WESTWOOD POST ACUTE

A complaint survey, prompted by #CO34817, #CO34853, #CO34862, #CO34863, #CO34896, #CO34922, #CO34961 and #CO34962 was conducted on 2/13/24 to 3/7/24. Seventeen deficiencies were cited.

Based on observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity. Specifically, the facility failed to provide residents with a dignified existence by ensuring that call lights were consistently answered in a timely manner. Findings include: I. Facility policy The Call Lights: Accessibility and Timely Response policy, revised February 2023, was received from the corporate nurse consultant (CNC) #1 on 2/20/24 at 12:10 p.m. It read in pertinent part, "The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response."All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified."II. Observation The facility's call light system consisted of call lights in each resident's room at the bedside and in each resident's bathroom. There was an audible sound with the call light activation and on the call board with the resident's room number located directly outside the nurses station at both the Mesa and Sante Fe hallways. Each hallway call light board chimed and lit up according to the resident's room number. The light above each resident's door was activated and lit up once the resident used their call light. Both the Mesa and Sante Fe call light systems were observed to monitor the operability of the facility's call light system. On 2/13/24 the following delays in answering resident call lights were observed:At 9:10 a.m. the resident's call light for room #48 was activated and the call light board outside the nurse's station blinked off and on. Certified nurse aide (CNA) #3 did not answer the call light until 10:41 a.m. At 9:25 a.m. the resident's call light for room #54 was activated. The call light board displayed the resident's room accurately. CNA #3 did not answer the call light until 10:22 a.m. At 10:17 a.m. the resident's call light for room #23 was activated and the call light board displayed the resident's room accurately. CNA #3 did not answer the call light until 11:00 a.m. At 11:00 a.m. the resident's call light for room #2 was activated and the call light board displayed the resident's room accurately. CNA #3 did not answer the call light until 11:40 a.m. At 2:20 p.m. the resident's call light for room #2 was activated. The call light board displayed the resident's room accurately. CNA #3 did not answer the call light until 3:20 p.m. At 2:22 p.m. the resident's call light for room #54 was activated. The call light board displayed the resident's room accurately. CNA #3 did not answer the call light until 3:00 p.m. The CNA entered the room, switched off the call light seconds later and exited the room. CNA #3 did not return to the resident's room until 20 minutes at 3:20 p.m. to help the resident. On 2/15/24 the following delays in answering call lights was observed:At 11:10 a.m the resident's call light for room #3 was activated. The call light board displayed the resident's room accurately. CNA #2 did not answer the call light until 11:32 a.m. At 11:30 a.m. the resident's call light for room #2 was activated. The call light board displayed the resident's room accurately. There were three CNAs standing outside the nurse station talking. Licensed practical nurse (LPN) #6 told two of the CNAs to go to the dining room to assist with lunch and the third CNA to answer the call lights. The third CNA walked in the opposite direction toward another resident room. LPN #6 went back to the nurses station to do some charting. No staff answered the call light in room #2 until 12:40 p.m., when LPN #6 got up from the desk to answer the call. III. Resident interviews Resident #6 was interviewed on 2/13/24 at 2:18 p.m. Resident #6 said when he was in his old room back in December 2023, he activated his call light and several times had to wait for two to four hours before a staff member responded. The resident said his old room was between bed assignments for two CNAs and neither CNA would answer his call light because neither knew who was assigned to his room and it was a dead zone. Resident #6 said once he was moved to a new room things got better but he still occasionally had to wait a long time for staff to respond to his call light. Resident #17 was interviewed on 2/13/24 at 2:24 p.m. The resident said in late January 2024 her bed was wet with urine and she activated her call light at 6:00 p.m. for assistance. The resident said it took 30 minutes for someone to respond. The resident said a CNA entered her room and turned off the call light and left without asking her what she needed or providing her any assistance. The CNA returned 30 minutes later with a nurse, when the resident asked the staff what took them so long the nurse told the resident she should have activated her call light again so the CNA knew to come back. The resident said she was shocked by the comment. Resident #16 was interviewed on 2/14/23 at 9:51 a.m. The resident said the night shift was the worst when it came to answering call lights timely and she sometimes waited anywhere from four to six hours for help. Resident #16 said it took two persons to reposition her so sometimes staff responded and left to find a second staff to assist her and it took a long time since there were not enough CNAs. Resident #18 was interviewed on 2/14/24 at 10:05 a.m. The resident said she did not use the call light because no staff answered the call light. The resident said if she needed something she would yell out loudly for help. Resident #7 was interviewed on 2/14/24 at 2:17 p.m. The resident said she waited anywhere from 30 to 45 minutes for staff to answer her call light during the evening shift and up to one hour on the night shift. The resident said the staff were either on their phones; she knew this because she could hear and see them in the hall on their phones or taking a long break. The resident said she should not have to wait to use the bathroom but she had no choice because she needed help. Resident #8 was interviewed on 2/14/24 at 2:22 p.m. The resident said agency staff (both nurses and CNAs) were always on the phone and did not respond to the call lights in a timely manner, especially the CNAs. The resident said she rarely saw more than one CNA during the evening shift. IV. Record reviewResident grievances were reviewed On 12/26/23 Resident #6 filed a grievance report that revealed on 12/23/23 the resident had asked for assistance to use the bathroom at 9:00 a.m. and the resident did not receive toileting assistance until 4:00 p.m. -The grievance form failed to document a resolution other than instruct the resident to get the staff's name so that that particular CNA could be provided education (see resident interview above). V. Staff interviews CNA #4 was interviewed on 2/20/24 at 2:08 p.m. CNA #4 said call lings should be answered within five to 10 minutes after a resident activated the call light. CNA #4 said call light response was often delayed if a CNA was in another room with another resident assisting with eating meals, showering or dressing. CNA #4 said the CNAs were assigned 11 residents each which was reasonable and allowed for sufficient time to care for the residents. CNA #4 said if there were residents in their rooms who need help with eating, one CNA would stay on the unit to help that resident eat and the other two CNAs would go to the dining room to assist residents with meals so sometimes there were delays in answering call lights at meal times. CNA #4 said CNAs help each other and it was really about time management rather than a lack of staff. CNA #3 was interviewed on 2/20/24 at 2:24 p.m. CNA #3 said poor call light response was likely due to miscommunication or no communication between CNAs related to who was taking a break or a failure in communicating with the nurses about why and when they were leaving the unit. CNA #3 said another issue with the call light response was the nurses did not answer call lights. CNA #3 said there were exceptions but very few nurses were willing to help answer call lights. CNA #3 said if they worked as a team, the light response would be much better. CNC #1 was interviewed on 2/20/24 at 12:00 p.m. CNC #1 said she and the new nursing home administrator would look into the call light delays.

Based on interviews and record review, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow up with residents' concerns regarding meals, staff cell phone usage, batteries not being charged and trash not being taken out. Findings include:I. Facility policy and procedureThe Grievances/Complaints, Filing policy, revised April 2017, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, "Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances."Any resident, family member, or appointed resident representative may file a grievance or complain concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished."All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response."II. Resident group interviewFive residents (#3, #12, #26, #29 and #27), who were identified as interviewable by the facility and assessment, were interviewed on 2/15/24 at 10:34 a.m. All of the residents interviewed said the following:-They had voiced concerns in food committee and resident council that were not addressed;-When concerns were brought up in resident council there was never a resolution; and.-The same concerns were brought up month after monthResident #26 said she found the food committee to be a waste of her time as she had raised concerns and they were never addressed. Resident #3 and Resident #12 said they voiced their food concerns in the resident council and food committee. They said they did not feel their concerns were being addressed. Resident #3 said she was afraid to voice her concerns in the resident council. Resident #3 said she thought she would be punished for complaining. Resident #12 said she was the resident president. She said she had brought up concerns in resident council on many occasions that had not been addressed. She felt the resident council meeting was the same concerns over and over again. III. Record reviewThe October 2023 resident council meeting minutes revealed the residents reported there were concerns with staff using their cell phones in care areas, staff not wearing name tags, bedside tables being removed from resident rooms, internet services not working well, trash cans were not being emptied, batteries not being charged regularly, doors not being propper up, cold meals, ancillary services, not enough free activities and funds not being managed properly by the business office. -It documented the cell phone usage was unresolved from the last council meeting and remained unresolved. It documented the batteries and trash bins were a work in process and currently unresolved. The notes documented new signs were going to be put up to keep the doors closed at all times. The cold meals and funds remained unresolved. The December 2023 resident council meeting minutes revealed the residents reported there were concerns with staff still using their cellphones in resident care areas; batteries were not being charged regularly by staff; trash bins were not being taken out when full; there were not enough cost free outings; door being propped open, food being cold, meals being late and funds not being managed properly by the business office. -It documented that cell phone usage was an ongoing problem in modern society and the nursing home administrator (NHA) would continue to educate staff on cell phone use. It documented the batteries and trash bins would be looked further into to resolve the current issue. It documented signs would be posted on the doorway to shut doors at all times. The minutes documented the cold meals would be looked further into. The January 2024 resident council meeting minutes revealed the residents reported there were concerns with staff using their cell phones in resident areas, batteries were not being charged regularly, trash cans were not being emptied, doors being propped open, meals being late and funds not being managed properly by the business office.-It documented cell phones, batteries, trash bins, doors being propped open, meals and funds were an ongoing issue. IV. Staff interviewsThe social services director (SSD) and the social services assistant (SSA) were interviewed on 2/15/24 at approximately 2:00 p.m. The SSD said anyone could fill out a grievance form. The SSD said the social services department then reviewed and logged the grievance form. The SSD said the form was then given to the department manager it pertained to. The SSD said the department manager was responsible for completing an investigation and developing a resolution alongside the resident. The SSD said the department manager needed to obtain approval from the resident submitting the grievance form and return it to the social services department. The SSD said the grievance form was then approved by the NHA and filed. The SSD said it was the responsibility of the NHA to ensure the resolution on the grievance was acceptable. The SSD and SSA said they were unsure of who was responsible for filling out grievances forms for concerns that were brought up in the monthly resident council meetings. The SSA said he used to work in the activities department and often took the resident council minutes. The SSA said he was never instructed to write grievance forms for concerns that were brought up in resident council. The activities director (AD) was interviewed on 2/15/24 at 4:25 p.m. The AD said she was new to the activities director role but had worked in the activities department at the facility for about three years. The AD said the resident council minutes were typically documented by herself or one of the activities assistants. The AD said the activities department did not fill out grievances for concerns that were brought up in resident council. The AD said she was unsure who was responsible for filling out grievances for concerns brought up in the council meetings. The AD said the same concerns had been brought up in the last several meetings and had not been resolved. The NHA, CNC #1 and CNC #2 were interviewed on 2/15/24 at 4:30 p.m. They all said concerns that were brought up in resident council needed to be documented on a grievance form and addressed in a timely manner.

Based on record review, observations and interview, the facility failed to ensure a clean, safe and homelike environment for two (#19 and #11) of 29 sample residents. Specifically, the facility failed to:-Ensure a system was implemented to clean and maintain Resident #19's chew and spit discarded food bucket; and,-Maintain a clean room environment for Resident #19 and Resident #11, who were roommates. Findings include:I. Facility policiesThe Safe and Home Like Environment policy, revised April 2019, was provided by corporate nurse consultant (CNC) #1 on 2/20/24 at 12:10 p.m. It read in pertinent part: "In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk."Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment." II. Resident #19A. Resident statusResident #19, under the age of 65, was admitted on 5/17/23. According to the February 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder, diabetes, acquired absence of parts of the digestive tract and artificial opening of the gastrointestinal tract (for gastric tube feeding). The 1/3/24 minimum data set (MDS) assessment failed to document an assessment of the resident's cognition by completing a brief interview for mental status (BIMS) with the resident or by a staff assessment of the resident's mental status. The 10/12/23 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The resident did not present with delirium. The assessment revealed the resident had a feeding tube and received caloric intake through the tube feeding. B. Observations and resident interviewResident #19 was interviewed on 2/13/24 at 1:54 p.m. Resident #19 said he ate food but was unable to digest the food because his stomach was disconnected. The food he ate collected at his throat and he had to dispose of it in a bucket he kept at his bedside. Resident #19 said most staff ignored the food waste bucket but eventually a staff would discard the bucket when it was full. -During the interview, a large square bucket (size approximately two gallons) was observed at the resident's bedside. The bucket was approximately two-thirds full of a thick brown liquid substance that resembled a liquid stool. -There was no lid on the container and the substance smelled of rotting food. Resident #19 was interviewed again on 2/15/24 at 10:02 a.m. Resident #19 said he did not want to complain because he and his roommate (resident #11) just moved to the facility and he did not want to be called a troublemaker.-During the interview, Resident #19's room (which he shared with Resident #1) was observed to be very cluttered, and tabletop surfaces for both residents over the bed tables where they ate were heavily soiled with dried food debris and a thick layer of dried liquid. -Both resident's privacy curtains were soiled with brown and black matter and Resident #19's privacy curtain had splattered dried tube-feeding liquid all down the side facing the resident's bed. -The floor was soiled with a black layer of dirt and there were food and dust crumbs and debris around the edges of the room. -There were dead flies on the windowsill and the sink in the room was covered with boxes and other personal care items. The basin of the sink was soiled with a brownish-black layer of dried matter. -The outer sides of the trash can were soiled with several colors of dried matter. On 2/20/24 at 12:33 p.m., the square bucket was observed at the resident's bedside half full with the same consistency substance as observed on 2/13/24. -There was no lid on the bucket and its contents were observable from the door to the resident's room. C. Record review The February CPO documented an order for a regular diet, regular texture and thin liquids consistency for pleasure feeds (allows for minimal oral intake of foods and fluids for people with tube feedings who crave the taste and experience of eating). A nurse practitioner's visit note dated 10/11/23 documented in pertinent part, "Resident #19 had a rupture of the esophagus, in July 2018 and has a gastric tube for nutrition with a stoma with an ostomy bag to the anterior (front) neck. The resident drank fluids and ate food for pleasure which was then collected in a bag and the resident then emptied the bag from his neck to a trashcan several times a day. Resident managed the ostomy bag and reported changing it daily."The resident's care plan, revised 10/29/23, revealed the resident had a diet order for pleasure eating.-The care plan failed to have a care plan focus to identify the resident's esophageal ostomy bag and implement interventions to manage the discarded food and liquid waste in a sanitary and hygienic manner. D. Staff interviewsLicensed practice nurse (LPN) #9 was interviewed on 2/13/24 at 1:59 p.m. LPN #9 said the certified nurse aides (CNA) were supposed to empty Resident #19's discarded food bucket every shift. III. Resident #11A. Resident status Resident #15, under the age of 65, was admitted on 5/17/23 and readmitted on 10/12/23. According to the February 2024 CPO, diagnoses included quadriplegia, benign prostatic hyperplasia with lower urinary tract infection and diabetes. The 2/14/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident needed substantial assistance with personal grooming and was dependent on staff to complete most activities of daily living (ADL). The resident did not reject or refuse care. B. Resident interview and observationResident #11 (who was Resident #19's roommate) was interviewed on 2/15/24 at 10:02 a.m. Resident #11 said the staff did not clean his room regularly and he thought it could be cleaner. He said staff did not clean his table and rarely mopped the floor (see observation of room above under Resident #19). IV. Staff interviewsThe nursing home administrator (NHA) and CNC #1 were interviewed together on 2/20/24 at 1:37 p.m. The NHA said she was implementing a rounding program where assigned staff would be responsible for bringing building and housekeeping concerns to the NHA and maintenance director's (MTD) attention. The NHA said one of the residents expressed interest in working with the MTD to tour the building and recommend improvement projects including cosmetic upgrades and housekeeping projects. The resident had been tasked with forming a committee of four to five interested residents to work with the MTD on proposing building improvement projects to the maintenance department.

Based on interviews and record review, the facility failed to ensure one (#4) of three residents out of 29 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #4's grievance, which he had communicated to staff on multiple occasions, regarding the resident's missing cigarettes and money. Findings include:I. Facility policy and procedureThe Grievances/Complaints, Filing policy, revised April 2017, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, "Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances."Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished."All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response."II. Resident #4A. Resident statusResident #4, under the age of 65, was admitted on 3/11/23 and readmitted on 1/15/24. According to the February 2024 computerized physician orders (CPO), diagnoses included depression, hypoglycemia (low blood sugar) type one diabetes mellitus, gastroparesis (slowed movement of the stomach), visual loss, need for assistance with personal care, schizophrenia (mental illness), cocaine dependence and heart failure. The 12/27/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required set-up assistance for eating. He required supervision for oral hygiene, toileting and personal hygiene. He required substantial assistance for showering. He was able to express his ideas and wants. B. Resident interviewResident #4 was interviewed on 2/13/24 at 12:59 p.m. Resident #4 said he was sent to the emergency room in January 2024 for low blood sugar. Resident #4 said he carried a lanyard around his neck that had a key to his locked dresser. Resident #4 said the staff were aware not to take the lanyard off of him. Resident #4 said when he woke up in the hospital, he realized his lanyard was not around his neck. Resident #4 said when he returned to the facility from the hospital he was missing two packs of cigarettes and $50 from his locked dresser. Resident #4 said he told the previous nursing home administrator (NHA) that he was missing cigarettes and money. Resident #4 said the previous NHA told the resident she was not going to do an investigation of the missing items and would not replace them. Resident #4 said he had notified several other staff members including licensed nurse staff of the missing items and nothing had been done to resolve his concern. C. Record reviewA request was made for the investigation and grievance regarding Resident #4's missing cigarettes and money. CNC #1 said there was no documentation that an investigation or grievance form had been filled out regarding Resident #4's concerns. III. Staff interviewsThe social services director (SSD) and the social services assistant (SSA) were interviewed on 2/15/24 at approximately 2:00 p.m. The SSD said anyone could fill out a grievance form. The SSD said the social services department then reviewed and logged the grievance form. The SSD said the form was then given to the department manager it pertained to. The SSD said the department manager was responsible for completing an investigation and developing a resolution alongside the resident. The SSD said the department manager needed to obtain approval from the resident submitting the grievance form and return it to the social services department. The SSD said the grievance form was then approved by the NHA and filed. The SSD said it was the responsibility of the NHA to ensure the resolution on the grievance was acceptable. The SSD and the SSA said they were both new to their positions. The SSD and the SSA said they had briefly heard, in passing, that Resident #4 had concerns regarding missing items. CNC #1 was interviewed on 2/15/24 at 3:27 p.m. CNC #1 said she had reviewed some of the filed grievance forms for the last few months. CNC #1 said the grievance forms did not have appropriate resolutions. CNC #1 said the facility had put a process improvement plan in place but it did not meet the correct criteria and would not be effective. CNC #1 said she would assist the facility in implementing corrective action in order to ensure grievances were addressed appropriately and in a timely manner. CNC #1 said there were no grievance forms regarding Resident #4's missing money and cigarettes. CNC #1 said she replaced the resident's cigarettes and money today (2/15/24).

