HIGHLAND PARK REHABILITATION & CARE CENTER

A recertification survey with complaint #CO37295 was completed on 12/2/24 to 12/5/24. Three deficiencies were cited.

An Emergency Preparedness survey was conducted from 12/2/24 to 12/5/24. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure three (#19, #54 and #25) of four residents who required respiratory care received care consistent with professional standards of practice out of 34 sample residents. Specifically, the facility failed to:-Follow physician's orders to maintain, clean, sanitize and store Resident #19's continuous positive airway pressure (CPAP) mask and machine and Resident #54's bilevel positive airway pressure (BiPAP) mask and machine; and,-Rinse and store cup and mouthpiece for Resident #25's nebulizer (a small machine that turns liquid medication into a mist that can be inhaled to treat lung conditions.)Findings includeI. Facility policy and procedureThe CPAP/BiPAP Cleaning policy, revised 6/1/24, was provided by the director of nursing (DON) on 12/5/24 at 1:36 p.m. The policy revealed in pertinent part "It is the policy of the facility to clean CPAP/BiPAP equipment with current Center for Disease Control (CDC) guidelines and manufacturer's recommendations in order to prevent the occurrence or spread of infection. "Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections. "Clean the mask frame daily after use with CPAP cleaning wipes or soap and water. Dry well. Cover with a plastic bag or completely enclosed in machine storage when not in use. "Wash headgear/straps and tubing in warm, soapy water and air dry weekly."The Nebulizer Therapy policy, revised 6/1/24, was provided by the DON on 12/5/24 at 1:36 p.m. The policy revealed in pertinent part, "Clean after each use. Wash hands before handling the equipment. Disassemble the parts after each treatment. Rinse the nebulizer cup and mouth piece with sterile or distilled water. Shake off excess water. Air dry on an absorbent towel. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag."II. Resident #19A. Resident statusResident #19, age greater than 65, was admitted on 1/29/21. According to the December 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, mild vascular dementia (caused by strokes), obstructive sleep apnea, obesity and nicotine dependence. The 11/6/24 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. She required maximum assistance with bathing and moderate assistance with upper and lower body dressing, putting on/off footwear and tub transfers. The assessment indicated the resident received oxygen and a non-invasive mechanical ventilator. -The assessment did not indicate if the non-invasive mechanical ventilator was a CPAP or a BiPAP.B. ObservationsOn 12/2/24 at 2:46 p.m. Resident #19's CPAP mask was sitting on the resident's dresser behind the CPAP machine. On 12/3/24 at 9:07 a.m. Resident #19's CPAP mask was sitting on top of the dresser behind the CPAP machine. On 12/3/24 at 2:44 p.m. Resident #19's CPAP mask was sitting on top of the dresser behind the CPAP machine. On 12/4/24 at 11:25 a.m. Resident #19's CPAP mask was lying on the floor under the head of the bed. The CPAP mask was attached to the tubing and the tubing was attached to the machine. On 12/4/24 at 3:43 p.m. the resident's CPAP mask was lying on the floor under the head of the bed. The CPAP mask was attached to the tubing and the tubing was attached to the machine. On 12/5/24 at 9:19 a.m. Resident #19's CPAP mask was on the resident's bedside table attached to the tubing. The CPAP machine was behind the bedside table on the dresser.-During all of the above observations, Resident #19's CPAP mask was not covered by a plastic bag or enclosed in a storage case, which was identified by the facility as the process for CPAP/BiPAP storage (see facility policy above). C. Resident interviewResident #19 was interviewed on 12/5/24 at 3:04 p.m. She said the CPAP machine should be cleaned weekly and themask daily, but the facility staff never cleaned them. She said when she was not using her CPAP mask, the staff stored it on top of her dresser. D. Record reviewReview of Resident #19's December 2024 CPO revealed the following physician's order:CPAP machine daily care: remove mask from head gear. Clean the mask with soapy water or with CPAP wipe. Clean the humidifier chamber with warm soapy water. Rinse the humidifier chamber using sterile or distilled water one time a day for CPAP maintenance, ordered 12/2/24. The altered respiratory status care plan, revised 7/30/24, revealed Resident #19 had difficulty breathing related to chronic obstructive pulmonary disease and obstructive sleep apnea. The interventions included assisting the resident with placement of the CPAP nightly at bed time and as needed with naps, and cleansing the CPAP water chamber and machine as instructed in the physician's orders. III. Resident #54A. Resident statusResident #54, age greater than 65, was admitted on 1/31/24. According to the December 2024 CPO, diagnoses included chronic respiratory failure with hypoxia (not enough oxygen), dependence on supplemental oxygen, morbid obesity and obstructive sleep apnea. The 10/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required maximum assistance with toileting hygiene, bathing, upper body dressing, personal hygiene, sitting to lying, lying to sitting, sitting to standing, chair to bed transfers and toilet transfers. She was dependent on staff for lower body dressing, putting on/off footwear and rolling left to right. The assessment indicated the resident received oxygen.-The assessment did not indicate the resident used a CPAP or a BiPAP.B. ObservationsOn 12/2/24 at 9:19 a.m. Resident #54's BiPAP mask was on the resident's night stand on top of the BiPAP machine. The BiPAP mask was attached to the tubing and placed on top of the night stand laying across the BiPAP machine. On 12/3/24 at 9:05 a.m. Resident #54's BiPAP mask was lying on the floor under the head of the bed. The BiPAP mask was attached to the tubing. On 12/4/24 at 11:23 a.m. Resident #54's BiPAP mask was on the resident's night stand on top of the BiPAP machine. The BiPAP mask and the tubing were bunched up on top of the BiPAP machine on the night stand. On 12/5/24 at 9:18 a.m. Resident #54's BiPAP mask was on the resident's night stand on top of the BiPAP machine. The BiPAP mask and the tubing were bunched up on top of the BiPAP machine on the night stand.-During all of the above observations, Resident #54's BiPAP mask was not covered by a plastic bag or enclosed in a storage case, which was identified by the facility as the process for CPAP/BiPAP storage (see facility policy above). C. Resident interviewResident #54 was interviewed on 12/5/24 at 2:45 p.m. Resident #54 said her BiPAP mask and machine had not been cleaned since she was admitted to the facility (1/31/24). She said the mask should be cleaned daily. She said she asked the facility staff to provide an instruction book for the BiPAP so she could properly care for the machine. She said the mask and tubing were stored over her machine on the night stand next to the bed. D. Record reviewReview of Resident #54's December 2024 CPO revealed the following physician's orders:Assist the resident with placement of BiPAP via nose mask nightly at bed time and as needed for naps, ordered 2/8/24. CPAP machine daily care: remove mask from head gear. Clean the mask with soapy water or with CPAP wipe. Clean the humidifier chamber with warm soapy water. Rinse the humidifier chamber using sterile or distilled water one time a day for CPAP maintenance, ordered 8/1/24.-The physician's order indicated Resident #54 had a CPAP, however, the resident had a BiPAP machine. The BIPAP care plan, revised 2/8/24, revealed Resident #54 required the BiPAP for effective symptom management of obstructive sleep apnea and chronic hypoxemic respiratory failure. Interventions included assisting the resident with the mask placement to ensure an appropriate seal. -The care plan failed to include cleaning and storage of the BiPAP.IV. Resident # 25A. Resident statusResident #25, age greater than 65, was admitted on 4/4/22 and readmitted on 4/19/22. According to the December 2024 CPO, diagnoses included chronic obstructive pulmonary disease, dependence on supplemental oxygen and vascular dementia. The 10/10/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. She required maximum assistance with lower body dressing and putting on/off footwear. She required moderate assistance with upper body dressing, toileting hygiene and personal hygiene. The assessment indicated the resident received oxygen. B. ObservationsOn 12/2/24 at 9:53 a.m. Resident #25's nebulizer was sitting on top of the night stand with what appeared to be drops of medication still in it. The nebulizer cup and mouthpiece had not been rinsed and stored appropriately after the resident received her nebulizer treatment. On 12/3/24 at 9:03 a.m. Resident #25's nebulizer was sitting on top of the night stand with what appeared to be drops of medication still in it. The nebulizer cup and mouthpiece had not been rinsed and stored appropriately after the resident received her nebulizer treatment. C. Resident interviewResident #25 was interviewed on 12/5/24 at 9:26 a.m. She said she received the nebulizer treatment three times a day. She said when the treatment was completed, staff sometimes put the nebulizer cup and mouthpiece in a bag, but she said usually the nurse just placed it on her night stand. She said she had never seen the nurses rinse it out after use. D. Record reviewReview of Resident #25's December 2024 CPO revealed the following physician's orders:Albuterol sulfate nebulization solution 2.5 milligrams (mg)/3 ml (milliliters). Inhale orally via nebulizer three times a day related to chronic obstructive pulmonary disease, ordered 6/13/24. Nebulizer mask cleaning: Place in warm, soapy water and soak/agitate for five minutes. Rinse with warm water and allow it to air dry between uses. Store it in a clean bag, ordered 6/13/24. The altered respiratory status care plan, revised 11/27/24 revealed Resident #25 had difficulty breathing related to chronic obstructive pulmonary disease and other long term drug therapy. The interventions included administering medication as ordered and monitoring for changes in orientation, increased restlessness, anxiety and air hunger (breathlessness). V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 12/5/24 at 9:21 a.m. CNA #1 said the facility had a respiratory therapist (RT) who was responsible for changing the oxygen tubing and the nurse was responsible for cleaning and storing the nebulizer, the CPAP and the BiPAP equipment. Licensed practical nurse (LPN) #2 was interviewed on 12/5/24 at 10:32 a.m. LPN #2 said the nurse was responsible for cleaning and storing the nebulizer, CPAP and BiPAP after each use. She said the nebulizer cup should be rinsed with water after each treatment and changed every three days and stored in a bag. She said medication should not be left in the nebulizer cup. She said the CPAP and BiPAP mask should be cleaned with soap and water and stored in a bag between uses to prevent infections. She said the mask should not be stored on the floor. The infection preventionist (IP) and the DON were interviewed together on 12/5/24 at 12:02 p.m. The IP said she had just started in the position a month prior to the survey (November 2024). The DON said with each and every nebulizer treatment, there was a physician's order for the cleaning and storing of the equipment. She said the nurses should be following the physician's orders. She said every resident using a CPAP/BiPAP had a physician's order in place for the cleaning and storage of the equipment. She said the mask should be cleaned after every use and stored in a bag to prevent any aspiration of foreign particles into the lungs and infections. She said the mask should not be stored on the floor.

Based on observations, record review and interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift. Findings include:I. Failure to have staffing hours postedObservations in the facility on 12/2/24 at 8:00 a.m. revealed there were no staff postings including hours worked posted in the facilityObservations in the facility on 12/3/24 at 12:40 p.m. revealed there were no staff postings including hours worked posted in the facility. Observations in the facility on 12/4/24 at 4:40 p.m. revealed there were no staff posting including hours worked posted in the facility. II. Staff interviewsThe regional clinical coordinator (RCC) was interviewed on 12/4/24 at 4:43 p.m.. The RCC said the facility did not have the staffing posted. The director of nursing (DON) was interviewed on 12/4/24 at 4:45 p.m.. The DON said she had not seen daily staffing with hours posted in the facility since she had started working there about six months ago. The nursing home administrator (NHA) was interviewed on 12/4/24 at 4:46 p.m.. The DON said he had not seen daily postings with the amount of hours worked posted in the facility. The NHA said he was unsure whose responsibility it was to ensure the daily hours worked were posted.

