COLUMBINE WEST HEALTH AND REHAB LLC

A complaint survey, prompted by #CO36806 and #CO36892 was conducted on 8/5/24 to 8/6/24. One deficiency was cited.

Based on observations and interviews, the facility failed to provide a clean, comfortable and homelike environment for residents who resided in 13 of 15 rooms out of a sample of 70 resident rooms. Specifically, the facility failed to ensure resident rooms had safe, comfortable temperatures that did not exceed 81 degrees Fahrenheit (F). Findings include:I. Facility policy and procedureThe Indoor Climate Control policy, reviewed on 8/15/23, was provided by the nursing home administration (NHA) on 8/5/24 at 12:52 p.m. The policy revealed the following considerations were made to ensure that the facility remained cool during the late spring and summer months:The facility had four rooftop air conditioning (AC) units to cool the facility's corridors. The AC units do not serve individual resident rooms. The facility team adopts other methods to help maintain resident room temperatures at comfortable and safe levels. These AC units were supported by the facility system maintenance team and serviced by contracted third-party vendors, as appropriate. The maintenance team would ensure that the units were in working order during the spring and would conduct regular maintenance checks during the summer months. In addition, the facility had one window AC unit installed on the secure unit to help maintain temperatures in the common sitting area. Throughout its operating history, the facility discovered that an effective way to maintain cool temperatures was to ensure windows were shut before the heat of the day increased (approximately 10:00 a.m.). Therefore, the staff was tasked with ensuring that resident room windows were closed and that client room doors remained open. This kept the warm outside air from entering the room and allowed the cooled corridor air to enter. The resident might choose to keep their window open, but the staff would advise that they keep their door closed, to lessen the warm air entering the facility. Residents might use a personal fan in their room to help with air movement and cooling. The social services and business office teams would work with residents/families to facilitate acquiring a fan, and the maintenance team would assist with installation. The facility's maintenance team directed the effort of frequently auditing resident room and common area temperatures throughout the facility. Any temperatures outside the regulated limits were noted for further investigation and potential repairs. II. Resident council minutesThe resident council minutes, dated 4/5/24, revealed one resident said it got hot in the facility and asked if there was any way to get a better air conditioning system. The NHA said she would talk with the chief executive officer (CEO) of the company. The resident council minutes, dated 6/5/24, revealed the activity director (AD) reminded everyone that as it got warmer, the only way to keep the facility cool was to keep the windows closed during the day. The AD said if the residents wanted their room window open, then the room entrance door to the hallway needed to be closed. Residents were to let staff know if they needed a fan. The resident council minutes, dated 7/3/24, revealed the maintenance supervisor (MS) reminded the residents to keep their windows closed after 10:30 a.m. to help keep their rooms cooler. He said fans could be made available if rooms were really hot. He said, if the residents wanted their room window open, then the room entrance door to the hallway needed to be shut. III. Maintenance temperature logThe July 2024 temperature log was provided by the MS on 8/5/24 at 3:51 p.m. The temperature log revealed the MS took temperatures on 7/11/24 for six resident rooms and the common area on the East hall. The temperatures ranged between 70 to 80 degrees F. No other temperatures were taken for the month of July 2024. IV. Resident room observations and interviewsA. Resident #6Resident #6 resided in room #East 107-2. The 6/26/24 minimum data set (MDS) assessment revealed the resident hadsevere cognitive impairments with a brief interview mental status (BIMS) score of four out of 15. On 8/5 24 at 12:22 p.m. Resident #6 was seated in a wheelchair in her room watching television. She said she liked it warm in her room. A digital thermometer was placed in the room at this time. -At 12:49 p.m. the temperature in Resident #6's was 84 degrees F.B. Resident #7Resident #7 resided in room #West 100-2. The 6/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. On 8/5/24 at 12:25 p.m. the resident was lying in her bed. A fan was blowing on the resident. She said sometimes in the afternoon it was very hot in her room. The door to the room was open only a few inches. A digital thermometer was placed in the room. -At 12:55 p.m. the temperature in Resident #7's room was 84 degrees F.On 8/6/24 at 9:16 a.m. Resident #7 was sitting in her room in a wheelchair and a fan was blowing on the resident. Her power of attorney (POA) was sitting on the resident's bed. The resident said she could only sleep at night when the fan was blowing on her. She said at times it was sticky hot and she sweated. The POA said at times the room was unbearable due to the heat and humidity and it was hard to breathe. The POA said the resident had told her at times, it was too hot in her room. The POA said she visited the resident often. C. Resident #20On 8/5/12 at 12:58 p.m. Resident #20 was not in their room #126-2, located in the special care unit. A digital thermometer was placed in the room. -At 1:47 p.m. the temperature in Resident #20's room was 84 degrees F. At 1:50 p.m. the unit manager (UM) of the special care unit observed the digital thermometer temperature reading and agreed on the room temperature. D. Resident #19On 8/5/24 at 12:59 p.m. Resident #19 was not in their room #127-1 located in the special care unit. A digital thermometer was placed in the room. -At 1:47 p.m. the temperature in Resident #19's room was 84 degrees F. At 1:50 p.m. the UM of the secure unit observed the digital thermometer temperature reading and agreed on the room temperature. E. Resident #18On 8/5/12 at 1:01 p.m. Resident #18 was not in their room #129-1 located in the special care unit. A digital thermometer was placed in the room. -At 1:49 p.m. the temperature in Resident #18's room was 84 degrees F. At 1:50 p.m. the UM of the secure unit observed the digital thermometer temperature reading and agreed on the room temperature. F. Resident #17On 8/5/24 at 1:02 p.m. Resident #17 was not in their room #128-1 located in the special care unit. A digital thermometer was placed in the room. -At 1:49 p.m. the temperature in Resident #17's room was 84 degrees F. At 1:50 p.m. the UM of the secure unit observed the digital thermometer temperature reading and agreed on the room temperature. G. Resident #16On 8/5/24 at 2:27 p.m. Resident #16 was not in their room #West 128-1. A digital thermometer was placed in the room. -At 3:06 p.m. the temperature in Resident #16's room was 84 degrees F.H. Resident #8Resident #8 resided in room #West 131-2. The 6/26/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. On 8/5/24 at 2:28 p.m. the resident was sitting on her bed and said it was often very warm in her room. A digital thermometer was placed in the room. -At 3:07 p.m. the temperature in Resident #8's room was 84 degrees F. On 8/6/24 at 9:22 a.m. Resident #8 said it was already hot in her room and when it was too hot she was sticky and uncomfortable. I. Resident #9Resident #9 resided in room #West 127-1. The 7/11/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15 with no behaviors. On 8/5/24 at 2:32 p.m. Resident #9 was not in their room. A digital thermometer was placed in the room. -At 3:08 p.m. the temperature in Resident #9's room was 84 degrees F. Resident #9, who had returned to her room, said it was excessively hot in herroom and she was not used to the heat. She said she had always had air conditioning in her home and in the previous assisted living facility. J. Resident #15On 8/5/24 at 2:33 p.m. Resident #15 was not in their room #West 109-1. A digital thermometer was placed in the room. -At 3:49 p.m. the temperature in Resident #15's room was 84 degrees F.K. Resident #14Resident #14 resided in room #124-1 on the special care unit. The 5/28/24 MDS assessment revealed the resident had both short and long term memory problems with no behaviors. On 8/5/24 at 4:30 p.m. Resident #14 was sitting on the bed in her room. Her daughter was sitting on the bed beside her. -The resident's daughter had placed a digital thermometer on the bedside table and it was 90 degrees F in the room. Resident #14's daughter said she came to the facility almost every day around 2:30 p.m. and often stayed until 8:00 p.m. She said often her mother was unable to sleep at night because it was too hot in the room. She said the room was stuffy, uncomfortable and excessively hot for her mother. She said her mother was unable to communicate that it was too hot. Resident #14's daughter said, at times, she had difficulty breathing in the room from the heat. She said her mother had been in assisted living facilities before coming to this facility and the other places had air conditioning. L. Resident #12Resident #12 resided in room #East 135-2 The 6/27/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. On 8/6/24 at 10:02 a.m. Resident #12 said it often was very hot on her side of the room. She said it often got excessively hot around 4:00 p.m. and it made her feel miserable. M. Resident #13Resident #13 resided in room #East 135-1. The 5/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. On 8/6/24 at 10:12 a.m. she said her side of the room could really get hot, humid and sticky. She said she felt uncomfortable with the hot temperatures in the room. V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 8/5/24 at 12:37 p.m. CNA #1 said one or two residents had told her that it was too hot in the facility. She said she thought it was too hot in the facility at times. CNA #2 was interviewed on 8/5/24 at 1:05 p.m. CNA #2 said a family member had told her the previous week that it was excessively hot on the secure unit. CNA #3 was interviewed on 8/5/24 at 1:14 p.m. CNA #3 said, at times during the middle of the day, it was excessively hot on the secure unit. CNA #4 and CNA #5 were interviewed together on 8/5/24 at 1:35 p.m. CNA #4 and CNA #5 said residents and family members had said it was excessively hot in the facility. Both CNAs felt that at times it was too hot in the facility, usually around 4:00 p.m. The MS was interviewed on 8/5/24 at 3:51 p.m. The MS said there were 70 resident rooms in the facility. He said the thermostat located at the East nurse's station controlled the temperature on the secure unit. He said the facility air conditioning system delivered cool air to the hallways and not into resident rooms. He said residents were informed to keep their room entrance doors open to get cool air from the hallway, into their rooms. He said all of the air conditioning units were functional and were integrated into the backup power generator system, if an electrical outage occurred. The MS said he took random air temperatures in the facility. He said for the month of July 2024, he took resident room temperatures only on one day. He said he took six resident room temperatures and one common sitting area room temperature on 7/11/24. The MS completed a walk through of the East nurse station and said the thermostat was set at 72 degrees Fahrenheit and the air temperature was 79 degrees Fahrenheit. He said the West nurse station revealed the thermostat was set at 70 degrees Fahrenheit and the air temperature was 81 degrees Fahrenheit.-However, observations of several rooms revealed digital thermometer readings above 81 degrees (see observations above). The NHA was interviewed on 8/5/24 at 4:53 p.m. The NHA said she was not aware the MS had only taken resident room temperatures on 7/11/24 and not more frequently. She agreed with the July 2024 resident room temperature log. She said the MS had not told her that there were hot temperatures in the facility. She said it was hot in the facility around mid-July 2024. She said when the staff told her it was too hot in the facility, she purchased neck fans for them. Licensed practical nurse (LPN) #1 was interviewed on 8/6/24 at 10:32 a.m. LPN #1 said the residents and their families had told her it was too hot in the facility at times. She said there had been times she observed temperatures in the facility about 81 degrees Fahrenheit. LPN #2 was interviewed on 8/6/24 at 10:45 a.m. LPN #2 said the residents and their families had said to her it was too hot in the facility and it made the residents feel tired. The NHA was interviewed again on 8/6/24 at 11:30 a.m. The NHA said she would like temperatures taken daily in different areas of the facility or at least every other day. She said she did not know there were temperatures over 81 degrees in the facility. She said the staff and the MS should let her know if there were hot temperatures in the residents' rooms. She said she did speak with the CEO regarding the 4/5/24 resident council minutes regarding hot temperatures in the facility.

