BERTHOUD CARE AND REHABILITATION

A complaint survey, prompted by #CO34082 was conducted on 11/14/23. No deficiencies were cited.

A revisit to the 3/14/2023 survey was completed on 5/12/2023. The facility was in compliance with the regulations surveyed.

A complaint survey, prompted by #CO31184 was conducted on 4/24/23. No deficiencies were cited.

A revisit to the 2/16/2023 survey was completed on 4/13/2023. The facility was in compliance with the 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). The facility is one story, Type V(111) (VA), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1960 and is license for 74 beds. This re-certification survey conducted on March 14, 2023, was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey. The Administrator reported the daily census to be 67 residents on March 14, 2023.

STANDARD is not met as evidenced by: During observation of the kitchen gas fired cooking equipment it did not meet the requirements of the 2012 Edition of NFPA 54 Fuel and Gas Code 9.6.1.2. This deficient practice could affect all residents, and staff should a fire occur due to failure to operate safely due to non-code compliant. This was evidence by the following. Gas fired cooking equipment with casters where not limited by a restraining device. The Maintenance Director acknowledge lack of a restraining device on the gas fired cooking appliancesNFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliance with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufactures installation instructions.

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following. 1) Pendent sprinkler shows signs of foreign materials around the working parts of the head. This condition found in the kitchen area and also the laundry facility. 2) Sprinkler Pipe unsupported from failure of support hanger, Laundry. The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility. NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

A recertification survey with complaint #CO30861 was completed from 2/13/23-2/16/23. Seven deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/13/23 to 2/16/23. No deficiencies were cited.

Based on observations, record review and staff interviews the facility failed to provide services for one (#172) out 31 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #172's vital signs were monitored prior to the administration of a blood pressure medication. Findings include:I. Professional referenceKhashayar. F., Arif, J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine.https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 2/21/2023 at 10:17 a.m."Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur."The patient's heart rate and blood pressure require monitoring while using beta-blockers."Kizior, R. J., Hodgson, K. J. (2023). Metoprolol. Saunders Nursing Drug Handbook. Elsevier. p. 770."Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse is 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician."II. Resident #172 A. Resident statusResident #172, age 82, was admitted on 2/9/23. According to the February 2023 computerized physician orders (CPO), the diagnoses included iron deficiency anemia related to blood loss, congestive heart failure and atrial fibrillation. The February 2023 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. He required the assistance of two people for bed mobility, transfers, personal hygiene dressing and toileting. B. ObservationsOn 2/16/23 at 9:06 a.m. registered nurse (RN) #2 was observed dispensing a Metoprolol 25 milligrams (mg) tablet for Resident #172. RN #2 did not check the order for the blood pressure parameters or the record for the resident's most recent vital signs. RN #2 then administered the Metoprolol medication to Resident #172. C. Record reviewThe February 2023 CPO documented a physician order of Metoprolol Succinate Extended Release 25 mg once a day for ventricular rate control in atrial fibrillation ordered on 2/9/23. The CPO did not document any vital signs parameters for the Metoprolol medication. The February 2023 medication and treatment administration record (MAR/TAR) documented the resident's vital signs should be checked every shift, initiated on 2/13/23. The first documented vital signs were on 2/13/23. The February 2023 vital signs summary revealed one blood pressure documented on 2/9/23, no blood pressures documented on 2/10/23 or 2/11/23, one blood pressure documented on 2/12/23, one blood pressure documented on 2/13/23, three blood pressures documented on 2/14/23 and one blood pressure documented on 2/15/23. III. Staff interviewsRN #2 was interviewed on 2/16/23 at 9:15 a.m. She reviewed the Metoprolol physician's order and said there were no parameters ordered. She confirmed she did not obtain the resident's vital signs prior to administering the Metoprolol medication. She said she was unsure when the resident's vital signs had been last taken. Licensed practical nurse (LPN) #1 was interviewed on 2/16/23 at 10:00 a.m. She said blood pressure medication did not always have documented parameters. She said if the resident was outside of their baseline, she would contact the physician prior to administering the medication. She said the resident's vital signs should be taken and checked prior to administering blood pressure medications to avoid causing severe low blood pressure. The director of nursing (DON) was interviewed on 2/16/23 at 6:50 p.m. She said that blood pressure medication should be given as ordered by the physician. She said if there were parameters ordered for blood pressure medications, the physician should be notified if the resident's blood pressure was outside of parameters. She said if there were no parameters were ordered, the physician should be notified if the resident was outside their baseline. She said resident's vital signs should be taken prior to every shift.

Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#47) of two residents out of 31 sample residents. Specifically, the facility failed to ensure Resident #47's socialization needs were met by developing a person-centered activity plan. Findings include:I. Facility policy and procedureThe Activity Documentation policy and procedure, revised January 2022, was provided by the nursing home administrator (NHA) on 2/17/23 at 2:26 p.m. It revealed, in pertinent part, "It is the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental and psychosocial well-being of the resident."Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations. "Cognitive impairment: smaller groups without interruption, one-to-one etc."II. Resident #47 status Resident #47, age 92 was admitted on 9/23/22. According to the February 2023 computerized physician orders (CPO), the diagnoses included dementia without behavioral disturbance, bipolar disorder, psychotic disturbance, mood disturbance and anxiety. The 1/20/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance of one to two people with bed mobility, transfers, personal hygiene, toileting and dressing. It indicated it was important to the resident to have books, newspapers, and magazines to read, be around pets, keep up with the news, do things with groups of people, do her favorite activities, go outside to get fresh air when the weather is good and participate in religious services. A. Resident interviewOn 2/15/23 at 11:15 a.m. Resident #47 said she had nothing to do. She said she did the same thing every day. She said she was not invited to group activities and did not receive any individualized activities. B. ObservationsOn 2/15/23 at 8:51 a.m. Resident #47 was observed laying in bed, sleeping.-At 9:12 a.m. Resident #47 was observed sitting in bed eating breakfast. The resident did not have a television nor was there music being played. There was no cognitive or social stimulation observed.-At 11:15 a.m. the resident was observed sitting up in bed. There were no meaningful activities provided for the resident.-At 1:28 p.m. Resident #47 was lying in her bed with her lunch tray in front of her. There were no meaningful activities observed.-At 2:26 p.m. the resident was laying in bed, asleep.-At 4:03 p.m. Resident #47 was observed sitting up in bed. There were no meaningful activities observed. C. Record review The 9/27/22 admission activity assessment documented the resident was interested in games, cards, trivia, BINGO, arts and crafts, drawing and painting. It indicated the resident's socialization plan was to encourage her to attend activities of choice and invite her to activities as tolerated. The activity care plan, initiated on 9/27/22, documented the resident was at risk for decreased socialization. It indicated the resident would benefit from small group settings. The interventions included communicating her activity interests to the health care team, introducing her to other residents with similar interests, inviting and encouraging the resident to attend activities with a low stimulation environment when available. The quarterly activity evaluation dated 12/23/22 documented the resident liked to watch people and attended group activities. It indicated the activity staff should continue to offer recreation to the resident. The one-to-one activity participation log documented the resident was provided one-to-one activities two times in November 2022, once in December 2022, zero times in January 2023 and zero times from 2/1/23 to 2/15/23. The social activity log documented the resident participated in social events three times in November 2022, once in December 2022, zero times in January 2023 and zero times from 2/1/23 to 2/15/23. According to the independent activity log, the resident watched television 10 times in November 2022, 10 times in December 2022, eight times in January 2023 and twice from 2/1/23 to 2/15/23. According to the entertainment activity log, the resident participated one time in November 2022, one time in December 2022, zero times in January 2023 and zero times from 2/1/23 to 2/15/23. III. Staff interviews The activity supervisor (AS) was interviewed on 2/16/23 at 6:23 p.m. She said Resident #47 was offered group activities but did not like to participate. She said the resident was a passive participant. The AS said Resident #47 did not watch television. The AS said they had attempted to paint with her but she was not interested. She said the resident was not part of an activity one-to-one program. She said the activity staff offered the resident music, however that was not regularly scheduled. She said she had not offered the resident to attend group activities.

Based on record review and interviews, the facility failed to ensure that five out of five certified nursing assistants (CNA) were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to conduct yearly staff competencies for certified nursing assistants. Findings include:I. Record reviewThe annual competency checklist was requested on 2/16/23 for certified nursing assistants (CNA) #4, #5, #6, #7 and#8. An annual competency checklist for 2022 was unable to be provided by the facility. II. Staff interviewsThe director of nursing (DON) was interviewed on 2/16/23 at 7:00 p.m. She said the facility had not completed competencies for the CNAs since she had become the DON (May 2022). She said there had been a recent change in nursing management, however she was unable to find documentation that competencies had been completed for 2022 for all CNAs that were employed by the facility.

