BOULDER CANYON HEALTH AND REHABILITATION

A complaint survey, prompted by #CO39872, #CO39873 and #CO40067 was conducted on 5/19/25. No deficiencies were cited.

A revisit survey was completed on 4/22/25 for all previous deficiencies cited on 3/5/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO37084, #CO39001, #CO39328 and Incident #38078 was conducted on 3/3/25 to 3/5/25. One deficiency was cited.

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 development and transmission of disease. Specifically, the facility failed to:-Follow transmission-based precautions when entering and exiting droplet precaution rooms; and,-Ensure vital signs machines were sanitized between each use to prevent the spread of infection. Findings include: I. Failure to follow transmission-based precautions when entering and exiting droplet precautions rooms A. Professional referenceThe Centers for Disease Control and Prevention (CDC) Viral Respiratory Pathogens Toolkit for Nursing Homes, revised 1/8/25, was retrieved on 3/10/25 from https://www.cdc.gov/long-term-care-facilities/hcp/respiratory-virus-toolkit/index.html#:~:text=HCP%20who%20enter%20the%20room,i.e.%2C%20goggles%20or%20a%20face. It revealed in pertinent part, "HCP (healthcare personnel) who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved (National Institute for Occupational Safety and Health) particulate respirator with N95 filters or higher, gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face). This PPE can be adjusted once the cause of the infection is identified."B. Facility policy and procedureThe Infection Control policy, last updated October 2022, was provided by the nursing home administrator (NHA) on 3/6/2025 at 6:56 p.m. It read in pertinent part, "Transmission-based precautions are the second tier of basic infection control and used in addition to Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. "Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status and include proper selection and use of PPE (gowns, gloves, facemasks, respirators, and eye protection) based on predictive interactions between staff and resident and the potential for blood, body fluids or pathogens, hand hygiene, safe injection practices, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and reprocessing of reusable medical equipment. "Droplet precautions are used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking (this includes influenza and COVID-19). Precautions include implementing source control by placing a mask on the patient, ensure appropriate patient placement in a single room if possible (in long term care make decisions on a case-by-case basis considering infection risks to other patients in the room and available alternatives), use PPE appropriately (don mask, and eye protection if indicated, upon entry into the patient room or patient space), and limit transport and movement of patients outside of the room for medical purposes (if necessary, instruct the resident to wear a mask and use proper respiratory hygiene and cough etiquette). "Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room."C. ObservationsDuring a continuous observation on 3/3/25, beginning at 9:35 a.m. and ending at 10:30 a.m. the following was observed: At 9:35 a.m. licensed practical nurse (LPN) #1 donned (put on) a gown, eye protection and gloves before entering room #504 to administer medications. There was a sign that indicated the resident in room #504 was on droplet precautions and a personal protective equipment (PPE) bin outside the door. She was wearing a N95 mask. At 9:40 a.m. LPN #1 exited room #504 with her gown, gloves, and mask on. She no longer had her eye protection or gloves on. She washed her hands in the common area then went to her medication cart where she doffed (removed) her gown and placed it in the overflowing medication cart trash bin. She then performed hand hygiene. She did not remove her N95 when she then began gathering and administering medications for other residents who were not COVID-19 positive. At 10:23 a.m. certified nursing assistant (CNA) #1 stood outside of resident toom #506. There was a sign on the door that indicated the resident was on droplet precautions. CNA #1 donned a gown and gloves. She removed her surgical mask and placed it on the PPE bin outside the door and put on a N95 mask. CNA #1 did not put on a face shield or goggles prior to entering the room. At 10:26 a.m. while in resident room #506, CNA #1 opened the door, removed her gloves, gown and mask while still in the room and put them in a trash bin in the room. The resident in the room had a productive cough (cough that produces mucous). She performed hand hygiene, exited the room and put the surgical mask that she had placed on the PPE bin back on. At 10:25 a.m. an unidentified nurse practitioner (NP) entered room #506 after applying a gown and gloves. The NP put an N95 on over her surgical mask. She did not apply eye protection. At 1:18 p.m. CNA #2 applied a gown and gloves before entering room #603 (a droplet precautions room). She did not apply eye protection and kept her surgical mask on. She performed hand hygiene and exited the room. She continued wearing the same surgical mask. B. Staff interviews LPN #1 was interviewed on 3/3/25 at 10:10 a.m. LPN #1 said that after she exited room #504, she did not remove her gown while in the room because there was not a separate receptacle in the room for PPE. She said she did not want to throw it in the trash bin near the resident so she chose to throw it in the medication cart trash. LPN #1 said that, when doffing PPE, she was taught to remove her gloves, eye protection or face shield and gown in the room and the N95 mask once she exited the room. She said she would ensure a PPE trash receptacle would be available for dirty PPE in the resident's room. CNA #2 was interviewed on 3/3/25 at 1:20 p.m. CNA #2 said, to prevent the transmission of infection, all PPE was applied before entering a droplet precaution room and removed before leaving the room except for her mask. She said the mask was removed outside of the room. -However, she did not apply a mask when entering and exiting a droplet precaution room (see observations above). The director of nursing (DON) was interviewed on 3/3/25 at 2:44 p.m. The DON said the staff were expected to don PPE before they entered an isolation room. The DON said if a resident was on droplet precautions , the staff were expected to don a N95 mask, face shield or goggles, gown and gloves. She said that before they exited the room, they were expected to take off their PPE in no particular order. She said the staff needed to ensure it was removed immediately after performing care, except the N95 mask which should remain on until they exit the room. The DON said she provided LPN #1 education today (3/3/25) regarding donning and doffing PPE for droplet precautions. The DON said LPN #1 said she was nervous and did not want to get in trouble taking the used gown out with the resident's trash so she chose to remove it when at the medication cart. The DON said the staff should throw away the N95 once they exited a droplet precaution room. The DON said when COVID-19 first emerged masks were being reused due to supply shortages. She said an inservice was held last week about PPE use. She said the staff were told that there was enough supplies to not have to reuse any of it. The DON said that staff should not apply N95s over surgical masks because it did not provide an adequate seal to protect the mouth and nares. She said she would provide the NP with training. II. Failure to clean vital sign machines between uses A. Professional referenceAccording to the CDC Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last updated September 2024, retrieved on 3/10/25 from https://www.cdc.gov/infection-control/hcp/isolation-precautions/index.html It revealed in pertinent part, "Noncritical equipment (including medical equipment used on residents'skin but not exposed to the bloodstream or other orifices) must be thoroughly cleaned and disinfected before use on another patient. All such equipment and devices should be handled in a manner that will prevent healthcare workers (HCW) and environmental contact with potentially infectious material. In all healthcare settings, providing patients who are on Transmission-Based Precautions with dedicated noncritical medical equipment has been beneficial for preventing transmission. When this is not possible, disinfection after use is recommended."According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, revised 12/7/23, retrieved on 3/10/25 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html. It revealed in pertinent part, "Perform low-level disinfection for noncritical patient-care equipment that touch intact skin. Disinfect noncritical medical devices with an environmental protection agency (EPA)-registered hospital disinfectant using the label's safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. However, multiple scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least one minute. By law, all applicable label instructions on EPA-registered products must be followed."Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly)."B. Facility policy and procedureThe Cleaning and Disinfection of Resident Care Equipment policy, revised in December 2024, was provided by the NHA on 3/6/25 at 6:56 p.m. It read in pertinent part, "It is the policy of the facility that when staff is utilizing equipment for resident care to clean and disinfect resident care equipment, such as vital signs equipment, in between each resident use. "Only approved cleaning products may be used and cleaning products manufacturers' recommendations will be followed in the cleaning and disinfection of equipment. Preferred cleaning methods available include Bleach wipes and Sani wipes. Please follow manufacturers' recommendations on dwell times for each wipe. To disinfect, if needed, use a properly mixed approved disinfectant and a clean cloth, wiping all surfaces." C. Observations and interviews At 12:20 p.m. CNA #1 was walking out of room #504 with the vital signs machine. CNA #1 then entered room #505 with the same vital signs machine. When she exited the room, she said she wiped the machine down with an alcohol wipe. -CNA #1 failed to wipe down the vital sign machine with the correct sanitizing wipes between room #504 and room #505 (see professional reference above). D. Staff interviewsCNA #1 was interviewed on 3/3/25 at 12:22 p.m. CNA #1 said when she entered room #505, after leaving room #504, she used alcohol wipes while in room #505 to wipe down the vitals machine while in the room. CNA #1 said she wiped down the vital sign machine with alcohol wipes after exiting and before entering each room to obtain vital signs. The DON was interviewed on 3/3/25 at 2:44 p.m. She said that the 2-inch by 2-inch alcohol wipes available at medication carts and alcohol-based hand rubs were ineffective in cleaning medical equipment. She said the sanitizing wipes labeled sani-wipes were the appropriate and preferred sterilization method used to wipe down vital sign machines between each use.