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

A revisit survey was completed on 7/1/24 for all previous deficiencies cited on 4/11/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 7/1/24 for all previous deficiencies cited on 4/11/24. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on May 9, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies". This structure is a one (1) story, Type V (111) wood frame construction with no basement. The facility was constructed in 1988. The facility is licensed for 100 beds and the census on the date of the survey was 90. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and anti-freeze fire sprinkler systems. Anti-freeze fire sprinkler system protects the front canopy and exterior overhangs. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Maintenance Director and the Facility Administrator during the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain the Means of Egress in accordance with NFPA 101, Life Safety Code, Section 7.1.6.3. This was evidence by the following:1. Southeast exit discharge walkway has an offset section of concrete with a deviation greater than ½" and does not have a level walking surface. Means of egress shall be continuously maintained and free of all obstructions or impediments to full use in the case of fire or other emergency. NFPA 101, 7.1.6.3 Level. Walking surfaces shall comply with all of the following:(1)Walking surfaces shall be nominally level. This deficient practice could affect all residents, staff, and visitors should this exit discharge be needed during an emergency. This deficiency was discussed during the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Sections 19.7.1.6 and 4.7.4. This was evidenced by the following: 1. Fire drills were not conducted during varying times and conditions. Time of drills were too close to previous drills on all shifts. NFPA 101 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This was discussed during the exit conference.