Based on interviews and record review, the facility failed to ensure two (#64 and #55) of two out of 31 sample residents received the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to:-Ensure Resident #64 was provided psychosocial support after he had voiced difficulty in adjusting to his new level of care and admission to the facility; and, -Ensure Resident #55 was provided person-centered interventions to address the resident's behavior and provided continued psychosocial support. Findings include:I. Facility policy and procedureThe Behavioral Health policy and procedure, revised January 2022, was provided by the nursing home administrator (NHA) on 2/17/23 at 2:26 p.m. It revealed in pertinent part, "The interdisciplinary team (IDT) will ensure that residents who display or is diagnosed with mental disorder or psychosocial adjustment difficulty receives the appropriate treatment and services to attain the highest practicable mental or psychosocial well-being and will have an individualized plan of care that addresses the needs of the resident, based on the comprehensive MDS assessment of the resident."The plan of care will include non-pharmacological interventions and individualized, person-centered care approaches as well as trauma-informed approaches in accordance with resident's customary routines, with input from the resident and/or resident representative." "The physician, in collaboration with the IDT team, will determine the appropriate psychiatric or psychological treatment or rehabilitative services needed. Treatment will be provided as ordered by the physician."II. Resident #64A. Resident statusResident #64, age 70, was admitted to the facility on 1/14/23. According to the February 2023 computerized physician orders (CPO) the diagnoses included post viral fatigue syndrome, dysarthria, anarthria, dysphonia (difficulty with speech), Parkinson's disease, repeated falls, and adult failure to thrive. The 1/18/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive intact with a brief interview for mental status score of 12 out of 15. He required extensive assistance with a two-person physical assist for transfers, dressing, toileting and bed mobility. It indicated the resident had mild depression with a PHQ-9 (patient health questionnaire) score of seven out of 27 indicating mild depression. B. Resident observations and interviewOn 2/13/23 at 5:17 p.m. Resident #64 was in his room sitting in a wheelchair eating from his dinner tray. He was watching his television while eating his dinner. He said was unhappy at the facility and there was nothing to do. He said he did not get visitors very often and he was tired of watching television. On 2/14/23 at 11:42 a.m. the resident was sitting in his wheelchair in his room. He said he was unhappy, bored and was unable to do anything because of an infection in his stool. He said the only thing he was able to do was watch television. Resident #64 was interviewed on 2/16/23 11:02 a.m. He said his goal was to move back to his apartment. He said he felt like he could not leave his room due to his medical condition. He said that he had nothing to do and no staff came by to do things with him or offer anything. He said he liked sports, especially baseball. He said he would really enjoy it if someone would come into his room and talk baseball with him. He said the only time he had any social interaction was when the staff entered the room to provide care. C. Record reviewThe potential for adjustment issues care plan, initiated 1/16/23, revealed Resident #64 had a potential for adjustment issues due to his admission to the skilled nursing facility (SNF). The interventions included encouraging conversations with staff and other residents, providing the resident the opportunity to communicate his feelings regarding his admission, providing the resident the opportunity to communicate his feelings regarding attending group activities, and providing the resident situations in which he will have control over his environment and care delivery. The 1/16/23 social services summary documented the resident did not have any behavior or mood concerns. The activity care plan, initiated 1/20/23, revealed the resident had little or no activity involvement. It indicated the resident was unsure if he would participate in recreation while he was at the facility, as the resident wanted to focus on getting better. The interventions included establishing and recording the resident's prior level of activity involvement and interests by talking with resident, caregivers and family upon admission and as necessary. The 1/22/23 nursing note revealed the resident was very frustrated and said "this is no way to live." The nurse said he had no plans to hurt himself and he would be monitored. The 1/23/23 behavior progress note revealed the resident was very frustrated with life and asked if the nurse could take him out and "just let him freeze." He said it was hard since his life changed so much, recently. The 2/2/23 activity assessment identified his needs as "he is eager to get back to his place and he wants to get better." It did not indicate what interventions would be put in place to address the resident's socialization needs. The activity participation log documented from 1/14/23 to 2/14/23 revealed that the resident was not provided any one-to-one activities. -A review of the resident's medical record did not reveal documentation of psychosocial support provided to the resident after he had voiced that he was having a difficult time since his admission to the facility and accepting his new level of care. -The facility failed to develop person-centered approaches to provide the resident with additional support and meet the resident's psychosocial needs. IV. Staff interviewsThe social services director (SSD) was interviewed on 2/16/23 at 5:47 p.m. She said she had spoken with Resident #64 after his behavior on 1/23/23. She said he had refused counseling. She said she had not offered the resident any other psychosocial support. She said she did not document this interaction in the resident's medical record. She said socialization helped Resident #64. She said the resident's brother and friends visited often. She said she had not documented any person-centered approaches to assist the resident with his difficulty in accepting his level of care or admission to the facility. She said the interdisciplinary team (IDT) had not discussed possible interventions for the resident. The director of nursing (DON) was interviewed on 2/16/23 at 6:52 p.m. The DON said during the care conference on 1/20/23, the resident had agreed to counseling. She said she was unsure if it was documented in the resident's medical record or if it had been arranged by social services. She confirmed the resident's plan of care did not document any psychosocial person-centered interventions to assist the resident in adjusting to his level of care or admission to the facility. The activity supervisor (AS) was interviewed on 2/16/23 at 6:23 p.m. She said she was not made aware of the resident's difficulty in adjusting to his admission to the facility. She said she was unaware the resident had made statements of "wanting to freeze outside."She said, when she completed the resident's admission assessment, he was focused on physical therapy and wanting to get better to go home. She said she had not placed the resident on a one-to-one activity program. She said she was unaware the resident enjoyed baseball. She confirmed the resident would benefit from socialization from facility staff. She confirmed the resident should receive socialization from the facility staff, other than just when the staff entered his room to provide care. III. Resident #55A. Resident statusResident #55, under the age of 65, was admitted on 5/17/21 and was readmitted on 8/17/22. According to the February2023 computerized physician orders (CPO), diagnoses included anxiety disorder due to known physiological conditions, a major depressive disorder with psychotic features and symptoms, mood disorder due to known physiological conditions with depressive features, moderate intellectual disabilities, cognitive communication deficit, and unspecified disorder of psychological development. According to the 12/30/22 minimum data set (MDS), the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required supervision with transfers, dressing, toileting, and personal hygiene. It indicated he did not have any behavioral concerns. B. Observations On 2/15/23 at 8:58 a.m., Resident #55 was observed leaving the dining room after eating breakfast. The resident's pants were soiled with urine. The resident was assisted by an unidentified staff member and returned to the dining area with new, clean pants.-At 9:52 a.m., the resident entered the dining room and filled a mug with water. He sat down on a chair. He sat down for approximately eight minutes, returned to his room, and then came back to the dining area with crayons. Upon returning to the dining room, he began drawing, however, he continued to pace back and forth between his room and the dining room. From 9:00 a.m. until 10:00 a.m., Resident #55 had gone between his room and the dining room seven times.-At 10:39 a.m. the resident paced back to his room and came right back to the dining area and continued drawing.-At 11:17 a.m. Resident #55 went back to his room.-At 11:18 a.m. he walked out of his room and went down the hallway, turned around, and walked right back to the dining room.-At 11:22 a.m. he paced back to his room and came out again in just a minute. He walked down halfway through the hallway and then returned to the dining room.-At 11:28 a.m. the resident paced back to his room and came out at 11:30 a.m., and then sat in the dining room. C. Record reviewThe PASRR (pre-admission screening and resident review) care plan, revised on 5/10/22, documented the resident had both a major mental illness and an intellectual developmental disability. The interventions included providing the resident an evaluation to community integration, a day program, and continuing to monitor any manic episodes. The cognitive impairment care plan, revised on 8/31/22, documented the resident had impaired cognitive function and thought processes due to a diagnosis of dementia. The interventions included administering medications as ordered; communicating with the resident's family regarding the resident's capabilities and needs; engaging the resident in simple, structured activities that avoid overly demanding tasks; giving step by step instructions one at a time to support cognitive function; keeping the resident's routine consistent and providing consistent caregivers; and providing assistance with all decision making. The mood problem care plan, revised 1/10/23, documented the resident had a potential for a mood problem related to his major mental illness. It indicated the resident had a major depressive disorder with behaviors such as being sad and down, sad at his loss of independence, and had potential for verbal aggression. The interventions included administering medications as ordered; monitoring, recording, and reporting to the physician any acute episodes of feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite or eating habits, change in sleeping patterns and diminished ability to concentrate; and monitoring increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone and possession of objects that could be used as weapons. The behavior problem care plan, revised 1/10/23, documented the resident had a potential behavioral problem related to his intellectual developmental disability. It indicated the resident had a history of drinking fluids excessively, tried to get multiple mouthwash bottles and then drink them, and excessively drinking water to the point that he threw up on 2/9/22. The interventions included administering medications as ordered, anticipating and meeting the resident's needs, approaching the resident in a calm manner, continuing to monitor how much mouthwash was given, and explaining all procedures to the resident before starting and allowing the resident to adjust to changes. The 12/1/22 psychiatric progress note documented the facility staff had reported Resident #55 had been refusing some care including bed changes at night. It indicated the resident continued to be incontinent at night and typically soaked through his briefs and soiled the linen on the bed. The staff had reported he was not easy to redirect at night when needing to change his linen and had increased agitation and aggression. It indicated the resident said, "They wake me up all the time at night" and that he just wanted to sleep. The psychiatrist documented the resident had episodes of mania evidenced by perseveration on drinking water and pacing. The recommendations included one change of linen/briefs at night approximately 10:00 p.m. to 11:00 p.m. with evening medications and allow the resident to sleep through the night until awaken at approximately 6:00 a.m.