A revisit survey was completed on 6/6/24 for all previous deficiencies cited on 5/2/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO35587, #CO35784, #CO35837 and Incident #CO35619 was conducted on 4/29/24 to 5/2/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure one (#9) of three residents received treatment and care in accordance with professional standards of practice out of 12 sample residents. Specifically, the facility failed to:-Ensure the emergency crash cart containing essential resuscitation equipment and a backboard was utilized during a resuscitation attempt for Resident #9;-Ensure a timely call was placed to emergency medical services (EMS) for immediate assistance when Resident #9 experienced a life threatening change of condition; and,-Ensure a licensed nurse remained with Resident #9 until EMS arrived. Findings include:I. Professional referenceAccording to the American Heart Association (AHA), (2020). Basic Life Support Provider Manual eBook, retrieved from https://ebooks.heart.org on 5/2/24 at 12:15 p.m,"The two key components of cardiopulmonary resuscitation (CPR) are chest compressions and breaths. High quality CPR improves a victim's chances of survival."Immediate activation of the emergency response system, early high-quality CPR, and rapid defibrillation are essential. In the workplace, every employee should know how to activate the emergency response system in their setting."A high performance team, three emergency responders who are called to assist in cardiac arrest will perform multi-rescuer coordinated CPR: rescuer one performs chest compression, rescuer two gives breaths with a bag-mask device, rescuer three uses the automated external defibrillator (AED). Rescuer three also assumes the role of CPR coach. The coach helps team members perform high quality CPR and minimize pauses in chest compressions"If the victim is not breathing normally or is only gasping and has no pulse, begin high quality CPR. Start cycles of CPR with 30 chest compressions followed by two breaths."Position the victim face up on a firm, flat surface, such as the floor or a backboard. This will help ensure that the chest compressions are as effective as possible. If the victim is on a soft surface, such as a mattress, the force from the chest compressions will simply push the victim's body into the soft surface. A firm surface allows compression of the chest and the heart to create adequate blood flow."For breaths to be effective, the victim's airway must be open. Two methods (for opening the airway): head tilt/chin lift and jaw thrust. Use a bag-mask device if available to provide positive pressure ventilation to victim who is either not breathing or not breathing normally."Because every second matters during a resuscitation attempt, it is important to define clear roles and responsibilities as soon as possible."II. Facility policy and procedureThe Emergency Procedures, Cardiopulmonary Resuscitation (CPR) policy, revised October 2018, was provided by the nursing home administrator (NHA) on 5/2/24 at 1:42 p.m. It read in pertinent part, "It is the policy of this facility to provide basic life support (BLS), including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel. Only staff members with current CPR certification for Healthcare Providers should perform the procedure."If unresponsive, not breathing (occasional gasps are not breathing) and no pulse, activate the EMS system. Page or yell loudly Code Blue to the area. Call 911."Position the resident face-up on a firm, flat surface. Start chest compressions. Open airway (tilt head back and lift the chin up), give two rescue breaths. May use a bag valve mask (BVM) or Ambu bag (a hand held device used to provide ventilation to someone who is not breathing) to give rescue breaths. Continue cycles of 30 chest compressions to two rescue breaths."III. Resident #9A. Resident statusResident #9, age 82, was admitted on 7/6/22. According to the April 2024 computerized physician orders (CPO), diagnoses included respiratory failure, dementia, Parkinson's disease (disorder of the central nervous system that affects movement) and dysphagia (difficulty swallowing). The 1/13/24 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. He required partial assistance with eating, hygiene and dressing. He required substantial assistance with transferring. The MDS assessment indicated he had loss of liquids/foods from his mouth when eating, held food in his mouth/cheeks or had residual food in his mouth after meals and had complaints of difficulty swallowing. B. ObservationsThe West hallway unit emergency crash cart was observed with the director of nursing (DON) on 4/30/24 at 9:40 a.m. A bag-mask device and airway supplies (including suction) were present on the cart. Two backboards were present next to the cart.-However, interviews during the survey revealed the supplies observed on the emergency crash cart on 4/30/24 were not utilized in the attempt to resuscitate Resident #9 on 2/29/24 (see interviews below). C. Record reviewA nursing progress note documented on 2/29/24 at 1:40 p.m. revealed Resident #9 had a change of condition which included nausea, vomiting, abnormal vital signs and shortness of breath. The nursing note revealed a report was provided to the primary care physician (PCP) at 1:50 p.m. The nursing note documented an emergency call was made to 911.-The progress note did not indicate what time 911 was called.-A review of the electronic medical record did not reveal any further documentation, details or timeline regarding the resuscitation/code of Resident #9. The Nurse Comprehensive Clinical Competency Review Skills Checklist was provided by the NHA on 4/29/24 at 9:49 a.m. The following items were included on the checklist:"Ambu bag, this is used in an emergent situation. Attach 15 liters (of oxygen) per minute to the ambu bag."Suctioning and airway management. Oral suctioning, trach suctioning, and deep suctioning (RN only)."The Emergency Crash Cart Daily Check Log was provided by the NHA on 5/2/24 at 11:35 a.m. Review of the daily check log revealed documentation indicating the following items were present on the West hallway crash cart on 2/29/24:-Suction machine (and documentation that it worked properly);-Suction kit;-Ambu Bag (bag/mask device);-Rebreather mask; and,-Oxygen mask.-However, none of the supplies present on the emergency crash cart on 2/29/24 were utilized in the attempt to resuscitate Resident #9 (see interviews below). IV. Staff interviews. Registered nurse (RN) #1 was interviewed on 4/29/24 at 2:01 p.m. RN #1 said she was Resident #9's nurse on 2/29/24. She said after lunch on 2/29/24, Resident #9 called for assistance with positioning. RN #1 said she and certified nurses aide (CNA) #1 assisted the resident with positioning. She said Resident #9 asked for a drink of water which was thickened per the dietary department. RN #1 said all of the liquids on the resident's bedside table were thickened. RN #1 said Resident #9's condition deteriorated after he drank the liquids. She said he began having difficulty breathing and his color was blue. RN #1 said she yelled out for staff to call 911. She said CNA #2 came into the room and the staff checked Resident #9's vital signs (heart rate, respiratory rate, oxygen saturation and blood pressure). RN #1 said Resident #9's oxygen saturation (oxygen level in the blood) was less than 85% and it was difficult to obtain other vital signs. RN #1 said she went to the door of the room and asked if anyone had called 911. RN #1 said there was no response from other staff. RN #1 said she left the room to call 911 since there was no response from other staff. She said Resident #9's color was blue when she left the room.