A licensure survey was completed on 4/8/24 to 4/11/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure one (#30) of four residents reviewed for pressure injuries out of 36 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Resident #30 was admitted on 9/18/23 for long term care. At the time of the admission, the resident was identified as being at risk for developing pressure injuries. Upon admission, the resident's skin was intact and she did not have any pressure injuries. Resident #30 attended dialysis three times a week. On 10/7/23, a nurse documented Resident #30 developed a deep tissue injury (DTI) on her right heel. Preventative measures to protect the resident's heels were not implemented until after the development of the DTI on 10/7/23. On 10/12/23, the wound care physician classified the resident's wound as an unstageable pressure injury. Due to the facility's failure to implement effective pressure injury prevention interventions in a timely manner, Resident #30 developed a facility-acquired DTI to her right heel. Findings include:I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 4/17/24, "Pressure ulcer classification is as follows:"Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk)."Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable"Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed."Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Facility policy and procedureThe Skin Protection and Wound Prevention policy, revised 6/29/23, was received from the nursing home administrator (NHA) on 4/11/24 at 1:45 p.m. It read in pertinent part, "Most residents admitted to the facility are considered at risk for developing wounds, although the level of risk may vary. Staff at the facility take an aggressive approach to wound prevention and will implement the following protocol upon admission on all residents. "Procedure: skin assessments will be completed upon admission, within one to two weeks of admission, quarterly, and with a significant change of condition. Nursing assessment of skin condition will be completed at least weekly and documented in medical record. "Care of residents with decreased mobility includes: off-loading heels with a pillow if resident is unable to reposition their lower extremities, turning or repositioning at least every two hours or more frequently, use of pillows or other positioning device to keep bony prominences from direct contact with one another. All residents with braces, splints, casts, or other mechanical devices will have skin closely monitored for breakdown."III. Resident #30A. Resident statusResident #30, age 73, was admitted on 9/18/23. According to the April 2024 computerized physician orders (CPO), diagnoses included diabetes mellitus (high blood sugar), end stage kidney disease (kidneys can no longer support body's needs) with hemodialysis (process where a machine filters and cleans the body's blood) and dementia. According to the 4/6/24 facility assessment, Resident #30 was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. She required touching assistance for rolling left to right and most transfers. She required substantial/maximal assistance for lower body dressing and putting on/taking off footwear. The assessment documented the resident was at risk of developing pressure ulcers and one unstageable pressure ulcer due to coverage of the wound bed with slough (soft, dead tissue, usually cream or yellow in color) and/or eschar (firm, dry dead tissue, usually black in color) which was not present upon admission. According to the 9/24/23 admission facility assessment, the resident was at risk of developing pressure injuries but had no current pressure injuries present at admission. B. Wound observation and interviewOn 4/9/24 at 3:56 p.m. a wound observation was completed in the presence of registered nurse (RN) #1. Resident #30 was positioned on the recliner with heels floating off the recliner. The resident was wearing soft blue foam booties. With consent from the resident, RN #1 removed the dressing to the resident's right heel. Moderate yellow discharge was observed on the dressing. The wound on the resident's heel was oblong in shape extending to both sides of the heel. The wound bed was pink in color with multiple areas of yellow tissue (slough) obstructing the wound. RN #1 said there was some yellow slough covering the wound bed. She said the pressure injury developed after admission and she believed it was from the resident sitting in the dialysis chair for extended periods of time without wearing pressure reducing boots. C. Record review The 9/18/23 admission nursing assessment documented this resident's only skin conditions on admission included a right lower extremity surgical wound and bilateral (right and left sides) lower extremities were dry and scaly. The skin integrity care plan, initiated 9/19/23 and revised 4/9/24, identified Resident #30 was at risk for skin breakdown due to age, limited mobility, occasional incontinence and diagnosis of diabetes. Interventions included encouraging the resident to wear long sleeves/long pants, use a pressure reducing mattress, use pillows or off-loading devices to relieve pressure on heels, use a cushion in a chair, keep linens clean, dry and wrinkle free, reposition the resident, encourage physical activity, use lift device to avoid shearing, assess and monitor risk factors, apply lotion to lower extremities, keep resident clean and dry, and encourage adequate intake of nutritional foods. -However, review of the September 2023 and October 2023 treatment administration records (TAR) revealed there was no documentation to indicate the resident had heel protection in place and staff were monitoring for the heel protection until 10/16/23, after the development of the right heel wound. A progress note documented by an RN on 10/7/23 revealed there was a new deep tissue injury (DTI) to the resident's right heel. The note documented new interventions for the wound included a dressing and heel protector boots. The wound care registered nurse (WCRN) documented an initial note on 10/9/23. It revealed the right heel had eschar surrounded by slough and maceration (soft skin, when skin is in contact with moisture for too long). A wound care physician note from 10/12/23 documented the resident was being evaluated for an unstageable pressure injury on the right heel. The injury obscured full thickness and tissue loss, had moderate serous (clear, watery plasma) drainage and 100% eschar. Orders included right heel wound care orders, specialty mattress, offloading heels, wheelchair cushion, nutritional supplements, turn and repositioning resident and monitor for signs of infection. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 4/9/24 at 1:49 p.m. CNA #1 said Resident #30 required assistance of one person for walking, transferring, showering and repositioning. She said she helped the resident put off-loading boots on before she went to dialysis, when she was in bed and up in her wheelchair. RN #2 was interviewed on 4/9/24 at 2:10 p.m. RN #2 said the resident required one person to assist her for care. She said the resident wore pressure reducing boots to dialysis, when she was seated in her wheelchair and when she was in bed. She said the WCRN was responsible for her right heel wound since it was a pressure injury but RN #2 said she would replace the dressing as needed if the WCRN was not in the building. The WCRN was interviewed on 4/10/24 at 3:00 p.m. The WCRN said she saw the resident for the first time once the right heel wound had already developed on 10/9/23. She said the first time she saw the wound there was slough and eschar. She said she notified the wound care physician, painted the wound with betadine, elevated the resident's legs, put pressure off-loading boots on both feet and encouraged the resident not to wear shoes. She said the wound was unstageable. She said on 10/10/23, she noticed the wound had a foul odor, the resident's pain was worse, and there was more drainage from the wound. The resident was put on antibiotics for possible infection. She said the resident would have benefited from elevating her legs and wearing the pressure off-loading boots upon admission. The WCRN said she had not participated in the admission of Resident #30 and therefore it was the responsibility of the admitting nurse to implement any preventive measures upon admission. She said she provided care to the residents in the facility only after they developed wounds. The wound care physician (WCP) was interviewed on 4/11/24 at 10:00 a.m. The WCP said Resident #30 had an unstageable pressure ulcer to her right heel when she began seeing the resident for wound care. She said if interventions, such as offloading the heels and elevating legs on admission had been done, the wound would have likely been prevented. The assistant director of nursing (ADON) was interviewed on 4/11/24 at 2:15 p.m. The ADON said it was likely Resident #30 developed the pressure injury on her heel by sitting for a long time in dialysis. He said the protective booties were not implemented until after the development of the wound. He said since it likely occurred at the dialysis clinic, it was beyond the facility's control to implement any measures while resident at the dialysis. He said the facility did communicate with dialysis prior to every session of the dialysis and could have implemented protective booties for the resident prior to her visits to dialysis.

A recertification survey was completed on 4/8/24 to 4/11/24. Eight deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/8/24 to 4/11/24. No deficiencies were cited.

Based on observation and interviews, the facility failed to post, in a form and manner accessible and understandable to residents, information on how to file a complaint with the State Agency. Specifically, the group interview revealed the facility failed to ensure residents knew where the required posting on how to file a complaint with the State Agency was located and that residents were able to easily access and read the information on the posting. Findings include:I. Resident group interviewThe resident group interview was conducted on 4/10/24 at 1:10 p.m. with eight residents (#1, #44, #146, #7, #35, #61, #8 and #21) who routinely attended monthly resident council meetings and were deemed interviewable by the facility and assessment. All eight residents said they did not know how to file a complaint with the State Agency and were not aware the information was posted in the facility. Resident #1 said whenever he had a concern and told a certified nurse aide (CNA) about it, the concern was never followed up on by the facility. II. ObservationOn 4/11/24 at 9:53 a.m. the required posting with the State Agency information on it was observed in the corner of the lobby. The information on how to file a grievance was posted above the eyeline for a resident in a wheelchair and was written in a small font. III. Staff interviewThe social services director (SSD) was interviewed on 4/11/24 at 9:46 a.m. The SSD was not sure where the State Agency information was posted and said he needed to ask someone. After asking someone, the SSD said the posting was located in the corner of the facility lobby. The SSD said the posting might not be visible to residents, depending on their level of visual impairment, but he said the residents felt comfortable asking staff members for help if they could not see the posting.

Based on record review and interviews, the facility failed to take steps to ensure the 15 residents, including Resident #39, who resided in the secure unit were free from potential sexual abuse by Resident #43. Record review revealed Resident #43 had a documented history of sexually inappropriate behavior toward male residents. Record review and interview revealed the facility failed to take timely steps to minimize the potential risks to other residents related to her behavior. Findings include: I. Facility policy and procedure The Abuse Prevention policy, revised 1/19/23, was received from the nursing home administrator (NHA) on 4/8/24 at 11:34 a.m. It read in pertinent parts: "The facility does not condone resident abuse, neglect, exploitation or misappropriation of resident property by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or any other individual. Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, or deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Sexual abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. III. Residents A. Resident #43 Resident #43, age greater than 65, was admitted on 10/11/23. According to the April 2024 computerized physician orders (CPO), the resident's diagnoses included vascular dementia, anxiety, bilateral age-related macular degeneration (an eye disorder that causes blurred vision or a blind spot), congestive heart failure, chronic respiratory failure, and reduced mobility. The 2/7/24 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. The 10/24/23 care plan identified the resident had dementia with behavioral disturbances. She may make inappropriate statements or gestures towards others. Interventions included administering Aricept and Seroquel, monitoring for adverse side effects, allowing the resident to have as much independence with personal care as safely possible, providing choices, and building a rapport with the resident at the beginning of the shift to facilitate trust. B. Resident #39 Resident #39, age greater than 65, was admitted on 6/27/23. According to the April 2024 CPO, diagnoses include Alzheimer's disease, reduced mobility, anxiety disorder, repeated falls, and unsteadiness on feet. The 1/31/24 MDS assessment revealed he did not have a BIMS assessment completed due to severe cognitive impairment. The resident's 7/10/23 care plan revealed he had impaired cognitive status related to Alzheimer's dementia. Interventions included reminding the resident of the location of his room, time for meals, etc. The 10/17/23 care plan revealed the resident had cognitive loss and communication deficits related to dementia. He may not understand what was said to him and was unable to make his needs known. Interventions included monitoring for signs and symptoms of restlessness. The 11/16/23 care plan revealed the resident had a diagnosis of anxiety disorder. Interventions included administering Gabapentin and Paxil as ordered, monitoring for adverse effects, and notifying the provider. Also, to provide emotional support and if the resident was irritable, ask for sources of discomfort and attempt to remedy. III. Incident of potential sexual abuse Interviews revealed an incident of potential sexual abuse involving Resident #43 and Resident #39. The incident was also documented in the facility's investigation conducted during the survey on 4/10/24, eight days after the incident occurred. A. The social servi