-However, these recommendations were not included in the resident's comprehensive plan of care. The 12/2/23 nursing progress note documented at approximately 5:09 a.m., and certified nurse aide (CNA) entered Resident #55's bedroom to check on him. It indicated the resident was standing by his bed, soiled of urine. Resident #55 swung at the CNA with an open hand and yelled for her to leave the room. The CNA left the room and reported the incident to the nurse.-At 5:26 a.m. the CNA went back into Resident #55's room and changed the resident's soiled sheets while he was in the bathroom. Resident #55 followed the CNA down the hallway shouting "I want my stuff back." The resident paced up and down the hallway, in and out of his room. -At 5:42 a.m. the resident continued to pace hallways and his bedroom and to and from the sink, drinking eight cups of water. The nurse called the physician and received an order to send the resident to the emergency department for evaluation and treatment. -At 11:45 a.m. the resident returned from the emergency department with a diagnosis of anxiety with a recommendation to start Lorazepam (anti-anxiety medication) and Seroquel (antipsychotic medication). The psychiatrist called the facility as Resident #55 was arriving back from the hospital and ordered Seroquel 25 milligrams (mg) every night. The 12/27/22 social service summary progress note documented Resident #55 had impaired decision-making and had a diagnosis of intellectual or developmental disability (IDD). He had an order for Seroquel and Lexapro (antipsychotic and anxiety medications) for the behaviors of refusal of care and anxiety management.-A review of the resident's electronic medical record on 12/14/23 did not reveal documentation that the resident had been provided additional psychosocial support to assist in determining the triggers for the resident's behavior.-The comprehensive care plan did not document person-centered, individualized interventions.. It did not also reflect the above interventions recommended by the resident's psychiatrist as the night staff continued to awaken the resident to offer incontinent care resulting in aggressive behaviors and refusal of care, as was documented in the nursing notes and within the staff interviews. The nursing progress note dated 12/12/22 documented at 1:10 a.m. that the nursing staff continued to offer incontinent care to the resident at night resulting in the resident yelling with an angry tone saying "get out."The CNA tasks documented in December 2022 (between 12/2/22 to 12/31/22) the facility staff attempted to provide incontinence care to the resident on seven occasions during the night. D. Staff interviewsCertified nursing aide (CNA) #2 was interviewed on 2/16/23 at 4:45 p.m. She said Resident #55 had behaviors and frequently refused care. CNA #2 said if the resident refused care, she would wait 10 minutes, come back and try again. She said Resident #55 would become agitated and angry when he was constantly being asked to change his clothing or bedding. The activity supervisor (AS) was interviewed on 2/16/23 at 6:05 p.m. She said Resident #55 has a diagnosis of intellectual or developmental disability. She said the resident used to participate in a lot of activities but did not anymore. The AD said the resident would become repetitive sometimes. She said leaving the resident alone and giving him a personal one-on-one task sometimes helped him calm down when he was anxious. The social services director (SSD) was interviewed on 2/16/23 at 5:45 p.m. She said Resident #55 had an intellectually disabled with obsessive-compulsive disorder. The SSD said she had identified some of the resident's triggers such as when the staff offered to change the resident multiple times. She said the resident would get really upset when the staff would ask him to change and then continued to ask him when he refused. She said part of the resident's manic episodes was pacing between his room and the common areas and drinking excessive amounts of water. She said when the resident was triggered, he would pace, become verbally aggressive, and drink water excessively. She said on 12/1/22, Resident #55 had probably been triggered because the CNA had entered his room after he yelled for her to leave and then changed his bedding without his permission. The SSD said she was responsible for developing the behavioral care plans. She said she was unsure of any person-centered interventions that assisted the resident when he became upset or was having a manic episode. The SSD said the resident had been seen regularly by a psychiatrist. She said she did not have time to read the psychiatrist's notes. She said she was unaware if the psychiatrist had developed any interventions to assist the resident in being triggered. She confirmed the resident's plan of care did not indicate any person-centered interventions to address the resident's behavior. The director of nursing (DON) was interviewed on 2/16/23 at 6:49 p.m. The DON said Resident #55 exhibited behaviors such as excessive drinking of water, agitation, pacing back and forth in the hallway, and refusal of care. She said sometimes the resident would get upset because the staff wanted to assist him with incontinence care. The DON said the facility struggled with the resident's incontinence care because of his refusals. She said part of the trigger for the resident's behavior was changing his bed sheets. She said the resident was frequently incontinent in bed and would get very upset when staff would change his bedding. She said the resident wanted a certain kind of sheet and a certain blanket. She said she believed that was what triggered the resident in early December 2022. She said she was aware of the recommendations made by the psychiatrist. She said she was not sure if those recommendations were documented in the resident's medical record or had been relayed to the facility staff. She said the comprehensive care plan should have person-centered approaches documented to assist the resident when he had exhibited behaviors. She said social services were responsible for developing behavioral care plans, but that the interdisciplinary team was able to update the interventions as needed.