-RN #1 failed to delegate CNA #1 or CNA #2, who were in Resident #9's room with her, to go call 911 while she remained with the resident. RN #1 said while she was calling 911, CNA #2 had started chest compressions. RN #1 said she did not know when Resident #9 stopped breathing or when his pulse stopped. RN #1 said the director of rehabilitation (DOR) was doing chest compressions when she returned to the room. RN #1 said she had a current Basic Life Support (BLS) for Healthcare Providers certification.-CNA #2 was unavailable for an interview during the survey. CNA #1 was interviewed on 4/29/24 at 2:16 p.m. CNA #1 said CNA #2 completed chest compressions on Resident #9. She said Resident #9 was turned to his side when he began vomiting with chest compressions. She said she never saw the emergency crash cart in or near the room. CNA #1 said, during the resuscitation, she never saw staff use a bag-mask device for providing breathing assistance for Resident #9. CNA #1 said there was not a backboard underneath Resident #9 during compressions. She said someone came in the room with an AED between two to four minutes after RN #1 called for help. The DOR was interviewed on 4/29/24 at 2:57 p.m. The DOR said she when she was informed Resident #9 was "coding" she brought the AED to the room. The DOR said when she arrived to Resident #9's room, CNA #2 was providing chest compressions and the resident was vomiting. The DOR said she used the AED for two cycles and provided chest compressions between cycles. She said the staff in Resident #9's room at the time did not ask for the emergency crash cart. The DOR said RN #1 was out of the room calling 911 when she arrived with the AED. The DOR said she did not know if anyone had suctioned Resident #9. The DOR said she had a current BLS for Healthcare Providers certification. Licensed practical nurse (LPN) #1 was interviewed on 4/29/24 at 3:19 p.m. LPN #1 said she arrived to the resident's room shortly after the DOR arrived. She said there was not a backboard under Resident #9 when the facility staff was performing CPR on Resident #9. LPN #1 said she asked for a non-rebreather mask and she thought staff were bringing the emergency crash cart to the room when the paramedics arrived. LPN #1 said EMS immediately put Resident #9 on the floor when they arrived. She said the paramedics intubated (insertion of a tube into a person's airway to enable oxygen to get through) the resident and used the AED several more times to shock the resident's heart. LPN #1 said the facility staff were aware of Resident #9's code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) and desire to be a full code, which included CPR. The DON was interviewed on 4/30/24 at 9:00 a.m. The DON said there was not a root cause analysis or investigation done after the unexpected death of Resident #9 at the facility. The DON said she was not at the facility during the resuscitation attempt of Resident #9. She said she received a text from CNA #4 which revealed Resident #9 was coding. She said she called CNA #4 and was told resuscitation attempts were still ongoing by staff and EMS had not arrived at the facility yet. The DON said based, on her phone information, Resident #9 had coded at approximately 1:44 p.m., staff were still resuscitating the resident at 1:51 p.m and EMS had not arrived (at least seven minutes). She said she did not have a timeline of events during the code and staff should have documented the events as they occurred. The DON said residents should be placed on a hard surface during chest compressions. She said certified staff were expected to perform CPR based on the BLS for Healthcare Providers standards. The DON said there was a bag-mask device on the cart and staff should have asked for it. She said it would have been difficult to use, however, as several staff told her Resident #9 was vomiting much of the time during the code. The DON said all staff knew where the emergency crash cart was located and the DON had not been aware until the survey that the cart was not in the room prior to EMS arrival. The DON said CNA #2 told her she provided chest compressions but did not ventilate (use bag-mask device) or manage the airway ofResident #9. The DON said she provided a staff inservice in early March 2024 to review how to respond to a code. She said the education included the need for the nurse to stay in the room to lead the code and to delegate responsibilities to other staff, including delegation to an individual for the responsibility to call 911. She said she had not been tracking who had BLS for Healthcare Provider certification but would start tracking it. CNA #4 was interviewed on 4/30/24 at 10:36 a.m. CNA #4 said she sent a text message to the clinical team (nursing staff), which included the DON, when the code was in progress. CNA #4 said EMS was not yet in Resident #9's room when the DON called CNA #4.-Based upon the DON's and CNA #4's interviews, Resident #9 was coding for at least seven minutes prior to the arrival of the EMS team without using a backboard or having airway equipment in the room to be available for use. The CPR Instructor (CPRI) was interviewed on 4/30/24 at 11:55 a.m. The CPRI said if a resident did not have a pulse and was not breathing, she would expect the staff to initiate chest compressions. The CPRI said if a bag-mask device and suction were available, she would expect them to be used if needed. She said students were taught to be prepared for and manage emesis (vomiting) during a code. The CPRI said if the resident was not actively throwing up, the staff should provide positive-pressure ventilation with a bag-mask device if the airway was clear. The primary care provider (PCP) was interviewed on 4/30/24 at 3:15 p.m. The PCP said if Resident #9 had no pulse, chest compressions were indicated. She said she would have expected the staff to take care of the airway and provide ventilations whenever possible. The PCP said ideally there should have been an ambu bag (bag-mask device) at the bedside during resuscitation for use if needed. The PCP said she would have expected the staff to use a backboard if there was one available as it could make chest compressions more effective. The PCP said she did not think the outcome would have been different due to Resident #9's medically fragile state. The DON was interviewed again on 5/1/24 at 8:38 a.m. The DON said she was told the team was considering using the emergency crash cart supplies when the paramedics arrived. She said she would have expected resuscitation equipment to be available in the room as soon as possible after a code had begun to be able to be used if the airway was able to be cleared. The DOR was interviewed again on 5/1/24 at 9:00 a.m. She said Resident #9 was vomiting most of the time while she was present. She said she did not see airway supplies or the emergency crash cart in the room. V. Facility follow-upAn In-Service Training Report titled CPR and dated 4/30/24 (during the survey) was provided by the NHA on 5/2/24 at 1:42 p.m. The training was conducted by the DON and included the following:"-The resident's nurse should remain at the bedside with the resident throughout the code, or until the resident is transferred to the hospital. The nurse should delegate the following activities:- 911 call-retrieval and set up of the crash cart (obtaining and setting up the resuscitation equipment needed)-documentation and timeline of events during the code."The DON planned to utilize mock codes (scenarios to simulate a real emergency code) to provide additional learning opportunities to the staff.