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for one (#15) of four residents reviewed for ADL care assistance out of 29 sample residents. Resident #15 admitted to the facility for long term care on 2/28/22 with diagnoses of depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The resident was dependent on staff for all of his ADLs. The resident expressed not getting out of his wheelchair, not bathing or receiving oral hygiene in weeks and not getting assistance with his meals regularly. The resident felt uncomfortable, itchy and his skin was burning due to not being bathed and wearing the same clothes for days. The resident said his current status affected his state of mind, he was frustrated and did not want to live anymore. Due to the facility's failure to provide adequate assistance to Resident #15 for his ADLs, the resident experienced a decline in his state of mind. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADLs), Supporting policy, revised March 2018, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It revealed in pertinent part, "Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene."Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care); mobility (transfer and ambulation, including walking); elimination (toileting), dining (meals and snacks); and, communication (speech, language, and any functional communication systems)."Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. "If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate." II. Resident #15 A. Resident statusResident #15, under the age of 65, was admitted on 2/28/22 and readmitted on 1/17/24. According to the February 2024 computerized physician orders (CPO), diagnoses included sepsis (infection of the blood), urinary tract infection (UTI), depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The 2/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #15 was dependent on staff for all ADLs including bathing, personal hygiene and eating. The assessment documented the resident had an indwelling catheter, colostomy, had a UTI within the last 30 days and had septicemia (blood infection). The resident's mood interview revealed the resident scored a 15 on the depression scale indicating the resident was experiencing moderate to severe depression. The interview revealed the resident had little interest or pleasure in doing things; was feeling down, depressed or hopeless; was having trouble falling asleep, staying asleep or sleeping too much; was feeling tired or having little energy; had a poor appetite; was feeling bad about himself; had troubles concentrating; had thoughts he would be better off dead or of hurting himself in some way. The resident did not reject care assistance or present with any behavioral symptoms. The 3/28/23 MDS assessment documented the resident interview for daily preferences indicated it was very important for the resident to choose what to wear; choose between a tub bath, shower, bed bath or sponge bath; choose bedtime; and be able to go outside to get fresh air when the weather was good. B. Resident interview and observation Resident #15 was interviewed on 2/13/24 at 4:07 p.m. Resident #15 said he had a lot of concerns regarding his care. Resident #15 said he refused to go to bed because he was afraid the staff would leave him in bed and he would not have access to his call light for assistance. -During the interview, Resident #15's call light was not within reach. His call light was clipped onto his bedside table. The bedside table was pushed up against his roommate's bed. Resident #15 was unable to get his power wheelchair close enough to the call light to initiate it. Resident #15 had a call light that was activated by the resident blowing into it. Resident #15 said he preferred to stay in his power wheelchair so if he needed help he could use his wheelchair to go down the hallway and find staff. Resident #15 said he preferred to have showers on Tuesdays, Thursdays and Saturdays before breakfast was served. Resident #15 said he received pain medication around 4:00 a.m. to 5:00 a.m., 12:00 p.m. and in the evening. Resident #15 said he had a lot of pain due to his condition and preferred to have a shower in the morning after his first dose of pain medication because he was in the least amount of pain at that time. -During the interview, Resident #15 had body odor, food on his clothes, his teeth were yellow and he had bad breath. Resident #15 said he often stayed in the same clothes for four to five days at a time. Resident #15 said he was embarrassed and felt like his body and breath smelled bad. Resident #15 said he had a catheter. He said his catheter was not emptied for an extended period of time in January 2024. He said his catheter backed up and soaked all of his clothes. He said because of this, he got a urinary tract infection (UTI) and ended up with sepsis. Resident #15 said he got a wound on his scrotum because of the moisture from the catheter backing up. He said the staff at the facility did not clean his scrotum well which also led to the development of the wound. Resident #15 said when he got to the hospital his clothes were soaked in urine from his shoulders to his toes. Resident #15 said his skin was itchy and dry. Resident #15 said he would ask staff to lotion his hands and feet but they would tell him they were busy. -Resident #15's hands and feet were observed to be dry and flaky. Resident #15's toenails were long and beginning to curl around the tip of his toes. Resident #15 said the staff only assisted him with eating french fries for lunch. -The resident's lunch tray was on his bed that had a sandwich, a glass of milk and a dessert all which were wrapped in plastic wrap. Resident #15 was interviewed again on 2/14/24 at 8:59 a.m. Resident #15 said he refused to shower yesterday (2/13/24) because he was in a lot of pain. Resident #15 said he did refuse care at times because he did not feel the staff knew what they were doing. Resident #15 said he was unsure of the last time he had a shower or had his teeth brushed. Resident #15 was observed to have a one inch hole in the tubing of his catheter. Resident #15 said his body was itching and it felt like his skin was burning because his clothes were so wet due to the hole in his catheter tubing. Resident #15 said when his clothes were wet it caused him to have spasms that caused him to sweat and caused pain. Resident #15 said his clothes were soaking wet. Resident #15 had sweat dripping from his forehead which he said was a symptom of his body spasms. Resident #15 said the care he received affected his state of mind. He said he felt frustrated and did not want to live anymore. Resident #15 began crying during the interview. During the interview, Resident #15 continued to have body odor, bad breath and yellowed teeth. Resident #15 had a white build-up around his mouth. He said he was extremely thirsty and starving. Resident #15 said his colostomy was full of gas that morning (2/14/24). Resident #15 said he had not been assisted with his breakfast and he was so hungry his stomach was full of gas. -Resident #15 had a breakfast tray on his bedside table that had half a bagel and two links of sausage. -Resident #15's lunch tray from 2/13/24 remained on his bed. The sandwich and dessert were still wrapped in plastic wrap. Resident #15 said the staff did not assist him with his meal for lunch the previous day (2/13/24). -There was a glass of milk on the resident's table that was room temperature to touch and had a dead fly in it. C. Record reviewThe ADL care plan, initiated on 1/2/23 and revised on 9/26/23, revealed Resident #15 had an ADL self-care performance deficit due to a traumatic spinal cord injury 12 years ago resulting in quadriplegia. The interventions included providing the resident with an electric wheelchair for mobility, providing total assistance with bathing, checking and trimming nails as needed, providing total assistance for bed mobility, providing total assistance for dressing, providing total assistance with eating, providing total assistance for personal hygiene and oral care, providing total assistance for toileting, providing total assistance of two staff members and mechanical lift for transfers, providing physical and occupational evaluations as needed and providing a restorative nursing program. The psychosocial care plan, initiated on 9/26/23, revealed Resident #15 had a history of refusing care and services which were within his rights. Resident #15 frequently refused to go to bed and refused care and treatments. Resident #15 frequently attempted to split staff and make false allegations of being denied care. Two staff members should be present when providing care to the resident. The interventions included providing behavioral and psychological services as indicated, collaborating with the interdisciplinary team to identify underlying causes of refusals, determining Resident #15's experiences and preferences to eliminate triggers, encouraging active participation with care, encouraging to set up a schedule for care which was acceptable for him, informing the resident of risks and ramifications of continued non-compliance and re-approaching the resident when he refused care. The 1/15/24 emergency department encounter note documented in pertinent part, "The resident had significant skin breakdown around his abdominal wall and his scrotum and was soaked in urine upon arrival." According to the resident and staff interviews, the resident was supposed to be bathed three times per week. -However, his bathing day preferences were not indicated in the medical record. The November 2023 shower documentation revealed Resident #15 received a bath on 11/9/23, 11/11/23, 11/16/23 and 11/25/23.-It indicated Resident #15 was provided bathing on four of 13 opportunities. The December 2023 shower documentation revealed Resident #15 received a bath on 12/14/23, 12/16/23, 12/21/23, 12/23/23, 12/28/23 and 12/30/23.-It indicated Resident #15 was provided bathing on six of 13 opportunities. The January 2024 shower documentation revealed Resident #15 received a bath on 1/2/24, 1/6/24 and 1/23/24. -It indicated the resident was provided bathing on three of 12 opportunities. The February 2024 shower documentation revealed Resident #15 received a bath on 2/6/24 and 2/13/24.-It indicated Resident #15 was provided bathing on two of six opportunities. -However, despite the shower records documenting the resident received a bath on 2/13/24, Resident #15 said he refused his shower on 2/13/24 due to pain (see resident interviews above). -Certified nurse aide (CNA) #1 said he did not provide Resident #15 a shower on 2/13/24 because the resident refused. -Review of the resident's medical record revealed there were no progress notes to indicate why the resident refused showers on multiple dates or that the staff had attempted to try at another time to complete the shower when he refused. -The medical record did not reveal the resident preferred to shower prior to breakfast related to his pain levels. III. Staff interviewsCNC #1 was interviewed on 2/14/24 at 10:08 a.m. CNC #1 said she had just visited with Resident #15. CNC #1 said Resident #15 had a hole in his catheter tubing and his clothes were soaked in urine. CNC #1 said the staff were replacing the catheter and providing the resident with dry clothing. CNC #1 said she was unsure why CNA #1 documented the resident had a shower yesterday (2/13/24) because it was clear the resident had not had a shower in awhile. CNC #1 said the care Resident #15 received was not acceptable. CNC #1 said the resident had emotional harm and was in distress when she was in his room that morning (2/14/24). CNC #1 said Resident #15 had been admitted to the hospital in January 2024 with sepsis related to a UTI. CNC #1 said the UTI was related to the resident's poor hygiene (cross-reference F690 for catheter care). CNA #1 was interviewed on 2/15/24 at 10:05 a.m. He said there was a piece of paper in the nurses station that had the shower schedule on it. CNA #1 said Resident #15 preferred to have showers on Tuesdays, Thursdays and Saturdays. CNA #1 said he did not give Resident #15 a shower on 2/13/24. CNA #1 said Resident #15 refused his shower and only wanted to be shaved. CNA #1 said he did not remember documenting that he gave Resident #15 a shower on 2/13/24. CNA #1 said Resident #15 refused his shower on 2/13/24 because he was in pain. CNA #1 said he wrote that the resident refused due to pain and put it in a box outside the director of nursing's (DON) office. CNA #1 said he did not talk to the licensed nurse on the unit regarding the resident's shower refusal due to pain. CNC #1 was interviewed again on 2/15/24 at 3:27 p.m. CNC #1 said the staff spoke with Resident #15 regarding his shower time. CNC #1 said it made sense that Resident #15 preferred to have his showers prior to breakfast due to his pain levels. CNC #1 said she would assist the facility in creating new shower preferences for all of the residents who resided at the facility. CNC #1 said there were a lot of holes in Resident #15's shower documentation indicating he missed showers. CNC #1 said some days it was documented that he had several showers. CNC #1 said the staff needed education on proper shower documentation. Cross-reference: F726 for staff competencies. CNC #1 was interviewed again on 2/20/24 at 12:37 p.m. CNC #1 said Resident #15's concerns regarding his care were valid. CNC #1 said she understood why Resident #15 refused care at times. CNC #1 said the facility needed to rebuild rapport with Resident #15 to help reduce his care refusals. CNA #2 was interviewed on 2/20/24 at 1:56 p.m. She said CNAs were responsible for providing oral care to the residents. CNA #2 said oral hygiene should be performed when getting the resident ready for the day and when assisting them to bed.

Based on record review and interviews, the facility failed to ensure one (#4) of three sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan of 29 sample residents. Specifically, the facility failed to provide regular and consistent supervised guidance to assist Resident #4 to make educated decisions on determining an appropriate sliding scale insulin dose based on blood glucose assessment and carbohydrate intake and document those efforts per physician's orders. Findings include:I. Facility policy and procedureThe Diabetes-Clinical Protocol, revised November 2020, was provided by the corporate nurse consultant (CNC) #1 on 2/19/24 at 4:30 p.m. It read in pertinent part, "The Physician and staff will summarize factors that are contributing to, or conditions that are affected by the residents diabetes or glucose intolerance and will assess the impact of diabetes on the individual's function and quality of life. "The Physician will address complications such as dyslipidemia, coronary artery disease, neuropathy, and nephropathy based on the individual's overall condition, prognosis, function, and treatment preferences."Risk of hypoglycemia should be considered in any treatment plan, as it is a significant and high-risk complication of treatment. It may be necessary to accept somewhat higher blood sugars in order to minimize the risk of hypoglycemia. "The idea of a diabetic diet is outdated and dietary restriction may be liberalized in most patients. "The Physician will order desired parameters for monitoring and reporting information related to blood sugar management: the staff will incorporate such parameters into the Medication Administration Record and care plan."II. Resident #4A. Resident statusResident #4, under the age of 65, was admitted on 3/11/23 and readmitted on 1/15/24. According to the February 2024 computerized physician orders (CPO), diagnoses included depression, hypoglycemia (low blood sugar) type one diabetes mellitus, gastroparesis (slowed movement of the stomach), visual loss, cocaine dependence, need for assistance with personal care, schizophrenia (mental illness), cocaine dependence and heart failure. The 12/27/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required set-up assistance for eating and supervision assistance with oral hygiene, toileting and personal hygiene. The resident displayed verbally aggressive behaviors and negative behaviors symptoms not directed towards others but the assessment documented that the resident did not reject evaluation of care necessary to achieve the resident's goals for health and wellbeing. B. Resident interviewResident #4 was interviewed on 2/13/24 at 12:59 p.m. He said the food was often served late. He said it was difficult to manage his diabetes since the meals were frequently late. He said the facility did not follow standardized portion sizes. Resident #4 said he was blind so it made it difficult for him to know how many carbohydrates he was consuming when the portion sizes were different each day. Resident #4 said his insulin was often late which caused his blood sugar to drop. He said he had been to the hospital three times related to his blood sugar dropping in the 20-40's. Resident #4 said he did not remember what happened during the three incidents of his blood sugar dropping. He said he woke up in the emergency room when they occurred and was unable to recall. C. Record reviewA review of the resident's physician's orders revealed the following order for management of diabetes mellitus:Novolog injection solution (insulin aspart), inject subcutaneously, at 7:30 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. as per sliding scale, before meals, for type 1 diabetes mellitus with hyperglycemia. Administer as supervised self-administration. Resident may titrate insulin dosing as requested for carbohydrate counting, do not exceed 12 units. Document in progress note for self titration. If blood glucose (BG) is 0-70 notify provider and initiate hypoglycemic protocol. Inject subcutaneously if BG is 71-149 give 0 units; if 150-199 give 2 units; if 200-249 give 4 units; if 250-299 give 6 units; if 300-349 give 9 units; if 350-399 give 11 units; 400-450 give 12 units. Call physician if BG is greater than 450, ordered date 8/4/23. Insulin glargine subcutaneous solution 100 unit/ml, inject 9 unit subcutaneously in the morning at 8:00 a.m., for type I diabetes mellitus, start date 1/13/24. Insulin glargine subcutaneous solution 100 unit/ml, inject 9 unit subcutaneously one time a day at 5:00 p.m., for type I diabetes mellitus, start date 1/12/24 -A review of progress notes revealed the nursing staff were not documenting the insulin dosage administered or rationale for the dose administered if not in line with the physician's order. -Progress note documentation failed to explain the supervision and guidance efforts of the nurses administering the resident's sliding scale insulin dose or how the dosing was determined based on assessment of the resident's BG level and carbohydrate intake. -It was unclear if the resident was advised on selecting the proper dosage or if the nursing staff accepted his dosage decision without discussion and appropriate nursing assessment based on the physician order and including an assessment of his daily carbohydrate intake.-A review of the medication administration record (MAR) records revealed insulin administration doses inconsistent with the physician's order for dosing per BG level assessment. A hospital treatment note, dated 8/17/23, revealed Resident #4 was brought to the emergency room on 8/15/23. The note documented in pertinent part, Patient brought in due to altered mental status and agitation. Arriving at the emergency room agitated requiring chemical and mechanical restraints at times. BG (blood glucose) level tested at 44 on arrival. Normalized after starting D5W (dextrose five percent in water intravenous (IV) infusion). Assessment plan continues D5W for now. BG again at 41 this morning 8/16/23; the patient refused juice, D50 (used to treat low BG) given. Hold long acting insulin, continue sliding scale insulin. The patient's evening BG was greater than 400 so restart lantus (long acting insulin. Resume his insulin home regimen at discharge. Diagnosis included infection, thyrotoxicosis (excessive thyroid activity), hypoglycemia (low blood glucose). He does not have thyrotoxicosis with normal free T4 (thyroid level lab), likely secondary to a urinary tract infection and hypoglycemia. Patient was much better today as BG was better and infection being treated. The 8/26/23 hospital progress note documented in pertinent part, the resident presented to the emergency room after emergency services found his blood glucose to be 20. The physician's highest concern was for an inadvertent insulin overdose. The resident was diagnosed with hypoglycemia and a urinary tract infection. The diabetic care plan, initiated on 9/20/23, revealed the resident had type one diabetes mellitus that was managed by insulin and diet. Resident #4 could titrate his insulin dosing as requested for carbohydrate counting. Resident #4 was not to exceed 12 units of insulin per physician order and his history of diabetes. The interventions included administering medications as ordered, educating the resident on medications and potential side effects, referring to nephrology as indicated, allowing Resident #4 to adjust his own insulin needs based on blood sugar levels and food consumed and monitoring the resident's blood sugar before each meal and before bedtime. A progress note dated 12/25/23 read in pertinent part: Patient's BG was 524, patient refusing to allow this nurse to call the provider to request to give insulin of 12 units. Call placed to the provider and awaiting a response. Provider to potentially order additional units. Patient will not allow this nurse to give any insulin, Patient states it will kill him if he takes the required units. Patient was educated on the need to avoid letting BG go any higher; the patient continued to decline medication treatment, awaiting provider call back. A nurse practitioner note, dated 12/26/23, read in pertinent part: "Reason for visit: hyperglycemia. Insulin dependent diabetes with hypoglycemia. Patient with hypoglycemic episode this morning, patient negotiated his insulin needs with the nurses as per usual and is now normoglycemic (normal BG). The patient is empirically well versed about his own diabetes condition and insulin sensitivity, allowed to titrate his insulin dosing within orders specified at MAR. The 1/16/24 physician progress note documented in pertinent part, "The resident was seen today (1/16/24) and was in no acute distress. The resident was sent out to the emergency department 1/14/24, for a hypoglycemic episode in which he was unconscious. Condition resolved. -Medication orders: 1/16/24, unchanged insulin glargine subcutaneous solution 100 unit/ml. Route: subcutaneously. Inject 9 unit subcutaneously in the morning for type I diabetes mellitus. 8/14/23 unchanged novolog injection solution (insulin aspart). Route: subcutaneously. Inject as per sliding scale, supervised self-administration (see order above).-Resident refuses to allow others to dictate his insulin dosage. Patient continued to have labile (hard to control BG levels characterized by wide variations of highs and lows) BG levels. III. Staff interviewsCNC #1 and the nursing home administrator (NHA) were interviewed on 2/15/24 at 11:39 a.m. They said they had received reports that the resident was acting weird. They said they believed the resident was under the influence of methamphetamines and were going to obtain a drug test. The RD and the NSD were interviewed together on 2/15/24 at 11:59 a.m. The RD said Resident #4 did not want nutrition education when it was offered to him previously. The RD was interviewed again on 2/15/24 at 1:23 p.m. The RD said he was unable to find documentation in Resident #4's medical record that diabetic nutrition education had been offered to the resident. The RD said he attempted to provide Resident #4 diet education on 2/15/24 (during the survey process). The RD said the resident was upset regarding the portion sizes at the facility. The RD said Resident #4 said the portion sizes were never consistent which made it difficult to dose his insulin correctly. Cross-reference F691 for nutrition and F803 for portion sizes. CNC #1 was interviewed on 2/20/24 at 12:37 p.m. CNC #1 said diabetic education should have been offered to Resident #4 and documented in his medical record if he refused it. CNC #1 said diabetic education was part of diabetic management. CNC #1 said she was unable to find any information on why Resident #4 was able to titrate his insulin. CNC #1 said that was not within normal standards of practice for a resident to titrate their own insulin. CNC #1 said Resident #4 smoked marijuana, was blind and had other comorbidities that could contribute to Resident #4 not being able to correctly dose his own insulin. CNC #1 said the resident had been to the emergency room multiple times related to low blood sugar.

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Based on observations, interviews and record review the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#15 and #11) of three residents reviewed for catheter care out of 29 sample residents. Resident #15 admitted to the facility for long term care on 2/28/22 with a diagnosis of depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The facility failed to provide the resident with catheter care per standards of practice, which resulted in Resident #15 being admitted to the hospital on 1/14/24 and diagnosed with severe sepsis (blood infection) related to a catheter associated urinary tract infection (CAUTI). The hospital paperwork documented the CAUTI was related to poor hygiene and catheter care. The hospital paperwork documented the resident was soaked in urine upon arrival to the emergency department. The resident had a large sacral decubitus ulcer and cellulitis of the scrotum likely associated with poor hygiene. The resident was started on intravenous (IV) antibiotics. The resident was readmitted to the facility on 1/17/24 and continued on IV Meropenem (an antibiotic medication) until 2/5/24. Additionally, the facility failed to provide consistent catheter care for Resident #11. Cross-referenced to F880 failure to use aseptic technique while replacing a suprapubic catheter and F726 failure to ensure sufficient competent nursing staff. Findings include:I. Professional reference According to the Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 6/6/19), retrieved on 3/1/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf, "Proper Techniques for Urinary Catheter Maintenance: Following aseptic insertion of the urinary catheter, maintain a closed drainage system. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment."Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. Maintain unobstructed urine flow. Keep the catheter and collecting tube free from kinking. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor."Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container."Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system."Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised."Routine hygiene is appropriate. If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction."I. Professional reference According to the Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 6/6/19), retrieved on 3/1/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf, "Proper Techniques for Urinary Catheter Maintenance: Following aseptic insertion of the urinary catheter, maintain a closed drainage system. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment."Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. Maintain unobstructed urine flow. Keep the catheter and collecting tube free from kinking. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor."Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container."Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system."Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised."Routine hygiene is appropriate. If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction."II. Facility policy and procedureThe Catheter Care, Urinary policy, revised August 2022, was provided by the corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, "The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections."Empty the collection bag at least every eight hours using a separate, clean collection container for each resident. Avoid splashing, and prevent contact of the drainage spigot with the nonsterile container."III. Resident #15A. Resident statusResident #15, under the age of 65, was admitted on 2/28/22 and readmitted on 1/17/24. According to the February 2024 computerized physician orders (CPO), diagnoses included sepsis (infection of the blood), urinary tract infection (UTI), depression, quadriplegia, neurogenic bladder (slow movement of the bladder), neuromuscular dysfunction of bladder and colostomy status. The 2/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff for all activities of daily living (ADLs). The MDS assessment documented the resident had an indwelling catheter, had a UTI within the last 30 days and had septicemia (blood infection). B. Resident interview and observationsResident #15 was interviewed on 2/13/24 at 4:07 p.m. Resident #15 said he had a catheter. He said his catheter was not emptied for an extended period of time in January 2024. He said his catheter backed up and soaked all of his clothes. He said because of this he got a UTI and ended up with sepsis. Resident #15 said he also got a wound on his scrotum because of the moisture from the catheter backing up. He said the staff at the facility did not clean his scrotum well, which also led to the development of the wound. At 5:20 p.m. Resident #15's catheter bag was hanging over the edge of his electric wheelchair. The catheter bag was three-fourths full of urine. The resident did not have a leg anchor to attach the catheter bag to his leg to alleviate the catheter from pulling. Resident #15 said the facility did not provide him with leg anchors which caused a pulling sensation on his bladder. He said it hurt when the catheter bag was pulled. He said he had a midline IV access site on his arm that was no longer in use. Resident #15 said he was on IV antibiotics after being in the hospital in January 2024. Resident #15 was interviewed again on 2/14/24 at 8:59 a.m. Resident #15 said he refused to shower yesterday (2/13/24) because he was in a lot of pain. He said he did refuse care at times because he did not feel the staff knew what they were doing. Resident #15 said he would refuse to go to bed because he was afraid the staff would leave him in bed and he would not have access to his call light for assistance. Resident #15's call light was not within reach during the interview. His call light was clipped onto his bedside table which was pushed up against his roommate's bed. Resident #15 was unable to get his power wheelchair close enough to the call light to initiate it. Because of his quadriplegia, Resident #15's call light was initiated by him blowing into it. Resident #15 said he preferred to stay in his power wheelchair, so if he needed help he could use his wheelchair to go down the hallway and find staff. Resident #15 said when his clothes were wet it caused him to have spasms that caused him to sweat and caused pain. He said his clothes were soaking wet. Resident #15 had a one inch hole in the tubing of his catheter. Resident #15 said his body was itching and it felt like his skin was burning because his clothes were so wet. C. Record reviewThe urinary care plan, initiated on 1/2/23 and revised on 1/5/23, revealed Resident #15 had a suprapubic catheter due to his diagnosis of a neurogenic bladder. The interventions included: providing the resident with a 24 French suprapubic catheter, positioning the catheter bag and tubing below the level of the bladder, changing the catheter as needed for displacement, infection and obstruction, checking the tubing for kinks when providing care to the resident and each shift, monitoring and documenting signs of pain or discomfort due to the catheter and monitoring and recording and reporting signs or symptoms of a UTI to the physician. The February 2024 CPO revealed Resident #15 had the following physician orders related to his catheter:-Suprapubic catheter size French #24/30 milliliters (ml) balloon. Monitor every shift for placement and functioning. Change as needed if dislodged, leaking or plugged, ordered 10/4/23;-Change suprapubic catheter 24 French, 10 cubic centimeter (CC) bulb attached to gravity drainage bag as needed for being pulled out, leaking or plugged, ordered 6/12/23;-Flush suprapubic catheter with 60 ml of normal saline at bedtime every Friday for patency, ordered 12/22/23; and,-Exchange suprapubic catheter immediately for infection, ordered 2/14/24. The 1/15/24 emergency department encounter note documented in pertinent part, "The resident had significant skin breakdown around his abdominal wall and his scrotum and was soaked in urine upon arrival." The 1/15/24 infectious disease hospital note documented in pertinent part, "The resident presented to have purulence (pus) around the suprapublic site." The 1/16/24 hospitalist progress note documented in pertinent part, "The resident had likely recurrent CAUTI related to poor hygiene and catheter care. The resident had scrotal cellulitis and his urine was growing mixed flora (an unusual growth of multiple types of bacteria)." The 1/17/24 inpatient hospital pain progress note documented in pertinent part, Resident #15 arrived at the emergency department and was found to be tachycardic (rapid heart rate), tachypneic (rapid breathing), febrile (fever) with an elevated white blood cell and lactate meeting systematic inflammatory response syndrome (SIRS) (an exaggerated defense response from your body to a harmful stressor) criteria. The patient had a large sacral decubitus (open wound) ulcer and cellulitis (infection of the skin) of his scrotum likely associated with poor hygiene. IV antibiotics were initiated. IV. Resident #11A Resident status Resident #11, under the age of 65, was admitted on 5/17/23 and readmitted on 10/12/23. According to the February 2024 CPO diagnosis included quadriplegia, neuromuscular neurogenic dysfunction of the bladder (lack of bladder control), overactive bladder, benign prostatic hyperplasia with lower urinary tract infection and diabetes. The 2/14/24 MDS assessment revealed the resident was cognitively intact with a BIMS with a score of 15 out of 15. The resident had impaired functional ability on both sides of the upper (shoulders, elbows, wrists and hands) and lower (hips, knees, ankles and feet) extremities due to quadriplegia and used a motorized wheelchair to get around. The resident needed substantial assistance with personal grooming and was dependent on staff to complete most ADLs. The resident did not reject or refuse care. The resident had an indwelling catheter (suprapubic catheter). B. Resident interview and observationResident #11 was interviewed on 2/15/24 at 10:02 a.m. Resident #11 said the staff did not check on his catheter regularly to empty his leg drainage bag when it was full. He said he usually had to ask staff to empty the bag unless it was bedtime and staff emptied the bag to change it over to the larger overnight bag. -At the time of the interview, the resident's urine drainage bag was more than two-thirds full and bulging with dark amber urine. Resident #11 was interviewed on 2/15/24 at 1:33 p.m. Resident #11 said staff had not emptied his drainage bag today (2/15/24) and the floor nurse had not checked his suprapubic stoma (insertion site) since yesterday (2/14/24). Resident #11 said he was experiencing some abdominal discomfort. -At the time of the interview, the resident's urine drainage bag was full almost to the section of the bag where the tubing entered the ag. The drainage bag was bulging with amber-colored urine. Resident #11 said the nurses were supposed to irrigate his suprapubic catheter twice a day and he was lucky if they irrigated the catheter once a day. C. Record reviewThe February 2024 CPO revealed the following physician orders related to Resident #11's suprapubic catheter: -Irrigate the suprapubic catheter twice a day with sterile water at 7:00 a.m. and bedtime, start date 9/11/23; and, -Suprapubic catheter #24 French with a 5 cubic centimeters (cc) bulb, drain to a gravity drainage bag. Monitor placement and patency during and after care every shift (6:00 a.m., 2:00 p.m. and 10:00 p.m.) every shift., start date 5/23/23. Review of Resident #11's December 2023 treatment administration records (TAR) revealed irrigation of the resident's suprapubic catheter was not completed on the following dates:-12/27/23 at 7:00 a.m.; and,-At bedtime on 12/9/23, 12/10/23, 12/17/23, 12/21/23, 12/22/23, 12/23/23, 12/26/23 and 12/31/23. Review of Resident #11's January 2024 treatment TAR revealed irrigation of the resident's suprapubic catheter was not completed on the following dates:-1/18/24 at 7:00 a.m.; and,-At bedtime on 1/21/24, 1/27/24 and 1/28/24. Review of the December 2023 TAR revealed monitoring for placement and patency of Resident #11's suprapubic catheter was not completed on the following dates:-12/27/23 at 6:00 a.m.; and,-12/9/23, 12/10/23, 12/17/23, 12/21/23, 12/22/23, 12/23/23, 12/26/23 and 12/31/23 at 2:00 p.m. Review of the January 2024 TAR revealed monitoring for placement and patency of Resident #11's suprapubic catheter was not completed on the following dates:-1/18/24 at 6:00 a.m.;-1/21/24 and 1/27/24 at 2:00 p.m.; and,-1/21/24 at 10:00 p.m. -A review of the medical record revealed no documentation of why the treatments were not provided. Progress notes revealed the resident had complications with the resident's catheter being dislodged. The condition was discovered on 12/11/23 during the scheduled order for the nurse to monitor the catheter for placement. The comprehensive care plan, revised on 10/13/23, revealed a care focus on managing the resident's suprapubic catheter with the goal of ensuring that the resident remained free from catheter-related trauma. Interventions included providing catheter care every shift, monitoring, documenting and reporting signs and symptoms of urinary tract infection. -There were no interventions to address the physician's order to irrigate the resident catheter. V. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/14/24 at 9:59 a.m. RN #1 said Resident #15 had a catheter. RN #1 said the certified nurse aides (CNA) were responsible for emptying the resident's catheter bag when needed. RN #1 said he observed Resident #15's catheter around 7:30 a.m. on 2/14/24 and did not notice any abnormalities. RN #1 said he did not empty the catheter bag at that time and noted it to have approximately 350 ml of urine in it. CNC #1 was interviewed on 2/14/24 at 10:08 a.m. CNC #1 said she had just visited with Resident #15. CNC #1 said Resident #15 had a hole in his catheter tubing and his clothes were soaked in urine. CNC #1 said the staff were replacing the catheter and providing the resident dry clothing. CNC #1 said Resident #15 needed a shower as it appeared he had not had one in a while. CNC #1 said the care Resident #15 received was not acceptable. CNC #1 said the resident had emotional harm and was in distress when she was in his room that morning. CNC #1 said Resident #15 had been admitted to the hospital in January 2024 with sepsis related to a UTI. RN #1 was interviewed again on 2/14/24 at 2:59 p.m. He said hand hygiene should be performed prior to catheter care. He said it was important to wear gloves. RN #1 said the first step to performing catheter care was assessing the resident's blood pressure and the output of the catheter. RN #1 said he would then gently remove the catheter. RN #1 said he would then dispose of the old catheter, take off his gloves, perform hand hygiene and put new gloves on. RN #1 said he then cleaned the area and lubricated the area. RN #1 said he would then insert the catheter and inflate the balloon based on the physician's orders. RN #1 said he would then gently tug on the catheter to ensure it was patent. RN #1 said he would ensure the catheter was draining. RN #1 said he would then remove his gloves and perform hand hygiene. Cross-reference F880 due the catheter care not being completed in a sanitary manner and F726 for competent nursing staff. CNC #1 was interviewed again on 2/15/24 at 3:27 p.m. She said catheter bags needed to be emptied once a shift or as needed. CNC #1 said the nurse should visually look at the catheter every shift to ensure it was functioning properly. CNC #1 was interviewed again on 2/20/24 at 12:37 p.m. CNC #1 said Resident #15's concerns regarding his care were valid. CNC #1 said she understood why Resident #15 refused care at times. CNC #1 said the facility needed to rebuild rapport with Resident #15 to help reduce his care refusals.

