binder were written by the previous owner's cooperation and although reviewed by the facility's current leadership had not been revised with the new corporate owner's guidance. The MTD said the facility corporate leadership was in the process of updating the policies for emergency preparedness for the facility but had not yet rolled out the new policies and procedures for the facility. The nursing home administrator was interviewed on 12/11/23 at 12:02 p.m. The NHA said he and the director of nursing reviewed the facility's EP program plan but had not made any changes to the plan except to update the leadership and staff contacts. The NHA said the EP plan needed some updates to make it current.

Based on record review and interviews, the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and was reviewed and updated annually. Specifically, the facility failed to document an up-to-date written emergency communication plan to include:-Updating the plan annually and when the new corporate ownership took over facility operations; and,-Document how the facility coordinates patient care within the facility, across healthcare providers and with State and local public health departments. Findings include: I. Facility plan The emergency preparedness (EP) program was provided by the maintenance director (MTD) on 12/6/23 at 8:45 a.m. The facility did not have an up-to-date communication plan that was updated annually. The facility's communication plan was revised in April 2019. The communication plan documented an EP plan-related compliance field support incident commander phone number that was no longer in service. The communication plan read in part: "Procedure: a central command center in the Atlanta Field Support Office will be established. The Field Support Incident command and Facility Commander will work together to establish multiple local communications devices/channels. Compliance line (phone number)." -The current facility ownership was not associated with the (city name in another State) field office and the telephone number was not an active phone number. II. InterviewsThe MTD was interviewed on 12/6/23 at 12:33 p.m. The MTD said the communication plan continued in the facility's EP program binder was written by the previous owner's cooperation and although reviewed by the facility's current leadership had not been revised with the new corporate owner's guidance. The MTD said the facility corporate leadership was in the process of updating the EP and communication plan for the facility but had not yet rolled out the new policies and procedures for the facility. The nursing home administrator was interviewed on 12/11/23 at 12:02 p.m. The NHA said he and the director of nursing reviewed the facility's EP program plan but had not made any changes to the plan except to update the leadership and staff contacts. The NHA said the EP plan needed some updates to make it current.

Based on record review and interview, the facility failed to develop and maintain an up-to-date emergency preparedness training and testing program that was based on the facility's emergency preparedness (EP) program plan, annual risk assessment, facility EP policies and procedures and the communication plan that was delivered to all staff annually. Specifically, the facility failed to:-Develop a written training and testing program based on the facility's updated EP program that was reviewed and revised annually;-Provide education and instruction to staff, contractors, and facility volunteers to ensure all individuals are aware of the facility's EP program;-Ensure the EP training includes the facility's expected response to the annual risk and all hazards risk assessment; and, -Ensure EP training included, at a minimum, training related to the facility's EP policies and procedures. Findings include: I. Facility plan The emergency preparedness program binder was provided by the maintenance director (MTD) on 12/6/23 at 8:45 a.m. The facility did not have a written training and testing program with provisions to ensure all staff, contractors, and facility volunteers received EP training specific to the facility's updated EP program. The EP management plan, revised June 2015, read in part: "The facility provides emergency preparedness orientation and education that addresses:-Annunciation codes and their meanings;-Specific roles and responsibilities during emergencies;-Information and skills required to perform duties during emergencies;-The backup communication system used during disasters and emergencies; and-How supplies and equipment are obtained during disasters or emergencies."-The policy/procedure did not document that training was to be provided to all staff and volunteers annually and did not refer to offering training to employees working under contract or volunteers. II. InterviewsThe MTD was interviewed on 12/6/23 at 12:33 p.m. The MTD was unable to provide the facility's written training policy. The MTD said the facility corporate leadership was in the process of updating the EP and communication plan for the facility but had not yet rolled out the new policies and procedures for the facility. The nursing home administrator was interviewed on 12/11/23 at 12:02 p.m. The NHA said he and the director of nursing reviewed the facility's EP program plan but had not made any changes to the plan except to update the leadership and staff contacts. The NHA said the EP plan needed some updates to make it current.

Based on record review and interview, the facility failed to develop and maintain an up to date emergency preparedness training program that aligns with the facility's specific individualized emergency preparedness (EP) program plan, annual risk assessment, facility EP policies and procedures, as well as the facility's communication plan, that was delivered to all staff upon hire and annually thereafter. Additionally, the facility will extend training to volunteers and contracted providers who provide care and services in the facility environment. Specifically, the facility failed to:-Provide staff initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role;-Provide emergency preparedness training at least annually;-Maintain documentation of all emergency preparedness training; and, -Demonstrate staff knowledge of emergency procedures. Findings include: I. Facility plan The emergency preparedness program binder was provided by the maintenance director (MTD) on 12/6/23 at 8:45 a.m. The facility did not have documentation to show that all staff, individuals providing services under arrangement, and volunteers were provided orientation and annual training on the facility's EP program. II. Training records The facility had approximately 89 facility hired staff, 17 housekeeping and dietary staff, nine agency certified nursing aides (CNA) and an unknown number of agency contracted nursing staff working in the facility at the time of the survey (from 12/4/23 to 12/11/23) based on the staffing roster provided by the nursing home administrator (NHA). The facility was able to provide proof of fire drill training and simulation drills and documentation that a few staff participated in training on 4/19/23, regarding the location of the emergency shut-off controls and the meeting location in the parking lot in the event of a temporary evacuation just outside of the building. The facility provided a second training where 32 staff were educated on where to locate the EP program binders. The facility was unable to provide proof that all staff were provided training on the facility's specific emergency preparedness policy and EP program to include their role and responsibilities in the event of an emergency or natural disaster. III. InterviewsThe MTD was interviewed on 12/6/23 at 12:33 p.m. The MTD said he had educated staff on the location of the facility's utility shutoffs and the location of the facility's EP program binders but had not provided staff an in-depth training on the facility's EP program and the staff's roles and responsibilities specific to the facility's unique EP plan which the staff were to follow in the event of an emergency as identified by the facility's annual natural disaster and community-based risk assessment. The nursing home administrator (NHA) was interviewed on 12/11/23 at 12:02 p.m. The NHA said the facility was unable to provide additional proof of the required training at the time of the survey (12/4/23-12/11/23). Licensed practical nurse (LPN) #3 was interviewed on 12/11/23 at 1:00 p.m. LPN #3 said she had worked in the facility for more than a year and had not received any disaster training from the facility. LPN #3 said she had been in a disaster in a different facility and she knew what to do at the other facility but was not sure if things would be the same if a disaster happened at this facility. CNA #5 was interviewed on 12/11/23 at 2:30 p.m. CNA #5 said she never experienced a real emergency and had not received training from the facility on what to do in the event of an emergency that required the staff to evacuate the residents to another location. CNA #5 said it would require a lot of staff support to be able to evacuate the residents to another location and she was not sure where the residents would go or how the facility planned totrack the evacuation. CNA #5 said she would just pack up the supplies and wait for direction from leadership. IV. Facility follow-upThe NHA provided additional information on 12/13/23 regarding and in-person training held on 11/28/23 on the topic of the emergency operations program. The training was provided to the chief executive officers (CEOs), maintenance directors and facility drivers. The training curriculum revealed the attendees were training on the EP regulatory requirements.-However, the training curriculum provided did not document that the attendees were training on the facility's specific EP program or emergency preparedness needs to the facility's location and community.-The NHA did not provide a list of attendees from the facility who attended the training.

Based on interviews and record review, the facility failed to ensure one (#5) of one resident reviewed for grievances out of 40 sample residents was provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #5's grievance, which the resident had communicated to staff on multiple occasions. Findings include:I. Facility policy and procedureThe Grievance policy, dated 5/8/23, was provided by the corporate director of clinical risk management (CDCRM) on 12/11/23 at 10:49 a.m. It revealed in pertinent part, "To provide residents and responsible party with information on the facility grievance procedure. To ensure that residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded promptly and in written form. "Administrator's review: the Grievance and Complaint Investigation Report must be filed with the administrator within five (5) working days of the receipt of the grievance of complaint form."II. Resident #5A. Resident statusResident #5, age less than 65, was admitted on 2/4/16. According to the December 2023 computerized physician orders (CPO), diagnoses included type two diabetes mellitus, paranoid schizophrenia and history of COVID-19. The 10/20/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 14 out of 15. He was independent with all activities of daily living (ADLs). B. Resident interviewResident #5 was interviewed on 12/4/23 at 10:45 a.m. Resident #5 said he had lived at the facility for over six years. Resident #5 said dietary aide (DA) #1 did not like him and targeted him. Resident #5 said DA #1 put sugar in his milk to make his blood sugar rise. Resident #5 said he would often go to other units to get milk so his blood sugar would not go up. Resident #5 said he had told multiple staff members, including the previous nursing home administrator (NHA), the DON and multiple nursing staff members, that DA #1 was putting sugar in his milk. Resident #5 said the facility had not addressed his concern and he was still receiving milk that had sugar in it often. C. Record reviewThe behavior care plan, initiated on 10/25/17 and revised on 10/18/23, revealed Resident #5 had a behavior problem related to his disease process of paranoid schizophrenia. Resident #5 had episodes of paranoia, especially surrounding the dining room and food. For example, when Resident #5 received oatmeal with regular sugar and when he found a hair in his food, he thought the kitchen staff did it intentionally. The interventions included: administering medications as ordered, allowing the resident to make his own choices, anticipating and meeting the residents needs, assisting the resident to develop more appropriate methods of coping and interacting and providing weekly clinical contact to focus on symptom management and encouragement in following the rules and guidelines. The diabetic care plan, initiated on 2/25/16, revealed Resident #5 had diabetes. The interventions included: checking all of the body for skin and treat promptly as ordered by the doctor, providing diabetes medication as ordered by the doctor, having a dietary consult for nutritional regimen and ongoing observation, educating the resident regarding medications and importance of compliance, educating the resident about diabetes, obtaining fasting serum blood sugars as ordered by the doctor, observing for any psychosocial problem areas and reporting to social services, observing for signs and symptoms of hyperglycemia, referring to podiatrist and referring to the registered dietitian as needed. The nutritional care plan, initiated on 11/18/16, revealed Resident #5 had a nutritional problem or potential nutritional problem related to vitamin deficiency. The interventions included: administering medications as ordered, determining the residents likes and dislikes and referring to other disciplines as needed. The 10/9/23 nurse practitioner (NP) progress note documented in pertinent part, "Nursing reports increased paranoia and behaviors. Patient washes his hands over 40 times a day, only drinks bottled water or milk from an unopened container."The 10/20/23 social services behavior progress note documented the writer went to Resident #5's room around 12:30 p.m. The resident expressed intense anger and paranoia about his milk being poisoned. Resident #5 expressed signs of physical aggression by slamming his hand on his desk and raising his voice. The progress note documented Resident #5 continued to make threatening comments directed towards the kitchen staff. The writer offered to get the resident milk, as Resident #5 was in isolation for COVID-19. The progress note documented the social worker would continue to monitor the resident throughout the isolation period. A request was made for grievances regarding Resident #5's concern about his milk on 12/5/23. -The NHA said the facility did not have any documented grievance forms for Resident #5 (see interview below). III. Staff interviewsThe NHA was interviewed on 12/5/23 at 2:15 p.m. The NHA said the facility did not have any grievance forms in regards to Resident #5's concerns. The NHA said he would follow up with Resident #5. The dietary manager (DM) was interviewed on 12/7/23 at 12:57 p.m. The DM said she had worked at the facility for a long time and knew Resident #5 very well. The DM said Resident #5 frequently alleged DA #1 was poisoning the milk by adding sugar to the milk to cause Resident #5's blood sugars to raise. The DM said Resident #5 had been concerned regarding the sugared milk for a long time. The DM said she had not filled out a grievance regarding Resident #5's concern about the milk. The DM said she would begin ordering individual milk cartons for Resident #5. The DM said she would update Resident #5's care plan so staff knew to provide Resident #5 with unopened individual milk cartons at each meal. Licensed practical nurse (LPN) #1 and certified nurse aide (CNA) #12 were interviewed on 12/7/23 at 1:47 p.m. LPN #1 said Resident #5 had a diagnosis of paranoid schizophrenia. LPN #1 said Resident #5 thought a dietary staff member was poisoning the milk with sugar. CNA #12 said she tried to open a new gallon of milk in front of Resident #5 but the kitchen did not always send a new gallon of milk to open in front of Resident #5. The NHA was interviewed on 12/11/23 at 2:53 p.m. The NHA said he was responsible for the grievance process. The NHA said when grievance forms were filled out they were brought to him. The NHA said he would then assign the grievance to the department director it pertained to. The NHA said the department director investigated and addressed the concern. The NHA said the department director was responsible for following up with the resident to ensure they were pleased with the resolution. The NHA said the grievance form would then be approved by himself. The NHA said the DM began ordering individual cartons of milk to address Resident #5's concern.

Based on observation, record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for two (#30 and #75) of two residents in two allegations of abuse reviewed out of 40 sample residents. Specifically, the facility failed to provide adequate supervision to prevent:-Resident #30 from being a victim of physical abuse by Resident #47; and, -Resident #75 from being a victim of physical abuse by Resident #12. Findings include: I. Facility policy The Abuse policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 12/4/23 at 9:36 a.m. It revealed in pertinent part: "Community does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. "Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. "Providing a safe environment for the resident is one of the most basic and essential duties ofour facility." II. Facility report incident investigation between Resident #30 and Resident #47 The facility filed an incident of physical abuse on behalf of Resident #30. The facility investigation report for the incident, which occurred on 10/17/23, revealed three residents were in the dining room as the lunch was starting. Resident #30 was in a manual wheelchair wheeling past Resident #47 as Resident #47 sat at his dining table and bumped into Resident #47's walker and knocked it over. Resident #47 began yelling at Resident #30 and the two residents started yelling at each other and Resident #47 hit Resident #30 in the left jaw with an open hand. Two certified nurse aides (CNA) were present when the resident-to-resident verbal and physical altercation and intervened after the incident began. Both residents were separated to prevent further confrontation. Staff implemented frequent checks on the two residents to monitor the resident for further escalating behaviors. There was no noted change in either resident's mood or behavior and the incident ended as quickly as it started. Both Resident #30 and Resident #47 were interviewed and neither resident expressed any concern after the incident ended. Both residents were examined and neither resident had any viable injury. Following the incident, the resident's seating placement for meals was evaluated and the table and chairs were moved further apart to allow more room for Resident #30 passing by on the way to his preferred mealtime seating. III. Resident #30 A. Resident status Resident #30, age 68 years old, was admitted on 12/17/21. According to the December 2023 computerized physician's orders (CPO), diagnoses included dementia with behavioral disturbance, lack of coordination and anxiety. The 10/5/23 minimum data set (MDS) assessment revealed the resident had severely impaired cognition as evidenced by a brief interview for mental status (BIMS) score of six out of 15. The resident had clear speech; was able to make himself understood and was able to understand others and comprehend conversations. The resident was assessed to display both physical and verbally aggressive behaviors directed toward others one to three days a week and has other behavioral symptoms not directed toward others four to six days a week, during the assessment time period. The resident used a manual chair to navigate his community. B. Record review The resident's comprehensive care plan, initiated care focus for inappropriate behavioral expressions revised on 10/23/23. The care focus revealed Resident #30 had a behavior problem related to a diagnosis of dementia. Resident #30 "may yell out in a loud tone of voice at other residents if they come close to him or when staff ask him questions. Resident #30 can become easily overstimulated. Resident #30's family reports even though the resident is social, he enjoys alone time, especially when over-stimulated." "The resident has had physical altercations from others when intrusive." Interventions included:-Anticipate and meet the resident's needs, initiated 12/22/21;-Seating in the dining room was evaluated. Chairs were removed to allow for more space for residents to move and allow residents to sit with others who are more compatible, initiated 10/23/23; and,-Placed Resident #30 on frequent checks, initiated 10/23/23. IV. Resident #47 A. Resident statusResident #47, age 71 years old, was admitted on 4/5/23. According to the December 2023 CPO, diagnoses included dementia with agitation, unresolved pain and major depression. The 11/8/23 MDS assessment revealed the resident had moderately impaired cognition as evidenced by a BIMS score of eight out of 15. The resident had clear speech; was able to make himself understood and was able to understand others and comprehend conversations. The resident did not exhibit any physical and verbally aggressive behaviors directed toward others nor did he display other behavioral symptoms not directed toward others, during the assessment period. The resident used a walker for stability and navigation of his community. B. Record reviewA review of progress notes revealed the resident had a history of aggressive behaviors. Progress note documentation read in pertinent part:-Physician notes dated 10/24/23 and 11/2/23 revealed: "Resident #47 has the potential to be physically aggressive. Staff reported Resident #47 can be territorial over his space, but his behaviors were easily redirectable and needed to keep other residents safe." The resident comprehensive care plan, initiated care focus for inappropriate behavioral expressions including a potential to become physically aggressive related to a diagnosis of dementia, initiated 10/18/23. The care focus revealed Resident #47 had a behavior problem related to a diagnosis of dementia and poor impulse control, initiated: on 10/18/2023. Interventions initiated 10/18/23 included:-Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level,body positioning, and pain.-If Resident #47 becomes agitated intervene before agitation escalates; guide away fromthe source of distress; engage calmly in conversation.; If the resident's response is aggressive, staff are to walk calmly away, and approach later.-Resident#47's triggers for physical aggression are anybody telling him what to do and peoplegetting in his space or going into his room. Resident #47 enjoys spending time in his roomwatching television.-Placed on frequent checks (as needed). Staff to monitor Resident #47 for changes in mood and behavior and for any concerns with interactions with others, intervening if needed. V. Staff interviewsCNA #5 was interviewed on 12/7/23 at 10:10 a.m. CNA #5 said she was not present when the altercation occurred between Resident #30 and Resident #47, so she could not speak to the incident. CNA #5 said that residents on the unit were not very social with each other and that they could easily be triggered by each other's behaviors so the residents needed to be monitored for behaviors as their demeanor changed quickly. It was helpful when the unit was staffed with consistent staff because the staff were more familiar with the residents' needs. The unit was usually staffed with a consistent staffing of two CNAs. Sometimes the two secured units had a floating CNA but not always and the unit nurse also floated between the two secured units and was not always present on the unit. CNA #5 said it was difficult with only two CNAs on the unit to monitor each resident consistently when the CNAs were assisting a particular resident with personal care and attending to other resident care issues. Some residents required the assistance of two CNAs and that took both CNAs out of the common area to monitor the resident activity. Since a behavioral escalation was not always predictable, this may or may not be ok due to the resident's behavioral responses to one another. The NHA was interviewed on 12/7/23 at 12:44 p.m. The NHA said he and the secured unit manager assessed the needs of the secured unit on a daily basis and from there the unit was staffed according to the daily assessment. The NHA said he felt that the facility had sufficient staffing to monitor the residents. The NHA said it was important for staff on the secured unit to be able to anticipate the resident's needs and communication between the staff was very important. The facility recently staffed the unit with resident assistants (RA) whose job it was to keep an eye on residents to make sure they were safe. The RAs were to get the residents snacks and provide activities with them. -However, observations of the RAs on the unit indicated this was not happening. Observations of the RAs included the RAs sitting or standing at a distance looking at the residents from a distance and not engaging or providing any activities programming to the residents. Cross-reference F744 failure to provide dementia-managed care to the residents living in the secured dementia care unit. VI. Incident of physical abuse between Resident #75 and Resident #12 The abuse investigation documented Resident #12 shoved Resident #75. The alleged assailant and victim were separated and placed on frequent checks. The investigation documented certified nurse aide (CNA) #14 observed Resident #12 push Resident #75 away from the drink cart in the hallway. Resident #12 was yelling at Resident #75. Resident #75 was interviewed after the incident and did not remember the incident. Resident #12 was interviewed on 10/27/23. Resident #12 said Resident #75 was always getting into the drink cart and she did not feel it was fair. The social services assistant (SSA) told Resident #12 that Resident #75 was confused. Resident #12 said she was confused as well. Resident #12 said she was upset that she was told not to touch the drink cart, but had seen other residents touching it. Resident #12 said it was the CNA's fault because she was not being served. Resident #12 said she did not feel safe. The abuse investigation documented at approximately 11:30 a.m. the CNA informed the nurse that Resident #75 was standing at the drink cart attempting to get his own drink when Resident #12 came up and pushed Resident #75 away and said "you cannot do that." The residents were separated and assessed by the registered nurse (RN) and there were no injuries noted. Resident #75 denied pain or fear. The resident was placed on frequent checks for 72 hours. The abuse investigation documented that Resident #12 reported she did not touch Resident #75 and that she just told him to stop touching the drinks. The investigation documented no changes were made to the victim or assailant's treatment regimen or care plan as a result of the incident. -However, physical abuse occurred due to Resident #12's willful and not accidental action of pushing Resident #75. VII. Resident #75A. Resident statusResident #75, age 75, was admitted on 9/15/23. According to the December 2023 CPO, diagnoses included dementia and history of COVID-19. The 9/21/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. He was independent with eating, toileting and dressing. He required set-up assistance with oral hygiene. He required supervision with showering. The MDS assessment indicated the resident did not have physical or verbal behaviors directed towards others during the review period. The resident had wandering behaviors one to three days during the review period. B. Record reviewThe 10/27/23 nursing progress note documented in Resident #75's electronic medical record (EMR) documented a skin check was completed following an altercation with another resident. There was no injury noted. The 10/27/23 nursing weekly nursing documentation documented in pertinent part, that the resident was not in pain or discomfort and had no skin issues. The cognitive impairment care plan, initiated on 9/22/23, documented Resident #75 had impaired cognitive function or impaired thought process related to dementia. The interventions included: asking yes or no questions, communication with the resident and family regarding the residents capabilities, using the residents preferred name, cueing and reorienting the resident as needed, discussing concerns about confusion, keeping the residents routine consistent, monitor and documenting changes in cognitive function, presenting one thought at a time, reminiscing with the resident and using task segmentation to support short term memory deficits. The elopement care plan, initiated on 9/25/3, documented Resident #75 was at risk for elopement related to disorientation, impaired safety awareness, and history of attempts to leave the facility unattended. The resident wandered aimlessly. The interventions included in pertinent part: distracting the resident from wandering by offering pleasant diversions, identifying a pattern of wandering, providing structured activities and providing a wanderguard. VIII. Resident #12A. Resident statusResident #12, age 77, was admitted on 9/15/21. According to the December 2023 CPO, diagnoses included depression, type two diabetes mellitus and fibromyalgia (chronic body pain). The 10/3/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 14. She was independent with all activities of daily living (ADLs). The MDS assessment indicated the resident did not have physical or verbal behaviors directed towards others during the review period. B. Resident interviewResident #12 was interviewed on 12/4/23 at 1:40 p.m. Resident #12 said she was told by staff to not touch the drink cart. Resident #12 said it upset her when other residents were allowed to touch the drink cart. Resident #12 said another male (not Resident #75) frequently came from another unit and used her unit's drink cart. Resident #12 said she did not feel this was fair. Resident #12 said she frequently called the other male resident names. Resident #12 said she would have no problem defending the units drink cart physically or verbally from other residents on and off her unit. C. Record reviewThe behavior care plan, initiated on 1/18/23, revealed Resident #12 voiced her frustration or fear if she felt others did not respond to her requests or disagreed with her. Resident #12 responded to reassurance and validation. The interventions included in pertinent part: administering medications as ordered, analyzing key times for de-escalation, assessing and anticipating the resident's needs, assessing resident's coping skills and support system, assessing the resident's understanding of the situation and allowing time for the resident to express self and feelings, giving the resident as many choices as possible about care, consulting psychiatric if needed, providing validation and reassurance and intervening before residents agitation escalates. IX. Additional staff interviewsRegistered nurse (RN) #1 was interviewed on 12/5/23 at approximately 4:00 p.m. RN #1 said she was not aware Resident #12 had any physical altercations with other residents. The social services director (SSD) and the social services assistant (SSA) were interviewed on 12/7/23 at 2:09 p.m. The SSD said Resident #12 was good at letting staff know her boundaries when she was angry. The SSA said staff attempted to place drink carts closer to the nursing station for better monitoring. The SSD said it was normal for Resident #12 to become angry but not physically aggressive. The SSD said the facility was in isolation due to a COVID-19 outbreak the week on 10/27/23. The SSD said Resident #12's care plan was not updated. The SSD said Resident #12's care plan should be reviewed to ensure further incidents do not occur. The NHA was interviewed on 12/7/23 at 2:17 p.m. The NHA said he was the abuse coordinator. The NHA said he was responsible for delegating investigation tasks to the interdisciplinary team (IDT). The NHA said all staff were responsible for reporting alleged abuse to him immediately. The NHA said they reported the incident on 10/27/23 out of caution. The NHA said Resident #12 pushed Resident #75 as she was upset he was touching the drink cart. The NHA said Resident #75 was not injured. The NHA said the 10/27/23 incident occurred during the COVID-19 outbreak at the facility. The NHA said there were a lot of drink carts throughout the hallways since the residents were eating in their rooms. The NHA said staff attempted to keep the drink carts out of the way to help prevent arguments.

