25
Inspections
34
Deficiencies
3
Actual Harm or Above
28
Occurrences
February 18, 2026
Last Inspection
S/S C Minimal potentialS/S D/E/F Potential for harmS/S G Actual harmS/S J Immediate jeopardy
The most recent inspection of ARBOR VIEW CARE CENTER on record is dated February 18, 2026. Across 25 published inspections, state surveyors cited 34 deficiencies, 3 of which reached actual harm or immediate jeopardy.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
SNF/NF Dual Certification
Administrator
Foster, Joseph
Owner
ARBOR VIEW CARE CENTER, LLC
Phone
(303) 403-3100
Payor Source
Medicare, Medicaid, Private Pay
City
ARVADA
ZIP
80004-1828
Inspections & Citations
25 inspections · 34 deficiencies2/18/2026Complaint Survey · ID 1E4550-H11 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2738753 was conducted on 2/17/26 to 2/18/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0689Free of Accident Hazards/Supervision/Devices▼
Findings
Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of three sample residents. Resident #1 was admitted on 7/18/23 for long-term care with a diagnosis of dementia. According to the care plan, Resident #1 was determined to be a high fall risk. The resident was independent with ambulation. On 1/16/26 Resident #1 was found on the floor in another resident's room. The resident was not wearing appropriate footwear at the time of fall. After the fall, Resident #1 was not able to walk and required the use of a wheelchair. Resident #1 did not participate in her usual daily activities, her pain level increased and she was confused. Two days after the fall, on 1/18/26, Resident #1 was transported to the hospital for further evaluation for her increased confusion, increased pain and continued inability to walk. Resident #1 was admitted to the hospital and diagnosed with a subdural hematoma (brain bleed) and a closed left hip fracture requiring surgical intervention. Specifically, the facility failed to follow care planned interventions and ensure Resident #1 was wearing appropriate footwear, which resulted in a fall with major injury on 1/16/26. Findings include:I. Resident #1A. Resident statusResident #1, age 86, was admitted on 7/18/23 and discharged to the hospital on 1/18/26. According to the January 2026 computerized physician orders (CPO), diagnoses included osteoarthritis, dementia, Alzheimer's disease and repeated falls. The 12/10/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She was independent with ambulation and required partial or moderate assistance with toileting hygiene and upper and lower body dressing. The MDS assessment indicated the resident did not use any ambulatory assistive devices and had a history of falls. B. Resident’s representative interviewResident #1’s representative was interviewed on 2/17/26 at 1:26 p.m. The representative said Resident #1 was admitted to the facility for rehabilitation and memory care management. She said she was notified of the resident’s 1/16/26 fall on 1/16/26, however, she said the nursing staff did not inform her that Resident #1 was requiring the use of a wheelchair until the next day (1/17/26). The representative said Resident #1 was more confused, could not make complete sentences and could not walk. She said the resident appeared to be completely different from what she normally was. C. Record reviewThe fall care plan, initiated 7/19/23 and revised 7/29/23, revealed Resident #1 was at risk for falls related to deconditioning, gait and balance problems, incontinence, poor communication and comprehension. The resident was unaware of her safety needs and had a history of falls. Pertinent interventions included anticipating and meeting the resident's needs (initiated 7/19/23) and encouraging that the resident was wearing appropriate footwear/non-skid socks when ambulating or mobilizing in a wheelchair (initiated 7/19/23). The 1/16/26 at 2:25 p.m. interdisciplinary team (IDT) note documented Resident #1 sustained an unwitnessed fall. The resident’s shoes/slippers were on the bed neatly and the resident was wearing general socks (instead of anti-slip socks). The physician was notified and Xrays and laboratory work was ordered. Neurological assessments were initiated and would be monitored per facility protocol. The resident was provided with non-slip socks which would be applied as tolerated. The note documented the root cause of the fall was due to the resident having a change of condition with altered mental status. -However, per documentation in the progress notes, including the IDT progress note, and the director of nursing’s (DON) interview, Resident #1 was not wearing anti-slip socks at the time of the fall, despite anti-slip (non-skid) socks being documented on her care plan as a fall intervention since 7/19/23 (see care plan above and progress notes and DON interview below). The 1/16/26 at 4:43 p.m. nursing progress note documented two facility staff members found Resident #1 lying on the floor of another resident's room at 11:45 a.m. The note documented the resident’s shoes/slippers were on the bed in the other resident’s room, positioned neatly. The resident was not wearing non-skid socks. The 1/16/26 at 4:43 p.m. nursing progress note further documented that the resident was alert and her speech was clear and she was at baseline mentation. The resident’s vital signs were taken and neurological checks were initiated. An active range of motion assessment was conducted and revealed the resident reported pain to her left forearm near the elbow and she had pain in her left thigh near her left hip. The resident presented with a stronger hand grasp to the right hand than to the left hand and she had noted difficulty following specific instructions. The resident was able to actively roll onto her back and move all four extremities. The staff assisted the resident to a sitting upright position. The 1/16/26 at 4:58 p.m. nursing progress note documented the facility nursing staff received physician’s orders for a STAT (immediately, instantly or at once) Xray for the resident. Registered nurse (RN) assessed Resident #1 after the unwitnessed fall. A neurological assessment was initiated, the resident’s pupils were equal, round and reactive to light accommodation (PERRLA) and her right hand grip was stronger than the left hand grip. The resident reported pain to her left arm and left leg. The nursing staff would continue with monitoring and neurological assessments. The 1/17/26 at 2:00 p.m. nursing progress note documented Resident #1 was noted to be alert but more confused with a slightly distant look compared to her baseline. The resident presented with difficulty taking steps and acting as though her left leg was "giving out.” The resident was requiring the assistance of a wheelchair for mobility. Nursing staff placed a call to an on-call physician and discussed the resident’s increased confusion, as well as the Xray results (which were negative) from 1/16/25. The 1/17/26 at 5:26 p.m. nursing progress note documented that while sitting in a wheelchair, Resident #1 was able to actively move both lower extremities without expressing pain. However, when the resident was assisted to a standing position, she had difficulty while taking steps and was complaining of pain to her left lower extremity. The progress note documented the resident continued to use a wheelchair for ambulation. The 1/18/26 at 4:45 p.m. change of condition note documented Resident #1 was having difficulty walking on her left leg and had used a wheelchair for ambulation throughout the shift. The nursing staff and the resident’s family reported that the resident had not been making sense when talking to the resident since her fall on 1/16/26. The nursing staff received a new physician’s order to send the resident to the hospital. Review of Resident #1’s 1/23/26 hospital discharge summary records revealed the resident was found to have a subdural hematoma and a left hip fracture. The resident underwent surgical repair of the left hip fracture on 1/19/26. II. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/18/26 at 10:30 a.m. CNA #1 said Resident #1 was not a fall risk and was independent with ambulation prior to her fall. She said she was not working in the facility the day Resident #1 had her fall (1/16/26). -However, Resident #1’s care plan indicated she was a high fall risk and was to be encouraged to wear non-skid socks when ambulating (see care plan above). The activities assistant (AA) was interviewed on 2/18/26 at 10:42 a.m. The AA said she was familiar with Resident #1. She said she was not working the day of the resident’s fall on 1/16/26, but she came into work the next day (1/17/26) and saw the resident was using a wheelchair. She said Resident #1 primarily ambulated independently without a walker or a wheelchair prior to the fall. She said Resident #1 seemed less talkative than normal after her fall and did not want to participate in coloring activities. CNA #2 was interviewed at 10:49 a.m. on 2/18/26. CNA #2 said she had worked in the facility for approximately a year and is primarily assigned to the secured unit. She said she would check the residents’ electronic medical records (EMR) to see if the residents required assisted devices or if residents were a fall risk. She said she was working on the secured unit the day Resident #1 was found on the floor. She said when she came back from her lunch break, she noticed that a lot of the residents on the security unit had left the security unit to go on an outing. She said Resident #1 typically went on the outings so she assumed that was where Resident #1 was. She said she asked the nurse if Resident #1 went to the outing and the nurse could not confirm if the resident had gone on the outing or not. CNA #2 said she began looking for Resident #1 with the memory care director, who found the resident on the floor lying on her side in another resident’s room. CNA #2 said the Resident #1 did not have non-skid socks on at the time of her fall. She said the resident had regular black socks on. She said she remembered the resident saying “Oh it hurts.” She said two facility staff nurses assisted the resident off the floor and into a wheelchair because Resident #1 was not able to walk. She said Resident #1 never used a wheelchair and walked independently before her fall. Licensed practical nurse (LPN) #1 was interviewed on 2/18/26 at 11:00 a.m. LPN #1 said she was the nurse assigned to Resident #1 the day the resident was found on the floor (1/16/26). She said after the resident was found on the floor, she requested the assistance of RN #1 to come provide a physical assessment for Resident #1. She said the resident was unable to provide a number for her pain scale due to her dementia. She said the resident repeatedly said “it hurts” multiple times after her fall. She said the resident was unable to walk and appeared to be in pain. She said she reported a concern of the resident having pain multiple times to RN #1. She said a STAT Xray was obtained and was negative. LPN #1 said the following day (1/17/26), Resident #1 appeared to be in significantly more pain and more confused. The memory care director was interviewed on 2/18/26 at 11:28 a.m. The memory care director said a CNA came to her to ask if she had recently seen Resident #1. She said she noticed a different resident’s room door, which was across from her office, was closed. She said Resident #1 often wandered into the other resident’s room where the door was closed. She said she decided to look in the other resident’s room where the door was closed and observed Resident #1 on the floor on her left side. She said she notified nursing staff for assistance. She said Resident #1 said “it hurt” when nursing staff attempted to assist Resident #1 to her feet. She said Resident #1 never complained of pain previously. She said after the fall, Resident #1 needed to use a wheelchair, which was not normal for the resident. RN #1 was interviewed on 2/18/26 at 11:41 a.m. RN #1 said she assessed Resident #1 when she was found on the floor on 1/16/26. She said the resident had no bruising to her head and no difficulty with range of motion on her upper and lower extremities when she was sitting in the wheelchair. RN #1 said the resident had difficulty standing on her left leg when staff were attempting to assist the resident to a standing position. She said she did the initial assessment for the neurological checks. She said she was unfamiliar with Resident #1 because she never worked in the memory care unit. She said Resident #1 was struggling to hold her own body weight and stand on both legs. RN #1 said she was concerned about injuries to the resident’s hips or knees because the resident was still showing signs of pain with facial grimacing and guarding the day she was found on the floor (1/16/26).
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH THE STATE OPERATIONS MANUAL.
F6891. Resident # 1 is no longer residing at the community. 2. Residents who had a fall on the secured neighborhood have the potential to be affected by this alleged deficient practice. A 30-day review was completed on 2/18/26 by the DON (director of nursing)/designee of residents on the secured neighborhood who had fallen to ensure supervision of previously implemented interventions to attempt to prevent falls was occurring and interventions were implemented. No other concerns were identified. 3. Education was initiated on 2/18/26 by the DON/designee with licensed nursing staff regarding falls and ensuring interventions were in place and being monitored. Education to be completed upon hire and PRN (as needed). DON/designee to complete weekly audit of five random resident falls for one month, and then monthly for two months, to ensure that previous interventions were in place, appropriate interventions were implemented. These audits will be documented on a spreadsheet and staff will follow up with any concerns that may be found. 4. The DON/designee will report findings from the audits to the QAPI Committee monthly for 90 days. The QAPI committee will identify any trends and take corrective action as needed.