Based on record review and staff interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner for two (#41 and #45) of five residents reviewed out of 31 sample residents. Specifically, the facility failed to ensure a response to pharmacist recommendations from monthly medication regimen reviews for:-Resident #41 regarding the physician's recommendation to discuss the risk and benefits of the drug interaction of Tramadol, Trazodone, Bupropion, and Ativan (psychotropic and pain medications); and, -Resident #45 regarding the physician's recommendation to refer medication questions to the hospice provider. Findings include:I. Facility policy and procedureThe Medication Regimen Review and Reporting policy and procedure, dated September 2018, was provided by the director of nursing (DON) on 2/17/23. It read in pertinent part: "The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medication each resident receives is clinically indicated. Resident-specific medication regimen review recommendations and findings are documented and acted upon by the nursing care center and/or physician. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days."II. Resident #41A. Resident statusResident #41, age 73, was admitted on 11/9/2020 and readmitted on 12/15/22. According to the January 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, bipolar disorder, end-stage renal disease, cognitive communication deficit, and chronic kidney disease. The 12/30/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of twelve out of 15. She required supervision and set-up help only with her activities of daily living (ADLs). B. Record review A review of the resident's medication administration record (MAR) and treatment administration record (TAR) revealed the resident had orders to receive the following medication:-Tramadol HCI tablet 50 milligrams, one tablet by mouth every six hours as needed for moderate pain. Ordered 12/7/22.-Trazodone HCI tablet 50 milligrams, give 0.5 tablets by mouth at bedtime for depression. Ordered 12/7/22. -Bupropion HCI tablet 75 milligrams, give 1 tablet by mouth two times a day for depression. Ordered 12/7/22. The 4/25/22 pharmacist medication regimen review reported a concern for Resident # 41 medication regimen. The recommendation indicated a concern with the use of Tramadol, Trazodone, and Bupropion which has two interactions with Tramadol. According to the report, these interactions increase the risk for death or ineffectiveness. The 6/21/22 pharmacist medication regimen review alerted the physician on the above concerns as Resident #41 had had three falls in three weeks. The report requested not to recommend Tramadol use in geriatrics due to unpredictable metabolism which increases the risk for death or ineffectiveness, serious drug interactions, and worrisome side effects. This was the second request, as the first time occurred on 4/25/22. The attending physician recommended on 6/28/22 the facility discuss the risk and benefits of these medications with the resident. III. Resident #45A. Resident status Resident #45, age 66, was admitted on 7/14/22. According to the February 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease and anxiety disorder. The 1/20/22 minimum data set (MDS) assessment revealed the facility was unable to conduct a brief interview for mental status (BIMS) as the resident was rarely/never understood. He required two-person physical assistance with his activities of daily living (ADLs). B. Record reviewA review of the resident's medication administration record (MAR), treatment administration record (TAR), and pharmacy recommendation note revealed the resident was receiving the following medications:-Cyclobenzaprine 5 milligrams, two times a day for muscle spasms. Discontinued 1/13/22 (see below).-Trazodone HCI 50 milligrams tablet, give 0.5 milligrams by mouth at bedtime for insomnia. Order date 7/14/22. -Celexa 15 milligrams tablets by mouth daily for depression. Order date 7/14/22. -Zyprexa 10 milligrams, by mouth every day for dementia. Order date 7/14/22. The 11/18/22 pharmacist medication regimen review for Resident #45 requested to not recommend Cyclobenzaprine for the elderly due to it causing sedation and requested for it to be evaluated and consider discontinuation. The attending physician's response on 12/19/22 indicated all medication requests and questions were to be referred to the hospice provider.-The facility had no records of any follow-up with the hospice provider. The Cyclobenzaprine was not discontinued until 1/13/22 by the hospice provider, which was more than a month later. IV. Staff interviewThe director of nursing (DON) was interviewed on 2/16/22 at 6:48 p.m. The DON said the facility had poor communication with the hospice care provider. She said scheduling appointments with the hospice care provider was difficult and the facility should have discussed the recommendations for Resident #45 with the hospice provider in a timely manner. The DON said she could not find any documentation of the facility discussing the pharmacy recommendations and the physician's request to discuss the recommendations with Resident #41.

Based on observation, record review, and staff interviews, the facility failed to provide therapeutic and mechanically altered diets consistent with dietary orders for two (#51 and #66) of two out of 31 sample residents. Specifically, the facility failed to:-Ensure Resident #51 was served puree textured vegetables, which was ordered by the physician; and, -Ensure Resident #66 was served large portions, which was ordered by the physician. Findings include I. Facility policy and procedureThe Food and Nutrition Services policy and procedure, last revised October 2021, was provided by the director of nursing (DON) on 2/17/23. It read, in pertinent part "It is the policy of the facility that therapeutic diet shall be prescribed as necessary for each resident. A tray identification system is established to ensure that each resident receives his/her diet as ordered. Dietary staff will follow menu extensions while preparing and serving meals." II. Tray line observationsDiner tray line service was observed on 2/15/23. The meal was ham and beans, mixed greens, broccoli, pureed vegetables, canned pineapple, and cornbread. A bistro menu was available for residents who did not want the main meal and consisted of tomato soup, cheese quesadilla, a hot dog, and a grilled cheese sandwich. Serving began