Based on staff interviews and record review, the facility failed to report alleged violations of potential abuse to the proper authority, including the policy and state oversight agency in accordance with state law for one alleged violations; involving one (#12) of one resident reviewed for allegations of abuse out of 40 sample residents. Specifically, the facility failed to report one allegation of resident abuse by staff to the facility administrator, director of nursing, local police or the State Agency, in a timely manner. Findings include:I. Facility policy and procedureThe Abuse policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 12/4/23 at approximately 9:35 a.m. It revealed in pertinent part, "Reporting abuse: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting can be completed verbally or in writing. "Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury."II. Resident #12A. Resident statusResident #12, age 77, was admitted on 9/15/21. According to the December 2023 CPO, diagnoses included depression, type two diabetes mellitus and fibromyalgia (chronic body pain). The 10/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 14. She was independent with all activities of daily living (ADLs). The MDS assessment indicated the resident did not have physical or verbal behaviors directed towards others during the review period. B. Record reviewThe 12/4/23 behavior note documented by registered nurse (RN) #1 at 3:47 p.m. revealed RN #1 went to Resident #12's room to administer insulin. RN #1 documented she noticed a bruise on the resident's right upper arm and mentioned it to Resident #12. RN #1 documented Resident #12 verbalized that RN #1 caused the bruising. RN #1 documented that she had not worked in several days and educated the resident that she may have gotten it from a shot that was given to her. Resident #12 then repeated "you did that to me." RN #1 informed the resident that she had not worked on the 400 unit recently. Resident #12 insisted on her claim. RN #1 asked Resident #12 why she singled her out. Resident #12 responded because you did that to me. III. Staff interviewsRN #1 was interviewed on 12/5/23 at approximately 4:00 p.m. RN #1 said that Resident #12 claimed RN #1 bruised her in October 2023. RN #1 said she documented a progress note regarding the allegation and was waiting for management to follow up with her regarding the progress note. -However, she never reported it directly to the administration. RN #1 said she had not heard from management for several weeks, so she spoke with the social services director (SSD) a few weeks ago. RN #1 said there still was no follow up from management regarding Resident #12's allegation of bruising caused by RN #1. Licensed practical nurse (LPN) #1 was interviewed on 12/7/23 at 1:36 p.m. LPN #1 said the NHA was the abuse investigator. LPN #1 said she reported all allegations to the NHA immediately. The social services director (SSD) was interviewed on 12/7/23 at 2:09 p.m. The SSD said she read the behavior progress note documented by RN #1 on 10/10/23 a few weeks after it was written. The SSD said she spoke with RN #1 and Resident #12 and completed an internal investigation. The SSD said she provided the investigation to the old NHA and she believed they disposed of it. The NHA was interviewed on 12/7/23 at 2:17 p.m. The NHA said he was the abuse coordinator. The NHA said he was responsible for delegating investigation tasks to the interdisciplinary team (IDT). The NHA said all staff were responsible for reporting alleged abuse to him immediately. The NHA said he heard about Resident #12's alleged physical abuse from RN #1. The NHA said the facility had completed an internal investigation and determined the allegation was not reportable. The NHA and the corporate director of clinical risk management (CDCRM) were interviewed on 12/7/23 at 1:12 p.m. The NHA said the SSD had followed up with RN #1 and Resident #12 a couple weeks after the 10/10/23 allegation of physical abuse. The CDCRM said she had created an action plan and did training with all staff regarding abuse reporting on 10/26/23.-The abuse action plan and training completed by the CDCRM was requested on 12/7/23. The NHA said he was unable to locate the action plan or abuse training (see interview below). The NHA and the CDCRM said they attempted to review all progress notes documented to ensure all allegations of abuse were reported. The NHA said this was the first time he had heard about the 10/10/23 allegation of physical abuse by Resident #12. The NHA was interviewed on 12/11/23 at 4:08 p.m. The NHA said he did not have any documentation that all staff, including RN #1, were educated on reporting abuse recently. IV. Facility follow-upOn 12/12/23 at 5:31 p.m., the NHA provided documentation that the 10/10/23 allegation of abuse was reported to the State Agency on 12/7/23. It revealed Resident #12 made an accusation of a nurse causing bruising to her right upper arm. The accusation was made to the nurse but was not reported to the proper individuals.

Based on observations, record review and staff interviews the facility failed to provide services for one (#6) of two reviewed out of 40 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #6 vital signs-blood pressure and heart rate/pulse were monitored and assessed for irregularities immediately before the administration of a blood pressure medication. Findings include: I. Professional reference According to Khashayar, F., Arif, J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 12/19/23. "Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. "The patient's heart rate and blood pressure require monitoring while using beta-blockers." According to McKeever, R.G., Hamilton, R.J. (2022). Calcium Channel Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK482473/ retrieved on 12/19/23. "Calcium channel antagonists, also known as calcium channel blockers (CCBs), have been widely used for many indications. This cardiovascular drug class is one of the leading causes of drug-related fatalities.-Patients require close monitoring. The improvement of their symptoms of angina or maintenance of their blood pressure is an indication of efficacy (effectiveness for the desired result). Hypotension (low blood pressure) may be profound and life-threatening. Many factors may affect the severity of overdose, including the calcium-channel antagonist dose, the formulation, ingestion with other cardioactive medications such as beta-blockers, the patient's age, and comorbidities. These medications may also be life-threatening with as little as one tablet in small pediatric patients." According to Kiziior, R. J., Hodgson, K. J. (2020). Saunders Nursing Drug Handbook. Elsevier. P 765. "Metoprolol: Classification Beta adrenergic blocker. Uses: treatment of hemodynamically stable acute myocardial infarction to reduce cardiovascular mortality; and long-term treatment of angina. Precautions: Hypersensitivity may lead to second or third-degree heart block. Nursing considerations: Assess blood pressure and apical pules immediately before drug administration. If the patient's pulse is 60 beats per minute or less or if systolic blood pressure is less than 90 mm/Hg withhold the medication. And contact the physician." II. Resident #6A. Resident status Resident #6, age 75, was admitted on 11/18/14. According to the December 2023 computerized physician orders (CPO), diagnoses included cerebrovascular disease, hypertension and dementia. The 10/9/23 minimum data set (MDS) assessment revealed the resident had severely impaired cognition and was unable to complete the brief interview for mental status (BIMS) exam. B. Record review The CPO documented the following order for Resident #6:-Metoprolol succinate ER (extended-release) oral tablet 200 milligrams (mg), give one tablet at 8:00 a.m. by mouth in the morning for hypertension. Hold for systolic (SBP) less than 100 or heart rate (HR) less than 60 beats per minute. Order date 7/28/23 and ongoing. -A review of the December 2023 medication administration (MAR) and treatment administration (TAR) record failed to show documentation of blood pressure and heart rate assessment immediately before the administration of the resident's metoprolol medication. -A review of the resident's medical record including the vital signs record failed to show evidence that the resident blood pressure and heart rate were monitored before the administration of the resident's metoprolol medication. -The vital signs blood pressure summary record and pulse (heart rate) summary sections of the resident medical record failed to show evidence of any blood pressure or heart rate monitoring since 11/26/23. C. Staff interviews Registered nurse (RN) #3 was interviewed on 12/11/23 at 12:45 p.m. RN #3 said a resident's vital signs blood pressure and pulse should be assessed before administering blood pressure medication when the physician wrote an order for the assessment of those vital signs. RN #3 said the assessment of the vital signs was recorded in the resident's record and would be recorded on the vital signs summary documentation. If the medication needed to be held due to being out of the prescribed parameters the nurse would document the outcome on the resident's MAR. The director of nursing (DON) was interviewed on 12/11/23 at 1:17 p.m. The DON said the nurses would monitor a resident's vital signs before administering metoprolol if the physician wrote an order that included parameters indicating a hold order. III. Facility follow-up The DON provided additional information regarding the administration of blood pressure medications. The documentation provided read in the pertinent part: "It is typical for a long-term regime that parameters do not coincide with the orders. Metoprolol tartrate may look at holding if systolic BP is below 90-100; however, it depends on the patient and MD (medical doctor) orders."

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for two (#60 and #78) out of three residents reviewed for discharge planning out of 40 sample residents. Specifically, the facility failed to ensure the discharge planning process was documented in Resident #60 and Resident #78's medical record. Findings include:I. Facility policy and procedureThe Discharge Planning policy, revised 5/17/23, was provided by the corporate director of clinical risk management (CDCRM) on 12/11/23 at 10:49 a.m. It revealed in pertinent part, "The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge. The facility will evaluate the resident's expected goals for discharge upon admission, then routinely in accordance with the MDS assessment cycle and as needed. Initial information and discharge goals will be included in the resident's baseline care plan. Subsequent information and discharge goals will be included in the resident's comprehensive plan of care with updates completed as needed. If discharge to community is identified to be the resident/representative's goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan and updating of the discharge plan, as needed to reflect the modifications."II. Resident #60A. Resident statusResident #60, age 76, was admitted on 1/5/23 and readmitted on 8/17/23. According to the December 2023 computerized physician orders (CPO), diagnoses included dementia, paranoid schizophrenia and chronic obstructive pulmonary disease (COPD). The 10/19/23 minimum data set (MDS) assessment revealed Resident #60 had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. He was independent with all activities of daily living (ADLs). The MDS assessment indicated the resident did not have an active discharge plan already occurring for the resident to return to the community. B. Resident interviewResident #60 was interviewed on 12/4/23 at 2:20 p.m. Resident #60 said he wanted to discharge to California to be closer to his friends. Resident #60 said his goal was to discharge to California. Resident #60 said the facility staff did not seem to be working quickly towards his goals and did not follow up with him regularly. Resident #60 said he was getting old and did not have a lot of time left so he desired to move. C. Record review-A review of Resident #60's medical record on 12/6/23 did not reveal documentation that the resident's discharge plan was part of the resident's comprehensive plan of care. -It did not document the resident's discharge goal, interventions used to achieve the resident's goals or the discharge planning process. The 1/11/23 discharge planning review documented the resident's anticipated stay was long term care, which was stated by family. The resident was expected to remain in the facility and discharge was determined to not be feasible. Resident #60 lived alone and required supervision and assistance because of his cognitive status. Resident #60 required assistance with his ADLs. The assessment documented the resident did not have family or a support network to provide assistance post-discharge. The resident required 24-hour care and supervision. The overall summary of the potential for discharge documented the resident's plan was for him to stay long-term care because he needed assistance with bathing, dressing, mobility, medical monitoring and medication management. The October 2023 multidisciplinary care conference assessment documented the resident desired to move to California. The 12/7/23 social services progress note (documented during the survey process) revealed Resident #60's brothers and a friend were invited to a care conference on 12/12/23 regarding discharge planning. D. Staff interviewsThe social services director (SSD) and the social services assistant (SSA) were interviewed on 12/6/23 at 4:46 p.m. The SSD said the discharge planning process for each resident began prior to admission. The SSD said the discharge planning process was an ongoing process that should be documented in the resident's electronic medical record (EMR) and be a part of the comprehensive care plan. The SSD said Resident #60 was originally from California but he had been living in Colorado prior to his admission to the facility. The SSA said Resident #60 reported to her about four or five weeks ago (in November 2023), during his quarterly care conference, that he wanted to move to California. The SSA said Resident #60 had been very focused on moving to California since his recent hospitalization. The SSA said she had spoken with Resident #60 regarding the safety of him discharging to California but had not documented it in the resident's EMR. The SSD said Resident #60's comprehensive care plan did not address Resident #60's discharge goals. The SSD and the SSA were interviewed again on 12/7/23 at 2:09 p.m. The SSD said Resident #60 had the right to discharge and fail. The SSD and the SSA said they scheduled a care conference to review the resident's discharge goals with the resident's family and friend that lived in California. III. Resident #78A. Resident statusResident #78, age 72, was admitted on 7/15/23 and discharged on 10/2/23. According to the October 2023 CPO, diagnoses included chronic pain, dementia, atrial fibrillation, type two diabetes, obesity, coronary artery, hypertension, insomnia, obstructive sleep apnea, asthma, muscle weakness and hypokalemia. The 7/28/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required setup assistance with eating, supervision for personal hygiene and extensive assistance for toileting and transfers. The MDS assessment documented the resident did not have an active discharge plan in place to return to the community. It indicated the resident did not want to talk to someone about discharging from the facility into the community. B. Record review-A review of Resident #78's medical record on 12/7/23 at 12:00 p.m. did not reveal documentation that the resident's discharge plan was part of the resident's comprehensive plan of care. It did not document the resident's discharge goal, interventions used to achieve the resident's goals or the discharge planning process. -The 7/15/23 baseline care plan did not document if the resident wanted to stay in the facility long term or to return to the community. The 7/25/23 initial discharge planning review progress note revealed that the outcome was uncertain. Contact with family was minimal. Outcome would be determined soon. The 8/2/23 interdisciplinary team (IDT) care conference progress note revealed that the resident planned to leave the facility after progress was made in therapy. Barriers for discharge included stairs, thin carpet, bathing and dressing. The 8/3/23 care plan meeting progress notes revealed the resident hoped to regain the ability to return home after therapy. Therapy recommended if the resident went home, a life alert necklace or bracelet was beneficial. Concerns for home included showering, dressing, getting in/out of bed and stairs. Resident #78 and his family agreed he would be without assistance from caregivers most of the day. The resident needed to be able to manage independently for the majority of time when returning home.-No further documentation was in Resident #78's medical record regarding his discharge plan and goals until 9/28/23. The 9/26/23 social services letter to the resident's provider revealed that the facility wanted to discharge the resident. The 9/28/23 nursing facility discharge summary, written by a nurse practitioner, documented that the resident was medically stable to transfer home with home health care services. The 9/29/23 discharge summary and education form revealed the resident was discharged home with home health and with a family member. The SSD was the contact if there were problems after the resident was discharged from the facility. The 10/2/23 nurse progress note said Resident #78 was discharged on 10/2/23 with his son after the dinner meal. Medication orders and the discharge instructions were reviewed with the resident. C. Staff interviews The SSD was interviewed on 12/7/23 at 12:35 p.m. She said that discharge planning should have occurred prior to admission, at admission and at the care conference that was held 72 hours after the resident was admitted. If the resident wanted to stay long term, they did not have a process on what the discharge care plan should be for those residents. The SSD said she did not include discharge planning on Resident #78's comprehensive care plans. She said there should have been a care plan for discharge plans. There should have been a discharge care conference prior to the resident's discharge. The care plan for discharge should be reviewed at least quarterly. Therapy could request a review and the care plan should be reviewed when the family and resident were ready to make discharge plans. The SSD said she frequently spoke to Resident #78 but did not document it in his medical record. She said when he was initially admitted, the plan was for him to stay at the facility long term. She said it was important to care plan potential discharge plans to communicate with staff, the resident and the family.