2/18/2026Licensure Complaint Survey · ID 1E4553-H11 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A survey prompted by #CO2738755 was completed on 2/17/26 to 2/18/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0704Res Care - Accident Prevention and Attention▼
Findings
Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of three sample residents. Resident #1 was admitted on 7/18/23 for long-term care with a diagnosis of dementia. According to the care plan, Resident #1 was determined to be a high fall risk. The resident was independent with ambulation. On 1/16/26 Resident #1 was found on the floor in another resident's room. The resident was not wearing appropriate footwear at the time of fall. After the fall, Resident #1 was not able to walk and required the use of a wheelchair. Resident #1 did not participate in her usual daily activities, her pain level increased and she was confused. Two days after the fall, on 1/18/26, Resident #1 was transported to the hospital for further evaluation for her increased confusion, increased pain and continued inability to walk. Resident #1 was admitted to the hospital and diagnosed with a subdural hematoma (brain bleed) and a closed left hip fracture requiring surgical intervention. Specifically, the facility failed to follow care planned interventions and ensure Resident #1 was wearing appropriate footwear, which resulted in a fall with major injury on 1/16/26. Findings include:I. Resident #1A. Resident statusResident #1, age 86, was admitted on 7/18/23 and discharged to the hospital on 1/18/26. According to the January 2026 computerized physician orders (CPO), diagnoses included osteoarthritis, dementia, Alzheimer's disease and repeated falls. The 12/10/25 comprehensive assessment revealed the resident had severe cognitive impairment. She was independent with ambulation and required partial or moderate assistance with toileting hygiene and upper and lower body dressing. The comprehensive assessment indicated the resident did not use any ambulatory assistive devices and had a history of falls. B. Resident’s representative interviewResident #1’s representative was interviewed on 2/17/26 at 1:26 p.m. The representative said Resident #1 was admitted to the facility for rehabilitation and memory care management. She said she was notified of the resident’s 1/16/26 fall on 1/16/26, however, she said the nursing staff did not inform her that Resident #1 was requiring the use of a wheelchair until the next day (1/17/26). The representative said Resident #1 was more confused, could not make complete sentences and could not walk. She said the resident appeared to be completely different from what she normally was. C. Record reviewThe fall care plan, initiated 7/19/23 and revised 7/29/23, revealed Resident #1 was at risk for falls related to deconditioning, gait and balance problems, incontinence, poor communication and comprehension. The resident was unaware of her safety needs and had a history of falls. Pertinent interventions included anticipating and meeting the resident's needs (initiated 7/19/23) and encouraging that the resident was wearing appropriate footwear/non-skid socks when ambulating or mobilizing in a wheelchair (initiated 7/19/23). The 1/16/26 at 2:25 p.m. interdisciplinary team (IDT) note documented Resident #1 sustained an unwitnessed fall. The resident’s shoes/slippers were on the bed neatly and the resident was wearing general socks (instead of anti-slip socks). The physician was notified and Xrays and laboratory work was ordered. Neurological assessments were initiated and would be monitored per facility protocol. The resident was provided with non-slip socks which would be applied as tolerated. The note documented the root cause of the fall was due to the resident having a change of condition with altered mental status. -However, per documentation in the progress notes, including the IDT progress note, and the director of nursing’s (DON) interview, Resident #1 was not wearing anti-slip socks at the time of the fall, despite anti-slip (non-skid) socks being documented on her care plan as a fall intervention since 7/19/23 (see care plan above and progress notes and DON interview below). The 1/16/26 at 4:43 p.m. nursing progress note documented two facility staff members found Resident #1 lying on the floor of another resident's room at 11:45 a.m. The note documented the resident’s shoes/slippers were on the bed in the other resident’s room, positioned neatly. The resident was not wearing non-skid socks. The 1/16/26 at 4:43 p.m. nursing progress note further documented that the resident was alert and her speech was clear and she was at baseline mentation. The resident’s vital signs were taken and neurological checks were initiated. An active range of motion assessment was conducted and revealed the resident reported pain to her left forearm near the elbow and she had pain in her left thigh near her left hip. The resident presented with a stronger hand grasp to the right hand than to the left hand and she had noted difficulty following specific instructions. The resident was able to actively roll onto her back and move all four extremities. The staff assisted the resident to a sitting upright position. The 1/16/26 at 4:58 p.m. nursing progress note documented the facility nursing staff received physician’s orders for a STAT (immediately, instantly or at once) Xray for the resident. Registered nurse (RN) assessed Resident #1 after the unwitnessed fall. A neurological assessment was initiated, the resident’s pupils were equal, round and reactive to light accommodation (PERRLA) and her right hand grip was stronger than the left hand grip. The resident reported pain to her left arm and left leg. The nursing staff would continue with monitoring and neurological assessments. The 1/17/26 at 2:00 p.m. nursing progress note documented Resident #1 was noted to be alert but more confused with a slightly distant look compared to her baseline. The resident presented with difficulty taking steps and acting as though her left leg was "giving out.” The resident was requiring the assistance of a wheelchair for mobility. Nursing staff placed a call to an on-call physician and discussed the resident’s increased confusion, as well as the Xray results (which were negative) from 1/16/25. The 1/17/26 at 5:26 p.m. nursing progress note documented that while sitting in a wheelchair, Resident #1 was able to actively move both lower extremities without expressing pain. However, when the resident was assisted to a standing position, she had difficulty while taking steps and was complaining of pain to her left lower extremity. The progress note documented the resident continued to use a wheelchair for ambulation. The 1/18/26 at 4:45 p.m. change of condition note documented Resident #1 was having difficulty walking on her left leg and had used a wheelchair for ambulation throughout the shift. The nursing staff and the resident’s family reported that the resident had not been making sense when talking to the resident since her fall on 1/16/26. The nursing staff received a new physician’s order to send the resident to the hospital. Review of Resident #1’s 1/23/26 hospital discharge summary records revealed the resident was found to have a subdural hematoma and a left hip fracture. The resident underwent surgical repair of the left hip fracture on 1/19/26. II. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/18/26 at 10:30 a.m. CNA #1 said Resident #1 was not a fall risk and was independent with ambulation prior to her fall. She said she was not working in the facility the day Resident #1 had her fall (1/16/26). -However, Resident #1’s care plan indicated she was a high fall risk and was to be encouraged to wear non-skid socks when ambulating (see care plan above). The activities assistant (AA) was interviewed on 2/18/26 at 10:42 a.m. The AA said she was familiar with Resident #1. She said she was not working the day of the resident’s fall on 1/16/26, but she came into work the next day (1/17/26) and saw the resident was using a wheelchair. She said Resident #1 primarily ambulated independently without a walker or a wheelchair prior to the fall. She said Resident #1 seemed less talkative than normal after her fall and did not want to participate in coloring activities. CNA #2 was interviewed at 10:49 a.m. on 2/18/26. CNA #2 said she had worked in the facility for approximately a year and is primarily assigned to the secured unit. She said she would check the residents’ electronic medical records (EMR) to see if the residents required assisted devices or if residents were a fall risk. She said she was working on the secured unit the day Resident #1 was found on the floor. She said when she came back from her lunch break, she noticed that a lot of the residents on the security unit had left the security unit to go on an outing. She said Resident #1 typically went on the outings so she assumed that was where Resident #1 was. She said she asked the nurse if Resident #1 went to the outing and the nurse could not confirm if the resident had gone on the outing or not. CNA #2 said she began looking for Resident #1 with the memory care director, who found the resident on the floor lying on her side in another resident’s room. CNA #2 said the Resident #1 did not have non-skid socks on at the time of her fall. She said the resident had regular black socks on. She said she remembered the resident saying “Oh it hurts.” She said two facility staff nurses assisted the resident off the floor and into a wheelchair because Resident #1 was not able to walk. She said Resident #1 never used a wheelchair and walked independently before her fall. Licensed practical nurse (LPN) #1 was interviewed on 2/18/26 at 11:00 a.m. LPN #1 said she was the nurse assigned to Resident #1 the day the resident was found on the floor (1/16/26). She said after the resident was found on the floor, she requested the assistance of RN #1 to come provide a physical assessment for Resident #1. She said the resident was unable to provide a number for her pain scale due to her dementia. She said the resident repeatedly said “it hurts” multiple times after her fall. She said the resident was unable to walk and appeared to be in pain. She said she reported a concern of the resident having pain multiple times to RN #1. She said a STAT Xray was obtained and was negative. LPN #1 said the following day (1/17/26), Resident #1 appeared to be in significantly more pain and more confused. The memory care director was interviewed on 2/18/26 at 11:28 a.m. The memory care director said a CNA came to her to ask if she had recently seen Resident #1. She said she noticed a different resident’s room door, which was across from her office, was closed. She said Resident #1 often wandered into the other resident’s room where the door was closed. She said she decided to look in the other resident’s room where the door was closed and observed Resident #1 on the floor on her left side. She said she notified nursing staff for assistance. She said Resident #1 said “it hurt” when nursing staff attempted to assist Resident #1 to her feet. She said Resident #1 never complained of pain previously. She said after the fall, Resident #1 needed to use a wheelchair, which was not normal for the resident. RN #1 was interviewed on 2/18/26 at 11:41 a.m. RN #1 said she assessed Resident #1 when she was found on the floor on 1/16/26. She said the resident had no bruising to her head and no difficulty with range of motion on her upper and lower extremities when she was sitting in the wheelchair. RN #1 said the resident had difficulty standing on her left leg when staff were attempting to assist the resident to a standing position. She said she did the initial assessment for the neurological checks. She said she was unfamiliar with Resident #1 because she never worked in the memory care unit. She said Resident #1 was struggling to hold her own body weight and stand on both legs. RN #1 said she was concerned about injuries to the resident’s hips or knees because the resident was still showing signs of pain with facial grimacing and guarding the day she was found on the floor (1/16/26). The DON and the regional nurse consultant were interviewed together on 2/18/25 at 2:30 p.m. The DON said Resident #1 was admitted to the memory care unit for her dementia. She said Resident #1 was at risk for falls, according to her MDS assessments. The DON said the resident had interventions in place to prevent the resident from sustaining a fall. The DON said a fall investigation was conducted after the resident’s 1/16/26 fall and the facility determined the root cause of Resident #1’s fall was having regular socks on her feet instead of non-skid socks. The physician was interviewed on 2/19/26 at 10:43 a.m. The physician said he was the physician on-call when he received a phone call from the facility’s nursing staff regarding Resident #1’s fall. He said he ordered a STAT Xray on 1/16/26. He said the Xray results were negative. The physician said it was very difficult to assess the pain level of a patient with dementia. He said he instructed the nurses to monitor the resident very closely for pain. He said if the resident was continuing to have pain or increasing pain, to call him back for further orders. The physician said if a resident with dementia was typically walking and after the fall she couldn't walk, but if the pain was steady, he was less concerned and he would recommend continuing observation. However, he said if after the fall, the pain was progressively getting worse, that was a red flag and indicated further work-up might be needed. The physician said he received a phone call on 1/17/26 from the nursing staff regarding ongoing concerns for Resident #1. He said he ordered STAT laboratory work due to the resident’s altered mental status and in an attempt to determine what led to the resident’s fall. He said he received a third call from the nursing staff on 1/18/26 requesting to send the resident to the hospital for continued difficulty walking with pain and he gave them the order.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE THE STATE OPERATIONS MANUAL.
S704 1. Resident # 1 is no longer residing at the community. 2. Residents who had a fall on the secured neighborhood have the potential to be affected by this alleged deficient practice. A 30-day review was completed on 2/18/26 by the DON (director of nursing)/designee of residents on the secured neighborhood who had fallen to ensure supervision of previously implemented interventions to attempt to prevent falls was occurring and interventions were implemented. No other concerns were identified, all fall interventions were in place and functioning. 3. Education was initiated on 2/18/26 by the DON/designee with licensed nursing staff regarding falls and ensuring interventions were in place and being monitored. Education to be completed upon hire and PRN (as needed). DON/designee to complete weekly audit of five random resident falls for one month, and then monthly for two months, to ensure that previous interventions were in place, appropriate interventions were implemented. These audits will be filled out on a form and staff will follow up with any concerns that may be found. 4. The DON/designee will report findings from the audits to the QAPI Committee monthly for 90 days. The QAPI committee will identify any trends and take corrective action as needed.
9/23/2025Complaint Survey · ID 1D79E2-H1No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2607120, #CO2619771 and Incident #2623324 was completed on 9/22/25 to 9/23/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
6/25/2025Complaint Survey · ID WGJ211No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO37867 and Incident #39961 was conducted on 6/25/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
12/20/2024Revisit: Recertification Survey · ID IAUT22No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed. A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed. A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.
Plan of correction
The state did not require a plan of correction for this citation.
12/20/2024Revisit: Federal Monitoring Survey Survey · ID JK2922No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
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.
Plan of correction
The state did not require a plan of correction for this citation.
10/2/2024Complaint Survey · ID 8X8J11No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, for Incident #CO37761 was conducted on 10/1/24 and 10/2/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
10/1/2024Revisit: State Licensure Survey · ID GOE412No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 10/1/24 for all previous deficiencies cited on 7/30/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
10/1/2024Revisit: Complaint, Recertification Survey · ID IAUT12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 10/1/24 for all previous deficiencies cited on 7/30/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
9/10/2024Federal Monitoring Survey Survey · ID JK2921No deficiencies▼
0000Initial CommentsSurveyor note2 building records▼
Findings · record 1 of 2
A Comparative Federal Monitoring Survey was conducted on 9/10/24, following a State Agency Annual Survey on 8/15/24, in accordance with 42 Code of Federal Regulations, Part 483: Requirements for Long Term Care Facilities. During this Comparative Federal Monitoring Survey, the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. The findings that follow demonstrate noncompliance with Title 42, Code of Federal Regulations, 483.90 (a) et seq. (Life Safety from Fire).
Findings · record 2 of 2
A Comparative Federal Monitoring Survey was conducted on 9/10/24, following a State Agency Annual Survey on 8/15/24, in accordance with 42 Code of Federal Regulations, Part 483: Requirements for Long Term Care Facilities. During this Comparative Federal Monitoring Survey, the facility was found to be in compliance with the Requirements for Participation in Medicare and Medicaid
Plan of correction
The state did not require a plan of correction for this citation.
9999Final ObservationsSurveyor note▼
Findings
The facility was found to be in compliance with Title 42, Code of Federal Regulations, 483.73 et seq. (Emergency Preparedness).
Plan of correction
The state did not require a plan of correction for this citation.
8/15/2024Recertification Survey · ID IAUT2112 deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (000) (VB) construction. The facility is protected by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinkled. The facility was constructed in 1978 and is licensed for 110 beds. This re-certification survey, conducted on August 15, 2024, was conducted to comply with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference at the end of the on-site survey. The Administrator reported the daily census to be 110 residents on August 15, 2024.
Plan of correction
The state did not require a plan of correction for this citation.
0222Egress DoorsS/S F▼
Findings
Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Delayed egress 200 doesn't have power; 2. the gym ramp to the patio gate needs one motion lock. 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 secondsNFPA 101 7.2.1.4.2 Door Leaf Swing Direction. Door leaves required to be of the side-hinged or pivoted-swinging type shall swing in the direction of egress travel under any of the following conditions:(1) Where serving a room or area with an occupant load of 50 or more, except under any of the following conditions:(a) Door leaves in horizontal exits shall not be required to swing in the direction of egress travel where permitted by 7.2.4.3.8.1 or 7.2.4.3.8.2.(b) Door leaves in smoke barriers shall not be required to swing in the direction of egress travel in existing health care occupancies, as provided in Chapter 19.(2) Where the door assembly is used in an exit enclosure, unless the door opening serves an individual living unit that opens directly into an exit enclosure(3) Where the door opening serves a high hazard contents areaNFPA 101 7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6. A.?7.2.1.5.10 Examples of devices that might be arranged to release latches include knobs, levers, and bars. This requirement is permitted to be satisfied by the use of conventional types of hardware, whereby the door is released by turning a lever, knob, or handle or by pushing against a bar, but not by unfamiliar methods of operation, such as a blow to break glass. It is also within the intent of this requirement that switches integral to traditional doorknobs, lever handles, or bars, and that interrupt the power supply to an electromagnetic lock, be permitted, provided that they are affixed to the door leaf. The operating devices should be capable of being operated with one hand and should not require tight grasping, tight pinching, or twisting of the wrist to operate. The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.
Plan of correction · submitted by the facility
K-222 Preparation and/or execution of this plan of correction do not constitute admission or agreement by the provider of the truth of the facts alleged or the conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because the provision of State and Federal law requires it. This plan correction is the facility’s credible allegation of compliance. No specific resident was identified in this alleged deficient practice. All residents could be affected by this alleged deficient practice. Other egress doors were inspected and meet standard. No other issues noted. A)The delayed egress 200 was repaired by the maintenance assistant by turning on the breaker which powered the lock. B )The gym ramp had a single motion lock installed. The Maintenance staff were educated on the requirement to have all single motion locks on all egress doors. The Maintenance Director will report the results of the inspections to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee
0231Means of Egress CapacityS/S D▼
Findings
Based on observation, it was found that the facility does not meet mean of egress requirements in accordance with NFPA 101. The metal roof floor from the gym to the patio is split, with an abrupt elevation changeNFPA 101 7.5.4.3 Each required accessible means of egress shall be continuous from each accessible occupied area to a public way or area of refuge in accordance with 7.2.12.2.2. NFPA 101 7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 in. (6.3 mm), but not exceeding 1/2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1/2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and Maintenance director discussed deficient items at the exit conference.
Plan of correction · submitted by the facility
No specific resident was noted in this alleged deficient practice. All residents have the potential to be affected if they use the gym. The metal roof floor from the gym to the patio was replaced to correct the split with abrupt elevation change The Maintenance Director or designee is going to present pictures for installing the new metal floor with NHA in (QAPI) Quality Assurance Performance Improvement The deficiency tag Number 0231 was corrected on 8/19/2024
0281Illumination of Means of EgressS/S E▼
Findings
Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. Add Exit signs on patiosNFPA 101, 7.8.1.1. Illumination of Means of Egress. Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The maintenance director discussed deficient items at the exit conference.
Plan of correction · submitted by the facility
1. No specific resident was noted in this alleged deficient practice. 2. All residents have the potential to be affected by this alleged deficient practice. 3. Exit signs were added to the patio on 8/21/24. 4. The Maintenance Director or designee will present pictures for all exit signs and a monthly audit to ensure they remain compliant with NHA in (QAPI) Quality Assurance Performance Improvement
0345Fire Alarm System - Testing and MaintenanceS/S F▼
Findings
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 72.1. Missing two (2) year smoke detector sensitivity report. 2. 300 hall speaker need to be mounted. NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 14.4.5.3.4; to ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:(1) Calibrated test method(2) Manufacturer's calibrated sensitivity test instrument(3) Listed control equipment arranged for the purpose(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range(5) Other calibrated sensitivity test methods approved by the authority having jurisdictionNFPA 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. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashesNFPA 72 18.4.4.1* To ensure that audible private mode signals are clearly heard, they shall have a sound level at least 10 dB above the average ambient sound level or 5 dB above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the area required to be served by the system using the A-weighted scale (dBA). If the fire alarm system fails to operate, this deficiency could harm all occupants, staff, and visitors in the building. The Administrator discussed the deficiencies during the exit conference.
Plan of correction · submitted by the facility
1. No specific residents were noted in this alleged deficient practice. 2. All residents could be affected by the alleged deficient practice. 3. A) The Maintenance Director will have the fire alarm contractor come and complete the smoke detector sensitivity report on 8/27/24 and B) the maintenance assist mounted a speaker in the 300 hall on __8/27/24________ 4. The Maintenance Director or Designess will audit the smoke detectors sensitivity test will be added to the fire system safety schedule to be completed every 2 years. Also Maintenance director or Designee will ensure notification devises are mounted in the correct manner 5. The Maintenance Director will report to the NHA and QAPI the results of fire safety schedules for 90 days.
0346Fire Alarm System - Out of ServiceS/S D▼
Findings
Based on observations and records review, it was determined that the facility did not have out-of-service guidance for the fire alarm in accordance with NFPA 101. Out of Service Fire Alarm Guidance | Does not include verbiage for state notificationNFPA 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 can potentially affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference.