Based on observations, interviews and record review, the facility failed to ensure that residents who require colostomy services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. for two (#15 and #11) of two residents reviewed for colostomy care out of 29 sample residents. Specifically, the facility failed to ensure Resident #15's and Resident #11's colostomy bags were maintained per physician's guidance and professional standards of practice. Findings include: I. Professional referenceThe American Cancer Society's Caring for a Urostomy (10/16/19), retrieved on 2/27/24 from https://www.cancer.org/cancer/managing-cancer/treatment-types/surgery/ostomies/urostomy/management.html, read in pertinent part, "During the day most people need to empty the pouch about as often as they used the bathroom before they had urostomy surgery or other bladder problems-for many people, this might mean every 2 (two) to 4 (four) hours, or more often if you drink a lot of fluids. "Different pouching systems are made to last different lengths of time. Some are changed every day, some every 3 (three) days or so, and some just once a week. It depends on the type of pouch you use."Your pouch should be changed on a schedule that fits your routine. And it's best to have a regular changing schedule so problems don't develop. In other words, don't wait for it to leak to change it. "Before changing your pouch, clean your hands well and put all your supplies on a clean surface. Clean pouches decrease the chances of germs (bacteria) getting into your urinary system. Bacteria can multiply quickly even in the tiniest drop of urine. These germs may travel up the ureters and cause a kidney infection. Bacteria can also cause foul-smelling urine." II. Facility policy and procedureThe Colostomy/Ileostomy Care policy, revised October 2010, was provided by the corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, "The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter."The following information should be recorded in the resident's medical record: the date and time the colostomy/ileostomy care was provided, the name and title of the individual(s) who provided the colostomy/ileostomy care, any breaks in the resident's skin, signs of infection, or excoriation of the skin, how the resident tolerated the procedure, if the resident refused the procedure, the reason(s) why and the intervention taken and the signature and title of the person recording the data." III. Resident #15 A. Resident statusResident #15, under the age of 65, was admitted on 2/28/22 and readmitted on 1/17/24. According to the February 2024 computerized physician orders (CPO) diagnoses included sepsis (infection of the blood), urinary tract infection (UTI), depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The 2/10/24 minimum date set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #15 was dependent on staff for all ADLs. The MDS documented the resident had an indwelling catheter, had a UTI within the last 30 days and had septicemia (blood infection). B. Observations and resident interview Resident #15 was interviewed on 2/13/23 at 4:07 p.m. Resident #15 said he had a colostomy. Resident #15 said his colostomy bag was often full of gas and would explode. He said the staff did not assist him with "burping" his colostomy to release some of the gas that built up inside of it. At 5:20 p.m. Resident #15's colostomy bag was fully inflated. There was a small amount of stool in the bottom of the bag and the rest of the bag was full of gas. Resident #15 said he often had to ask staff to assist him with his colostomy care because he was afraid of it exploding. Resident #15 was interviewed again on 2/14/24 at 8:59 a.m. Resident #15 said he had a lot of gas in his colostomy bag. His colostomy bag was full of gas and fully inflated. C. Record review The colostomy care plan, initiated on 1/5/23, revealed Resident #15 had a colostomy. The interventions included utilize colostomy supplies specific to Resident #15's needs, maintaining intact peristomal skin by using the appropriate pouch, cleaning and prepping the skin, applying skin barrier as order and applying the pouch correctly, keeping the pouch emptied routinely, monitoring for compilations and reporting concerns to the physician and monitoring the color, consistency, odor and amount of stool. The February 2024 CPO revealed Resident #15 had the following physician orders related to his colostomy:Colostomy care once a shift, empty colostomy bag as needed, every shift related to quadriplegia, ordered 1/5/23.-There were no orders for routine maintenance including replacing the colostomy bag per standards of practice. IV. Resident #11A Resident status Resident #11, under the age of 65, was admitted on 5/17/23 and readmitted on 10/12/23. According to the February 2024 CPO diagnosis included quadriplegia, neuromuscular neurogenic dysfunction of the bladder (lack of bladder control), overactive bladder, benign prostatic hyperplasia with lower urinary tract infection and diabetes. The 2/14/24 MDS assessment revealed the resident was cognitively intact with a BIMS with a score of 15 out of 15. The resident had impaired functional ability on both sides of the upper (shoulders, elbows, wrists and hands) and lower (hips, knees, ankles and feet) extremities due to quadriplegia and used a motorized wheelchair to get around. The resident needed substantial assistance with personal grooming and was dependent on staff to complete most ADLs. The resident did not reject or refuse care. The assessment revealed the resident had a colostomy device. B. Resident interview and observationResident #11 was interviewed on 2/15/24 at 1:33 p.m. Resident #11 said he had a lot of gas in his colostomy. Staff were supposed to check on his colostomy every couple of hours to "burp" the colostomy bag when it was full of gas to prevent the colostomy from popping open and leaking feces on his person. Resident #11 said staff did not check on the colostomy as they should and the device has popped open and covered him with feces on a number of occasions. Resident #11 said he had to remind staff to assist him with the management of his colostomy or they would not provide the needed care. Resident #11 said he was always worrying that the bag would pop open.-At the time of the interview, the resident ' s colostomy bag contained a medium bowel movement and was extremely extended with gas. C. Record reviewResident #11' s February CPO documented the following order: -Check resident's colostomy bag every two hours, start date 1/20/24. - There were no other orders or maintenance instructions for care of the resident ' s colostomy. -The comprehensive care plan, revised on 10/13/23, failed to document a care focus for the care and maintenance of the resident ' s newly placed colostomy (placed on 1/10/24). A progress note dated 1/18/24 documented: "Resident is complaining that his colostomy bag keeps leaking."A progress note dated 1/23/24 documented: "Resident ' s colostomy was leaking, and the bag was changed and cleaned." V. Staff interviews CNC #1 was interviewed on 2/14/24 at 10:08 a.m. CNC #1 said after visiting with Resident #15, she did not feel he was receiving good colostomy care. Licensed practical nurse (LPN) #1 was interviewed on 2/15/24 at 3:00 p.m. LPN #1 said colostomy bags needed to be burped to release the gas build up. LPN #1 said colostomy bags should be emptied and changed as needed. LPN #1 said she used her clinical judgment to know when to change a colostomy bag. CNC #1 was interviewed again on 2/15/24 at 3:27 p.m. CNC #1 said colostomy care should include burping the bag as needed, emptying the bag as needed and replacing the bag every few days. CNC #1 said colostomy bags needed to be checked frequently. CNC #1 said the facility had several agency staff members. CNC #1 said the facility also had several residents who had colostomies. CNC #1 said all staff should have received competencies regarding colostomy care. CNC #1 said the staff had not been provided education on how to care for colostomies. CNC #1 was interviewed again on 2/20/24 at 11:50 a.m. CNC #1 said Resident #15's colostomy bag exploded over the weekend. CNC #1 said the resident refused care after it exploded. CNC #1 said the bag should not have gotten to the point where it exploded. CNC #1 said Resident #15 had a lot of gas which caused his colostomy bag to fill with gas quickly. CNC #1 said Resident #15's colostomy bag needed to be monitored closely. CNC #1 said she would contact the resident's physician to ask about a gas reducing pill to help the resident with his increased gas. CNC #1 was interviewed again on 2/20/24 at 12:37 p.m. CNC #1 said Resident #15's concerns regarding his care were valid. CNC #1 said she understood why Resident #15 refused care at times. CNC #1 said the facility needed to rebuild rapport with Resident #15 to help reduce his care refusals.

Based on observations, record review and interviews, the facility failed to ensure two (#11 and #4) of two residents out of 29 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #11 was admitted to the facility for long term care on 5/17/23 for long term care with diagnoses of quadriplegia (decreased or no control of all four limbs), neuromuscular dysfunction of the bladder (decreased movement of the bladder), hypoglycemia (low blood sugar), type I diabetes mellitus, neurogenic bowel (decreased bowel movement) and anxiety. Upon admission, Resident #11 weighed 188 pounds (lbs) and he reported he preferred to eat vegetarian meals. Resident #11 was started on Glucerna (diabetic nutritional supplement) once a day on 7/20/23. On 7/6/23, Resident #11 weighed 182.4 lbs. Resident #11 had lost 5.6 lbs, which was not considered significant. On 12/13/23, Resident #11 weighed 166.8 lbs. Resident #11 lost 10.6 lbs or 6% (percent) of his body weight in one month, which was considered significant. At this time the registered dietitian (RD) completed an assessment and increased Resident #11's Glucerna to twice a day. Resident #11 often refused the Glucerna. Resident #11 lost an additional 7.2 lbs from 12/13/23 to 1/23/24. On 1/25/24 30 cubic centimeters (cc) of liquid protein was ordered two times a day for the resident's skin and protein status. On 2/8/24, Resident #11 weighed 156.4 lbs. Resident #11 lost 25.8 lbs (14.2%) from 8/3/23 to 2/8/24, a period of six months, which was considered significant. The facility failed to implement person centered effective nutritional interventions, meet the resident's dietary preferences to prevent significant weight loss and consistently weigh the resident to monitor his weight. Additionally, the facility failed to offer diabetic education to Resident #4 upon admission and ongoing throughout his stay at the facility. Findings include:I. Facility policy and procedureThe Nutrition (Impaired)/Unplanned Weight loss-Clinical protocol, revised September 2017, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, "The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. "The physician will help identify medical conditions (cancer, cardiac or renal disease, depression, dental problems) and medications that may be causing weight gain or loss or increasing risk for either gaining or losing weight. "The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting)."The Therapeutic Diets policy, revised October 2017, was provided by CNC #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, "A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). "A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet."The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. "The dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical record. "If the resident or the resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives."II. Resident #11A. Resident statusResident #11, under the age of 65, was admitted on 5/17/23 and readmitted on 1/15/24. According to the February 2024 computerized physician orders (CPO), diagnoses included quadriplegia (decreased or no control of all four limbs), neuromuscular dysfunction of the bladder (decreased movement of the bladder), hypoglycemia (low blood sugar), type I diabetes mellitus, neurogenic bowel (decreased bowel movement) and anxiety. The 2/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial assistance with eating, oral hygiene, toileting and personal hygiene. He was dependent on staff for showering. The assessment documented the resident was 76 inches (six foot, four inches) tall and weighed 156 lbs. It indicated the resident had no weight loss or weight gain in the last six months. -However, Resident #11 had sustained a significant weight loss of 25.8 lbs (14.2%) in the last six months. B. Observations and resident interviewDuring a continuous observation of the lunch meal service on 2/14/24 beginning at 11:24 a.m. and ending at 1:03 p.m., the following was observed:At approximately 12:20 p.m., an unidentified dietary staff member put a cookie and an individual sized bag of potato chips on Resident #11's meal tray. Resident #11 was interviewed on 2/14/24 at 1:54 p.m. Resident #11 said he preferred not to eat meat. He said he had been a vegetarian for 35 years. Resident #11 said he only got a cookie and a bag of chips for lunch. He said the menu item was a sloppy joe and he was unable to eat it due to his preferences. Resident #11 said he had to purchase most of his own food since the facility did not accommodate his preferences. Resident #11 said he had lost weight since he was admitted to the facility. Resident #11 did not feel his nutrition needs were being met. Resident #11 said he preferred to stay in bed until 11:00 a.m. Resident #11 said if he got up before then he was in his wheelchair for several hours which caused him pain (see weight change note below). C. Record reviewThe nutrition care plan, initiated on 5/25/23 and revised on 2/15/24 (during the survey), revealed Resident #11 had potential for alteration in body composition integrity (muscle and fat wasting) and potential for unintended weight changes related to worsening condition secondary to numerous comorbidities including: type one diabetes mellitus, quadriplegia, history of pressure ulcer and depression. The interventions included: monitoring, recording and report to the physician signs and symptoms of malnutrition as needed (5/25/23), obtaining and monitoring lab/diagnostic work as ordered and reporting results to physician to follow up as needed (5/25/23), monitoring need for occupational therapy to screen for adaptive equipment (5/25/23), providing and serving supplements as ordered (2/15/24, added during the survey), providing and serving diet as ordered (5/25/23), offering vegetarian items per resident preferences and obtaining preferences (2/15/24, added during the survey), evaluating the resident by the registered dietitian (RD) as needed (5/25/23) and obtaining weights per facility protocol (5/25/23). Resident #11's weights were documented in the resident's medical record as follows:-On 5/18/23, the resident weighed 188 lbs; -On 6/14/23, the resident weighed 185.5 lbs; -On 7/16/23, the resident weighed 182.4 lbs; -On 7/31/23, the resident weighed 182.6 lbs;-On 8/3/23, the resident weighed 182.2 lbs; -On 8/14/23, the resident weighed 182.4 lbs; -On 9/7/23, the resident weighed 175.8 lbs; -On 11/10/23, the resident weighed 177.4 lbs; -On 11/17/23, the resident weighed 177.4 lbs; -On 12/13/23, the resident weighed 166.8 lbs; -On 1/23/24, the resident weighed 159.6 lbs; and, -On 2/8/24, the resident weighed 156.4 lbs. -The resident lost 25.8 lbs (14.2%) from 8/3/23 to 2/8/24 in six months, which was considered significant. The 7/8/21 preadmission screening and resident review (PASRR) documented the resident preferred to eat a vegetarian diet. The PASRR documented vegetarian diet options should be offered to the resident atevery meal. The 5/18/23 dietary interview assessment documented Resident #11 had a good appetite. Resident #11 said he preferred to have 2% milk and cranberry juice to drink at breakfast and dinner. The resident did not like to snack between meals. Resident #11 did not like fried eggs and did not eat meat. The resident was on a regular diet and did not have any food allergies. The resident was aware the alternative meals were available upon request. The resident preferred to eat in his room. The resident typically ate breakfast, lunch and dinner. The resident preferred to follow a vegetarian diet and enjoyed cheese sandwiches, quesadillas, fish, eggs, salads and burritos for lunch and dinner. The 12/14/23 interdisciplinary (IDT) weight variance assessment documented by the registered dietitian (RD) revealed the resident weighed 166.8 lbs and had lost 5.6% of his body weight in one month (however, the resident had sustained a 6% weight loss in one month). The resident was currently receiving Glucerna or Boost Glucose Control (diabetic nutritional supplement) once a day and liquid protein. The resident was on a vegetarian diet. The resident previously weighed 177.4 lbs. The resident was receiving Ativian (antianxiety medication) and Morphine (pain medication). The resident was a slow eater; had poor ability to feed himself; complained of the taste of the food, disliked the food, disliked the diet and was a picky eater; and, had variable intake. The resident had a recent illness within the last 30 days, a recent significant change in medications and was on psychotropic medication. The resident had a recent illness. The resident had a decline or had low hemoglobin and/or hematocrit and had a decline or low albumin. The assessment documented the root cause analysis was Resident #11 experienced a 5.6% weight loss in 30 days. The resident's current body mass index (BMI) was 20.3, which was considered within normal limits for his height and age. Resident #11 continued to have good intakes and would consume greater than 75% of his meals. Resident #11 received liquid protein and another supplement to assist with his protein intakes. The assessment documented the weight was questioned. Glucerna was increased to twice a day to assist. The RD documented he would continue to monitor. The new intervention was to increase the supplement to twice a day. The IDT member who participated in the review was the RD. -Despite the 12/14/23 IDT note documenting the resident had a 5.6% weight loss, the resident had sustained a 6% (10.6 lbs) weight loss, which was considered significant, from 11/17/23 to 12/13/23, in one month. The physician order revealed the Glucerna eight ounces was increased to two times a day for weight management on 12/14/23. The resident went to the hospital from 1/7/24 to 1/15/24. According to the hospital records, Resident #11 weighed 165 lbs on 1/7/24. On 1/15/24, while he was still in the hospital, he weighed 165 lbs. -The resident had a 10.6 lbs weight loss prior to his admission to the hospital and he was not weighed until 1/23/24, which was eight days after his readmission, where he sustained an additional 7.2 lbs weight loss. The 1/25/24 IDT weight variance assessment documented by the RD revealed the resident weighed 159.6 lbs. The resident had lost 10% of his body weight in two months. The resident was currently receiving Glucerna or Boost Glucose Control twice a day. The resident was on a vegetarian diet. The resident previously weighed 166.8 lbs. The resident was receiving Ativian (antianxiety medication) and Morphine (pain medication). The resident was a slow eater; had poor ability to feed himself; complained of the taste of the food, disliked the food, disliked the diet and was a picky eater; and, had variable intake. The resident had a recent illness within the last 30 days, a recent significant change in medications and was on psychotropic medication. The resident had a recent illness. The resident had a decline or had low hemoglobin and/or hematocrit and had a decline or low albumin. The assessment documented the root cause analysis was Resident #11 continued to lose weight. The resident had a BMI of 19.4 which was within normal limits for his height and age. Resident #11 was a vegetarian and ordered mostly special meals. The resident said he refused meals, because the facility did not offer vegetarian options. The RD spoke with the dietary manager and they have several vegetarian options including grilled cheese, cheese pizza, bean and cheese burritos, salads, eggs and vegetable burgers. The RD notified the resident of the options and the resident said he was not aware the kitchen had these options. The RD documented the kitchen staff reported to the RD that they had notified the resident of these options previously. The RD encouraged the resident to order meal choices he wanted. The RD recommended starting the liquid protein supplement to assist with the resident's low protein status and continuing the Glucerna. The RD documented he would continue to monitor the resident. The IDT member who participated in the review was the RD.-Despite the IDT note documenting the RD met with Resident #11 regarding his vegetarian diet, the resident was not provided with vegetarian options during the survey (see observations above). The resident had a 10% (17.8 lbs) weight loss, which was considered significant, from 11/17/23 to 1/23/24, in two months. -While some nutritional interventions were implemented to address the resident's significant weight loss of 10% (17.8 lbs) from 11/17/23 to 1/23/24 (a period of two months), the facility failed to monitor the resident's weight more frequently to see if the implemented interventions were effective and the resident continued to lose weight. Liquid Protein 30 cc two times a day for low protein and skin integrity. Liquid protein 30 milliliters (ml) twice a day, mixed with juice, ordered 1/25/24. The RD said he recommended the liquid protein upon the resident's request (see interview below).-Despite the addition of the Liquid Protein intervention, the facility again failed to implement more frequent monitoring of the resident's weight to determine if the new intervention was effective, and the resident continued to lose weight. The February 2024 medication administration record (MAR) revealed Resident #11 consumed an average of 41% of the ordered Glucerna from 2/1/24 to 2/14/24. The 2/15/24 dietitian note documented the RD met with Resident #11 to review the resident's weight and discuss the menu options. The resident said he had been ordering smaller meals and was no longer ordering off the always available menu like he used to. Resident #11 reported he was a picky eater and had concerns about the food. The RD documented the nutrition services director (NSD) was present during the conversation to assist with the menu discussion. The resident reported he was a very picky eater and did not like the selection of food being offered. The RD documented he reminded the resident of the discussion they had regarding the always available menu options. The resident said he was picky regarding those options as well. The resident said he liked spaghetti with marinara, fish sticks with tarter sauce and yogurt. The RD mentioned to the resident the other options that were offered and the resident said he wanted more variety. The RD documented the current options available were reviewed with Resident #11 which included bean and cheese burritos that were currently on backorder, grilled cheese, quesadillas and Resident #11 said he needed salsa and sour cream, vegetarian burgers, salads, yogurt, fruits, eggs and other vegetables. Resident #11 raised his voice and said he was tired of those options and the facility was forcing him to purchase his own frozen meals to eat. The resident continued to raise his voice and became visibly frustrated. Resident #11 continued to criticize the quality of the food and said the food options did not meet his preferences or cooking techniques. The RD notified the resident that there are menu options the kitchen can provide and the staff can make a more personalized menu to try and assist the resident. The resident became emotional and said "I am just done with this." The RD encouraged the resident to suggest additional meals that he would like, so the facility could build a menu that represented his wants and needs. Resident #11 said he would think of options. The RD documented the resident had several organic snacks in his room that he had purchased.-The resident had a 14.2% (25.8 lbs) weight loss, which was considered significant, from 8/3/23 to 2/8/24, in six months. While interventions were put in place, the interventions were not assessed for their effectiveness. The resident only accepted Glucerna, on average, 41% of the time. -The facility did not provide the resident with his dietary preferences, which resulted in a decreased oral intake. Cross-reference F806 for preferences. The 2/15/24 weight change note documented at 7:41 a.m. revealed the resident had refused his weight that week. The RD documented he would continue to request weekly weights (see RD and resident interview). D. Staff interviewsThe RD and the NSD were interviewed together on 2/15/24 at 11:59 a.m. The RD said Resident #11 preferred to be a vegetarian. The RD said Resident #11 did eat fish. The RD said Resident #11 was a very picky eater. The RD said he would visit with the resident and try to establish the resident's food preferences and help create a menu for Resident #11 that was nutritionally balanced. The RD said Resident #11's lunch of chips and cookies was not a complete meal and did not provide the resident with adequate nutrition. The NSD said the kitchen had been offering Resident #11 alternative items such as a bean burrito, grilled cheese and cheese quesadilla. The NSD and the RD said they understood that Resident #11 was tired of the alternative options. The RD said resident preferences and nutrition interventions should be included in the care plan. The RD said the certified nurse aides (CNA) documented the resident frequently consumed greater than 75% of his meals. The RD said the CNAs should not document the resident was consuming more than 75% of his meals if he was only consuming cookies and chips. The RD said that was not a complete meal. The RD said he had not provided any recent education on accurate meal consumption documentation. The RD said the CNAs should look at the meal as a whole and refer to MyPlate (food pyramid) as a representation of a complete nutritionally balanced meal. The RD said it was important for meal intakes to be documented accurately to help with his nutritional assessments. The RD said Resident #11 triggered as a significant weight loss in December 2023. The RD said he completed an assessment and increased the Glucerna supplement to twice a day to improve oral nutrition intake. The RD said the resident triggered significant as a weight loss again in January 2024. The RD said at that time he spoke with the resident and the resident requested a protein supplement to help with his skin integrity and protein status. The RD said no further nutrition interventions had been implemented to prevent further significant weight loss. The RD said the resident's comprehensive care plan did not include the resident's significant weight loss, dietary preferences or nutrition interventions that were implemented to help prevent further weight loss. The RD said he completed the IDT assessment and did not have collaboration from other members of the team. The RD said he believed the resident's physician was aware of the weight loss but did not have any documentation indicating the physician had been notified of the significant weight loss. The RD said the facility's policy was to weigh a resident upon admission and then be weighed weekly for three to four weeks to create a baseline. The RD said if the resident's weightwas stable the resident was then weighed monthly. The RD said he had requested the nursing staff to weigh Resident #11 weekly in December 2023, so he could monitor the weights more closely. The RD said the facility did not obtain weekly weights for Resident #11. The RD said he was aware that Resident #11 refused his weekly weight on 2/15/24. The RD said he was not aware that Resident #11 preferred to stay in bed tuntil 11:00 a.m. and the staff attempted to get his weight prior to 11:00 a.m. The RD said Resident #11 had been in and out of the hospital a couple times and the resident recently got a colostomy bag. The RD said he had not reviewed the February 2024 MAR to determine if Resident #11 was accepting the Glucerna. CNC #1 was interviewed on 2/20/24 at 12:37 p.m. CNC #1 said the facility needed to review weight loss as an IDT team weekly. CNC #1 said the provider needed to be notified if a resident had a significant weight loss. CNC #1 said Resident #11's significant weight loss needed to be reviewed with the IDT to discuss nutrition interventions. III. Resident #4A. Resident statusResident #4, under the age of 65, was admitted on 3/11/23 and readmitted on 1/15/24. According to the February 2024 CPO, diagnoses included depression, hypoglycemia (low blood sugar) type one diabetes mellitus, gastroparesis (slowed movement of the stomach), visual loss, need for assistance with personal care, schizophrenia (mental illness), cocaine dependence and heart failure. The 12/27/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required set-up assistance for eating. He required supervision for oral hygiene, toileting and personal hygiene. He required substantial assistance for showering. The assessment indicated he was on a therapeutic diet. His vision was adequate and he did not have corrective lenses. -However, the resident was blind. B. Resident interviewResident #4 was interviewed on 2/13/24 at 12:59 p.m. Resident #4 said the food was not good. He said the food was often served late. He said it was difficult to manage his diabetes since the meals were frequently late. He said the facility did not follow standardized portion sizes. Resident #4 said he was blind so it made it difficult for him to know how many carbohydrates he was consuming when the portion sizes were different each day. C. Record reviewThe nutrition care plan, initiated on 9/20/23, revealed Resident #4 had potential for alteration in body composition integrity (body and fat wasting) and potential for unintended weight changes related to worsening of his condition secondary to numerous comorbidities such as: type one diabetes, schizoaffective disorder, chronic kidney disease, gastroparesis (slow stomach movement), hypertension (high blood pressure), gastro-esophageal reflux disease (GERD), depression and chronic heart failure. The interventions included obtaining and monitoring lab as ordered and reporting abnormalities to the physician, completing an occupational therapy screen as needed, providing a bowl for the resident's food if requested, providing and serving the diet as ordered, providing double portions as requested even if the resident did not eat it all as he was a picky eater, completing a nutritional evaluation as needed and completing weights per facility protocol. The meal preferences care plan, initiated on 9/2023 and revised on 10/30/23, revealed Resident #4 had a history of voicing that staff were not taking his orders correctly or some of the items he ordered were missing on his meal trays. Resident #4 preferred to have his order read back to him after being taken. Resident #4 became verbally aggressive with staff related to his food items being missed, not getting what he ordered or his order being taken incorrectly. Staff needed to take Resident #4's orders and deliver his meals with two staff members present. The interventions included anticipating and meeting the resident's needs, providing positiveinteraction, following up on grievances as needed, discussing the resident's behavior, intervening as necessary to protect the rights and safety of others, praising the resident for behavior improvement and taking the resident orders and delivering meals with a second staff member present. The diabetic care plan, initiated on 9/20/23, revealed the resident had type one diabetes mellitus that was managed by insulin and diet. Resident #4 could titrate his insulin dosing as requested for carbohydrate counting. Resident #4 was not to exceed 12 units of insulin per physician order and his history of diabetes. The interventions included administering medications as ordered, educating the resident on medications and potential side effects, referring to nephrology as indicated, allowing Resident #4 to adjust his own insulin needs based on blood sugar levels and food consumed and monitoring the resident's blood sugar before each meal and before bedtime. The visual impairment care plan, initiated on 9/20/23, revealed Resident #4 was legally blind. The interventions included announcing oneself when entering the resident's area, answering the call light timely, placing the call light within reach, ensuring there is adequate lighting, involving the resident in auditory activities, keeping the resident environment free of small objects, keeping visual devices clean and assisting as needed for placement, providing medication as ordered, monitoring the resident's eyes for irritation, monitoring for changes in ability to perform activities of daily living and providing a clean and hazard free environment. D. Staff interviewsThe RD and the NSD were interviewed together on 2/15/24 at 11:59 a.m. The RD said Resident #4 did not want nutrition education. The RD said Resident #4 was non-complaint with his diet and made his own food choices. The RD was interviewed again on 2/15/24 at 1:23 p.m. The RD said he was unable to find documentation in Resident #4's medical record that diabetic nutrition education had been offered to the resident. The RD said he attempted to provide Resident #4 diet education on 2/15/24 (during the survey process). The RD said the resident was upset regarding the portion sizes at the facility. The RD said Resident #4 said the portion sizes were never consistent which made it difficult to dose his insulin correctly. Cross-reference F804 failure to follow the correct portion size. The RD was interviewed again on 2/15/24 at 3:59 p.m. The RD said he was contracted through the facility. The RD said he reviewed his billing documentation. The RD said he found documentation that he billed for diabetic education for Resident #4 several months ago but the resident refused. The RD said there was no documentation in the resident's medical record indicating diabetic education had been offered. CNC #1 was interviewed on 2/20/24 at 12:37 p.m. CNC #1 said diabetic education should have been offered to Resident #4 and documented in his medical record if he refused it.