Based on record review and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised timely to include the instructions needed to provide effective and person-centered care for one (#56) of six residents out of 36 sample residents. Specifically, the facility failed to revise Resident #56's care plan to address the resident's pattern of repeated refusals of three physician ordered pain medications. I. Resident #56 A. Resident status Resident #56, age 78, was admitted on 10/4/21. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, Parkinson's disease, psychotic disturbance, mood disturbance, anxiety, hallucinations, post traumatic stress disorder, depression, pain in right and left knee, stiffness of left knee and chronic pain syndrome. The 1/2/24 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. The assessment indicated the resident had moderate pain frequently which interfered with her day to day activities. B. Record review The pain risk care plan, revised 4/5/24, revealed the resident was at risk due to her knee pain related to arthritis, headaches, jaw pain, and diagnoses of chronic pain syndrome neurologia. The resident was able to express her pain to staff. She voiced complaints of muscle spasms. Interventions included administering pain medications as ordered and monitoring effects,pain medications included acetaminophen, biofreeze gel and gabapentin.-The pain care plan failed to document Resident #56 frequently refused her pain medications or interventions to try to get her to take her medications. The April 2024 CPO revealed the following physician orders: Acetaminophen 500 mg (milligrams). Take two tablets three times a day for arthritic pain. Start date 2/23/24. Biofreeze gel 4%. Apply a thin layer to the right knee three times a day for arthritic pain. Start date 10/27/22. Gabapentin 400 mg. Take one capsule three times a day for pain. Start date 6/1/22. Resident #56's January 2024 medication administration record (MAR) revealed the following: Biofreeze gel 4% was not administered due to the resident's refusal on:-1/5/24 at 7:00 a.m. and 12:00 p.m;-1/8/24 at 12:00 p.m;-1/9/24 at 7:00 a.m., 12:00 p.m. and 5:00 p.m;-1/13/24 at 12:00 p.m;-1/14/24 at 5:00 p.m;-1/18/24 at 7:00 a.m., 12:00 p.m. and 5:00 p.m;-1/21/24 at 12:00 p.m;-1/26/24 at 12:00 p.m; and,-1/31/24 at 7:00 a.m. Resident #56's February 2024 MAR revealed the following: Biofreeze gel 4% was not administered due to the resident's refusal on:-2/8/24 at 7:00 a.m. and 12:00 p.m;-2/10/24 at 7:00 a.m. and 12:00 p.m;-2/19/24 at 7:00 a.m;-2/22/24 at 7:00 a.m. and 12:00 p.m; and, -2/23/24 at 12:00 p.m. Resident #56's March 2024 MAR revealed the following:Acetaminophen 500 mg, two tablets was not administered due to the resident's refusal on:-3/1/24 at 5:00 p.m;-3/8/24 at 5:00 p.m;-3/16/24 at 5:00 p.m;-3/17/24 at 6:30 a.m;-3/20/24 at 5:00 p.m; and,-3/25/24 at 12:00 p.m. Biofreeze gel 4% was not administered due to the resident's refusal on:-3/1/24 at 7:00 a.m. and 5:00 p.m-3/6/24 at 7:00 a.m. and 5:00 p.m;-3/8/24 at 5:00 p.m;-3/13/24 at 5:00 p.m;-3/14/24 at 5:00 p.m;-3/16/24 at 5:00 p.m;-3/17/24 at 7:00 a.m. and 5:00 p.m;-3/19/24 at 5:00 p.m;-3/20/24 at 5:00 p.m;-3/21/24 at 5:00 p.m;-3/22/24 at 7:00 a.m. and 5:00 p.m;-3/25/24 at 12:00 p.m. and 5:00 p.m;-3/26/24 at 5:00 p.m; and,-3/31/24 at 5:00 p.m. Gabapentin 400 mg was not administered due to the resident's refusal on:-3/8/24 at 5:00 p.m;-3/16/24 at 5:00 p.m;-3/17/24 at 7:00 a.m; and, -3/25/24 at 12:00 p.m. Resident #56's April 2024 MAR revealed the following:Acetaminophen 500 mg, two tablets was not administered due to the resident's refusal on:-4/6/24 at 12:00 p.m; and,-4/7/24 at 6:30 a.m. Biofreeze gel 4% was not administered due to the resident's refusal on:-4/2/24 at 12:00 p.m;-4/3/24 at 5:00 p.m;-4/4/24 at 7:00 a.m. and 12:00 p.m;-4/5/24 at 5:00 p.m;-4/6/24 at 12:00 p.m; and,-4/7/24 at 7:00 a.m. Gabapentin 400 mg was not administered due to the resident's refusal on:-4/6/24 at 12:00 p.m; and,-4/7/24 at 7:00 a.m.-There was no documentation in Resident #56's electronic medical record (EMR) to indicate the facility had attempted to address the resident's repeated pattern of pain medication refusals or update the resident's care plan. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 4/11/24 at 11:36 a.m. LPN #1 said if a resident refused medications it was the resident's right to refuse. He said he tried to educate residents why they should take their medication. He said there was a trend of medication refusals, the provider and family should be notified. He said the provider should be notified because the provider could see what other medication options were available for the resident. LPN #1 said the residents ' family should be notified because they might know other ways that helped get the resident take the medication. LPN #1 said he was familiar with Resident #56 and she never refused medications from him. He said he built a rapport with her and thought she did better with male nurses and aides. LPN #1 said it was important to figure out how to approach Resident #56 so she did not refuse her medications. Nurse manager (NM) #1 was interviewed on 4/11/24 at 11:03 a.m. NM #1 said every resident had a right to refuse medications. She said nurses should educate the residents why they should take the medication. She said the nurse should reattempt a couple times before the nurse documented the refusal in a progress note. NM #1 said if a resident refused medications for a couple of days the facility should try to see what was going on and if there was something that triggered the refusals. She said she would collaborate with the provider or hospice. She said Resident #56's refusals could be due to her receiving too many medications at once. She said the family should be notified when there was a trend and asked for input on what might work to ensure the resident took their medicationsNM #1 was interviewed again on 4/11/24 at 12:19 p.m. NM #1 said she reviewed Resident #56's chart and she saw the resident had multiple refusals of her pain medications. She said the Biofreeze gel was cold to the touch which could be why Resident #56 was refusing the medication. She said she would talk with the nurse to find out what might be causing the resident to refuse her medications. NM #1 said she saw a trend with a specific nurse who documented the resident refused medications frequently. She said this might be a training opportunity for that specific nurse on how to approach the resident and what to do when the resident refused medications. The assistant director of nursing (ADON) was interviewed on 4/11/24 at 1:01 p.m. The ADON said if a resident refused medications the nurse should reapproach a couple times. He said if the resident still refused, the nurse should go to the charge nurse because they might have tips on how to approach the resident for medication administration. He said if there was a trend, the provider and family should be notified. An event in the resident's electronic medical chart should be opened and the trend should be discussed in the morning nurse's meeting to identify a plan to address the refusals. The ADON said he was familiar with Resident #56. He said he knew she refused medications but did not know or could not remember why she refused.