Based on observations 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 diseases and infection on one of four units. Specifically, the facility failed to:-Ensure housekeepers followed appropriate infection control processes when cleaning resident rooms; and,-Ensure high touch areas in resident rooms were disinfected. Findings include:I. Professional referenceAssadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 11/12/24 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, "High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment." The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 11/12/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, "High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility."Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs."Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."II. Facility policy and procedureThe Routine Cleaning and Disinfection policy and procedure, undated, was received from the director of nursing (DON) on 12/5/24 at 1:36 p.m. It revealed in pertinent part "It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible."Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge."Cleaning considerations include, but are not limited to, the following:-Dry cleaning procedures will be conducted before wet procedures;-Clean from areas that are visibly clean and least likely to be contaminated to areas usually visibly dirty;-Clean from top to bottom (bring dirt from high levels down to floor levels); and,-Clean from back to front areas."Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to toilet flush handles, bed rails, tray tables, call buttons, TV (television) remotes, telephones, toilet seats, monitor control panels, touch screens and cables, resident chairs, IV poles, blood pressure cuffs, sinks and faucets, light switches and door knobs and levers."III. ObservationsOn 12/3/24 at 8:45 a.m. housekeeper (HSK) #1 was cleaning resident room #511, a double occupancy room. HSK #1 put on gloves collected Oxivir (disinfectant spray) from her cleaning cart and sprayed the sink and counter top. HSK #1 then entered the shared resident bathroom and sprayed the toilet riser, the toilet seat and the grab bars. She returned to her cart, collected Victoria Bay toilet cleaner and put it on the floor around the toilet pedestal. -HSK#1 failed to sanitize her hands prior to putting on gloves and beginning to clean the resident room. HSK #1 did not put toilet bowl cleaner into the toilet bowl. HSK #1 returned to the cleaning cart, collected the Oxivir disinfectant spray again and sprayed the resident's dresser handles, bedside table and night stand on side B of the room. -HSK #1 failed to disinfect the resident's call light. HSK #1 returned to her cart, collected a bucket with a toilet scrub brush and proceeded to place the bucket on the bedside table of the resident on side B of the room, returned to her cart and changed her gloves.-HSK #1 placed the dirty toilet bowl bucket on the resident bed side table and failed to perform hand hygiene between glove changes. HSK #1 returned to the toilet brush bucket, entered the bathroom and dunked the toilet brush into the toilet bowl water. HSK #1 proceeded to scrub the toilet bowl. After scrubbing the toilet bowl, HSK #1 scrubbed the toilet rim and then the toilet seat with the scrub brush. HSK #1 dunked the toilet bowl brush into the toilet a second time and scrubbed the seat of the toilet riser.-HSK #1 failed to use disinfectant to clean the toilet.-HSK #1 failed to clean the toilet from the cleanest area to the dirtiest area. HSK #1 returned to her cleaning cart, collected a wet mop pad from the bucket on her cleaning cart, then mopped the bathroom. -HSK #1 failed to change her gloves after cleaning the toilet and prior to putting her soiled gloves into the mop bucket to collect the mop pad. HSK #1 collected a second mop pad and placed it on the floor on side B of the room. She collected trash from both residents' trashcans and removed it from the room. -After dumping the trash, HSK #1 changed her gloves but failed to perform hand hygiene. HSK #1 sprayed Oxivir disinfectant spray on the resident's TV and trash can on side B, wiping them with a dry rag. HSK #1 proceeded to side A of the room and sprayed disinfectant spray on the resident's dresser, bedside table and trash can and dried the items with the same rag she had used on side B of the room.-HSK #1 failed to use separate rags to clean the two sides of the room. HSK #1 returned to side B of the room, mopped the floor and retrieved a new mop pad from the bucket on her cleaning cart and mopped the floor on side A to the door. -HSK #1 failed to clean/disinfect high touch areas in the room such as the call lights, door knobs and TV remotes. HSK #1 failed to perform hand hygiene when changing gloves. HSK #1 mopped both sides of the room with mop pads from the bucket she contaminated when reaching in with soiled gloves from cleaning the toilet. At 9:44 a.m. HSK #1 completed cleaning room #511, removed her gloves and placed a wet floor sign in the entry way of the room. At 9:49 a.m. HSK #1 moved her cart to begin cleaning room #509. HSK #1 put on new gloves and entered room #509, a double occupancy room.-HSK #1 failed to perform hand hygiene after removing gloves and between cleaning the residents' rooms. HSK #1 collected Oxivir disinfectant spray from her cleaning cart, entered room #509 and sprayed the sink and counter top. After spraying the sink, HSK #1 entered the bathroom, moved a pile of briefs, wipes and multiple bottles of barrier creams from on top of the toilet. HSK #1 dropped a tube of barrier cream into the toilet. HSK #1 reached into the toilet with her gloved hands, retrieved the tube of barrier cream, sprayed it with Oxivir disinfectant spray and placed the tube into the sink. -HSK #1 failed to dispose of the tube of barrier cream after it fell into the toilet. After retrieving the tube of barrier cream from the toilet bowl, HSK #1 sprayed Oxivir disinfectant spray on the resident's bedside table on side A. She then sprayed the resident's bedside table on side B of the room and returned to the bathroom. -HSK #1 failed to change her gloves and perform hand hygiene after reaching into the toilet bowl to retrieve the barrier cream. HSK #1 collected trash from the bathroom, removed her gloves and carried the trash bag across the hall to the soiled utility room. HSK #1 then put on new gloves and returned to the room.-HSK #1 did not perform hand hygiene before putting on the new pair of gloves. After returning to the room, HSK #1 went back and forth between side A and side B side of the room, spraying Oxivir disinfectant spray and wiping surfaces on both sides of the room with the same cloth.-HSK #1 failed to clean all of one side of the room before moving to the other side of the double occupancy room and used the same cloth to wipe the disinfectant spray on both sides of the room. HSK #1 returned to her cart, collected Victoria Bay toilet cleaner and put it on the floor around the pedestal of the toilet. -HSK #1 failed to apply toilet bowl cleaner to the toilet bowl. HSK #1 returned to her cleaning cart, changed her gloves, collected a dry rag and returned to the sink. HSK #1 wiped the skin bowl, then the rim and then the counter top with the same rag.-HSK #1 failed to perform hand hygiene between glove changes. -HSK #1 failed to clean the sink from the cleanest area to the dirtiest area. HSK #1 collected the toilet bowl brush from her cart and scrubbed the toilet bowl. She proceeded to spray Oxivir disinfectant spray on the toilet handles, the toilet rim, the toilet tank lid and the outside of the toilet to the floor. She returned to her cleaning cart, collected a new dry rag and wiped the toilet from top to bottom.-HSK #1 failed to change her gloves and perform hand hygiene after scrubbing the toilet. HSK #1 returned to her cleaning cart to collect a new dry cloth and a mop pad from the mop bucket with her soiled gloves. She placed the mop pad in the bathroom then went to side B of the room and sprayed Oxivir disinfectant spray on the TV, dresser handles, head/footboards of the bed and the resident's personal picture frames.-HSK #1 sprayed side B of the room with the same soiled gloves she cleaned the toilet with. After cleaning side B of the room, HSK#1 changed her gloves and sprayed side A of the room with Oxivir disinfectant spray.-HSK #1 failed to perform hand hygiene in between glove changes.-HSK #1 failed to clean the high touch areas in room #509 such as call lights, light switches, bathroom door handles and TV remotes. IV. Staff interviewsHSK #1 was interviewed on 12/3/24 at 10:31 a.m. HSK #1 said she needed to change her gloves after cleaning the bathroom or before moving to a different area in the residents' rooms to prevent contamination. HSK #1 said she needed to sanitize her hands when she exited a room and when she finished cleaning it. HSK #1 said she did not need to change her gloves or perform hand hygiene when she was cleaning the same room. HSK #1 said high touch areas in the residents' rooms were call lights, light switches, handles, grab bars and bedside tables. HSK #1 said she did not clean those items daily unless they looked soiled. HSK #1 said the Oxivir disinfectant she sprayed on the toilet was enough to clean the toilet bowl with and that another cleaner was not necessary to effectively clean the toilet bowl. HSK #1 said she should clean one side of the room, then the other side and then the bathroom last to prevent the spread of infection. HSK #1 said she did not realize she was going back and forth between side A and side B of the room. HSK #1 said she was unaware she did not change her gloves or perform hand hygiene after cleaning the toilet and before she started cleaning the living space of the residents' rooms. HSK #1 said the way she cleaned room #511 and room #509 was not effective for preventing infections. HSK #1 said she felt the barrier cream tube was clean enough because she sprayed Oxivir disinfectant on it after it fell into the toilet. The housekeeping and laundry manager (HLM) was interviewed on 12/5/24 at 9:57 a.m. The HLM said she trained all housekeepers on hire on the chemicals to be used for what and their dwell times. The HLM said housekeepers were taught to clean from the cleanest areas to the dirtiest areas in residents' rooms. The HLM said housekeepers should clean residents' rooms in the following order: side B, then side A and the bathroom last to prevent the spread of infection. The HLM said the toilet scrub brush should only be used on the inside of the toilet bowl to prevent infection, as the bowl was considered dirtier than other areas of the toilet. The HLM said housekeepers should change their gloves when moving from side B to side A in residents' rooms and after cleaning the bathroom. The HLM said housekeepers should perform hand hygiene when changing gloves and on completion of cleaning a room, prior to starting cleaning a new room, in order to prevent the spread of infection. The HLM said high touch surface areas in residents' rooms were call lights, bed controls, light switches, bedside tables and door handles. The HLM said high touch areas should be cleaned daily to prevent the spread of infection. The HLM said she did daily audits of her housekeeping staff and watched them clean a room. She said she would do on the spot education if she observed something not being cleaned appropriately. The HLM said she did not have any documentation of her audits or documentation of the on the spot education she had provided to her housekeeping staff. The HLM said she would provide immediate education to HSK #1. The infection preventionist (IP) was interviewed on 12/5/24 at 11:15 a.m. The IP said she worked with the housekeeping department frequently to ensure they were following all precautions. The IP said she liked to know what cleaners or disinfectants were being used to ensure the housekeeping staff were using them correctly. The IP said high touch areas in residents' rooms were call lights, door knobs, hand rails, TV remote controls, phones, toilet handles, bedside tables and light switches. The IP said high touch areas should be cleaned daily with Oxivir disinfectant spray to help prevent the spread of infection. The IP said housekeepers should follow room appropriate cleaning procedures and clean from top to bottom and from cleanest areas to dirtiest areas. The IP said all staff should perform hand hygiene between glove changes. The IP said the housekeepers should change gloves after cleaning the toilet and when they changed the chemicals they were using to clean. The IP said housekeepers should perform hand hygiene after cleaning a resident's room and prior to starting cleaning another resident's room in order to prevent the spread of infection.

A revisit survey was completed on 5/29/24 for all previous deficiencies cited on 4/17/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO34212 was completed from 4/16/24 and 4/17/24. No deficiencies were cited.

A complaint survey, prompted by #CO35253, #CO35422, #CO35447 and #CO35448 was conducted from 4/16/24 and 4/17/24. Two deficiencies were cited.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure:-Hair restraints were worn by staff in the main kitchen while preparing, handling, cooking and serving food for the residents: and, -Ensure fluorescent ceiling lights above areas where food was prepared, cooked, and served were covered by light shades. Findings include:I. Professional referenceAccording to the Colorado Retail Food Establishment Rules and Regulations (2024)) retrieved from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view on 4/18/24, "Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair,that are designed and worn to effectively to keep their hair from contacting exposed food; clean equipment, utensils, and linens."Lights bulbs shall be shielded, coated, or otherwise shatter-resistant, in areas where there is exposed food; clean equipment, utensils, and linens."II. Facility policy and procedureThe Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions policy, revised January 2024, was provided by the regional corporate consultant (RCC) #2 on 4/17/24 at 1:54 p.m. It read in pertinent part,"Staff always wear proper clothing, and foot wear, uniforms, and hair restraints on."III. Hair nets A. ObservationsOn 4/16/24 at 9:45 a.m. the dietary manager (DSM), dietary cook (DC) #1 and DC #3 were not wearing hair restraints in the kitchen while handling, preparing, or serving food. On 4/16/24 at 12:00 p.m. the nursing home administrator (NHA), the environmental service director (ESD), and RCC #1 were standing at the entry door to the kitchen. The NHA, ESD, and RCC #1 said they could not go into the kitchen because there were no hair nets available to wear. On 4/16/24 at 12:05 p.m. the DSM, DC #1, DC #2 and DC #4 were not wearing hair restraints as they prepared, cooked and served food for the residents. B. Staff interviews The DSM was interviewed on 4/16/24 at approximately 9:45 a.m. The DSM said he did not know where the box of hair nets was for staff to utilize when entering the kitchen. He said he ordered the hair nets but he could not remember when he placed the order. He said the box of hair nets might not have been delivered or was stolen. The DSM said he was not aware the kitchen staff did not have hair nets on when handling food or that the staff did not have hair restraints to use. He said he did not purchase additional hair restraints from the store when he realized the box he had ordered was missing. He said staff should know to wear hair nets when they were in the kitchen. He said he did not know if hair nets could be reworn since there were no new hair nets available to be used. He said he did not know how long it had been since the kitchen staff had hair restraints to use while preparing and cooking food. The DSM said he did not wear a hair restraint because his hair was short. He said he did not know he needed to wear a hair net when he was the cook. He said if staff did not properly wear hair restraints the resident's food could potentially become contaminated. He said he knew there was a regulation the staff were to wear hair restraints when they handled the food in the kitchen. RCC #1 was interviewed on 4/16/24 at 12:00 p.m. RCC #1 said she would go to the supply store and get hair nets immediately. She said the supply store was close to the facility. She said the DSM should have gone to get a box of hair restraints when the kitchen ran out of the supply. At 12:15 p.m. RCC #1 returned with a supply of hair restraints for the kitchen staff. DC#1 and DC #3 were interviewed together on 4/16/24 at 12:05 p.m. DC #1 and DC #3 said they knew they should be wearing hair restraints when they were in the kitchen handling, preparing and serving food. They said there were no hair nets available to wear so they did not wear one. They said they did not remember when there were hair nets available to wear in the kitchen. DC #4 was interviewed on 4/16/24 at 12:10 p.m. DC #4 said she did not have a hair restraint on because there were no hair nets available for her to use. She said she knew she should have worn a hair net while preparing food. DC #3 was interviewed again on 4/17/24 at 11:45 a.m. DC #3 said he had a hair net on today. He said the kitchen staff were provided education on wearing hair nets while in the kitchen on 4/16/24. IV. Kitchen lightsA. ObservationsOn 4/16/24 at approximately 9:40 a.m. three of four light fixtures which held fluorescent lights on the ceiling were observed in the main kitchen. Each light fixture held two long light bulbs (each bulb was four feet in length), which totaled six fluorescent lights. The three light fixtures above food preparation areas did not have protective light shades over them (see ESD interviews below). B. Staff interviewsThe DSM was interviewed on 4/16/24 at 9:45 a.m. The DSM said he did not know why there were no shades over the lights in the kitchen where the food was prepared, cooked and served. He said it was not his job to make sure there were covers over the lights. He said he could not remember if he told the ESD to order covers for the lights. He said if a light were to break, the glass could go in the resident's food as well as onto the dietary staff. He said light covers were for safety and should be installed in the kitchen. RCC #2 was interviewed on 4/17/24 at 9:30 a.m. RCC #2 said the light bulbs in the kitchen above the food stations were fluorescent bulbs. She said yesterday afternoon (4/16/24) the fluorescent bulbs were replaced with LED lights and shades for the lights were ordered. The ESD was interviewed on 4/17/24 at 2:30 p.m. He said yesterday he replaced the fluorescent light bulbs in the kitchen where the food was prepared with LED lights. He said he ordered more LED (light-emitting diode) lights as well as shades for the light fixtures. He said he knew certain types of light bulbs could break and then the resident's food would be contaminated. He said he knew it was a regulation to have shades on the lights but the lights were without shades.