Based on staff interviews and record reviews, the facility failed to ensure certified nurse aides and licensed nurses were able to demonstrate competency skills and techniques necessary to care for residents' needs. This placed all residents at the facility at risk of receiving inadequate care. Specifically, the facility failed to conduct staff competency evaluations for all certified nurse aides (CNA), licensed practical nurses (LPN) and registered nurses (RN). Cross-reference F677: failure to provide adequate assistance for activities of daily living for a resident who was dependent on staff for all care. Cross-reference F684: failure to provide diabetic care per standards of care. Cross-reference F689: failure to ensure the needs of a resident with substance use disorder. Cross-reference F690: failure to provide catheter care per standards of care. Cross-reference F691: failure to provide colostomy care per standards of care. Cross-reference F692: failure to implement effective interventions to ensure resident nutrition needs were met. Cross-reference F760: failure to ensure medications were administered according to physician orders. Cross-reference F880: failure to follow appropriate infection control practice while performing prescribed procedures for residents with indwelling medical devices and wounds. Findings include:I. Facility policy The Staffing, Sufficient and Competent Nursing policy, revised August 2002, was provided by corporate nurse consultant (CNC) #1 on 2/20/24 at 12:10 p.m. It read in pertinent part: "Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with · the resident care plans and the facility assessment. "Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment."1. 'Competency' is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully."2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law."3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas:a. Resident rights;b. Behavioral health;c. Psychosocial care;d. Dementia care;e. Person-centered care;f. Communication;g. Basic nursing skills;h. Basic restorative services;i. Skin and wound care;j. Medication management;k. Pain management;I. Infection control;m. Identification of changes in condition; andn. Cultural competency."4. Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities."5. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that:a. programming for staff training results in nursing competency;b. gaps in education are identified and addressed;c. education topics and skills needed are determined based on the resident population;d. tracking or other mechanisms are in place to evaluate the effectiveness of training; ande. training includes critical thinking skills and managing care in a complex environment with multiple interruptions."II. Competency recordsThe competency skill assessment checks and associated training records were requested on 2/19/24 at 1:02 p.m. The facility was not able to provide documentation of competency or training related to areas where the staff lacked competency in performing care tasks and medical procedures for any of the facility's nursing staff including RNs, LPNs or CNAs. III. Staff interviewsCNC #1 and the newly hired nursing home administrator (NHA) were interviewed together on 12/20/24 at 1:20 p.m. CNC #1 said the facility had no record of completing any staff competency evaluations for nursing staff (CNAs, LPNs or RNs) although they should have conducted a skill fair session to ensure the nursing staff were competent with all care tasks. CNC #1 said several key members of the facility leadership team were no longer working in the facility and she and the NHA were hiring a new leadership group to manage nursing services. CNC #1 said the facility had several agency nursing staff on contract filling open nursing shifts and the leadership was in the process of assessing the staff's competency to determine which staff would be scheduled for additional shifts until the facility could hire permanent nursing staff.

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents nutritional needs. Specifically, the facility failed to:-Follow correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Follow recipe modifications for the texture modified diets. Findings include:I. Facility policy and procedureThe Kitchen Weights and Measures policy, revised April 2007, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, "Food services staff will be trained in proper use of cooking and serving measurements to maintain portion control."Staff will be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators (color-coded) on utensils will be prominently displayed for reference."The Therapeutic Diets policy, revised October 2017, was provided by CNC #1 on 2/19/24 at 4:30 p.m. It read in pertinent part, "Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences."A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: diabetic/calorie controlled diet, low sodium diet, cardiac diet; and, altered consistency diet. "If a mechanically altered diet is ordered, the provider will specify the texture modification."II. Correct portion sizesA. Observations and record reviewDuring a continuous observation during the lunch meal on 2/14/24, beginning at 11:24 a.m. and ending at 1:03 p.m., cook #1 utilized the following scoop sizes:A 2.67 ounce (oz) scoop (0.33 cup) for the cole slaw for the regular diet and the carbohydrate controlled diets. A 2.67 oz scoop (0.33 cup) for the pasta salad for the mechanically altered diets. The residents on a regular diet received one cookie.-The 2.67 oz scoop (0.33 cup), was 1.33 oz less than the 4 oz specified on the menu extension sheet for the cole slaw for the regular and carbohydrate controlled diets. -The 2.67 oz scoop (0.33 cup), was 1.33 oz less than the 4 oz specified on the menu extension sheet for the pasta salad for the mechanically altered diets. -The menu extension sheet specified the residents on a regular diet were supposed to receive two cookies. During the same continuous observation of the lunch meal on 2/14/24, the following was additionally observed:At 12:28 p.m., cook #1 placed a couple scoops of meat into the food processor. Cook #1 added approximately 0.5 cups of hot water and one scoop of powdered thickener to the food processor. Cook #1 used a spatula to put the pureed meat into a bowl. At 12:31 p.m., cook #1 put four scoops of zucchini that was sitting in water into the blender. The scoops of zucchini had a lot of water in them. Cook #1 blended the zucchini with one scoop of powdered thickener. She poured the pureed zucchini into a bowl. -Cook #1 did not use a measuring device to ensure she provided the residents on the pureed diet the correct portion size. The recipe sheet for the pureed sandwich sloppy joe on a bun specified to puree the bread and the meat separately. The residents on a pureed diet were supposed to receive one #8 scoop and two #20 scoops of bread. The recipe specified to add broth or gravy to the items if they needed thinning. -Cook #1 did not puree the bread. -The residents on a pureed diet did not receive the bread.-Cook #1 added water instead of gravy or sauce to the meat when pureeing it. The menu extension sheets indicated the residents on a pureed diet were supposed to receive a pureed cookie, a pureed sloppy joe with a bun, pureed pasta salad, pureed vegetable of the day, whole milk and a beverage of choice. -Cook #1 did not provide the residents on a pureed diet a bun, pasta salad, cookie or milk. III. Follow recipe modifications for mechanically altered diets. A. Observations and record reviewDuring a continuous observation of the lunch meal on 2/14/24, beginning at 11:24 a.m. and ending at 1:03 p.m, cook #1 served the residents on a mechanically altered diet the regular textured meat on the sloppy joes. -The menu extension sheet specified for residents on a mechanically altered diet to receive one #8 scoop of pureed meat and two #20 scoops of the pureed bun. IV. Staff interviewsThe nutrition services director (NSD) was interviewed on 2/14/24 at 4:16 p.m. The NSD said the cooks utilized the menu extension sheet to serve the correct portion sizes and texture. The NSD said cook #1 did not use the correct portion size for the cole slaw for the regular and carbohydrate controlled diet. The NSD said the menu extensions needed to be followed for mechanically altered residents. The NSD said if residents were not served the correct texture of food it put them at risk for choking. The NSD said the residents on a regular diet were supposed to get two cookies and only received one. The NSD said cook #1 needed to use broth or gravy to thin the meat. The NSD said adding water decreased the nutritional value of the food item. The NSD said cook #1 should have used scoops to ensure the residents on a pureed diet received the correct portion size. The NSD said the cooks needed to ensure all menu items that were listed on the meal extension sheets were served to the residents to meet their nutritional needs. The registered dietitian (RD) was interviewed on 2/15/24 at 11:59 a.m. The RD said the residents who were on a pureed diet did not receive adequate nutrition for lunch on 2/14/24. The RD said cook #1 needed to serve all components of the meal to the residents. The RD said cook #1 needed to utilize scoops to ensure the correct portion sizes were served to the residents. The RD said cook #1 did not serve the correct diet texture to the residents on a mechanically altered diet on 2/14/24. The RD said this put the residents at risk for choking. The RD said the menu extensions were not accurate and he would need to look at them to ensure each diet reflected what each diet type was to receive and the correct texture.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture and appearance. Findings include:I. Facility policy and procedureThe Food and Nutrition Services policy, revised October 2017, was provided by corporate nurse consultant (CNC) #1 on 1/19/24 at 4:30 p.m. It read in pertinent part, "Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident."II. ObservationsA test tray for a regular diet was evaluated by three surveyors immediately after the last resident had been served their room tray for lunch on 2/14/24 at 1:05 p.m. The test tray consisted of a sloppy joe sandwich, a bag of potato chips and coleslaw. -The individual bag of potato chips was set directly on top of the sloppy joe sandwich. -The cole slaw was 48.4 degrees fahrenheit (F). The cole slaw was bland and soggy.-The sloppy joe sandwich was greasy. III. Record reviewThe 10/11/23 food committee notes documented the residents said the food orders were not always being taken and they wanted more strawberry yogurt and jelly. The residents wanted more soups and sandwiches for dinner. The 11/9/23 food committee notes documented the residents requested the menu to be posted. The residents wanted more ice cream flavors. The 1/11/24 food committee notes documented the residents wanted deep fried breakfast burritos, hash browns, ham, chile rellenos, clam chowder, gumbo, crispy bacon, fried chicken, tacos, shrimp alfredo and beef stroganoff. IV. Resident interviewsResident #4 was interviewed on 2/13/24 at 12:59 p.m. Resident #4 said the food was not good. Resident #4 said the food was often served late. Resident #15 was interviewed on 2/13/24 at 4:07 p.m. He said the food was often served cold. He said the food was bland. Resident #15 said there were some days the food tasted so bad he was unable to eat it. Resident #1 was interviewed on 2/14/23 at 10:33 a.m. Resident #1 said the food was not good because it was served cold when it should have been hot. The resident said he was not going to eat his lunch because it did not look good to him. Resident #19 and Resident #11 were interviewed together on 2/14/24 at 1:54 p.m. Resident #11 said the food was not good. He said he was a vegetarian and ordered vegetables frequently. Resident #11 said the vegetables were over cooked and turned into mush. He said the food was not presented in a tasteful manner. Resident #11 said it often looked like someone had taken a bite out of his food. Resident #19 said both he and Resident #11 ordered a cheese quesadilla the other day that was curled up on the edges and hard. Resident #11 and Resident #19 said the food was cold and tasteless. Resident #11 and Resident #19 said they often ordered their own food because the food provided by the facility was so bad. Resident #11 and Resident #19 said the food was often dry. Resident #12 was interviewed on 2/14/24 at 4:47 p.m. Resident #12 said the food was not good. She said cold foods were often served at room temperature and hot foods were served cold. She said the kitchen often ran out of food. Resident #12 said she often had to ask for her meals to be heated. Resident #20 was interviewed on 2/15/23 at 1:45 p.m. Resident #20 said the food in the facility was usually cold by the time it was served and it did not taste good cold. V. Resident group interviewFive residents (#3, #12, #26, #29 and #27), who were identified as interviewable by the facility and assessment, were interviewed on 2/15/24 at 10:34 a.m. All of the residents interviewed said the following:-Thefood was not good; -The food was often cold;-The food was tasteless; and, -The food was often not cooked correctly. Resident #26 said she found the food committee to be a waste of her time as she had raised concerns and they were never addressed. Resident #3 and Resident #12 said they voiced their food concerns in the resident council and food committee. They said they did not feel their concerns were being addressed. VI. Staff interviewsThe nutrition services director (NSD) and CNC #1 were interviewed together on 2/14/24 at 4:16 p.m. The NSD said she had tried the coleslaw that was served for lunch (2/14/24) and said it was bland. The NSD said cook #1 was new to the department and she would provide her with education. The NSD said the coleslaw needed to be kept under 41 degrees fahrenheit for serving. The NSD said the facility had a food committee meeting once a month. CNC #1 said serving the potato chip bag on top of the sloppy joe did not make the meal look appetizing. CNC #1 said the food should be the correct temperature, tasty and look good when served to the residents.

Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for one (#11) of three residents out of 29 sample residents. Specifically, the facility failed to ensure Resident #11's requests and preferences for a vegetarian diet were served to him. Findings include:I. Facility policy and procedureThe Resident Food Preferences policy, Revised July 2017, was provided by corporate nurse consultant (CNC) #1 on 2/19/24 at 4:30 p.m. It read in pertinent part, "Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. "Upon the resident's admission (or within 24 hours after his/her admission the dietitian or nursing staff will identify the resident's food preferences."Nursing staff will document the resident's food and eating preferences in the care plan. "If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with."II. Resident #11A. Resident statusResident #11, under the age of 65, was admitted on 5/17/23 and readmitted on 1/15/24. According to the February 2024 computerized physician orders (CPO), diagnoses included quadriplegia (decreased or no control of all four limbs), neuromuscular dysfunction of the bladder (decreased movement of the bladder), hypoglycemia (low blood sugar), type one diabetes mellitus, neurogenic bowel (decreased bowel movement) and anxiety. The 2/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interview and observationDuring a continuous observation of the lunch line service on 2/14/24, beginning at 11:24 a.m. and ending at 1:03 p.m., the following was observed:At approximately 12:20 p.m. an unidentified dietary staff member put a cookie and an individual sized bag of potato chips on Resident #11's meal tray. Resident #11 was interviewed on 2/14/24 at 1:54 p.m. Resident #11 said he preferred not to eat meat. He said he had been a vegetarian for 35 years. Resident #11 said he only got a cookie and a bag of chips for lunch. He said the menu item for lunch was a sloppy joe and he was unable to eat that due to his preferences. Resident #11 said he had to purchase most of his own food since the facility did not accommodate his preference. Resident #11 said he had lost weight since he was admitted to the facility. Resident #11 said there was an alternative menu that had a grilled cheese, cheese quesadilla and a bean burrito. Resident #11 said he was tired of these options. Cross reference: F692 for nutrition. C. Record reviewThe nutrition care plan, initiated on 5/25/23 and revised on 2/15/24 (during the survey), revealed Resident #11 had potential for alteration in body composition integrity (muscle and fat wasting) and potential for unintended weight changes related to worsening condition secondary to numerous comorbidities including: type one diabetes mellitus, quadriplegia, history of pressure ulcer and depression. The interventions included: monitoring, recording and reporting to the physician signs and symptoms of malnutrition as needed (5/25/23), obtaining and monitoring lab/diagnostic work as ordered and reporting results to physician to follow up as needed (5/25/23), monitoring need for occupational therapy to screen for adaptive equipment (5/25/23), providing and serving supplements as ordered (2/15/24, added during the survey), providing and serving diet as ordered (5/25/23), offering vegetarian items per resident preferences and obtaining preferences (2/15/24, added during the survey), evaluating the resident by the registered dietitian (RD) as needed (5/25/23) and obtaining weights per facility protocol (5/25/23). III. Resident group interviewFive residents (#3, #12, #26, #29 and #27), who were identified as interviewable by the facility and assessment, were interviewed on 2/15/24 at 10:34 a.m. All of the residents interviewed said the following:-Their meal orders were not always taken;-They often were served food they did not order; and,-They would like their orders to be taken everyday and wanted the kitchen staff to follow what was written on the meal tickets. Resident #27 said he ate in his room. He said he requested double portions for all meals. Resident #27 said he often did not get double portions and was hungry afterwards. Resident #12 said she ordered a side of coleslaw with her meal yesterday (2/14/24) and did not get it. IV. Staff interviews The nutrition services director (NSD) was interviewed on 2/14/24 at 4:16 p.m. The NSD said the certified nurse aides (CNA) were responsible for taking the residents' orders. The NSD said food preferences, such as Resident #11's, should be on the resident's care plan. The NSD said she did not update the residents' care plans. The NSD said if she thought something needed to be on the care plan she would notify the RD. The NSD said the kitchen provided whatever Resident #11 wrote on his meal ticket. The NSD and the RD were interviewed together on 12/15/23 at 11:59 a.m. The RD said Resident #11 preferred to be a vegetarian. The RD said Resident #11 did eat fish. The RD said Resident #11 purchased a lot of his own food. The RD said Resident #11 was a picky eater. The RD said he would visit with the resident and try to establish the resident's food preferences and help create a menu for Resident #11 that was nutritionally balanced. The RD said resident preferences should be included in the care plan. The RD said Resident #11's lunch of chips and cookies was not a complete meal and did not provide the resident with adequate nutrition. The NSD said the kitchen had been offering Resident #11 the alternative items such as a bean burrito, grilled cheese and cheese quesadilla. The NSD and the RD said they understood that Resident #11 was tired of the alternative options.