Based on observations, record review and interviews, the facility failed to ensure one (#30) of four residents reviewed for pressure injuries out of 36 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Resident #30 was admitted on 9/18/23 for long term care. At the time of the admission, the resident was identified as being at risk for developing pressure injuries. Upon admission, the resident's skin was intact and she did not have any pressure injuries. Resident #30 attended dialysis three times a week. On 10/7/23, a nurse documented Resident #30 developed a deep tissue injury (DTI) on her right heel. Preventative measures to protect the resident's heels were not implemented until after the development of the DTI on 10/7/23. On 10/12/23, the wound care physician classified the resident's wound as an unstageable pressure injury. Due to the facility's failure to implement effective pressure injury prevention interventions in a timely manner, Resident #30 developed a facility-acquired DTI to her right heel. Findings include:I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 4/17/24, "Pressure ulcer classification is as follows:"Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk)."Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable"Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed."Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Facility policy and procedureThe Skin Protection and Wound Prevention policy, revised 6/29/23, was received from the nursing home administrator (NHA) on 4/11/24 at 1:45 p.m. It read in pertinent part, "Most residents admitted to the facility are considered at risk for developing wounds, although the level of risk may vary. Staff at the facility take an aggressive approach to wound prevention and will implement the following protocol upon admission on all residents. "Procedure: skin assessments will be completed upon admission, within one to two weeks of admission, quarterly, and with a significant change of condition. Nursing assessment of skin condition will be completed at least weekly and documented in medical record. "Care of residents with decreased mobility includes: off-loading heels with a pillow if resident is unable to reposition their lower extremities, turning or repositioning at least every two hours or more frequently, use of pillows or other positioning device to keep bony prominences from direct contact with one another. All residents with braces, splints, casts, or other mechanical devices will have skin closely monitored for breakdown."III. Resident #30A. Resident statusResident #30, age 73, was admitted on 9/18/23. According to the April 2024 computerized physician orders (CPO), diagnoses included diabetes mellitus (high blood sugar), end stage kidney disease (kidneys can no longer support body's needs) with hemodialysis (process where a machine filters and cleans the body's blood) and dementia. According to the 4/6/24 minimum data set (MDS) assessment, Resident #30 was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. She required touching assistance for rolling left to right and most transfers. She required substantial/maximal assistance for lower body dressing and putting on/taking off footwear. The assessment documented the resident was at risk of developing pressure ulcers and one unstageable pressure ulcer due to coverage of the wound bed with slough (soft, dead tissue, usually cream or yellow in color) and/or eschar (firm, dry dead tissue, usually black in color) which was not present upon admission. According to the 9/24/23 admission MDS assessment, the resident was at risk of developing pressure injuries but had no current pressure injuries present at admission. B. Wound observation and interviewOn 4/9/24 at 3:56 p.m. a wound observation was completed in the presence of registered nurse (RN) #1. Resident #30 was positioned on the recliner with heels floating off the recliner. The resident was wearing soft blue foam booties. With consent from the resident, RN #1 removed the dressing to the resident's right heel. Moderate yellow discharge was observed on the dressing. The wound on the resident's heel was oblong in shape extending to both sides of the heel. The wound bed was pink in color with multiple areas of yellow tissue (slough) obstructing the wound. RN #1 said there was some yellow slough covering the wound bed. She said the pressure injury developed after admission and she believed it was from the resident sitting in the dialysis chair for extended periods of time without wearing pressure reducing boots. C. Record review The 9/18/23 admission nursing assessment documented this resident's only skin conditions on admission included a right lower extremity surgical wound and bilateral (right and left sides) lower extremities were dry and scaly. The skin integrity care plan, initiated 9/19/23 and revised 4/9/24, identified Resident #30 was at risk for skin breakdown due to age, limited mobility, occasional incontinence and diagnosis of diabetes. Interventions included encouraging the resident to wear long sleeves/long pants, use a pressure reducing mattress, use pillows or off-loading devices to relieve pressure on heels, use a cushion in a chair, keep linens clean, dry and wrinkle free, reposition the resident, encourage physical activity, use lift device to avoid shearing, assess and monitor risk factors, apply lotion to lower extremities, keep resident clean and dry, and encourage adequate intake of nutritional foods. -However, review of the September 2023 and October 2023 treatment administration records (TAR) revealed there was no documentation to indicate the resident had heel protection in place and staff were monitoring for the heel protection until 10/16/23, after the development of the right heel wound. A progress note documented by an RN on 10/7/23 revealed there was a new deep tissue injury (DTI) to the resident's right heel. The note documented new interventions for the wound included a dressing and heel protector boots. The wound care registered nurse (WCRN) documented an initial note on 10/9/23. It revealed the right heel had eschar surrounded by slough and maceration (soft skin, when skin is in contact with moisture for too long). A wound care physician note from 10/12/23 documented the resident was being evaluated for an unstageable pressure injury on the right heel. The injury obscured full thickness and tissue loss, had moderate serous (clear, watery plasma) drainage and 100% eschar. Orders included right heel wound care orders, specialty mattress, offloading heels, wheelchair cushion, nutritional supplements, turn and repositioning resident and monitor for signs of infection. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 4/9/24 at 1:49 p.m. CNA #1 said Resident #30 required assistance of one person for walking, transferring, showering and repositioning. She said she helped the resident put off-loading boots on before she went to dialysis, when she was in bed and up in her wheelchair. RN #2 was interviewed on 4/9/24 at 2:10 p.m. RN #2 said the resident required one person to assist her for care. She said the resident wore pressure reducing boots to dialysis, when she was seated in her wheelchair and when she was in bed. She said the WCRN was responsible for her right heel wound since it was a pressure injury but RN #2 said she would replace the dressing as needed if the WCRN was not in the building. The WCRN was interviewed on 4/10/24 at 3:00 p.m. The WCRN said she saw the resident for the first time once the right heel wound had already developed on 10/9/23. She said the first time she saw the wound there was slough and eschar. She said she notified the wound care physician, painted the wound with betadine, elevated the resident's legs, put pressure off-loading boots on both feet and encouraged the resident not to wear shoes. She said the wound was unstageable. She said on 10/10/23, she noticed the wound had a foul odor, the resident's pain was worse, and there was more drainage from the wound. The resident was put on antibiotics for possible infection. She said the resident would have benefited from elevating her legs and wearing the pressure off-loading boots upon admission. The WCRN said she had not participated in the admission of Resident #30 and therefore it was the responsibility of the admitting nurse to implement any preventive measures upon admission. She said she provided care to the residents in the facility only after they developed wounds. The wound care physician (WCP) was interviewed on 4/11/24 at 10:00 a.m. The WCP said Resident #30 had an unstageable pressure ulcer to her right heel when she began seeing the resident for wound care. She said if interventions, such as offloading the heels and elevating legs on admission had been done, the wound would have likely been prevented. The assistant director of nursing (ADON) was interviewed on 4/11/24 at 2:15 p.m. The ADON said it was likely Resident #30 developed the pressure injury on her heel by sitting for a long time in dialysis. He said the protective booties were not implemented until after the development of the wound. He said since it likely occurred at the dialysis clinic, it was beyond the facility's control to implement any measures while resident at the dialysis. He said the facility did communicate with dialysis prior to every session of the dialysis and could have implemented protective booties for the resident prior to her visits to dialysis.