Plan of correction · submitted by the facility
1. No specific residents were noted in this alleged deficient practice. 2. All residents could be affected by the alleged deficient practice. 3. The Maintenance Director and staff have been educated and trained to report any fire services outages to the authorities having jurisdiction and DFPC. 4. The Maintenance Director will keep records of fire service outages and audit the compliance. 5. The Maintenance Director or Designee will report to the NHA and QAPI team the compliance of fire services outages for the next 90 days (about 3 months) and whenever there is an outage of the fire services
0353Sprinkler System - Maintenance and TestingS/S E▼
Findings
Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13.1. Quarterly- needed. 2. The main riser room needs a new gauge 3. Aux drain sign outside of the gym. 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. NFPA 101 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 13.4.4.1.3 Systems with auxiliary drains shall require a sign at the dry or preaction valve indicating the number of auxiliary drains and location of each individual drain. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator discussed deficient items at the exit conference.
Plan of correction · submitted by the facility
No individual resident was identified but all residents have the possibility of being affected by this allegedly deficient practice. 2. All individuals could be affected by this alleged deficient practice. 3. A) The Maintenance Director has contacted the ARAPAHOE FIRE and scheduled quarterly inspections beginning October 1, 2024 which will continue ever quarter thereafter. B) New gauge install on 8/26/24 C) Auxiliary Drain sign replaced 4. Maintenance Director and designee were provided education regarding scheduling quarterly sprinkler system testing and inspection, and expiration of gauges 5 years after MFG date and placement of Aux drain signage. 5. Maintenance director will report compliance of maintenance on a monthly basis to the QA committee for 90 days to assure compliance.
0354Sprinkler System - Out of ServiceS/S D▼
Findings
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 25Out-of-service Sprinkler Guidance - Does not include verbiage for state notification NFPA 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 throughout the facility. The administrator discussed deficient items at the exit conference.
Plan of correction · submitted by the facility
1. No specific residents were noted in this alleged deficient practice. 2. All residents could be affected by the alleged deficient practice. 3. The Maintenance Director and staff have been educated and trained to report any fire alarm service outages to the authorities having jurisdiction and DFPC 4. The Maintenance Director will keep records of fire alarm service outages and audit the compliance. 5. The Maintenance Director will report to the NHA and QAPI team the compliance of fire services outages for the next 90 days and whenever there is an outage of the fire services
0355Portable Fire ExtinguishersS/S F▼
Findings
Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. 1. Class K fire extinguisher failed the annual report and has not been replaced. 2. The kitchen ABC fire extinguisher failed, and the annual report has not been replaced. Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire ExtinguishersThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.
Plan of correction · submitted by the facility
Identify the deficiency; During the facility Life safety walk through, the officer noticed the class K and ABC fire extinguishers failed the annual report and has not been replaced Proposed Solution: Maintenance Director is going to be responsible for checking annual report for deficiencies to get fixed immediately. Deficient fire extinguishers were replaced on 8/26/24 by Arapahoe Fire. Verification and Testing: Maintenance Director will send report from Arapahoe Fire when received Documentation and Reporting: The Maintenance Director is going to present documentation for the fire extinguisher replacement with NHA in (QAPI) Quality Assurance Performance Improvement The deficiency tag Number 0355 was corrected from Arapahoe Fire on 8/26/2024
0363Corridor - DoorsS/S D▼
Findings
Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3 The door seal falling off at the ramp delayed egress. NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. This deficient practice could affect all residents within the smoke compartments should the egress become untenable due to smoke and heat transfer via the non-latching corridor doors and gaps in the door smoke seal. The maintenance director and administrator discussed deficient items during the survey and at the exit conference.
Plan of correction · submitted by the facility
Identify the deficiency; During the facility Life safety walk through, the officer noticed the class K and ABC fire extinguishers failed the annual report and has not been replaced Proposed Solution: Maintenance Director is going to be responsible for checking annual report for deficiencies to get fixed immediately. Deficient fire extinguishers were replaced on 8/26/24 by Arapahoe Fire. Verification and Testing: Maintenance Director will send report from Arapahoe Fire when received Documentation and Reporting: The Maintenance Director is going to present documentation for the fire extinguisher replacement with NHA in (QAPI) Quality Assurance Performance Improvement The deficiency tag Number 0355 was corrected from Arapahoe Fire on 8/26/2024
0372Subdivision of Building Spaces - Smoke BarrieS/S D▼
Findings
Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:The IT room has multiple penetrations. NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The maintenance director discussed deficient items at the exit conference.
Plan of correction · submitted by the facility
1. No specific residents were noted in this alleged deficient practice. 2. All residents could be affected by the alleged deficient practice. 3. The Maintenance Director has repaired the smoke barrier walls with fire sealant caulking in the IT room on 8/19/24. 4. The Maintenance Director will audit the compliance of smoke barrier walls are without penetrations on the Quarterly inspections. 5. The Maintenance Director or Designee will report to the NHA and QAPI team on the compliance of the smoke barrier walls without penetration for the next 90 days.
0920Electrical Equipment - Power Cords and ExtensS/S D▼
Findings
Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by: 1) The fridge is plugged into a power strip. Flexible cords and cables in accordance with Chapter 4 of NFPA 70, Section 400.8(1), in part, flexible cords and cables shall not be used as a substitute for the fixed wiring of a structure. Furthermore, Health Care Facilities Code section 10.2.3.6 (2), "The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets."This deficiency has the potential to affect the occupants, who might include the residents, staff, and visitors within affected smoke compartments. The maintenance staff and facility administrator discussed deficient items during the exit conference.
Plan of correction · submitted by the facility
No individual residents were identified in this alleged deficient practice. All individuals could be affected by this alleged deficient practice. The Maintenance Director completed inspections and removed all non-sensitive electronics from surge protectors on 8/15/24 . Education and training completed with the all staff that have refrigerators in their offices. Non-medical grade surge protectors may only be used for sensitive electronics by 8/27/24 The Maintenance Director is going to present documentation every month with NHA in (QAPI) Quality Assurance Performance Improvement The deficiency tag Number 0920 was corrected for Maintenance department on 8/15/2024
0923Gas Equipment - Cylinder and Container StoragS/S F▼
Findings
Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:Oxygen Transfill rooms need a vent 12" of the floor. NFPA 556.15.7 Inlets to the Exhaust System. 6.15.7.1 The exhaust ventilation system design shall take into account the density of the potential gases released. 6.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor. 6.15.7.3 For gases that are lighter than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the ceiling. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and Maintenance director discussed deficient items at the exit conference.
Plan of correction · submitted by the facility
No individual resident was identified for this alleged deficient practice. All individuals could be affected by this alleged deficient practice. The technician installed the new exhaust duct (2) 12 inches from the floor on 8/26/24. The Maintenance Director is going to present pictures for the new vents on oxygen rooms with NHA in (QAPI) Quality Assurance Performance Improvement. The deficiency tag Number 0923 was corrected on 8/26/24
7/30/2024Complaint, Recertification Survey · ID IAUT118 deficiencies▼
0000Initial CommentsSurveyor note2 building records▼
Findings · record 1 of 2
A recertification survey with complaint #CO36754, #CO36757, #CO36769 and #CO36780 was completed on 7/24/24 to7/30/24. Eight deficiencies were cited.
Findings · record 2 of 2
An Emergency Preparedness survey was conducted from 7/24/24 to 7/30/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0550Resident Rights/Exercise of RightsS/S E▼
Findings
Based on observations, record review and interviews, the facility failed to ensure residents were treated with dignity in two out of four dining rooms. Specifically, the facility failed to:-Ensure an adequate system was in place to provide meal service in a timely fashion to residents waiting to be served their meals in the Aspen and Pine Ridge dining rooms, which resulted in some residents at the same table receiving their meals 40 to50 minute after other residents; and, -Ensure residents were treated with respect and dignity by staff in the dining rooms, including engaging with residents and addressing residents by his/her preferred name. Findings include: I. Facility policies and procedure The Quality of Life - Dignity policy, revised February 2020, was requested and received from the nursing home administrator (NHA) on 7/30/24. It read in pertinent part,"Residents are treated with dignity and respect at all times. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice."The Assistance with Meals policy, revised March 2022, was requested and received from the nursing home administrator (NHA) on 7/30/24. It read in pertinent part,"All residents will be encouraged to eat in the dining room. Residents who can not feed themselves will be fed with attention to safety, comfort and dignity, for example, not standing over residents while assisting them with meals and keeping interactions with other staff to a minimum while assisting residents with meals."II. Dining room meal timesThe posted meal times for the facility's dining rooms were scheduled to begin as follows: breakfast began at 6:45 a.m., lunch began at 11:30 a.m. and supper began at 4:20 p.m. III. Aspen dining room observationsDuring a continuous observation of the lunch meal in the Aspen dining room on 7/24/24, beginning at 11:54 a.m. and ending at 12:53 p.m., the following observations were made: At 11:54 a.m. eight residents were present and seated at tables in the dining room. One of the residents spilled water that ran all over the table and the floor. -No staff were present in the dining room and the water spill went unnoticed. At 12:00 p.m. lunch meal trays were delivered on a cart to the dining room by the dietary staff. At 12:04 p.m. staff started to pass the lunch meal trays to the residents seated at the tables. At 12:08 p.m the spilled water was noticed by an unidentified certified nurse aide (CNA) who cleaned up the spill. Another unidentified CNA was overheard telling two other staff members "You guys will be feeding them (referring to residents) today" before leaving the dining room. At 12:14 p.m. one of the CNAs was standing up next to a resident and assisting her with eating lunch.-The CNA failed to sit down next to the resident while assisting her to eat her lunch. At 12:20 p.m. five of the eight residents present in the dining room had received their meals. At 12:24 p.m. more meal trays were delivered to the Aspen dining room, however the lunch meal trays were for residents who chose to eat in their rooms and not for the three remaining residents in the dining room who had not yet received their meals. At 12:44 p.m. a third cart of lunch meal trays was delivered to the Aspen dining room. The three other residents in the dining room received their lunch meals, 40 minutes after lunch service began and at least 20 minutes after the other five residents had received their meals. At 12:53 p.m.one of the residents at the front right dining room table was heard asking if she could have toast. CNAs walking by the table ignored her request. A resident who was sitting next to her at the table said "They told me they don't make toast."Staff members in the middle of the dining room were discussing another resident and were overheard saying "She already ate, all she wanted was a sandwich and we offered her everything."-The staff members did not refer to the resident by name. During a continuous observation of the lunch meal in the Aspen dining room on 7/25/24, beginning at 12:00 p.m. and ending at 12:52 p.m., the following observations were made:At 12:00 p.m. The first lunch meal trays were delivered on a cart to the dining room. Two of the eight residents in the dining room received lunch meal trays from the first meal cart delivery. At 12:40 p.m. the second cart of meal trays was delivered to the dining room, however, the meal trays on the cart were for residents who were eating in their rooms and not for the remaining six residents in the dining room who had not yet received their meals. At 12:52 p.m. the third cart of lunch trays was delivered to the Aspen dining room. The six other residents in the dining room received their lunch meals, 52 minutes after the other two residents in the dining room had received their meals. During a continuous observation of the lunch meal in the Aspen dining room on 7/29/24, beginning at 12:01 p.m. and ending at 12:47 p.m., the following observations were made:At 12:01 p.m. a housekeeper pushed a resident in a wheelchair into the dining room and was overheard asking a CNA "Where do you want her?" The CNA responded "Put her with (resident name), she gets along with her."-The housekeeper and the CNA failed to refer to the resident in the wheelchair by her name. At 12:06 p.m. the first lunch meal tray cart arrived in the dining room. One out of seven residents present in the dining room received a lunch meal tray. The other meal trays on the cart were served to residents who were eating in their room. At 12:09 p.m. a second meal tray cart was delivered to the dining room. One of three residents, who were sitting at the same table, were served their lunch meal. At 12:21 p.m. a third meal cart was delivered to the Aspen dining room. All of the lunch meal trays on the cart were for residents who were eating in their rooms. At 12:30 p.m. a fourth lunch meal tray cart arrived in the dining room. Four of the remaining residents in the dining room received their meals. One resident in the dining room, who was sitting next to a resident who had received her meal tray at 12:00 p.m., still had not received her lunch meal. At 12:39 p.m. a fifth meal cart of lunch trays was delivered. All of the meal trays went to residents in their rooms. At 12:46 p.m. an unidentified CNA sat next to the resident with the face mask who required assistance with eating and started assisting the resident (21 minutes after she had received her meal). The resident's mask was still touching her lower lip. The CNA began helping another resident on her other side as well as the resident with the mask. The CNA did not remove the resident's mask or lower it below her chin. At 12:47 p.m. a sixth cart of lunch meal trays was delivered to the Aspen dining room and the last resident in the dining room was served (41 minutes after the first resident received their lunch meal tray). IV. Pine Ridge dining room observationsDuring a continuous observation of the lunch meal in the Pine Ridge dining room on 7/24/24, beginning at 11:31 a.m. and ending at 12:42 p.m., the following observations were made: The Pine Ridge dining room had two round tables which accommodated five residents each and bistro seating for two residents. From 11:31 a.m. to 11:40 a.m., nine residents were assisted to the dining room for meal time. Four additional residents were seated by 11:52 a.m., for a total of 12 residents seated in the dining room. At 12:04 p.m. the first meal tray cart arrived at the Pine Ridge dining room. Two meal trays were delivered to two residents in the dining room. No other residents received a meal tray. At 12:08 p.m. an unidentified staff member told a resident that the food was coming. At 12:22 p.m., five additional meal trays arrived on a cart and were passed to residents. At 12:30 p.m., 38 minutes after the last residents were seated, five residents did not have meal trays. Two residents from each of the two dining tables and one ofthe two residents seated at the bistro counter waited to receive their meal tray while the other seven residents in the dining room were eating their lunch. An unidentified staff member said to a resident who was waiting for their meal tray, "You are getting sleepy waiting for your lunch huh." Between 12:31 p.m. and 12:42 p.m., the remainder of the lunch meal trays were delivered and at 12:42 p.m. the last resident seated at the bistro counter in the dining room received his meal tray, 50 minutes after the last resident was initially seated for lunch. -The facility failed to ensure residents seated at the same table were served their meals in a timely manner during the lunch meal. During a continuous observation of the lunch meal in the Pine Ridge dining room on 7/25/24, beginning at 11:15 a.m. and ending at 12:50 p.m., the following observations were made:At 11:42 a.m. eight residents were seated in the dining room with four residents each seated at the two round tables. At 11:45 a.m. Resident #38 was just brought to the dining room and seated at the bistro counter. Three additional residents were seated in the dining room for a total of twelve residents. All residents had drinks in front of them but no food. At 12:02 p.m. Resident #38 made a short, low groaning sound. Registered nurse (RN) #3 approached Resident #38 and asked her if she was okay. Resident #38 replied she was okay and RN #3 asked Resident #38 if she was getting hungry. Resident #38 replied yes she was. At 12:07 p.m. four meal trays arrived and were delivered to residents seated in the dining room. Resident #38 continued to make a short, low groaning sound while seated in the dining room. At 12:14 p.m. Resident #38 was sitting with her eyes closed in the dining room. At 12:15 p.m. CNA #11 escorted a resident from the dining room and no other facility staff were present in the dining room. At 12:22 p.m. five more meal trays had been delivered to residents seated in the dining room. Three residents seated at the round dining table did not have a meal tray while the remainder of the residents in the dining room had received meal trays and were eating their lunch. At 12:37 p.m. three residents had not yet received a meal tray. A resident who received her meal tray first finished eating, while the resident seated next to her had not received a meal yet and watched her eat her meal. At 12:42 p.m a cart of additional meat trays was delivered to the dining room. At 12:49 p.m. the final resident without a meal tray was given her lunch. RN #3 set up her tray and said to the resident, "You look hungry." -The facility failed to ensure residents seated at the same table were served their meals in a timely manner during the lunch meal. V. Main dining room observationsDuring a continuous observation of the dinner meal in the main dining room on 7/30/24, beginning at 4:16 p.m and ending 5:54 p.m., the following observations were made::At 5:04 p.m. CNA #9 was observed standing next to a table in the dining room. A resident was seated in her wheelchair next to CNA #9. CNA #9 was eating out of a clear plastic container while standing in the dining room during meal service. -Dietary aide (DA) #1 was interviewed at 5:05 p.m. DA #1 said CNA #9 was employed at the facility and assisted feeding residents at meal time. At 5:07 p.m. CNA #9 sat down at the table and set his cell phone on the dining room table in front of him. CNA #9 offered the resident a drink with his left hand while looking down at his cell phone on the table. CNA #9 continued to hold the drink glass in front of the resident while he looked at his phone for approximately 45 seconds. CNA #9 put down the drink glass and continued to look at his phone instead of looking at the resident and engaging with herAt 5:14 p.m. CNA #9 was looking down at his phone on the table while sitting with the resident, not making eye contact with her or engaging with her.