Based on observations, record review and interviews, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure hallway ceiling light fixtures on hallways 200 and 500, and Resident #4's room were free from bugs. Findings include:I. Professional referenceAccording to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, updated July 2019, pp. 94-95, retrieved on 4/22/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf"Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (able to transmit infectious diseases). Arthropods recovered from health-care facilities have been shown to carry a wide variety of pathogenic microorganisms. "From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from all indoor environments, including health-care facilities. Modern approaches to institutional pest management usually focus on: eliminating food sources, indoor habitats, and other conditions that attract pests; excluding pests from the indoor environments and applying pesticides as needed."A pest-control specialist with appropriate credentials can provide a regular insect-control program that is tailored to the needs of the facility and uses approved chemicals and/or physical methods. Industrial hygienists can provide information on possible adverse reactions of patients and staff to pesticides and suggest alternative methods for pest control, as needed."II. Facility policy and procedureThe Pest Control policy revised May 2008, was provided by the regional corporate consultant (RCC) #3 on 4/17/24 at 10:19 a.m. It revealed in pertinent part,"Our facility shall maintain an effective pest control program. "The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. "Maintenance services assist, when appropriate and necessary, in providing pest control services."III. ObservationsOn 4/16/24 at 9:45 a.m. the following was observed:-On the 200 hallway, two of five hallway ceiling light fixtures had bugs visible inside the protective light covers (see interviews below).-On the 500 hallway, four of nine hallway ceiling light fixtures had bugs visible inside the protective light covers. On 4/16/24 at 1:00 p.m. on the 500 hallway, Resident #4's window ledge had approximately 20 dead bugs on it. The window track inside his closed window sill had approximately 20 alive and dead bugs. IV. Staff and resident interviewsThe environmental service director (ESD) was interviewed on 4/16/24 at 9:45 a.m. The ESD took off the covers over the light fixtures on the 200 hallway. He said the bugs were maybe flying ants and mosquitos but he was not sure exactly what type of bugs were in the light covers. He said it was difficult to count the exact amount of bugs but maybe there were 60-100 small bugs in the light fixture covers. He said he was never told there were bugs in the light fixtures. He said he had not noticed the bugs in the lights. He said bugs in the light fixtures were not his job to handle. The nursing home administrator (NHA) was interviewed on 4/16/24 at 9:50 a.m. The NHA said it was the job of the floor technician (FT) to keep the light fixtures cleaned. The FT was interviewed on 4/16/24 at 10:00 a.m. The FT said part of his job was to clean the ceiling light fixtures. He said he noticed bugs in the ceiling light covers on the 200 and 500 hallway. He said he told the assistant environmental service director (AESD) about the problem last Wednesday. (see AESD interview below)The NHA was interviewed again on 4/16/24 at 10:03 a.m. The NHA said the bug problem in Resident #4's room was brought to her attention in the morning meeting today on 4/16/24 around 9:15 a.m. She said she did not know why the ESD did not know about the bug problems on the 200 and 500 hallway. She said the ESD had worked in the position for about one year and he could not know everything there was to know about his job in that amount of time. The AESD was interviewed on 4/16/24 at 12:30 p.m over the phone. He said the FT had told him about the bugs in the light covers the week before. The AESD said he told the ESD about the problem with the bugs in the lights. He said a few weeks prior to telling the ESD about the bugs in the lights, a company came to the facility to spray for bugs. He said the environmental company met with him and the ESD. He said the company said they were going to order bug traps for the facility and that was the last he heard about the traps. He said he did not know what happened with the order for bug traps but no traps ever came in to handle the ongoing bug problem. Resident #3 was interviewed on 4/16/24 at 12:15 p.m. Resident #3 said she was the resident council president and she tried to speak for the residents in the facility as needed. She said she lived on the 500 hallway and there was an ongoing bug problem in the ceiling lights. She said she had told facility staff many times about the bugs but the problem was never fixed. Certified nurse aide (CNA) #1 was interviewed on 4/16/24 at 12:50 p.m. She said she observed bugs in the ceiling lights on several occasions. She said Resident #4 had concerns about the bugs yesterday (4/15/24) in his care conference meeting. She said the bugs were on his window ledge today (4/16/24). Resident #4 was interviewed on 4/16/24 at 1:00 p.m. Resident #4 said his room had an ongoing bug problem. He said he told the staff about the bugs at his care conference yesterday (4/15/24). He said the social services staff said it would be addressed but it had not gotten any better. He said he thought the bugs on his window sill and ledge were flying ants. He said he kept a fly swatter by his bed in case any bugs landed on him. He said he told the assistant social worker (SSA) and two of his relatives who were at the care conference about the bugs. He said the SSA and his family members saw all of the bugs in his room during the care conference. Resident #4's family member was interviewed on 4/16/24 at 1:05 p.m. She said she was not at the care conference yesterday. She said she saw all of the bugs in his room today (4/16/24). She said she hoped the facility would fix the problem. RCC #1 was interviewed on 4/16/24 at 1:30 p.m. She said housekeeping went into Resident #4's room within the last half hour and cleaned his window area from the bugs but did not get them all. She said all of the bugs would be removed immediately. The social service director (SSD) and the NHA were interviewed together on 4/16/24 at 2:36 p.m. The SSD said the SSA did not tell her about the bug problem. She said this morning (4/16/24)she went through the papers (stacked on the SSA's desk) and found a grievance form about the bug problem in Resident #4's room. She said she brought the grievance form to the morning meeting today at approximately 9:15 a.m. She said she discussed it with the facility management team. She said she did not know why the bug problem for Resident #4 was not handled as soon as it was brought to the attention of the SSA. She said she did not know why the problem had not been resolved yet as it had been discussed in the morning meeting.. The NHA said nothing had been done to fix the bug problem yet because the problem was just brought to her attention today (4/16/24) around 9:30 a.m She said she did not know why the resident still had bugs in his room four hours after it was brought to the facility managements attention. The SSA was interviewed on 4/16/24 at 2:57 p.m. over the phone. She said she attended the care conference with Resident #4 on 4/15/24. She said the conference took place in Resident #4's room. She said two of his family members were in attendance. She said Resident #4 complained about the flyingants and he showed everyone the bugs. She said Resident #4 kept a fly swatter by his bed so that he could kill the bugs. She said she told the SSD about the situation shortly after the care conference on 4/16/24. She said the SSD told her to write down on a white piece of paper what had happened in the care conference and the bug problem would get handled the following morning on 4/16/24. She said she did her job to report the situation about the bugs before she went home on 4/15/24. RCC #1 was interviewed on 4/16/24 at 3:05 p.m. RCC #1 said she immediately implemented education to all facility staff that if they saw any bugs at any time it was to be reported to the NHA immediately. RCC #1 said she had a team of staff members immediately walk around the building both inside and outside to investigate the building for any pest control needs. She said she told the team of staff members to look for any areas where bugs could come in, holes or gaps in the walls or windows. The ESD was interviewed on 4/16/24 at 3:45 p.m. The ESD said he and the AESD had a meeting with a bug extermination company about a month ago. He said the company said they were going to order bug traps for the facility. He said the company did not order the bug traps for the facility. He said he did not know why the bug traps were not ordered. He said he did not follow up with the situation to investigate when the bug traps would arrive at the facility. The NHA was interviewed again on 4/17/24 at 1:44 p.m. The NHA said she requested the company that owned the facility to provide her with a new bug extermination company that she could rely on. She said the company who owned the facility agreed to her request and that by tomorrow (4/18/24) they would hire a new company for her. She said the bug problem would get resolved immediately.

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 to the 9/21/2023 survey was completed on 2/1/2024. The facility was in compliance with the regulation surveyed.

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.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/23/2023 and 10/29/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/16/2023 and 10/22/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit survey was completed on 10/12/23 for all previous deficiencies cited on 7/13/23. The facility is in compliance with all regulations surveyed.

A Life Safety Code (LSC) comparative Federal Monitoring Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on September 21, 2023, following a State of Colorado Department of Public Health & Environment survey, that was conducted on August 2, 2023. At this comparative Federal Monitoring Survey Summit Rehabilitation and Care Community, CCN 065176 was found not in substantial compliance with the requirements for participation in Medicare/Medicaid, 42 CFR, Subpart 483.90(a), Life Safety from fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 EXISTING Health Care Occupancies. The facility is determined to be one story with no basement (slab on grade). Construction is a brick exterior with combustible wood studs, Type III(200) construction type. The nursing home facility was stated to be built around 1966, with no recent major renovations. The building had a zone smoke detection system with smoke detectors in the corridors tied to a monitoring company. Resident rooms had single station smoke detection. The nursing home was fully sprinkler protected with a wet sprinkler system. The sprinkler system is on domestic water with no fire pump. Emergency backup power to the building was supplied by a 20KW natural gas generator outside the facility. The facility generator is stated to be partially tied to the building including the fire alarm control panel, red outlets, emergency lights, doors and life safety components utilized for preservation of life. The facility is approximately two miles from a local paid fire department. The facility did not admit residents on life support and stated they do admit bariatric residents based on the facility equipment and ability to provide care. The facility has a capacity of 109 beds with a census of 103 at the time of the survey. The requirement at 42 CFR Subpart 483.90(a) is NOT MET as evidenced by:

An Emergency Preparedness (EP) and Life Safety Code (LSC) comparative Federal Monitoring Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on September 21, 2023, following a State of Colorado Department of Public Health & Environment survey, that was conducted on August 2, 2023. At this comparative Federal Monitoring Survey Summit Rehabilitation and Care Community, CCN 065176 was found not in substantial compliance with the requirements for participation in Medicare/Medicaid, 42 CFR, Subpart 483.73 Emergency Preparedness. The building is described in the K000 section for the Life Safety Code survey. Emergency backup power to the building was supplied by a 20KW natural gas generator outside the facility. The facility generator is stated to be partially tied to the building including the fire alarm control panel, red outlets, emergency lights, doors and life safety components utilized for preservation of life. The facility is approximately two miles from a local paid fire department. The facility did not admit residents on life support and stated they do admit bariatric residents based on the facility equipment and ability to provide care. The facility has a capacity of 109 beds with a census of 103 at the time of the survey. The requirement at 42 CFR Subpart 483.73 is NOT MET as evidenced by:

Based on record review and interview, the facility failed to verify the facility has the required emergency and standby power systems to meet the requirements of a reliable uninterruptible power source in accordance with 42 CFR 483.73(e)(1)(2) and NFPA 99, 2012 Edition, Section 6.4.1.1.4. This deficient practice could affect 103 of 103 residents, as well as an indeterminable number of staff and visitors. Findings Include:Record review on 09/21/2023 at approximately 9:30am to 12:00pm identified the facility had a natural gas generator (20KW) outside the facility with no records documenting the facility has two independent sources of power for the building, as both sources of power are reliant on outside utilities and one of the two sources is not in the control of the facility. Essential electrical system power supply for emergency power supply (EPS) that meet the required emergency power supply system (EPSS) for nursing homes are required to be of reliable source or in the control of the provider for one of two supplied power sources for uninterruptible power supply. Interview at the time of record review with the Maintenance Director verified the facility had the generator tied to LSC functions in the facility including the fire alarm control panel, emergency facility lighting, red outlets and life safety components utilized for preservation of life which would require a Level 1 system per NFPA 99, 2012 Edition, Chapter 6 and NFPA 110, 2010 Edition Chapter 4, but had no information available at the time of record review regarding the reliability of the natural gas supplier in an emergency situation. Interview on 09/21/2023 with the Maintenance Director, at the time of record review, verified there was no documented letter from the natural gas provider and the facility could not provide information to support reasonable reliability with a statement of supporting description of the system from the utility company. Reliability letters from natural gas venders regarding fuel supply shall contain all of the following:1. A statement of reasonable reliability of the natural gas delivery. 2. A brief description that supports the statement regarding the reliability. 3. A statement that there is a low probability of interruption of the natural gas. 4. A brief description that supports the statement regarding the low probability of interruption. 5. The signature of technical personnel from the natural gas vendor. The findings were verified by the Maintenance Director at the time of record review.

Based on observation and interview, the facility failed to provide protection of a hazardous area by failing to ensure hazardous area is safeguarded by a fire barrier having a one hour rating and was separated by smoke partitions from other areas in accordance with LSC Section 19.3.2.1, 19.3.2.4 and 8.7. This deficient practice could affect one smoke zone, 20 residents, as well as an indeterminable number of staff and visitors. Findings include:Observation on 09/21/2023 at approximately 1:00pm to 3:00pm during the facility tour identified one facility soiled linen room opened directly into the facility corridor did not close to latch. Observation of the door identified the door latch had materials stuffed into the reciever preventing the door from closing to latch. Interview on 09/21/2023 at the time of observation with the Maintenance Director confirmed the door to the corridor was not closing to latch and was identified as being a hazardous area. This finding was verified by Maintenance Director at the time of observation.

Based on record review and interview, the facility failed to maintain the documentation of the sensitivity testing for the smoke detective devices tied to the fire alarm control panel in accordance with NFPA 72, 2010 Edition, Section 14.4.5.3 and LSC Section 9.6.1.3, 9.6.1.5 and 9.6.1.7. This deficient practice could affect all smoke zones, 103 of 103 residents, and an indeterminable number of staff and visitors. Findings Include:Record review on 09/21/2023 at approximately 11:00am identified records from Cintas documentation of sensitivity testing identified the most recent records stated, "not due" and previous documentation of sensitivity identified all of the sensitivity measures for each of the smoke detectors was identical year after year with no variations based on placement or loading of smoke detectors. Documentation dated 09/20/2023, 03/06/2023, 09/08/2022, and 03/11/2022 identified several smoke detectors failed which did not support the same sensitivity measures or why the sensitivity was, "not due." Interview on 09/21/2023 with the Maintenance Director at the time of record review confirmed the findings. The finding was verified by the Maintenance Director at the time of record review.

Based on record review and interview, the facility failed to maintain documentation of the sprinkler system in accordance with LSC Section 19.3.5.1, Section 4.6.12, and Section 9.7, and NFPA 25, 2011 Edition, Section 5.2 and 5.4. The deficient practice could affect all smoke zones, 103 of 103 residents, as well as an indeterminable number of staff and visitors. Findings Include:Record review on 09/21/2023 at approximately 11:00am during record review identified two quarterly sprinkler inspections (06/12/2023 and 06/02/2022) from Cintas, one annual sprinkler inspection (dated 03/06/2023) and one semi-annual sprinkler inspection (dated 09/20/2023). At the time of record review, there was not any inspection from 06/02/2022 to 03/06/0223. Interview on 09/21/2023 at the time of record review with the Maintenance Director confirmed one quarterly (or semi-annual) inspection was not available (most likely the December 2022 quarterly inspection). The findings were verified by the Maintenance Director at the time of observation and record review.

Based on observation and interview, the facility failed ensure portable fire extinguishers were checked monthly and ready for use in accordance with NFPA 10, 2010 Edition, Chapter 7, Section 7.2.1.2 and LSC Section 19.3.5.12, 9.7.4.1. This deficient practice affected all smoke zones, 103 of 103 residents, as well as an indeterminable number of staff and visitors. Findings Include:Observation on 09/21/2022 at approximately 1:00pm to 3:00pm during the facility tour identified fire extinguishers throughout the facility were missing inspections for July of 2023. Interview with the Maintenance Director at the time of observation confirmed the finding per the inspection tag, missing the monthly inspections. The findings were verified by the Maintenance Director at the times of observation.