Based on observations, record review and interviews, the facility failed to ensure effective interventions were in place to address weight loss timely in one (#54) of seven residents out of 40 sample residents. Resident #54, who was identified as being at increased nutritional risk related to decreased oral intake and Alzheimer's disease, experienced a significant weight loss of 10.25% in a one month period of time and 12.42% in a three month period. The facility failed to ensure effective and timely interventions were in place to monitor, identify and prevent Resident #54's significant weight loss. The facility failed to monitor weekly weights, failed to consistently monitor meal intakes and failed to offer snacks when the resident refused or slept through meals. Additionally, the facility failed to implement new nutritional supplement interventions until 11/21/23, after the significant weight loss was identified. Due to the facility failures, the resident sustained a significant weight loss of 10.25% in one month and 12.42% in three months. Findings include:I. Professional referenceRoigk. P. (2018) Chapter 8: Nutrition and Hydration. In K. Hertz and J. Santy-Tomlinson Eds. Fragility Fracture Nursing: Holistic Care and Management of the Orthogeriatric Patient (Internet). Springer Publishing. https://www.ncbi.nlm.nih.gov/books/NBK543833/ retrieved on 12/12/23 at 1:37 p.m."According to the North American Nursing Diagnoses Association (NANDA) malnutrition is: 'Intake of nutrients insufficient to meet metabolic needs'. The criteria for malnutrition are: Body mass index (BMI) < (less than) 18.5 kg (kilograms)/m2 (height in meters squared), unintended weight loss > (greater than) 10% in the last 3-6 (three to six) months, BMI < 20 kg/m2 and unintended weight loss>5% in the last 3-6 (three to six)months, fasting period >7 (seven) days."II. Facility policy and procedureThe Food and Nutrition Services policy and procedure, revised October 2017, was provided by the nursing home administrator (NHA) on 12/11/23 at 10:47 a.m. It read in pertinent part,"The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional and psychosocial doctors that affect eating and nutritional intake and utilization."Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for significant nutritional problems. Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian."III. Resident #54A. Resident statusResident #54, age over 65, was admitted on 12/21/21. According to the December 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, anemia and gastroesophageal reflux disease (GERD). The 11/17/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He required substantial or maximal assistance with dressing, partial to moderate assistance with toileting and personal hygiene and supervision or touch assistance with bed mobility, transfers and eating. The MDS assessment did not indicate the resident was at risk for malnutrition or had a weight loss of 5% or more in one month or 10% or more in 6 months. B. ObservationsOn 12/5/23 at 11:00 a.m., Resident #54 was observed lying in bed on his right side sleeping with an untouched meal tray sitting at his bedside. On 12/5/23 at 12:00 p.m., Resident #54 was observed standing at his bedside and picking through the food on his tray. The resident did not attempt to eat anything on his tray. C. Recordreview The nutrition care plan, initiated on 12/23/21 and revised on 11/21/23, indicated that Resident #54 had a nutrition problem related to decreased oral intakes with a history of Alzheimer's, anemia and GERD. Interventions included fortified mashed potatoes with lunch and dinner, monitor oral intake, monitor skin integrity, monitor labs, monitor weights, monitor for malnutrition and significant weight loss, honor food/beverage preferences, obtain weekly weight for close weight monitoring, off snacks, provide diet as ordered and provide supplements as ordered. A comprehensive review of the care plan indicated Resident #54 had a prior history of significant weight loss in December 2022 and February 2023. The resident's weights were documented as follows:-8/20/23 124 pound (lbs);-8/30/23 122 lbs;-11/1/23 121 lbs;-11/6/23 112.6 lbs; and,-11/21/23 108.6 lbs. A comprehensive review of the resident's weights revealed a weight loss of 10.25% in less than one month ( between 11/1/23 to 11/21/23) and a loss of 12.42% in three months (between 8/20/23 to 11/21/23). The December 2023 CPO indicated weekly standing weights every Monday or Tuesday, ordered on 8/17/23.-There were no weekly weights documented for Resident #54 from 8/30/23 until 11/1/23.-There were no weekly weights documented for the resident from 11/6/21 until 11/21/23. A comprehensive review of Resident #54's physician orders revealed the following diet and supplementation orders:-Magic cup in the evening for a low body mass index (BMI) of 18.3, ordered 8/5/22;-House nourishment twice a day, ordered 2/10/22 and discontinued 11/21/23;-Regular, dysphagia advanced texture diet with regular thin consistency, ordered 1/5/23;-Offer snacks if the resident slept through the meal, ordered 2/10/23; and, -House nourishment after meals for weight loss offer 4 ounces (oz) shake if less than 50% of the meal consumed, ordered 11/21/23. -There was no documentation in the resident's electronic medical record (EMR) for snacks being provided to the resident for October 2023, November 2023 or December 2023.-New interventions were not put into place until 11/21/23 when a weight loss of 10.25% in one month time and 12.42% in three months was identified. The 8/31/23 nutrition progress note documented the resident's BMI was 20.3 with house shakes ordered twice a day, Magic cup once a day and snacks as needed. The progress note documented that the resident had variable intakes and no new interventions were ordered. The 11/7/23 nutrition progress note documented a weight of 112.6 lbs, which was a decrease of 6.9% in less than one week. A reweight was requested.-There was no documentation in the resident's EMR of a reweight being obtained until 11/21/23. The 11/21/23 nutrition progress note documented a weight of 108 lbs with nursing reporting the resident was not eating much and sleeping more. Interventions were to increase house shake to three times a day and to offer snacks when less than 50% of the meal was consumed. The 11/17/23 nutrition quarterly assessment indicated the resident had a weight loss of 6.9% in less than 30 days (11/1/23-11/6/23) and a reweight was requested.-There was no documentation of a reweight being done until 11/21/23.-A comprehensive review of the nutrition progress notes did not indicate any further documentation between 8/31/23 and 11/7/23. A comprehensive review of meal intakes for Resident #54 revealed inconsistent documentation of the resident's food intake. There were multiple days when staff failed to record the resident's meal intake including:-On 11/7/23, there was no documentation of intake for dinner;-On 11/8/23; documentation of 50% or less for lunch and there was no documentation of intake for dinner;-On 11/9/23; there was no documentation of intake for dinner;-On 11/10/23; there was no documentation of intake at breakfast or lunch;-On 11/11/23; there was no documentation of intake for dinner;-On 11/13/23; documentation of 50% or less for for lunch;-On 11/14/23; there was no documentation of intake for dinner;-On 11/15/23; there was no documentation of intake for breakfast or lunch;-On 11/16/23; there was no documentation of intake for dinner;-On 11/17/23; documentation of 50% or less for lunch and there was no documentation of intake for dinner;-On 11/18/23; there was no documentation of intake for breakfast or lunch;-On 11/19/23; there was no documentation of intake for breakfast, lunch or dinner;-On 11/21/23; documentation of 50% or less for dinner;-On 11/22/23; there was no documentation of intake for breakfast or lunch;-On 11/23/23; documentation of 50% or less for breakfast and there was no documentation of intake for lunch or dinner;-On 11/24/23; there was no documentation of intake for breakfast;-On 11/25/23; there was no documentation of intake for breakfast, lunch or dinner;-On 11/27/23; there was no documentation of intake for dinner;-On 11/28/23; there was no documentation of intake for dinner;-On 12/1/23; there was no documentation of intake for breakfast or lunch;-On 12/2/23; there was no documentation of intake for breakfast or lunch; and,-On 12/3/23; there was no documentation of intake for breakfast, and documentation of 50% or less for lunch and dinner.-Review of Resident #54's EMR revealed there was no documentation of snacks being provided when the resident refused or slept through meals or had an intake of 50% or less. IV. Staff interviewsCertified nurse aide (CNA) #8 was interviewed on 12/7/23 at 11:50 a.m. She said all residents needed to have their meal intakes documented and all CNAs were responsible for documenting meal intakes. She said that residents with nutrition and weight loss issues should have a weekly weight done. Licensed practical nurse (LPN) #1 was interviewed on 12/6/23 at 10:40 a.m. She said the CNAs documented meal intakes on the resident's record and provided meal assistance. She said residents with weight loss and nutrition issues had weekly weights ordered. She said Resident #54 was identified recently as declining with weight loss and said he should have weekly weights and meal intakes documented. The registered dietitian (RD) was interviewed on 12/7/23 at 11:50 a.m. She said all residents, especially those with identified weight loss, needed to have their meal intakes and weekly weights documented. She said Resident #54 was identified as losing weight on 11/1/23. She said there was a gap in the documentation for weights between August 2023 and November 2023 and that his meal intakes had been documented as variable at times. She said she had recently increased his house supplement to three times a day with meals. The director of nursing (DON) was interviewed on 12/11/23 at 2:30 p.m. She said CNAs could provide meal assistance to residents and were responsible for documenting meal intakes. She said that agency CNAs were given access to the documentation system in their orientation packet to the facility. She said weekly weights were to be completed on Resident #54 and all residents who had been identified with significant weight loss.

Based on observations, record review and interviews, the facility failed to effectively address the care and treatment needs of residents in the secured dementia care unit for the residents to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being; and provide person-centered care for three (#30, #40 and #4) of three residents reviewed for dementia care out of 40 sample residents. Specifically, the facility failed to provide the residents living in the Mountain View South with consistent and engaging activity programming of interest that was meaningful and person-centered. Additionally, the facility failed for Residents #30, #47 and #4 to: -Identify, address, and/or obtain necessary services to effectively meet the interests of the residents; and, -Implement person-centered approaches for residents with a dementia diagnosis to alleviate boredom and reduce the risk of the development of negative and or aggressive behaviors. Findings include: I. Facility policy The Dementia policy, revised November 2018, was provided by the director of clinical operations (DCO) on 2/15/23 at 3:30 p.m. It read in pertinent part: "For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the reviews. The facility will strive to optimize familiarity through consistent staff-resident assignments. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. "The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise.-Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT." II. Mountain View South secured unit observations and staff interviews On 12/4/23 at 8:49 a.m. the secured unit was observed. Five residents were sitting in the common area one resident was watching Home Alone on the television the other four residents were staring off into space or sleeping. One resident was wondering about the unit under the supervision of a one-to-one agency certified nurse aide (CNA). The morning activity "news update" scheduled for 8:50 a.m. did not occur. The secured unit was observed continuously from 8:59 a.m. to 11:59 p.m. There was no activity occurring. The two facility-hired CNAs were busy assisting residents with personal care (using the bathroom and getting up out of bed) and a third CNA was assigned exclusively to provide supervision for one resident to ensure he did not fall. The one-to-one CNA was from an agency and said this was her first day on the unit and she did not know anything about the needs of the other 14 residents on the unit. Several residents were sitting around the common area doing nothing but staring at the floor and or sleeping. Two residents were wandering the unit. The activities calendar posted on the unit revealed that there was to be an activity scheduled at 9:00 a.m. The activity "what's your reindeer's name craft" did not occur. Throughout the observation one resident was reading a book on his own, one resident continued to watch a movie on the television and three residents wandered the unit up and down the hallway. Two residents sat in the common area staring at the floor and dozing, another resident was in his room visiting with family playing cards and seven other residents were alone in their rooms. At 11:00 am the staff announced it was lunch time and assisted the residents to the dining room a couple of residents at their meals in their rooms. Resident #30 was observed during the observation he stayed mostly but would wander in the hall just outside his doorway and then go back into his room. Resident #30 came to the common area and said he was not interested in the television show and went back to his room until lunch was announced. Resident #30 went to the dining room for lunch. He drank his beverages but was not interested in his lunch. Staff asked him to try his meal but the resident refused the meal. The resident left the dining room looking unhappy. Staff brought the resident back to the dining room and placed him at his table, the resident did not eat and immediately left the dining room complaining about the dining room and the meal. Staff did not explore with the resident why he did not want the meal or if he wanted an alternative meal option. Resident #47 was observed sitting in the common area the entire observation until lunch was served. Resident #47 sat in a chair staring at the floor and dozing for the entire observation. Resident #4 remained in his room during the observation and did not come out until staff provided a prompt for him to come to the dining room for lunch. On 12/5/23 the secured unit was observed continuously from 2:20 p.m. to 3:35 p.m. Two CNAs were working on the unit assisting residents with personal care (helping residents use the bathroom, showering and getting up out of bed). Staff provided the residents with snacks in between assisting residents with care but were not available to monitor the residents in the common area or provide any type of activity. Some residents were wandering up and down the hallways others were sitting in the common area staring into space and dozing. At 2:41 p.m. a resident started yelling for staff assistance. CNA #6 could not leave the common area to check on the resident because the one resident she was assisting was very unsteady on his feet and would not sit long enough for the CNA to go check on the resident who was yelling out. CNA #5 was assisting a resident in the shower room. At 2:43 p.m. the director of rehabilitation (DOR) walked through the unit and assisted CNA #6 with the unsteady resident. The CNA assisted the resident with stabilization and the DOR pushed the resident's wheelchair behind his so it would catch him if the resident continued to lean or fall backward. At 2:49 p.m. CNA #6 was able to get the resident to sit in a chair with a book and then went to check on the resident who had been yelling for staff assistance and then she returned back to the common area to check on the resident sitting in there. At 3:00 p.m. CNA #4 finished giving a resident shower. Several management-level staff entered and exited the unit staying for a couple of minutes to talk with the residents. One manager was asked to stay in the common area with the residents while the two CNAs went to get a resident who had been yelling for staff assistance up out of bed. The manager passed out books to the residents in the common area and initiated interest in the books. The manager left the unit when the CNAs returned. The CNAs continued with their duties and offered the residents additional snacks. CNA #4 was interviewed at 3:13 p.m. CNA #4 said it was really hard to supervise the resident, meet the resident's care needs and complete all required tasks for the shift let alone provide activities programming, when it was just two CNAs on duty. It was a nice surprise yesterday when there was a third staff from agency on duty to watch the residents in the common area while the two regular CNAs attended to other resident care needs. CNA #4 said there was one resident who was unsteady on his feet and that evening the resident was up and walking wound from 5:00 p.m. until 9:00 p.m. and it was nice to have a dedicated staff to monitor him so he did not fall. CNA #4 said the CNAs tried to offer the residents activities but there just was not time to initiate an activity and keep interest if the CNA could not dedicate a significant amount of time to set up and be able to encourage resident interest and resident engagement throughout the activity; as the residents have short attention spans if not continually re-engaged in an activity. CNA #4 said sometimes the evening shift had only one CNA for each of the secured dementia units and one floating CNA between the two units, for the entire shift, making it extremely difficult to meet all of the resident care needs in a timely manner. This caused more concern when resident care needed to be provided in a resident room or in the resident's bathroom where the CNA was unable to monitor or intervene when a resident was experiencing an increase in aggressive or unsafe wandering behaviors. CNA #4 said sometimes leadership staff were able to assist but leadership staff were not usually in the building past 3:30 p.m. On 12/7/23 the secured unit was observed continuously from 9:30 a.m. to 11:05 a.m. The activities calendar for the secured memory care neighborhood revealed there was an activity scheduled at 9:30 a.m. café social. CNA #4 said the activity was held off the unit but none of the residents attended the activity due to a lack of staff to take the residents off the unit. There was no alternative activity provided to the residents in the unit. Eight residents were in the common area. One resident was reading a book on his own, two residents were watching The Lion King on the television. Two residents were staring off into space and the other two residents were dozing; this continued. The activities calendar revealed the next scheduled activity devotions and hymns was to begin at 10:30 a.m. but that activity did not start on time. The CNA continued to assist residents with care (using the bathroom and getting up out of bed and resident aide (RA) #5 stood off to the side watching the residents but did not provide any social interaction or resident engagement. Resident #47 was one of the residents dozing in the common area. Registered nurse (RN) #3 was in the nursing office and came out occasionally to check on residents and provide redirection to a resident who was walking around unassisted without his walker and or struggling to position himself correctly in front of his walker, as he pushed it across the floor. The unit smelled strongly of urine. At 10:33 a.m., Resident #30 who had been watching The Lion King started wandering the hallway complaining about the day and the other resident. RA #5 continued to observe the residents from a distance offering no engagement with any of the residents. When the Lion King movie ended RA #5 turned on Toy Story the movie. The resident who was reading a book was now walking in circles in an approximate four-foot area and was rummaging through items on the table. Resident #4 came out of his room to the common area. Resident #4 stood in the common area for a couple of minutes and said he was bored then he started wandering the unit hallway. Resident #4 said he liked driving and was interested in trucks. Resident #4 smelled strongly of urine and his sweatpants were heavily soaked with urine from the waistband to below his knees in both the front and back of his pants. After a few minutes of walking. CNA #2 noticed the resident was soiled and took Resident #4 to his room to get changed. At 10:41 a.m. activities, assistant (AA) #1 arrived in the unit to offer the 10:30 a.m. scheduled activity. The AA turned off the television and started the activity with the residents already in the common area. No other residents were gathered or invited to attend the activity. Six residents were in the common area. The AA introduced the activity by saying she was going to read a devotional passage offering no pre or post-discussion about the reading and then play a hymn for the residents. The residents sat silent. The AA engaged briefly with one resident when he asked a question about the hymn she played. After that hymn was over, the AA advanced to the next hymn and instructed the resident to listen to the music until lunch. The AA left the unit at 10:47 a.m. The activity lasted six minutes. RA #5 continued to monitor the residents in the common area from a distance, providing no social engagement, while the CNA attended to the other resident's care needs. Resident #30 was still wandering the hallway asking when lunch would be served. Resident #4 came back to the common area and said that he was not doing well RA #5 did not respond to him so he headed back to his room and shut the door. CNA #2 said that at yesterday's activity (on 12/6/23) four of the residents made pom pom animals and enjoyed the activity. At 10:56 a.m. six of the residents remaining in the common area were dozing as the hymns played in the background and or staring off into space. Resident #30 was asking for staff assistance to use the bathroom. At 11:00 a.m. lunch arrived and staff assisted the residents to the dining room. At 1:30 the afternoon activity "What is Hanukah" was observed. AA #1 arrived to the unit and presented the activity to only the residents already in the common area. AA #1 introduced the activity and turned on a short video for the resident to watch. Not all of the residents in attendance paid attention to the video. AA #1 tried to get the residents to pronounce some of the words in the video but the resident would not respond to the AA. Two family visitors were present and were watching the video than any of the seven residents in attendance. Once the video was over, AA #1 said goodbye and left the unit. The activity lasted five minutes. III. Residents #30, #47 and #4A. Resident #301. Resident statusResident #30, age 68 years old, was admitted on 12/17/21. According to the December 2023 computerized physician's orders (CPO), diagnoses included dementia with behavioral disturbance, lack of coordination and anxiety. The 10/5/23 minimum data set (MDS) assessment revealed the resident had severely impaired cognition as evidenced by a brief interview for mental status (BIMS) score of six out of 15. The resident had clear speech; was able to make himself understood and was able to understand others and comprehend conversations. The resident was assessed to display both physical and verbally aggressive behaviors directed toward others one to three days a week and has other behavioral symptoms not directed toward others four to six days a week, during the assessment time period. 2. Record reviewThe resident's comprehensive care plan, revised on 10/19/23, documented a care focus on recreational activities. The care focus document that Resident #30 enjoyed eating "everything;" like baseball and football; liked reading westerns; sitting in the sun; sitting by himself in the dining room; watching movies, especially action movies; listening to 60's and 70's rock and roll music; and liked joking with staff. At times the resident would participate in group activities such as exercise, animal visits, devotions, news reviews, sing-a-longs and sensory activities. Additionally, the care plan documented a care focus for elopement wandering risk, and behavioral aggression. Interventions included:-"Encourage the resident's participation in activities and explain to the resident the importance of social interaction, and leisure activity time.- Provide a program of activities that is of interest and accommodates the resident's status.- Activities and staff will provide scheduled activities within the resident's capabilities.-Offer emotional and psychological support.-Provide structured activities: toileting, walking inside and outside, and reorientation strategies including signs, pictures, and memory boxes." B. Resident #47 1. Resident status Resident #47, age 71 years old, was admitted on 4/5/23. According to the December 2023 CPO, diagnoses included dementia with agitation, unresolved pain and major depression. The 11/8/23 MDS assessment revealed the resident had moderately impaired cognition as evidenced by a BIMS score of eight out of 15. The resident had clear speech; was able to make himself understood and was able to understand others and comprehend conversations. The resident did not exhibit any physical and verbally aggressive behaviors directed toward others nor did he display other behavioral symptoms not directed toward others, during the assessment period. 2. Record review The resident's comprehensive care plan, revised on 11/17/23, documented a care focus on recreational activities. The care focus documented that Resident #47 enjoyed playing games and going for walks. His favorite television shows movies were Disney movies, westerns, Mickey Mouse, the news and sports programming. The resident enjoyed pets and country Western music. Additionally, the care plan documented a care focus for elopement and wandering risk, and behavioral aggression. Interventions included:-"All staff to converse with residents while providing care.-Ensure that the activities the resident attends is: compatible with physical andmental capabilities; compatible with known interests and preferences; adapted asneeded (such as large print, holders if resident lacks hand strength, tasksegmentation); compatible with individual needs and abilities; and is age appropriate.-Invite the resident to scheduled activities, and,-Provide a program of activities that is of interest and empowers the resident by-Encouraging while allowing choice, self-expression, and responsibility.-Offer the resident reminders, assistance, and escort him to activity functions." C. Resident #4 1. Resident status Resident #4, under the age of 65, was admitted on 12/21/12. According to the December 2023 CPO, diagnoses included schizophrenia, developmental disorder of scholastic skills, depression and dementia. The 9/15/23 MDS assessment revealed the resident had moderately impaired cognition as evidenced by a BIMS score of 11 out of 15. The resident had clear speech; was able to make himself understood and was able to understand others and comprehend conversations. The resident did not exhibit any physical and verbally aggressive behaviors directed toward others but displayed other behavioral symptoms not directed towards others, during the assessment period. 2. Record reviewThe resident's comprehensive care plan, revised on 9/9/23, documented a care focus on recreational activities. The care focus documented that Resident #4 enjoyed remote control cars; taking naps; watching television; visiting with staff, smoking and going for walks outside. The resident enjoyed group activities such as arts and crafts; snack socials; animal visits; trivia games; news; puzzles; and Bingo. Additionally, the care plan documented a care focus for elopement and wandering risk; preadmission screening and resident review (PASRR) level II diagnosis; expressions of sadness and boredom; suicidal ideations; and behavioral aggression. Interventions included:-"Encourage resident to participate in activities that he enjoys as accepted (the resident enjoys model car building, but he has a lack of motivation to self-start)- Provide and assist the resident in developing a program of activities that are meaningful and of interest.-Encourage and provide opportunities for exercise and physical activity.-Encourage, invite, and assist the resident to attend programs of interest.-Offer independent leisure material as appropriate or requested.-Staff to provide escort/supervision to/from areas of activities off the unit.-Provide cognitively appropriate activities." IV. Staff interviewsRA #4 was interviewed on 12/7/23 at 10:15 a.m. RA #4 said because the RAs were not licensed CNAs they were not allowed to provide any personal care but were responsible for watching the residents to ensure the residents were safe, providing snacks and beverages and talking with the residents to keep them occupied. RA #4 said sometimes the resident liked to toss a balloon around and talk about the books spread around the common area space. RA #4 was unsure how to keep the resident interested and occupied, did not know what to talk to the resident about to keep their interest and said the facility had not provided much training on how to keep the resident busy throughout the shift. RA #4 wished the facility offered more training on how to work with residents with dementia. The nursing home administrator (NHA) was interviewed on 12/7/23 at 12:44 p.m. The NHA said he talked daily with the secured unit life enrichment coordinator (LEC) to determine the staffing needed for each of the secured units. It was assessed that resident supervision levels were not being met they would increase staffing. The NHA said things could change from day to day; however, the existing staffing levels met the resident needs that week 12/4/23 to 12/7/23. The NHA said in addition to the scheduled CNA staffing the facility scheduled a resident assistant (RA) staff to provide additional monitoring in the secured units and also to engage the resident in activity programming. The NHA said the RAs were not permitted to provide hands-on personal care assistance to the residents but they were relied upon to keep the residents lively. The RA's assignment required the RAs to float between the two secured units providing social support and activities programming to keep the resident engaged at the directed by the nursing staff. The RAs were new to the secured unit and had been trained to perform their duties by the lead CNA; however, the activities staff had not provided the RAs any additional training on how to provide social engagement or activity programming. The NHA said in the event of a resident-to-resident altercation the RA could provide verbal de-escalation assistance but was not permitted to provide hands-on assistance, instead the RA was to call for nursing staff to provide physical redirection. The NHA said the secured unit staff including activities should be tailoring and customizing activities to meet the resident's needs and interests. They were not to provide precautionary activities or provide hot beverages such as coffee activities for safety reasons. The LEC was interviewed on 12/7/23 at 1:30 p.m. The LEC said the programming on the secured units was different from the activities programming provided on the non-secured units. The secured unit programming was designed to meet the needs of residents diagnosed with dementia. The LEC said she was responsible for developing the secured unit activity calendars and used several resources such as Pinterest to develop appropriate programming for the residents based on the resident's known interests. In addition, each of the units had a life stories binder containing the resident's background history and current interests so staff could provide additional social engagement activities between the scheduled activities. The LEC said the secured units had an assigned activities assistant to provide structured activities and the CNAs and RA staff were to provide additional recreation activities as needed to keep the residents engaged and occupied. The LEC said the RA's responsibilities were to keep an eye on the residents to make sure they were safe, provide snacks, water and activity programming. The RAs had access to activity supplies in the linen closets and could ask for other items as needed. The LEC said the CNA received dementia care training but did not believe that any of the four RAs had received training in dementia managed care. Cross-reference F949, failure toensure all staff were trained on the topic of behavioral health care and dementia managed care. The LEC said the resident did best when provided light and cheerful activities because a lot of the residents had post-traumatic stress disorder (PTSD). It was harder to find activities to engage the male residents but cartoons and comedy seemed to get their interest. The LEC said the male residents tend to have short attention spans and the residents needed more engaging activities to keep their interest. The LEC said engagement in activities helped prevent the resident from engaging in negative behaviors but this group of male residents needed some downtime between activities. The LEC said Resident #4 in particular liked to sleep a lot. The LEC said the activities department was short staffed at this time and the facility was in the process of hiring another part-time and one full-time activities staff. The CNAs were encouraged to provide additional activities programming but it was not always possible because they had their hands full with attending to the direct care needs of the resident in the secured unit. CNA #4 was interviewed on 12/11/23 at 2:15 p.m. CNA #4 said to prevent resident-to-resident altercations and other negative behaviors from occurring the staff on the secured unit needed to know what resident triggers were and who could and could not be around to maintain safety. CNA #4 said having consistent and sufficient staff was the key to a successful shift. CNA #4 acknowledged that the activities programming was too short and offered the residents little engagement and encouragement to participate. The CNA described the activities event the day prior (Sunday 12/10/23 around 4:00 p.m.) the activities staff arrived on the unit to start the scheduled activity dog stories, the Broncos football game was about to start and the television was up loud. The activities staff had to be told to turn down the television so the residents could hear her. When the residents did not respond to the activities, the staff gave up and left the unit. The activities staff did not even try to talk to the resident about the game that was about to begin. CNA #4 said they counted on activities staff to give them a little time to care for residents who did not like to come to the common area because it was impossible to monitor resident safety give resident care and provide activities all at the same time.

.Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in one of two medication carts and two of four medication refrigerators. Specifically, the facility failed to:-Ensure that expired medications were removed from the medication carts and disposed of in a safe manner;-Ensure that an open tuberculin vial was dated upon opening; and-Ensure that an expired Pneumovax 23 vaccine was removed from the medication refrigerator in a timely manner. Findings include:I. Professional referenceSanofi Pasteur. (2020). Package insert. Tuberculin Purified Protein Derivative (PPD)(Mantoux): Tubersol. Food and Drug Administration (FDA). https://www.fda.gov/media/74866/download, retrieved on 12/14/23 at 9:52 a.m. read in pertinent part, "A vial of Tubersol (tuberculin PPD) which has been entered and in use for 30 days should be discarded. Do not use it after the expiration date."Merck & Co., Inc. (2023). Package insert. Pneumovax 23. Food and Drug Administration (FDA). https://www.fda.gov/media/80547/download, retrieved on 12/14/23 at 9:52 a.m. read in pertinent part,"Store at two to eight degrees Celsius (36-46 degrees Fahrenheit). All vaccines must be discarded after the expiration date."U. S. Food and Drug Administration (FDA). (2/8/21). Don ' t be tempted to use expired medications. https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines#:~:text=Expired%20medical%20products%20can%20be,serious%20illnesses%20and%20antibiotic%20resistance retrieved on 12/14/23 at 9:52 a.m. read in pertinent part,"Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. "Once the expiration date has passed there is no guarantee that the medicine will be safe and effective."II. ObservationsOn 12/6/23 at 9:19 a.m., registered nurse (RN) #4 was observed throwing an unused liquid oral Multi Vite (multivitamin), expired 2022, into the trash on the side of the medication cart. On 12/7/23 at 10:16 a.m. medication refrigerators were inspected with the director of nursing (DON). The following items were found:-A vial of Tuberculin PPD was found in the refrigerator in the DON office, opened and undated;-A vial of Pneumovax 23 vaccine, opened and expired August 2023, was found in the refrigerator at the nursing station; and-A box of Acetaminophen suppositories, expired 1/2023, was found in the refrigerator at the nursing station. III. Staff interviewsRN #4 was interviewed on 12/6/23 at 9:30 a.m. She said that all resident medications, prescription and over the counter, should be disposed of in the facility's drug disposal system. She said medications should not be thrown into the trash because medications could be accessed and ingested by other residents. She said it was the responsibility of all nursing staff to check for expiration dates prior to administering any medications. She said an expired medication could be less effective or have unforeseen side effects. The DON was interviewed on 12/6/23 at 10:15 a.m. She said there was no way to ensure expired medications or vaccines were effective. She said all medications, prescription or over the counter, should be put into a slurry (a watery mixture which makes medications irretrievable) and disposed of by the medical disposal company. She said medications should not be thrown into the trash because dementia patients could get the medication and ingest it. She said the nurses were responsible for checking medication expiration dates prior to administering medications. She said, in the past, the pharmacy checked for expiration dates on all of the medication carts. She said currently the facility was transitioning to a new pharmacy company. She said all nurses were responsible to check for expiration dates in the refrigerators but there was no set process or assigned person to do it.

Based on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for one (#58) of two residents out of 40 sample residents. Specifically, the facility failed to offer food choices according to resident preferences for Resident #58. Findings include:I. Facility policy The Resident Food Preferences policy, revised July 2017, was provided by the corporate director of clinical risk management (CDCRM) on 12/11/23 at 10:49 a.m. It revealed in pertinent part, "Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team (IDT). When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and meal times. Nursing staff will document the resident's food and eating preference in the care plan."II. Resident Representative Interview The resident's representative was interviewed on 12/4/23 at 3:27 p.m. He said that the facility only offered coffee during meals so he bought the unit coffee. He said coffee was important to his Resident #58, especially when it was cold outside. He did not understand why the facility did not have coffee readily available for Resident #58's unit because she was not the only resident who enjoyed coffee. III. Resident #58 A. Resident statusResident #58, age 80, was admitted on 10/14/22. According to the December 2023 computerized physician orders (CPO), diagnoses included dementia, respiratory failure, acute kidney failure, anxiety, psychotic mood disturbance, muscle weakness, unsteadiness on feet and repeated falls. The 7/13/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She required extensive assistance with mobility, transfers, dressing, toileting and personal hygiene. She required supervision with eating. The resident resided in the secure women's unit. B. Record review The nutrition care plan, revised on 12/6/23, revealed Resident #58's food preferences were strawberries, soups, BLT (bacon, lettuce and tomato) sandwiches, crispy bacon, fresh vegetables and gravy. She did not like dry meat and dry chicken that was difficult to chew. -The care plan did not reveal the resident liked coffee. The quarterly dietary assessments for April 2023, July 2023 and October 2023 were reviewed. -The assessments did not reveal the resident liked coffee. Resident #58's food preferences form was provided by the dietary manager (DM) on 12/7/23 at 2:05 p.m. It revealed she liked coffee. The form was initiated on 10/17/22 and was updated on 3/13/23. IV. Observation On 12/5/23 at 9:51 a.m., the resident's representative came to the unit. He brought a large cup of coffee for Resident #58. The resident continued to drink her coffee until the observation ended at 11:42 a.m. On 12/7/23 at 1:39 p.m., the women's secure unit's 12-cup coffee maker was observed with certified nurse aide (CNA) #3 in the unit's supply closet. The supply closet also contained a small decaffeinated coffee container. CNA #3 said that Resident #58's representative brought the coffee for the residents. IV. Staff interviewsCook (CK #1) was interviewed on 12/6/23 at 12:00 p.m. He said coffee was offered three times a day at meal time. If a resident wanted coffee at non meal times they had coffee available. He said for the secured units, carafes of coffee were provided. CK #1 said if the secured units ran out of coffee they needed to ask the kitchen for more coffee. CNA #3 was interviewed on 12/6/23 at 12:48 p.m. She said they kept a coffee maker in the supply closet. She said she made the coffee, took the temperature, added ice if needed and then served coffee. She said they ran out of coffee frequently. When they ran out, families brought coffee for the residents. She said residents loved to drink coffee because it was therapeutic for them and reminded themof what they used to do. She said Resident #58 loved coffee and if she could, she would drink coffee all day long. The DM was interviewed on 12/7/23 at 12:57 p.m. She said the kitchen brewed the coffee. She said the life enrichment coordinator (LEC), who provided residents with activities, handled the coffee hour activity in the secure unit. The coffee for the coffee hour activity came from the kitchen. The DM was not aware that the secured unit had their own coffee maker-or that the unit ran out of coffee and families would bring coffee for the residents. She said she would make sure that the secured unit had coffee in their unit. She was aware that the women's secured unit residents loved coffeeThe DM said she was familiar with Resident #58. Prior to when the resident moved to the secure unit, the resident lived in the unit closest to the kitchen. The DM talked to the resident daily. She said the resident would drink coffee all day long. She thought the resident liked to drink coffee all day because it was a habit she had throughout her life. She said it was good to offer coffee to Resident #58 because it helped keep routines with the resident as well as helping the resident reminisce about her life. The DM provided Resident #58's food preferences form that the kitchen used to ensure the resident's likes and dislikes were honored. She said this was a paper form and was not attached to the resident's electronic medical record. She provided a new food preferences form that the facility used for new admissions and for quarterly review. She said Resident #58 would have the food preferences form filled out at the next quarterly review. She said the form was not shared with other team members such as CNAs, the LEC and nurses.

Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments. Findings include:I. Facility policy and procedureThe Facility Assessment policy, dated October 2018, was provided by the nursing home administrator (NHA) on 12/11/23 at 4:38 p.m. It revealed in pertinent part, "A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. "The facility assessment includes a detailed review of the resident population. "The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population."The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps determine budget, staffing, training, equipment and supplies needed. It is separate from the quality assurance and performance improvement evaluation."II. Record reviewThe facility assessment was last reviewed in November 2023 by the NHA and the interdisciplinary team. The facility assessment failed to include the following:-Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs were met for all new and existing staff;-Include staff trainings/education necessary to provide the level and types of support and care needed for the resident population; and,-Identify facility resources needed and equipment to provide competent resident support during day-to-day operations and emergencies. III. Staff interviewsThe NHA was interviewed on 12/11/23 at 12:05 p.m. The NHA said the interdisciplinary team reviewed the facility assessment in November 2023 during the Quality Assurance and Performance Improvement (QAPI) meeting. The NHA said the facility assessment had many missing components. The NHA said the facility assessment had several areas that were missing and said "fill in the blank."The NHA said the facility assessment did not include trainings needed for staff, the staffing plan, the secured unit or the bus and shuttle the facility had. The NHA said the emergency preparedness portion of the facility assessment had missing components such as a facility map. The NHA said he needed to review the facility assessment again to ensure it included all of the necessary items. The NHA said it was his first time completing a facility assessment and realized it needed to be a lot more thorough.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to:-Obtain committee feedback; collect data; monitor adverse events; identify areas for improvement; prioritize improvement activities; implement corrective and preventative actions; and conduct performance improvement projects related to problem-prone areas identified; and,-Address concerns related to the facility's failure to provide pneumonia vaccines as requested and per physician's orders. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) policy, dated 9/29/23, was provided by the nursing home administrator (NHA) on 12/4/23 at 9:30 a.m., it read in part: "Purpose: (facility name) have an ongoing Quality Management and Quality Assurance and Performance Improvement (QAPI) Program designed to objectively and systematically monitor and evaluate the resident's care and health care services. The comprehensive program is designed to provide care that is optimal within available resources and is consistent with the achievable goals for (facility name). "Policy: To ensure that monitoring quality of residents' care is performed systematically and continuously. To identify the organizational components responsible for Quality Management and QAPI Program functions and to delineate the components which include the line of authority, responsibility, and accountability. To ensure communication among all departments in improving resident care and identifying problems through the use of ongoing monitors by focusing on the identification, analysis, and resolution of problems. To evaluate the results of actions taken by each department and maximize the use of resources available within the facility."II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct F883 Influenza and pneumococcal immunizations During the survey conducted between 12/4/23 and 12/11/23 failure to provide pneumococcal vacancies as requested and as required; it was cited at a scope and severity of substandard quality of care. Cross-referenced to F883. III. Other cross-reference citations Cross-reference F692 nutritional parameters: During the survey from 12/4/23 to 12/11/23, the facility failed to provide consistent and effective nutritional care to prevent a resident from experiencing signifying weight loss, which was cited at a G scope and severity, harm that was isolated. Cross-reference F600 free from abuse and neglect: During a recertification survey on 8/25/22, F600 was cited at a G scope and severity, which was harm. During the survey from 12/4/23 to 12/11/23, the facility failed to prevent resident-to-resident physical altercations, was cited at a D scope and severity, with the possibility of more than minimal harm. IV. Staff interviewsThe NHA was interviewed on 12/11/23 at 4:36 p.m. The NHA said he was new to the facility and had only been to one QAPI meeting. The NHA said that all department managers attended QAPI meetings. In addition, the medical director and pharmacy consultant attended meetings. The NHA said the committee reviewed resident grievances and presented concerns from each facility's department leaders, and staffing issues. Once the committee identified concerns they developed a plan of action to address the concern. Each identified concern was referred back to the leadership member/department in charge of the concern area and the department worked on the improvement plan and presented results back to the committee at each month's meeting. Each identified concern was followed by QAPI until the concern was considered resolved.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to:-Ensure tracking, offering and administration of the COVID-19 vaccination;-Ensure professional standards of infection control were followed while cleaning resident rooms and resident room bathrooms, so they did not contaminate surfaces with water from the inside of the toilet bowl;-Ensure razors and sharps were disposed of properly in a biohazard container;-Ensure that foley catheter care and incontinence care were performed in a sanitary manner; and, -Ensure a used suction canister was disposed of in a sanitary manner. Findings include: I. Tracking of COVID-19 vaccinations for residents A. Facility policy and procedureThe Immunization policy, dated 7/28/23, was provided by the nursing home administrator (NHA) on 12/4/23 at 12:08 p.m. It revealed in pertinent part, "Purpose: to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza, pneumococcal pneumonia, and COVID-19 by assuring that each resident is informed about the benefits and risks of immunizations and has the opportunity to be immunized unless medically contraindicated or if refused by the resident or their legal representative."Before offering the influenza, pneumococcal, or COVID-19 immunization, each resident, or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunizations. They will be provided with this information on the informed consent form."The resident or resident representative has the opportunity to refuse immunizations; and the resident's medical record includes documentation that indicates, at a minimum:that the resident or resident's representative was provided education regarding the benefits and potential side effects of each of these immunizations and that the resident either received the immunization(s) or did not receive them due to medical contraindications or refusal. "The resident or the resident's representative will be provided education materials from the CDC (Centers for Disease Control and Prevention) and this will be recorded in the EHR (electronic health record). "If the resident is unsure of immunizations(s) has been administered, the medical provider or medical director will be contacted to determine appropriateness of administration of immunization and documented in the medical record. "Historial immunization will be documented in the Immunization section of the EHR when the information is available. "Refusals of immunizations will be documented in the Immunization section of the EHR with education provided to resident or resident's representative." B. Resident interview Resident #5 was interviewed on 12/4/23 at 10:48 a.m. Resident #5 said the facility had not offered him a COVID-19 booster recently. Resident #5 said he contracted COVID-19 in October 2023. Resident #5 said he desired to stay up to date on the COVID-19 vaccination. C. Record reviewAccording to the electronic medical record (EMR) of Residents #232, #233, #59, #42, #47, #75, #17, #5 and #35 it was not up to date with the residents' COVID-19 vaccination status. According to the EMR Residents #232, #233, #59, #42, #47, #76, #75, #35, #5 and #35 had not been offered a COVID-19 vaccination or offered an additional COVID-19 booster. According to the EMR Residents #6, #47, #35 and #17 did not have a documented declination form with risk versus benefit education. D. Staff interviewsThe director of nursing (DON) and the corporate nurse consultant (CNC) were interviewed on 12/5/23 at 10:53 a.m. The DON said the infection preventionist (IP) began working at the facility on 11/16/23. The DON said the facility used the immunization tab in the resident's EMR to track immunizations. The DON said the immunization tab should be up to date for each resident to include when they received or refused the influenza, pneumococcal and COVID-19 vaccination. The DON said some residents' immunization tabs were not up to date and she had to utilize the Colorado Immunization Information System (CIIS) to determine if the residents had received vaccinations. The DON said Resident #35's immunization tab was not up to date. The DON said Resident #35 had received three COVID-19 vaccinations. The DON said Resident #35 was offered a COVID-19 booster in October 2022. The DON said there was no documented declination form or education regarding the risks versus benefits. The DON said she would call the resident's representative and offer a COVID-19 booster. The DON said Resident #5 had received four COVID-19 vaccinations. The DON said she had spoken with Resident #5 and he did not want an additional COVID-19 vaccination. The DON said she would speak with Resident #5 again and offer a COVID-19 booster. The DON said the immunization tab in Resident #59's EMR did not indicate if the resident had received any COVID-19 vaccinations. The DON said she was able to locate Resident #59's vaccination card and it documented Resident #59 had received three COVID-19 vaccinations. The DON said Resident #59 had not been offered additional COVID-19 vaccinations. The DON said Resident #17 EMR was not up to date with his current COVID-19 vaccinations. The DON said she would need to look up the residents in CIIS to find more information regarding their COVID-19 immunization status. The DON said she had noticed in October 2023 that the facility was not tracking residents ' immunizations appropriately. The DON said she had not put an action plan in place to ensure all residents were up to date on their immunizations and a tracking process was in place. The DON, IP and CNC were interviewed on 12/6/23 at 12:37 p.m. The IP said she had recently started working at the facility and had not begun tracking immunizations. The DON said she was unsure of Resident #75's COVID-19 vaccination status, because she was unable to find the resident in CIIS. The DON said Resident #75 admitted from a different state. The DON said the facility should have asked the resident's family for his vaccination history upon admission and documented it in the resident's EMR. The DON said she would reach out to the family to determine if Resident #75 needed additional COVID-19 vaccinations. The DON said the facility did not have a clear process on who was responsible for offering immunizations upon admission. The DON said recently the admitting nurse had been offering the immunizations. The DON said the nurse was then responsible for contacting the physician to obtain an order to administer the vaccination. The DON said she was unsure of Resident #76's COVID-19 vaccination status. The DON said Resident #76 had not been offered a COVID-19 vaccine since he admitted to the facility. The DON said Resident #6's EMR was not up to date with his COVID-19 vaccination status. The DON said she would need to look the resident up in CIIS to determine his vaccination status. The DON said Resident #6 refused the COVID vaccine on 10/7/22, but there was not documented declination form or documented risk versus benefit education. The DON said she had to utilize CIIS to look up Resident #42's COVID-19 vaccination status. The DON said the process to track immunizations needed to be ironed out. The DON said going forward the IP or the admissions coordinator would look the resident up in CIIS and review hospital documentation to determine which immunizations the resident had received prior to admission. The DON said the IP would document the historical immunizations under the immunization tab in the EMR. The DON said the IP would determine which vaccines needed to be offered to the resident. The DON said the floor nurse would call the physician for orders to administer the vaccination. The DON said the facility would re-offer the COVID-19 vaccination annually with the influenza vaccination clinic or as directed by the resident's physician. The DON said she would have the IP conduct an audit of all resident's EMR to ensure all residents were up to date on their COVID-19 immunizations. The DON said the facility had not been tracking immunizations to determine if residents needed additional COVID-19 vaccinations or needed to be re-offered. The DON said a consent form should be in each resident's EMR that indicates if they wanted the vaccine or refused the vaccine, why they refused the vaccination and education or the risk versus benefit of the vaccination. The DON and the CNC were interviewed again on 12/6/23 at 2:16 p.m. The DON said Resident #232 recently passed away. The DON said Resident #232's EMR did not document if Resident #232 had received any COVID-19 vaccinations. The DON said Resident #233 had recently passed away. The DON said Resident #233's EMR was not up to date with the COVID-19 vaccinations Resident #233 had received. The NHA was interviewed on 12/6/23. At 3:59 p.m. The NHA said the immunization tracking process was not in order. The NHA said the facility needed to be monitoring and tracking the COVID-19 vaccination status of all residents. II. Ensure professional standards of infection control were followed while cleaning resident roomsA. Professional reference According to ECOLAB, Rapid Multi Surface Disinfectant Cleaner, retrieved on 12/19/23, from: https://mail.google.com/mail/u/0/?tab=rm&ogbl#search/alicia.hurd%40state.co.us/WhctKKZPFSNxtzwHTVqMhMqFxpBRlmwFZkWGzcWZBbqPvSCknQflVHXpZPPLGqsHcGdPmtQ?projector=1&messagePartId=0.1, revealed in pertinent part, "Non-Food contact Sanitization: Three minutes."B. Facility policy and procedureThe 7-Step Daily Washroom Cleaning policy, undated, was provided by the NHA on 12/11/23 at 10:50 a.m. It revealed in pertinent part, "Remember when using cleaning products always refer to the manufacturer's recommended dwell time. Dwell time, also referred to as contact time, is how long a chemical needs to be in contact with the surface in order to effectively sanitize or disinfect."C. ObservationsDuring a continuous observation on 12/5/23 beginning at 2:18 p.m. and ended at approximately 2:40 p.m. the following was observed:-HSKP #1 got a towel that was sitting in a multi surface disinfectant cleaner. HSKP #1 began wiping off the bedside table. HSKP #1 picked up items off the bedside table, wiped the table and placed the items back on the wet surface. She then began wiping off the bed frame, the blinds, window sill and vent. The surfaces stayed wet for approximately 30 seconds. -HSKP #1 got the toilet brush and cleaned the inside of the toilet. She did not use a chemical to disinfect the toilet. HSKP #1 flushed the toilet and placed the toilet brush back in the canister. During a continuous observation on 12/7/23 beginning at 9:38 a.m. and ended at approximately 10:00 a.m. the following was observed:-At 9:38 a.m. HSKP #2 entered room 105. There were two residents residing in room 105. HSKP #2 put on a pair of gloves and got a towel that was soaking in multi surface disinfectant cleaner. HSKP #2 began wiping off the door handles throughout the room. HSKP #2 then wiped off the A side bedside table, nightstand and pull cord. HSKP #2 used the same towel to wipe off the wheelchair that was in the middle of the room. HSKP #2 used the same towel to wipe off the B side nightstand, bedside table and sitting chair. HSKP #2 did not ensure the surfaces remained wet for three minutes. The surfaces were dry in approximately 30 seconds. -HSKP #2 grabbed another towel soaking in multi surface disinfectant and entered the bathroom. HSKP #2 wiped off the grab bars, the medicine cabinet and the sink. HSKP #2 got a new towel that was soaked in multi surface disinfectant and the toilet brush in a caddy. HSKP #2 wiped off the outside of the toilet. HSKP #2 used the toilet brush to wipe out the inside of the toilet. HSKP #2 did not ensure the surfaces remained wet for three minutes. HSKP #2 did not use a chemical to clean the toilet or the toilet brush. HSKP #2 flushed the toilet and returned to the cart. -HSKP #2 took off his gloves, sanitized his hands and put new gloves on. HSKP #2 got a mop head and mopped the B side of the room and then mopped the A side of the room. HSKP #2 got another mop head and mopped the bathroom. HSKP #2 returned to the cart, disposed of the mop head, took off his gloves and sanitized his hands. D. Staff interviewsHSKP #2 was interviewed on 12/7/23 at approximately 10:00 a.m. HSKP #2 said he had a guide that instructed him that the multi surface disinfectant cleaner had a dwell time of three minutes. The housekeeping supervisor (HSKS) and the HDM were interviewed on 12/7/23 at 11:02 a.m. The HSKS said the housekeepers should treat the A and B side of the room as separate rooms and not go from one side to the other without changing gloves and performing hand hygiene. The HSKS said separate towels and mop heads should be used for each side of the room. The HSKS said the housekeepers utilized a multi surface disinfectant cleaner that had a dwell time of three minutes. The HSKS said the surface must remain saturated for three minutes for the disinfectant to work. The HSKS said the facility did not currently have a toilet bowl cleaner. The HSKS said the housekeepers were utilizing a toilet brush without a disinfectant. The HSKS said the toilet brush was not disinfected between uses. The HSKS said the housekeepers were not effectively cleaning the toilets. The HDM said he would have the housekeepers use the multi surface disinfectant cleaner to clean the brush between uses and would order a toilet bowl cleaner to ensure the toilets were being cleaned appropriately throughout the entire facility. The HSKS said she would provide some education to the staff regarding treating shared rooms as two rooms, cleaning the toilet and ensuring the surfaces remain wet for a full three minutes. The IP was interviewed on 12/7/23 at 1:27 p.m. The IP said the A and B side of rooms should be cleaned as separate rooms. The IP said if the dwell time of a chemical was three minutes, the surface needed to remain wet for three minutes to effectively work. The IP said items should not be placed on the wet surface during the three minute surface disinfectant time of the multi surface disinfectant cleaner. The IP said the housekeepers should utilize a toilet bowl cleaner to properly sanitize the toilet. The IP said if the housekeepers did not sanitize the toilet properly it could potentially spread disease and infection. III. Ensure razors and sharps were disposed of properly in a biohazard containerA. Facility policy and procedureThe Medical Waste Handling policy, dated May 2012, was provided by the corporate director of clinical risk management (CDCRM) on 12/11/23 at 10:49 a.m.. It revealed in pertinent part, "Medical waste will be handled and disposed of safely and in accordance with regulatory requirements. "All sharps must be handled as medical waste, placed in approved sharps containers, and sent for eventual incineration."B. ObservationsOn 2/5/23 at approximately 2:44 p.m. in the 200 unit shower room there was a used razor that was not labeled with a resident name. On 12/6/23 at 2:16 p.m. there was a cardboard box that contained several sharps containers that were full in the DON's office. On 12/7/23 at 1:27 p.m. the box full of sharps containers remained in the DON's office. On 12/7/23 at 4:05 p.m. in the 500 unit shower room the sharps container was overflowing with used razors. -At 4:08 p.m. in the 300 unit shower room there was a used razor with hair on it. The razor was not labeled. There was a bin of seven electric razors that were not labeled with resident names. C. Staff interviewsThe DON, the IP and the corporate resource consultant (CRC) were interviewed on 12/7/23 at 1:27 p.m. The DON saidwhen sharps containers were full, nursing staff was responsible for removing the filled sharps container and placing it in the biohazard room. The DON said an outside company then disposed of the sharps containers. The IP said she had recently found a few full sharps containers. The DON said the full sharps containers should not be stored in her office for infection control practices. The DON said the razors in the shower rooms should be labeled with residents' names. The DON said razors should not be used for more than one resident. The DON said the sharps containers in the shower rooms should not be overflowing with razors. IV. Standard and Enhanced Barrier PrecautionsA. Professional referenceCenters for Disease Control (CDC). (1/30/2020). Hand Hygiene in Healthcare Settings. https://www.cdc.gov/handhygiene/providers/guideline.html, retrieved 12/17/23 at 1:15 p.m."Healthcare personnel should use an alcohol based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient; before performing an aseptic task (placing an indwelling device) or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or the patient's immediate environment; after contact with blood body fluid or contaminated surfaces and immediately after glove removal."B. ObservationsOn 12/5/23 at 1:00 p.m. certified nurse aides (CNA) #7 and #8 were observed entering Resident #59's room to provide incontinence care. CNA #7 and #8 did not perform hand hygiene or don gloves. CNA #7 and #8 left the room with bagged linen and did not perform hand hygiene upon exit of the room. On 12/6/23 at 9:46 a.m. CNA #10 and #11 provided incontinence care for Resident #59. CNA #10 and #11 donned gloves, repositioned Resident #59 onto her side and removed a soiled brief with a large semi liquid bowel movement. CNA #10 and #11 used disposable wipes and cleaned stool from her bottom. CNA #10 and #11 used fresh wipes and cleaned the front area around her urethra and proceeded down the foley catheter tubing. CNA #10 and #11 removed gloves and performed hand hygiene after wiping the foley catheter.-CNA #10 and #11 did not remove gloves and perform hand hygiene after cleaning bowel movement and before moving to the front and cleaning around the urethra and handling an indwelling foley catheter. C. Staff interviewsCNA #10 was interviewed on 12/6/23 at 9:15 a.m. She said when performing resident care and catheter care she puts on gloves and performs hand hygiene before and after care. CNA #10 was interviewed on 12/6/23 at 10:00 a.m. She said that gloves and hand hygiene were performed after cleaning a dirty area and before a clean area, including a foley catheter to prevent spreading bacteria from the dirty to clean area. Licensed practical nurse (LPN) #1 was interviewed on 12/7/23 at 10:40 a.m. She said that peri care for a female should start from front to back, going clean to dirty. She said if a dirty area was cleaned first before a clean area, gloves should be removed and hand hygiene performed. She said gloves should be changed before cleaning a foley catheter. The director of nursing (DON) was interviewed on 12/7/23 at 1:45 p.m. She said when providing resident care standard precautions were used. She said female incontinence care should go from clean to dirty and start in front to back. She said if a dirty area was cleaned first gloves should be removed and hand hygiene performed, especially before cleaning a foley catheter tubing. V. Suction canisterA. ObservationsOn 12/6/23 at 7:20 a.m. Resident #59 had a suction canister, hooked to a suction unit, filled halfway with yellow red tinged drainage on the nightstand. B. Staff interviewsRegistered nurse #4 was interviewed on 12/6/23 at 7:25 a.m. She said she did not know the policy on how often used suction canisters should be changed. She said Resident #59 no longer required being suctioned orally for secretions. She said she did not know how long the canister had been sitting on the nightstand. She said used canisters should be changed because the drainage contained bacteria and could be a source of infection. The DON was interviewed on 12/7/23 at 1:45 p.m. She said that used suction canisters should be changed every 24 hours as they could harbor bacteria and be a source of infection.