A revisit survey was completed on 4/24/24 for all previous deficiencies cited on 2/6/24. The facility is in compliance with all regulations surveyed.

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

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 February 27, 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) construction with no basement. The original facility was constructed in 1963. The facility is licensed for 140 beds and the census on the date of the survey was 103. This facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and anti-freeze fire sprinkler systems. The anti-freeze system protects the front entrance canopy. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Administrator and Maintenance Director during the exit conference.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This was evidenced by the following: 1. Fire doors have a gap when closed, near the copy room, leading into the 200 rooms hallway. NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors and gaps in the door smoke seal. This was discussed with the Maintenance Director and Administrator during the exit conference.

A recertification survey was conducted on 1/31/24 to 2/6/24. Four deficiencies were cited.

An Emergency Preparedness survey was conducted from 1/31/24 to 2/6/24. No deficiencies were cited.

Based on observations and interviews the facility failed to provide a comfortable and homelike environment for the residents on three of five units in the facility. Specifically, the facility failed to:-Residents were provided with clean washcloths and hand towels in their rooms on the West, Flatiron and North units; and, -Ensure holes in the residents' bathroom doors and ceiling were fixed. Findings include:I. Facility policy and procedureThe Safe and Homelike Environment policy, revised December 2020, was provided by the nursing home administrator (NHA) on 2/6/24 at 1:47 p.m. It read in pertinent part: "In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk."The facility will create and maintain, to the extent possible, a homelike environment that de­-emphasizes the institutional character of the setting."The facility will provide and maintain bed and bath linens that are clean and in good condition."Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment."Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment as the resident allows."II. Lack of washcloths and hand towels in resident rooms A. ObservationsOn 1/31/24 beginning at approximately 8:40 a.m., the following observations were made:-Room #108 had no hand towels or washcloths;-Room #109 had no hand towels or washcloths;-Room #111 had no hand towels or washcloths; and,-Room #503 had no hand towels or washcloths. On 2/1/24 beginning at approximately 9:35 a.m., the following observations were made:-Room #108 had no hand towels or washcloths;-Room #109 had no hand towels or washcloths;-Room #111 had no hand towels or washcloths;-Room #503 had no hand towels or washcloths;-Room #504 had no hand towels or washcloths;-Room #505 had no hand towels or washcloths;-Room #507 had no hand towels or washcloths;-Room #601 had no hand towels or washcloths;-Room #603 had no hand towels or washcloths;-Room #604 had no hand towels or washcloths;-Room #609 had no hand towels or washcloths;-Room #701 had no hand towels or washcloths;-Room #703 had no hand towels or washcloths;-Room #708 had no hand towels or washcloths; and,-Room #709 had no hand towels or washcloths; On 2/5/24 beginning at approximately 3:12 p.m., the following observations were made:-Room #108 had no hand towels or washcloths;-Room #109 had no hand towels or washcloths;-Room #111 had no hand towels or washcloths;-Room #503 had no hand towels or washcloths;-Room #504 had no hand towels or washcloths;-Room #505 had no hand towels or washcloths;-Room #507 had no hand towels or washcloths;-Room #601 had no hand towels or washcloths;-Room #603 had no hand towels or washcloths;-Room #604 had no hand towels or washcloths;-Room #609 had no hand towels or washcloths;-Room #701 had no hand towels or washcloths;-Room #703 had no hand towels or washcloths;-Room #708 had no hand towels or washcloths; and,-Room #709 had no hand towels or washcloths; On 2/5/24 at 3:05 p.m., two linen supply closets were observed with certified nurse aide (CNA) #4. The observations revealed the following:-Flatiron hall linen supply closet contained some hand towels and no washcloths;-West hall linen supply closet contained only six washcloths, no bath towels and no hand towels; and,-The North Hall linen supply closet contained only two hand towels and five washcloths. B. Resident interviews The resident group interview was conducted on 2/1/24 at 11:00 a.m. The group consisted ofsix residents (#90, #162, #57, #59, #5, and #72) who were interviewable based on facility assessment. Resident #72, #90 and #59 said hand towels and washcloths were not delivered to their rooms unless they asked for them. All the other residents agreed. Resident #72 was interviewed on 2/5/24 at 9:14 a.m. Resident #72 said the facility did not have enough linen hand towels or washcloths. He said staff were too busy to bring hand towels and washcloths to the residents' rooms. Resident #72 said he had to keep asking staff repeatedly for the linens. He said he did not even have paper towels in place of a linen hand towel to dry his hands in his room. -There were no hand towels or washcloths observed in Resident #72's room during the resident's interview. Resident #32 was interviewed on 2/5/24 at 3:16 p.m. Resident #32 said the facility did not have enough hand towels or washcloths. Resident #32 said she did not like to use paper towels to dry her face but most of the time she had to because there were no hand towels in her room. Resident #32 said she had to yell before someone would get her washcloths and hand towels. She said linen hand towels and washcloths would make her room feel more comfortable. The resident said she used wet wipes to wash with because she did not often have a washcloth. -There were no hand towels or washcloths observed in Resident #32's room during the resident's interview. III. Holes in residents' bathroom doors and ceiling A. Observations On 1/31/24 beginning at approximately 10:14 a.m., the following observations were made:-The bathroom doors in Room 109 and Room 503 had holes on both the outside and inside at the bottom part of the door; and,-Room 109 had a hole in the ceiling right above where the resident's bed was positioned. B. Staff interviews CNA #4 was interviewed on 2/1/24 at approximately 4:15 p.m. CNA #4 said hand towels and washcloths were stocked in the linen supply closets by the laundry personnel. CNA #4 said it was the responsibility of the unit CNAs to ensure residents' rooms were stocked with hand towels and washcloths. CNA #4 said it was important for resident's dignity to provide them with hand towels and washcloths. The NHA and the maintenance supervisor (MS) were interviewed on 2/6/24 at approximately 12:40 p.m. The MS said the facility was working on a maintenance schedule to fix the holes on the residents' bathroom doors and the ceiling. He said holes in the ceiling and bathroom doors were safety concerns and did not represent a homelike environment for residents. The NHA said the maintenance project had begun with the front part of the building and would proceed gradually to individual residents' rooms.