-The dietary manager (DM) was interviewed at 5:17 p.m. The DM confirmed CNA#9 was an employee of the facility and the DM asked if CNA #9 was on his phone again in the dining room. The DM said she told CNA #9 to get off his phone at lunch and he was not happy he was told to put his phone away. The DM said in the orientation for new employees, she reviewed staff should not have their personal cell phones in the dining room. The DM said CNA #9 was not a new staff member and did not have an orientation with her but she said he should still know cell phones were not allowed in the dining room. At 5:31 p.m. CNA #9 was observed checking his hands and not looking at or engaging with the resident during meal time.-CNA #9 failed to assist and engage with the resident while assisting her during meal service. VI. Staff trainingThe DON provided an inservice on 7/30/24 at 1:25 p.m. The course title was nursing meeting and dated 4/11/24. The description of the education included addressing weight concerns (of residents), dining services, meal orders and encouraging residents to come to the main dining room. CNA #9 signed the inservice on 4/11/24. -However, the inservice did not provide details that specifically addressed resident meal time assistance. VII. Staff interviewsCNA #12 was interviewed on 7/30/24 at 10:35 a.m. CNA #12 said the residents could choose which dining room they preferred to dine in and what menu items they preferred to eat. CNA #12 said, after facility staff took resident meal orders, the orders were given to the dietary staff. CNA #12 said she was unsure why resident meal trays were served so far apart for one dining room instead of being served together. CNA #12 said the facility staff usually had the residents seated in the dining room around 11:30 a.m. for lunch (however lunch was served between 11:30 a.m. and 1:00 p.m.) CNA #12 said residents expressed frustration about waiting too long for their meal trays to be delivered and dietary staff were aware of the resident's concerns. The DM and the nursing home administrator were interviewed together on 7/30/24 at 11:00 a.m. The NHA said the timing of meal delivery was an issue the facility was working on. The NHA said the facility only sent a few trays to one dining room at a time so the food was served hot. The NHA said the CNAs spent three days with another staff member for their initial training. The NHA said resident meal assistance, as well as feeding the residents, was part of the CNAs initial training. The DM said the goal was for staff to be able to pass some meal trays before sending more so the food stays hot. The DM said the dietary staff did not always know where the residents preferred to eat and where to send the meal trays. The DM said meal service usually took almost an hour. CNA #9 was interviewed on 7/30/24 at 11:30 a.m. CNA #9 said he was a full time CNA and was working occasionally at nights and on the weekends. He said dining room assignments for CNAs were not clear as far as which CNA needed to present in which dining room. He said sometimes CNAs were told to go to the main dining room and sometimes they were to go to the small dining room. He said the facility had new agency staff coming daily and those staff members were not aware of the resident's preferences and had a tendency to ask questions about personal care in front of the residents. CNA #9 said the general rules of meal assistance were to sit next to the resident and assist the resident with the meal until the resident was finished eating. He said all residents should be referred to by name and personal care and needs should not be discussed in front of other residents. CNA #9 said the kitchen always delivered meal trays in random order and there was no system to who received the first meal or which resident received the last meal. Licensed practical nurse (LPN) #1 was interviewed on 7/30/24 at 11:45 a.m. LPN #1 said she was not sure if there was an order for meal tray delivery. She said the kitchen delivered the trays randomly and it was unclear if there was any system to it. LPN #1 said when staff assisted residents in the dining room they should refer to residents by name, be attentive to their needs and help residents until they were finished with the meal. The NHA and the director of nursing (DON) were interviewed together on 7/30/24 at 12:45 p.m. The DON said the facility provided a meal service education in April 2024 to encourage residents to come to the dining room and CNA assistance with meals. She said staff were talked to about not being on their phones. The DON said meal service was something the facility had been working on and they were trying to get residents into a type of seating arrangement.-However, the inservice did not provide details that specifically addressed resident meal time assistance (see staff training above). The NHA said a cart of meal trays was delivered to the Pine Ridge dining room, and then another cart of meal trays was delivered to a different dining room so the CNAs had time to get trays set up for residents and the residents were not waiting too long. The NHA said the facility was trying to improve socialization with residents at meal time and improve overall meal service. The NHA said the facility had not yet considered staggering the start times of meals in the different dining rooms. CNA #11 was interviewed on 7/30/24 at 2:00 p.m. CNA #11 said the residents sometimes expressed concern they felt hungry while waiting for lunch. CNA #11 said the staff did their best to offer residents a drink or something small to eat while waiting for meal trays to be delivered at mealtime. CNA #11 said the late arrival of lunch meals could disrupt the resident's afternoon schedules. CNA #11 said longer mealtimes made it difficult to manage if residents were eating and needed assistance and another resident had to use the restroom, which caused the staff to leave the dining room to assist a resident with continence care. CNA #11 said she was trained how to assist a resident at meal time and a personal cell phone should not be used while assisting a resident. CNA #11 said staff should be seated and make eye contact with the residents because it was respectful to the resident and helped the residents trust the staff. The DON was interviewed again on 7/30/24 at 5:24 p.m. The DON said while assisting a resident at meal time, staff should sit so they were at eye level with the residents. The DON said staff's hands should be clean, staff should talk to the resident, inform the resident what menu items were on their plates and cue or assist them to eat as needed. The DON said cell phones were not acceptable to use while assisting a resident at meal time, nor were conversations about other residents. The DON said residents should be discussed on the side and resident's personal matters should not be discussed in front of other residents. The NHA was interviewed again on 7/30/24 at 5:50 p.m.. The NHA said all residents were to be treated with respect and dignity. He said CNAs should be seated next to the residents when they were providing meal assistance and remain with the resident until the resident finished his or her meal. He said staff should not discuss any personal information in front of other residents.
Plan of correction
The state did not require a plan of correction for this citation.
0561Self-DeterminationS/S E▼
Findings
Based on record review and interviews, the facility failed to honor resident choices for three (#56, #6 and #65) of five residents reviewed for activities of daily living (ADL) out of 51 sample residents. Specifically, the facility failed to:-Ensure Resident #56, Resident #6 and Resident #65 received two showers a week per their preferences; and,-Ensure Resident #65 was assisted with a leg catheter bag on Sundays when he was attending church. Findings include: I. Resident #56A. Resident statusResident #56, age 79, was admitted on 11/14/23. According to the July 2024 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia (decreased oxygen levels), chronic obstructive pulmonary disease (COPD) and dependance on supplemental oxygen. The 6/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required substantial maximal assistance with showers and did not reject the care. B. Resident interviewResident #56 was interviewed on 7/24/24 at 3:28 p.m. Resident #56 said she had not had a shower in a week. She said her preference was to receive two showers a week. She said there were new staff members working at the facility every day and they were not familiar with the shower schedule. She said the staff would come into her room and say they would come back. She said the staff never returned to her room to assist her with a shower. She said sometimes the staff said there was not enough staff so they could not help with showers. C. Record reviewThe care plan, initiated 11/15/23, identified Resident #56 had impaired balance and limited mobility. Interventions included staff to assist with showers. -A review of the care plan revealed the care plan did not address Resident #56's current shower preferences. The care plan, initiated on 5/24/24, revealed that the resident was resistive to bathing, and would decline showers and bed baths at times. Interventions included allowing the resident to make decisions about treatment regimens, providing a sense of control and if possible negotiating a time for showers so that the resident participated in the decision making process. A review of the certified nurse aide (CNA) shower task for July 2024 revealed Resident #56 was to receive showers on Tuesdays and Thursdays on the evening shift. -The shower logs for 6/23/24 to 7/26/24 revealed the resident received one bed bath on 7/6/24 (Saturday), and one shower on 7/10/24 (Wednesday). The resident refused care on 7/5/24 (Friday) and 7/12/24 (Friday). -Resident #56 was supposed to receive nine showers a month and she received only one. -Review of the progress notes from 6/23/24 to7/26/24 revealed no documented notes for resident refusals of showers. II. Resident #6A. Resident statusResident #6, age 76, was admitted on 6/21/24. According to the July 2024 CPO, diagnoses included COPD and hypertension (high blood pressure). The 6/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required substantial/maximal assistance with showers and did not reject care. B. Resident interviewResident #6 was interviewed on 7/29/24 at 1:28 p.m. Resident #6 said she received showers inconsistently. She said her preference was to receive showers twice a week. She said the agency staff did not know what the shower schedule was and who was to provide showers. She said the staff frequently said they were understaffed and could not provide showers. She said the facility used to have a shower aide, but with the new management, that position was eliminated. She said it was impossible to get a shower per her preference or at all. C. Record reviewThe care plan, initiated 2/24/23, identified Resident #6 had impaired balance and decreased mobility. Interventions included assisting the resident with showers. -A review of the care plan revealed the care plan did not address Resident #6's current shower preferences. A review of the CNA shower task for July 2024 revealed the resident was to receive showers on Mondays and Thursdays on the day shift. -The shower logs for 7/1/24 to 7/30/24 revealed the resident received a total of five showers out of nine scheduled opportunities for showers. -Review of the progress notes from 7/21/24 to 7/30/24 revealed no documented notes for resident refusals of showers. III. Resident #65A. Resident statusResident #65, age 82, was admitted on 11/25/22. According to the July 2024 CPO, diagnoses included hypertension, heart disease and diabetes. The 5/10/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required substantial moderate assistance with showers and did not reject care. B. Resident interviewResident #65 was interviewed on 7/25/24 at 1:28 p.m. Resident #65 said showers were provided inconsistently. He said his preference was to receive showers twice a week on assigned days. He said the agency staff did not know the shower schedule or who was to provide the showers. He said his showers were frequently skipped or not offered at all. Resident #65 said when he voiced his concerns to staff they would say they were too busy. He said every Sunday around 10:30 a.m. he went to church. He said he told staff that his regular catheter bag needed to be replaced with a leg catheter bag prior to attending church. He said the agency staff did not know what a leg catheter bag was. He said the prior Sunday when he was getting ready to go to church, the agency nurse did not know what a leg catheter bag was and it took 30 minutes to find someone who was able to help. He said every Sunday he had to find a nurse who knew what a leg catheter bag was. He said since there was no consistent staff working on the unit, his leg catheter bag was never ready in time for him to go to church. He said he was very frustrated with care. C. Record reviewThe care plan, initiated 11/27/22, identified Resident #65 had impaired balance and decreased mobility. Interventions included assisting the resident with showers. -A review of the care plan revealed the care plan did not address Resident #65's current shower preferences. -The care plan for the urinary catheter, initiated on 11/27/22, did not mention resident's preference for a leg catheter bag on Sundays for church. A review of the CNA shower task for July 2024 revealed the resident was to receive showers on Tuesdays and Fridays on the day shift. -The shower logs for 7/1/24 to 7/30/24 revealed the resident received six out of nine scheduled opportunities for showers. -Review of the progress notes from 7/21/24 to 7/30/24 revealed no documented notes for resident refusals of showers. IV. Staff interviewsLicensed practical nurse (LPN) #5 was interviewed on 7/30/24 at 10:45 a.m.. LPN #5 said the facility was understaffed especially on the Aspen unit where resident care was more heavy than on other units. LPN #5 said she was aware of Resident #65's preference for the leg catheter bag on Sundays. She said when she worked on the weekends she would help him with it. She said she did not know how agency staff could be aware of personal preferences since it was not documented anywhere. LPN #5 said on most days the facility did not have shower aides and CNAs were responsible for providing showers. She said she did not know shower preferences for any of the residents who had shower concerns. She said it was the CNAs responsibility to locate a binder at the nurses station and figure out who was due for showers. CNA #9 was interviewed on 7/30/24 11:47 a.m. CNA #9 said he used to be a shower aide at the facility but since a full time position as shower aide was eliminated with the new management, he was working as a CNA on various shifts. He said, on some rare occasions like today (7/30/24), he was assigned to work as a shower aide. CNA #9 said the facility used to have a schedule for showers where he and other CNAs were assigned to complete the showers. However, he said with new changes and new agency staff in the building, the old schedule did not work because agency CNAs would tell the facility staff what they would do and would not do. He said the rest of the staff would have to scramble and do extra work to provide the care that agency staff would not do. He said agency staff were frequently late or did not show up for work at all and that compromised the care for residents. He said he was certain many showers were missed for residents due to late arrivals and call offs by agency staff. Registered nurse (RN) #2 was interviewed on 7/30/24 at 11:59 a.m. RN #2 said she was an agency nurse and worked in the building on several occasions on different shifts, including weekends. She said she did not know about shower preferences as it was CNAs responsibility to provide showers. RN #2 said she did not know anything about Resident #65's routine on Sundays. She said her orientation to the unit consisted of shift to shift reports from nurses. She said all preferences residents could communicate directly to staff. She said when residents could not communicate, staff could call family and ask about preferences. CNA #11 was interviewed on 7/30/24 12:23 p..m. CNA #11 said she was new to the unit and worked different shifts. She said she did not know when residents were to receive showers. She said she looked at the roster the facility provided to her before shifts and said showers or any specific resident preferences were not mentioned on that roster. The director of nursing (DON) was interviewed in the presence of a nursing home administrator (NHA) on 7/30/24 at 5:20 p.m. The DON said the facility had identified that shower preferences were missed, and they were actively working on implementing a new system to ensure showers were provided per preferences. She said unit managers were working to ensure that agency staff had easy access to residents' preferences and would be updating it on the rosters that staff received at the beginning of the shift. The DON said she was not aware of Resident #65's leg catheter bag preference. The DON said the facility did employ agency staff and all staff were provided with the policies and expectations of the facility.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: On 7/30/24, Residents #56 and #6, were interviewed to determine their preferences for showers and those preferences were updated on daily report sheets to communicate preferences. On 7/30/24, Resident #65 was interviewed to determine preferences for showers and those preferences were updated on daily report sheets to communicate preferences. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: All residents have potential to be affected by deficient practice. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: On 7/30/2024, DON (director of nursing)/Designee completed resident interviews to determine preferences for showers. Preferences were updated on daily report sheets to communicate preferences. On 7/30/2024, DON/Designee interviewed residents with indwelling catheters to determine preferences. Identified residents had no additional changes requested. During the period from 7/31/24 through 8/1/24, education completed with staff on honoring resident shower and catheter preferences. Beginning 8/1/24, DON/Designee to complete random weekly audit of showers and resident preferences to determine compliance. Results of audits to be recorded on a facility implemented audit tool. Any discrepancy to be corrected upon discovery. Beginning 8/1/24, DON/Designee to complete random weekly interviews with residents with indwelling catheters to ensure resident preferences are followed. Results of audits to be recorded on a facility implemented audit tool. Any discrepancy to be corrected upon discovery. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly, the DON/Designee will provide to the Medical Director and Interdisciplinary team a summary report of compliance at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue for 3 months or until sustained compliance is achieved.