Based on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for 12 (#6, #59, #42, #47, #76, #75, #17, #35, #5, #27, #232 and #233) of 12 residents reviewed for immunizations out of 40 sample residents. Specifically the facility failed to:-Offer Resident #6 an annual influenza vaccination;-Offer Resident #59 and Resident #75 a pneumococcal vaccination upon admission;-Ensure Resident #42, Resident #47, Resident #76 and Resident #5's electronic medical records (EMR) were up to date with immunization records;-Determine if additional doses of the pneumococcal vaccination were needed and offer the additional doses of the pneumococcal vaccination as needed to Resident #42, Resident #47, Resident #76, Resident #35, Resident #5, Resident #232 and Resident #233; and,-Document declination forms, document risk versus benefit education and re-offer the pneumococcal vaccination annually for Resident #6, Resident #75, Resident #17 and Resident #35. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2022, retrieved on 12/13/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, "Routine vaccination-pneumococcal-For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20)." (see notes)For those "over the age of 65 who meet age requirements and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20."Special situations: Age 19-64 years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups."Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies."Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies."II. Facility policy and procedureThe Immunization policy, dated 7/28/23, was provided by the nursing home administrator (NHA) on 12/4/23 at 12:08 p.m. It revealed in pertinent part, "Purpose: to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza, pneumococcal pneumonia, and COVID-19 by assuring that each resident is informed about the benefits and risks of immunizations and has the opportunity to be immunized unless medically contraindicated or if refused by the resident or their legal representative. "Before offering the influenza, pneumococcal, or COVID-19 immunization, each resident, or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunizations. They will be provided with this information on the informed consent form."The resident or resident representative has the opportunity to refuse immunizations; and the resident's medical record includes documentation that indicates, at a minimum:that the resident or resident's representative was provided education regarding the benefits and potential side effects of each of these immunizations and that the resident either received the immunization(s) or did not receive them due to medical contraindications or refusal. "The resident or the resident's representative will be provided education materials from the CDC (Centers for Disease Control and Prevention) and this will be recorded in the EHR (electronic health record). "The facility will assess whether or not a resident has received the influenza vaccination at the time of admission to the facility and annually thereafter during the specified time frame (October 1 through March 31). "The facility will determine whether or not a resident has received a pneumococcal immunization at the time of admission to the facility and again after age 65 if the resident ages in place to turn 65. Pneumococcal immunizations to be offered as indicated following CDC recommendations. "If the resident is unsure of immunizations(s) has been administered, the medical provider or medical director will be contacted to determine appropriateness of administration of immunization and documented in the medical record. "Historial immunization will be documented in the Immunization section of the EHR when the information is available. "Refusals of immunizations will be documented in the Immunization section of the EHR with education provided to resident or resident's representative." III. Resident #6 A. Resident statusResident #6, age 75, was admitted on 6/9/08 and readmitted on 11/18/14. According to the December 2023 computerized physician orders (CPO), diagnoses included dementia, depression, history of COVID-19 and cerebrovascular disease (affects blood flow to the brain). The 11/20/23 minimum data set (MDS) assessment revealed Resident #6 had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of zero out of 15. He was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing and personal hygiene. The MDS assessment documented the resident was offered the pneumococcal vaccination and declined. The MDS assessment documented the resident last received the influenza vaccine on 9/29/22. B. Record review-A review of Resident #6's EMR revealed Resident #6 had not been offered the influenza vaccine in 2023.-There was no documentation as to why the resident did not receive the influenza vaccination in 2023. -Further review of the EMR revealed Resident #6 had not been offered the pneumococcal vaccination since 1/30/2019 and education regarding the risk versus benefit was not documented in the resident's EMR. IV. Resident #59A. Resident statusResident #59, age 82, was admitted on 11/12/22 and readmitted on 6/28/23. According to the December 2023 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), asthma, chronic kidney disease stage three and history of malignant neoplasm of bronchus and lung (history of lung cancer). The 9/4/23 MDS assessment revealed the resident had severed cognitive impairment with a BIMS score of seven out of 15. She required extensive assistance of two people for bed mobility dressing and personal hygiene. She required total dependence of two people for transfers and toileting. She required total dependence of one person for locomotion on and off the unit and for eating. The MDS assessment documented the resident was up to date on her pneumococcal vaccination. B. Record review-A review of Resident#59's EMR revealed there was no documentation to indicate Resident #59 had been offered the pneumococcal vaccination. V. Resident #42A. Resident statusResident #42, age 71, was admitted on 11/1/22 and readmitted on 9/8/23. According to the December 2023 CPO, diagnoses included adult failure to thrive, protein-calorie malnutrition and type two diabetes mellitus. The 10/3/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required set-up assistance for eating. She required supervision for oral hygiene. She required substantial assistance for toileting, upper body dressing and personal hygiene. She was dependent for showering and lower body dressing. The MDS assessment documented the Resident was up to date on her pneumococcal vaccination. B. Record review-A review of Resident #42's EMR revealed there was no documentation to indicate Resident #42 had been offered the updated pneumococcal vaccination. VI. Resident #47A. Resident statusResident #47, age 71, was admitted on 4/5/23. According to the December 2023 CPO, diagnosis included chronic obstructive pulmonary disease (COPD) and dementia. The 11/8/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. He required set-up assistance for eating. He required substantial assistance for oral hygiene, showering and personal hygiene. He required partial assistance for toileting and upper and lower body dressing. The MDS assessment documented the resident was not up to date on the pneumococcal vaccination. B. Record review-A review of Resident #47's EMR revealed Resident #47 had not received a pneumococcal vaccination since 5/2/98.-There was no documentation in the EMR to indicate why the resident had not received an updated pneumococcal vaccination. VI. Resident #76A. Resident statusResident #76, age 72, was admitted on 9/29/23. According to the December 2023 CPO, diagnoses included Alzheimer's disease and cardiac pacemaker. The 10/5/23 MDS assessment revealed the resident had severe cognitive impairment with a BISM score of six out of 15. He was independent with eating, toileting and dressing. He required partial assistance with oral hygiene. He required supervision with showering. He required substantial assistance with personal hygiene. The MDS assessment documented the resident was up to date on the pneumococcal vaccination. B. Record reviewA review of Resident #76's EMR revealed Resident #76 had received a pneumococcal vaccination on 11/22/22. -The EMR did not indicate which pneumococcal vaccination the resident had received. VII. Resident #75A. Resident statusResident #75, age 75, was admitted on 9/15/23. According to the December 2023 CPO, diagnoses included dementia and history of COVID-19. The 9/21/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. He was independent with eating, toileting and dressing. He required set-up assistance with oral hygiene. He required supervision with showering. The MDS documented the resident was not up to date on the pneumococcal vaccination and the pneumococcal vaccination was not offered to the resident. B. Record reviewA review of Resident #75's EMR revealed the pneumococcal vaccination was not offered to the resident.-There was no documentation in the EMR as to why the pneumococcal vaccination was not offered to the resident. VIII. Resident #17A. Resident statusResident #17, age 73, was admitted on 12/4/23 and readmitted on 11/29/23. According to the December 2023 CPO, diagnoses included dementia and history of COVID-19. The 10/27/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required set-up assistance for eating. He required substantial assistance with oral hygiene, toileting, showering, upper body dressing and personal hygiene. He was dependent for lower body dressing. The MDS assessment documented the resident was offered the pneumococcal vaccination and declined. B. Record reviewA review of Resident #17's EMR revealed Resident #17 refused the pneumococcal vaccination on 1/10/19. -There was no documentation in the EMR to indicate education regarding the risk versus the benefit of the vaccination was provided to the resident. IX. Resident #35A. Resident statusResident #35, age 65, was admitted on 1/19/21 and readmitted on 3/7/21. According to the December 2023 CPO, diagnoses included history of traumatic brain injury, dementia and history of COVID-19. The 9/21/23 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. She required extensive assistance of two people for bed mobility, transfers and toileting. She required extensive assistance of one person for locomotion on the unit and personal hygiene. She required supervision with set-up for eating. The MDS assessment documented the resident was up to date with the pneumococcal vaccination. B. Record reviewA review of Resident #35's EMR revealed Resident #35 had refused the Prevnar 13 and received the Pneumovax on 2/23/22. There was not a declination form or a risk versus benefit education documented in the resident's EMR. X. Resident #5A. Resident statusResident #5, under the age of 65, was admitted on 2/4/16. According to the December 2023 CPO, diagnoses included type two diabetes mellitus, paranoid schizophrenia and history of COVID-19. The 10/20/23 MDS assessment revealed the resident was cognitively intact with a BIMSscore of 14 out of 15. He was independent with all activities of daily living (ADLs). The MDS assessment documented the resident was not up to date on the pneumococcal vaccination. B. Record reviewA review of Resident #5's EMR revealed the resident had received a pneumococcal vaccination on 2/21/22. The EMR did not specify which pneumococcal vaccination the resident received. XI. Resident #27A. Resident statusResident #27, age 69, was admitted on 9/13/2020 and readmitted on 3/29/22. According to the December 2023 CPO, diagnoses included Alzhemier's disease, dementia and type two diabetes mellitus. The 10/19/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. She required set-up assistance for eating. She was dependent for oral hygiene, toileting, showering, lower body dressing and personal hygiene. The MDS assessment documented the resident was not up to date on the pneumococcal vaccination and was offered the pneumococcal vaccination and declined. B. Record reviewA review of Resident #27's EMR revealed the resident refused the Prevnar 13 vaccination on 11/27/19. -There was no documentation that revealed the vaccination was offered to the resident or resident representative or that risk versus benefit education was provided to the resident or the resident representative. -There was no documentation that the pneumococcal vaccination had been reoffered. XII. Resident #232 A. Resident statusResident #232, age 86, was admitted on 4/8/23 and expired on 11/14/23. According to the November 2023 CPO, diagnoses included anxiety. The 8/28/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. He was dependent for oral hygiene, toileting and showeringHe required substantial assistance for upper body dressing. The MDS assessment documented the resident was up to date on the pneumococcal vaccination. B. Record reviewA review of Resident #232's EMR revealed the resident had received the Prevnar 23 on 9/15/2017. -There was no documentation of the pneumococcal vaccination being offered again. XIII. Resident #233 A. Resident statusResident #233, age 86, was admitted on 6/9/21, readmitted on 5/15/22 and discharged on 11/16/23. According to the November 2023 CPO, diagnoses included cardiac pacemaker, morbid obesity, dementia, asthma and history of COVID-19. The 9/14/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. He required extensive assistance of two people for bed mobility, transfers, dressing and toileting. He required supervision with set-up assistance for locomotion on and off the unit and for eating. He required extensive assistance of one person for personal hygiene. The MDS assessment documented the resident was up to date with the pneumococcal vaccination. B. Record reviewA review of Resident #233's EMR revealed the resident had received a pneumovax vaccination on 6/30/11. -The EMR did not specify which pneumococcal vaccination the resident received. -There was no documentation to indicate the resident had been offered additional pneumococcal vaccinations. XIV. Staff interviews The director of nursing (DON) and the corporate nurse consultant (CNC) were interviewed on 12/5/23 at 10:53 a.m. The DON said the infection preventionist (IP) began working at the facility on 11/16/23. The DON said the facility used the immunization tab in the resident's EMR to track immunizations. The DON said the immunization tab should be up to date for each resident to include when they received or refused the influenza, pneumococcal and COVID-19 vaccinations. The DON said some residents immunization tabs were not up to date and she had to utilize the Colorado immunization information system (CIIS) to determine if the residents had received vaccinations. The DON said Resident #35's immunization tab was not up to date. The DON said the resident had refused the Prevnar 13 vaccine in the presence of her husband according to the immunization tab; however, the resident had consented to the pneumococcal vaccine in 2017. The DON said the resident may have received the vaccine, but it was not updated in the resident's medical record. The DON said further research needed to be conducted to ensure Resident #35's immunizations were up to date and determine which immunizations the resident needed to receive. The DON said Resident #5 received the Prevnar 23 vaccination in 2013 per CIIS. The DON said the EMR did not document which pneumococcal vaccination the resident had received in 2013. The DON said Resident #5 had received Prevnar 23 again on 2/21/22. The DON and the CNC said they were not sure how often the Prevnar 23 should be administered. The DON said the immunization tab in Resident #59's EMR did not indicate if the resident had received any pneumococcal vaccinations. The DON said Resident #17 refused the Prevnar 13 on 11/27/19. The DON said no documentation was found regarding risk versus benefit education or a consent form that was signed by the resident or her representative. The DON said she would need to look up the residents in CIIS to find more information regarding their pneumococcal immunization status. The DON said she had noticed in October 2023 that the facility was not tracking resident's immunizations appropriately. The DON said she had not put an action plan in place to ensure all residents were up to date on their immunizations and a tracking process was in place. Licensed practical nurse (LPN) #1 was interviewed on 12/6/23 at 1:36 p.m. LPN #1 said when a resident was admitted to the facility the admitting nurse would offer the influenza and pneumococcal vaccination. LPN #1 said if the resident wanted the pneumococcal vaccination she would obtain consent and administer the vaccine. The DON and CNC were interviewed again, along with the IP on 12/6/23 at 12:37 p.m. The IP said she had recently started working at the facility and had not begun tracking immunizations. The DON said Resident #17 refused the pneumococcal vaccination on 1/10/19. The DON said she was unable to find a documented consent form or education regarding the risk versus benefit for Resident #17. The DON said she would offer the resident the pneumococcal vaccination soon. The DON said she was unsure of Resident #75's pneumococcal vaccination status because she was unable to find the resident in CIIS. The DON said Resident #75 admitted from a different state. The DON said the facility should have asked the resident's family for his vaccination history upon admission and documented it in the resident's EMR. The DON said the physician had ordered Resident #75 to receive Prevnar 20 upon admission but Resident #75 had not received it. The CNC said Resident #75's medication administration record (MAR) indicated Resident #75 had refused Prevnar 20 on 9/15/23, but there was not further documentation revealing education was provided or why the resident refused the vaccination. The DON said the facility did not have a clear process on who was responsible for offering immunizations upon admission. The DON said recently the admitting nurse had been offering the immunizations. The DON said the nurse was responsible for contacting the physician to obtain an order to administer the vaccination. The DON said Resident #76 received Prevnar 13 on 8/26/21 per CIIS. The DON said Resident #76 had not been offered additional pneumococcal vaccines since the resident admitted. The DON said after additional research she was able to determine the resident had received Prevnar 20 on 11/22/22. The DON said Resident #6 had not received an influenza vaccination this season. The DON said the facility had reached out to the resident's representative to obtain consent. The DON said she was unsure of when the facility reached out and did not have documentation indicating the facility had attempted to obtain consent for the influenza vaccine for Resident #6. The DON said the facility should have documented their attempts to reach the resident's representative. The DON said if something was not documented that meant it did not happen. The DON said Resident #6 refused the pneumococcal vaccination on 1/30/19. The DON said the EMR did not indicate why the resident refused the vaccination. The DON said there was no documentation indicating the pneumococcal vaccination had been reoffered to Resident #6. The DON said Resident #42's EMR indicated the resident had received the Pneumovax on 9/1/2020. The DON said per CIIS the resident received the Prevnar 23. The DON said the process to track immunizations needed to be ironed out. The DON said going forward the IP or the admissions coordinator would look the resident up in CIIS and review hospital documentation to determine which immunizations the resident had received prior to admission. The DON said the IP would document the historical immunizations under the immunization tab in the EMR. The DON said the IP would determine which vaccines needed to be offered to the resident. The DON said the floor nurse would call the physician for orders to administer the vaccination. The DON said the facility would reoffer the pneumococcal vaccination yearly with the influenza vaccination clinic. The DON said she would have the IP conduct an audit of all resident's EMRs to ensure all residents were up to date on their immunizations. The DON said the facility had not been tracking immunizations to determine if residents needed additional pneumococcal vaccinations or needed to be re-offered the vaccination. The DON said a consent form should be in each resident's EMR that indicates if they wanted the vaccine or refused the vaccine, why the refused the vaccination and education or the risk versus benefit of the vaccination. The DON and the CNC were interviewed again on 12/6/23 at 2:16 p.m. The DON said Resident #233 recently passed away. The DON said Resident #233's EMR indicated he had received the Prevnar 23 in 2011. The DON said there was no documentation indicating the resident had been offered additional doses of the pneumococcal vaccination. The DON said Resident #232 was administered the Prevnar 23 in 2017. The DON and the CNC said they were unsure how often the pneumococcal vaccination should be administered. The DON said they should reach out to the resident's physician to determine if additional doses of the pneumococcal vaccination should be offered. The CNC said she located information regarding Resident #47's pneumococcal vaccination. She said she had received an additional dose in 2011. The CNC said Resident #47's physician needed to be contacted to determine if the resident should receive an additional dose of the pneumococcal vaccine. The NHA was interviewed on 12/6/23 at 3:59 p.m. The NHA said the immunization tracking process was not in order. The NHA said the facility needed to be proactive in offering pneumococcal and influenza vaccinations regularly. The medical director (MD) was interviewed on 12/6/23 at 4:24 p.m. The MD said it was important for the facility to monitor pneumococcal vaccinations. The MD said the facility should consult with the pharmacist and the attending physicians to determine which vaccinations each resident needed and how often the vaccinations should be administered.

Based on observations and interviews, the facility failed to maintain emergency response carts and equipment in safe operating condition for four of four emergency (crash) carts. Specifically, the facility failed to:-Ensure staff completed daily equipment checks;-Ensure expired items were removed from the crash cart;-Ensure missing items were replaced on the crash cart;-Ensure staff knew how to open the crash carts; and,-Ensure staff were trained on how to use the emergency oxygen cylinders. Findings include:I. Professional reference According to Mortell, Manfred, (2022). Crash cart preparedness and failure to rescue.. Retrieved on 12/14/23, from https://www.researchgate.net/publication/360555126_Crash_cart_preparedness_and_Failure_to_rescue_A_case_study_review and read in pertinent part,"A crash cart is a mobile cabinet on wheels that contains equipment required for emergency cardio-pulmonary resuscitation. The carts are individualized and conveniently located throughout healthcare facilities for rapid access in the event of an emergency. "A crash cart is typically located in the setting of an unexpected medical emergency. This could include severe allergic reaction, cardiac or respiratory arrest, and conditions with an unexpected sudden deterioration of vital signs. This would require equipment located on the card cart which would be used by a credentialed life support provider. While crash carts vary depending on location, the fundamentals for the crash cart will contain similar equipment. "Although the organization of requirements for a crash cart is not generic, there is a fundamental standard which provides effortless access to emergency medical equipment. Note that all these organizational points are checked, dated, and signed by the staff member who performed the daily routine inventory and inspection. "Top shelf/drawer-The top section typically has the most frequently used equipment employed in a resuscitation event such as power cords and personal protective equipment."Side or rear-The oxygen cylinder should be secure on the side of the cart, with a full oxygen pressure level;-A suction apparatus/charging battery for the portable use;-A sharps container should be secure on cart; and,-A rigid plastic/fiberglass backboard for chest compressions."Recommended equipment and medications-Organization and location specific."Recommended maintenance-Check expiration dates on equipment and medications per organization policy and replace as required."Schedule inventory check"The purpose of a crash cart inventory is to organize a schedule of when to check for expiration dates of equipment and supplies."Check that equipment is operating as required in the event of an emergency. In addition to recording who performed the inventory checks, with dates, times, and signatures. An alarming situation for the healthcare personnel requiring a crash cart is to find unusable equipment or expired medications in an emergency. Ensuring that an up-to-date, accurate, and truthful inventory record can avoid potential patient safety situations such as absence of equipment, equipment failure, expired or missing medication, and empty oxygen cylinders."The patient safety risk incident failure to rescue is perpetrated by healthcare professionals when they do not check cart accurately. Failure to follow standard or policy for checking equipment compromises patient safety and creates potential to harm patients." II. Observations and interviewsLicensed practical nurse (LPN) #1 was interviewed on 12/11/23 at 1:13 p.m. LPN #1 said she was unsure how to open the emergency crash cart in the dining room. At 1:31 p.m. the crash cart in the dining room was closed. The director of nursing (DON) walked by and said she was unsure if the crash cart in the main dining room was in use, but she would find out. At 1:35 p.m. the dietary manager (DM) walked through the main dining room. The DM said the crash cart was in use and she was unsure how to open it. After a few minutes, the DM was able to open the crash cart. The suction machine was covered in dust. There was an open artificial manual breathing unit (AMBU) bag on the bottom of the cart. There were no suction canisters available on the cart. There was a suction bag that expired on 7/8/16. -At 1:44 p.m. the crash cart in the women ' s unit had two dusty suction canisters and no supplies on the cart. The infection preventionist (IP) said the suction tanks on the women's unit had dust build up on them and they needed to be cleaned. -At 1:48 p.m. the crash cart in the men ' s unit had a broken suction canister. The crash cart and suction machine were dusty. There was a clipboard with a sign off sheet. The sheet was last signed in October 2022. Registered nurse (RN) #3 was present on the unit. RN #3 said she was unsure where the oxygen key was and would have to locate it. RN #3 said the night nurses were responsible for monitoring the crash carts. -At 1:53 p.m. the staffing coordinator (SC) was interviewed. The SC said the gloves that were on the crash cart on the men ' s unit expired in 2016. The SC said she went through the four crash carts on 12/11/23 and they all needed a lot of help to get up to speed. The SC said the carts were dirty, had expired items and were missing supplies. The SC said the suction canister on the men's unit was broken. The SC said the crash cart on the women ' s unit was missing supplies and only had two dirty suction machines on the cart. The SC said the night shift nurses were responsible for checking the carts and ensuring all items were present and functioning. -At 1:57 p.m. the crash cart for the 400 and 500 unit did not have oxygen available and the suction tank had a layer of dust on them. III. Facility administration interviewThe DON was interviewed on 12/11/23 at 2:28 p.m. The DON said there were four crash carts throughout the building. The DON said the crash carts needed to be checked monthly to ensure all of the supplies were present and working. The DON said the night shift nurses were responsible for checking the crash carts. The DON said the crash carts should be clean and free of dust. The DON said staff should not use dirty supplies. The DON said open AMBU bags should be disposed of properly and not left on the crash carts. The DON said the nurses should be trained on how to open the crash carts since they were a little tricky.