Based on record review and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to medication errors. Findings include: I. Facility policyThe Quality Assurance and Performance Improvement (QAPI) Program policy, revised February 2020, was provided by the interim director of nursing (IDON) on 3/7/24 at 2:40 p.m. It revealed in pertinent part,"The objectives of the QAPI Program are to:"Provide a means to measure current and potential indicators for outcomes of care and quality of life."Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators."Reinforce and build upon effective systems and processes related to the delivery of quality care and services."Establish systems through which to monitor and evaluate corrective actions."The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include:A. Tracking and measuring performance;B. Establishing goals and thresholds for performance measurement;C. Identifying and prioritizing quality deficiencies;D. Systematically analyzing underlying causes of systemic quality deficiencies;E. Developing and implementing corrective action or performance improvement activities; andF. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed."The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan."II. Respeat deficiencies The facility ' s recertification survey on 9/28/23 included F760 (residents are free of significant medication errors) cited at actual harm scope and severity, isolated. III. Significant medication errors Cross-reference F760 failure to prevent significant medication errors. During the 3/5/24 survey, the facility was cited for significant medication errors which rose to the scope and severity of immediate jeopardy. The facility failed to ensure medications were available from the pharmacy and ensure medications were given according to the physician's orders. IV. Staff interviewsThe nursing home administrator (NHA) and IDON were interviewed on 3/8/24 at 1:30 p.m. They said the QAPI committee met monthly. They said from September 2023 through today 3/8/24 the facility had several NHAs. They said the committee evaluated the root cause of problems, reviewed plans and made sure the right departments took care of the needed problems. They said from September 2023 up until recently, notes for the QAPI meetings were requested from former NHAs but the facility was never provided with any notes from the QAPI meetings. The IDON said she was unaware that the same citation that was given this week was cited in September 2023. She said she was unaware if the committee discussed the F760 from September 2023. The NHA and IDON said the upcoming QAPI meeting would discuss the issues with medication errors to ensure it was resolved. V. Facility follow-upThe IDON provided the following plan on 3/6/24 at 3:15 p.m. to address significant medication errors in upcoming QAPI meetings. "The Administrator implemented a QAPI PIP (quality assurance and performance improvement, performance improvement plan) as a means to gather and process information from the audit. Findings will be reported at the monthly QAA meeting for a minimum of 3 months."

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to:-Follow aseptic technique when replacing Resident #15's suprapubic catheter; and -Follow aseptic technique when performing Resident #18's wound care. Findings include:I. Suprapubic Catheter insertion procedure for Resident #15A. Professional referencesAccording to Dawson, B.C. 2001, (8/16/21) Nursing Standards, How to Change a Suprapubic Catheter Effectively, retrieved on 2/27/24 from https://journals.rcni.com/nursing-standard/how-to-series/how-to-change-a-suprapubic-catheter-effectively-ns. 2021.e11766/abs, "A suprapubic catheter is inserted through the lower abdominal wall, above the pubic bone and below the navel, and into the bladder."A suprapubic catheter change is an aseptic procedure that was undertaken to reduce the risk of infection at the catheter site and in the tract, which has direct access to the bladder."According to Alsolami, F. and Tayyib, N., 9/24/23 International Journal of Urological Nursing: Nurse's knowledge and practice towards prevention of catheter-associated urinary tract infection: A systematic review, retrieved on 2/27/24 from, https://onlinelibrary.wiley.com/doi/full/10.1111/ijun. 12380"Catheter-associated urinary tract infection (CAUTI) is a common complication associated with indwelling urinary catheters, frequently used in healthcare settings. Nurses play a critical role in preventing CAUTI, as they are often responsible for inserting, maintaining and removing urinary catheters. Therefore, it is important to comprehensively assess nurses' level of knowledge about CAUTIs and the variables that influence their application of best practices and recommendations for preventing these infections."Complications from catheter-associated urinary tract infections (CAUTIs) can extend hospital stays, cause patient discomfort, and raise medical expenses and death. 1 Meanwhile, catheterization of the urinary tract is a routine hospital operation with a high risk of hospital-acquired urinary tract infections (UTIs). It is responsible for over 70% of all UTIs. Similarly, an indwelling urinary catheter (IUC) is the leading risk factor for CAUTIs."Several barriers to preventing CAUTIs include age, gender, work experience, professional qualification, in-service training, lack of adherence to guidelines, time, equipment, staff availability, and working unit were identified. The review also identified facilitators for preventing CAUTIs, including ongoing/in-service education and self-instructed modules. These educational interventions have improved nurses' knowledge and adherence to prevention guidelines, in addition to applying the competency outcomes and performance assessment-based training programs for nurses to prevent CAUTIs."Therefore, to avoid UTIs, nurses should be well-trained in properly caring for catheters and how to use them."B. Facility policyThe Suprapubic Catheter Care policy, revised October 2010, was provided by corporate nurse consultant (CNC) #1 on 2/20/24 at 12:10 p.m. It read in pertinent part,: "The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract."Steps in procedure: 1. Place the clean equipment on the bedside stand or overbed the table. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly ..."-Note hand hygiene was step two after the staff was instructed to handle the catheter care supplies. The Catheter Care, Urinary policy, revised August 2022, was provided by CNC #1 on 2/20/24 at 12:10 p.m. It read in pertinent part, "The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections."Follow aseptic technique when insertinga urinary catheter. Maintain a closed drainage system when possible."The Handwashing Hand Hygiene policy, revised October 2023, was provided by CNC #2 on 2/20/24 at 12:13 p.m. It read in penitent part, "This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.-"Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device), after contact with blood, body fluids, or contaminated surfaces, after touching a resident, after touching the resident's environment,before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal."D. Observation On 2/14/24 at 11:10 a.m., registered nurse (RN) #1 was observed changing Resident #15's suprapubic catheter. RN #1 entered the resident's room with gloved hands holding a catheter change kit. The resident was already in bed and lying flat. RN #1 explained the procedure to the resident and uncovered the resident exposing the suprapubic catheter site. Without glove removal, hand hygiene, or setting up a clean or sterile field, RN #1 pulled open the lid of the new sterile catheter kit with the same gloved hands he had just uncovered and positioned the resident with and set the new catheter kit directly on top of the resident bedding. RN #1 reached his dirty gloved hands into the new/sterile catheter kit and removed the new prefilled syringe meant to inflate the new catheter after insertion. RN #1 was about to place the new sterile syringe on the catheter balloon port to remove the saline inside so the old catheter could be removed when he realized the syringe was already full of saline. RN #1 stared at the syringe for a few minutes and placed it back into the new sterile catheter kit. RN #1 reached for the resident's used irrigation syringe and attempted to place it onto the catheter's balloon port, but in his attempts to fit the syringe onto the balloon catheter, he realized it was too big to fit and would not pull any fluid out of the balloon port. RN #1 left the resident's room and returned with the same gloves on and a new empty syringe. RN #1 opened the syringe, placed it on the old catheter's balloon port, extracted the saline holding the old catheter in place and gently slipped the old catheter out of the resident's suprapubic catheter insertion site. RN #1 coiled the removed old catheter in his right gloved hand until the trash can was brought to him for disposal. RN #1 then used his right gloved hand to adjust his own surgical mask and proceeded to the next step of replacing Resident #15's suprapubic catheter without changing his gloves or performing hand hygiene. RN #1 picked up the new catheter, tore off the protective wrapping from the tip of the catheter and used his other hand to pick up and tear open a small packet of lubricant. RN #1 dripped some lubricant on the tip of the catheter and then, without cleaning or lubricating the suprapubic stoma site, inserted the new catheter. RN#1 grabbed the new prefilled saline syringe, uncapped it, attached it to the new catheter balloon port and inflated the balloon to make sure the new catheter would stay in place. RN #1 gave the newly placed catheter a light tug to make sure it was in place and ended the procedure. Cross-reference F726 competent nursing staffE. InterviewsRN #1 was interviewed on 2/11/24 at 12:33 p.m. RN #1 said hand hygiene should be performed prior to performing a supra pubic catheter change and gloves should be worn during the procedure. RN #1 said after the old catheter was removed the nurse should remove the used gloves and perform hand hygiene before inserting the new catheter. RN #1 said the suprapubic stoma site should be cleaned and lubricated just before the insertion of the new catheter. Once the new catheter was in place, the nurse should inflate the catheter balloon to hold the new catheter in place. Once the procedure was completed the nurse was to clean up the supplies. CNC #1 was interviewed on 2/20/24 at 12:37 p.m. CNC #1 said RN #1 did not perform hand hygiene properly when he replaced Resident #15's suprapubic catheter. II. Wound care procedure for Resident #18A. Facility policyThe Wound Care Policy was received on 2/20/24 at 12:10 p.m. from CNC #1. It read in pertinent part: "Use disposable cloth (paper towel is adequate) to establish a clean field on the resident's bedside table. Place all items to be used during the procedure on the clean field. Arrange all the supplies so they can be easily reached. Wash and dry hands thoroughly. Place disposable cloth next to the resident under the wound to serve as a barrier to protect the bed linens and other body sites. Put on exam gloves and loosen tape and remove dressing. Pull the gloves over the removed dressing and discard in the appropriate receptacle. Wash and dry your hands thoroughly. Use sterile gloves when physically touching the wound or holding a moist surface over the wound. Apply treatments as necessary. Dress wound. Mark tape with initials, time, and date and apply dressing." B. ObservationOn 2/14/24 at 11:45 a.m., the wound care nurse (WCN) entered the Resident #18's room with wound care supplies, including tape. -The WCN did not wash her hands before entering the resident's room and setting up the supplies to perform wound care. -The WCN set up the wound care supplies on the resident's nightstand without first cleaning the surface that was cluttered with an open drink, candy, stacks of paper, and painting supplies. The resident transferred herself from her wheelchair to the bed and lowered her pants to expose her sacral (tailbone area) wound. -Without performeng hand hygiene, the WCN put on exam gloves and proceeded to remove the resident's soiled dressing from the sacral wound. -Without performing hand hygiene and changing her gloves, the WCN proceeded to open the clean dressing supplies with the same exam gloves on her hands she had used to remove the soiled wound dressing from the resident's wound. -The WCN next handled the opened clean wound dressing supplies and moved the supplies, setting them directly on the resident's bed without a secondary clean field barrier. -The WCN nurse removed her used exam gloves and put on another pair of exam gloves but did not perform hand hygiene between the glove change. The WCN proceeded to clean Resident #18's sacral wound with saline and walked to the wastebasket to throw away the soiled wound care materials. -The WCN removed her used gloves and, without performing hand hygiene, put on another pair of gloves and packed the resident's wound, using her hands, with dry Kerlix (gauze). The WCN covered the wound with a large butterfly shaped dressing and reinforced the dressing with tape. C. Staff interviewsThe WCN was interviewed on 2/14/24 at 1:00 p.m. The WCN said she was new to the facility and her start date was 2/12/24. The WCN said she did not have wound care certification but would be working toward obtaining wound care certification in the near future. The wound care nurse said that regular glove changes during wound care was the key to infection control. The WCN said preserving a clean work station for dressing materials was also important. CNC #1 was interviewed on 2/20/24 at 1:30 p.m. CNC #1 said nurses performing wound care should wash their hands prior to starting wound care. She said nurses should set up a clean field for supplies, wash their hands and put on clean gloves after removing the old dressing and disposing of it, prior to cleansing the wound and prior to applying a new dressing to prevent the potential spread of infection. CNC #1 said the facility would ensure that the WCN obtained wound care certification.

A survey prompted by complaint #CO35237 was completed on 2/13/24 to 3/7/24. Four deficiencies were cited.

Based on observations, interviews and record review the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#15 and #11) of three residents reviewed for catheter care out of 29 sample residents. Resident #15 admitted to the facility for long term care on 2/28/22 with a diagnosis of depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The facility failed to provide the resident with catheter care per standards of practice, which resulted in Resident #15 being admitted to the hospital on 1/14/24 and diagnosed with severe sepsis (blood infection) related to a catheter associated urinary tract infection (CAUTI). The hospital paperwork documented the CAUTI was related to poor hygiene and catheter care. The hospital paperwork documented the resident was soaked in urine upon arrival to the emergency department. The resident had a large sacral decubitus ulcer and cellulitis of the scrotum likely associated with poor hygiene. The resident was started on intravenous (IV) antibiotics. The resident was readmitted to the facility on 1/17/24 and continued on IV Meropenem (an antibiotic medication) until 2/5/24. Additionally, the facility failed to provide consistent catheter care for Resident #11. Findings include:I. Professional reference According to the Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 6/6/19), retrieved on 3/1/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf, "Proper Techniques for Urinary Catheter Maintenance: Following aseptic insertion of the urinary catheter, maintain a closed drainage system. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment."Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. Maintain unobstructed urine flow. Keep the catheter and collecting tube free from kinking. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor."Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container."Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system."Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised."Routine hygiene is appropriate. If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction."I. Professional reference According to the Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 6/6/19), retrieved on 3/1/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf, "Proper Techniques for Urinary Catheter Maintenance: Following aseptic insertion of the urinary catheter, maintain a closed drainage system. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment."Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. Maintain unobstructed urine flow. Keep the catheter and collecting tube free from kinking. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor."Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container."Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system."Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised."Routine hygiene is appropriate. If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction."II. Facility policy and procedureThe Catheter Care, Urinary policy, revised August 2022, was provided by the corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, "The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections."Empty the collection bag at least every eight hours using a separate, clean collection container for each resident. Avoid splashing, and prevent contact of the drainage spigot with the nonsterile container."III. Resident #15A. Resident statusResident #15, under the age of 65, was admitted on 2/28/22 and readmitted on 1/17/24. According to the February 2024 computerized physician orders (CPO), diagnoses included sepsis (infection of the blood), urinary tract infection (UTI), depression, quadriplegia, neurogenic bladder (slow movement of the bladder), neuromuscular dysfunction of bladder and colostomy status. The 2/10/24 facility assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff for all activities of daily living (ADLs). The facility assessment documented the resident had an indwelling catheter, had a UTI within the last 30 days and had septicemia (blood infection). B. Resident interview and observationsResident #15 was interviewed on 2/13/24 at 4:07 p.m. Resident #15 said he had a catheter. He said his catheter was not emptied for an extended period of time in January 2024. He said his catheter backed up and soaked all of his clothes. He said because of this he got a UTI and ended up with sepsis. Resident #15 said he also got a wound on his scrotum because of the moisture from the catheter backing up. He said the staff at the facility did not clean his scrotum well, which also led to the development of the wound. At 5:20 p.m. Resident #15's catheter bag was hanging over the edge of his electric wheelchair. The catheter bag was three-fourths full of urine. The resident did not have a leg anchor to attach the catheter bag to his leg to alleviate the catheter from pulling. Resident #15 said the facility did not provide him with leg anchors which caused a pulling sensation on his bladder. He said it hurt when the catheter bag was pulled. He said he had a midline IV access site on his arm that was no longer in use. Resident #15 said he was on IV antibiotics after being in the hospital in January 2024. Resident #15 was interviewed again on 2/14/24 at 8:59 a.m. Resident #15 said he refused to shower yesterday (2/13/24) because he was in a lot of pain. He said he did refuse care at times because he did not feel the staff knew what they were doing. Resident #15 said he would refuse to go to bed because he was afraid the staff would leave him in bed and he would not have access to his call light for assistance. Resident #15's call light was not within reach during the interview. His call light was clipped onto his bedside table which was pushed up against his roommate's bed. Resident #15 was unable to get his power wheelchair close enough to the call light to initiate it. Because of his quadriplegia, Resident #15's call light was initiated by him blowing into it. Resident #15 said he preferred to stay in his power wheelchair, so if he needed help he could use his wheelchair to go down the hallway and find staff. Resident #15 said when his clothes were wet it caused him to have spasms that caused him to sweat and caused pain. He said his clothes were soaking wet. Resident #15 had a one inch hole in the tubing of his catheter. Resident #15 said his body was itching and it felt like his skin was burning because his clothes were so wet. C. Record reviewThe urinary care plan, initiated on 1/2/23 and revised on 1/5/23, revealed Resident #15 had a suprapubic catheter due to his diagnosis of a neurogenic bladder. The interventions included: providing the resident with a 24 French suprapubic catheter, positioning the catheter bag and tubing below the level of the bladder, changing the catheter as needed for displacement, infection and obstruction, checking the tubing for kinks when providing care to the resident and each shift, monitoring and documenting signs of pain or discomfort due to the catheter and monitoring and recording and reporting signs or symptoms of a UTI to the physician. The February 2024 CPO revealed Resident #15 had the following physician orders related to his catheter:-Suprapubic catheter size French #24/30 milliliters (ml) balloon. Monitor every shift for placement and functioning. Change as needed if dislodged, leaking or plugged, ordered 10/4/23;-Change suprapubic catheter 24 French, 10 cubic centimeter (CC) bulb attached to gravity drainage bag as needed for being pulled out, leaking or plugged, ordered 6/12/23;-Flush suprapubic catheter with 60 ml of normal saline at bedtime every Friday for patency, ordered 12/22/23; and,-Exchange suprapubic catheter immediately for infection, ordered 2/14/24. The 1/15/24 emergency department encounter note documented in pertinent part, "The resident had significant skin breakdown around his abdominal wall and his scrotum and was soaked in urine upon arrival." The 1/15/24 infectious disease hospital note documented in pertinent part, "The resident presented to have purulence (pus) around the suprapublic site." The 1/16/24 hospitalist progress note documented in pertinent part, "The resident had likely recurrent CAUTI related to poor hygiene and catheter care. The resident had scrotal cellulitis and his urine was growing mixed flora (an unusual growth of multiple types of bacteria)." The 1/17/24 inpatient hospital pain progress note documented in pertinent part, Resident #15 arrived at the emergency department and was found to be tachycardic (rapid heart rate), tachypneic (rapid breathing), febrile (fever) with an elevated white blood cell and lactate meeting systematic inflammatory response syndrome (SIRS) (an exaggerated defense response from your body to a harmful stressor) criteria. The patient had a large sacral decubitus (open wound) ulcer and cellulitis (infection of the skin) of his scrotum likely associated with poor hygiene. IV antibiotics were initiated. IV. Resident #11A Resident status Resident #15, under the age of 65, was admitted on 5/17/23 and readmitted on 10/12/23. According to the February 2024 CPO diagnosis included quadriplegia, neuromuscular neurogenic dysfunction of the bladder (lack of bladder control), overactive bladder, benign prostatic hyperplasia with lower urinary tract infection and diabetes. The 2/14/24 facility assessment revealed the resident was cognitively intact with a BIMS with a score of 15 out of 15. The resident had impaired functional ability on both sides of the upper (shoulders, elbows, wrists and hands) and lower (hips, knees, ankles and feet) extremities due to quadriplegia and used a motorized wheelchair to get around. The resident needed substantial assistance with personal grooming and was dependent on staff to complete most ADLs. The resident did not reject or refuse care. The resident had an indwelling catheter (suprapubic catheter). B. Resident interview and observationResident #11 was interviewed on 2/15/24 at 10:02 a.m. Resident #11 said the staff did not check on his catheter regularly to empty his leg drainage bag when it was full. He said he usually had to ask staff to empty the bag unless it was bedtime and staff emptied the bag to change it over to the larger overnightbag. -At the time of the interview, the resident's urine drainage bag was more than two-thirds full and bulging with dark amber urine. Resident #11 was interviewed on 2/15/24 at 1:33 p.m. Resident #11 said staff had not emptied his drainage bag today (2/15/24) and the floor nurse had not checked his suprapubic stoma (insertion site) since yesterday (2/14/24). Resident #11 said he was experiencing some abdominal discomfort. -At the time of the interview, the resident's urine drainage bag was full almost to the section of the bag where the tubing entered the ag. The drainage bag was bulging with amber-colored urine. Resident #11 said the nurses were supposed to irrigate his suprapubic catheter twice a day and he was lucky if they irrigated the catheter once a day. C. Record reviewThe February 2024 CPO revealed the following physician orders related to Resident #11's suprapubic catheter: -Irrigate the suprapubic catheter twice a day with sterile water at 7:00 a.m. and bedtime, start date 9/11/23; and, -Suprapubic catheter #24 French with a 5 cubic centimeters (cc) bulb, drain to a gravity drainage bag. Monitor placement and patency during and after care every shift (6:00 a.m., 2:00 p.m. and 10:00 p.m.) every shift., start date 5/23/23. Review of Resident #11's December 2023 treatment administration records (TAR) revealed irrigation of the resident's suprapubic catheter was not completed on the following dates:-12/27/23 at 7:00 a.m.; and,-At bedtime on 12/9/23, 12/10/23, 12/17/23, 12/21/23, 12/22/23, 12/23/23, 12/26/23 and 12/31/23. Review of Resident #11's January 2024 treatment TAR revealed irrigation of the resident's suprapubic catheter was not completed on the following dates:-1/18/24 at 7:00 a.m.; and,-At bedtime on 1/21/24, 1/27/24 and 1/28/24. Review of the December 2023 TAR revealed monitoring for placement and patency of Resident #11's suprapubic catheter was not completed on the following dates:-12/27/23 at 6:00 a.m.; and,-12/9/23, 12/10/23, 12/17/23, 12/21/23, 12/22/23, 12/23/23, 12/26/23 and 12/31/23 at 2:00 p.m. Review of the January 2024 TAR revealed monitoring for placement and patency of Resident #11's suprapubic catheter was not completed on the following dates:-1/18/24 at 6:00 a.m.;-1/21/24 and 1/27/24 at 2:00 p.m.; and,-1/21/24 at 10:00 p.m. -A review of the medical record revealed no documentation of why the treatments were not provided. Progress notes revealed the resident had complications with the resident's catheter being dislodged. The condition was discovered on 12/11/23 during the scheduled order for the nurse to monitor the catheter for placement. The comprehensive care plan, revised on 10/13/23, revealed a care focus on managing the resident's suprapubic catheter with the goal of ensuring that the resident remained free from catheter-related trauma. Interventions included providing catheter care every shift, monitoring, documenting and reporting signs and symptoms of urinary tract infection. -There were no interventions to address the physician's order to irrigate the resident catheter. V. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/14/24 at 9:59 a.m. RN #1 said Resident #15 had a catheter. RN #1 said the certified nurse aides (CNA) were responsible for emptying the resident's catheter bag when needed. RN #1 said he observed Resident #15's catheter around 7:30 a.m. on 2/14/24 and did not notice any abnormalities. RN #1 said he did not empty the catheter bag at that time and noted it to have approximately 350 ml of urine in it. CNC #1 was interviewed on 2/14/24 at 10:08 a.m. CNC #1 said she had just visited with Resident #15. CNC #1 said Resident #15 had a hole in his catheter tubing and his clothes were soaked in urine. CNC #1 said the staff were replacing the catheter and providing the resident dry clothing. CNC #1 said Resident #15 needed a shower as it appeared he had not had one in a while. CNC #1 said the care Resident #15 received was not acceptable. CNC #1 said the resident had emotional harm and was in distress when she was in his room that morning. CNC #1 said Resident #15 had been admitted to the hospital in January 2024 with sepsis related to a UTI. RN #1 was interviewed again on 2/14/24 at 2:59 p.m. He said hand hygiene should be performed prior to catheter care. He said it was important to wear gloves. RN #1 said the first step to performing catheter care was assessing the resident's blood pressure and the output of the catheter. RN #1 said he would then gently remove the catheter. RN #1 said he would then dispose of the old catheter, take off his gloves, perform hand hygiene and put new gloves on. RN #1 said he then cleaned the area and lubricated the area. RN #1 said he would then insert the catheter and inflate the balloon based on the physician's orders. RN #1 said he would then gently tug on the catheter to ensure it was patent. RN #1 said he would ensure the catheter was draining. RN #1 said he would then remove his gloves and perform hand hygiene. CNC #1 was interviewed again on 2/15/24 at 3:27 p.m. She said catheter bags needed to be emptied once a shift or as needed. CNC #1 said the nurse should visually look at the catheter every shift to ensure it was functioning properly. CNC #1 was interviewed again on 2/20/24 at 12:37 p.m. CNC #1 said Resident #15's concerns regarding his care were valid. CNC #1 said she understood why Resident #15 refused care at times. CNC #1 said the facility needed to rebuild rapport with Resident #15 to help reduce his care refusals.