Based on record review and interview, the facility failed to conduct fire drills one per shift, once per quarter and at varied times in accordance with LSC Sections 19.7.1.4 through 19.7.1.7. This deficient practice could affect 103 of 103 residents, as well as an indeterminable number of staff and visitors. Findings Include:Record review on 09/21/2023 at approximately 10:30am identified no documented fire drills for any of the shifts since 06/30/2023. For the first shift (6:00am to 2:00pm), no fire drills were documented since 01/31/2023. Two first shift fire drills conducted on 10/05/2022 and 01/31/2023 were documented at the same times (1:15pm on 10/05/2022 and 1:00pm on 01/31/2023). For the second shift no fire drills were documented between 11/16/2022 and 04/25/2023. Two documented fire drills (of three conducted on the second shift) for the second shift were documented at the same time (7:15pm on 08/20/2022 and 7:30pm on 11//16/2022). For the third shift (10:00pm to 6:00am), two fire drills were documented at 10:00pm (on 02/16/2023 and 05/08/2023) and four fire drills were documented at the same times (09/30/2022 at 5:15am, 12/10/2022 at 5:30am, 03/26/2023 at 5:00am and 06/30/2023 at 5:00am). Interview on 09/21/2023 at approximately 10:30am at the time of record review with the facility Maintenance Director stated that the facility has three shifts and stated the shifts are 6:00am to 2:00pm, 2:00pm to 10:00pm, and 10:00pm to 6:00am. The findings were verified with the Maintenance Director at the time of record review.

Based on observation, record review and interview, the facility failed to prohibit portable space heating devices in resident occupied spaces in accordance with LSC Section 19.7.8. This deficient practice could affect one smoke zone, 10 resident, as well as an indeterminable number of staff and visitors. Findings include:Observation on 09/21/2023 during a facility tour at approximately 2:50pm identified that the facility had a portable space-heating device, in a office open to the common area at the facility entrance, which could produce heat above 212F. Record review on 09/21/2023 at approximately 9:45am revealed that the facility did not have a policy stating that portable space-heating device were allowed to be used in the facility in non-sleeping staff and employee areas. Interview with the Administrator and Maintenance Director at the time of record review, confirmed that the facility does not have a policy stating that portable space-heating device were allowed to be used in the facility in non-sleeping staff and employee areas and that space heaters were not allowed in the facility. The findings were verified by the Maintenance Director at the times of observation.

INITIAL COMMENTS (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 August 2nd, 2023 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) (VA) construction. This original facility was constructed in 1972. There is no basement. The facility is licensed for 110 beds. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 Fire Sprinkler Systems. The wet-pipe system protects the main level and attic space. There is an anti-freeze loop that protects the front canopy. The facility is classified as fully-sprinklered. Deficient items were discussed at the time of the survey and again with the Administrator, Administrator, Maintenance Assistant, and Housekeeping Director at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Hazardous Areas – Enclosure requirements in accordance with NFPA 101. This requirement was NOT MET by the following:The restorative office/storage area has damaged sheetrock that does not resist the passage of smoke and or fire. The medication supply room near the Rockies nurse station does not close and latch. The laundry room area has damaged sheetrock that does not resist the passage of smoke and or fire. The boiler room area has damaged sheetrock that does not resist the passage of smoke and or fire. The fire-rated door has been modified kitchen and does not properly operateThe fire roll down the door in the kitchen was blocked by a milk crate and would not be able to operate the way it is intended in the event of a fire. Clean utility 500 hall does not positively latch shutCodes/Regulations referenced. 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 4.6.12.5 Maintenance, inspection, and testing shall be performed under the supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire faciility. Deficient items were discussed with the administrator during the inspection and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Cooking Facilities requirements in accordance with NFPA 101. This requirement was NOT MET by the following:The kitchen hood cleaning report had no noted deficiencies, however, the pictures for the last 3 cleanings or 9 months showed the same protective cap not properly installed. While in the kitchen the surveyor asked the kitchen staff to remove the grease filter to look inside the exhaust hood, it was confirmed that the protective cap was in fact off of the nozzle. Additionally, there was a build-up of grease from cooking oil dripping onto the pulley system for the kitchen hood fire suppression system. It appears that there is no way for the grease to drain out of the hood and was spilling over the ends of the hood. The hood contained a slight slope to the middle of the hood system and contains a bracket assembly for what appeared to be intended to hold a grease tray but no grease tray a hole in this location also appears to be patched shut and it is thought it be to allow the oil to drain into the grease cup. To keep the grease filters in the proper location a plastic coffee cup was turned upside down and placed in the hood between the two filters to keep them in the desired location. Codes/Regulations referenced. NFPA 96 Section 6.2.4.1 Grease filters shall be equipped with a grease drip tray beneath their lower edges. NFPA 96 Section 4.1.2 All such equipment and its performance shall be maintained in accordance with the requirements of this standard during all periods of operation of the cooking equipment. NFPA 96 Section 4.1.3.1 Maintenance and repairs shall be performed on all components at intervals necessary to maintain good working conditionNFPA 96 Section 5.1.4* Internal hood joints, seams, filter support frames, and appurtenances attached inside the hood shall be sealed or otherwise made greasetight. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 smoke compartment. Deficient items were discussed with the administrator during the inspection and at the exit conference.

Through observation during the documentation review, it was determined that the facility failed to meet the Fire Alarm System - Testing and Maintenance requirements in accordance with NFPA 101, and NFPA 72. This requirement was NOT MET by the following:Fire Alarm inspection documentation provided to the surveyor included an annual inspection from 03/06/2023 and another annual inspection from 03/11/2022. No semi-annual inspection was available for review. Fire alarm devices in the dining room were covered because the facility is retexturing and painting the dining room. Upon interview with the contractor completing the work texturing and painting had not been in progress for at least 24 hours. These devices shall be maintained in working condition. Codes/Regulations referenced. NFPA 72: See table 14.4.5 for testing frequencies required for NFPA 72NFPA 101 Section 9.6.1.6 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to serviceThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator during the inspection and at at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Sprinkler System – Maintenance and Testing requirements in accordance with NFPA 101, and NFPA 25. This requirement was NOT MET by the following:Activities storage at the end of the corridor has a pendent-style sprinkler head. The distance from the sprinkler head to the furthest wall is 12 ' 7" which likely exceeds the sprinkler head capacity as these heads typically cover a 15 ' by 15 ' area. The distance from the wall shall not exceed one–half the distance of the sprinkler. Prove that this sprinkler head can cover a 25 by 25 area or modify the system to be in compliance. The dining room sprinkler hears had protective caps installed because the facility is retexturing and painting the dining room. Upon interview with the contractor completing the work texturing and painting had not been in progress for at least 24 hours. These devices shall be maintained in working condition when work is not being completed. Codes/Regulations referenced. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). NFPA 13 Section 1.4.2 In those cases where the authority having jurisdiction determines that the existing situation presents an unacceptable degree of risk, the authority having jurisdiction shall be permitted to apply retroactively any portions of this standard deemed appropriate. NFPA 13 section 8.5.3.2.1 The distance from sprinklers to walls shall not exceed one-half of the allowable maximum distance between sprinklers. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 2 smoke compartments. Deficient items were discussed with the administrator during the inspection and at at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Corridor - Doors requirements in accordance with NFPA 101. This requirement was NOT MET by the following: Room 210 door has a gap that would allow the passage of smoke because the gap between the door and frame was too large. Room 303 door would not positively latch shut, Corrected During the Survey. Codes/Regulations referenced. 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 and shall be constructed of materials such as the following:(1)13/4 in. (44 mm) thick, solid-bonded core wood(2)Material that resists fire for a minimum of 20 minutesThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 2 smoke compartments. Deficient items were discussed with the administrator during the inspection and at at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Subdivision of Building Spaces – Smoke Barrier Construction requirements in accordance with NFPA 101. This requirement was NOT MET by the following: Above the ceiling, in the Restorative office, the smoke barrier wall was witnessed to have numerous penetrations that were made for conduit, MC wire, low voltage wire, and HVAC ducts. There were many unprotected penetrations and there was what appears to be a rated access door with a spring. The spring was disabled and the door was in the open position. In many locations, it appears that joint compound was applied to penetrations, the joint compound is separating from the surfaces and cracking in many locations. The facility shall survey all smoke compartment walls to ensure compliance. Codes/Regulations referenced. NFPA 101 Section 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 2 smoke compartments. Deficient items were discussed with the administrator during the inspection and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Subdivision of Building Spaces - Smoke Barrier Doors requirements in accordance with NFPA 101. This requirement was NOT MET by the following:Cross corridor doors throughout the facility are missing sequencers. Without these systems in place if these doors do not close in proper order this arrangement can not prevent the passage of smoke. Codes/Regulations referenced. 19.3.7.8* Doors in smoke barriers shall comply with 8.5.4 and all of the following:(1)The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.(2)Latching hardware shall not be required.(3)The doors shall not be required to swing in the direction of egress travel. 19.3.7.9 Door openings in smoke barriers shall be protected using one of the following methods:(1)Swinging door providing a clear width of not less that 32 in. (810 mm)(2)Horizontal-sliding door complying with 7.2.1.14 and providing a clear width of not less than 32 in. (810 mm)8.5.4.2 Where required by Chapters 11 through 43, doors in smoke barriers that are required to be smoke leakage-rated shall comply with the requirements of 8.2.2.4.8.2.2.4 Where door assemblies are required elsewhere in this Code to be smoke leakage-rated in accordance with 8.2.2.4, door assemblies shall comply with all of the following:(1)They shall be tested in accordance with ANSI/UL 1784, Standard for Air Leakage Tests for Door Assemblies.(2)The maximum air leakage rate of the door assembly shall be 3.0 ft3/min/ft2 (0.9 m3/min/m2) of door opening at 0.10 in. water column (25 N/m2) for both the ambient and elevated temperature tests.(3)Door assemblies shall be installed in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.(4)Door assemblies shall be inspected in accordance with 7.2.1.15. NFPA 105 Section 5.2.1.2 Doors shall be operated to confirm full closure. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 3 smoke compartments. Deficient items were discussed with the administrator during the inspection and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Utilities – Gas and Electric requirements in accordance with NFPA 101. This requirement was NOT MET by the following:The two new gas dryers indicate on the information tag on the back that they are designed for elevation levels of 0-2000 feet of elevation. The elevation of Aurora Colorado is 5,403 ft. It was determined through interview that these dryers are new. Codes/Regulations referenced. NFPA 54, section 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft. (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft. (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction(3) In accordance with the manufacturer ' s installation instructionsThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 smoke compartment. Deficient items were discussed with the administrator during the inspection and at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Smoking Regulations requirements in accordance with NFPA 101. This requirement was NOT MET by the following:The smoking area does not have the proper ashtray cans. The smoking area has non-combustible material and safe designs, however, the facility does not have metal containers with self-closing cover devices into which those can be emptied. Codes/Regulations referenced. 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:(1)Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.(2)In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.(3)Smoking by patients classified as not responsible shall be prohibited.(4)The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.(5)Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.(6)Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 smoke compartment. Deficient items were discussed with the administrator during the inspection and at the exit conference.

A recertification survey was conducted from 7/9/23 to 7/13/23. Eleven deficiencies were cited.

An Emergency Preparedness survey was conducted from 7/9/23 to 7/13/23. No deficiencies were cited.

Based on observations, record review, and resident and staff interviews, the facility failed to provide one (#91) of two residents reviewed for dignity, out of 43 sample residents, care in a dignified, respectful and individualized manner. Specifically, on 7/11/23, Resident #91 said she did not receive her dinner meal, and the cook disagreed and refused to prepare a meal for her. Resident #91 said this made her feel "unimportant and that she did not matter."Findings include:I. Facility policy and ProcedureThe Dignity policy, last revised in February 2021 was received on 7/12/23 from the nursing home administrator. The policy read in pertinent part, "Each resident should be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, and feelings of self-worth and self-esteem." II. Resident #91Resident #91, age 69, was admitted on 10/28/22. According to the July 2023 computerized physician orders (CPO), diagnoses included a history of falling, diabetes mellitus, kidney failure, and neuropathy. The 4/12/23 minimum data set (MDS) assessment coded the resident with no cognitive impairments with a score of 15 out of 15 for the brief interview for mental status. The resident required supervision or oversight for activities of daily living. III. Resident interviewResident #91 was interviewed on 7/11/23 at 3:59 p.m. The resident said she was upset because she did not get a dinner meal last night. She said the dinner carts were not delivered until 6:55 p.m. to the floor. She said she waited for her meal, however, it did not arrive. She said at 7:30 p.m., she inquired about her meal. The certified nurse aide (CNA) told her she did not get a meal. The receptionist, who was in the nearby area, went to the kitchen. The resident said she followed the receptionist and there was no one in the kitchen. After the fourth call out to the kitchen, the dietary aide came in, followed by the cook, and said she and the cook were on break. The cook told the resident that she had received a meal. The resident told the cook no, she had not received it. The cook stated he would get her a meal. At 8:30 p.m., about an hour later, the resident said she went back to the dining room area. At that time, the cook said the kitchen was closed; the dishes had been washed. The resident said she never received her meal and went to bed hungry. She said she woke up hungry, too. She said the whole situation made her cry, and she was angry. She said she felt unimportant and that she did not matter. IV. Staff interviewThe receptionist was interviewed on 7/11/23 at 4:49 p.m. The receptionist said she was present when Resident #91 came out to the circle common area, visibly upset, and stating she had not received a dinner meal. The receptionist said she spoke with the resident's assigned certified nurse aide (CNA) who confirmed the resident had not received a meal tray. The CNA offered the resident a snack until the kitchen could prepare a meal. The receptionist said she went into the kitchen and hollered for the cook, but there was no response. She said on the fourth call-out, the kitchen staff answered back that they were on break. She said the cook told the resident that she had received soup, but the resident denied it. The cook then said he would get the resident something to eat. The receptionist said she then left the kitchen area as she thought the issue was resolved. The receptionist said she felt bad for the resident who was so upset and was crying, both when she met the resident in the common area and while talking with the cook She said the resident told her this morning that she never received her meal and at 8:30 p.m., she went back to the kitchen and she was told that the dishes needed to be done and the kitchen was closed. The receptionist said she would not have left the resident if she had known the situation was not resolved. V. Record reviewThe concern form dated 7/10/23 documented that the resident was very upset that she did not receive dinner, the CNA had confirmed that was correct (the resident had not received dinner) and no one was in the kitchen when she and the receptionist went to the kitchen. The resident spoke to the cook to notify him about the situation and said he was going to help the resident get a meal. However, see above; she never received one. The follow-up action dated 7/12/23 documented, "discussed with staff being in the kitchen, honoring request."VI. Additional interviewsThe regional registered dietitian (RRD) was interviewed on 7/13/23 at 9:00 a.m. The RRD said the dietary manager had instituted some changes in meal service. She said the meals were being served to the residents in their rooms because the kitchen was being remodeled. She said the kitchen staff was available to get a resident a meal if it was missed. She also spoke with the new dietary manager in regard to the events that occurred on 7/11/23.