at 4:40 p.m. The kitchen manager (KM) served all the meals, including the bistro menu requests. One dietary aide and the dietary manager (DM) stayed at the other end and assisted with the tray line and served the food to the residents. At 5:15 p.m. a tray for Resident #51 was prepared by the KM. She served the resident a regular textured diet, even though the tray card indicated the resident should be served pureed texture vegetables. The tray was passed on to the DM, she inspected the tray and placed the wrong order on the cart ready to leave the kitchen to be served to the resident. She did not observe that the vegetable was served in the incorrect texture. Upon prompting, the DM brought the tray back to the kitchen. The DM confirmed the tray was not accurate and contained regular-texture broccoli. She asked the KM to redo the tray, confirmed the correct texture of the vegetables, and placed it on the cart to be served. At 5:22 p.m. a meal tray with a large portion diet ordered indicated on the tray card for Resident #61 was dished up by the KM and passed on to the DM. The plate did not contain double portions, which was indicated on the tray card. The DM placed the tray on the cart to be served. Upon prompting, the DM confirmed the order was not accurate and gave it back to the kitchen for additional food items to be dished onto the plate. III. Resident #51 A. Resident status Resident #51, age 81, was admitted on 1/28/21. According to the February 2023 computerized physician orders (CPO), diagnosis included unspecified dementia and dysphagia (swallowing difficulty). The 12/25/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required extensive assistance of one person for dressing and toileting and supervision for bed mobility, transfers, and eating. B. Record reviewThe December 2022 CPO documented a dysphagia mechanical soft diet with puree vegetables. IV. Resident #61A. Resident status Resident #66, age 81, was admitted on 1/8/23. According to the January 2023 CPO, diagnosis included malnutrition. The 1/13/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required supervision with bed mobility, transfers, dressing, toileting, and eating. B. Record reviewThe January 2023 CPO documented a regular diet and texture with large portions for his meals. The resident care plan, dated 1/13/23 and revised on 2/13/23, indicated the resident was at risk of malnutrition and unexpected weight loss. The interventions included large portions for meals. V. Staff interviews The dietary manager (DM) was interviewed on 2/15/23 at 5:40 p.m. The DM said Resident # 51 was assessed by a speech-language pathologist therapist who recommended puree vegetables for the resident. The DM said Resident #51 was ordered, by the physician, to be served pureed vegetables. She said Resident #66 was admitted with a high risk of malnutrition and had experienced weight loss. She said it was ordered by the physician that the resident be served large portions for meals. The director of nursing (DON) was interviewed on 2/16/23 at 6:49 p.m. The DON said diets were prescribed by the physician. She said all diets should be followed and served according to physician orders. She said she would ensure that periodic audits would be completed to eliminate any future occurrences.

Based on observations, interviews and record review, 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 in three out of three units. Specifically, the facility failed to:-Ensure orientation for outside agency personnel regarding COVID-19 isolation precautions and donning/doffing of appropriate personal protective equipment;-Ensure an effective water management plan was in place; and, -Ensure residents' rooms were cleaned in a sanitary manner. Findings include:I. COVID-19 isolation precautionsA. Facility policy and procedureThe COVID-19 donning and doffing competency policy and procedure, initiated March 2020, and provided by the nursing home administrator (NHA) on 2/15/23 at 3:00 p.m. It revealed in pertinent part,"Donning step 1-gown fully cover torso from neck to knees, arms to end of wrists, and wrap around the back, fasten in back of neck and waist; step 2-mask or respirator secure ties or elastic band at middle of head and neck, fit flexible band to nose bridge, fit snug to face and below chin, fit check respirator; step 3- goggles or face shield place over face and eyes and adjust to fit; step 4 -gloves extend to cover wrist of isolation gown."Standard precautions wipe down equipment between residents. Isolation precaution residents have designated equipment."B. ObservationsOn 2/15/23 at 2:30 p.m. certified nursing assistant (CNA) #3 was observed entering a COVID-19 positive isolation room without donning personal protective equipment (PPE) and with a portable blood pressure/temperature/oxygen saturation monitor. COVID isolation precautions signs were observed on the door and a PPE cart was next to the door. After taking the resident's vital signs, CNA #3 left the room and observed the PPE cart next to the door. CNA #3 wiped the temperature probe and machine with sanitizing wipes and washed his hands at the sink. He did not remove or change his mask. CNA #3 then took the same portable blood pressure monitor and entered the resident room next to the COVID-19 isolation room. C. Staff interviewsCNA #3 was interviewed on 2/15/23 at 2:30 p.m. He said that he was not aware the resident in the isolation room was COVID-19 positive. He confirmed he entered the COVID-19 positive room without donning PPE. He confirmed after he exited the COVID-19 positive room, he entered another resident's room to continue taking vital signs. He said it was his first day at the facility. The director of nursing (DON) was interviewed on 2/15/23 at 3:15 p.m. She said the facility did not provide orientation to outside agency personnel. She said she the previous shift should have informed CNA #3 which residents were under isolation precautions. The infection preventionist (IP) was interviewed on 2/15/23 at 3:30 p.m. She said the facility's current process did not include orienting outside agency personnel at the beginning of their shift on isolation precautions, use of PPE or the sanitization of equipment. She said that information should have been covered by their agency. She said the outside agency personnel should follow the information regarding isolation precautions and use of dedicated equipment posted on the residents' doors and CNAs