Based on observations, record review and interviews, the facility failed to ensure two (#11 and #4) of two residents out of 29 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #11 was admitted to the facility for long term care on 5/17/23 for long term care with diagnoses of quadriplegia (decreased or no control of all four limbs), neuromuscular dysfunction of the bladder (decreased movement of the bladder), hypoglycemia (low blood sugar), type I diabetes mellitus, neurogenic bowel (decreased bowel movement) and anxiety. Upon admission, Resident #11 weighed 188 pounds (lbs) and he reported he preferred to eat vegetarian meals. Resident #11 was started on Glucerna (diabetic nutritional supplement) once a day on 7/20/23. On 7/6/23, Resident #11 weighed 182.4 lbs. Resident #11 had lost 5.6 lbs, which was not considered significant. On 12/13/23, Resident #11 weighed 166.8 lbs. Resident #11 lost 10.6 lbs or 6% (percent) of his body weight in one month, which was considered significant. At this time the registered dietitian (RD) completed an assessment and increased Resident #11's Glucerna to twice a day. Resident #11 often refused the Glucerna. Resident #11 lost an additional 7.2 lbs from 12/13/23 to 1/23/24. On 1/25/24 30 cubic centimeters (cc) of liquid protein was ordered two times a day for the resident's skin and protein status. On 2/8/24, Resident #11 weighed 156.4 lbs. Resident #11 lost 25.8 lbs (14.2%) from 8/3/23 to 2/8/24, a period of six months, which was considered significant. The facility failed to implement person centered effective nutritional interventions, meet the resident's dietary preferences to prevent significant weight loss and consistently weigh the resident to monitor his weight. Additionally, the facility failed to offer diabetic education to Resident #4 upon admission and ongoing throughout his stay at the facility. Findings include:I. Facility policy and procedureThe Nutrition (Impaired)/Unplanned Weight loss-Clinical protocol, revised September 2017, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, "The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. "The physician will help identify medical conditions (cancer, cardiac or renal disease, depression, dental problems) and medications that may be causing weight gain or loss or increasing risk for either gaining or losing weight. "The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting)."The Therapeutic Diets policy, revised October 2017, was provided by CNC #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, "A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). "A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet."The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. "The dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical record. "If the resident or the resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives."II. Resident #11A. Resident statusResident #11, under the age of 65, was admitted on 5/17/23 and readmitted on 1/15/24. According to the February 2024 computerized physician orders (CPO), diagnoses included quadriplegia (decreased or no control of all four limbs), neuromuscular dysfunction of the bladder (decreased movement of the bladder), hypoglycemia (low blood sugar), type I diabetes mellitus, neurogenic bowel (decreased bowel movement) and anxiety. The 2/14/24 facility assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial assistance with eating, oral hygiene, toileting and personal hygiene. He was dependent on staff for showering. The assessment documented the resident was 76 inches (six foot, four inches) tall and weighed 156 lbs. It indicated the resident had no weight loss or weight gain in the last six months. -However, Resident #11 had sustained a significant weight loss of 25.8 lbs (14.2%) in the last six months. B. Observations and resident interviewDuring a continuous observation of the lunch meal service on 2/14/24 beginning at 11:24 a.m. and ending at 1:03 p.m., the following was observed:At approximately 12:20 p.m., an unidentified dietary staff member put a cookie and an individual sized bag of potato chips on Resident #11's meal tray. Resident #11 was interviewed on 2/14/24 at 1:54 p.m. Resident #11 said he preferred not to eat meat. He said he had been a vegetarian for 35 years. Resident #11 said he only got a cookie and a bag of chips for lunch. He said the menu item was a sloppy joe and he was unable to eat it due to his preferences. Resident #11 said he had to purchase most of his own food since the facility did not accommodate his preferences. Resident #11 said he had lost weight since he was admitted to the facility. Resident #11 did not feel his nutrition needs were being met. Resident #11 said he preferred to stay in bed until 11:00 a.m. Resident #11 said if he got up before then he was in his wheelchair for several hours which caused him pain (see weight change note below). C. Record reviewThe nutrition care plan, initiated on 5/25/23 and revised on 2/15/24 (during the survey), revealed Resident #11 had potential for alteration in body composition integrity (muscle and fat wasting) and potential for unintended weight changes related to worsening condition secondary to numerous comorbidities including: type one diabetes mellitus, quadriplegia, history of pressure ulcer and depression. The interventions included: monitoring, recording and report to the physician signs and symptoms of malnutrition as needed (5/25/23), obtaining and monitoring lab/diagnostic work as ordered and reporting results to physician to follow up as needed (5/25/23), monitoring need for occupational therapy to screen for adaptive equipment (5/25/23), providing and serving supplements as ordered (2/15/24, added during the survey), providing and serving diet as ordered (5/25/23), offering vegetarian items per resident preferences and obtaining preferences (2/15/24, added during the survey), evaluating the resident by the registered dietitian (RD) as needed (5/25/23) and obtaining weights per facility protocol (5/25/23). Resident #11's weights were documented in the resident's medical record as follows:-On 5/18/23, the resident weighed 188 lbs; -On 6/14/23, the resident weighed 185.5 lbs; -On 7/16/23, the resident weighed 182.4 lbs; -On 7/31/23, the resident weighed 182.6 lbs;-On 8/3/23, the resident weighed 182.2 lbs; -On 8/14/23, the resident weighed 182.4 lbs; -On 9/7/23, the resident weighed 175.8 lbs; -On 11/10/23, the resident weighed 177.4 lbs; -On 11/17/23, the resident weighed 177.4 lbs; -On 12/13/23, the resident weighed 166.8 lbs; -On 1/23/24, the resident weighed 159.6 lbs; and, -On 2/8/24, the resident weighed 156.4 lbs. -The resident lost 25.8 lbs (14.2%) from 8/3/23 to 2/8/24 in six months, which was considered significant. The 7/8/21 preadmission screening and resident review (PASRR) documented the resident preferred to eat a vegetarian diet. The PASRR documented vegetarian diet options should be offered to the resident at every meal. The 5/18/23 dietary interview assessment documented Resident #11 had a good appetite. Resident #11 said he preferred to have 2% milk and cranberry juice to drink at breakfast and dinner. The resident did not like to snack between meals. Resident #11 did not like fried eggs and did not eat meat. The resident was on a regular diet and did not have any food allergies. The resident was aware the alternative meals were available upon request. The resident preferred to eat in his room. The resident typically ate breakfast, lunch and dinner. The resident preferred to follow a vegetarian diet and enjoyed cheese sandwiches, quesadillas, fish, eggs, salads and burritos for lunch and dinner. The 12/14/23 interdisciplinary (IDT) weight variance assessment documented by the registered dietitian (RD) revealed the resident weighed 166.8 lbs and had lost 5.6% of his body weight in one month (however, the resident had sustained a 6% weight loss in one month). The resident was currently receiving Glucerna or Boost Glucose Control (diabetic nutritional supplement) once a day and liquid protein. The resident was on a vegetarian diet. The resident previously weighed 177.4 lbs. The resident was receiving Ativian (antianxiety medication) and Morphine (pain medication). The resident was a slow eater; had poor ability to feed himself; complained of the taste of the food, disliked the food, disliked the diet and was a picky eater; and, had variable intake. The resident had a recent illness within the last 30 days, a recent significant change in medications and was on psychotropic medication. The resident had a recent illness. The resident had a decline or had low hemoglobin and/or hematocrit and had a decline or low albumin. The assessment documented the root cause analysis was Resident #11 experienced a 5.6% weight loss in 30 days. The resident's current body mass index (BMI) was 20.3, which was considered within normal limits for his height and age. Resident #11 continued to have good intakes and would consume greater than 75% of his meals. Resident #11 received liquid protein and another supplement to assist with his protein intakes. The assessment documented the weight was questioned. Glucerna was increased to twice a day to assist. The RD documented he would continue to monitor. The new intervention was to increase the supplement to twice a day. The IDT member who participated in the review was the RD. -Despite the 12/14/23 IDT note documenting the resident had a 5.6% weight loss, the resident had sustained a 6% (10.6 lbs) weight loss, which was considered significant, from 11/17/23 to 12/13/23, in one month. The physician order revealed the Glucerna eight ounces was increased to two times a day for weight management on 12/14/23. The resident went to the hospital from 1/7/24 to 1/15/24. According to the hospital records, Resident #11 weighed 165 lbs on 1/7/24. On 1/15/24, while he was still in the hospital, he weighed 165 lbs. -The resident had a 10.6 lbs weight loss prior to his admission to the hospital and he was not weighed until 1/23/24, which was eight days after his readmission, where he sustained an additional 7.2 lbs weight loss. The 1/25/24 IDT weight variance assessment documented by the RD revealed the resident weighed 159.6 lbs. The resident had lost 10% of his body weight in two months. The resident was currently receiving Glucerna or Boost Glucose Control twice a day. The resident was on a vegetarian diet. The resident previously weighed 166.8 lbs. The resident was receiving Ativian (antianxiety medication) and Morphine (pain medication). The resident was a slow eater; had poor ability to feed himself; complained of the taste of the food, disliked the food, disliked the diet and was a picky eater; and, had variable intake. The resident had a recent illness within the last 30 days, a recent significant change in medications and was on psychotropic medication. The resident had a recent illness. The resident had a decline or had low hemoglobin and/or hematocrit and had a decline or low albumin. The assessment documented the root cause analysis was Resident #11 continued to lose weight. The resident had a BMI of 19.4 which was within normal limits for his height and age. Resident #11 was a vegetarian and ordered mostly special meals. The resident said he refused meals, because the facility did not offer vegetarian options. The RD spoke with the dietary manager and they have several vegetarian options including grilled cheese, cheese pizza, bean and cheese burritos, salads, eggs and vegetable burgers. The RD notified the resident of the options and the resident said he was not aware the kitchen had these options. The RD documented the kitchen staff reported to the RD that they had notified the resident of these options previously. The RD encouraged the resident to order meal choices he wanted. The RD recommended starting the liquid protein supplement to assist with the resident's low protein status and continuing the Glucerna. The RD documented he would continue to monitor the resident. The IDT member who participated in the review was the RD.-Despite the IDT note documenting the RD met with Resident #11 regarding his vegetarian diet, the resident was not provided with vegetarian options during the survey (see observations above). The resident had a 10% (17.8 lbs) weight loss, which was considered significant, from 11/17/23 to 1/23/24, in two months. -While some nutritional interventions were implemented to address the resident's significant weight loss of 10% (17.8 lbs) from 11/17/23 to 1/23/24 (a period of two months), the facility failed to monitor the resident's weight more frequently to see if the implemented interventions were effective and the resident continued to lose weight. Liquid Protein 30 cc two times a day for low protein and skin integrity. Liquid protein 30 milliliters (ml) twice a day, mixed with juice, ordered 1/25/24. The RD said he recommended the liquid protein upon the resident's request (see interview below).-Despite the addition of the Liquid Protein intervention, the facility again failed to implement more frequent monitoring of the resident's weight to determine if the new intervention was effective, and the resident continued to lose weight. The February 2024 medication administration record (MAR) revealed Resident #11 consumed an average of 41% of the ordered Glucerna from 2/1/24 to 2/14/24. The 2/15/24 dietitian note documented the RD met with Resident #11 to review the resident's weight and discuss the menu options. The resident said he had been ordering smaller meals and was no longer ordering off the always available menu like he used to. Resident #11 reported he was a picky eater and had concerns about the food. The RD documented the nutrition services director (NSD) was present during the conversation to assist with the menu discussion. The resident reported he was a very picky eater and did not like the selection of food being offered. The RD documented he reminded the resident of the discussion they had regarding the always available menu options. The resident said he was picky regarding those options as well. The resident said he liked spaghetti with marinara, fish sticks with tarter sauce and yogurt. The RD mentioned to the resident the other options that were offered and the resident said he wanted more variety. The RD documented the current options available were reviewed with Resident #11 which included bean and cheese burritos that were currently on backorder, grilled cheese, quesadillas and Resident #11 said he needed salsa and sour cream, vegetarian burgers, salads, yogurt, fruits, eggs and other vegetables. Resident #11 raised his voice and said he was tired of those options and the facility was forcing him to purchase his own frozen meals to eat. The resident continued to raise his voice and became visibly frustrated. Resident #11 continued to criticize the quality of the food and said the food options did not meet hispreferences or cooking techniques. The RD notified the resident that there are menu options the kitchen can provide and the staff can make a more personalized menu to try and assist the resident. The resident became emotional and said "I am just done with this." The RD encouraged the resident to suggest additional meals that he would like, so the facility could build a menu that represented his wants and needs. Resident #11 said he would think of options. The RD documented the resident had several organic snacks in his room that he had purchased.-The resident had a 14.2% (25.8 lbs) weight loss, which was considered significant, from 8/3/23 to 2/8/24, in six months. While interventions were put in place, the interventions were not assessed for their effectiveness. The resident only accepted Glucerna, on average, 41% of the time. -The facility did not provide the resident with his dietary preferences, which resulted in a decreased oral intake. The 2/15/24 weight change note documented at 7:41 a.m. revealed the resident had refused his weight that week. The RD documented he would continue to request weekly weights (see RD and resident interview). D. Staff interviewsThe RD and the NSD were interviewed together on 2/15/24 at 11:59 a.m. The RD said Resident #11 preferred to be a vegetarian. The RD said Resident #11 did eat fish. The RD said Resident #11 was a very picky eater. The RD said he would visit with the resident and try to establish the resident's food preferences and help create a menu for Resident #11 that was nutritionally balanced. The RD said Resident #11's lunch of chips and cookies was not a complete meal and did not provide the resident with adequate nutrition. The NSD said the kitchen had been offering Resident #11 alternative items such as a bean burrito, grilled cheese and cheese quesadilla. The NSD and the RD said they understood that Resident #11 was tired of the alternative options. The RD said resident preferences and nutrition interventions should be included in the care plan. The RD said the certified nurse aides (CNA) documented the resident frequently consumed greater than 75% of his meals. The RD said the CNAs should not document the resident was consuming more than 75% of his meals if he was only consuming cookies and chips. The RD said that was not a complete meal. The RD said he had not provided any recent education on accurate meal consumption documentation. The RD said the CNAs should look at the meal as a whole and refer to MyPlate (food pyramid) as a representation of a complete nutritionally balanced meal. The RD said it was important for meal intakes to be documented accurately to help with his nutritional assessments. The RD said Resident #11 triggered as a significant weight loss in December 2023. The RD said he completed an assessment and increased the Glucerna supplement to twice a day to improve oral nutrition intake. The RD said the resident triggered significant as a weight loss again in January 2024. The RD said at that time he spoke with the resident and the resident requested a protein supplement to help with his skin integrity and protein status. The RD said no further nutrition interventions had been implemented to prevent further significant weight loss. The RD said the resident's comprehensive care plan did not include the resident's significant weight loss, dietary preferences or nutrition interventions that were implemented to help prevent further weight loss. The RD said he completed the IDT assessment and did not have collaboration from other members of the team. The RD said he believed the resident's physician was aware of the weight loss but did not have any documentation indicating the physician had been notified of the significant weight loss. The RD said the facility's policy was to weigh a resident upon admission and then be weighed weekly for three to four weeks to create a baseline. The RD said if the resident's weight was stable the resident was then weighed monthly. The RD said he had requested the nursing staff to weigh Resident #11 weekly in December 2023, so he could monitor the weights more closely. The RD said the facility did not obtain weekly weights for Resident #11. The RD said he was aware that Resident #11 refused his weekly weight on 2/15/24. The RD said he was not aware that Resident #11 preferred to stay in bed tuntil 11:00 a.m. and the staff attempted to get his weight prior to 11:00 a.m. The RD said Resident #11 had been in and out of the hospital a couple times and the resident recently got a colostomy bag. The RD said he had not reviewed the February 2024 MAR to determine if Resident #11 was accepting the Glucerna. CNC #1 was interviewed on 2/20/24 at 12:37 p.m. CNC #1 said the facility needed to review weight loss as an IDT team weekly. CNC #1 said the provider needed to be notified if a resident had a significant weight loss. CNC #1 said Resident #11's significant weight loss needed to be reviewed with the IDT to discuss nutrition interventions. III. Resident #4A. Resident statusResident #4, under the age of 65, was admitted on 3/11/23 and readmitted on 1/15/24. According to the February 2024 CPO, diagnoses included depression, hypoglycemia (low blood sugar) type one diabetes mellitus, gastroparesis (slowed movement of the stomach), visual loss, need for assistance with personal care, schizophrenia (mental illness), cocaine dependence and heart failure. The 12/27/23 facility assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required set-up assistance for eating. He required supervision for oral hygiene, toileting and personal hygiene. He required substantial assistance for showering. The assessment indicated he was on a therapeutic diet. His vision was adequate and he did not have corrective lenses. -However, the resident was blind. B. Resident interviewResident #4 was interviewed on 2/13/24 at 12:59 p.m. Resident #4 said the food was not good. He said the food was often served late. He said it was difficult to manage his diabetes since the meals were frequently late. He said the facility did not follow standardized portion sizes. Resident #4 said he was blind so it made it difficult for him to know how many carbohydrates he was consuming when the portion sizes were different each day. C. Record reviewThe nutrition care plan, initiated on 9/20/23, revealed Resident #4 had potential for alteration in body composition integrity (body and fat wasting) and potential for unintended weight changes related to worsening of his condition secondary to numerous comorbidities such as: type one diabetes, schizoaffective disorder, chronic kidney disease, gastroparesis (slow stomach movement), hypertension (high blood pressure), gastro-esophageal reflux disease (GERD), depression and chronic heart failure. The interventions included obtaining and monitoring lab as ordered and reporting abnormalities to the physician, completing an occupational therapy screen as needed, providing a bowl for the resident's food if requested, providing and serving the diet as ordered, providing double portions as requested even if the resident did not eat it all as he was a picky eater, completing a nutritional evaluation as needed and completing weights per facility protocol. The meal preferences care plan, initiated on 9/2023 and revised on 10/30/23, revealed Resident #4 had a history of voicing that staff were not taking his orders correctly or some of the items he ordered were missing on his meal trays. Resident #4 preferred to have his order read back to him after being taken. Resident #4 became verbally aggressive with staff related to his food items being missed, not getting what he ordered or his order being taken incorrectly. Staff needed to take Resident #4's orders and deliver his meals with two staff members present. The interventions included anticipating and meeting the resident's needs, providing positive interaction, following up on grievances as needed, discussing the resident's behavior, intervening as necessary to protect the rights and safety of others, praising the resident for behavior improvement and taking the resident orders and delivering meals with a second staff member present. The diabetic care plan, initiated on 9/20/23, revealed the resident had type one diabetes mellitus that was managed by insulin and diet. Resident #4 could titrate his insulin dosing as requested for carbohydrate counting. Resident #4 was not to exceed 12 units of insulin per physician order and his history of diabetes. The interventions included administering medications as ordered, educating the resident on medications and potential side effects, referring to nephrology as indicated, allowing Resident #4 to adjust his own insulin needs based on blood sugar levels and food consumed and monitoring the resident's blood sugar before each meal and before bedtime. The visual impairment care plan, initiated on 9/20/23, revealed Resident #4 was legally blind. The interventions included announcing oneself when entering the resident's area, answering the call light timely, placing the call light within reach, ensuring there is adequate lighting, involving the resident in auditory activities, keeping the resident environment free of small objects, keeping visual devices clean and assisting as needed for placement, providing medication as ordered, monitoring the resident's eyes for irritation, monitoring for changes in ability to perform activities of daily living and providing a clean and hazard free environment. D. Staff interviewsThe RD and the NSD were interviewed together on 2/15/24 at 11:59 a.m. The RD said Resident #4 did not want nutrition education. The RD said Resident #4 was non-complaint with his diet and made his own food choices. The RD was interviewed again on 2/15/24 at 1:23 p.m. The RD said he was unable to find documentation in Resident #4's medical record that diabetic nutrition education had been offered to the resident. The RD said he attempted to provide Resident #4 diet education on 2/15/24 (during the survey process). The RD said the resident was upset regarding the portion sizes at the facility. The RD said Resident #4 said the portion sizes were never consistent which made it difficult to dose his insulin correctly. The RD was interviewed again on 2/15/24 at 3:59 p.m. The RD said he was contracted through the facility. The RD said he reviewed his billing documentation. The RD said he found documentation that he billed for diabetic education for Resident #4 several months ago but the resident refused. The RD said there was no documentation in the resident's medical record indicating diabetic education had been offered. CNC #1 was interviewed on 2/20/24 at 12:37 p.m. CNC #1 said diabetic education should have been offered to Resident #4 and documented in his medical record if he refused it.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for one (#15) of four residents reviewed for ADL care assistance out of 29 sample residents. Resident #15 admitted to the facility for long term care on 2/28/22 with diagnoses of depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The resident was dependent on staff for all of his ADLs. The resident expressed not getting out of his wheelchair, not bathing or receiving oral hygiene in weeks and not getting assistance with his meals regularly. The resident felt uncomfortable, itchy and his skin was burning due to not being bathed and wearing the same clothes for days. The resident said his current status affected his state of mind, he was frustrated and did not want to live anymore. Due to the facility's failure to provide adequate assistance to Resident #15 for his ADLs, the resident experienced a decline in his state of mind. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADLs), Supporting policy, revised March 2018, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It revealed in pertinent part, "Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene."Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care); mobility (transfer and ambulation, including walking); elimination (toileting), dining (meals and snacks); and, communication (speech, language, and any functional communication systems)."Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. "If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate." II. Resident #15 A. Resident statusResident #15, under the age of 65, was admitted on 2/28/22 and readmitted on 1/17/24. According to the February 2024 computerized physician orders (CPO), diagnoses included sepsis (infection of the blood), urinary tract infection (UTI), depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The 2/10/24 minimum data set facility assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #15 was dependent on staff for all ADLs including bathing, personal hygiene and eating. The assessment documented the resident had an indwelling catheter, colostomy, had a UTI within the last 30 days and had septicemia (blood infection). The resident's mood interview revealed the resident scored a 15 on the depression scale indicating the resident was experiencing moderate to severe depression. Theinterview revealed the resident had little interest or pleasure in doing things; was feeling down, depressed or hopeless; was having trouble falling asleep, staying asleep or sleeping too much; was feeling tired or having little energy; had a poor appetite; was feeling bad about himself; had troubles concentrating; had thoughts he would be better off dead or of hurting himself in some way. The resident did not reject care assistance or present with any behavioral symptoms. The 3/28/23 facility assessment documented the resident interview for daily preferences indicated it was very important for the resident to choose what to wear; choose between a tub bath, shower, bed bath or sponge bath; choose bedtime; and be able to go outside to get fresh air when the weather was good. B. Resident interview and observation Resident #15 was interviewed on 2/13/24 at 4:07 p.m. Resident #15 said he had a lot of concerns regarding his care. Resident #15 said he refused to go to bed because he was afraid the staff would leave him in bed and he would not have access to his call light for assistance. -During the interview, Resident #15's call light was not within reach. His call light was clipped onto his bedside table. The bedside table was pushed up against his roommate's bed. Resident #15 was unable to get his power wheelchair close enough to the call light to initiate it. Resident #15 had a call light that was activated by the resident blowing into it. Resident #15 said he preferred to stay in his power wheelchair so if he needed help he could use his wheelchair to go down the hallway and find staff. Resident #15 said he preferred to have showers on Tuesdays, Thursdays and Saturdays before breakfast was served. Resident #15 said he received pain medication around 4:00 a.m. to 5:00 a.m., 12:00 p.m. and in the evening. Resident #15 said he had a lot of pain due to his condition and preferred to have a shower in the morning after his first dose of pain medication because he was in the least amount of pain at that time. -During the interview, Resident #15 had body odor, food on his clothes, his teeth were yellow and he had bad breath. Resident #15 said he often stayed in the same clothes for four to five days at a time. Resident #15 said he was embarrassed and felt like his body and breath smelled bad. Resident #15 said he had a catheter. He said his catheter was not emptied for an extended period of time in January 2024. He said his catheter backed up and soaked all of his clothes. He said because of this, he got a urinary tract infection (UTI) and ended up with sepsis. Resident #15 said he got a wound on his scrotum because of the moisture from the catheter backing up. He said the staff at the facility did not clean his scrotum well which also led to the development of the wound. Resident #15 said when he got to the hospital his clothes were soaked in urine from his shoulders to his toes. Resident #15 said his skin was itchy and dry. Resident #15 said he would ask staff to lotion his hands and feet but they would tell him they were busy. -Resident #15's hands and feet were observed to be dry and flaky. Resident #15's toenails were long and beginning to curl around the tip of his toes. Resident #15 said the staff only assisted him with eating french fries for lunch. -The resident's lunch tray was on his bed that had a sandwich, a glass of milk and a dessert all which were wrapped in plastic wrap. Resident #15 was interviewed again on 2/14/24 at 8:59 a.m. Resident #15 said he refused to shower yesterday (2/13/24) because he was in a lot of pain. Resident #15 said he did refuse care at times because he did not feel the staff knew what they were doing. Resident #15 said he was unsure of the last time he had a shower or had his teeth brushed. Resident #15 was observed to have a one inch hole in the tubing of his catheter. Resident #15 said his body was itching and it felt like his skin was burning because his clothes were so wet due to the hole in his catheter tubing. Resident #15 said when his clothes were wet it caused him to have spasms that caused him to sweat and caused pain. Resident #15 said his clothes were soaking wet. Resident #15 had sweat dripping from his forehead which he said was a symptom of his body spasms. Resident #15 said the care he received affected his state of mind. He said he felt frustrated and did not want to live anymore. Resident #15 began crying during the interview. During the interview, Resident #15 continued to have body odor, bad breath and yellowed teeth. Resident #15 had a white build-up around his mouth. He said he was extremely thirsty and starving. Resident #15 said his colostomy was full of gas that morning (2/14/24). Resident #15 said he had not been assisted with his breakfast and he was so hungry his stomach was full of gas. -Resident #15 had a breakfast tray on his bedside table that had half a bagel and two links of sausage. -Resident #15's lunch tray from 2/13/24 remained on his bed. The sandwich and dessert were still wrapped in plastic wrap. Resident #15 said the staff did not assist him with his meal for lunch the previous day (2/13/24). -There was a glass of milk on the resident's table that was room temperature to touch and had a dead fly in it. C. Record reviewThe ADL care plan, initiated on 1/2/23 and revised on 9/26/23, revealed Resident #15 had an ADL self-care performance deficit due to a traumatic spinal cord injury 12 years ago resulting in quadriplegia. The interventions included providing the resident with an electric wheelchair for mobility, providing total assistance with bathing, checking and trimming nails as needed, providing total assistance for bed mobility, providing total assistance for dressing, providing total assistance with eating, providing total assistance for personal hygiene and oral care, providing total assistance for toileting, providing total assistance of two staff members and mechanical lift for transfers, providing physical and occupational evaluations as needed and providing a restorative nursing program. The psychosocial care plan, initiated on 9/26/23, revealed Resident #15 had a history of refusing care and services which were within his rights. Resident #15 frequently refused to go to bed and refused care and treatments. Resident #15 frequently attempted to split staff and make false allegations of being denied care. Two staff members should be present when providing care to the resident. The interventions included providing behavioral and psychological services as indicated, collaborating with the interdisciplinary team to identify underlying causes of refusals, determining Resident #15's experiences and preferences to eliminate triggers, encouraging active participation with care, encouraging to set up a schedule for care which was acceptable for him, informing the resident of risks and ramifications of continued non-compliance and re-approaching the resident when he refused care. The 1/15/24 emergency department encounter note documented in pertinent part, "The resident had significant skin breakdown around his abdominal wall and his scrotum and was soaked in urine upon arrival." According to the resident and staff interviews, the resident was supposed to be bathed three times per week. -However, his bathing day preferences were not indicated in the medical record. The November 2023 shower documentation revealed Resident #15 received a bath on 11/9/23, 11/11/23, 11/16/23 and 11/25/23.-It indicated Resident #15 was provided bathing on four of 13 opportunities. The December 2023 shower documentation revealed Resident #15 received a bath on 12/14/23, 12/16/23, 12/21/23, 12/23/23, 12/28/23 and 12/30/23.-It indicated Resident #15 was provided bathing on six of 13 opportunities. The January 2024 shower documentation revealed Resident #15 received a bath on 1/2/24, 1/6/24 and 1/23/24. -It indicated the resident was provided bathing on three of 12 opportunities. The February 2024 shower documentation revealed Resident #15 received a bath on 2/6/24 and 2/13/24.-It indicated Resident #15 was provided bathing on two of six opportunities. -However, despite the shower records documenting the resident received a bath on 2/13/24, Resident #15 said he refused his shower on 2/13/24 due to pain (see resident interviews above). -Certified nurse aide (CNA) #1 said he did not provide Resident #15 a shower on 2/13/24 because the resident refused. -Review of the resident's medical record revealed there were no progress notes to indicate why the resident refused showers on multiple dates or that the staff had attempted to try at another time to complete the shower when he refused. -The medical record did not reveal the resident preferred to shower prior to breakfast related to his pain levels. III. Staff interviewsCNC #1 was interviewed on 2/14/24 at 10:08 a.m. CNC #1 said she had just visited with Resident #15. CNC #1 said Resident #15 had a hole in his catheter tubing and his clothes were soaked in urine. CNC #1 said the staff were replacing the catheter and providing the resident with dry clothing. CNC #1 said she was unsure why CNA #1 documented the resident had a shower yesterday (2/13/24) because it was clear the resident had not had a shower in awhile. CNC #1 said the care Resident #15 received was not acceptable. CNC #1 said the resident had emotional harm and was in distress when she was in his room that morning (2/14/24). CNC #1 said Resident #15 had been admitted to the hospital in January 2024 with sepsis related to a UTI. CNC #1 said the UTI was related to the resident's poor hygiene (cross-reference S708 for catheter care). CNA #1 was interviewed on 2/15/24 at 10:05 a.m. He said there was a piece of paper in the nurses station that had the shower schedule on it. CNA #1 said Resident #15 preferred to have showers on Tuesdays, Thursdays and Saturdays. CNA #1 said he did not give Resident #15 a shower on 2/13/24. CNA #1 said Resident #15 refused his shower and only wanted to be shaved. CNA #1 said he did not remember documenting that he gave Resident #15 a shower on 2/13/24. CNA #1 said Resident #15 refused his shower on 2/13/24 because he was in pain. CNA #1 said he wrote that the resident refused due to pain and put it in a box outside the director of nursing's (DON) office. CNA #1 said he did not talk to the licensed nurse on the unit regarding the resident's shower refusal due to pain. CNC #1 was interviewed again on 2/15/24 at 3:27 p.m. CNC #1 said the staff spoke with Resident #15 regarding his shower time. CNC #1 said it made sense that Resident #15 preferred to have his showers prior to breakfast due to his pain levels. CNC #1 said she would assist the facility in creating new shower preferences for all of the residents who resided at the facility. CNC #1 said there were a lot of holes in Resident #15's shower documentation indicating he missed showers. CNC #1 said some days it was documented that he had several showers. CNC #1 said the staff needed education on proper shower documentation. CNC #1 was interviewed again on 2/20/24 at 12:37 p.m. CNC #1 said Resident #15's concerns regarding his care were valid. CNC #1 said she understood why Resident #15 refused care at times. CNC #1 said the facility needed to rebuild rapport with Resident #15 to help reduce his care refusals. CNA #2 was interviewed on 2/20/24 at 1:56 p.m. She said CNAs were responsible for providing oral care to the residents. CNA #2 said oral hygiene should be performed when getting the resident ready for the day and when assisting them to bed.