Based on observations, resident and staff interviews the facility failed to provide a comfortable and homelike environment for the residents of the facility for three out of four units. Specifically the facility failed to ensure:-Residents were provided with washcloths and hand towels; and-Room walls, furniture were properly maintained. Findings include:I. Lack of walls and furniture properly maintainedA. Observations7/9/23 at 10:30 a.m.-Room #316 the window blinds were bent both forward and backward and were not effective in keeping light out of the room when closed. -Room #324 the wall behind the resident ' s headboard had deep scratches and gouges approximately 12 inches long by one inch wide from the bed being lifted and lowered. -Room #326 the bathroom door got stuck and was difficult to open.-Room #327 the top two dresser drawers were missing. 7/11/23 at 12:15 p.m.-Room #318 the dresser drawers were not aligned and falling out. 7/12/23 at approximately 10:00 a.m. -Room #320 the towel bar was broken near the sink.-Room #327 had scuffs on the wall near the bed.-Room #314 had a plastic bag covering a hole in the ceiling.-Room #516 the heat register was unattached from the wall.-Room #521 the dresser in the room was missing two drawers out of four.-Room #522 the dresser drawers were not aligned and falling out.-Room #524 the dresser drawers were not aligned and falling out.-Room #527 the dresser drawers were not aligned and falling out.-Room #529 the decorative shelf hanging on the wall was not attached securely. -Room #607 the towel bar was broken which was near the sink. B. InterviewsThe regional maintenance director (RMTD) was interviewed on 7/13/23 at 11:37 a.m. The above detailed observations were reviewed. The RMTD said any work requests should be completed on the TELS computer system or on the 24 hour report. He said the facility had one maintenance director. He said he would conduct an audit of the areas which needed to be repaired. The clinical nurse consultant was interviewed on 7/13/23 at approximately 12:00 p.m. She said the building was going to order some new dressers to replace the broken ones. II. Lack of washcloths and hand towels in resident roomsA. Observations7/10/23 at 1:58 p.m. -Room #320 had no towels. 7/11/23 at 1:47 p.m. Room #328 still had no towels. Room #327 had no towels. Room #325 had no towels. Room #326 had one bar that only had one wash cloth on it and it was a shared room. Room #323 had one wash cloth on the bar and it was a shared room. Room #324 had no towels. Room #322 had one bar with one hand towel for a shared room. Room #319 had no towels. 7/12/23 at 10:00 a.m.-Room #607 had no towels.-Room #507 had no towels.-Room #514 had no towels.-Room #507 had no towels.-Room #509 had no towels.-Room #511 had no towels.-Room #514 had no towels.-Room #520 had no towels.-Room#527 had no towels. 7/12/23 at 11:36 a.m.-Room #330 had no towels. -Room #322 had no towels.-Room #326 had no towels.-Room #330 had no towels.-Room #331 had no towels.-Room #332 had no towels.-Room #327 had no towels. 7/12/23 at 10:00 a.m.-Room #507 had no towels.-Room #509 had no towels.-Room #511had no towels.-Room #514 had no towels.-Room #520 had no towels.-Room#527 had no towels. B. Resident interviewsThe resident group interview was conducted on 7/11/23 at 1:00 p.m. The group consisted offour residents (#14, #19, #25 and #28) who were interviewable based on assessment and facility. The residents said the following in regards to not having towels in the rooms:-Towels were not delivered to rooms unless they asked for them.-The facility runs out of towels, so they have purchased their own towels. Resident #67 was interviewed on 7/12/23 at approximately 10:15 a.m. The resident said she did not have towels at her sink. She said she used paper towels to wash her face and to dry her hands. She said she would like to have linen towels. C. InterviewsThe assistant director of nurses (ADON) was interviewed on7/12/23 at 2:00 p.m. The ADON confirmed select rooms randomly selected from the above observation revealed there were no towels in the rooms. She said there were towels available in the linen closets. She said there were plenty of towels and residents could request towels. She said the night shift certified nurse aides should pass towels to the resident rooms.

Based on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice in accordance with a resident's inability to carry out activities of daily living (ADLs) for three (#68, #47 and #20) out of seven residents reviewed for ADLs of 43 sample residents. Specifically, the facility failed to provide supervision, encouragement, cueing and assistance during meals to Resident #68, Resident #47 and Resident #20. Findings include:I. Resident #68A. Resident statusResident #68, age 78, was admitted on 7/10/19. According to July 2023 computerized physician's orders (CPO), diagnoses included dementia, chronic kidney disease, depression and nutritional deficiency. The 4/25/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and unable to complete a brief interview for a mental status (BIMS). She required extensive assistance of one person with one-person assistance with bed mobility, personal hygiene, dressing and toilet use. She required oversight, encouragement and cueing with eating. B. ObservationsOn 7/9/23 at 11:57 a.m. Resident #68 was observed walking around the dining room. Lunch was served at 12:04 p.m. Staff did not direct her to her food nor did they set a plate down for her. The resident continued to walk through the hallways until 12:35 p.m. The resident continued to walk through the hallway. On 7/11/23 at 11:12 a.m. Resident #68 was observed walking around wandering through the hallway holding her tummy and crying. One unknown staff member walked by her but did not stop to check on the resident. At 12:01p.m. Resident #68 was observed walking around the dining room. The resident sat down before the meal was served where she cried and put her hands on her face. The resident got up and continued to walk through the dining room and hallway. Lunch was served at 12:04 p.m. Staff never directed her to her food nor did they set a plate down for her. She was not offered food by 12:20 p.m. C. Record reviewThe nutritional care plan, reviewed on 2/6/23, documented the resident was at risk for nutritional deficiencies. The documented interventions were to monitor and report signs of dysphagia (swallowing difficulty), choking, coughing, drooling, holding food in their mouth, refusing to eat and appearing concerned during meals. The activities of daily living (ADL) care plan, reviewed on 9/6/22, documented the resident's interventions including the resident was independent with eating set up as needed.-However, according to the MDS assessment, she required oversight, encouragement and cueing with meals. D. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 7/13/23 at 9:10 a.m. CNA #4 said the resident ate finger foods. CNA #4 said the resident did not like staff to physically help her eat. CNA #4 said the staff helped her sit down and encouraged her to eat. CNA #4 said they would leave her food so she could come and get her food and walk with it since she has difficulty sitting down. Licensed practical nurse (LPN) #3 was interviewed on 7/13/23 at 10:35 a.m. LPN #3 said Resident #68 ate finger foods. LPN#3 said they should leave the residents food out on a table and encourage her to eat. LPN #3 said the resident was at nutritional risk. The director of nursing (DON) was interviewed on 7/13/23 at 2:32 p.m. The DON said Resident #68 wandered a lot and had difficulty sitting down during lunch. The DON said staff should put out her food and encourage the resident to eat. The DON said the resident often threw her food away. The DON said the staff gave her a Boost throughout the day. II. Resident #47A. Resident statusResident #47, 97 years old, was admitted on 11/11/16. According to July 2023 CPO, diagnoses included major dementia, psychotic disturbance, anxiety and chronic kidney disease. The 4/5/23 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of two out of 15. She required extensive assistance of two people with bed mobility, transfers and toileting. She required extensive assistance from one person with personal hygiene, dressing and eating. B. ObservationsOn 7/9/23 at 11:38 a.m. the resident was in the dining room eating lunch. She had one eight ounce cups filled half way full of liquid. The cup was far away from her and she was unable to reach it and no staff offered to help her with eating or drinking. On 7/10/23 at 11:45 a.m. until 12:30 p.m. the resident was in the dining room. There was not a drink in front of her and the staff did not offer to help her or offer her a drink. C. Record reviewThe activity of daily living care plan, revision on 1/27/23, documented the resident had activity of daily living decline. The resident may need assistance with eating at times. D. Staff interview CNA #4 was interviewed on 7/13/23 at 9:18 a.m. CNA #4 said Resident #47 required assistance while eating and drinking. CNA #4 said the staff should help her at meal times. III. Resident #20A. Resident status Resident #20, 85 years old, was admitted on 7/8/22. According to July 2023 CPO, diagnoses included major depressive disorder, legal blindness, acute kidney failure and dementia. The 6/8/23 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. She required extensive assistance of one person with bed mobility, transfers, personal hygiene, dressing and supervision with walking. The resident needed supervision which included oversight, encouragement and cueing with setup of one-person assistance with eating. B. ObservationsOn 7/9/23 at 11:50 a.m. until 12:38 p.m. the resident was in the dining room. The resident had a drink but it was too far for her to reach. The resident was barely able to put food to her mouth and no staff offered to help her. On 7/11/23 at 11:04 a.m. until 12:57 p.m. the resident was in the dining room and the water was out of reach from the resident. Staff did not assist her at the meal. C. Staff interviews CNA #4 was interviewed on 7/13/23 at 9:18 a.m. CNA #4 said Resident #20 was blind but could eat and drink on her own. CNA #4 said the staff help the residents if they see that they need assistance. CNA #4 said the staff should put the residents' drinks and meals close enough for the resident to reach. The nursing home administrator (NHA) was interviewed on 7/13/23 at 9:54 a.m. The NHA said staff should assist residents with eating and drinking if needed.

Based on observations, record review, and interviews, the facility failed to implement an ongoing resident centered activities program to enhance the interest of, and support the physical, mental, and psychosocial well-being for one resident (#7) of 13 residents reviewed for activities out of 43 sample residents. Specifically, the facility failed to ensure Resident #7 was provided with meaningful, individualized activities and social engagement in accordance with the resident's functional and psychological strengths and abilities in fulfillment with the resident's plan of care. Findings include: I. Facility policy and procedureThe Activity Schedule policy, revised 3/14/23, was provided by the director of nursing (DON) on 7/13/23 at 2:55 p.m. It read in pertinent part, "All activities can be therapeutic, regardless of what population is being served. The community will provide daily activities that not only meet the requirements of state and federal guidelines, but also the interests, preferences, hobbies and the culture of the participants and community. Daily activities include community sponsored group and individualized activities, in addition to assistance with independent daily activities." II. Resident #7A. Resident status Resident #7, age 97, was admitted 3/8/18. According to the July 2023 computerized physicians orders (CPO) diagnoses included chronic diastolic heart failure, chronic respiratory failure with hypoxia, obstructive pulmonary disease and chronic kidney disease. The 6/20/23 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of seven out of fifteen. The resident was dependent on two or more staff members for activities of daily living. The resident's activity preference included reading books, papers, and magazines, spending time outside the facility and spending time outdoors. B. Resident and representative interviewThe resident declined to be interviewed on 7/11/23 at 9:18 am. The resident's representative was interviewed on 7/11/23 at 9:18 a.m. The resident's representative said he was involved in the resident's plan of care but did not hear from the facility very often. The resident's representative said the resident loved gardening and classical music and said he had shared this information with the facility some time ago. The resident's representative said the resident had a garden of flowers at home but did not believe the facility had taken the resident outside to enjoy the outdoors. C. Observations7/9/23 -At 11:00 a.m. the resident was sitting at the bedside in a high back wheelchair staring out the window. The television was turned off. No activities calendar is posted in the resident's view.-At 3:00 p.m. to 3:43 p.m. the resident was in bed asleep, there was music playing in the "circle" about three feet from the resident's room. No staff invited the resident to attend. 7/10/23 -At 3:34 p.m. the resident was sitting upright in the wheelchair facing the bed with no meaningful activity. A musician playing a guitar and singing in a circle. However, staff failed to invite the resident to the activity. 7/13/23 -At 10:55 a.m. an activity assistant was pushing a cart of books, magazines, puzzles, pictures, and colored pencils around the unit. The staff member did not enter the resident's room. The resident's television remained off. D. Record review The care plan, dated 6/16/23, revealed the resident may at times enjoy outings, activity cart, socials, and outdoor activities. The resident prefers independent activities like watching television, shopping in catalogs, make-up, writing letters, napping, relaxing in her room, and visiting with family. Staff to provide monthly activities calendar and independent leisure supplies via the activities cart. Staff will remind and invite the resident to activities of interest. Pertinent interventions included: to write things down for better communication, the resident with independent leisure supply via the activities cart or upon request and staff would invite the resident to activities of interest. The resident's recreational summary via a care conference dated 2/20/23 showed the resident enjoyed socials, outings, coffee hour, resident meetings and outdoor activities. The resident enjoyed independent activities as outlined in the resident's plan of care. A history of the resident's participation in activities beginning 6/14/23 to 7/11/23 revealed the resident participated in a one-on-one social activities without revealing the source of the social activity: -6/14/23 to 6/25/23 at 11:59 p.m. daily-6/26/23 at 11:59 a.m. -6/27/23 to 7/2/23 at 1:59 p.m. daily-7/4/23 at 11:38 a.m. -7/5/23 to 7/6/23 at 1:59 p.m. -7/7/23 at 11:44 a.m. -7/8/23 at 1:13 p.m.-7/9/23 to 7/11/23 at 1:59 p.m. E. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 7/13/23 at 8:45 a.m. CNA #3 said the resident was offered items from the activities cart every day and knew the resident liked magazines and catalogs to look through and activities staff brought these items to the resident at least once a week. CNA #3 said the resident had a drawer full of make-up and puts on make-up everyday unless she was too tired. Licenced practical nurse (LPN) #4 was interviewed on 7/13/23 at 9:50 a.m. LPN #4 said the resident spent most of her time in her room and participated in one-to-one socialization either with the activities staff or her son. LPN #4 said the activities staff invited the resident to activities on a daily basis but the resident declined each time. LPN #4 said the resident had catalogs she looked through. The social service director (SSD) was interviewed on 7/13/23 at 1:20 pm. The SSD said she worked directly with activities staff. The SSD said she had been working with the activities staff to incorporate activities that promote visual and tactile stimulation for the resident via "pet a cat." The activities director (AD) was interviewed on 7/13/23 at 1:59 p.m. The AD said she had been working on storyboards to offer visual stimulation for the resident. The AD said the resident liked magazines with pictures of flowers and animals that were bright and colorful; the activities staff have cut out pictures of flowers and animals for the resident because she liked to stay in her room. The AD said the staff encouraged the resident to join other residents in the circle for socialization and reminded the resident she was always welcome. The AD said she respected the resident's wishes for peace and quiet but always encouraged the resident to participate in the circle activities.

Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#61) out of one reviewed for the use of the trilogy bilevel positive airway pressure (BIPAP) machine out of 43 sample residents. Specifically, the facility failed to for Resident #61: -Ensure the physician orders included settings of the Trilogy BIPAP; -Ensure the licensed nurses and certified nurse aides were trained on the system; and, -Ensure the care plan was updated to include the settings of the TrilogyFindings include:I. Resident statusResident #61, age 71, was readmitted on 5/16/23. The July 2023 computerized physician orders (CPO) diagnoses included obstructive sleep apnea and diabetes mellitus type II.The 4/29/23 minimum data set (MDS) assessment coded the resident with no cognitive impairments with a score of 15 out of 15 for the brief interview for mental status. The resident required extensive assistance with activities of daily living. The resident used oxygen. -However, the assessment was inaccurately coded since the resident used a ventilator. II. Observations7/9/23 -At 11:48 a.m., the resident was sleeping in bed. He had his trilogy mask on. The trilogy machine was next to his bed on a stand.-At approximately 1:30 p.m., the resident continued to sleep. He continued to have the trilogy mask on. 7/10/23-At 9:34 a.m., the resident was awake while he laid in bed. The resident had the trilogy mask laying on the bed. He was able to talk with no labored breathing. III. Resident interviewThe resident was interviewed on 7/10/23 at 9:34 a.m. The resident said he used the trilogy mask when he slept. He said he could put it on himself and when he took it off, he could turn off the alarm. He said he had to use it whenever he slept as he had sleep apnea. He said the machine and tubing were cleaned weekly. He did not know the settings, he said that it did not change. IV. Record reviewThe July 2023 CPO showed the following:-Assist patient with Trilogy PAP placement nightly. Contact (corporate) respiratory therapist for any questions or concerns or replacement with a start date of 5/16/23. -The physician's orders failed to show the specific settings. The care plan last revised on 5/10/23 identified the resident had altered respiratorystatus /difficulty breathing related to sleep apnea, COPD (chronic obstructive pulmonary disease), congestive heart failure. He used a trilogy PAP to help minimize complications. Pertinent approaches included breathing treatments for shortness of breath. BIPAP provider would provide in depth cleaning of canister, filter one time a month. Monitor for signs and symptoms of respiratory distress and report to the physician. Trilogy BIPAP to be used at bedtime and every morning for obstructive sleep apnea (OSA). V. InterviewsThe corporate respiratory therapist (CRT) was interviewed on 7/12/23 at 1:00 p.m. The CRT said she was familiar with the Resident #61's trilogy system. She said he needed to wear it whenever he slept as he had a history of hypovent (shallow, slow breathing) obstructive apnea, so therefore he required more support. She said the machine was a bilevel positive airway pressure (BIPAP) which was a device that helped with breathing. She said the physician orders should include the settings as to what the BIPAP was set at. She said there was a contract service who maintained the machine and they were available 24 hours a day for assistance from a respiratory therapist. She said she had not completed any training on the Trilogy machine with any staff for quite sometime. She said the staff should be educated on the machine. Certified nurse aide (CNA) #1 was interviewed on 7/12/23 at approximately 2:00 p.m. The CNA said the resident used the mask every time he slept. She said he was able to place and remove the mask himself. She said he could turn it off. She said she had not received any training on the Trilogy machine. Licensed practical nurse (LPN) #5 was interviewed on 7/12/23 at approximately 2:15 p.m. The LPN said the resident wore the trilogy BIPAP when he slept. She said he was able to remove it and put it on by himself. She said that she did not know what setting the machine was set to and she had not received any training on the machine. The LPN said the alarm to the trilogy machine was not connected to anything to alert them if there was something wrong. LPN #6 was interviewed on 7/12/23 at approximately 3:30 p.m. The LPN said he was not too familiar with the trilogy machine. He said the resident maintained the mask himself and he had not received any training on the machine and the functions. The respiratory therapist (RT) was interviewed on 7/12/23 at p.m. The RT said she worked for the corporation and there was a contract company who oversaw the trilogy machine for the resident. The director of nurses (DON) was interviewed on 7/13/23 at 8:57 a.m. The DON said he reviewed the physician orders and he said he had the order revised to include, when the water tank needed to be filed, information about the contract company and the settings of the machine. He said he had started training the licensed nurses and the CNAs about the functions of the machine. VI. Facility follow-upThe physician's orders received 7/12/23 documented the following:-The phone number to the contract respiratory therapist was added;-AVAPS-AE VT (average volume-assured pressure support)target 730 mas pressure-30 PS (pressure support ventilation) Max-26 PS Min-15 expiratory positive airway pressure (EPAP) min four.-Breath rate automatic

Based on observations, record review and interviews, the facility failed to effectively address the care and service needs of two (#53 and #66) of three residents reviewed for dementia care out of 43 sample residents. Specifically, the facility failed to:-Provide personalized activities programming to Resident #53 and Resident #66, who had a diagnosis of dementia; -Consistently monitor behaviors of concern including aggression toward others for Resident #53; and, -Implement personalized interventions in response to Resident #53's behaviors towards other residents. Findings include: I. Facility policyThe Memory Care Program, not dated, was provided by the nursing home administrator (NHA) on 7/13/23. It documented, in the pertinent part,"Connections is specifically designed to provide the highest level of care for people living with all stages of Alzheimer's and dementia related diseases. We have a comprehensive, person directed approach that helps residents experience life to the fullest. We believe, persons, living with dementia, continue to grow, and given the opportunity can learn new skills and new relationships. Opportunities for growth and development abound in the connections experience. These might include artistic expression, musical endeavors, taking an adult learning class, teaching a class to care, partners, and other residence, dance class, or other individualized pursuits, to meet the goals and interests of each person. empathy creates an opportunity to recognize that every action or behavior has a purpose. It is our challenge to discover the communication in the action or behavior. Person centered dementia care is centered on the whole person rather than the disease of the brain. Centered on the abilities, emotions, and cognitive capacities of the person not the losses. Care gives equal credence to the psychosocial context of the individual and physical/medical care. One to one programming this programming is for individuals that may be unable to actively participate in group activities based on cognitive and physical functional status, as well as individuals who are unable to self- initiate their own leisure pursuits."Care partners meet with these individuals one on one and provide leisure and recreational activities based on the residence remaining abilities minimum standard would be meeting with these individuals 1 to 3 times a week. The amount of time per visit based on the individual's desire and attention Span. Resident wandering may be a behavioral expression of a basic human need such as the need for social contact, or the response to environmental irritants, physical discomfort, or psychological distress. Care goals are to encourage support and maintain residence, mobility and choice, enabling the resident to move about safely in independently. To ensure the causes of wandering are addressed with particular attention to unmet needs. To prevent unsafe, wandering or successful exit seeking."II. Resident #53A. Resident statusResident #53, 69 years old, was admitted on 3/3/23. According to July 2023 computerized physician's orders (CPO), diagnoses included anxiety, depression and dementia. The 6/6/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for a mental status score of three out of 15. She required extensive assistance of one person with bed mobility, transfers and personal hygiene, eating, dressing and supervision with walking. B. ObservationsOn 7/9/23 at 11:28 a.m. Bingo was being played in the dining room. Resident #53 was wandering through the dining room and was behind another resident and grabbed the other resident's bingo card the unknown resident got upset and yelled at Resident #53. Resident #53 went to another resident and grabbed her card. Activity assistant (AA) #1 did not ask Resident #53 if she wanted to participate in the activity. AA #1 did not offer Resident #53 her own card. Resident #53 put her hands on another resident's shoulder. That resident yelled at her and asked her to stop. Resident #53 continued to grab the unknown resident's cards and that resident got upset and tried to strike out at Resident #53. On 7/11/23 at 9:27 a.m. AA#1 came into the secured unit to give coffee and read the daily chronicle to the residents. Resident#53 walked into the dining room and grabbed the chronicle out of another resident's hand. AA #1 said she would give Resident #53 coffee. Resident #53 wandered off.-At 9:54 a.m. the resident was in the dining room and walking to occupied tables grabbing the other resident's coffee out of their hands. Two staff were present but did not redirect the resident or give the resident her own coffee.-At 10:53 a.m. the resident was yelling at another resident. Two staff present, a nurse was sitting behind the desk watching the residents and the certified nurse aide (CNA) was assisting residents into the dining room. Staff did not appear to notice the resident yelling. -At 11:33 a.m. the resident was in the dining room and she started to scream at a resident that was singing. Resident #53 tried to hit the resident but missed. Staff were present but did not see the event. The other resident got upset, started yelling and that was when staff got up and went to see what was wrong with the resident that was yelling. C. Record reviewThe dementia care plan, dated on 3/15/23, documented the resident has vascular dementia which requires her to be in the secure neighborhood. Interventions include: staff would provide scheduled activities within the resident's capabilities. Ask yes/no questions in order to determine a resident's needs. Keep the residents routine consistent and try to provide consistent care providers. Monitor/document any changes in cognitive function, specifically changes in; decision making ability, recall, and general awareness, difficulty in expressing themselves, difficulty understanding others, level of consciousness and mental status.-However, the dementia care plan was not personalized to the resident's behaviors with interventions to address her behaviors (see observations). The activity care plan, dated on 3/28/23, documented that Resident #53 would participate in independent activities five to six times a week. This included walking, socializing, listening to music and sitting in common areas. It documented that Resident #53 would participate in preferred activities four to six times a week. This included outdoor activities, snack shack, music, socials, coffee hour and rise and shine. Interventions included directing Resident #53 to activities, anticipate needs of the resident, staff would assist Resident #53 to activities, staff would offer the resident leisure supplies. Behavior tracking from 6/14/23 to 7/12/23 showed the resident had no behaviors towards other residents. Behaviors to be tracked included grabbing, screaming at others, cursing at others, kicking, pushing, scratching, threatening others and abusing others sexually.-However, the resident had behaviors towards other residents on 7/9/23 and 7/11/23 (see observations). Behavior tracking from 6/14/23 to 7/12/23 showed the resident had six episodes of grabbing, one episode of pushing and one episode of screaming directed towards staff. D. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 7/13/23 at 9:10 a.m. CNA #4 said the resident wandered a lot. CNA#4 said the resident did yell but typically it was aimed at staff. CNA #4 said she would grab items out of other resident's hands. CNA#4 did not think this behavior bothers other residents. CNA #4 said the resident was not easy to redirect. CNA#4 said when the resident needed to be redirected the staff would ask if she wanted to help him. CNA #4 said there were no activities on the unit to offer to the residents. Licensed practicing nurse (LPN) #3 was interviewed on 7/13/23 at 10:35 a.m. LPN #3 said the resident was found wandering around and agitating other residents because she grabbed things and yelled at other residents at times. LPN #3 said the resident was found wandering in and out of other resident's rooms. The social service director (SSD) was interviewed on 7/13/23 at 1:01 p.m. The SSD said staff should redirect residents when they were agitated or were bothering other residents. The SSD said the social services and activities department worked together to come up with behavior programs. The SSD said interventions were in the care plan and staff should know what the interventions were. The SSD said Resident #53 did wander and grabbed things from other residents. The SSD said Resident #53 could be difficult to redirect but staff could see if they can help the other residents move if they feel agitated by Resident #53. The SSD said the resident's behavior could be managed when staff redirected her out of busy spaces and kept her busy. The director of nursing (DON) was interviewed on 7/13/23 at 2:32 p.m. The DON said staff should follow care plans. The DON said staff would document behaviors in tracking documentation or progress notes. The DON said staff should redirect residents when they notice they were agitated or were agitating other residents. The DON said when Resident #53 was crying or agitated, staff should redirect her and reassure her she was okay. The activities director (AD) was interviewed on 7/13/23 at 2:40 p.m. The AD said the departments worked together to ensure behavioral needs were met through activities programming. The AD said the activities department would get suggestions from the other departments. The AD said Resident #53 participated in most activities and would come and go. The AD said staff should offer the resident to participate in all activities. The AD staff should redirect the resident to participate in the activity. The AD said the resident did not have one-on-one time but would probably benefit from one-on-one time. III. Resident #66A, Resident status Resident #66, age 77, was admitted 10/30/2020. According to the July 2023 CPO diagnoses included Alzheimer's disease/dementia, chronic kidney disease and peripheral vascular disease. The 5/8/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of fifteen. The resident was unable to speak or rarely/never understood others. The resident required extensive assistance for bed mobility, dressing, and personal hygiene and was dependent on two or more staff members for activities of daily living. B. Representative interviewThe resident's representative was interviewed on 7/11/23 at 12:18 pm. The resident's representative said he had been involved in the resident's care planning and care conferences, and periodically heard from the facility every six months or so. The resident's representative said he was concerned the resident could not speak and was not sure how they involved the resident in activities. The resident representative said the resident had a beautiful flower and vegetable garden at home and loved the outdoors. The resident's representative said the resident had a dog and he died soon after the resident entered the facility. The resident's representative said the resident went to church every Sunday and dressed up in a hat, dress and high heels; he said the resident would readily participate in the facility church services but he was not sure if the resident was included in anything. C. Observations 7/9/23-At 10:30 a.m. the resident was sitting behind the nurses station. The resident had no meaningful activity as she sat alone. -At 12:40 p.m. the resident was assisted to eat while behind the nurses station. As she was assisted with eating, the unidentified CNA did not communicate with the resident. -At 1:00 p.m. there were religious services taking place in a circle with multiple residents and family members gathered. The resident did not attend nor was she invited. 7/9/23 -At 2:15 p.m. the resident was sitting in herwheelchair in the corner of the nurses station. She was alone at the nurses station with no meaningful activity. 7/10/23-At 12:22 p.m. there was big band music playing in the circle. The resident was not assisted or invited to attend the music program. She remained in the corner of the nurses station. 7/11/23The resident was observed continuously from 9:33 a.m. to 11:20 a.m The resident was lying in bed awake, blinds were closed, the television was turned off. Music was playing in the common area (circle) with a group activity, however, no staff invited her to the program. -At 11:34 a.m. the resident was assisted to the nurses station from her room. -At 1:30 p.m. there was a female entertainer playing guitar and singing in the circle surrounded by four or five residents in attendance, some clapping and singing along. The resident was watching the performer and seemed to be enjoying it. 7/12/23The resident was observed continuously from 10:32 a.m. to 1:47 p.m. The resident was seated in the circle with music heard overhead. The resident was awake with her eyes open. Multiple staff members passed the resident but did not acknowledge her or speak to her.-At 3:00 p.m. the resident was seated in the circle sitting in a wheelchair. The resident was mumbling to herself and the music was turned on. A staff member pushed a cart to offer magazines to four other residents and did not acknowledge the resident. D. Record review The resident's recreational summary via a care conference dated 1/30/23 showed the resident enjoyed music, one-on-one visits two to three times per week. Visits consisted of stroll through the community, chats, hair styling, aromatherapy and outdoor visitsThe care plan revised on 5/10/23 identified the resident required staff assistance to get to and from activities and encouragement during the activity. Staff would need to provide the resident with leisure supplies as needed. The resident enjoyed listening to music, going outdoors, manicures, watching television pets and sensory activities. Pertinent interventions included: to provide the resident with help to and from activities of interest. Staff would provide the resident with two to three one-to-one visits per week. A history of the resident's participation in activities beginning 6/14/23 to 7/11/23 revealed the resident participated in one-on-one social activities without revealing the source of the social activity.-Social group on 6/14/23, 6/20/23 6/21/23 and 6/23/23 at 1:59 p.m. -One-on-one visit on 6/14/23, 6/16/23, 6/20/23, 6/21/23 and 6/28/23 at 1:59 p.m. -Social group on 7/1/23, 7/2/23 and 7/5/23 at 1:59 p.m. -One-on-one visits on 7/1/23, 7/2/23 and 7/5/23 at 1:59 p.m.-One-on-one visit 7/7/23 at 12:13 p.m. -One-on-one visit 7/10/23 at 12/04 p.m.-One-on-one visit 7/11/23 at 1:50 p.m. E. Staff interviews CNA #3 was interviewed on 7/13/23 at 8:21 a.m. CNA #3 said the resident sat behind the nurses station and slept. CNA #3 said staff members on duty would check on her and talk and hold her hands throughout the day. CNA #3 said the resident had been brought to the circle a number of times for very small intervals because she thought the resident got agitated because she could not say whether the resident had enough of the noise. The AD was interviewed on 7/13/23 at 8:43 a.m. The activities director said she provided a variety of activities for the resident including music therapy. The activities director said she invited the resident's representative and granddaughter to one-on-one activities with the resident but it depended when and if they wanted to be involved and the resident's energy level. The AD said she used verbal cues with the resident. The AD said the resident was seated at the nurses station because it was more beneficial to her, provided her social stimulation because the staff converse with her and staff would let the activities department know if the resident needs anything. LPN #4 was interviewed on 7/13/23 at 10:10 a.m. LPN#4 said the resident participated in activities a few times per week. LPN #4 said she knew the resident's mood by her facial expressions and it really depended on what activity was going on. LPN #4 said the activities staff help the nursing staff bring the resident to the circle for activities or the nurses would escort the resident themselves. Generally the resident stays with the nurses to avoid any behavioral issues or signs of agitation. The resident squirmed in her wheelchair when she was in the circle and staff recognized that as the beginning of behavioral issues. LPN #4 said the resident did like 60s music and soul music but they could not play it for her at the nurses station because it may disturb other residents. LPN #4 said the nursing staff did remind the resident of activities and tried to maximize her participation. The SSD was interviewed on 7/13/23 at 10:18 am. The SSD said it was an interdisciplinary team effort to include the resident in activities because of the resident's diagnosis. The SSD said, "We know what this resident likes and we encourage the resident to participate in listening to music. At one time, the resident was more engaged and she loved 60s music and would dance a little and it was nice to see." The SSD said they were looking into other options for residents with dementia. The SSD said the facility was considering soft music for the resident in her room or a music channel. The DON was interviewed on 7/13/23 at 2:45 p.m. The DON said the facility was making changes to activities for residents with dementia. The DON said he knew the facility could do better on behalf of the resident and was moving toward that direction. The DON said he knew the resident liked music and religious services. The DON said it was important to the resident to engage in spiritual activity and knows the resident needs extra attention and the facility was aware of the issues because seating the resident in the nurses station was not enough.