Based on interviews, observations and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain personal hygiene for five (#66, #24, #72, #54 and #26) of eight residents reviewed for ADLs out of 38 sample residents. Specifically, the facility failed to:-Ensure Residents #66, #24, #72, #54 and #26, who required assistance with bathing, were showered or bathed according to their preferences in order to maintain personal hygiene;-Provide Resident #24 assistance with shaving; and,-Provide Resident #54 assistance with shaving and nail care. Findings include:I. Facility policy and procedureThe ADL policy, which was undated, was received from the nursing home administrator (NHA) on 2/6/24 at 1:37 p.m. It read in pertinent part:"The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. "Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care."A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will maintain individual objectives of the care plan and periodic review and evaluation."II. Resident #66A. Resident statusResident #66, age 74, was admitted on 7/11/22. According to the February 2024 computerized physician orders (CPO), diagnoses included history of transient ischemic attack and cerebral infarction (stroke), aphasia (affects a person's ability to express and understand written and spoken language) and left hip pain. The 11/2/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required substantial to maximum assistance for bathing. B. Resident interviewResident #66, who had difficulty with communicating verbally due to his aphasia, was interviewed on 1/31/24 at 4:00 p.m. He indicated he had not been offered a shower in seven days by using his hands to hold up seven fingers. He indicated that he was to receive two showers a week by holding up two fingers. C. Record reviewThe bathing plan of care for Resident #66 revealed the resident's preferred shower days were Wednesdays and Sundays. The ADL care plan, initiated on 7/12/22 and revised on 7/19/22, revealed Resident #66 had a self care deficit related to right sided weakness, stroke and impaired cognition. Pertinent interventions included encouraging the resident to participate to the fullest extent possible with interactions and requiring one to two staff members participation with bathing tasks. Review of Resident #66's shower records from 1/8/24 to 2/6/24 revealed the resident received one shower on 1/24/24 and refused showers on 1/17/24 and 1/28/24.-There was no further documentation to indicate whether Resident #66 received a shower or was offered and refused a shower for the other seven opportunities he had for showering during the time frame reviewed. On 2/1/24, during the survey, a grievance form was completed with Resident #66 by an unknown facility staff member. It revealed Resident #66 was upset regarding not getting a shower for more than five days. He enjoyed showering and being clean and would like to receive showers twice weekly. The grievance revealed follow up was conducted with the infection preventionist (IP) who confirmed Resident #66's shower days were Wednesdays and Sundays and he had not been offered a shower on 1/21/24 (Sunday). The grievance documented staff would be educated on offering residents showers on their scheduled days. The grievance further documented social services (SS) #1 spoke with Resident #66 to confirm his preferred shower days were Wednesdays and Sundays. SS #1 informed the resident staff would be educated on offering showers. -However, Resident #66's electronic medical record (EMR) revealed there was no documentation to indicate the resident had been offered or refused a shower on 2/4/24, three days after the staff was supposed to be educated, according to the grievance form..D. Staff interviewsCertified nursing assistant (CNA) #1 was interviewed on 2/5/24 at 4:00 p.m. She said resident bathing preferences were posted in the nurses station as well as on the bathing plan of care. She said resident refusals of bathing were documented in the EMR and there was an option to indicate a reason for refusal. She said it was important to document refusals so staff knew to continue offering showers. She said consistent showers were important for resident hygiene and honoring preferences. The infection preventionist (IP) was interviewed on 2/5/24 at 4:00 p.m. She said bathing tasks were primarily completed by the CNAs. She said bathing tasks were documented in the EMR. She said there was an option to indicate refusals and why a resident refused. She reviewed the bathing plan of care for Resident #66 and said his scheduled bathing days were Wednesdays and Sundays. She said he last received a shower on 1/24/24. III. Resident #24A. Resident statusResident #24, age 70, was admitted on 10/18/2013 and readmitted on 8/23/23. According to the February 2024 CPO, diagnoses included quadriplegia (paralysis affecting all limbs and body from the neck down), paraplegia (Paralysis affecting the lower half of the body), bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood), and cauda equina syndrome (damaged nerves below the end of spinal cord). The 10/16/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was dependent with two person assistance for toileting, shower/bathing, dressing, personal hygiene, bed mobility and transfers. B. Resident observations and interviewsOn 1/31/24 at 11:39 a.m., Resident #24's hair was greasy and pulled back into a ponytail and his face was unshaven. Resident #24 said he last received a shower approximately 12 weeks ago. He said he thought he had bugs or lice in his hair. He said he wanted to receive a shower and get his hair washed at least once a week but twice a week would be better. Resident #24 said he preferred a shower before going to bed between 9:00 p.m. and 10:00 p.m. Resident #24 said he had to "beg" to get a staff member to shave him. He said the beard style he wanted was to keep his mustache, sideburns, a small part of the goatee and have the rest of his face shaved. Resident #24 said he did not refuse showers or shaves. On 2/6/24 at 9:29 a.m., Resident #24 was lying in bed, his ponytail was removed, his hair was long, dirty and greasy. Resident #24 said he still had not received a shower although the social worker had visited him yesterday (2/5/24) and said he would get one (see record review below). Resident #24 said a shower was not offered by the staff on 2/5/24. Resident #24 said he would not refuse a shower because showers were important to him for his personal hygiene. C. Record ReviewThe shower preference sheet dated 12/27/22 revealed the resident preferred a shower one time per week on Tuesday evenings. Resident #24's ADL self care performance deficit care plan, revised 7/26/23, revealed the resident was totally dependent on staff to provide a bath, required a mechanical lift for transfers and required total assistance with transfers with two staff members. The 1/27/24 nursing progress note revealed the resident "was offered and refused a shower this shift."-However, a reason was not documented as to why the resident refused his shower so that a root cause could be identified.-It was not documented on the shower task documentation that a shower was offered or refused. The 2/5/24 social services progress note revealed in pertinent part, "He also agreed to a shower tonight at nine or 10 pm only. I then passed that along to his care team today as well. He then told the writer that he will be happy to get a shower tonight because the bugs that crawl from head to his eyes while he sleeps, and that the bugs crawl to his eyes and drink the moisture from his eyes and then leave salt in his eyes and it burns. Then the bugs crawl back to his head when he wakes up. This writer asked him what bugs he was talking about? He stated, "The microscopic ones" This writer tried to assure him that he does not have bugs in his hair, but he stated they are microscopic, you'll never see them without a microscope. SS (social services) then left his room. SS to follow."