Based on observations, interviews and record review, the facility failed to ensure residents received person-centered dementia care that met their needs for one (#43) of five residents reviewed for dementia care out of 36 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #43 in order to provide the resident with her highest practicable quality of life and care. Findings include: I. Facility policy A dementia policy was requested from the facility on 4/11/24, however, one was not provided..A Dementia Tools document, which was undated, was received from the nursing home administrator (NHA) on 4/11/24 at 12:58 p.m. It read in pertinent part: "Meal tips - food and fluids. Let them eat what sounds good, even if it was not good for them." A dementia training document, which was undated, was received from the NHA on 4/11/24 at 12:58 p.m. It read in pertinent part: "Provide remarkable individualized care. Build meaningful relationships that enrich lives in a stimulating and supportive environment."The Expression of Need Management policy, revised 3/7/24, was received from the NHA on 4/11/24 at 12:58 p.m. It read in pertinent part: "Necessary care and services will be provided with a person-centered approach that reflects the resident's goals while maximizing the resident's quality of life." II. Resident #43 A. Resident status Resident #43, age greater than 65, was admitted on 10/11/23. According to the April 2024 computerized physician order (CPO), diagnoses included vascular dementia, anxiety, bilateral age related macular degeneration (eye disorder that causes blurred vision or a blind spot), congestive heart failure, chronic respiratory failure and reduced mobility. The 2/7/24 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. The assessment indicated the resident wandered daily and her behavior remained the same from the previous assessment. The resident did not refuse care. B. Resident representative interview The resident's representative was interviewed on 4/8/24 at 2:09 p.m. He said that Resident #43 struggled emotionally and he wished he understood the resident. He said her dementia caused her to be excited. He said she had lost her independence which caused her some frustration. He thought Resident #43 wished she had free range mobility and that her friends visited her. He said the secured unit tempered her ability to move as she wished, however, he said it was important for the facility to keep a close eye on her because she wandered and said she wanted to go outside to her children and grandchildren. C. Observations On 4/9/24, during a continuous observation beginning at 10:57 a.m and ending at 11:57 a.m., the following observations were made:At 10:57 a.m. Resident #43 was sitting in the community area of the secured unit. She sat at a table by herself facing a wall of cabinets and a small refrigerator. She had animal graham crackers and a cup of liquid.-There was no staff interacting with her. At 10:59 a.m. the resident asked for food. An unidentified staff member reminded the resident she had crackers on the table. Resident #43 said she wanted something other than crackers. The unidentified staff member offered yogurt, pudding or applesauce. The resident said she wanted all of the options. -The unidentified staff member gave the resident yogurt, but did not provide her with the other two options that had been mentioned. -The unidentified staff member made no attempt to engage the resident in conversation or provide any other interaction other than to give the resident yogurt. At 11:05 a.m., another resident was escorted to the same table as Resident #43. At 11:09 a.m. an unidentified nurse walked by and Resident #43 said she wanted food. The nurse said lunch was coming.-The nurse did not interact further with Resident #43 or provide the resident with any other type of activity in an attempt to distract the resident from her repetitive requests for food. At 11:15 a.m. Resident #43 said she wanted coffee. The other resident at her table agreed and said they needed coffee. At 11:20 a.m. Resident #43 asked about food again.-None of the staff who were nearby getting drinks for residents acknowledged Resident #43's question about food. At 11:26 a.m. Resident #43 again asked about lunch. Certified nurse aide (CNA #1) said lunch was coming in four minutes.-CNA #1 did not interact further with Resident #43 or provide the resident with any other type of activity in an attempt to distract the resident from her repetitive requests for food. At 11:28 a.m. Resident #43 asked the other resident at her table about food. The other resident said she had to wait. At 11:30 a.m. Resident #43 told the other resident at her table there were two minutes until lunch and she wondered what was for lunch. At 11:41 a.m. the other resident's lunch arrived at the table. At 11:42 a.m. the other resident told an unidentified staff member to give Resident #43 her lunch. At 11:44 a.m. Resident #43's lunch arrived. At 11:53 a.m. Resident #43 said she wanted dessert. -None of the staff acknowledged the resident's request for dessert. On 4/10/24, during a continuous observation beginning at 2:40 p.m and ending at 3:40 p.m., the following observations were made:Resident #43 had a one-to-one staff member sitting next to her in the community room in the secured unit. Resident #43 was in a wheelchair. -At 2:40 p.m. Resident #43 said she wanted breakfast. She was near several unidentified staff members, including the one-to-one staff member. One unidentified staff member asked her what she wanted besides breakfast because the kitchen was closed. Another staff member told her the kitchen was closed and they did not have breakfast.-Neither of the unidentified staff members made an attempt to get Resident #43 something to eat. At 2:53 p.m. the resident again asked for breakfast. The one-to-one staff member told her what time it was and that dinner was soon.-The one-to-one staff member did not attempt to get the resident something to eat or engage her in any type of meaningful activity to distract her from her repeated request for breakfast. From 2:53 p.m. until 3:00 p.m. the one-to-one staff member pushed Resident #43 up and down the hallway of the secure unit in her wheelchair in an attempt to distract the resident. At 3:00 p.m. the one-to-one staff member returned to the community room with Resident #43. At 3:03 p.m. Resident #43 asked when she could eat. The one-to-one staff member said it was a couple hours until dinner. The resident said she did not want dinner, she wanted breakfast. The staff member said let's go to your room and see what was there.-The one-to-one staff member did not offer Resident #43 anything to eat or attempt to engage the resident in any type of meaningful activity to distract her from her repeated request for breakfast. -At 3:05 p.m. the one-to-one staff member asked CNA #2 where snacks were located. CNA #2 told her where the snacks were. -The one-to-one staff member did not offer the resident any snacks despite having just been told where the snacks were located. -From 3:05 p.m. to 3:40 p.m. the one-to-one staff member proceeded to push Resident #43 up and down the hallway of the secure unit. During the 35 minute timeframe, Resident #43 said four different times that she wanted to get out of here (the secure unit). One time she was asked where she wanted to go and she pointed to the door to leave the secure unit.-The one-to-one staff member did not attempt to interact with or engage Resident #43 in a more meaningful activity than being pushed up and down the hallway of the secure unit. D. Record review The 10/24/23 dementia care plan identified the resident had dementia with behavioral disturbances. Interventions included administering aricept and seroquel and monitoring for adverse side effects, allowing the resident to have as much independence with personal care as safely possible, providing choices and building a rapport with the resident at the beginning of the shift to facilitate trust.-The care plan failed to include the resident's repetitive requests for food, especially breakfast, or any interventions to address the resident's need. The 10/19/23 activities care plan revealed the resident was pleasant and engaged in conversation easily. Barrier to leisure activity was tolerance. Interventions included offering one on one visits for increased social interaction, inviting the resident to activities of interest, staff to introduce resident to other residents during group activities, invite theresident to spiritual programs, set up independent activities as desired and staff to refocus on tasks at hand when distracted. The 3/11/24 care plan identified the resident was at risk for wandering and exit seeking. Interventions included developing a plan of care and recommendations in caring for the resident, maintaining door closures, frequent rounding to ensure the resident was in the facility, providing redirection as appropriate and determining reasons and triggers for wandering. Review of Resident #43's electronic medical record (EMR) revealed the following progress notes: On 2/7/24, the nurse progress note said the resident was shouting and calling out asking for staff to stay with her prior to dinner. On 2/8/24, the nurse progress note said the resident called out to staff, needed company and wanted to talk. The resident thought another resident was her boyfriend and she wanted to feed him. On 2/9/24, the nurse progress note revealed Resident #43 did not feel safe in the room alone. She was brought to the community room. She felt safer with other people around her. She was put into bed and the resident reported she was very anxious and wanted a staff member to stay with her until she fell asleep. Resident #43 calmed down and fell asleep. On 2/14/24, the social worker's progress note revealed the resident had moments of sadness. On 4/5/24, the nurse progress note revealed the resident asked another resident to go to bed with her. Resident was hallucinating. She saw a boy/male in her room and did not want the staff to leave her alone. The resident talked about dying. III. Staff interviewsThe nurse manager (NM) #1 was interviewed on 4/11/24 at 11:03 a.m. NM #1 said if a resident had dementia and they asked for food, the staff should give them food. She said if a resident said they were hungry, the staff should not withhold a snack. She said it was important to offer food with dementia residents because it was hard to determine if the resident's satiety (fullness) was reached with the meals provided. NM #1 said she was familiar with Resident #43. She said she used to be the night nurse for the unit Resident #43 lived in. She said if a resident was hungry, she would not withhold a snack. She said she was not aware Resident #43 asked for meals and snacks and that staff said the kitchen was closed and it was not breakfast time and did not offer snacks. She said she would educate the staff. The assistant director of nursing (ADON) and corporate nurse consultant (CNC) #2 were interviewed on 4/11/24 at 1:01 p.m. The ADON and CNC #2 said they were not familiar with Resident #43. The ADON said snacks should be offered to a resident regardless if the resident recently ate something. The resident might have been hungry and the staff should have found a snack. CNC #2 said it was important to offer a resident food that was specific to what they were asking for. If a resident asked for breakfast the staff should offer some breakfast food. CNC #2 said it was not effective telling a resident with dementia that it was not time for breakfast or dinner. CNC #2 said residents with dementia were hard to redirect and if the resident was focusing on food that was the subject of the moment for the resident. CNC #2 said maybe the resident was hungry. The ADON and CNC #2 said they needed to work to train the staff on dementia care.