Based on observations, record review and interviews, the facility failed to ensure consistent behavior monitoring was conducted for target behaviors related to the use of psychotropic medications for two (#258 and #89) of five residents reviewed for medications of 43 sample residents. Specifically, the facility failed to:-Ensure staff identified triggers for the residents use of the antipsychotic medication for Resident #258 and Resident #89;-Ensure provided non-pharmacological interventions for Resident #258 and Resident #89; and, -Ensure the facility developed specific target behaviors and ensure the behavior monitoring forms consistently matched the target behaviors were documented for Resident #258 and Resident #89. Findings include:I. Resident #258A. Resident statusResident #258, age 79, was admitted on 7/6/23. According to July 2023 computerized physician's orders (CPO), diagnoses included vascular dementia and depression. According to the 6/15/23 minimum data set (MDS) assessment revealed the resident was unable to complete the brief interview for mental status (BIMS). The resident had short term and long term memory loss. The resident did not speak English and primarily spoke Korean. She required limited assistance of one person with dressing, toileting personal hygiene and locomotion. She required set-up help with bed mobility, transfers, eating and walking. Staff were unable to complete a PHQ-9 (measures depression) assessment. The resident did not have hallucinations or delusions or other behavioral symptoms. The resident lived on a secured unit. B. Resident observationsContinuous observations on 7/11/23 starting at 9:31 a.m. to 12:15 p.m. revealed the resident walked through the hall and sang but did not display aggressive or agitated behavior. The resident would go into another resident's room and reorganize items but this did not appear to disturb the other residents. C. Record reviewAccording to the July 2023 CPO the following medications were provided:Risperidone tablet 0.25 mg (milligrams) give one tablet at bedtime for dementia with other behavioral disturbances order date 7/6/23 and discontinued on 7/10/23. Risperidone tablet 0.5 mg give one tablet at bedtime for dementia with other behavioral disturbances order date 7/10/23. The behavioral care plan, dated on 7/10/23, documented Resident #258 was diagnosed with dementia, depression and some signs of anxiety related to her transition into the facility. She had been noted to wander in and out of rooms, approach other residents, sometimes putting her face in other residents' faces. "She may think that she is an employee and is trying to manage situations." Interventions included the following: administer medications as ordered, anticipate and meet the needs of the resident. Assist the resident to develop more appropriate methods of coping and interacting by offering to call her daughter or daughter in law or by giving her busy work like folding towels. Monitor behavioral episodes and attempt to determine the underlying cause. According to a nursing note on 7/7/23 at 9:13 p.m. the resident continues to be monitored for a new admission and was adjusting well to the unit. The resident was very sociable and caring, trying to assist everyone, sometimes upsetting other residents. The resident got upset and aggressive when redirected. According to a nursing note on 7/8/23 at 12:56 p.m. the resident continued to be monitored for a new admission and was adjusting well. The resident wanders and paces all the time. Disruptive at meals as she moves from table to table and touching food and drinks upsetting other residents. She tried to clean tables even when the resident had not finished eating. Very difficult to redirect. According to a nursing note on 7/8/23 at 9:16 p.m. the resident had no aggressive or combative behaviors noted at this time.-The progress notes that were documented relating to the resident's behaviors were not consistent in justifying the Risperdol being increased on 7/10/23. -Per staff interviews (see below), the resident had minimal behaviors and was not aggressive. D. InterviewsLicensed practicing nurse (LPN) #3 was interviewed on 7/13/23 at 10:35 a.m. LPN #3 said the resident was not aggressive and had minimal behaviors. LPN #3 said Resident #258 wandered around through the unit and at meal time she went table to table. LPN#3 said the resident tried to help other residents that were in wheelchairs. The social service director (SSD) was interviewed on 7/13/23 at 1:01 p.m. The SSD said when putting residents on psychotropic, the interdisciplinary team (IDT) looked at their behaviors such as physical aggression. The SSD said aggressive behaviors would be documented in progress notes or in tasks and would be discussed as a team. The SSD did not remember if Resident #258 had aggressive behaviors. The SSD said being diagnosed with dementia would not be a reason to be placed on a psychotropic medication. The director of nursing (DON) was interviewed on 7/13/23 at 1:47 p.m. The DON said residents should have behaviors or a diagnosis that would cause a resident to be on psychotropic medication. The DON said the nurse practitioner had known the resident from another facility. The DON said the nurse practitioner wanted to lower the resident's depression medication because she did not see behaviors related to depression. The DON said the resident was new to the facility and the behavior tracking would be indicated in the progress notes. II. Resident #89A. Resident status Resident #89, age 66, was admitted on 5/31/22. According to computerized physician's orders (CPO), diagnoses included, diagnoses included dementia (without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety), epilepsy and depression. According to the 5/3/23 minimum data set (MDS) assessment revealed the resident was unable to complete the brief interview for mental status (BIMS). The resident had short term and long term memory loss. He required assistance from two people for transfers. He required limited assistance of one person with dressing, toileting, eating, personal hygiene and bed mobility. The resident required set-up help with locomotion and walking. Staff were unable to complete a PHQ-9 (a depression questionnaire) assessment. The resident did not have hallucinations or delusions or other behavioral symptoms. The resident resided in a secured unit. B. Resident observationsContinuous observations on 7/11/23 at 9:15 a.m. to 12:00 p.m. revealed the resident paced through the hallway. The resident did not enter other resident rooms. The resident did not display any aggressive or disturbing behavior. C. Record reviewAccording to the July 2023 CPO the following medications were provided:Risperidone (Antipsychotic) tablet 0.5 mg (milligrams) give one tablet at bedtime for dementia with other behavioral disturbances order date 4/10/23 and discontinued on 4/24/23. Risperidone tablet 0.5 mg give one tablet in the morning for dementia with other behavioral disturbances order date 4/28/23 and discontinued on 5/18/23. Risperidone tablet 1 mg give one tablet before bedtime for dementia with other behavioral disturbances order date 4/28/23 and discontinued on 5/18/23. Risperidone tablet 1 mg give one and a half tablets at bedtime for dementia with other behavioral disturbances order date 5/18/23. The dementia care plan, dated on 2/24/23, documented the resident has dementia with impaired cognitive function. Interventions include the following; behavior monitoring, keep residents routine consistent and staff will anticipate resident's needs. According to a psych note on 3/16/23 at 6:51 p.m. documented the resident had dementia without behavioral disturbances. Staff endorsed the resident remains at baseline and mood remains stable. According to a psych note on 3/20/23 at 6:43 p.m. documented the resident was assessed for depressive symptoms and behavioral disturbances. No agitation or aggressive behaviors noted inthe chart after review. Easy to redirect and resists care sometimes. According to a nursing note on 3/30/23 at 10:02 a.m. documented no aggressive behaviors noted. According to a nursing note on 4/5/23 at 2:49 p.m. documented the resident becomes combative during personal care. Resident #89 could get restless and pacing up and down the hallway. According to a nursing note on 4/10/23 documented the resident was seen pacing through the hallways. According to nursing reports, he was aggressive with care and staff primarily in the evenings. According to a nursing note on 4/10/23 at 10:08 p.m. documented the resident was given the first dose of Risperdal for dementia with behaviors.-The resident was ordered Risperdal for behaviors, however per the progress notes (see above) he had only been combative or aggressive with care on two occasions. According to a nursing note on 4/24/23 at 9:56 p.m. documented the resident was extremely restless and agitated today around 10:30 a.m. He continued to pull curtains, pushing chairs, tables. He continued to blow his nose which resulted in a nose bleed. Called the NP (nurse practitioner) and got a one time Ativan (anti-anxiety medication) order and it was helpful. Resident was one-to-one in his room to contain the nose bleeding and from spreading everywhere. The NP visited the resident later and made some medication changes. According to the medical provider note on 4/26/23 at 1:25 p.m. the resident had agitation/aggression and increased Risperdal.-The resident was not provided any non-pharmacological intervention before the Ativan was administered. In addition, after he was provided the one time dose of Ativan it was documented by the nurse as helpful. The Risperdal medication was still increased after one documented episode on 4/24/23. D. Staff interviewsLPN #3 was interviewed on 7/13/23 at 10:35 a.m. LPN#3 said the resident was not aggressive and had minimal behaviors. LPN#3 said when the resident first arrived he had some aggressive behaviors but he had not seen these behaviors recently. LPN #3 said the resident mostly walked up and down the hallways and did not disturb anyone. The SSD was interviewed on 7/13/23 at 1:01 p.m. The SSD did not believe Resident #89 had aggressive behaviors lately. The DON was interviewed on 7/13/23 at 2:34 p.m. The DON said the resident was put on Risperdal because the resident was breaking chairs and improved after he was placed on the medication.-However, the only progress note that mentioned chairs was 4/24/23 (noted above). The medication was started on 4/10/23.