0585GrievancesS/S E▼
Findings
Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve any grievances for six (#65, #6, #81, #92, #58 and #87) of ten residents reviewed for grievances out of 51 sample residents. Specifically, the facility failed to ensure grievances regarding competency of agency staff were followed up timely with a satisfactory resolution for Residents #65, #6, #81, #92, #58 and #87. Findings include:I. Facility policyThe Grievance policy, dated 5/8/23, was provided by the nursing home administrator (NHA) on 7/30/24 at 5:15 p.m. It read in pertinent part, "To provide residents and responsible parties with information on the facility grievance procedure. To ensure that residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded promptly and in written form."Upon the receipt of a grievance and complaint report or complaint concern form, the social service director or designee will begin an exploration into the allegations/concerns. The appropriate department director will be notified of the nature of the complaint that follow up is necessary. "The resident or person acting on behalf of the resident will be informed of the findings of the investigation, as well as any corrective actions recommended within 10 working days of the filing of the grievance or complaint."II. Resident interviewResident #87 was interviewed on 7/24/24 at 3:45 p.m. She said agency staff were inconsiderate. She said she took her medications only with hot water because her tooth was sensitive and staff frequently came with cold water. She said, regardless of how many times she communicated it to the staff, they never passed the message on and she had to educate every new staff member about her preferences. III. Group interviewA group of five, alert and oriented residents( (#65, #6, #81, #92 and #58) was interviewed on 7/29/24 at 1:05 p.m. The residents were deemed interviewable per the facility and assessment. Residents said agency nursing staff was working in the building and they were unaware of resident's preferences and daily routines. Resident #65 said showers were provided inconsistently. He said the agency staff did not know the shower schedule and who was to provide the showers. He said his showers were frequently skipped or not offered at all. He said when she voiced his concerns to staff, they would say they were too busy. Resident #65 said every Sunday, around 10:30 a.m. he went to church. He said she told staff that his regular catheter bag was supposed to be replaced with a leg catheter bag prior to attending church. He said the agency staff did not know what a leg catheter bag was. He said the prior Sunday when he was getting ready to go to church, the agency nurse did not know what a leg catheter bag was and it took 30 minutes for the nurse to find someone who was able to help. He said every Sunday he had to find a nurse who knew what a leg catheter bag was. Resident #65 said since there was no consistent staff working on the unit, his leg catheter bag was never ready in time for him to go to church. He said he was very frustrated with care. Cross reference F561 for failure to honor resident preferences. Resident #6 said the agency staff did not know what the shower schedule was or who was to provide showers. She said the staff frequently said they were understaffed and could not provide showers. She said the facility used to have a shower aide, but with the new management, the shower aide position was eliminated. She said it was impossible to get a shower per her preference or at all. Resident #81 said she had memory problems and would frequently forget things. She said, in the past, nursing staff would keep a reminder in her room about her shower days, but she said the sign was gone and agency staff did not know when her shower days were. Resident #92 and Resident #58 said agency staff frequently did not show up for work and were late. Resident #92 said staff frequently walked into his room in the middle of the night to check on his roommate and would turn the light on at the sink area instead of next to his roommate and it would frequently wake him up. He said he asked nurses not to turn on the light at the sink area, but it continued to happen. Resident #58 said, during the shift changes, all staff would loudly argue at the nurses station about assignments. IV. Record reviewResident council minutes were reviewed for the last six months. The 7/17/24 resident council meeting documented a concern that certified nurse aides (CNA) were not working as a team and showers were not done as scheduled. -Both concerns were marked as resolved, however, there was no added information to explain how the concerns were resolved or if the residents were satisfied with the resolution to the concerns. V. Staff interviewsLicensed practical nurse (LPN) #5 was interviewed on 7/30/24 at 10:45 a.m.. LPN #5 said the facility was understaffed especially on the Aspen unit where resident care was more heavy than on other units. LPN #5 said she was aware of Resident #65's preference for the leg catheter bag on Sundays. She said when she worked on the weekends she would help him with it. She said she did not know how agency staff could be aware of personal preferences since it was not documented anywhere. LPN #5 said on most days they did not have shower aides and CNAs were responsible for providing showers. She said she did not know shower preferences for any of the residents who had shower concerns. She said it was the CNAs responsibility to locate a binder at the nurses station and figure out who was due for showers. CNA #9 was interviewed on 7/30/24 11:47 a.m. CNA #9 said he used to be a shower aide at the facility but since a full time position as shower aide was eliminated with the new management, he was working as a CNA on various shifts. He said, on some rare occasions like today (7/30/24), he was assigned to work as a shower aide. CNA #9 said the facility used to have a schedule for showers where he and other CNAs were assigned to complete the showers. However, he said with new changes and new agency staff in the building, the old schedule did not work because agency CNAs would tell the facility staff what they would do and would not do. He said the rest of the staff would have to scramble and do extra work to provide the care that agency staff would not do. He said agency staff were frequently late or did not show up for work at all and that compromised the care for residents. He said he was certain many showers were missed for residents due to late arrivals and call offs by agency staff. Registered nurse (RN) #2 was interviewed on 7/30/24 at 11:59 a.m. RN #2 said she was an agency nurse and worked in the building on several occasions on different shifts, including weekends. She said she did not know about shower preferences as it was CNAs responsibility to provide showers. RN #2 said she did not know anything about Resident #65's routine on Sundays. She said her orientation to the unit consisted of shift to shift reports from nurses. She said all preferences residents could communicate directly to staff. She said when residents could not communicate, staff could call family and ask about preferences. CNA #11 was interviewed on 7/30/24 12:23 p..m. CNA #11 said she was new to the unit and worked different shifts. She said she did not know when residents were to receive showers. She said she looked at the roster the facility provided to her before shifts and said showers or any specific resident preferences were not mentioned on that roster. The director of nursing (DON) was interviewed in the presence of a nursing home administrator (NHA) on 7/30/24 at 5:20 p.m. The DON said the facility had identified that shower preferences were missed, and they were actively working on implementing a new system to ensure showers were provided per preferences. She said unit managers were working to ensure that agency staff had easy access to residents' preferences and would be updating it on the rosters that staff received at the beginning of the shift. The DON said the facility did employ agency staff and all staff were provided with the policies and expectations of the facility. The NHA said the facility had agency staff in the building for some time and recently switched to a different company. He said agency staff received the same orientation to the unit as other new staff. He said staff who were familiar with the unit were expected to help and assist new staff with details of care.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: Residents 65, 6, 81, 92, 58, and 87 were identified as affected by this alleged deficient practice. NHA met with each identified resident to review the previous grievances submitted to ensure appropriate resolution. No further concerns were identified. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: On 7/29/24, NHA completed an audit of previous 60 days of grievances to identify similar concerns. No similar concerns were identified. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: Grievance training was initiated with staff on 7/24/24 to address the grievance process to include assisting residents with filing a grievance if the resident is unable to complete one independently and timely follow up to resolve the grievance with the resident. Follow-up with staff training was completed from 7/31/24 through 8/1/24. On 7/31/24, NHA met with resident council president to review grievance process and will review in next resident council. Grievances generated during the resident council process will be recorded on a grievance form and reviewed by department indicated. The results of intervention will be reviewed in the next resident council to ensure identified concern is resolved to the satisfaction of resident council as indicated by the signature of the resident council president on grievance form. Grievances regarding agency staff competency and agency packet completion will be reviewed in morning meeting. Any discrepancy noted to be corrected upon discovery. Beginning 8/1/24, the NHA or designee will conduct random weekly audit of grievances for 3 months to ensure that grievances regarding staffing concerns are reported and resolved promptly. Facility actions taken to address the concern will be reviewed with the resident that filed the grievance to ensure satisfactory response until a resolution is reached as indicated by the signature of the resident on grievance form. Audit results to be recorded on facility developed audit tool. SSD or designee will review new grievances daily to identify staffing related grievances, Monday-Friday, in the morning IDT meeting until resolution is completed. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly, the DON/Designee will provide to the Medical Director and Interdisciplinary team a summary report of compliance at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue for 3 months or until sustained compliance is achieved.
0692Nutrition/Hydration Status MaintenanceS/S G▼
Findings
Based on observations, record review and interviews, the facility failed to ensure one (#93) of three residents reviewed for nutrition received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being out of 51 sample residents. Resident #93 was admitted to the facility for long term care on 3/27/24 with diagnoses of severe dementia with mood disturbance, hypothyroidism (underactive thyroid), depression and dysphagia of the oropharyngeal stage (food sticks to the mouth or throat or gets pocketed in cheeks). Upon admission (3/27/24), Resident #93 weighed 114.6 pounds (lbs). On 4/4/24 the facility placed the resident on restorative dining services, however, observations during the survey revealed the resident did not receive consistent assistance at meals. On 5/20/24, the resident weighed 112.6 lbs and on 6/20/24 the resident weighed 106 lbs. The resident sustained a 5.9% (6.6 lbs) weight loss from 5/20/24 to 6/20/24 in one month, which was considered severe. On 7/21/24 the resident weighed 100.5 lbs. At this time the resident sustained an additional 5.2% (5.5 lbs) weight loss from 6/20/24 to 7/21/24 in one month, which was considered severe. On 7/23/24 the facility implemented a four ounce house nutritional supplement. Due to the facility's failures to provide total assistance in a timely manner and consistently offer alternatives of equal nutritional value and accurately record her food intake, Resident #93 sustained a 9.1% (10.1 lbs) weight loss in three months, which was considered severe. Findings include:I. Facility policy and procedureThe Weight Management policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 5/30/24 at 5:30 p.m. It revealed in pertinent part,"Residents identified with weight change will be assessed by the interdisciplinary team (IDT), and further interventions will be implemented to minimize the risk for further weight change where possible and to promote weight stability."All residents will be weighed upon admission, then weekly or as indicated by physician orders. Results will be documented in the medical record."Residents will be screened by a registered dietitian (RD) or designee for their risk for weight change on admission, quarterly, annually, and with significant change of condition with completion of the minimum data set (MDS). "Residents with weight variance (loss or gain) are reweighed. Significant/severe weight variance is defined as: 5 percent (%) in one month; 7.5% in three months; or 10% in six months"Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, RD evaluation and assisted dining."The following categories of residents should be weighed weekly unless otherwise indicated: residents with significant weight changes until weight is stabilized as defined in the policy; as determined by the physician, DON (director of nursing), RD (registered dietitian), or IDT teams discretion."The IDT meets weekly to review residents with identified weight changes, develops a plan, implements, evaluates, and re-evaluates interventions to minimize the risk for weight change."Nursing staff are responsible to communicate weight changes to the attending physician and resident's family. The nurse documents the notification in the medical record."Nursing staff is to notify food and nutrition services and the RD of a resident's weight change. The RD further assesses the resident to determine root cause of the weight change and makes recommendations to reduce or stabilize the weight change."Nursing staff or the RD are to notify the speech therapist (ST) if swallowing or chewing problems are suspected."II. Resident #93A. Resident statusResident #93, age 85, was admitted on 3/27/24. According to the July 2024 computerized physician orders (CPO), diagnoses included severe dementia with mood disturbance, hypothyroidism, depression and dysphagia of the oropharyngeal stage. The 6/28/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required substantial/maximum assistance with showering and personal hygiene, and supervision and/or touching assistance with eating. -However, according to the 6/6/24 physician's order, the resident required total supervision and assistance with meals. The assessment documented the resident was 66 inches (five feet, six inches) tall, and weighed 106 lbs. It indicated the resident had weight loss (a loss of 5% or more in the last month, or 10% or more in the last six months). The resident had no signs or symptoms of a possible swallowing disorder. B. ObservationsDuring a continuous observation on 7/24/24, beginning at 12:04 p.m. and ending at 1:37 p.m., the following was observed:At 12:10 p.m., Resident #93 was served a chicken salad sandwich, a cup of diced oranges and a glass of water. She took small sips of the water unassisted. Certified nurse aide (CNA) #3 sat down next to the resident and assisted her with two bites of the sandwich and then left the room at 12:24 p.m. -The resident did not touch her food until another CNA returned. At 12:39 p.m., Resident #93 took a few bites of her sandwich after prompting from CNA #3. CNA #3 left the resident. At 12:55 p.m. Resident #93 tried to eat her diced mandarin oranges by picking up the cup of oranges and sipping the fruit and juice from the cup. She spilled the juice from the cup, but was unable to get any mandarin oranges in her mouth. -No staff member assisted the resident in her attempts to eat her mandarin oranges. At 12:57 p.m., Resident #92, who was sitting at another table, moved to Resident #93's table and tried to help her eat her oranges. Resident #93 took a bite from the spoon full of oranges and then Resident #92 returned to his table. -Resident #93 did not receive any additional assistance from staff members and was not able to feed herself. At 1:07 p.m., the resident's meal was taken away from her. She had eaten one-fourth to one-third of the sandwich and one quarter of the cup of oranges, -However, the amount of food Resident #93 ate, charted at 3:01 p.m., was recorded as 51 to 75%.During a continuous observation on 7/25/24, beginning at 11:57 a.m. and ending at 1:15 p.m., the following was observed: Resident #93 was assisted by a staff member to the dining room. She received an egg salad sandwich, a cup of tater tots, a piece of apple pie and a glass of water for lunch. At 12:57 p.m. Resident #93 was assisted by CNA #7. She ate two bites of her egg salad sandwich, a few tater tots and a few sips of water. The resident ate less than 25% of her meal and started tearing-up, breathing heavily and was confused. She coughed and then CNA #7 prompted her to go to her room and relax. Resident #93 said she was tired. -Resident #93 was not offered any alternative to her lunch or any additional drinks. Meal intake documentation at 11:00 a.m. and 11:32 a.m, read the resident consumed 76 to 100% of her meal. -However, observations revealed she consumed less than 25% of her meal. During a continuous observation on 7/29/24, beginning at 12:10 p.m. and ending at 1:15 p.m., the following was observed:At 12:10 p.m., Resident #93 was assisted to the dining room. At 12:24 p.m., an unidentified licensed practical nurse (LPN) approached the resident's table and asked another resident if she wanted anything to drink and offered her choices, then she left. Resident #93 had no food or drink in front of her. Resident #93 cried out softly, "Why didn't you ask me? I don't have anything." There were no staff nearby to hear Resident #93's question. When the staff returned, they did not ask Resident #93 what she would like to drink. At 12:25 p.m. Resident #93 received her lunch, which consisted of iced tea in a sealed cup with two handles, a peanut butter and jelly sandwich and a cup of diced peaches. Resident #93 sat at the table talking quietly to herself. There were no staff members assisting the resident with her meal. At 12:29 p.m., Resident #93 took one sip from her fruit cup and took one bite of her sandwich without assistance. At 12:45 p.m., CNA #1 sat down next to the resident and assisted her with her meal. At 12:54 p.m., CNA #1 asked Resident #93 if she was done eating and the resident said "yes". CNA #1 asked the resident if she could drink some more tea. Resident #93 did not reply and did not drink any more. The resident's meal was removed from the table. The resident ate one-fourth of the sandwich, four diced peaches, and drank two or three sips of the tea. -The meal intake, documented at 3:18 p.m. indicated Resident #93 ate 26 to 50% of her lunch. During a continuous observation on 7/29/24, beginning at 5:41 p.m. and ending at 5:55 p.m., the following was observed:At 5:55 p.m. Resident #93 was finished eating. She had eaten one-fourth of the sandwich, one-third of the cookie and drank approximately one-fourth of the water.