Based on record review and interview, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (# 66) of five residents reviewed for unnecessary medications out of 36 sample residents. Specifically, the facility failed to track and monitor behaviors for Resident #66 who was on four different psychotropic medications. Findings include:I. Facility policyThe Psychotropic Medication policy, revised February 2024, was provided by the nursing home administrator (NHA) on 4/11/24. It documented in pertinent part, "An event will be opened to document target symptoms prior to initiation of antipsychotics and will remain open until the resident stabilizes as determined by IDT (interdisciplinary team). Residents are continually monitored for adverse side effects. If noted, an event will be opened and the provider will be notified. "Residents taking antidepressant may have target symptoms monitored as recommended by the IDT. "If a new hypnotic medication is ordered or recommended, the IDT will open an event to determine the sleep patterns of the resident, and review with consideration on non-medication based approaches to encourage the resident's sleep."II. Resident statusResident #66, age above 65, was admitted on 2/22/24. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and depression. The 2/28/24 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score (BIMS) score of nine out of 15. The assessment indicated the resident did not display or feel little interest or pleasure in doing things and was not feeling down, depressed or hopeless. He did not display any signs of social isolation. The assessment indicated the resident was not physically or verbally aggressive towards others and he did not reject the care. The assessment indicated Resident #66 was receiving antipsychotic and antidepressant medications. III. Record reviewThe care plan for psychotropic medications, initiated 1/15/24 and revised 3/11/24, documented the resident was at risk for side effects related to the use of antidepressant medications. Interventions included administering mirtazapine (an antidepressant medication), sertraline (an antidepressant medication) and trazodone (an antidepressant medication) as ordered, monitoring for potential side effects such as headache, tremor, dizziness, insomnia, somnolence, fatigue or allergic reactions and notifying the physician if appropriate. The care plan for cognition, initiated 2/29/24 and revised 3/6/24, revealed the resident had impaired cognitive status related to diagnosis of dementia. Interventions included to provide assistance and verbal cues with activities of daily living (ADL) as needed.-The care plan did not mention the resident's use of psychotropic medication for dementia and specific behaviors the resident displayed. The April 2024 CPO documented Resident #66 was receiving the following medications:Mirtazapine tablet 15 milligrams (mg) orally at bedtime for depression. Start date 2/28/24. Olanzapine (an antipsychotic medication) tablet 2.5 mg orally twice a day for dementia with associated behavior. Start date 2/28/24.-The physician's order did not indicate what associated behavior the medication was used for. Sertraline tablet 200 mg orally, once in the morning, for depression. Start date 2/28/24. Trazodone tablet 25 mg orally at bedtime. Start date 3/8/24. -There was no diagnosis documented for the use of the medication.-The April 2024 CPO did not include daily monitoring for side effects of the psychotropic medications and/or monitoring of targeted behavior related to the use of the medications. -Review of Resident #66's progress notes revealed no documented behaviors. -Review of Resident #66's monitoring events demonstrated no active events for the documentation of targeted behaviors for psychotropic medications. IV. Staff interviewsThe social services director (SSD) was interviewed on 4/11/24 at 11:30 a.m. The SSD said he participated in psychotropic review meetings but he did not recall discussing any specifics about Resident #66's medications. He was not sure why the resident was on three different antidepressants. The SSD was interviewed again on 4/11/24 at 12:15 p.m. The SSD said he clarified medications with the resident's physician and trazodone was administered for insomnia, not depression. He said he was still uncertain why the resident was on two other antidepressants and he was not able to locate a physician statement which documented a rationale for the use of two antidepressants. The SSD said he did not know what specific behaviors the resident displayed to justify the use of the olanzapine antipsychotic medication for dementia. Certified nurse aide (CNA) # 2 was interviewed on 4/11/24 at 1:30 p.m. CNA #2 said the resident did not have any aggressive behaviors. He said the resident would occasionally raise his voice when he needed help from staff. He said all of the resident's requests were reasonable and related to care. CNA #2 said the resident did not use the call light but preferred to yell to help when needed. Registered nurse (RN) #3 was interviewed on 4/11/23 at 2:05 p.m. RN #3 said the resident did not have any aggressive behaviors and he did not usually refuse care. She said the resident would occasionally get upset with care provided in the middle of the night. She said the resident used to live in assisted living and he was not accustomed to the call light system. She said the resident did not use the call light and often yelled for help. RN #3 said all the resident's requests were reasonable and pertinent to the care he needed. She said the resident had several hospitalizations during his stay in the facility and every time after his return he was more agitated and would "yell" for help. Once settled and adjusted to the routine he would not "yell" as much. RN #3 said if Resident #66 had behaviors they would be documented under progress notes. She said if the behavior was new and acute in onset, the event task would be started and behaviors would be monitored daily. RN #3 said for residents who were started on medications for insomnia, hours of sleep should be documented to ensure the medication was effective. She said Resident #66 was admitted with the medication for insomnia and she was not sure how and when tracking of hours of sleep should have been started. The assistant director of nursing (ADON) was interviewed on 4/11/23 at 2:45 p.m. The ADON said behavior tracking was usually documented under events. He said assessments for side effects of psychotropic medications should be documented under progress notes. He said resident's medication administration records did not include daily behavior tracking.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one kitchen and one of two nourishment rooms. Specifically, the facility failed to: -Ensure holding temperatures were at appropriate temperatures; and, -Ensure food was labeled, dated and disposed of in a timely manner. I. Failure to ensure holding temperatures were at appropriate temperatures. A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, (3/16/24) were retrieved on 4/17/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view and read in pertinent part, "The food shall have an initial temperature of 41ºF (fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control."B. Observations During a continuous observation of the kitchen on 4/10/24, beginning at 11:30 a.m. and ending at 12:20 p.m., tartar sauce was observed on a cart next to the oven and stove. The tartar sauce was portioned into two ounce (oz) to four oz sized plastic cups. The cups were on a cookie sheet. There was no mechanism to keep it cold. At 12:20 p.m. cook (CK) #1 took the temperature of the tartar sauce. CK #1 said the tartar sauce contained mayonnaise and lemon juice. -The temperature of the tartar sauce read 62 degrees F, which was above the appropriate cold holding temperature of 41 degrees F. CK #1 spoke to the dietary manager (DM) to confirm she was to discard the tartar sauce. The tartar sauce was discarded in the trash. C. Interviews The registered dietician (RD) was interviewed on 4/11/24 at 11:52 a.m. The RD said the tartar sauce needed to be discarded if it was not kept at a cold holding temperature of 41 degrees F or below in order to avoid the danger zone for potential food-borne illnesses. The dietary manager (DM) was interviewed on 4/11/24 at 2:02 p.m. The DM said there should be a cooling mechanism to keep the tartar sauce at the appropriate holding temperature. She said the tartar sauce should remain below 41 degrees F below for cold foods. II. Failure to ensure food was labeled, dated and disposed of in a timely mannerA. Professional reference The Colorado Retail Food Establishment Rules and Regulations (3/16/24), retrieved on 4/17/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, read in pertinent part, "A date marking system that meets the criteria stated in one (1) and two (2) of this section may include: Using a method approved by the department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine, marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded, marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request."B. Observations On 4/8/24 at 9:40 a.m. an observation of the main refrigerator in the kitchen revealed the following:. There was an eight ounce plastic cup covered with aluminum foil in the refrigerator. The foil was labeled with a resident's name and indicated the cup contained a chocolate milkshake.-The foil was labeled with date 3/29/24 (10 days earlier).-There was an opened almond milk carton without a discard date on it. On 4/11/24 at 10:34 a.m. observations of the refrigerator in the west unit's nourishment room revealed the following: There was one opened Pedialyte (a liquid product to replace fluids and minerals) plastic carton. The manufacturer label said to discard if not used within 48 hours. -There was no date to indicate when the Pedialyte carton was opened. There was one Magic Cup nutritional supplement in the refrigerator. The manufacturer label said to use it within five days if thawed for pudding-like texture.-There was no date on the Magic Cup to indicate when the supplement was thawed. C. Staff interviewsThe RD and the nursing home administrator (NHA) were interviewed on 4/11/24 at 11:52 a.m. The RD said milkshakes that are poured into a plastic cup and covered with aluminum foil expired within the same date the cups were labeled. The NHA said the resident's personal chocolate milkshake, opened almond milk carton, Pedialyte carton and the Magic Cup should have had a used by date on them. The DM was interviewed on 4/11/24 at 2:02 p.m. The DM said the opened containers should have an opened on and use by date. She said the opened items in the main kitchen refrigerator and the west unit's nourishment room should have had a used by date on them.