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

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 complaint survey, prompted by #CO34167 and #CO34169 was conducted on 11/20/23 to 11/29/23. No deficiencies were cited.

A revisit survey was completed on 11/27/23 for all previous deficiencies cited on 9/28/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 11/27/23 for all previous deficiencies cited on 9/28/23. The facility is in compliance with all regulations surveyed.

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K0000), are informational only and a representation of the facility's general characteristics. The facility is a one story of Type II (111) construction. A partial basement is used for support service and is not used by residents. The basement has an exterior exit to grade level. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. The facility was licensed for 85 beds and operated as a non-secured facility at the time of this survey. The survey was conducted on October 17, 2023, for compliance to fire safety requirements of NFPA 101, Life Safety Code (LSC), 2012 Edition, Chapter 19 for "Existing Health Care Occupancies". The facility will meet these requirements when the following deficiencies are corrected. The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section NFPA 101. 1. Delayed egress door not working by room 482. Double egress doors need two mag locks installed so both sides are delayed egress enabled 3. Laundry room exit door racked (difficult to open)NFPA 101, 7.2.1.6.1.1 A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS or PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 30 SECONDS (if approved by the local fire department) (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds,NFPA 101: 7.2.1.4.5.1 The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to open the leaf to the minimum required width, This 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 and Maintenance director at the exit conference.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101. 1. Emergency Lighting - No records for Oct 22- Feb 23 available for review 2. Exit Lighting - No records for Oct 22- Feb 23 available for reviewNFPA 101, 7.9.2.3. The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting. NFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. (3) An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This 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 and maintenance director at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section NFPA 101. 1. Need to relocated exit sign by dietary office | Exit sign needs to be moved back to direct toward exit doorNFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner. NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. 1. Kitchen Suppression - 6 month inspection overdue | Facility states it was completed no report available for review | Previous suppression report shows system failed but does not mention what failed 2. Kitchen Hood Cleaning - Report dated 07/20/23 does not document that roof hood system components were cleaned 3. Kitchen suppression system yellow tagged NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer installation instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this smoke compartment of the facility. Deficient items were discussed with the Administrator at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. Fire Alarm - Facility did not have an semi-annual report available for the fire alarm systemNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility did not have Fire Alarm out of service guidance in accordance with NFPA 101. Out of Service Fire Alarm Guidance - Does not include verbiage for state web page notification- Documentation has old facility namesNFPA 101 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 service. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011.18 inches of clearance not maintained at reception desk 2. Sprinkler gauges out of date (Dated 2018 Reports showed June 2018) NFPA 13 8.5.5.3* Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3. NFPA 25: 5.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. 5.3.2.2 Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This 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 and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility did not have Sprinkler System out of service guidance in accordance with NFPA 101 and NFPA 25. Out of Service Fire Sprinkler Guidance - Does not include verbiage for state web page notification- Documentation has old facility namesNFPA 101, 9.7.6 Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:(1) The extent and expected duration of the impairment have been determined.(2) The areas or buildings involved have been inspected and the increased risks determined.(3) Recommendations have been submitted to management or the property owner or designated representative.(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:(a) Evacuation of the building or portion of the building affected by the system out of service(b) *An approved fire watch(c)*Establishment of a temporary water supply(d)* Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire(5) The fire department has been notified.(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.(7) The supervisors in the areas to be affected have been notified.(8) A tag impairment system has been implemented. (See Section 15.3.)(9) All necessary tools and materials have been assembled on the impairment site. This 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 and maintenance director at the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1and NFPA 54, 7.9.2.1. This was evidenced by the following:1. Gas orifice on dryer rated for 0-2000 feet in elevation in the laundry room | Facility needs high altiltude orifice installed NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 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 instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

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

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1. Generator Weekly - No inspection records available Dec 22 - Feb 232. Generator Battery Conductance - No monthly records available for review 3. Generator Monthly - No inspection records available Dec 22 - Feb 234. Generator Monthly Transfer Switch: No monthly records available for reviewNFPA 110:8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

A licensure survey was completed on 9/25/23 to 9/28/23. One deficiency was cited.

Based on observation, record review and interviews, the facility failed to ensure two (#272 and #7) residents out of 28 sample residents were free from significant medication errors. Resident #272, was admitted on 5/17/23 for long term care with a goal to return home. The resident was prescribed medication of Ativan for his anxiety disorder. The facility ran out of the prescribed medications and he missed 18 doses of Ativan across six days from 9/4/23 to 9/9/23. The facility failed to implement effective interventions to prevent the resident from running out of his medications (discovered on 9/4/23) from progressing to the resident experiencing withdrawal symptoms and subsequently being hospitalized on 9/10/23 (six days after the facility identified the medication was out of stock). In addition, the facility failed to: -Ensure medications were ordered from the pharmacy STAT (urgent or rushed) to prevent missed medication doses for Resident #272;-Ensure nurses were educated on the availability and use of the emergency medication kit;-Ensure the emergency medication kit was accessible to nursing staff;-Ensure nurses were educated on the side effects and signs and symptoms of benzodiazepine withdrawals.-Ensure insulin (medications used to regulate blood glucose levels) pens were primed prior to medication administration for Residents #7. Findings include: I. Resident #272A. Professional referenceAccording to American Addiction Center, Benzo Withdrawl Symotoms Symptoms accessed on 10/9/23 at https://americanaddictioncenters.org/benzodiazepine/length-of-withdrawal, it read n pertinent part, "Benzodiazepines (Benzo) are all designed as central nervous system depressants; however, they each may work slightly differently at targeting certain symptoms. "Withdrawal side effects are not generally lethal, although they are best managed with professional medical attention and supervision."Benzo withdrawal symptoms may include:NauseaPanic attacksTremorsAnxietySweatingHeadachesHeart palpitationsMuscle painSeizures"Most benzodiazepine (benzo) withdrawal symptoms start within 24 hours and can last from a few days to several months, depending on the length of the abuse and the strength of the benzo used."B. Facility policy and procedureThe Medication Order and Receipt Record policy, last revised April 2007, was provided by the nursing home administrator (NHA) on 9/28/23. The policy read in part, "Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. Emergency medications ordered and or received shall also be entered into the medication order and receipt record. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than 3 days prior to the last dosage being administered to ensure that refills are readily available."C. Resident statusResident #272, age under 65 years old, was admitted on 5/17/23. According to the September 2023 computerized physician orders (CPO) diagnoses included major depressive disorder, recurrent, moderate anxiety disorder and quadriplegia. According to the facility assessment dated 8/14/23 the resident had intact cognition with a score of 15 out of 15 for the brief interview mental status (BIMS). The resident did not have any rejection of care behaviors and required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and hygiene. D. Resident interviewResident #272 was interviewed on 9/26/23 at approximately 11:00 a.m. The resident said he went into withdrawal because the facility did not want to give him his prescribed medication which led to him calling 911 and being hospitalized to get the medicine and care he needed. He said after missing four days of medications that were prescribed three times a day he became agitated, scared, restless and confused. He physically had suffered from sweating, shaking, racing thoughts, headaches and abdominal cramps. The resident said the staff did not seem to care or recognize that he was having withdrawal side effects. The resident said he even informed the staff he was not feeling right but they did not take action. The resident said he had to call 911 because the facility did not want to get him medications in time and they did not want to send him out to a hospital. E. Record reviewThe September 2023 computerized physician orders revealed the resident was ordered Ativan oral tablet 0.5 MG (Lorazepam); give one tablet by mouth three times a day related to anxiety disorder, unspecified. The September 2023 medication administration record (MAR) revealed the resident had missed 18 doses of Ativan across six days from 9/4/23 to 9/9/23 (see below). 9/4/23Morning doseThe MAR read the drug was not given and to review the nursing progress note.-The 9/4/23 9:26 a.m. nursing progress note was reviewed on 9/27/23 it revealed "Ativan was reordered."Mid day doseThe MAR read the drug was not given and to review the nursing progress note.-The 9/4/23 11:35 a.m. nursing progress note was reviewed on 9/27/23 it revealed "Awaiting delivery for Ativan."Night doseThe MAR read the drug was not given and to review the nursing progress note.-The 9/4/23 8:46 p.m. nursing progress note was reviewed on 9/27/23 it revealed "Ativan was reordered and the pharmacy was called."9/5/23Morning doseThe MAR entry was not completed by the nurse and therefore the administration record was blank. Mid day doseThe MAR read the medication was held by the physician due to lack of availability of the medication. Night doseThe MAR read the medication was held by the physician due to lack of availability of the medication. 9/6/23Morning doseThe MAR entry read the medication was administered by a nurse.-The drug was still not available at the time and the medication was on hold by the physician due to lack of availability. Mid day doseThe MAR entry was not completed by the nurse and therefore the administration record was blank. Night doseThe MAR read the medication was held by the physician due to lack of availability of the medication. 9/7/23Morning doseThe MAR read the medication was held by the physician due to lack of availability of the medication. Mid day doseThe MAR read the medication was held by the physician due to lack of availability of the medication. Night doseThe MAR read the medication was held by the physician due to lack of availability of the medication. 9/8/23Morning doseThe MAR read the medication was held by the physician due to lack of availability of the medication. Mid day doseThe MAR read the medication was held by the physician due to lack of availability of the medication. Night doseThe MAR read the drug was not given and to review the nursing progress note.-The 9/8/23 nursing progress note was reviewed on 9/27/23 it revealed no notes were entered related to Ativan. 9/9/23Morning doseThe MAR read the drug was not given and to review the nursing progress note.-The 9/9/23 nursing progress note was reviewed on 9/27/23 it revealed no notes were entered related to Ativan for the morning dose. Mid day doseThe MAR read the drug was not given and to review the nursing progress note. The 9/9/23 2:11 p.m. nursing progress note was reviewed on 9/27/23 it revealed "Ativan 0.5 mg out of stock,provider notified of needing medication script after nurse spoke to pharmacy. Medication script to be provided to the pharmacy."Night doseThe MAR read the drug was held because the resident was hospitalized.-The 9/9/23 8:20 p.m. nursing progress note was reviewed on 9/27/23 it revealed the resident was hospitalized. Review of the progress notes from 9/4/23 to 9/9/23 did not capture the resident had a change of condition. The progress notes address the Ativan medication was out of stock and what was mentioned (see above). The hospital discharge notes dated 9/10/23 at 12:02 a.m. read "the resident was hospitalized for benzodiazepine withdrawal. (Benzodiazepines are depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures). It is important to talk to your provider about weaning you off your Ativan. It is very important that wean off on a scheduled medically supervised taper, as weaning off too rapidly can be dangerous."The 9/10/23 progress note documented the resident returned from the hospital. Per hospital report, the residnet was diagnosed with urinary tract infection (UT) and ordered antibiotics for seven days. After Ativan was restarted, the resident stated he was feeling better. -However, a review of the hospital discharge notes in the resident's medical record revealed the resident was hospitalized for benzodiazpine withdrawl (see above). There were no documentation of the resident's stay in the hospital or of the resident having a UTI. F. Staff InterviewsLicensed practical nurse (LPN) #1 was interviewed on 9/26/23 at 6:17 p.m. He said he would reorder medications once he realized a specific medication was out of stock. Once he identified a medication was out of stock he would let his supervisor know, notify the provider and the pharmacy. He said he was unfamiliar with benzodiazepine withdrawal signs and symptoms and he was unfamiliar with the potential side effects of missing benzodiazepine medications consecutively for a few days. The pharmacy consultant was interviewed on 9/27/23 at 5:05 p.m. She said when medications were running low on stock (approximately three days prior to medications running out) the nurse should place an order through contacting the pharmacy the facility works with. The pharmacy consultant said she reviewed the resident's MAR for the month of September 2023 and said the resident missed 18 doses, however, she did not have any recommendations or concerns for the facility because at the time she reviewed the MAR the situation was resolved since the facility received the out of stock medications by 9/10/23. The director of nursing (DON) was interviewed on 9/27/23 at 5:07 p.m. She said the Ativan was out of stock and the resident missed his doses from 9/4/23 to 9/10/23. The side effects of stopping a benzodiazepine without weaning them off could lead someone to become uncomfortable, anxious, experience panic attacks, sweat and having headaches. The DON said she was uncertain as to why he missed so many doses because she had an emergency kit in her office and a backup pharmacy. The DON said during the time period the medications were out of stock, the facility had access to Ativan in the emergency kit in her office. The emergency kit in her office had seven days of mediations available for someone that has Ativan ordered three times a day. The facility coordinator (FC) was interviewed on 9/28/23 at 9:11 a.m. She said the facility dropped the ball regarding the resident's benzodiazepine withdrawal due to the medications being out of stock. The nursing home administrator (NHA) and the FC were interviewed on 9/28/23 at 10:05 a.m. They said they were not aware of the missed medication doses until it was identified during the survey process. The process to obtain out of stock medications were the nurses' responsibility. The medication should be ordered through pharmerica and the medications should be ordered upon identifying there was a seven day supply left. The nurse should call the physician to notify them and call the pharmacy to order the medication. The nurse has the option to order the medication immediately (STAT) which would be delivered within two to four hours. No staff in the facility knew about the emergency medication kit in the DON's office, therefore no staff used it. They said the nurses would be trained on the use of the emergency kit and the nurses would document low stock medications on the nursing shift report which will be reviewed by administration the following morning to ensure medications were always stocked. The emergency kit would be moved out of the DON's office and stored on each medication cart to promote ease of accessibility. II. Resident #7A. Professional reference According to the Lantus insulin package insert, retrieved on 10/3/23 from:https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf "instructions for use; do a safety test before each injection to: check pen and the needle to make sure they were working properly. To make sure that you get the correct Lantus dose. Select 2 units by turning the dose selector until the dose pointer was at the two mark. Press the injector button all the way in. when insulin comes out the needle tip your pen was working correctly: this may need to be repeated up to three times before seeing insulin. If no insulin comes out after the third time, the needle may be blocked." B. Facility policyThe Insulin Administration policy and procedure, revised September 2014, was received from the nursing home administrator (NHA) on 9/28/23 at 12:27 p.m. It revealed in pertinent part, "to provide guidelines for the safe administration of insulin to residents with diabetes."C. Resident statusResident #7, younger than 65 years old, admitted on 2/8/22. According to the September 2023 computerized physician orders (CPO), diagnoses included type two diabetes mellitus (abnormal blood glucose) and chronic kidney disease (abnormal kidney function). The 7/31/23 facility assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The facility assessment revealed the resident received insulin for the past seven days. D. Physician ordersThe CPO documented: "Lantus solo star solution pen-injector 100 units/milliliter (ml) Inject 25 units subcutaneous every evening for diabetes."E. ObservationsOn 9/26/23 at 4:49 p.m. licensed practical nurse (LPN) #1 was administering medications to Resident #7. He collected the Lantus solo star pen, applied a new needle cap to the pen and dialed the pen to 25 units. LPN #1 injected the insulin into the resident's right arm. LPN #1 failed to prime the insulin pen prior to dialing up the ordered 25 units of insulin. F. Staff interviewsLPN #2 was interviewed on 9/26/23 at 5:28 p.m. She said she was unaware of insulin pens needing to be primed prior to administration of insulin to a resident. LPN #1 was interviewed on 9/26/23 at 5:38 p.m. He said he did not prime the insulin pen prior to the administration to Resident #7 as the pen had already been used and pens were to be primed only on initial use and not with every injection. LPN #1 said if a resident did not get the correct amount of insulin it would not help regulate blood glucose levels appropriately. The director of nursing (DON) was interviewed on 9/26/23 at 5:45 p.m. She said best practice was for the insulin pen to be primed to remove bubbles from the needle and ensure the needle was functioning correctly for administration of insulin. The DON said the needle should be primed with two units to ensure the correct amount of insulin was administered to the resident. The DON said not priming the pen could result in the incorrect dose of insulin being administered to a resident.

A recertification survey with complaint #CO33653 was conducted 9/25/23-9/28/23. Five deficiencies were cited.