-There was no documentation which indicated the resident was offered or refused a shower on 2/5/24. The visual/bedside kardex (a tool utilized by staff to provide consistent care for residents) report, dated 2/1/24, revealed the resident was totally dependent on staff to provide a bath or shower on Tuesday evenings and he preferred female caregivers. Resident #24's bathing task records were reviewed from 12/1/23 to 2/6/24. The records revealed the resident was scheduled for one shower per week on Tuesday evenings, and he preferred a female caregiver. The bathing task records further revealed the following:From 12/1/23 to 12/31/23, there were no showers documented for Resident #24.-The records documented the resident refused bathing on 12/3/23 (a Sunday), 12/4/23 (a Monday), 12/7/23, (a Thursday), 12/20/23 (a Wednesday) and 12/29/23 (a Friday).-None of the showers documented as offered and refused occurred on a Tuesday, which was Resident #24's preferred shower day. From 1/1/24 to 1/30/24, there was one shower documented for Resident #24 on 1/23/24.-The resident received a full body bath on 1/3/24, however, the resident's preference for bathing was a shower.-The records documented the resident refused bathing on 1/24/24 (a Wednesday) and 1/30/24 (a Tuesday).-The refusal on 1/24/24 occurred on a Wednesday, which was not Resident #24's preferred shower day. From 2/1/24 to 2/6/24, there were no showers documented as given or refused for Resident #24.-According to review of Resident #24's bathing task records from 12/1/23 to 2/6/24 the resident received one shower in 68 days. D. Staff interviewsCNA #5 was interviewed on 2/5/24 at 4:26 p.m. CNA #5 said the CNAs documented showers on the computer in the resident' electronic medical records (EMR). She said if a resident refused their shower she would tell the nurse and the nurse asked the resident a second time if they wanted a shower. CNA #5 said the nurse would chart in the progress note why the resident refused. CNA #5 said it was important for the residents to have a shower in order to stay clean. Licensed practical nurse (LPN) #3 was interviewed on 2/5/24 at 4:29 p.m. LPN #3 said the CNAs completed the showers and there was a list at the nurses station of which residents were scheduled for showers each day. LPN #3 said if a resident refused a shower the CNA should ask the resident a second time and then tell the nurse so the nurse could try to convince the resident and educate them about the importance of a shower. LPN #3 said she would chart in the progress note why the resident refused to see if there was a pattern or problem. LPN #3 said regular showers were important to prevent infections, skin breakdown and to promote cleanliness. The IP was interviewed on 2/6/24 at 1:55 p.m. The IP said she assessed Resident #24's hair/head upon receiving the report of possible bugs in his hair. She said she did not find any bugs but the resident needed to have his hair/head washed and cleaned. She said Resident #24 had requested a special shampoo due to his head being itchy. IV. Resident #26A. Resident statusResident #26, over the age of 65, was admitted on 9/14/17. According to the February 2024 CPO, diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, muscle weakness, severe obesity, and unsteadiness on feet. The 9/12/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He required supervision with bathing, and toileting and had no rejection of care. B. Resident observations and interviewsOn 2/1/24 at 10:35 a.m., Resident #26 was sitting at the edge of his bed wearing an adult incontinent brief. The resident's room had a strong odor of urine. On 2/5/23 at 3:23 p.m., Resident #26 was in his room with food debris on his pants and shirt. Resident #26 was interviewed on 2/5/2 at 3:30 p.m. He said he required assistance with his shower/bath due to weakness and his inability to reach some areas of his body. The resident said the staff were not assisting him with his showers. C. Record reviewThe care plan, revised on 10/31/21, identified an ADL self-care performance deficit such as bowel and bladder incontinence related to diagnoses of COPD, muscle weakness and impaired mobility. Interventions included one staff assistance with bathing. The shower/bath records revealed Resident #26's preferred shower days were Mondays and Fridays. A review of Resident #26's shower/bath records from 12/5/23 to 2/5/24 revealed Resident #26 received two showers out of nineteen opportunities, refused seven shower sections, and ten none applicable (N/A). V. Resident #54A. Resident statusResident #54, over the age of 65, was admitted on 7/25/22 and readmitted on 10/19/23. According to the February 2024 CPO, diagnoses included schizoaffective disorder, major depressive disorder, problems related to care provider dependency, abnormalities of gait and mobility,s and the need for assistance with personal care. The 9/12/23 MDS assessment revealed Resident #54 was cognitively intact with a BIMS score of 15 out of 15. He was independent with toilet use, and oral hygiene and required supervision with touching assistance with showers. Rejection of care and other behavioral symptoms were not exhibited. B. Resident observations and interviewsOn 2/1/23 at 10:35 a.m., Resident #54 was laying on his bed. Resident #54's fingernails were half an inch long, jagged, and untrimmed with dark brown matter underneath the resident's nails. The resident had food stains on his clothes, an unshaved beard, and his hair was unkempt. On 2/5/24 at 3:28 p.m., Resident #54 was returning to his room from an activity program. The resident had on the same clothes he was wearing on 2/1/24, four days prior. There were food stains on both his pants and sweater. The resident's fingernails were, and untrimmed with dark brown matter underneath his fingernails. The resident's hair was unkempt and he was not shaved. Resident #54 was interviewed on 2/5/24 at 3:38 p.m. Resident #54 said he would like his fingernails, trimmed but no one had offered to assist him. Resident #54 said he did not remember the last time he showered. The resident said he preferred his fingernails short and clean. The resident said he would prefer to have clean clothes on. C. Record reviewThe ADL care plan, revised on 11/22/23, revealed the resident had an ADL self-care performance deficit, however, he was independent with ADL care in bathing, grooming, personal hygiene, dressing, transfer, bed mobility, and toileting. The care plan focus documented the resident had the potential for a behavior problem related to wearing visibly soiled clothing and refused offers for personal hygiene and showers. Interventions related to bathing, grooming, and personal hygiene included staff to negotiate a time for ADLs so the resident could participate in the decision making process and staff to offer to wash the resident's clothes.-The care plan excluded fingernail care support for the resident. A progress note dated 1/30/24 at 1:44 p.m. documented Resident #54 clipped and cleaned his fingernails.