Based on interview, record review, and observation the facility failed to provide routine dental services to one (#44) of three residents out of 43 sample residents. Specifically, the facility failed to provide dental services to Resident #44. Finding include:I. Facility policy and procedureThe Ancillary Services-Dental, Vision, Audiology, Podiatry policy and procedure, dated 8/19/14, was delivered by the nursing home administrator (NHA) on 7/18/23 at 1:01 p.m. it read in pertinent part "ancillary services, including but not limited to, dental, vision, audiology, and podiatry will be provided to the resident per state and federal regulatory guidelines; at the resident / responsible family member's request and as needed. "Any resident needing or requesting ancillary services such as dental will have their needs met timely. The facility will keep available a provider for ancillary services and / or assist the resident with utilizing the provider of their choice. "Social services/designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner."II. Resident statusResident #44, age 77, was admitted on 1/12/23. According to the July 2023 computerized physician orders (CPO) diagnoses include type I diabetes mellitus, Parkinson's disease, unspecified convulsions, chronic pain due to trauma, major depressive disorder, need for assistance with personal care and bilateral hearing loss. The 6/27/23 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment deficit with a brief interview for mental status (BIMS) with a score of 11 out of 15. The resident required extensive one person assistance with bed mobility, dressing, and personal hygiene. The resident required extensive two person assistance with transfers and toileting. The resident had no dental issues. III. Resident interview and observationResident #44 was interviewed on 7/10/23 at 9:41 a.m. The resident said the facility had not offered a dentist and he would like to get his broken and missing teeth fixed. The resident had several missing and broken teeth in the front of his mouth. IV. Record review The ancillary care plan, initiated on 1/30/23 and revised on 2/1/23, documented the resident wishes to participate in receiving ancillary services as the needs arise. The resident will have access to ancillary services annually and as needed. Interventions include staff will monitor for ancillary services needs and will forward the proper documentation to dentistry. V. Nursing notesNursing notes from 1/13/23 to 7/6/23 documented the resident had his own teeth and no dental concerns. -The facility failed to document the resident's broken and missing teeth. -There are no social services notes indicating the resident had ancillary services from a dentist. VI. Staff interviewThe social services director (SSD) was interviewed on 7/12/23 at 1:51 p.m. The SSD said when a resident was admitted to the facility, the social services team gets the consent forms ready and dental scheduled. The SSD said there were some residents with other service providers so they had to set up through the other provider for the care and they could be very difficult to get scheduled. The SSD said Resident #44 had Veterans Administration services, which made it difficult to get ancillary services for him. -However, there was no correspondence on the facility attempting to arrange dental services for him.

Based on interviews, observations and record review the facility failed to ensure that each resident received food that was palatable, attractive and an appetizing temperature. Specifically, the facility failed to:-Ensure food was palatable and attractive when delivered to residents; and, -Ensure food was served at a safe and appetizing temperature. Findings include:I. Facility policy and procedureThe Meal Preparation policy and procedure, revised 2021, was delivered by the nursing home administrator (NHA) on 7/12/23 at 11:15 a.m. It read in pertinent part: "each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance; food that is palatable, attractive, and at the proper temperature. "Food is served at palatable temperatures, above 125 degrees for hot food and below 50 degrees for cold food."II. Resident interviewsResident #28 was interviewed on 7/9/23 at 10:52 a.m. The resident said the eggs were often over cooked. Resident #15 was interviewed on 7/9/23 at 10:55 a.m. The resident said his daughter brought in his dinners and he kept them in the refrigerator because he did not like the food at the facility. Resident #14 was interviewed on 7/9/23 at 11:11 a.m. The resident said the dining room had been closed for reconstruction since 5/23/23. She said she had been eating in her room since. She said the food was served cold. She said her breakfast meal was served cold, as she did not receive her meal timely. Resident #88 was interviewed 7/9/23 at 11:30 a.m. The resident said the food was served cold, there was a lack of seasoning and flavor to the food. He said the meat was tough and difficult to cut with a knife. He said they provide the menu for choices but then he did not receive what he had requested. He said he complained about the food but did not receive any answer to the cold food. Resident #61 was interviewed on 7/10/23 at 9:28 a.m. The resident said he ate in his room and the food was served cold. He said it had no flavor and it was "straight out of the can." He said he was not eating his eggs as they were cold. Resident #27 was interviewed on 7/10/23 at 9:45 a.m. The resident said she loved cauliflower and broccoli but it was mushy and served cold. She said she had to put salt and pepper on it to get flavor. She said in general the food was not good and was served cold. Resident #9 was interviewed on 7/10/23 at 10:10 a.m. The resident said the food was served cold, the meat was tough and there was a lack of seasoning. She said she did not like the food. Resident #91 was interviewed on 7/10/23 at 11:22 a.m. The resident said her meals were served cold. She said oftentimes the staff did not send condiments. She said the hamburger she received the other day was burnt and served with no condiments. Resident #13 was interviewed on 7/11/23 at 9:41 a.m. The resident said she had milk and cookies last night for dinner. She said she did not want what the facility served. Resident #4 was interviewed on 7/11/23 at 9:52 a.m. The resident said the facility served small portion sizes. She said she could have had more food. III. Resident council interviewThe resident council was interviewed on 7/11/23 at 1:10 p.m. four residents (#28, #25, #19 and #14) attended and participated in a resident council meeting. The majority of the residents said the food was delivered cold and had no flavor. Resident #28 said they had noodles that were so cold the resident could not melt her soft butter on it. Resident #25 said food was delivered cold when it was supposed to be hot. The resident said they kept the salads under the light so the lettuce was limp and warm. Resident #19 and Resident #14 said the food did not taste good and the items that were to be hot were served cold. IV. Test tray A test tray of the breakfast meal was performed on 7/13/23. The tray left the kitchen at 8:13 a.m. and was delivered to the unit and was served after the last resident was served at 8:49 a.m. The meal test tray for palatability was tried by four surveyors:-The scrambled eggs were 88 degrees F (farenheit); the eggs were cold, bland and had no palatable taste. They did not have a palatable texture. -The biscuit was 87 degrees F; the biscuit was cold, bland and did not have a palatable taste. The biscuit was covered with white gravy that had soaked into the bottom which made it soggy and slimy. -The sausage links were 86 degrees F and were cold and bland. The sausage tasted undercooked. -The oatmeal was 122 degrees F and was slimy, cold and tasteless. No condiment such as sugar was offered. V. ObservationsDuring continuous kitchen observation on 7/12/23 from 7:04 a.m. to 8:13 a.m. the delivery carts were not big enough for all the trays going out to units. Some carts had trays on top and the dietary director (DD) had to carry some items by hand to the units. On 7/12/23 at 8:53 a.m. Resident #11 was sitting in the doorway of her room. She motioned to the assistant director of nursing (ADON) in an upset manner that she had not received her meal. The ADON told the resident that it was coming. The resident left to go smoke a cigarette. At 9:00 a.m., the resident returned and her meal was on her bed. The resident uncovered the meal and found scrambled eggs and sausage. The resident gave permission to have the temperature of the food taken. The eggs were 84 degrees F and the sausage was 92 degrees F. The resident said the eggs were cold. Certified nurse aide (CNA) #2 walked into the room and was asked by the resident to heat the food up. VI. Record reviewA complaint form dated 4/9/23 at 6:30 p.m. documented "the food is not good, two pieces of turkey lunch meat on bread is not dinner. The food is the same everyday. Eggs - biscuit and bread lunch meat is dry and old. Salads are dry and has some slime on it. Coffee needs creamer of choice, old potato chips - stale, same choice daily!"Food committee meeting minutes dated 6/2/23 at 3:00 p.m. recorded the meals were not being served on regular plates but on paper plates and it was cold. Food committee meeting minutes dated 6/9/23 at 3:00 p.m. recorded the meals were not being served on regular plates. Food committee meeting minutes dated 7/11/23 at 10:30 a.m. recorded residents suggested training for the chefs on how to cook eggs, pancakes, chicken quesadillas and low sodium soups. VII. Staff interviewsDietary aide (DA) #1 was interviewed on 7/12/23 at 9:08 a.m She said she was setting aside the broken plate warmers. She said the facility did not have enough warming bases for every plate. DA #1 said the dietary director (DD) had ordered the warming bases but they did not have them yet so they did not have enough. She said there were 106-108 residents at the facility and they did not have enough. The DD was interviewed on 7/13/23 at 9:40 a.m. The DD said she had received a test tray that morning and did not get condiments with it that were requested. The DD said the facility had used paper plates and did not have condiments with meals. The DD said the facility had to use plastic silverware and there was not enough regular silverware for every resident tray. The DD said the plate heater had been unplugged on 7/12/23 and the plates were cold. The DD said the evening cook had been a cook for two weeks, he had been a dietary aide prior to obtaining the position and his only experience was cooking at home.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility failed to have a thermometer and monitor temperatures for Resident #28, #15, #9, #38, #37 and #19's personal refrigerators. Findings include:I. Facility policy and procedureThe Food from Outside Sources policy, dated 5/3/23, was delivered by the nursing home administrator (NHA) on 7/10/23 at 2:01 p.m. It read in pertinent part, "to allow access to foods not provided by the facility and to assure foods are safe to prevent foodborne illness and to add quality to residents' life. "If food is not consumed upon arrival, it may be stored in a suitable container and labeled with date, residents name and item description if needed. "Resident's food stored under refrigeration shall have name, date, and expiration date of the label."Perishable food is discarded within three days from any resident refrigerator sources unless the food item is safe until a printed expiration date."II. ObservationPersonal resident refrigerators for Resident #28, #15, #9, #38, #37 and #19 were observed on 7/12/23. None of the personal refrigerators had thermometers to monitor the temperatures. Resident #28 was interviewed on 7/12/23 at 10:05 a.m. The resident said the refrigerator did not have a thermometer and the resident did not know who monitored the temperature. At 10:23 a.m. a refreshment refrigerator was observed with resident food stored in it. The temperature log was incomplete with missing temperatures. The refrigerator had an opened undated bottle of apple juice, creamer and other items that were not provided by the dietary department. III. Staff interviewsThe regional registered dietitian (RRD) was interviewed on 7/12/23 at 9:51 a.m. The RRD said the personal refrigerators should have a thermometer to monitor the temperatures and daily temperature logs.

Based upon an observation and interviews, the facility failed to provide a safe and sanitary environment consistent with professional standards of practice to help prevent the development and transmission of communicable disease and infections. Specifically, the facility failed to:-Ensure standard hand hygiene precautions and donning and doffing gloves were followed by staff involved in direct resident incontinent care and contact; -Clean high touch items, call button and door knobs, in resident rooms; and,-Follow the recommended surface disinfectant time for cleaning solution. Findings include: I. Lack of proper hand washingA. Facility policy and procedureThe Handwashing/Hand Hygiene policy, revised August 2009, was provided by the nursing home administrator on 7/12/23 at 11:30 am. It read in pertinent part, "The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is the last step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single use disposable gloves should be used before aseptic procedures and when anticipating contact with blood or body fluids." B. ObservationOn 7/11/23 at 12:47 p.m. certified nurse aide (CNA) #2 entered Reisdent #66's room and did not perform hand hygiene prior to resident contact. The CNA donned gloves and moved to the resident's bedside. The CNA proceeded to turn the resident to the right side. The resident was incontinent of both stool and urine. The CNA obtained wipes from the resident's bathroom. The CNA opened the wipes and provided peri-care. .The CNA obtained the barrier cream from atop the resident's dresser drawers and removed the barrier cream cap. The CNA applied the barrier cream to the resident's peri-area, replaced the barrier cream cap and placed a new undergarment on the resident without changing his gloves during the entire process. The CNA did not perform hand hygiene before leaving the resident's room. C. InterviewsCNA #2 was interviewed on 7/11/23 at 12:59 pm. CNA #2 said he washed his hands before entering the resident's room. CNA #2 said he did not realize he did not change his gloves after performing incontinent care. CNA #2 said his gloves did not appear soiled and believed the wipes sanitized his gloves. The director of nurses (DON) was interviewed on 7/11/23 at 3:40 p.m. The DON said the CNAs had been educated on proper handwashing. He said they educated staff on infection control, hand washing and personal protective equipment (PPE) on hire and annually. The DON said the CNA should have removed gloves after contact with bodily fluids, including stool and urine. The DON said the CNA should have changed gloves after performing peri-care and applying barrier cream. The DON said he would provide education to the CNA. II. Housekeeping failuresA. Professional referenceThe Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 7/21/23 read in pertinent part, "High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility."Common high-touch surfaces include:-bedrails-IV (intravenous) poles-sink handles-bedside tables-counters-edges of privacy curtains-patient monitoring equipment (keyboards, control panels)-call bells-door knobs"Proceed From Cleaner To DirtierProceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include:-During terminal cleaning, clean low-touch surfaces before high-touch surfaces.-Clean patient areas (patient zones) before patient toilets.-Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone.-Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions." B. Manufacturer recommendations The disinfectant in the facility was identified as: Spic and Span with a five minute dHwell time. C. Observation and interviewDuring continuous observation on 7/13/23 between 11:37 a.m. and 12:03 p.m. housekeeper (HSK) #1 failed to spray the door knobs and call buttons in the room. The HSK sprayed the bedside tables, night stands, refrigerator, television stand, bedside fan and dressers and immediately wiped them off without waiting for the five minute surface disinfectant time. HSK #1 said the cleaning spray had a three to five second surface disinfectant time. During continuous observation of a deep clean of a room from 1:09 p.m. to 1:39 p.m. it was HSK #2 and HSK #3 failed to follow the manufacturer's recommended five minute surface disinfectant time while cleaning. The housekeeping director (HD) joined at 1:11 p.m. HSK #3 cleaned the metal bed frame with a surface disinfectant time of two minutes. The HD cleaned the bedside commode with a surface disinfectant time of one minute. The HD failed to apply cleaning spray directly to the call button, she sprayed a cloth to wipe the button. She failed to clean the pull cord to the overhead light. The HD cleaned the recliner and pillow allowing a two minute surface disinfectant time. HSK #3 said the cleaning spray had a 20 minute surface disinfectant time. The HD was interviewed on 7/13/23 at 1:42 p.m. She said the cleaning spray that was currently in use had a five minute surface disinfectant time and housekeeping staff were trained on the cleaning process and surface disinfectant times when they started. She said tops of furniture were the high touch areas and should be cleaned first. She said call buttons and door knobs were high touch areas and should be disinfected to prevent infections.

A revisit survey was completed on 2/6/23 for all previous deficiencies cited on 12/1/22. The facility is in compliance with all regulations surveyed.