Based on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and resident abuse prevention; for 17 of 17 nursing staff hired between 10/1/23 and 12/6/23 out of 49 nursing staff members. Specifically, the facility failed to ensure that 11 certified nurse aides (CNA) (#4, #8, #10, #13, #15, #16, #17, #18, #19, #20, #21), four resident aides (RA) (#1, #2, #3 and #4) one registered nurse (RN) (#6) and one licensed practical nurse (LPN) (#2) received training on abuse identification, prevention and reporting. Findings include:I. Facility policy and proceduresThe Staff Training policy, revised 6/4/19, was provided by the corporate nurse consultant (CNC) on 12/11/23 at 10:49 a.m. It revealed in pertinent part "The community recognizes the importance of having a skilled workforce in order to achieve positive outcomes and operational plans and is committed to providing an environment that is conducive to effective performance and promotes training and development opportunities for all staff. There will be equality of opportunity for all community staff to develop their knowledge, skills and abilities through a blend of learning methods including mentoring, coaching, on the job learning, self study courses and training meetings."-The policy did not document the need for orientation and annual retraining in abuse identification, prevention and reporting. The Abuse policy, revised on 5/3/23, was provided by the nursing home administrator (NHA) on 12/4/23 at 9:36 a.m. It revealed in pertinent part "Identification of abuse shall be the responsibility of every employee."Education is provided at staff orientation and training programs that include topics such as abuse prevention, the Elder Justice Act, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior."Training programs were held at least annually on working with residents with dementia, dealing with behavior problems and resident rights. Abuse prevention training for all staff was offered semi-annually. Facilities's taff and outside resources are utilized. Certified nurse aides (CNA) were provided an opportunity to attend abuse prevention training outside the facility, as programs were offered in the community. General staff meetings include reminders and statements regarding facility policy on abuse."II. Staff training recordsA request was made for a list of all staff names, titles and hire dates. The NHA provided a list of all active staff on 12/7/23. From the all staff list, a request was made for proof of all newly hired (after 10/1/23) staff's participation in abuse training. The director of nursing (DON) provided a record of facility staff participation, however, the training records included a 60-minute training on the topic of abuse and incidents that occurred between 8/7/23 and 10/4/23. Staff hired after 10/4/23 were not included on the attendance list. A second request was made on 12/7/23 for proof that all newly hired staff received training on the topic of abuse management care. The DON said she would provide the requested training records. A third request was made on 12/7/23 for proof that all newly hired staff received training on the topic of abuse. The DON said she would provide the requested training records. The DON said she was gathering the requested records and would provide them by the end of the day. A fourth request was made on 12/11/23 at 8:00 a.m. and again at 12:00 p.m. The DON said she was still working on gathering the documents.-The requested training records for the new hire staff, including CNA #4, CNA #8, CNA #10, CNA #13, CNA #15, CNA #16, CNA #17, CNA #18, CNA #19, CNA #20, CNA #2, RA #1, RA #2, RA #3 RA #4, RN #6, and LPN #2 were not provided by the end of the survey or in the 24-hour post-survey period. III. Staff interviewsThe DON and CNC were interviewed on 12/11/23 at 3:09 p.m. The DON said the files provided on 12/11/23 at 2:37 p.m. and the annual training packet of signatures provided were all the training that the facility had for staff education. The CNC said that employee training records were not tracked through a computerized program that provided course status reports for compliance with each employee's training records. She said that the facility was looking into using a computerized training system to ensure staff were in compliance with the requirement for participation in annual abuse identification, prevention and reporting or dementia management training. The NHA was interviewed on 12/11/23 at 4:36 p.m. The NHA was aware that the DON and CNC were looking for training records for newly hired staff and existing staff's training over the past 12 months. The NHA said that the training provided was most likely the only training provided for staff in the past 12 months.-As of 12/14/23, there were no additional staff training records provided by the facility that training was completed.

Based on interviews and record review, the facility failed to develop, implement, and maintain a mandatory effective training program for all staff, which includes, at a minimum, training on the facility's quality assurance and performance improvement (QAPI) program, including the goals and various elements of the program, how the facility intends to implement the program the staff's role in the facility's QAPI program and how to communicate concerns, problems or opportunities for improvement to the facility's quality assessment and assurance (QAA) committee for 17 of 17 nursing staff hired between 10/4/23 and 12/6/23 out of 49 nursing staff members. Specifically, the facility failed to ensure that 11 certified nurse aides (CNA) (#4, #8, #10, #13, #15, #16, #17, #18, #19, #20, #21); four resident aide (RA) (#1, #2, #3 and #4); one registered nurse (RN) (#6); and, one licensed practical nurse (LPN) (#2) received training on the facility's QAPI program. Findings include:I. Facility policyThe Quality Management Plan/Quality Assurance and Performance Improvement Plan policy, dated 9/29/23, was provided by the clinical nurse consultant (CNC) on 12/11/23 at 3:52 p.m. It read in pertinent part: "It is the goal of the facility to integrate quality management program (QMP)/QAPI into all care and service areas of the organization. The following will be key areas of focus of the facility."Team member education: Action plans are reviewed at bi-monthly in-services with team members. (Corporation name) online education is adapted to address ongoing problems, issues, and risks; including Colorado Department of Public Health and Environment (CDPHE) required education topics."II. Facility assessmentA review of the facility assessment implemented on 12/1/23 and last reviewed with the quality assessment quality improvement (QAPI) revealed that the facility failed to document any details of the training needs of facility staff; including staff training/education necessary to provide the level and types of support and care needed for the resident population. Cross-reference F838 failure to develop a comprehensive facility assessment. III. Staff training recordsA request was made for a list of all staff names, titles and hire dates. The nursing home administrator (NHA) provided a list of all active staff on 12/7/23. From the all staff list, a request was made for proof of all newly hired (after 10/1/23) staff's participation in QAPI management training. The director of nursing (DON) provided proof of other staff's training but did not provide a record of facility staff participation in a QAPI training. A second request was made on 12/7/23 for proof that all newly hired staff received training on the topic of QAPI management care. The DON said she would provide the requested training records. A third request was made on 12/7/23 for proof that all newly hired staff received training on the topic of the facility's QAPI program. The DON said she would provide the requested training records. The DON said she was gathering the requested records and would provide them by the end of the day. A fourth request was made on 12/11/23 at 8:00 a.m. and again at 12:00 p.m., the DON said she was still working on gathering the documents.-The requested training records for the new hire staff including CNA #4, CNA #8, CNA #10, CNA #13, CNA #15, CNA #16, CNA #17, CNA #18, CNA #19, CNA #20, CNA #2, RA #1, RA #2, RA #3 RA #4, RN #6, and LPN #2 was not provided by the end of the survey or in the 24-hour post-survey period. IV. Staff interviewsThe CNC and DON were interviewed on 12/11/23 at 4:10 p.m. The CNC said the facility did not have the requested records. The NHA was interviewed on 12/11/23 at 12:05 p.m. The NHA said the facility assessment did not include training needed for staff and all training records had been provided.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all staff, which includes, at a minimum, training on behavioral health based on requirements and as outlined in the facility's assessment, for 17 of 17 nursing staff hired between 10/4/23 and 12/6/23 out of 49 nursing staff members. Specifically, the facility failed to ensure that 11 certified nurse aides (CNA) (#4, #8, #10, #13, #15, #16, #17, #18, #19, #20, #21), four resident aides (RA) (#1, #2, #3 and #4), one registered nurse (RN) (#6) and one licensed practical nurse (LPN) (#2) received training on behavioral health issues to include care specific to the individual needs of residents that are diagnosed with dementia and how to promote meaningful activities which promote engagement and positive meaningful relationships. Cross-reference F744 failure to provide dementia focused care. Findings include: I. Facility policyThe Dementia Clinical Protocol, revised November 2018, was provided by the clinical nurse consultant (CNC) on 12/11/23 at 3:52 p.m. It read in pertinent part: "Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the reviews. All clinical nursing staff received training to provide competent care for residents with behavioral and psychosocial needs including dementia management/dementia care to ensure that all facility staff and services to ensure two of six nurses reviewed completed required behavioral health training."-The protocol failed to document training protocols for other staff including the nurses, resident assistants and non-clinical staff. II. Facility assessmentA review of the facility assessment was implemented on 12/1/23 and last reviewed with the quality assessment quality improvement (QAPI) on 12/13/23, revealed that the facility served individuals with mental health and dementia diagnoses and staff had skills to support resident care needs including: "managing the medical conditions and medication-related issues causing psychiatric symptoms and behavior; identify and implement interventions to help support individuals with issues such as dealing with anxiety; care of someone with cognitive impairment; care of individuals with depression, trauma/post-traumatic stress disorder (PTSD); and, other psychiatric diagnoses, intellectual or developmental disabilities. -The facility assessment failed to document any details of the training needs of facility staff, including staff training/education necessary to provide the level and types of support and care needed for the resident population. Cross-reference F838 failure to develop a comprehensive facility assessment. III. Staff training recordsA request was made for a list of all staff names, titles and hire dates. The nursing home administrator (NHA) provided a list of all active staff on 12/7/23. From the all staff list, a request was made for proof of all newly hired (after 10/1/23) staff's participation in behavioral health and dementia management training. The director of nursing (DON) provided a record of facility staff participation; however, the training records which included a 60-minute training on the topic of dementia and behaviors that occurred between 8/7/23 and 10/4/23. Staff hired after 10/4/23 were not included on the attendance list. A second request was made on 12/7/23 for proof that all newly hired staff received training on the topic of behavioral health and dementia management care. The DON said she would provide the requested training records. A third request was made on 12/7/23 for proof that all newly hired staff received training on the topic of behavioral health and dementia management care. The DON said she would provide the requested training records. The DON said she was gathering the requested records and would provide them by the end of the day. A fourth request was made on 12/11/23 at 8:00 a.m. and again at 12:00 p.m. The DON said she was still working on gathering the documents.-The requested training records for the new hire staff including CNA #4, CNA #8, CNA #10, CNA #13, CNA #15, CNA #16, CNA #17, CNA #18, CNA #19, CNA #20, CNA #2, RA #1, RA #2, RA #3 RA #4, RN #6, and LPN #2 was not provided by the end of the survey or in the 24-hour post-survey period. IV. Staff interviews The CNC and DON were interviewed on 12/11/23 at 4:10 p.m. The CNC said the facility did not have the requested training records. The nursing home administrator (NHA) was interviewed on 12/11/23 at 12:05 p.m. The NHA said the facility assessment did not include training needed for staff and all training records had been provided.

A licensure survey was completed on 12/4/23 to 12/11/23. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure effective interventions were in place to address weight loss timely in one (#54) of seven residents out of 40 sample residents. Resident #54, who was identified as being at increased nutritional risk related to decreased oral intake and Alzheimer's disease, experienced a significant weight loss of 10.25% in a one month period of time and 12.42% in a three month period. The facility failed to ensure effective and timely interventions were in place to monitor, identify and prevent Resident #54's significant weight loss. The facility failed to monitor weekly weights, failed to consistently monitor meal intakes and failed to offer snacks when the resident refused or slept through meals. Additionally, the facility failed to implement new nutritional supplement interventions until 11/21/23, after the significant weight loss was identified. Due to the facility failures, the resident sustained a significant weight loss of 10.25% in one month and 12.42% in three months. Findings include:I. Professional referenceRoigk. P. (2018) Chapter 8: Nutrition and Hydration. In K. Hertz and J. Santy-Tomlinson Eds. Fragility Fracture Nursing: Holistic Care and Management of the Orthogeriatric Patient (Internet). Springer Publishing. https://www.ncbi.nlm.nih.gov/books/NBK543833/ retrieved on 12/12/23 at 1:37 p.m."According to the North American Nursing Diagnoses Association (NANDA) malnutrition is: 'Intake of nutrients insufficient to meet metabolic needs'. The criteria for malnutrition are: Body mass index (BMI) < (less than) 18.5 kg (kilograms)/m2 (height in meters squared), unintended weight loss > (greater than) 10% in the last 3-6 (three to six) months, BMI < 20 kg/m2 and unintended weight loss>5% in the last 3-6 (three to six)months, fasting period >7 (seven) days."II. Facility policy and procedureThe Food and Nutrition Services policy and procedure, revised October 2017, was provided by the nursing home administrator (NHA) on 12/11/23 at 10:47 a.m. It read in pertinent part,"The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional and psychosocial doctors that affect eating and nutritional intake and utilization."Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for significant nutritional problems. Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian."III. Resident #54A. Resident statusResident #54, age over 65, was admitted on 12/21/21. According to the December 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, anemia and gastroesophageal reflux disease (GERD). The 11/17/23 facility assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He required substantial or maximal assistance with dressing, partial to moderate assistance with toileting and personal hygiene and supervision or touch assistance with bed mobility, transfers and eating. The facility assessment did not indicate the resident was at risk for malnutrition or had a weight loss of 5% or more in one month or 10% or more in 6 months. B. ObservationsOn 12/5/23 at 11:00 a.m., Resident #54 was observed lying in bed on his right side sleeping with an untouched meal tray sitting at his bedside. On 12/5/23 at 12:00 p.m., Resident #54 was observed standing at his bedside and picking through the food on his tray. The resident did not attempt to eat anything on his tray. C. Record review The nutrition care plan, initiated on 12/23/21 and revised on 11/21/23, indicated that Resident #54 had a nutrition problem related to decreased oral intakes with a history of Alzheimer's, anemia and GERD. Interventions included fortified mashed potatoes with lunch and dinner, monitor oral intake, monitor skin integrity, monitor labs, monitor weights, monitor for malnutrition and significant weight loss, honor food/beverage preferences, obtain weekly weight for close weight monitoring, off snacks, provide diet as ordered and provide supplements as ordered. A comprehensive review of the care plan indicated Resident #54 had a prior history of significant weight loss in December 2022 and February 2023. The resident's weights were documented as follows:-8/20/23 124 pound (lbs);-8/30/23 122 lbs;-11/1/23 121 lbs;-11/6/23 112.6 lbs; and,-11/21/23 108.6 lbs. A comprehensive review of the resident's weights revealed a weight loss of 10.25% in less than one month ( between 11/1/23 to 11/21/23) and a loss of 12.42% in three months (between 8/20/23 to 11/21/23). The December 2023 CPO indicated weekly standing weights every Monday or Tuesday, ordered on 8/17/23.-There were no weekly weights documented for Resident #54 from 8/30/23 until 11/1/23.-There were no weekly weights documented for the resident from 11/6/21 until 11/21/23. A comprehensive review of Resident #54's physician orders revealed the following diet and supplementation orders:-Magic cup in the evening for a low body mass index (BMI) of 18.3, ordered 8/5/22;-House nourishment twice a day, ordered 2/10/22 and discontinued 11/21/23;-Regular, dysphagia advanced texture diet with regular thin consistency, ordered 1/5/23;-Offer snacks if the resident slept through the meal, ordered 2/10/23; and, -House nourishment after meals for weight loss offer 4 ounces (oz) shake if less than 50% of the meal consumed, ordered 11/21/23. -There was no documentation in the resident's electronic medical record (EMR) for snacks being provided to the resident for October 2023, November 2023 or December 2023.-New interventions were not put into place until 11/21/23 when a weight loss of 10.25% in one month time and 12.42% in three months was identified. The 8/31/23 nutrition progress note documented the resident's BMI was 20.3 with house shakes ordered twice a day, Magic cup once a day and snacks as needed. The progress note documented that the resident had variable intakes and no new interventions were ordered. The 11/7/23 nutrition progress note documented a weight of 112.6 lbs, which was a decrease of 6.9% in less than one week. A reweight was requested.-There was no documentation in the resident's EMR of a reweight being obtained until 11/21/23. The 11/21/23 nutrition progress note documented a weight of 108 lbs with nursing reporting the resident was not eating much and sleeping more. Interventions were to increase house shake to three times a day and to offer snacks when less than 50% of the meal was consumed. The 11/17/23 nutrition quarterly assessment indicated the resident had a weight loss of 6.9% in less than 30 days (11/1/23-11/6/23) and a reweight was requested.-There was no documentation of a reweight being done until 11/21/23.-A comprehensive review of the nutrition progress notes did not indicate any further documentation between 8/31/23 and 11/7/23. A comprehensive review of meal intakes for Resident #54 revealed inconsistent documentation of the resident's food intake. There were multiple days when staff failed to record the resident's meal intake including:-On 11/7/23, there was no documentation of intake for dinner;-On 11/8/23; documentation of 50% or less for lunch and there was no documentation of intake for dinner;-On 11/9/23; there was no documentation of intake for dinner;-On 11/10/23; there was no documentation of intake at breakfast or lunch;-On 11/11/23; there was no documentation of intake for dinner;-On 11/13/23; documentation of 50% or less for for lunch;-On 11/14/23; there was no documentation of intake for dinner;-On 11/15/23; there was no documentation of intake for breakfast or lunch;-On 11/16/23; there was no documentation of intake for dinner;-On 11/17/23; documentation of 50% or less for lunch and there was no documentation of intake for dinner;-On 11/18/23; there was no documentation of intake for breakfast or lunch;-On 11/19/23; there was no documentation of intake for breakfast, lunch or dinner;-On 11/21/23; documentation of 50% or less for dinner;-On 11/22/23; there was no documentation of intake for breakfast or lunch;-On 11/23/23; documentation of 50% or less for breakfast and there was no documentation of intake for lunch or dinner;-On 11/24/23; there was no documentation of intake for breakfast;-On 11/25/23; there was no documentation of intake for breakfast, lunch or dinner;-On 11/27/23; there was no documentation of intake for dinner;-On 11/28/23; there was no documentation of intake for dinner;-On 12/1/23; there was no documentation of intake for breakfast or lunch;-On 12/2/23; there was no documentation of intake for breakfast or lunch; and,-On 12/3/23; there was no documentation of intake for breakfast, and documentation of 50% or less for lunch and dinner.-Review of Resident #54's EMR revealed there was no documentation of snacks being provided when the resident refused or slept through meals or had an intake of 50% or less. IV. Staff interviewsCertified nurse aide (CNA) #8 was interviewed on 12/7/23 at 11:50 a.m. She said all residents needed to have their meal intakes documented and all CNAs were responsible for documenting meal intakes. She said that residents with nutrition and weight loss issues should have a weekly weight done. Licensed practical nurse (LPN) #1 was interviewed on 12/6/23 at 10:40 a.m. She said the CNAs documented meal intakes on the resident's record and provided meal assistance. She said residents with weight loss and nutrition issues had weekly weights ordered. She said Resident #54 was identified recently as declining with weight loss and said he should have weekly weights and meal intakes documented. The registered dietitian (RD) was interviewed on 12/7/23 at 11:50 a.m. She said all residents, especially those with identified weight loss, needed to have their meal intakes and weekly weights documented. She said Resident #54 was identified as losing weight on 11/1/23. She said there was a gap in the documentation for weights between August 2023 and November 2023 and that his meal intakes had been documented as variable at times. She said she had recently increased his house supplement to three times a day with meals. The director of nursing (DON) was interviewed on 12/11/23 at 2:30 p.m. She said CNAs could provide meal assistance to residents and were responsible for documenting meal intakes. She said that agency CNAs were given access to the documentation system in their orientation packet to the facility. She said weekly weights were to be completed on Resident #54 and all residents who had been identified with significant weight loss.

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 11/13/2023 and 11/19/2023, 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 11/06/2023 and 11/12/2023, 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 10/30/2023 and 11/05/2023, 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 10/23/2023 and 10/29/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A health survey with complaint #CO33811 was completed 10/25/23 to 10/26/23. No response necessary.

A complaint survey, prompted by #CO33818 and Incident #32387 was completed on 10/25/23 to 10/26/23. No deficiencies were cited.

A revisit survey was completed on 10/6/23 for all previous deficiencies cited on 8/7/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO32030 was conducted 8/2/23 to 8/7/23. Two deficiencies were cited.