-However, Resident #54's fingernails were observed to be long, jagged and dirty during the survey on 2/1/24 and 2/5/24 (see observations above). The shower/bath records revealed Resident #54 preferred to shower once a week on Mondays. A review of Resident #54's shower/bath records from 11/5/23 to 2/5/24 revealed out of fourteen bathing opportunities, Resident #54 received one sponge bath, one shower, refused six showers and six opportunities were documented as N/A (not applicable). D. Staff interviewsCNA #5 was interviewed on 2/5/24 at 5:10 p.m. CNA #5 said CNAs were responsible for providing fingernail care except when the resident was diabetic. CNA #5 said dirty and long fingernails could cause skin issues such as skin tears, scratches and transfer of germs. LPN #3 was interviewed on 2/5/24 at 5:16 p.m. LPN #3 said the CNAs and floor nurses were responsible for providing fingernail care for all residents. LPN #3 said nail care should be provided nail care with their showers. LPN #3 said nurses were responsible for cutting for residents who were diabetic. LPN #3 said it was important for residents to have regular fingernail care for good personal hygiene and to prevent the transmission of infectious diseases. VI. Resident #72A. Resident statusResident #72, over the age of 65, was admitted on 1/11/24. According to the February 2024 CPO, diagnoses included fibromyalgia, paroxysmal atrial fibrillation, weakness, abnormalities of gait and mobility, muscle weakness and need for assistance with personal care. The 1/16/24 MDS assessment revealed Resident #72 was cognitively intact with a BIMS score of 15 out of 15. She required supervision with toileting, personal hygiene and moderate assistance with showers. Rejection of care and other behavioral symptoms were not exhibited. B. Resident interviewResident #72 was interviewed on 1/31/24 at 10:05 a.m. The resident said her shower preference was once a week on Wednesdays, however, she had not been receiving her showers. The resident said she had not been offered a shower since she was admitted to the facility on 1/11/24. The resident said the staff always told her there was no time to complete her shower. C. Record reviewThe ADL care plan, revised 1/17/24, revealed Resident #72 had an ADL performance deficit related to weakness and required one staff assistance with toileting and bathing. She preferred to bathe once per week on Wednesdays.-A review of the January 2024 and February 2024 progress notes revealed there was no documentation to indicate Resident #72 had refused any of her showers since her admission.-The shower/bath records revealed Resident #72 had received one shower in 27 days. VII. Additional interviewThe director of nursing (DON) was interviewed on 2/6/24 at 10:00 a.m. She said CNAs were mainly responsible for assisting residents with bathing and bathing was documented in the EMR to include refusals and reasons for refusal. She said residents were asked about bathing preferences, to include what days of week they preferred to bathe as part of the admission process, and preferences were available to staff in the bathing plan of care. If residents did not have a preference, staff would suggest bathing at least twice a week and tell residents what days were available. The DON said documenting refusals was important for recognizing trends that aided in implementing effective interventions. She said CNAs should document the reason a resident refused their shower and also re-approach the resident to offer them the opportunity for bathing again. She said CNAs should attempt to bathe a resident three times and inform the unit manager if a resident continued to refuse. The DON said resident refusals of bathing were discussed in the morning meetings with the interdisciplinary team (IDT) to determine possible interventions which might encourage a resident to bathe. She said consistent bathing was important for residents to promote cleanliness and dignity. The DON reviewed the EMR from 1/16/24 to 2/6/24 for Resident #66 and said he received one shower on 1/24/24. She said he refused bathing on 1/17/24 and 1/28/24but she was unable to find a reason for the refusals documented in theEMR. The DON reviewed the EMR for Resident #24 and said the documentation reflected the resident received one shower, on 1/23/24, in 30 days. The DON was unable to find documentation in the EMR to explain why only one shower within 30 days had been provided to the resident. The DON said CNAs should be providing showers, shaving assistance and nail care to Resident #54. She said untrimmed, long and dirty fingernails could cause skin issues such as skin tears, scratches and the transmission of germs and infectious diseases. She said Resident #54 had behaviors that made providing bathing and personal hygiene for the resident difficult at times. The DON said Resident #72 should receive assistance from staff for bathing per her care plan. The DON said she became aware of resident concerns regarding not receiving showers during the week of 1/28/24 to 2/3/24. She said she had begun education with staff on the importance of documenting resident's bathing refusals and the reason for the refusal.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in two of five medication carts. Specifically, the facility failed to ensure expired or discontinued medications were removed from medication carts in a timely manner. Findings include:I. Facility policy and procedureThe Medication Access and Storage Policy, revised August 2019, was provided by the nursing home administrator (NHA) on 2/5/24 at 2:56 p.m. The policy read in pertinent part:"Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists."II. Professional referencesAccording to the manufacturer Sanofi Aventis US, Using Lantus? Learn How to Inject Insulin (2023), retrieved on 2/7/24 from https://www.lantus.com/how-to-use/how-to-inject, "Lantus vials should be thrown away after 28 days even if it still has insulin left in it."According to the manufacturer Eli Lilly and Company, Humalog-Insulin Lispro Injection, Solution (August 2023), retrieved on 2/7/24 from https://uspl.lilly.com/humalog/humalog.html#ug, "Throw away all opened vials after 28 days of use, even if there is insulin left in the vial."III. Observations and interviewsOn 2/1/24 at 2:39 p.m., the West One medication cart was observed with licensed practical nurse (LPN) #1. The following items were found:A vial of Insulin Glargine (Lantus) 100 units/milliliter (ml) was dated as opened on 12/14/23.-The insulin vial should have been discarded on 1/11/24, 28 days after it was opened. Humalog insulin (Lispro) 100 units/ml was dated as opened on 12/15/23.-The insulin vial should have been discarded on 1/12/24, 28 days after it was opened. LPN #1 said if insulin was used more than 28 days after opening it could be ineffective. The registered pharmacist (RPH) was also present and said she knew both medications were good for 28 days after opening. The RPH said after 28 days it was unknown whether the medications were effective. On 2/5/24 at 11:26 a.m., the North medication cart was observed with LPN #2. The following item was found:A Fluticasone 50 microgram (mcg) nasal spray bottle was dated as opened on 4/16/23. Instructions on the bottle label directed use for seven days. LPN #2 said the nasal spray was discontinued on 4/23/23 and should have been discarded when it was discontinued. She removed the medication from the cart for disposal. IV. Additional interviewThe director of nursing (DON) was interviewed on 2/6/24 at 10:47 a.m. She said insulins were to be discarded 28 days after opening. She said discontinued medications should be removed from the medication cart within 24 hours.