Based on observations, record review, and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections on three of five units. Specifically, the facility failed to:-Ensure enhanced barrier precautions (EBP) were implemented and followed for residents with wounds and/or indwelling medical devices; and,-Ensure staff used appropriate personal protective equipment (PPE) when entering the room of a COVID-19 positive resident. Findings include:I. PPE failures for EBPA. Facility policy The Infection Prevention and Control Program policy, revised January 2023, was received by the nursing home administrator (NHA) on 4/9/24 at 10:38 a.m. The policy read in pertinent part, "Multi-drug resistant organisms (MDRO) are defined as microorganisms that are resistant to one or more cases or antimicrobial agents. Enhanced barrier precautions (EBP) may be indicated for residents with any of the following, as directed by the infection preventionist and/or provider: wounds or indwelling medical devices, regardless of MDRO colonization status or infection or colonization with an MDRO. EBP include the use of gloves and gown during a high-contact care activities such as: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) or wound care for any open skin requiring a dressing." B. Resident #9 observationsResident #9 was observed on 4/8/24 at 2:01 p.m. He was inside the room seated in a wheelchair and had an indwelling catheter bag hanging from his wheelchair. Resident #9 was observed on 4/10/24 at 2:00 p.m. An unidentified certified nursing aide (CNA) and registered nurse (RN) #1 went into the resident's room to transfer the resident from the recliner chair to his bed for a wound dressing change. -The unidentified CNA and RN #1 did not put on gloves or gowns before they initiated the transfer. The wound care registered nurse (WCRN) entered the resident's room once he was in bed. -The WCRN did not put on a gown prior to completing the wound care dressing change for the resident. C. Resident #30 observationsResident #30 was observed on 4/8/24 at 1:49 p.m. Resident #30 was seated in a wheelchair in her room. An unidentified CNA went into her room to provide care. -The CNA did not put on a gown or gloves while transferring the resident from her wheelchair to the recliner chair. Resident #30 was observed on 4/9/24 at 3:56 p.m. RN #1 went into the resident's room to look at her pressure ulcers on both heels. She peeled back the resident's wound dressings to look at the wounds and put the dressings back into place.-RN #1 did not put on a gown while completing the resident's wound care. D. Staff interviewsThe infection preventionist (IP) and corporate nurse consultant (CNC) #1 were interviewed on 4/11/24 at 10:40 a.m. The IP said the facility currently did not have EBP in place for residents without MDROs who had indwelling medical devices or wounds. She said placing residents on EBP had not been done yet due to the lengthy process that was involved. She said the process involved educating residents, resident representatives and staff on the procedure. The IP said the facility had adequate PPE, such as gloves, gowns, eye protection, and masks in order to place all residents with indwelling devices/wounds on EBP. CNC #1 said they were aware of new requirements for EBP and were planning to implement it next week (week of 4/15/24). II. PPE Failures for COVID-19 positive roomA. Professional referenceAccording to the Center for Disease Control and Prevention (CDC) Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 (6/3/2020), retrieved on 4/17/24 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/communication/print-resources/A_FS_HCP_COVID19_PPE_card.pdf,"PPE must be donned correctly before entering the patient area (for example, isolation room, unit if cohorting). PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted (for example, retying gown, adjusting respirator/face mask) during patient care. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care."B. Observations On 4/10/24 at 12:11 p.m. CNA #4 was observed delivering a lunch tray to room #104. The sign on the door indicated staff were to wear PPE, including a gown, gloves, N95 mask and face shield. CNA #4 donned a yellow gown, placed a N95 mask on top of the surgical mask he was wearing, put on a face shield and gloves and entered the room. CNA #4 exited the room at 12:15 p.m. wearing a surgical mask. On 4/10/24 at 12:22 p.m. CNA #3 entered room #104. -CNA #3 donned a gown, face shield and gloves prior to entering the resident's room, however, he failed to remove his surgical mask and put on a N95 mask. CNA #3 entered the room wearing a surgical mask. C. Staff interviewsCNA #3 was interviewed on 4/10/24 at 12:39 p.m. CNA #3 said he should have been wearing a N95 mask but he forgot. The infection preventionist (IP) was interviewed on 4/10/24 at 1:20 p.m. The IP said the resident in room #104 tested positive for COVID-19. She said appropriate PPE for the room was a N95 mask, gown, gloves and face shield. The IP said a N95 mask should not be worn on top of a surgical mask. She said having a surgical mask under a N95 mask compromised the seal of the N95 mask and did not provide adequate protection.

A focused infection control survey was conducted on 9/2723. No deficiencies were cited.

An Emergency Preparedness focused infection control survey was conducted on 9/27/23. No deficiencies were cited.

A complaint survey, prompted by #CO32980 was conducted on 7/26/23 to 7/27/23. No deficiencies were cited.