Based on observations and interviews the facility failed to ensure residents had the right to a safe, clean and comfortable homelike environment in their rooms. Specifically, the facility did not facilitate the necessary housekeeping and maintenance services to maintain the resident rooms on two of five halls in a sanitary and comfortable manner. Findings include: I. Facility policies and procedures The Maintenance Service policy, revised December 2009, was provided by the director of nursing (DON) on 8/2/23 at 3:29 p.m. The policy revealed that services should be provided to all areas of the building, grounds, and equipment. The maintenance personnel should maintain the facility in compliance with current federal, state and local laws, regulations and guidelines. The facility should be maintained in good repair and free from hazards. The maintenance director was responsible for developing and maintaining a schedule of maintenance service, to assure that the buildings, grounds, and equipment were maintained in a safe and operable manner. The Maintenance Work Orders policy, revised April 2010, was provided by the DON on 8/2/23 at 3:29 p.m. The policy revealed work orders should be completed in order to establish a priority of maintenance service. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director. It should be the responsibility of the department directors to fill out and forward work orders to the maintenance director. A supply of work orders was maintained at each nurses' station. Work order requests should be placed in the appropriate file basket at the nurses' station. Work orders were picked up daily. The Cleaning and Disinfection of Environmental Surfaces, revised August 2019, was provided by the DON on 8/2/23 at 3:29 p.m. The policy revealed housekeeping surfaces (such as floors and tabletops) would be cleaned on a regular basis, when spills occurred, and when those surfaces were visibly soiled. Environmental surfaces would be disinfected (or cleaned) on a regular basis (for example daily or three times per week) and when surfaces were visibly soiled. II. Room observations On 8/2/23 at 11:29 a.m., a walkthrough of the women's secure unit was conducted. The observations revealed: Resident room #200 had loose and torn room cove base, chipped paint on the entrance door frame, a missing light fixture on one light over the sink, and a loose bathroom transition strip. Resident room #201 had a torn bathroom linoleum floor, black marks on the bathroom door, chipped paint on the bathroom door frame, chipped paint on the bathroom walls, a loose bathroom transition strip, multiple bugs in the room ceiling light fixture, and chipped paint on the entrance door frame. Resident room #202 had chipped paint on the bathroom door frame, a large hole in one room wall, chipped paint on one room wall, and a loose wooden wall cover on one room wall. Resident room #203 had a large hole in one room wall, black marks on the bathroom door, chipped paint on one bathroom wall, and multiple bugs in the room ceiling light fixture. Resident room #207 had loose entrance door laminate, missing cove base in the room, loose cove base in the room, loose entrance night light cover on the wall by the entrance, torn bathroom linoleum floor, eight exposed screw heads on two room walls, four small holes in one room wall, and cracked caulk around the in room sink. On 8/2/23 at 11:55 a.m., a walkthrough of the men's secure unit was conducted. The observations revealed: Resident room #300 revealed missing cove base on one room corner, chipped paint on the bathroom door, chipped pain on the bathroom door frame, black marks on the closet doors, loose room cove base, sheet rock damage on one room wall corner, dirty (unclean, grimy) room corners, loose caulk around the in room sink, chipped paint on the entrance door frame, bathroom door stuck to room floor while opening, torn plastic entrance door laminate, and multiple bugs in the room light ceiling fixture. Resident room #301 revealed a small hole in the bathroom door, loose cove base in the room, missing bathroom floor transition strip, multiple bugs in bathroom light fixture, chipped paint with rust on bathroom door frame, and bubble (raised) bathroom floor linoleum. Resident room #302 revealed missing room cove base, unpainted sheetrock patch on a room wall, loose cove base in the bathroom, chipped paint on the bathroom door frame, torn laminate on the entrance door, dirty room corners, and sheet rock damage on the wall by a recliner. Resident room #303 revealed loose room cove base, separated caulk around the room sink, 17 black adhesive spots on two room walls, multiple bugs in the room ceiling light fixture, chipped pain on the entrance door frame, loose metal night light cover on the wall at the entrance to the room, sheet rock damage on a room wall by the bathroom, loose bathroom transition strip, chipped paint on one bathroom wall, chipped paint with rust on the bathroom door frame, multiple bugs in the bathroom ceiling light fixture, dirty room corners, chipped paint on the room wall chair molding and separated sink caulking around the room sink. Resident room #304 revealed dirty room corners, missing room cove base, large sheet rock damage hole under the room sink, two padlock hasps (sharp to the touch) on the room metal heater cover, loose bathroom cove base, white towels surrounding the toilet base that appeared wet, rusty bathroom door frame, multiple bugs in the bathroom ceiling light fixture, and multiple uncleaned spots on one recliner fabric. Resident room #305 revealed chipped paint on the entrance door, torn laminate on the entrance door, dirty room corners, missing room cover base, sheet rock damage on one room corner, chipped paint with rust on the bathroom door frame, and chipped paint on the closet door frame. Resident room #306 revealed a missing room mirror at the sink, dirty room corners, dirty cove base, loose room cove base and sheet rock damage on one room corner. Resident room #308 revealed missing room cove base, unpainted sheetrock patches, cove base lying on room floor under the sink, chipped paint on one room corner, loud bathroom exhaust fan, chipped paint on the bathroom door frame, chipped paint on the bathroom door, multiple bugs in the room ceiling light, loose bathroom cove base, raised bathroom linoleum floor, small hole in wall by recliner, and loose entrance door laminate. Resident room #310 revealed the bathroom door scraped against the room floor when opened and closed, chipped paint on the bathroom door frame, chipped paint on one wall, multiple bugs in the room ceiling light fixture, chipped paint on the entrance door, and a pink basin under the room sink with approximately one inch of water. III. Staff interviews An environmental tour of the above mentioned rooms was conducted on 8/2/23 at 1:26 p.m. with the nursing home administrator (NHA), nurse mentor (NM) #1, NM #2 and the director of maintenance (DM). They acknowledged the above observations in the residents' rooms and bathrooms. The DM said there were maintenance work order logs on three of the five halls at the nurse's station. The DM said the logs should be checked daily, however there were times they might not be checked for two days. The DM said he could be reached by phone for emergency repairs. The NHA touched the towels that surrounded the toilet base in room #304 and acknowledged that the towels were wet. The NHA acknowledged the pink basin under the sink in room #310. The basin had water in it that dripped from the sink. The housekeeping supervisor (HSK) was interviewed on 8/3/23 at 9:45 a.m. She said resident rooms and bathrooms were cleaned daily. She said each room was deep cleaned once a year. She said the rooms were waxed once a year. She said the room corners were dirty with a mixture of wax build up and grime (unclean debris). She said the corners of the rooms should be cleaned daily. She said the room cove base would be cleaned as needed. She said she had not filled out any maintenance requests (work orders) for needed repairs. An interview was conducted on 8/3/23 at 4:30 p.m. with the NHA and DM. They again acknowledged all of the concerns that were seen on the environmental tour of the facility. The DM said the facility did not use the TELS (computerized maintenance system) for staff to notify maintenance of needed repairs. He said staff were to fill out work order logs. He said the maintenance assistance was to review the logs daily and sometimes there was a two-day delay in looking at the logs. He said the staff did text him and verbally tell him what needed to be repaired. He said the rooms were cleaned on a daily basis. He said he tried to do a daily walk through of the facility to observe any items that needed repairs and prioritized the times that were urgent. He said they periodically removed bugs from the ceiling light fixtures, however they continued to be inundated by the bugs. He said the facility had replaced six resident bathroom floors and five more were scheduled for replacement on 8/14/23. Certified nurse aide (CNA) #3 was interviewed on 8/7/23 at 10:00 a.m. She said she typically worked on the men's secure unit. She pointed out the maintenance log that was on the shelf in a yellow binder. She said she had not placed any requests in the logs, but had texted or verbally told the DM.

Based on observations, record review and interviews, the facility failed to ensure the highest practicable quality of care for one (#10) of three out of eight sample residents that were reviewed for falls and post-fall assessments. Specifically, the facility failed to ensure neurological assessments were started and completed for Resident #10's three unwitnessed falls in his room. On 4/24/23, the resident sustained fractures of the left frontal process of the maxilla (a major bone of the face below the nose that forms the upper jaw) and nasal bones. The resident also had a laceration and a contusion to the forehead. On 4/28/23, the resident fell and did not sustain any injuries. On 7/21/23, the resident sustained a contusion with a laceration to his forehead. Neurological assessments were not conducted following any of these falls to identify potential head injuries. Findings include:I. Facility policies and proceduresThe Neurological Check Sheet, undated, was provided by the director or nursing (DON) on 8/7/23 at 8:38 a.m. The sheet revealed that neurological assessments would be completed according to the frequency listed on the sheet. The frequency was to assess the resident every 15 minutes' times four, every 30 minutes' times four, every one hour times four and every shift times eight. The ledger on the right side of the sheet revealed that staff were to assess the resident's vital signs, pupil shape/reaction (equal/round, unequal, misshapen, pinpoint, dilated, fixed, brisk, sluggish and non-reactive), extremities (strong, weak, flaccid and rigid), consciousness (alert, confused, restless, lethargic), orientation (person, place, date, time), speech (clear, slurred or garbled), response (name, pain, environment, unresponsive), and other (unsteady gait/balance, visual disturbances, seizure, headache, vomiting). The Fall Management policy, dated 3/20/23, was provided by the DON on 8/8/23 at 4:31p.m. The policy required that if a resident experienced a fall with a head injury, the fall was unwitnessed, or the resident self-reported a fall, then neurological checks would be initiated. II. Resident statusResident #10, age 58, was admitted on 7/2/15 and readmitted on 3/30/23. According to the August 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, schizophrenia, anxiety, obsessive compulsive disorder, muscle weakness, and fracture of the nasal bones. The 5/11/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The resident had functional limitations in range of motion in the upper or lower extremities. During surface to surface transfers (transfer between bed and chair or wheelchair), the resident was not steady and only able to stabilize with staff assistance. The resident had one fall in the facility since admission or a prior assessment. III. Resident observation/interviewThe resident was interviewed on 8/8/23 at 10:23 a.m. He had a small red abrasion to the upper left forehead and said it did not currently hurt. He said he fell in his room, approximately a week ago. IV. Record reviewThe care plan for an actual unwitnessed fall with injury due to attempting to stand at times unsafely was initiated on 3/7/18. It revealed the resident had a history of falls and declined the use of a helmet or other safety devices. Some of the pertinent interventions were to monitor for pain/injury related to falls, the resident's room had been assessed and no issues were noted, offer to assist to the toilet frequently as accepted (10/11/19), offer toileting as the resident allowed after meals (5/10/22), remove pedals when resident transfers from wheelchair to bed to avoid tripping (5/10/22), offer toileting every two hours (4/25/23), monitor laceration to left eyebrow as ordered (5/17/23), therapy to place walker next to bed to assist with transfers and toileting (6/28/23), resident's walker was to be kept at bedside to assist the resident when he attempted to self-transfer (6/29/23), and staff educated the resident on 7/21/23 to call for assistance when needed to toilet (8/3/23). The care plan for being at high risk for falls related to Parkinson's disease was initiated on 6/29/21 and included similar interventions.-However, the resident's fall risk and actual falls care plans did not document interventions to conduct thorough post-fall assessments such as neurological checks. A. Unwitnessed fall on 4/24/23 with injuriesReview of incident notes and an incident report dated 4/24/23 at 4:20 p.m. by a registered nurse (RN) revealed she was notified by a certified nurse aide (CNA) that the resident was on the floor. This nurse observed the resident lying on his left side and was alert. The resident stated he was trying to go to the bathroom. The resident was unable to rate his pain. This nurse had administered routine Morphine and Ativan about five minutes prior to the fall. The resident had a significant amount of bleeding. This nurse assessed the resident. The resident's injuries were cleaned with a wound cleanser. The resident's injuries were covered with a dry dressing to the front of his forehead and bridge of his nose. The resident also had a laceration to his inner upper lip and redness and abrasions to his bilateral knees. Emergency services were called. An ambulance arrived and the resident was assessed. A neck brace was placed on the resident and he was transported to the hospital. The DON (director of nursing) and hospice were notified. The hospital emergency room (ER) summary visit printed on 4/25/23 at 9:07 p.m. revealed fractures of the left frontal process of the maxilla and nasal bones with minimal displacement. There was also a laceration/contusion to the forehead.-There was no documentation of neurological assessments when the resident was first assessed after his fall, or after he returned from the hospital after treatment for a head injury. B. Unwitnessed fall on 4/28/23 with no injuriesAn incident report for an unwitnessed fall on 4/28/23 at 12:10 p.m. was written by an RN. This report revealed the resident was found on the floor adjacent to his bed around 12:10 p.m. The resident was lying on his left side. The resident had gotten up from his wheelchair and fell. The resident was alert and responsive. The resident was put to bed and assessed further. The resident was able to follow simple instructions such as raising his arms and raising both legs without difficulty. The resident was able to finger count without difficulty. The resident was assessed by this RN and neurological assessments were initiated. The resident was not taken to the hospital and no injuries were observed at this time. The resident was only oriented to person.-Although the RN documented in the incident report that neurological assessments were initiated, there was no evidence of neurological assessments in the resident's medical record. C. Unwitnessed fall on 7/21/23 with injuriesNurse notes and an incident report dated 7/21/23 at 6:00 p.m. by an LPN revealed this nurse clocked in for work and was asked to help with the resident that fell in his room at 5:57 p.m. The resident was in bed with several 4-inch by 4-inch bandages over a wound. The bleeding was controlled. The bandages were removed and the wound was cleaned with a wound cleanser. The resident had a 4.5 cm by 3.0 cm contusion with a 0.5 cm by 0.5 cm laceration at the bottom edge of the contusion. The skin was approximated and antibiotic ointment was applied. Hospice was called and neurological assessments were started. The hospice nurse arrived at 8:00 p.m. and assessed the resident. The resident denied pain at this time. The hospice nurse gave orders to continue neurological assessments with a frequency of every 15 minutes times six, every hour times six and then every shift and to be notified if a status change was observed. Staff were to monitor the resident's wound until it healed for signs or symptoms of infection. Nursing would continue to monitor. (See RN note below.)-Although the hospice nurse instructed facility nursing staff to conduct neurological assessments, there was no evidence in the resident's medical record that they were conducted. Further, there was no evidence that a registered nurse (RN) assessed the resident after his fall until a late entry was documented on 8/3/23 (below). A late entry incident note dated 8/3/23 at 8:28 p.m. by an RN revealed this nurse was called by a CNA to the resident's room on 7/21/23 at 5:57 p.m., and notified the resident was on the floor. The resident was on the floor between his wheelchair and a dresser. There was urine on the floor. The resident had a cut on his forehead. The resident said he had tried to get up and go to the bathroom to urinate. The resident said he had not lost consciousness. The resident was assessed for injuries. His range of motion and pupils were also assessed. The resident was then lifted from the floor and assisted to his wheelchair. The resident's vital signs and neurological status was assessed. The cut to the resident's forehead was bleeding. The bleeding stopped when it was washed and bandaged with 4-inch by 4-inch gauze. The only other injury that was observed was slight abrasions (approximately dime or 1.791 cm in diameter) to the bilateral kneecaps. A report was given to the oncoming nurse (see LPN notes above). The nurse said she would notify the family and physician.-Although the RN documented the resident's neurological status was assessed, there was no further evidence in the medical record that neurological assessments were conducted. V. Staff interviewsThe DON was interviewed on 8/7/23 at 8:34 a.m. She said that neurological assessments should be completed for all unwitnessed falls and a fall with a head injury. She said neurological assessments were performed to ensure the resident did not have a brain injury, any changes in vital signs, changes in levels of conspicuous, slurred speech, or any changes in ranges of motion. She said if neurological assessments were not performed and completed, a resident might have complications such as a serious brain injury, fracture, bleeding or even death. She said the staff should fill out the neurological check sheet according to the frequency at the top of the form and follow the ledger (assessments to perform) on the left side of the form. She said the entire sheet of the form should be completed accurately by staff. She said the facility started charting neurological assessments on paper on 5/1/23 and not in a resident's computerized clinical record. She said the facility developed a falls action plan on 8/2/23 (after the survey started), when a lack of neurological assessments was brought to their attention. Unit manager (UM) #1 and UM #2 were interviewed on 8/7/23 at 9:34 a.m. They said that neurological assessments should be completed for all unwitnessed falls and falls with a head injury. They said the nursing staff should fill out the neurological check sheet according to the frequency at the top of the form and follow the ledger on the left side of the form. They said the reason neurological assessments were performed was to look for changes in the resident's baseline (normal assessments), brain bleeds, change in consciousness, concussions, fractures, bleeding, stroke, death and change in pupil sizes. They said the neurological assessments were also performed to prevent any complications from getting worse, especially those that staff were unable to visualize. The NHA, DON, and nurse mentor (QM) #1 were interviewed on 8/7/23 at 1:29 p.m. They acknowledged the resident had an unwitnessed fall in his room on 4/24/23 and was assessed by a RN. The resident went to the hospital ER and was found to have a nasal fracture. They said they were unable to locate any neurological assessments for this fall. They said neurological assessments should have been started and completed for this unwitnessed fall. They said when the resident returned from the hospital the facility did not start neurological assessments and they should have. They acknowledged the resident had an unwitnessed fall in his room on 4/28/23 and was assessed by a RN. They said the resident did not receive any injuries from this fall. They said they were unable to locate any neurological assessments for this fall. They said neurological assessments should have been started and completed for this unwitnessed fall. They acknowledged the resident had an unwitnessed fall in his room on 7/21/23 and was assessed by an RN. They said the resident received a laceration and contusion to the head from this fall. They said the resident did not go to the hospital for the injuries. They said neurological assessments should have been started and completed for this unwitnessed fall. VI. Additional facility documenting during surveyThe facility developed and educated staff related to falls on 8/2/23. The education revealed: When a resident fell, the following must be completed and an RN must assess every resident who falls. The appropriate Risk Management tool needed to be opened (Witnessed Fall or Unwitnessed Fall) with all of the sections completed;-Details: (describe what happened and what you did about it in detail including the immediate intervention to prevent re-occurrence of a fall) and if the nurse was an LPN, include if an RN assessed the resident;-Injuries: list injuries and document pain, level of consciousness, mobility status and mental status at time of fall;-Factors: check all predisposing factors that apply;-Witnesses: if it was a witnessed fall, check the box and list who witnessed the fall;-Action: list who was notified, put in a detailed progress note that included the immediate intervention to prevent re-occurrence of a fall and if the nurse was an LPN include if an RN assessed the resident;-Notes: this was for the IDT team's investigation and did not need to be completed by the nurse; and-Signatures: sign the nursing section;Initiate the Neurological Assessment Sheet on all unwitnessed falls and any fall that resulted in the resident hitting their head. An RN #1 education was conducted on 8/3/23 at 4:55 p.m. by QM #1. The RN #1 was educated on the facility fall policies and procedures by phone as related to the resident's fall on 7/21/23 at 5:57 p.m. The RN was instructed on the need to document resident's assessments in a timely manner (13 days after the event). The RN acknowledged the education and wrote a late entry progress note on 8/3/23 (see above). The facility developed and educated staff on the Fall Process on 8/4/23. The education revealed the process for what to do when a resident fell was as follows: assess resident for injury and have an RN assess as well, follow Post Fall Checklist, neurological assessments must be done on every unwitnessed fall and/or a fall that resulted in the resident hitting their head, the vital signs and neurological assessment frequency was every 15 minutes x 4, every 30 minutes x 2, every hour x 4, every shift x 8, neurological assessment could not be refused, and vital signs could be refused. If a resident refused, complete the neurological assessments from a distance and document refusal of vital signs on the neurological assessment sheet. Neurological assessments sheets should be left on the nurses' cart until completed then placed in the DON's box. Before handing the cart off to an on-coming nurse, ensure all neurological assessments for your shift were completed. The on-coming nurse should require all neurological assessments from the prior shift were complete before accepting the cart. Changes in neurological assessments or vital signs should be reported to the provider. Every fall needed to be reported to the UM or DON regardless of time of day or night.