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 development and transmission of disease and infection on four of five units. Specifically, the facility failed to:-Wear the appropriate personal protective equipment (PPE) when entering transmission based precaution rooms (entire memory care unit with COVID-19 outbreak);-Follow infection control practices when administering feeding via jejunostomy tube (J-tube); and,-Ensure residents personal hygiene items were labeled. Findings include:I. Facility status: On 1/31/24, the facility was in a COVID-19 outbreak contained to the memory care unit. Signage on the entrance to the locked unit doors revealed PPE for droplet precautions, including N95 respirator mask, eye protection, mask, and gloves were necessary prior to entering the unit. The outbreak began 1/23/24, and as of 2/6/24, 16 residents (including two deceased residents on hospice) and eight staff members had tested positive. No residents or staff had tested positive for COVID-19 outside of the memory care unit. II. Failed to wear personal protective equipmentA. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), Recommended Infection Prevention and Control Practices when Caring for a Patient with Suspected or Confirmed SARS-COV2 Infection, revised 5/8/23, retrieved on 2/8/24 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html,"HCP (healthcare personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves and eye protection (i.e., goggles or a face shield that covers the front and sides of the face)."B. Facility policyThe Transmission Based Precaution policy, revised July 2022, was provided by the nursing home administrator (NHA) on 2/6/24 at 5:18 p.m. It read in pertinent part:"The facility will provide appropriate PPE for each specific infectious disease. The facility will follow CDC guidelines for all isolation measures and PPE use."C. ObservationsOn 2/1/24 at 3:30 p.m., certified nurse aide (CNA) #7 was talking to Resident #91 on the memory care unit. -CNA #7 was not wearing proper eye protection (goggles or face shield) and the top of her N95 mask was resting on the tip of her nose which did not create a full seal around her nose. On 2/1/24 at 3:40 p.m., CNA #8, who identified herself as a hospice CNA, entered the memory care unit with only a N95 mask on. -CNA #8 did not apply eye protection, gown, or gloves prior to entering the unit. D. Staff interviewsThe infection preventionist (IP) and director of nursing (DON) were interviewed together on 2/6/24 at 12:08 p.m. The IP said all staff were to wear N95 masks, goggles or face shield, gown and gloves when they entered the memory care unit. She said hospice CNAs and nurses were aware of the COVID-19 outbreak on the unit and the requirements for appropriate PPE upon entering the unit. E. Facility follow-upOn 2/6/24 at 3:16 p.m., additional signage was present near the entry keypad to the memory care unit. The signage included stopping and applying all PPE for droplet precautions prior to entering the unit. The DON said the additional signage was added to reinforce teaching. III. Failed to follow infection control practices for J- tube feedingA. Facility policyThe Gastrostomy Tube Policy, revised March 2022, was provided by the nursing home NHA on 2/6/24 at 5:18 p.m. It read in pertinent part:"Clean all accessories after each use. Change entire tube feeding set every time a new formula is hung or at least every 24 hours. Ensure either bottle or tube set is dated."B. Observation and interviewsOn 2/5/24 at 10:02 a.m., registered nurse (RN) #1 administered a tube feeding to Resident #13. RN #1 said the previous feeding was stopped and disconnected on 2/5/24 at 3:00 a.m because the continuous feeding was ordered for 18 hours per day and that day's feeding had been completed. She picked up the previously used tubing (which was attached to the feeding pump) off of the resident's bed and connected the tip of the tubing to the resident's tube feeding port. The tip was open to air on the bed and was not capped.-RN #1 did not clean the end of the tubing, which had been resting on the bed uncapped, prior to connecting the tubing to Resident #13's tube feeding port. C. Staff interviewsThe IP and DON were interviewed together on 2/6/24 at 12:08 p.m., The IP said there should have been a protective cap or cover for the tubing used for Resident #13's feedings. She said if the feeding was disconnected for any reason, the tip of the tubing should not rest on a dirty surface without the cap on. She said the bed was a dirty surface and could contaminate the tubing. RN #1 was interviewed on 2/6/24 at 1:30 p.m. She said the tube feeding set should be discarded after 24 hours. She said she did not know how long the tube feeding set had been in use because it had not been labeled with the date and time it was hung .IV. Failed to ensure personal hygiene supplies were labeledA. Facility policyThe Infection Prevention and Control Program policy was provided by the NHA on 1/31/24 at 2:35 p.m. It read in pertinent part:"Goals of the facility include decreasing the risk of infection to residents. The facility will investigate, control, and prevent infections in the facility, and decide what measures/interventions should be applied in individual circumstances." B. ObservationsOn 1/31/24 at 11:00 a.m. and again on 2/5/24 at 3:15 p.m., the following shared resident rooms did not have personal hygiene supplies labeled and contained or separated:-Room #111 had unlabeled toothbrushes, a hairbrush and toothpaste on the sink counter in the residents' room; -Room #108 had an unlabeled comb, toothbrushes and two unbagged urinal containers hanging on the bathroom grab bar;-Room #503 had one unlabeled and unbagged urinal container, unlabeled toothbrushes, hair brushes and body wash-Room #504 had unlabeled comb, body wash, deodorant, hygiene container and toothbrushes;-Room #505 had unlabeled toothbrushes, two unlabeled hygiene containers with unlabeled personal hygiene items such as hair brushes, toothbrushes and toothpaste;-Room #507 had unlabeled toothbrushes, toothpaste and a comb;-Room #601 had unlabeled toothbrushes, toothpaste. hair brushes, deodorant and body wash;-Room #603 had unlabeled toothbrushes, toothpaste. hair brushes and body wash. Unlabeled hygiene supplies were on the residents' sink;-Room #604 had unlabeled toothbrushes, toothpaste. hair brushes, shampoo, deodorant and body wash;-Room #701 had unlabeled toothbrushes, toothpaste. hair brushes, deodorant and body wash; -Room #703 had unlabeled toothbrushes, toothpaste. hair brushes, deodorant and body wash; An unlabeled hairbrush was on the sink counter;-Room #708 had unlabeled toothbrushes, toothpaste. hair brushes and body wash. The hygiene containers in the residents' room were not labeled; and,-Room #709 had unlabeled toothbrushes, toothpaste. hair brushes and body wash. The hygiene containers in the residents' room were not labeled. C. Staff interviewsCNA #5 was interviewed on 2/5/24 at 1:40 p.m. She said the personal hygiene items in room #111, #503 and #505 were unlabeled and the urine containers were not bagged and properly stored. She said the CNAs were responsible for labeling residents' hygiene items and storage of urine containers. The CNA said labeling was important to prevent the spread of germs. The IP was interviewed on 2/5/24 at 2:15 p.m. The IP said the CNAs were responsible for labeling personal hygiene items and hygiene containers/bags. The IP said it was important to label personal hygiene items to prevent the possibility of residents using each others' items and to prevent the spreadof diseases. The IP said she would ensure the facility staff were retrained. The DON was interviewed on 2/6/24 at 10:43 a.m. She said personal hygiene items should be labeled when rooms were shared. She said the facility did a "clean sweep" in January 2024 and personal hygiene items were placed in bags and labeled. The DON said the process was not being followed consistently. She said the CNAs knew the residents but they should not have relied upon residents to identify their personal items. She said it was important to label the items so the residents would not use each other's items, as this could transmit disease. D. Facility follow upOn 2/5/24 at 5:16 p.m., the IP provided documentation of staff inservice education signed by 22 staff which was provided to ensure residents who shared rooms had labeled personal hygiene items. On 2/6/24 at 10:50 a.m. the DON said the facility had separated and labeled all residents' personal hygiene items and the facility would be rounding at least weekly to ensure the process continued. She said the facility ordered hooks to assist with hanging and separating items.

A health survey with complaints #CO33799 was completed on 10/23/23 to 10/31/23. No response necessary.

A complaint survey, prompted by #CO30968, #CO34021, #CO34036 and Incident #31883 was conducted on 10/26/23 to 10/31/23. No deficiencies were cited.

A complaint survey, prompted by #CO32436 was conducted on 6/14/23 to 6/15/23. No deficiencies were cited.

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

A revisit survey was completed on 1/12/23 for all previous deficiencies cited on 11/3/22. The facility is in compliance with all regulations surveyed.