would give a change of shift report on residents that were on isolation precautions. The nursing home administrator (NHA) was interviewed on 2/15/23 at 5:15 p.m. He said a binder was now created to orient outside agency personnel on isolation precautions and the use of PPE prior to the beginning of their shift. II. Failure to ensure the water management plan was effectiveA. Record reviewThe Water Management plan was provided by the nursing home administrator on 2/14/23. It did not include documentation to indicate the control measures, how often the control measures were being conducted and the monitoring system for the control measures. It did not indicate a risk assessment had been completed. It did not indicate how the facility was ensuring the water management program was working and effective. B. Staff interviewsThe nursing home administrator and the maintenance director (MD) were interviewed on 2/16/23 at 5:12 p.m. The maintenance director said she was unable to locate the risk assessment within the facility's water management plan. She said the control measures included testing, however was unable to provide documentation that showed the control measures, how often the control measures were being conducted and a monitoring system. She said she was unable to determine if the water management plan was working or effective because the control measures had not been documented as completed and the facility did not have a monitoring system in place. III. Failed to ensure resident rooms were cleaned in a sanitary mannerA. Facility policy and procedureThe Proper Glove Usage policy and procedure, undated, was provided by the nursing home administrator (NHA) on 2/17/23. It revealed, in pertinent part, "When cleaning a resident room, it is best practice to change gloves and rags in between cleaning the restroom and both sides of the patient room."When you clean the restroom, use one rag and one set of gloves, then discard the rag in dirty rags and remove gloves. Sanitize hands, put on new gloves, and grab a new rag to clean side B of the room. Once side B is complete, discard the rag and gloves, sanitize hands and then repeat for side A of the room."B. ObservationsOn 2/15/23 at 2:20 p.m. housekeeper (HSKP) #1 was observed cleaning resident room 17. With gloved hands, he grabbed a rag, soaked in disinfectant, from the housekeeping cart and entered the bathroom. He wiped the inside of the bowl first and with the same rag wiped the toilet handle, the bottom of the toilet, on the ground around the toilet and then the toilet seat. He used the toilet brush to scrub the inside of the toilet and then exited the bathroom. He returned to the housekeeping cart in the hallway, placed the rag in a dirty bin and put the toilet brush away. With the same gloved hands, he grabbed the broom and entered the room. He swept the bathroom and the debris into the dust pan. He emptied the dust pan, put the broom away, grabbed a mop pad (with the same gloved hands) and the mop handle and re-entered the room. He placed the dripped wet mop head on the floor of the bathroom and mopped the bathroom. He mopped into the window side of the room with the same mop head. He then picked up the mop, discarded the mop head into the dirty bin and put the mop away. He doffed his gloves and obtained alcohol based hand rub (ABHR) from the wall unit. He rubbed the ABHR on his hands for three seconds and grabbed a new pair of gloves. His hands were visibly wet with white residue from the ABHR in between his fingers. He had difficulty donning the gloves due to his visibly wet hands. He was only able to don the gloves to cover halfway up the palms of his hand with an inch of glove not utilized at the fingertips. He grabbed a rag, soaked in disinfectant and entered the room. He wiped down the sink and counter and then moved to the window side of the room. After cleaning the window side of the room, he moved to the other side of the room and began cleaning off surfaces with the same rag and same gloved hands. After disposing of trash from the room, he grabbed a mop pad, the mop handle and entered the room. He mopped the window side of the room and then the hallway side of the room. HSKP #1 put the mop back on the cart and moved to resident room 19. He obtained ABHR from the wall unit, rubbed it in his hands for four seconds and then attempted to don gloves. His hands were visibly wet with white residue from the ABHR on his knuckles and in between his fingers. He was only able to put the gloves halfway up his palm. He grabbed a red rag, soaked in disinfectant, toilet bowl cleaner and a toilet bowl brush and entered the resident bathroom. The bathroom was a shared bathroom between two resident rooms. Using the red rag, HSKP #1 wiped the window sill, the toilet seat, inside the toilet bowl, the bottom of the toilet and the toilet handle. He then moved to the commode and wiped the top of the commode seat and then the commode handles. He then used the toilet brush to scrub the inside of the toilet bowl, grabbed the trash from the trash can and moved the commode back over the toilet, with the same gloved hands. He put the rag in the dirty bin and then doffed his gloves, obtained ABHR and rubbed it in for five seconds and attempted to don a new pair of gloves. He had visibly wet hands with white residue from the ABHR and was unable to get the gloves all the way past his palm. C. Staff interviewsThe maintenance director was interviewed on 2/16/23 at 5:12 p.m. He said ABHR should be used prior to cleaning the room and in between glove changes. He said the ABHR should be rubbed in for approximately 20 seconds or until it is completely dry. He said once it was dry, then gloves should be donned. He confirmed the ABHR was not effective if not used according to the manufacturer's instructions. He said new gloves should be donned after cleaning the bathroom and each side of the room. He said, in a shared room, each side of the room should be cleaned separately and the housekeeper should not share the rag between both sides of the room. He said the toilet should be cleaned from the top down starting with the tank, handle and then the seat. He said the seat should be cleaned last and once it was cleaned the rag should not be used to clean any other surfaces. He said he provided education with return demonstrations to all the housekeeping staff regarding glove usage and hand hygiene that day following the observation of HSKP #1.