-Meal intake documentation at 5:00 p.m. indicated the resident ate 26 to 50% of her dinner. During a continuous observation on 7/30/24, beginning at 9:15 a.m. and ending at 10:24 a.m., the following was observed:At 9:15 a.m. Resident #93 was assisted to the dining room. At 9:50 a.m., Resident #93 was served her breakfast which consisted of a banana, a glass of juice, one pancake and a glass of water. At 9:57 a.m., Resident #93 tried to drink her juice and it spilled. LPN #2 cleaned the spill and re-filled her cup. LPN #2 did not assist the resident with drinking. At 10:01 a.m., Resident #93 sat at the table and fiddled with the banana. LPN #2 sat across the table from the resident, occasionally interacting with her. LPN #2 was charting on her computer. She did not assist the resident with her meal. At 10:24 a.m., Resident #93 said she had enough. CNA #7 asked if she wanted more water. The resident said yes and had one sip. The resident consumed one-third of the pancake, approximately three-fourths of the banana and less than eight ounces of fluid between the water and juice. -However, meal intake documentation at 10:49 a.m. indicated the resident ate 76 to 100% of her breakfast. C. Record reviewThe nutrition care plan, revised 3/29/24, revealed Resident #93 had the potential for nutritional problems related to her health status, secondary to her multiple disease processes. Interventions included explaining and reinforcing to the resident the importance of maintaining her diet ordered, encouraging the resident to comply, and explaining the consequences of refusal risk factors, monitoring weights as ordered, monitoring/documenting and reporting as needed any signs and symptoms of swallowing difficulties, refusal to eat, or if she appeared concerned during meals, obtaining food preferences and offering as able, offering food alternates of equal nutritional value, providing the ordered diet, monitoring and recording intake each meal and having the RD evaluate and make diet changes and recommendations as needed. Resident #93's weights were documented in the resident's electronic medical record (EMR) as follows:-On 3/27/24, the resident weighed 114.6 pounds;-On 4/5/2024, the resident weighed 115.5 pounds;-On 4/8/2024, the resident weighed 115.5 pounds;-On 4/9/2024, the resident weighed 112.6 pounds;-On 4/16/2024, the resident weighed 114.9 pounds;-On 4/23/2024, the resident weighed 110.6 pounds;-On 5/8/2024, the resident weighed 111.9 pounds;-On 5/13/2024, the resident weighed 110.2 pounds;-On 5/20/2024, the resident weighed 112.6 pounds;-On 5/28/2024, the resident weighed 111.2 pounds;-On 5/30/2024, the resident weighed 111.0 pounds;-On 6/7/2024, the resident weighed 107.8 pounds;-On 6/20/2024, the resident weighed 106.0 pounds;-On 6/27/2024, the resident weighed 105.5 pounds;-On 7/7/2024, the resident weighed 100.5 pounds;-On 7/11/2024, the resident weighed 103.0 pounds;-On 7/21/2024, the resident weighed 100.5 pounds; and,-On 7/25/2024, the resident weighed 100.5 pounds.-Resident #93 lost 7 lbs (6.2%) from 5/20/24 to 6/20/24 in one month, which was considered severe.-The resident lost 7 lbs (6.5%) from 6/7/24 to 7/7/24 in one month, which was considered severe.-The resident lost 10.1 lbs (9.1%) from 4/23/24 to 7/25/24 in three months, which was considered severe. The 4/2/24 food preferences document revealed the resident had an excellent appetite and liked all food, with fish being her least favorite. She had not lost or gained weight recently. She drank milk. She liked dairy, vegetables, fruits, meat, protein, and carbohydrates like rice, potatoes, bread and cereal. She preferred water and was encouraged to drink four glasses per day. The document revealed her family brought her soda. On 4/4/24, a food and nutrition progress note revealed Resident #93 was underweight due to inadequate energy intake. The resident was referred to the restorative dining program for meal assistance, and RD #1 recommended a nutritional supplement, however the resident and her family refused the supplement as they preferred food and snacks brought by the family. The 5/22/24 and 5/29/24 weight meeting notes revealed Resident #93 continued to have weight loss. The resident ate 51 to 100% of most meals, which was a decrease in intake. She still had family-provided snacks in her room. The resident had recently reported jaw pain and was on antibiotics for a urinary tract infection. Both were resolved by 5/29/2024. The recommendations were to continue the restorative dining program and weekly weight meetings. The notes documented the resident's food preferences were discussed with the resident's daughter on 5/29/24. The 6/5/24 weight meeting note revealed Resident #93 was still on restorative dining and ate 76 to 100% of most of her meals the past week, occasionally less. She had snacks in her room and was on a regular diet with thin liquids. She received occupational therapy and had a new order for a speech therapy (ST) evaluation due to swallowing concerns. The 6/7/24 nursing progress note revealed the resident had a ST evaluation on 6/6/24 to address safe swallow function and diet tolerance, compensatory strategies and cueing. The 6/12/24 weight meeting note revealed that based on the resident's weight on 6/7/24, she had lost 3.2 lbs in one week. Resident #93 received restorative-dining assistance and generally consumed 51 to 100% of her meals. The note documented that daily menu items were discussed and the resident was told she could bring in fast food. The 6/24/24 restorative nursing note revealed the resident required varying degrees of verbal/tactile encouragement. She continued to need set up assistance and reminders to take sips of liquid after each bite. She consumed 75% of her food at each meal. The 7/3/24 weight meeting note revealed, based on the resident's weight on 6/27/24, she had a weight loss of 0.5 lbs in one week. The resident received physical therapy (PT) as of 6/26/24, and consumed 26 to 50% of most of her meals, occasionally more. The note documented she had snacks in her room and she continued to be monitored in weight meetings. The 7/10/24 weekly nursing note revealed the resident had no weight loss. -However, a review of the resident's recorded weights revealed she had lost five pounds between 6/20/24 and 7/7/24. The 7/11/24 progress note revealed the resident had lost five pounds in 10 days and another weight would be obtained for accuracy. The resident was re-weighed and weighed 103 lbs. The note revealed the resident continued to lose weight. Her intake was generally 26 to 50% of meals and 75% while receiving restorative nursing services. Resident #93 coughed with meals, causing herself to vomit and that it had been happening for over one month. The resident was eating a sandwich at the time and an RN assessessed the resident and determined the resident was not choking. The note documented this was a problem with the resident's teeth, but a speech evaluation was discussed. The 7/17/24 weight meeting note revealed the resident's weight had increased by 2.5 pounds in five days to 103 lbs. Weight meeting notes between 7/22/24 and 7/24/24 revealed the resident consumed 50% or more of her meals but was still losing weight. The resident's doctor and daughter were updated and a daily four ounce nutritional supplement was ordered on 7/24/24. The 7/29/24 restorative nursing note revealed Resident #93 needed total assistance with food intake, and continued verbal/tactile cueing to drink fluids at most meals. She ate 50 to 75% of her meals, and recommendations included continuing with the restorative nursing program and re-evaluating as needed.-Review of Resident #93's meal intake record revealed between 7/1/24 and 7/30/24, the resident consumed 50% or less of over half of her meals. The July 2024 CPO revealed the following orders:-Regular diet, easy to chew, thin liquids total supervision/assistance, no straws, use of two handed cups with a lid, and that softer textures may be ordered if appropriate, ordered on 6/6/24.-A four ounce house stock supplement once a day, ordered 7/23/24. A review of the July 2024 medication administration record (MAR) revealed Resident #93 was consuming an average of 27% from 7/23/24 to 7/29/24. III. Staff interviewsCNA #3 was interviewed on 7/30/24 at 10:31 a.m. CNA #3 said Resident #93 could not say what she wanted or liked to eat. She said, through trial and error, the facility determined she preferred sandwiches. She said sandwiches were easier for her to pick up and the restorative nurse aide who worked with her suggested them. She said Resident #93 needed varying amounts of assistance depending on her mood. She said the resident did not have a physical problem preventing her from being able to pick up her food, it was her mood that interfered. CNA #3 said if the resident was sad or anxious, she started crying, coughing and occasionally vomited, which prevented her from finishing eating. CNA #3 said staff talked to her to keep her occupied and happy, because then she would eat more. She said the resident's appetite had been pretty poor the last few weeks and thought she was now on an oral nutritional supplement. LPN #1 was interviewed on 7/30/24 at 12:53 p.m. LPN #1 said she noticed the resident needed assistance with eating and had asked staff to help her eat. She said if a resident could not state their food preferences, she would ask whoever was caring for them before they were admitted to the facility. The dietary manager (DM) was interviewed on 7/30/24 at 1:44 p.m. The DM said Resident #93's food and drink preferences changed depending on her level of confusion. She said she thought the CNAs chose her meals. The DM said, per the resident's EMR, she started taking a house supplement on 7/23/24 because she had a 7.5% weight loss of 11 lbs. She said the restorative nursing program had requested sandwiches for the resident to help her regain some independence with eating. The DM said she sometimes gave the resident handheld snacks, such as brownies and sweets. RD #2 was interviewed on 7/30/24 at 2:01 p.m. RD #2 said Resident #93 had lost about 10 lbs since April 2024, but was fairly stable until July 2024. RRD #2 said the provider and the resident's daughter were notified of the weight loss, a supplement was ordered and the resident started working with the restorative nursing program. She said originally, the resident refused the supplement, but after losing weight and talking to the resident's daughter, she agreed to take it. RD #2 said if the restorative nursing staff found something a resident liked, they offered that in addition to regular food items on the menu. She said Resident #93's food preferences were discussed at the care conference with the resident's daughter in April 2024. RD #2 said they learned the resident preferred home foods, grilled items,fast food and snacks that the family brought to the facility. RD #2 said the facility did not document consumption of family snacks because those were considered self-administered. The director of rehabilitation (DOR) was interviewed on 7/30/24 at 2:01 p.m. The DOR said when the weight loss was noticed in April 2024, the resident was added to the restorative program for eating and swallowing. She said for the past month (July 2024) the resident needed almost total assistance with eating and cueing, including showing her the motions and providing some touch-assist. She said sometimes the resident ate by herself, but other times she needed full assistance. She said the resident's meal intake stayed consistent between 50 to 75%. CNA #4 was interviewed on 7/30/24 at 3:03 p.m. CNA #4 said Resident #93 could point to pictures of food and say yes or no but could not say verbally what she wanted to eat. She said when she asked the resident what she wanted to eat, she offered the main entree first and showed her pictures so the resident could choose, before offering her a sandwich. She said she had never seen snacks in the resident's room and that her family was rarely there. She said she only saw Resident #93 snacking when occupational therapy was evaluating her. She said some of the CNAs had snacks that residents could eat, but she had not seen Resident #93 eating them and had never seen documentation of snacks eaten. CNA #5 was interviewed on 7/30/24 at 3:14 p.m. CNA #5 said the CNAs took meal orders and circled chosen items on the meal ticket. He said CNAs kept track of how much residents ate, especially residents who received meal assistance or were being watched for weight loss. He said if a resident ordered a sandwich, chips and jello for lunch and they only ate one-fourth of the sandwich, he would document that the resident ate 0 to 25% of the meal. He said if a resident ate that little of a meal, he would write a progress note and tell the nurse. He said if the decreased intake became a trend, it should be documented in the resident's EMR. LPN #3 was interviewed on 7/30/24 at 3:18 p.m. LPN #3 said she never saw snacks in the resident's room that the family had provided. She said she had seen the resident eat snacks before that were provided by one of the CNAs who had snacks for residents. LPN #3 said, in addition to the drinks Resident #93 had at meals, she encouraged fluids throughout the day and tried to give her water from her pitcher. She said the resident had not shown any signs of dehydration. RD #1 was interviewed via the phone on 7/30/24 at 4:16 p.m. RD #1 said she had only been employed at the facility for 24 hours so she did not know Resident #93 personally. She said she reviewed the resident's EMR and said the resident had weight loss of 7.5% since 5/8/24, which she considered significant. She said the resident was around 110 lbs to 111 lbs in April 2024, then had steady weight loss since May 2024. RD #1 said, given that information, she would have done a full assessment, requested the resident's food and liquid intake, and talked to nursing staff. She said if the resident was able, she would talk to the resident. She said she would have written a progress note, particularly if the weight loss occurred between quarterly assessments. RD #1 said in April 2024, the previous RD had recommended adding a nutritional supplement after dinner.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: On 7/23/24, Resident 93 had a house supplement added to resident intake program. Both the care plan and dietary card were updated to reflect changes made to increase intake and attempt to reduce weight loss risk. Meal items to be offered in separate bowls and alternative of equal nutritional value to be offered when indicated. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: On 7/31/24, DON/Designee completed an audit of current weights to ensure no other residents were triggering for significant and avoidable weight loss. No additional residents were identified. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: During the period from 7/31/24 through 8/1/24, staff education was provided to include accurate recording of food intake and timeliness of assistance with meals. In-service training provided by a registered dietician, for all direct care staff, including certified nurse aides, nurses, nursing leadership, and dietary leadership specified to include: -Importance of maintaining nutritional and hydration status in promoting overall resident health and well-being. -Direct care staff's role in identifying, reporting, and addressing changes in a resident's meal and fluid consumption. -Importance of consulting and following care plans when promoting maintenance of resident nutritional and hydration status. -Importance of providing a pleasant and compliant meal experience for those residents requiring set-up, limited, or total assistance with eating. -Techniques for promoting intake for residenst that need assistance and encouragement to eat and for those residents eating independently. -How identifying and honoring resident preferences can promote maintenance of nutrition and hydration status. - Accurately documenting resident intakes. All nurses, nurse leaders, dietary management, and facility dietician. - Identifying and implementing orders, recommendations, and care plans to promote resident nutrition and hydration maintenance. - How early identification and intervention in nutrition status changes can prevent significant, avoidable weight/hydration change and decline in health status. -Identifying resident nutrition and intake changes that merit physician consultation/ referral. -Identifying and addressing signs and symptoms of declining nutrition/hydration status. -Understanding avoidable versus unavoidable weight changes. -Accurately documenting supplement intakes. The facility will offer and encourage residents to participate in weekly weights. All weights obtained will be entered into EMR to ensure weight concern triggers are identified. Any identified weight variances concerns will be reported to the Registered Dietician for review. Weekly, the interdisciplinary team will conduct a weight meeting to review active residents current weights, meal intakes, identified weight discrepancies/concerns to ensure appropriate interventions to address concerns are implemented. Results of reviews to be recorded on facility implemented audit tool. Any concerns identified to be addressed upon discovery. Beginning 8/1/24, DON/Designee to complete random weekly observations of resident meals and review percentages recorded in EMR to ensure accurate intakes are recorded. Results of audit to be recorded on facility implemented audit tool. Any concerns identified to be addressed upon discovery. The director of nursing (DON), restorative nurse, dietary manager, therapy manager, and facility dietician and other applicable interdisciplinary team (IDT) members: -Established and implemented a system of measuring, verifying, and documenting resident weights. -Established and implemented a therapy communication to improve resident nutrition and hydration status. -Established and implemented a dietician communication and referral procedure for residents with new or worsening wounds, trending weight changes, and changes in meal consumption that put them at-risk for decline in nutritional status. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: The registered dietician will be responsible for conducting a written, post-training evaluation of staff to ensure all facility staff have an understanding of maintaining resident nutrition and hydration status. By no later than one week after all staff training is completed, the registered dietician the Department the Department with a written report documenting the training's completion and a summary of the outcome of all staff post-training evaluation results. Monthly, the DON/Designee will provide to the Medical Director and Interdisciplinary team a summary report of compliance at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue for 3 months or until sustained compliance is achieved.