An Emergency Preparedness survey was conducted from 9/25/23 to 9/28/23. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure three (#32, #41 and #272) of five residents reviewed for psychotropic medications out of 28 sample residents had the right to be informed of, and participate in, his or her treatment including the right to be informed, in advance, of the care to be furnished. Specifically the facility failed to ensure Resident #32, #41 and #272 were made aware of the risk/benefit and side effects of prescribed psychotropic medications. Findings include: I. Facility policy and procedureThe Antipsychotic Medication Use policy, revised July 2022, was provided by the case manager on 9/28/23 at 1:15 p.m. it read in pertinent part, "residents and or resident representatives will be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents and or resident representatives may refuse medications of any kind. Nursing staff shall monitor for and report any side effects and or adverse effects of antipsychotic medications to the attending physician. "II. Resident #32A. Resident statusResident #32, age under 65 years, was admitted on 7/8/23. According to the September 2023 computerized physician orders (CPO) diagnoses included other specified anxiety disorders and opioid dependence, uncomplicated. According to the most recent minimum data set (MDS) dated 8/29/23 the resident had intact cognition with a score of 15 out of 15 for the brief intervention mental status (BIMS). The resident did not have any rejection of care behaviors and required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and hygiene. B. Record reviewThe September 2023 CPO was reviewed on 9/28/23, it revealed the resident was prescribed psychotropic medications:Aripiprazole tablet 10 mg give 1 tablet by mouth in the morning for constant yelling out to staff, severe anxiety, hopelessness related to major depressive disorder,recurrent severe without psychotic features. Antipsychotic target behaviors: yelling out to staff, severe anxiety and hopelessness.-The facility failed to provide documentation to evidence the risks and side effects of psychotropic medications were discussed with Resident #32 during the survey process. III. Resident #41A. Resident statusResident #41, age under 65 years, was admitted on 5/17/23. According to the September 2023 CPO diagnoses included anxiety disorder, unspecified and schizoaffective disorder, bipolar type. According to the most recent MDS dated 7/15/23 the resident had intact cognition with a score of 15 out of 15 for the BIMS. The resident did not have any rejection of care behaviors and required supervision with bed mobility, transfers, toilet use and walking. The resident required limited assistance with dressing and extensive assistance with hygiene. B. Record reviewThe September 2023 CPO was reviewed on 9/28/23, it revealed the resident was prescribed psychotropic medications:Zyprexa oral tablet 20 mg (olanzapine) give 1 tablet via g-tube at bedtime for hallucinations, striking out, verbal aggression related to schizoaffective disorder, bipolar type. Antipsychotic target behaviors: verbal aggression, hallucinations and striking out.-The facility failed to provide documentation to evidence the risks and side effects of psychotropic medications were discussed with Resident #41 during the survey process. IV. Resident #272A. Resident StatusResident #272, age under 65 years old, was admitted on 5/17/23. According to the September 2023 CPO diagnoses included major depressive disorder. According to the most recent MDS dated 8/14/23 the resident had intact cognition with a score of 15 out of 15 for the BIMS. The resident did not have any rejection of care behaviors and required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and hygiene. B. Record reviewThe September 2023 CPO was reviewed on 9/28/23, it revealed the resident was prescribed psychoactivemedications:Venlafaxine 150 mg by mouth once daily for depression. Anti-depressant target behaviors: worrisome thoughts, fixating on medical issues, difficulty sleeping, hopelessness, low self worth, passive thoughts of suicide. Ativan 0.5 mg by mouth three times daily for anxiety. Anti-anxiety target behaviors :worrisome thoughts, fixating on medical issues, difficulty sleeping, hopelessness, low self worth, passive thoughts of suicide.-The facility failed to provide documentation to evidence the risks and side effects of psychoactive medications were discussed with Resident #272 during the survey process. V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 9/28/23 at 11:45 p.m. She said psychotropic medication consents were supposed to be completed and on the resident's care plan if a psychotropic was ordered. She did not review the psychotropic medication consent before administering psychotropic medications because she assumed they were always completed by the doctor and she administered psychotropic medications if there was an order for the medication. Registered nurse (RN) #1 was interviewed on 9/28/23 at 11:55 p.m. He said he would always check the psychotropic medication consent in the resident's chart before he would administer a psychotropic medication. He said if the psychotropic medication consent was not in the chart he would not give the medication because the resident would not know the risks and side effects of the medication and the resident would not be able to make an informed decision. RN #1 said he would obtain consent from a resident, power of attorney or guardian if the resident did not have the psychotropic medication consent in the chart. The MDS coordinator was interviewed on 9/28/23 at 12:15 p.m. She said all three residents (#32, #41 and #272) did not have psychotropic medication consents and/or documentation the residents were aware of the risks and/or side effects of psychotropic medications. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 9/28/23 at 12:22 p.m. They said residents on psychotropic medications should have psychotropic medication consents because it was important for the resident to be able to exercise their right to be informed and make treatment decisions. The resident has the right to understand the reason to take psychotropic medications and know the risks, benefits and side effects of the prescribed psychotropic medications.

Based on observations and interviews the facility failed to provide a homelike environment, including but not limited to receiving treatment and support for daily living safely in two out of two units. Specifically, the facility failed to:-Ensure smoking residents smoked in designated areas;-Ensure non-smoking residents were protected from smoking odors. Findings include:I. ObservationsThree residents were observed on 9/27/23 at 12:40 p.m. smoking cigarettes under the gazebo in a non-designated area. II. Resident interviewsResident #3 was interviewed on 9/27/23 at 12:15 p.m. She said her room constantly smelled like smoke and it bothered her. She said residents were allowed to smoke in non-designated smoke areas. Resident #37 was interviewed on 9/27/23 at 12:20 p.m. She said the smoke smell always entered her room and it bothered her because the smokers were allowed to smoke in non-designated areas. The smoke that entered her room made it hard for her to breathe at times. Resident #10 was interviewed on 9/27/23 at 11:11 a.m. She said smoke constantly entered her room and she complained to staff about it. Staff told her to shut her room door but the smoke still entered her room since it was near the courtyard. Resident #10 said she did not enjoy the smell and it made her angry that no staff had enforced the smoking rules to smoke in designated areas only. Resident #8 was interviewed on 9/27/23 at 11:29 a.m. She said she did not enjoy the smell of smoke going into her room at all times of the day because smokers could smoke whenever they want. She said she was worried about the exposure to the smoke. She said she was disappointed that the facility did not enforce the smoking policy to smoke in designated areas only. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 9/27/23 at 2:29 p.m. She said many residents smoked in non designated smoking areas in the courtyard and at the entrance of the building. Licensed practical nurse (LPN) #1 was interviewed on 9/27/23 at 2:49 p.m. She said the residents smoked whenever they wanted to and they smoked all over the courtyard even though the residents had a designated smoking area. The nursing home administrator (NHA) was interviewed on 9/27/23 at 3:19 p.m. He said he recently (9/27/23, during the survey) received a complaint from a resident. The resident complained they smelled smoke in the courtyard and in the back section of the building and the smell was bothersome. Additionally, staff notified the NHA three weeks ago (9/5/23) that the building smelled like smoke. The NHA said the facility had implemented a designated smoking area that could be accessed by residents that smoked. Smokers should not be allowed to smoke in non-designated areas which included the gazebo. The NHA said he would provide resident education to smokers related to designated smoking areas. IV. Facility follow-upThe facility immediately requested residents to smoke cigarettes only in designated areas.

Based on observation, record review and interviews, the facility failed to ensure two (#272 and #7) residents out of 28 sample residents were free from significant medication errors. Resident #272, was admitted on 5/17/23 for long term care with a goal to return home. The resident was prescribed medication of Ativan for his anxiety disorder. The facility ran out of the prescribed medications and he missed 18 doses of Ativan across six days from 9/4/23 to 9/9/23. The facility failed to implement effective interventions to prevent the resident from running out of his medications (discovered on 9/4/23) from progressing to the resident experiencing withdrawal symptoms and subsequently being hospitalized on 9/10/23 (six days after the facility identified the medication was out of stock). In addition, the facility failed to: -Ensure medications were ordered from the pharmacy STAT (urgent or rushed) to prevent missed medication doses for Resident #272;-Ensure nurses were educated on the availability and use of the emergency medication kit;-Ensure the emergency medication kit was accessible to nursing staff;-Ensure nurses were educated on the side effects and signs and symptoms of benzodiazepine withdrawals.-Ensure insulin (medications used to regulate blood glucose levels) pens were primed prior to medication administration for Residents #7. Findings include: I. Resident #272A. Professional referenceAccording to American Addiction Center, Benzo Withdrawl Symotoms Symptoms accessed on 10/9/23 at https://americanaddictioncenters.org/benzodiazepine/length-of-withdrawal, it read n pertinent part, "Benzodiazepines (Benzo) are all designed as central nervous system depressants; however, they each may work slightly differently at targeting certain symptoms. "Withdrawal side effects are not generally lethal, although they are best managed with professional medical attention and supervision."Benzo withdrawal symptoms may include:NauseaPanic attacksTremorsAnxietySweatingHeadachesHeart palpitationsMuscle painSeizures"Most benzodiazepine (benzo) withdrawal symptoms start within 24 hours and can last from a few days to several months, depending on the length of the abuse and the strength of the benzo used."B. Facility policy and procedureThe Medication Order and Receipt Record policy, last revised April 2007, was provided by the nursing home administrator (NHA) on 9/28/23. The policy read in part, "Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. Emergency medications ordered and or received shall also be entered into the medication order and receipt record. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than 3 days prior to the last dosage being administered to ensure that refills are readily available."C. Resident statusResident #272, age under 65 years old, was admitted on 5/17/23. According to the September 2023 computerized physician orders (CPO) diagnoses included major depressive disorder, recurrent, moderate anxiety disorder and quadriplegia. According to the most recent minimum data set (MDS) dated 8/14/23 the resident had intact cognition with a score of 15 out of 15 for the brief interview mental status (BIMS). The resident did not have any rejection of care behaviors and required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and hygiene. D. Resident interviewResident #272 was interviewed on 9/26/23 at approximately 11:00 a.m. The resident said he went into withdrawal because the facility did not want to give him his prescribed medication which led to him calling 911 and being hospitalized to get the medicine and care he needed. He said after missing four days of medications that were prescribed three times a day he became agitated, scared, restless and confused. He physically had suffered from sweating, shaking, racing thoughts, headaches and abdominal cramps. The resident said the staff did not seem to care or recognize that he was having withdrawal side effects. The resident said he even informed the staff he was not feeling right but they did not take action. The resident said he had to call 911 because the facility did not want to get him medications in time and they did not want to send him out to a hospital. E. Record reviewThe September 2023 computerized physician orders revealed the resident was ordered Ativan oral tablet 0.5 MG (Lorazepam); give one tablet by mouth three times a day related to anxiety disorder, unspecified. The September 2023 medication administration record (MAR) revealed the resident had missed 18 doses of Ativan across six days from 9/4/23 to 9/9/23 (see below). 9/4/23Morning doseThe MAR read the drug was not given and to review the nursing progress note.-The 9/4/23 9:26 a.m. nursing progress note was reviewed on 9/27/23 it revealed "Ativan was reordered."Mid day doseThe MAR read the drug was not given and to review the nursing progress note.-The 9/4/23 11:35 a.m. nursing progress note was reviewed on 9/27/23 it revealed "Awaiting delivery for Ativan."Night doseThe MAR read the drug was not given and to review the nursing progress note.-The 9/4/23 8:46 p.m. nursing progress note was reviewed on 9/27/23 it revealed "Ativan was reordered and the pharmacy was called."9/5/23Morning doseThe MAR entry was not completed by the nurse and therefore the administration record was blank. Mid day doseThe MAR read the medication was held by the physician due to lack of availability of the medication. Night doseThe MAR read the medication was held by the physician due to lack of availability of the medication. 9/6/23Morning doseThe MAR entry read the medication was administered by a nurse.-The drug was still not available at the time and the medication was on hold by the physician due to lack of availability. Mid day doseThe MAR entry was not completed by the nurse and therefore the administration record was blank. Night doseThe MAR read the medication was held by the physician due to lack of availability of the medication. 9/7/23Morning doseThe MAR read the medication was held by the physician due to lack of availability of the medication. Mid day doseThe MAR read the medication was held by the physician due to lack of availability of the medication. Night doseThe MAR read the medication was held by the physician due to lack of availability of the medication. 9/8/23Morning doseThe MAR read the medication was held by the physician due to lack of availability of the medication. Mid day doseThe MAR read the medication was held by the physician due to lack of availability of the medication. Night doseThe MAR read the drug was not given and to review the nursing progress note.-The 9/8/23 nursing progress note was reviewed on 9/27/23 it revealed no notes were entered related to Ativan. 9/9/23Morning doseThe MAR read the drug was not given and to review the nursing progress note.-The 9/9/23 nursing progress note was reviewed on 9/27/23 it revealed no notes were entered related to Ativan for the morning dose. Mid day doseThe MAR read the drug was not given and to review the nursing progress note. The 9/9/23 2:11 p.m. nursing progress note was reviewed on 9/27/23 it revealed "Ativan 0.5 mg out of stock,provider notified of needing medication script after nurse spoke to pharmacy. Medication script to be provided to the pharmacy."Night doseThe MAR read the drug was held because the resident was hospitalized.-The 9/9/23 8:20 p.m. nursing progress note was reviewed on 9/27/23 it revealed the resident was hospitalized. Review of the progress notes from 9/4/23 to 9/9/23 did not capture the resident had a change of condition. The progress notes address the Ativan medication was out of stock and what was mentioned (see above). The hospital discharge notes dated 9/10/23 at 12:02 a.m. read "the resident was hospitalized for benzodiazepine withdrawal. (Benzodiazepines are depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures). It is important to talk to your provider about weaning you off your Ativan. It is very important that wean off on a scheduled medically supervised taper, as weaning off too rapidly can be dangerous."The 9/10/23 progress note documented the resident returned from the hospital. Per hospital report, the residnet was diagnosed with urinary tract infection (UT) and ordered antibiotics for seven days. After Ativan was restarted, the resident stated he was feeling better. -However, a review of the hospital discharge notes in the resident's medical record revealed the resident was hospitalized for benzodiazpine withdrawl (see above). There were no documentation of the resident's stay in the hospital or of the resident having a UTI. F. Staff InterviewsLicensed practical nurse (LPN) #1 was interviewed on 9/26/23 at 6:17 p.m. He said he would reorder medications once he realized a specific medication was out of stock. Once he identified a medication was out of stock he would let his supervisor know, notify the provider and the pharmacy. He said he was unfamiliar with benzodiazepine withdrawal signs and symptoms and he was unfamiliar with the potential side effects of missing benzodiazepine medications consecutively for a few days. The pharmacy consultant was interviewed on 9/27/23 at 5:05 p.m. She said when medications were running low on stock (approximately three days prior to medications running out) the nurse should place an order through contacting the pharmacy the facility works with. The pharmacy consultant said she reviewed the resident's MAR for the month of September 2023 and said the resident missed 18 doses, however, she did not have any recommendations or concerns for the facility because at the time she reviewed the MAR the situation was resolved since the facility received the out of stock medications by 9/10/23. The director of nursing (DON) was interviewed on 9/27/23 at 5:07 p.m. She said the Ativan was out of stock and the resident missed his doses from 9/4/23 to 9/10/23. The side effects of stopping a benzodiazepine without weaning them off could lead someone to become uncomfortable, anxious, experience panic attacks, sweat and having headaches. The DON said she was uncertain as to why he missed so many doses because she had an emergency kit in her office and a backup pharmacy. The DON said during the time period the medications were out of stock, the facility had access to Ativan in the emergency kit in her office. The emergency kit in her office had seven days of mediations available for someone that has Ativan ordered three times a day. The minimum data set coordinator (MDSC) was interviewed on 9/28/23 at 9:11 a.m. She said the facility dropped the ball regarding the resident's benzodiazepine withdrawal due to the medications being out of stock. The nursing home administrator (NHA) and the MDSC were interviewed on 9/28/23 at 10:05 a.m. They said they were not aware of the missed medication doses until it was identified during the survey process. The process to obtain out of stock medications were the nurses' responsibility. The medication should be ordered through pharmerica and the medications should be ordered upon identifying there was a seven day supply left. The nurse should call the physician to notify them and call the pharmacy to order the medication. The nurse has the option to order the medication immediately (STAT) which would be delivered within two to four hours. No staff in the facility knew about the emergency medication kit in the DON's office, therefore no staff used it. They said the nurses would be trained on the use of the emergency kit and the nurses would document low stock medications on the nursing shift report which will be reviewed by administration the following morning to ensure medications were always stocked. The emergency kit would be moved out of the DON's office and stored on each medication cart to promote ease of accessibility. II. Resident #7A. Professional reference According to the Lantus insulin package insert, retrieved on 10/3/23 from:https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf "instructions for use; do a safety test before each injection to: check pen and the needle to make sure they were working properly. To make sure that you get the correct Lantus dose. Select 2 units by turning the dose selector until the dose pointer was at the two mark. Press the injector button all the way in. when insulin comes out the needle tip your pen was working correctly: this may need to be repeated up to three times before seeing insulin. If no insulin comes out after the third time, the needle may be blocked." B. Facility policyThe Insulin Administration policy and procedure, revised September 2014, was received from the nursing home administrator (NHA) on 9/28/23 at 12:27 p.m. It revealed in pertinent part, "to provide guidelines for the safe administration of insulin to residents with diabetes."C. Resident statusResident #7, younger than 65 years old, admitted on 2/8/22. According to the September 2023 computerized physician orders (CPO), diagnoses included type two diabetes mellitus (abnormal blood glucose) and chronic kidney disease (abnormal kidney function). The 7/31/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident received insulin for the past seven days. D. Physician ordersThe CPO documented: "Lantus solo star solution pen-injector 100 units/milliliter (ml) Inject 25 units subcutaneous every evening for diabetes."E. ObservationsOn 9/26/23 at 4:49 p.m. licensed practical nurse (LPN) #1 was administering medications to Resident #7. He collected the Lantus solo star pen, applied a new needle cap to the pen and dialed the pen to 25 units. LPN #1 injected the insulin into the resident's right arm. LPN #1 failed to prime the insulin pen prior to dialing up the ordered 25 units of insulin. F. Staff interviewsLPN #2 was interviewed on 9/26/23 at 5:28 p.m. She said she was unaware of insulin pens needing to be primed prior to administration of insulin to a resident. LPN #1 was interviewed on 9/26/23 at 5:38 p.m. He said he did not prime the insulin pen prior to the administration to Resident #7 as the pen had already been used and pens were to be primed only on initial use and not with every injection. LPN #1 said if a resident did not get the correct amount of insulin it would not help regulate blood glucose levels appropriately. The director of nursing (DON) was interviewed on 9/26/23 at 5:45 p.m. She said best practice was for the insulin pen to be primed to remove bubbles from the needle and ensure the needle was functioning correctly for administration of insulin. The DON said the needle should be primed with two units to ensure the correct amount of insulin was administered to the resident. The DON said not priming the pen could result in the incorrect dose of insulin being administered to a resident.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in two of three medication carts. Specifically, the facility failed to ensure medications were properly labeled with open dates for insulin (medication used for blood glucose management) pens and vials. Findings include:I. Professional reference According to the Lantus insulin package insert, retrieved on 10/3/23 from:https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf "After Lantus solo star pens have been opened they can be stored at room temperature for up to 28 days. The Lantus solo star pen should be thrown away after 28 days, even if it still has insulin left in it." According to the Humalog insulin package insert, retrieved on 10/4/23 from:https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf "In use humalog vials stored at room temperature must be used within 28 days or be discarded."II. Facility policyThe Insulin Administration policy and procedure, revised September 2014, was received from the nursing home administrator (NHA) on 9/28/23 at 12:27 p.m. It revealed in pertinent part, "Check expiration date, if drawing from a multi-dose vial. If opening a new vial, record the expiration date and time on the vial."III. Observations and staff interviewsOn 9/26/23 at 4:49 p.m. licensed practical nurse (LPN) #1 was administering medications from the Santa Fe south medication cart. A Lantus solo star Insulin pen had no open date on it. LPN #1 said the pen should have a date on it to indicate the open date as insulin was only good for 28 days from the first access/administration. LPN #1 said if an insulin was used past the 28 day it could not be as effective for the resident use. On 9/27/23 at 2:30 p.m. the mesa medication cart was reviewed with LPN #3. A box of Humalog insulin was located to have two vials within one box, neither vial had an open date on it. LPN #3 was unable to determine which vial belonged to the box and there were no open dates on either vial. He said he needed to speak with a supervisor. The director of nursing (DON) was interviewed on 9/27/23 at 2:39 p.m. She said there should only be one vial in the box, not two. The DON said insulin vials should have an open date written on the bottle indicating when they were first accessed as insulin was only good for 30 days. The date written on the vial would ensure they were not used past the expiration open date. The DON removed the vial from the medication cart so they could not be used.

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 disease and infection. Specifically the facility failed to:-Ensure Insulin (medication used for blood glucose management) pens and vials were properly cleaned prior to drawing up medications; -Ensure wound care was provided in a hygienic manner; and,-Ensure hand hygiene was performed when changing gloves. Findings include:I. Failure to wipe insulin vials and pens appropriately A. Professional referenceAccording to the Lantus Insulin package insert retrieved on 10/4/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf "wipe the rubber seal of the insulin pen with an alcohol swab before use. Wipe the top of the insulin vial with an alcohol swab prior to drawing up insulin."B. Facility policy and procedureThe Insulin Administration policy and procedure, revised September 2014, received from the nursing home administrator on 9/28/23 at 12:27 p.m. It revealed in pertinent part, "disinfect the top of the vial with an alcohol wipe."C. ObservationsLicensed practical nurse (LPN) #1 was observed on 9/26/23 at 4:39 p.m. He was passing medications and collected an Lantus insulin vial from the medication cart along with an insulin syringe. LPN #1 then drew up 10 units of insulin into the syringe.-He failed to wipe off the top of the insulin vial prior to drawing up the insulin into the syringe. LPN #1 was observed on 9/26/23 at 4:49 p.m. He was administering medications, collected a Lantus solo star insulin pen from the medication cart and applied a new needle to the pen, dialed the medication to an ordered dose and administered it to the resident. -LPN #1 failed to wipe the rubber seal of the pen prior to applying the needle to the pen. D. Staff interviewsLPN #1 was interviewed on 9/26/23 at 5:00 p.m. He said the tops of vials and pens should be wiped down prior to drawing up insulin or applying a new needle to the pen to prevent infection. LPN #1 said he did not clean the vial or the pen used (see above observations). The director of nursing (DON) was interviewed on 9/28/23 at 10:51 a.m. She said insulin vials/pens should be cleansed with alcohol prior to drawing them up to prevent infection. II. Failed to provide wound care in a hygienic mannerA. Professional reference According to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. Louis Missouri, pg. 1265. "Clean away from the wound. Never use the same piece of gauze to clean across an incision or wound twice."According to the Center for Disease Control (CDC), Hand Hygiene Basics retrieved on 10/5/23 from: https://www.cdc.gov/handhygiene/providers/index.html (2021) read in pertinent part, "healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood,body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves were not enough to prevent the transmission of pathogens in a healthcare settings)."B. Treatment orderAccording to Resident #49's physician orders, "Left buttock wound, cleanse with Dakin's (prescription wound solution). Apply skin prep (skin protectant) on the peri wound (area around the wound), pack the wound with hydrofera blue (specialized wound dressing), cover with a foam dressing three times per week and as needed."C. Observations and staff interviewsThe certified wound nurse (CWN) was observed on 9/27/23 at 1:13 p.m. providing wound care for Resident #49. The CWN collected supplies for wound care placing them on a clean working surface (see above wound order for supplies). He washed his hands with soap and water, applied gloves and removed the resident's old dressing. The old dressing had a small amount of yellow drainage. The CWN changed his gloves then collected a piece of gauze soaked with Dakins, took the piece and packed it into the wound with a cotton tip applicator and removed it completing this process twice. The CWN took a new piece of gauze soaked in Dakins and wiped the outer wound bed three times with the same piece of gauze. The CWN then took a second piece of dry gauze and dried the wound three times with the same gauze. The CWN removed his gloves, cut an abdominal pad with a pair of scissors and then applied new gloves. The CWN then took skin prep and applied it to the peri wound, then hydrofera blue was packed into the wound with a cotton tip applicator. He covered the wound with the abdominal pad he had cut in half and secured with tape. The CWN cleared the area of trash and washed his hands with soap and water along with washing his scissors with soap and water. The CWN then dried the scissors off with a paper towel and placed them into his pocket.-The CWN failed to change gauze to a new piece for each wipe of the wound, to properly disinfect the scissors after wound care and perform hand hygiene between gloves changes. The CWN was interviewed on 9/27/23 at 1:28 p.m. He said to clean a resident's wound, nursing staff should clean from outside to inside and only use one wipe for each piece of gauze to help prevent the spread of infection. The CWN said he wiped the wound multiple times with the same piece of gauze. The CWN said the scissors he used were his personal scissors he used on multiple residents and he washed them with soap and water after every use. The CWN said the soap and water should disinfect them enough to use them on the next resident as each resident did not have scissors assigned to them. The director of nursing (DON) was interviewed on 9/28/23 at 10:51 a.m. She said staff were to perform hand hygiene before and after applying gloves. The DON said nurses were to clean the wound from the outside in and only use one piece of gauze per wipe or a clean section of the gauze for each wipe to prevent infection. The DON said scissors could be cleaned with soap and water followed by an alcohol swab for disinfecting. She said if residents were on any kind of contact precautions they would have their own scissors assigned to them labeled in a bag in the treatment cart.

A complaint survey, prompted by #CO30447 and #CO30866 was conducted on 2/16/23 to 2/21/23. No deficiencies were cited.