0695Respiratory/Tracheostomy Care and SuctioningS/S D▼
Findings
Based on observations, record review and interviews, the facility failed to ensure two (#56 and #21) of five residents reviewed for oxygen therapy was provided respiratory care consistent with professional standards of practice out of 51 sample residents. Specifically, the facility failed to:-Ensure Resident #56's CPAP (continuous positive airway pressure) machine was working appropriately and used as ordered by the physician; and,-Ensure Resident #21 was wearing oxygen as ordered by the physician. Findings include:I. Facility policy and procedureThe Oxygen Administration policy and procedure, reviewed June 2023, was provided by the nursing home administrator (NHA) on 7/30/24 at 4:43 p.m. It read in pertinent part, "Oxygen is administered under orders of the physician. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy."-The policy did not include any pertinent information for the use of CPAP/biPAP (bilevel positive airway pressure) machines. II. Resident #56A. Resident statusResident #56, age 79 , was admitted on 11/14/23. According to the July 2024 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia (decreased oxygen levels), chronic obstructive pulmonary disease (COPD) and dependance on supplemental oxygen. The 6/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She was receiving oxygen therapy. -CPAP therapy was not documented on the assessment. B. Observations and resident interviewResident #56 was interviewed on 7/24/24 at 3:11 p.m. Resident #56 was wearing oxygen via nasal cannula. At the bedside, a CPAP machine was observed on the table. Resident #56 said she had not used the CPAP machine for at least three months. She said the machine was broken. She said the staff were aware that it was broken. She said the staff would come and tell her that they would take care of it but no one did. She said the facility had new staff every day and she could not remember the names of all the staff who knew about the broken machine. C. Record reviewThe oxygen therapy care plan, initiated 5/21/24, indicated Resident #56 required a CPAP machine for effective symptom management of COPD. Interventions included administering supplemental oxygen as ordered, ensuring the oxygen tubing was connected to the CPAP unit and verifying the liter flow prior to CPAP mask placement.-The care plan referred to machine BIPAP or CPAP interchangeably and the specific settings were not documented. -Review of the July 2024 CPO revealed Resident #56 did not have a physician's order for the use of a CPAP or BiPAP. Review Resident #56's physician progress notes between 5/1/2424 and 7/30/24 revealed a note on 5/20/24 that documented the resident was not using the CPAP machine because it was leaking water on her face when she was using it. The physician recommended service or replacement of the CPAP as soon as possible. -However, there was no additional documentation indicating the facility had attempted to service or replace the CPAP machine. D. Staff interviewsCertified nurse aide (CNA) #10 was interviewed on 7/25/24 at 2:30 p.m. CNA #10 said she did not know if the resident used a CPAP or BiPAP machine. She said she worked the morning shift and she had not observed the resident wearing the mask early in the morning. Registered nurse (RN) #2 was interviewed on 7/25/24 at 2:43 p.m. RN #2 said she did not know if the resident should or should not use the CPAP machine. She reviewed the physician's orders and said the resident did not have a physician's order for the CPAP machine. She said she was an agency nurse and did not know the resident well enough to know if the resident used the machine in the past. Licensed practical nurse (LPN) #1 was interviewed on 7/25/24 3:36 p.m. LPN #1 said she was a unit manager. She said she was new to the unit and today (7/25/24) was her eighth day of work on the unit. She said she remembered from the recent care conference that the resident was not using the CPAP machine but she did not know why and she did not ask the resident about it. The director of nursing (DON) was interviewed on 7/25/24 at 3:57 p.m. The DON said she did not know if the resident was using the CPAP machine. She reviewed the physician's orders and said the resident did not have a physician's order for the use of a CPAP machine. She said she was not aware that the machine was broken and did not know why it was not serviced since the physician's recommendation in May 2024. The DON said she would clarify the need for the CPAP machine with the physician and find out what needed to be fixed. III. Resident #21A. Resident statusResident #21, age greater than 65, was admitted on 6/8/22. According to the July 2024 CPO, diagnoses included dementia without mood disturbances, anemia (not enough oxygen in the cells to fuel the body), and a history of COVID-19 and stroke (blocked blood flow to the brain). The 6/7/24 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of three out of 15. The resident required substantial assistance with personal hygiene, showering, bathing, toileting and dressing her lower body. She required moderate assistance for dressing her upper body and supervision and/or touching assistance with eating. She required substantial assistance for rolling in bed and for most transfers. The assessment documented the resident was on oxygen. B. ObservationsOn 7/25/24 at 9:55 a.m. Resident #21's nasal cannula (tubing device that supplies oxygen through the nose) was not in her nose properly (only one of two nasal prongs was in her nose). At 10:07 a.m. the resident's nasal cannula was completely out of her nose. At 2:35 p.m. CNA #1 assisted the resident in her wheelchair to an activity. CNA #1 carried the portable oxygen on her back but the nasal cannula was not in the resident's nose. On 7/29/24 at 9:14 a.m. Resident #21 was lying flat in bed. The nasal cannula was not in her nose but was laying on her bed. At 11:29 a.m. Resident #21 was awake, lying flat in bed. The nasal cannula was not in her nose. C. Family member interviewResident #21's representative was interviewed on 7/30/24 at 11:05 a.m. Resident #21's representative said a few days prior to the survey, the resident called at night with a confusing question. He said he came to the facility the next morning and said the resident was more confused than normal. He said the resident's nasal cannula was not in her nose and was on top of the oxygen machine by the closet. The representative said he assumed that meant she did not get her oxygen overnight. He said he thought a CNA noticed in the morning and told the NHA because the NHA called the family later that day. He said there had been a few times he had noticed the nasal cannula had not been in her nose and the resident did not have the dexterity to put it back in herself. He said the staff did check her oxygen levels but he was not sure how often. The representative said the staff told him that even when she was not wearing her oxygen, her saturations were within normal limits. D. Record reviewThe July 2024 CPO revealed the resident had a physician's order that indicated to administer oxygen at a rate of two liters per minute via nasal cannula every shift for hypoxia, ordered 4/12/24. The care plan, revised on 9/19/23, revealed the resident had oxygen therapy related to ineffective gas exchange. The oxygen was ordered at two liters per minute continuously. Interventions included changing her position often to ease movement and drainage of fluid in the lungs, positioning the resident to facilitate breathing and oxygenation by assisting her into an upright position whenever possible. The care plan revealed if the resident was on her side, her good side should be down (damaged lung facing up). The care plan indicated the resident should be monitored for signs and symptoms of respiratory distress and, if noted, reported to the physician.-The care plan did not address interventions to ensure the resident was wearing her nasal cannula and getting her oxygen as ordered. A review of the resident's electronic medical record (EMR) revealed between 7/1/24 and 7/29/24, the resident's oxygen saturations were documented three times per day and were 90% or above. On 7/12/24, they were not documented in the morning check. E. Staff interviewsCNA #8 was interviewed on 7/30/24 at 12:44 p.m. CNA #8 said the CNAs and the nurses checked Resident #21's nasal cannula to make sure it was in. She said the resident sometimes took off the cannula to blow her nose and forgot to put it back in. She said the resident could not put it back in herself. CNA #8 said for the past three weeks she had been working at the facility and it had always been in. LPN #2 was interviewed on 7/30/24 at 12:56 p.m. LPN #2 said Resident #21 was on two liters of oxygen continuously but sometimes she took it off. LPN #2 said the resident could not put the nasal cannula back in her nose herself so staff frequently checked on her to make sure it was in. LPN #3 was interviewed on 7/30/24 at 3:20 p.m. LPN #3 said the staff frequently checked on Resident #21 at night to make sure her nasal cannula was in because she had a history of removing it. She said she noticed it was not in her nose sometimes. She said if she noticed it was out of her nose she would put it back in. She said oxygen saturation levels were checked every shift for all residents on oxygen and more often if their oxygen had not been on consistently.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: On 7/29/24, an evaluation was completed for Resident 21 with no adverse effects noted for Resident 21. Medical record reviewed demonstrated no adverse effects as evidenced by consistent oxygen saturations above 90%. Oxygen order verified. On 7/26/24, orders were clarified for Resident 56’s BiPAP. BiPAP noted to be in functional condition upon review from oxygen provider on 7/25/24. Care plan was updated on 7/31/24. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: All residents with prescribed oxygen had potential to be affected by alleged deficient practice. Resident 56 was the only resident identified in facility with use of BiPAP. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: During the period from 7/31/24 though 8/1/24, education was provided to nursing staff on appropriate oxygen administration to include BiPAP Beginning 8/1/24, DON/Designee to complete random weekly observations of residents with prescribed oxygen to ensure oxygen is applied appropriately and at the correct settings. Results of observations to be recorded on a facility implemented audit tool. Any discrepancies noted to be corrected upon discovery. Beginning 8/1/24, DON/Designee to complete random weekly observations/interview of residents with prescribed BiPAP applied appropriately and at the correct settings. Results of observations to be recorded on a facility implemented audit tool. Any discrepancies noted to be corrected upon discovery. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly, the DON/Designee will provide to the Medical Director and Interdisciplinary team a summary report of compliance at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue for 3 months or until sustained compliance is achieved.
0732Posted Nurse Staffing InformationS/S C▼
Findings
Based on observations, interviews and record reviews, the facility failed to post nurse staffing information daily. Specifically, the facility failed to:-Post the daily number of hours worked for each nursing staff category in a clear and readable format. Findings include: I. Observations On 7/29/24 and 7/30/24 the daily staff information that was posted was dated 7/25/24. II. Staff interviewThe director of nursing (DON) was interviewed on 7/30/24 at 10:38 a.m. The DON said the posted nursing staff schedule information was posted near the front desk of the facility. She said the staff information should be posted daily. She said the posted schedule which was dated 7/25/24 was outdated. The DON said the scheduler was responsible for updating and posting the daily staff information. The scheduler was interviewed on 7/30/24 at 10:47 a.m. The scheduler said it was her responsibility to post the daily staff information and she had delegated the task to her assistant. The scheduler said she was unsure why the staff schedule information had not been updated after 7/25/24. She said she would follow up with her assistant and educate her assistant with the posting requirement.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: Correct nursing staff information posted on 7/30/24. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: No residents are affected from this deficient practice III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: On 7/30/24, education was provided to Staffing Coordinator to ensure nursing hours are posted daily. Beginning 8/1/24, NHA/Designee to complete random weekly observational audits to ensure nursing hours are posted accurately. Results of audits to be recorded on a facility initiated auditing tool. Any discrepancy noted to be corrected upon discovery. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly, the NHA/Designee will provide to the Medical Director and Interdisciplinary team a summary report of compliance at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue for 3 months or until sustained compliance is achieved.
0759Free of Medication Error Rts 5 Prcnt or MoreS/S E▼
Findings
Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 16.1%, or five errors out of 31 opportunities for error. Findings include: I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 606-607, retrieved on 7/31/24, "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication."II. Facility policy and procedureThe Medication Administration policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 7/30/24 at 5:30 p.m. It read in pertinent part, "Medications are to be administered in an accurate, safe, timely, and sanitary manner. Medication is to be given in compliance with physician orders."The Medication Time and Administration Guidelines were provided by the NHA on 7/25/24. The guidelines read in pertinent part,"To better comply with our resident's rights, we have adopted the following guidelines for medication passing."Routine medications will be passed according to the following schedule:-EA: early am (6:00 a.m.); -AM: upon arising (6:00 a.m. - 11:00 a.m.); -MD: midday (11:00 a.m. - 1:00 p.m.); -PM: afternoon (4:00 p.m. - 7:00 p.m.); and, -BT: bedtime (7:00 p.m.- 10:00 p.m.). "Medications scheduled between 11:00 p.m. and 6:00 a.m. will be documented as time specific." III. ObservationsOn 7/24/24 during a continuous observation, beginning at 9:30 a.m. and ending at 11:30 a.m., registered nurse (RN) #1 was observed passing medications to residents. At 9:30 a.m. RN #1 was administering medications to Resident #87. The medication administration record (MAR) for July 2024 read that Resident #87 was due for the following medications:-Lactaid 3,000 units to be administered at 7:30 a.m. for lactose intolerance; and,-Fluticasone propionate nasal spray, two sprays in each nostril to be given in the morning for allergies. RN #1 could not locate the appropriate dose of Lactaid medication in his cart. He went to the unit manager for help. While RN #1 was trying to locate the appropriate dose of Lactaid medication, he locked all other medications in his cart. At 10:45 a.m., after locating the correct dose of Lactaid, RN #1 returned to his medication cart, added the medication to the medication cup containing Resident #87's other oral medications and proceeded to the resident's room to administer the medications. He did not take the resident's fluticasone propionate nasal spray to the room with the other medications. RN #1 administered the medications and returned to his medication cart.-RN #1 administered Resident #87's Lactaid two hours and 15 minutes after the allowed administration time.-RN #1 failed to administer the nasal spray to Resident #87. On 7/29/24 at 9:23 a.m., licensed practical nurse (LPN #2) was observed during medication administration for Resident #97. LPN #2's medication screen listed three medications that were color-coded red, which indicated the medications were late (see interviews below). The late medications were as follows:-Celecoxib 200 milligrams (mg) two times a day for pain, scheduled at 8:00 a.m.; -Clobazam 20 mg tablet, give 40 mg two times a day for seizures, scheduled at 8:00 a.m.; and, -Lacosamide 50 mg two times a day for seizures, scheduled at 8:00 a.m. -LPN #2 administered the three medications at 9:23 a.m. (23 minutes after the allowed administration time. IV. Staff interviewsLPN #4 was interviewed on 7/24/24 at 10:05 a.m. LPN #4 said that when items were color-coded red on the medication administration record (MAR), it meant that something was late or missing. RN #1 was interviewed on 7/24/24 at 10:50 a.m. RN #1 said he was an agency nurse and this was his first day working on the unit. He said he did not know specific preferences for the residents and it took extra time for him to find out what the preferences were. He said, for example, he had to approach Resident #87 three times before he was able to administer her morning medications. RN #1 said initially Resident #87 said she would take her medications only with warm to hot water due to her tooth sensitivity. He said when he came back with warm water she did not like that he had mixed her miralax medication with the hot water and he had to remix the miralax in a separate cup and bring a fresh cup of hot water. He said because he had to approach Resident #87 three times with her medications, he forgot about her nasal spray. LPN #2 was interviewed during medication administration on 7/29/24 at 9:23 a.m. LPN #2 said she had a lot of medications to give and she was behind and did not want to be slowed down by being interviewed. The DON was interviewed on 7/30/24 at 5:14 p.m. The DON said all medications that were labeled as "AM" could be administered any time between 6:00 a.m. and 11:00 a.m. However, she said medications that were scheduled at a specific time should be administered as scheduled. The DON said because it was not possible to administer all medications at the exact scheduled hour, it was acceptable to administer medications one hour before or one hour after the documented scheduled time. She said she was not aware that medications were not administered on time. She said she would audit the medication administration to ensure all medications were administered on time.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: No adverse affects were observed for Resident 87. No adverse affects were observed for Resident 97. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: All residents had potential to be affected by alleged deficient practice. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: During the period from 7/31/24 though 8/1/24, education was provided to licensed nursing staff on appropriate medication protocols to include medication administration guidelines, safety, and documentation. Beginning 8/1/24, DON/Designee to complete random weekly observations of nursing medication administrations to ensure medications are administered as prescribed and within acceptable time frame. Results of observations to be recorded on a facility implemented audit tool. Any discrepancies noted to be corrected upon discovery. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly, the DON/Designee will provide to the Medical Director and Interdisciplinary team a summary report of compliance at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue for 3 months or until sustained compliance is achieved.
0882Infection Preventionist Qualifications/RoleS/S E▼
Findings
Based on record review and interviews, the facility failed to employ an infection preventionist (IP) who had completed specialized training in infection prevention and control. Specifically, the facility failed to have a qualified IP involved with the facility's infection prevention and control program. Findings include:I. Facility policy and procedureThe Infection Control and Surveillance policy, dated 7/28/23, was provided by the nursing home administrator (NHA) on 7/23/24. The policy documented in pertinent part,"An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections."The IPCP is developed to address the facility-specific infection control needs, requirements identified in the facility assessment and the infection control risk assessment."The elements of the IPCP consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety."The IPCP is coordinated and overseen by an IP specialist."II. Record reviewOn 7/24/24 at 12:19 p.m. the NHA wrote in an email message that the facility did not have a designated IP and was recruiting to fill the position. III. Staff interviewThe director of nursing (DON) was interviewed on 7/29/24 at 10:25 a.m. The DON said the facility did not currently have a qualified IP. The DON said she and the unit nurse managers shared the duties and the responsibilities of the IP position, but they had not completed the required specialized education for the IP position.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: No residents were identified. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: All residents had potential to be affected. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: The facility hired an infection preventionist on 7.18.24. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly the Infection Preventionist will provide the Medical Director and Interdisciplinary team a summary report as indicated at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue for 3 months or until sustained compliance is achieved.
7/30/2024State Licensure Survey · ID GOE4111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure survey was completed on 7/24/24 to 7/30/24. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0709Resident Care - Weight Changes▼
Findings
Based on observations, record review and interviews, the facility failed to ensure one (#93) of three residents reviewed for nutrition received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being out of 51 sample residents. Resident #93 was admitted to the facility for long term care on 3/27/24 with diagnoses of severe dementia with mood disturbance, hypothyroidism (underactive thyroid), depression and dysphagia of the oropharyngeal stage (food sticks to the mouth or throat or gets pocketed in cheeks). Upon admission (3/27/24), Resident #93 weighed 114.6 pounds (lbs). On 4/4/24 the facility placed the resident on restorative dining services, however, observations during the survey revealed the resident did not receive consistent assistance at meals. On 5/20/24, the resident weighed 112.6 lbs and on 6/20/24 the resident weighed 106 lbs. The resident sustained a 5.9% (6.6 lbs) weight loss from 5/20/24 to 6/20/24 in one month, which was considered severe. On 7/21/24 the resident weighed 100.5 lbs. At this time the resident sustained an additional 5.2% (5.5 lbs) weight loss from 6/20/24 to 7/21/24 in one month, which was considered severe. On 7/23/24 the facility implemented a four ounce house nutritional supplement. Due to the facility's failures to provide total assistance in a timely manner and consistently offer alternatives of equal nutritional value and accurately record her food intake, Resident #93 sustained a 9.1% (10.1 lbs) weight loss in three months, which was considered severe. Findings include:I. Facility policy and procedureThe Weight Management policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 5/30/24 at 5:30 p.m. It revealed in pertinent part,"Residents identified with weight change will be assessed by the interdisciplinary team (IDT), and further interventions will be implemented to minimize the risk for further weight change where possible and to promote weight stability."All residents will be weighed upon admission, then weekly or as indicated by physician orders. Results will be documented in the medical record."Residents will be screened by a registered dietitian (RD) or designee for their risk for weight change on admission, quarterly, annually, and with significant change of condition with completion of the facility assessment."Residents with weight variance (loss or gain) are reweighed. Significant/severe weight variance is defined as: 5 percent (%) in one month; 7.5% in three months; or 10% in six months"Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, RD evaluation and assisted dining."The following categories of residents should be weighed weekly unless otherwise indicated: residents with significant weight changes until weight is stabilized as defined in the policy; as determined by the physician, DON (director of nursing), RD (registered dietitian), or IDT teams discretion."The IDT meets weekly to review residents with identified weight changes, develops a plan, implements, evaluates, and re-evaluates interventions to minimize the risk for weight change."Nursing staff are responsible to communicate weight changes to the attending physician and resident's family. The nurse documents the notification in the medical record."Nursing staff is to notify food and nutrition services and the RD of a resident's weight change. The RD further assesses the resident to determine root cause of the weight change and makes recommendations to reduce or stabilize the weight change."Nursing staff or the RD are to notify the speech therapist (ST) if swallowing or chewing problems are suspected."II. Resident #93A. Resident statusResident #93, age 85, was admitted on 3/27/24. According to the July 2024 computerized physician orders (CPO), diagnoses included severe dementia with mood disturbance, hypothyroidism, depression and dysphagia of the oropharyngeal stage. The 6/28/24 minimum data set facility assessment documented the resident had severe cognitive impairments. The resident required substantial/maximum assistance with showering and personal hygiene, and supervision and/or touching assistance with eating. -However, according to the 6/6/24 physician's order, the resident required total supervision and assistance with meals. The assessment documented the resident was 66 inches (five feet, six inches) tall, and weighed 106 lbs. It indicated the resident had weight loss (a loss of 5% or more in the last month, or 10% or more in the last six months). The resident had no signs or symptoms of a possible swallowing disorder. B. ObservationsDuring a continuous observation on 7/24/24, beginning at 12:04 p.m. and ending at 1:37 p.m., the following was observed:At 12:10 p.m., Resident #93 was served a chicken salad sandwich, a cup of diced oranges and a glass of water. She took small sips of the water unassisted. Certified nurse aide (CNA) #3 sat down next to the resident and assisted her with two bites of the sandwich and then left the room at 12:24 p.m. -The resident did not touch her food until another CNA returned. At 12:39 p.m., Resident #93 took a few bites of her sandwich after prompting from CNA #3. CNA #3 left the resident. At 12:55 p.m. Resident #93 tried to eat her diced mandarin oranges by picking up the cup of oranges and sipping the fruit and juice from the cup. She spilled the juice from the cup, but was unable to get any mandarin oranges in her mouth. -No staff member assisted the resident in her attempts to eat her mandarin oranges. At 12:57 p.m., Resident #92, who was sitting at another table, moved to Resident #93's table and tried to help her eat her oranges. Resident #93 took a bite from the spoon full of oranges and then Resident #92 returned to his table. -Resident #93 did not receive any additional assistance from staff members and was not able to feed herself. At 1:07 p.m., the resident's meal was taken away from her. She had eaten one-fourth to one-third of the sandwich and one quarter of the cup of oranges, -However, the amount of food Resident #93 ate, charted at 3:01 p.m., was recorded as 51 to 75%.During a continuous observation on 7/25/24, beginning at 11:57 a.m. and ending at 1:15 p.m., the following was observed: Resident #93 was assisted by a staff member to the dining room. She received an egg salad sandwich, a cup of tater tots, a piece of apple pie and a glass of water for lunch. At 12:57 p.m. Resident #93 was assisted by CNA #7. She ate two bites of her egg salad sandwich, a few tater tots and a few sips of water. The resident ate less than 25% of her meal and started tearing-up, breathing heavily and was confused. She coughed and then CNA #7 prompted her to go to her room and relax. Resident #93 said she was tired. -Resident #93 was not offered any alternative to her lunch or any additional drinks. Meal intake documentation at 11:00 a.m. and 11:32 a.m, read the resident consumed 76 to 100% of her meal. -However, observations revealed she consumed less than 25% of her meal. During a continuous observation on 7/29/24, beginning at 12:10 p.m. and ending at 1:15 p.m., the following was observed:At 12:10 p.m., Resident #93 was assisted to the dining room. At 12:24 p.m., an unidentified licensed practical nurse (LPN) approached the resident's table and asked another resident if she wanted anything to drink and offered her choices, then she left. Resident #93 had no food or drink in front of her. Resident #93 cried out softly, "Why didn't you ask me? I don't have anything." There were no staff nearby to hear Resident #93's question. When the staff returned, they did not ask Resident #93 what she would like to drink. At 12:25 p.m. Resident #93 received her lunch, which consisted of iced tea in a sealed cup with two handles, a peanut butter and jelly sandwich and a cup of diced peaches. Resident #93 sat at the table talking quietly to herself. There were no staff members assisting the resident with her meal. At 12:29 p.m., Resident #93 took one sip from her fruit cup and took one bite of her sandwich without assistance. At 12:45 p.m., CNA #1 sat down next to the resident and assisted her with her meal. At 12:54 p.m., CNA #1 asked Resident #93 if she was done eating and the resident said "yes". CNA #1 asked the resident if she could drink some more tea. Resident #93 did not reply and did not drink any more. The resident's meal was removed from the table. The resident ate one-fourth of the sandwich, four diced peaches, and drank two or three sips of the tea. -The meal intake, documented at 3:18 p.m. indicated Resident #93 ate 26 to 50% of her lunch. During a continuous observation on 7/29/24, beginning at 5:41 p.m. and ending at 5:55 p.m., the following was observed:At 5:55 p.m. Resident #93 was finished eating. She had eaten one-fourth of the sandwich, one-third of the cookie and drank approximately one-fourth of the water.-Meal intake documentation at 5:00 p.m. indicated the resident ate 26 to 50% of her dinner. During a continuous observation on 7/30/24, beginning at 9:15 a.m. and ending at 10:24 a.m., the following was observed:At 9:15 a.m. Resident #93 was assisted to the dining room. At 9:50 a.m., Resident #93 was served her breakfast which consisted of a banana, a glass of juice, one pancake and a glass of water. At 9:57 a.m., Resident #93 tried to drink her juice and it spilled. LPN #2 cleaned the spill and re-filled her cup. LPN #2 did not assist the resident with drinking. At 10:01 a.m., Resident #93 sat at the table and fiddled with the banana. LPN #2 sat across the table from the resident, occasionally interacting with her. LPN #2 was charting on her computer. She did not assist the resident with her meal. At 10:24 a.m., Resident #93 said she had enough. CNA #7 asked if she wanted more water. The resident said yes and had one sip. The resident consumed one-third of the pancake, approximately three-fourths of the banana and less than eight ounces of fluid between the water and juice. -However, meal intake documentation at 10:49 a.m. indicated the resident ate 76 to 100% of her breakfast. C. Record reviewThe nutrition care plan, revised 3/29/24, revealed Resident #93 had the potential for nutritional problems related to her health status, secondary to her multiple disease processes. Interventions included explaining and reinforcing to the resident the importance of maintaining her diet ordered, encouraging the resident to comply, and explaining the consequences of refusal risk factors, monitoring weights as ordered, monitoring/documenting and reporting as needed any signs and symptoms of swallowing difficulties, refusal to eat, or if she appeared concerned during meals, obtaining food preferences and offering as able, offering food alternates of equal nutritional value, providing the ordered diet, monitoring and recording intake each meal and having the RD evaluate and make diet changes and recommendations as needed. Resident #93's weights were documented in the resident's electronic medical record (EMR) as follows:-On 3/27/24, the resident weighed 114.6 pounds;-On 4/5/2024, the resident weighed 115.5 pounds;-On 4/8/2024, the resident weighed 115.5 pounds;-On 4/9/2024, the resident weighed 112.6 pounds;-On 4/16/2024, the resident weighed 114.9 pounds;-On 4/23/2024, the resident weighed 110.6 pounds;-On 5/8/2024, the resident weighed 111.9 pounds;-On 5/13/2024, the resident weighed 110.2 pounds;-On 5/20/2024, the resident weighed 112.6 pounds;-On 5/28/2024, the resident weighed 111.2 pounds;-On 5/30/2024, the resident weighed 111.0 pounds;-On 6/7/2024, the resident weighed 107.8 pounds;-On 6/20/2024, the resident weighed 106.0 pounds;-On 6/27/2024, the resident weighed 105.5 pounds;-On 7/7/2024, the resident weighed 100.5 pounds;-On 7/11/2024, the resident weighed 103.0 pounds;-On 7/21/2024, the resident weighed 100.5 pounds; and,-On 7/25/2024, the resident weighed 100.5 pounds.-Resident #93 lost 7 lbs (6.2%) from 5/20/24 to 6/20/24 in one month, which was considered severe.-The resident lost 7 lbs (6.5%) from 6/7/24 to 7/7/24 in one month, which was considered severe.-The resident lost 10.1 lbs (9.1%) from 4/23/24 to 7/25/24 in three months, which was considered severe. The 4/2/24 food preferences document revealed the resident had an excellent appetite and liked all food, with fish being her least favorite. She had not lost or gained weight recently. She drank milk. She liked dairy, vegetables, fruits, meat, protein, and carbohydrates like rice, potatoes, bread and cereal. She preferred water and was encouraged to drink four glasses per day. The document revealed her family brought her soda. On 4/4/24, a food and nutrition progress note revealed Resident #93 was underweight due to inadequate energy intake. The resident was referred to the restorative dining program for meal assistance, and RD #1 recommended a nutritional supplement, however the resident and her family refused the supplement as they preferred food and snacks brought by the family. The 5/22/24 and 5/29/24 weight meeting notes revealed Resident #93 continued to have weight loss. The resident ate 51 to 100% of most meals, which was a decrease in intake. She still had family-provided snacks in her room. The resident had recently reported jaw pain and was on antibiotics for a urinary tract infection. Both were resolved by 5/29/2024. The recommendations were to continue the restorative dining program and weekly weight meetings. The notes documented the resident's food preferences were discussed with the resident's daughter on 5/29/24. The 6/5/24 weight meeting note revealed Resident #93 was still on restorative dining and ate 76 to 100% of most of her meals the past week, occasionally less. She had snacks in her room and was on a regular diet with thin liquids. She received occupational therapy and had a new order for a speech therapy (ST) evaluation due to swallowing concerns. The 6/7/24 nursing progress note revealed the resident had a ST evaluation on 6/6/24 to address safe swallow function and diet tolerance, compensatory strategies and cueing. The 6/12/24 weight meeting note revealed that based on the resident's weight on 6/7/24, she had lost 3.2 lbs in one week. Resident #93 received restorative-dining assistance and generally consumed 51 to 100% of her meals. The note documented that daily menu items were discussed and the resident was told she could bring in fast food. The 6/24/24 restorative nursing note revealed the resident required varying degrees of verbal/tactile encouragement. She continued to need set up assistance and reminders to take sips of liquid after each bite. She consumed 75% of her food at each meal. The 7/3/24 weight meeting note revealed, based on the resident's weight on 6/27/24, she had a weight loss of 0.5 lbs in one week. The resident received physical therapy (PT) as of 6/26/24, and consumed 26 to 50% of most of her meals, occasionally more. The note documented she had snacks in her room and she continued to be monitored in weight meetings. The 7/10/24 weekly nursing note revealed the resident had no weight loss. -However, a review of the resident's recorded weights revealed she had lost five pounds between 6/20/24 and 7/7/24. The 7/11/24 progress note revealed the resident had lost five pounds in 10 days and another weight would be obtained for accuracy. The resident was re-weighed and weighed 103 lbs. The note revealed the resident continued to lose weight. Her intake was generally 26 to 50% of meals and 75% while receiving restorative nursing services. Resident #93 coughed with meals, causing herself to vomit and that it had been happening for over one month. The resident was eating a sandwich at the time and an RN assessessed the resident and determined the resident was not choking. The note documented this was a problem with the resident's teeth, but a speech evaluation was discussed. The 7/17/24 weight meeting note revealed the resident's weight had increased by 2.5 pounds in five days to 103 lbs. Weight meeting notes between 7/22/24 and 7/24/24 revealed the resident consumed 50% or more of her meals but was still losing weight. The resident's doctor and daughter were updated and a daily four ounce nutritional supplement was ordered on 7/24/24. The 7/29/24 restorative nursing note revealed Resident #93 needed total assistance with food intake, and continued verbal/tactile cueing to drink fluids at most meals. She ate 50 to 75% of her meals, and recommendations included continuing with the restorative nursing program and re-evaluating as needed.-Review of Resident #93's meal intake record revealed between 7/1/24 and 7/30/24, the resident consumed 50% or less of over half of her meals. The July 2024 CPO revealed the following orders:-Regular diet, easy to chew, thin liquids total supervision/assistance, no straws, use of two handed cups with a lid, and that softer textures may be ordered if appropriate, ordered on 6/6/24.-A four ounce house stock supplement once a day, ordered 7/23/24. A review of the July 2024 medication administration record (MAR) revealed Resident #93 was consuming an average of 27% from 7/23/24 to 7/29/24. III. Staff interviewsCNA #3 was interviewed on 7/30/24 at 10:31 a.m. CNA #3 said Resident #93 could not say what she wanted or liked to eat. She said, through trial and error, the facility determined she preferred sandwiches. She said sandwiches were easier for her to pick up and the restorative nurse aide who worked with her suggested them. She said Resident #93 needed varying amounts of assistance depending on her mood. She said the resident did not have a physical problem preventing her from being able to pick up her food, it was her mood that interfered. CNA #3 said if the resident was sad or anxious, she started crying, coughing and occasionally vomited, which prevented her from finishing eating. CNA #3 said staff talked to her to keep her occupied and happy, because then she would eat more. She said the resident's appetite had been pretty poor the last few weeks and thought she was now on an oral nutritional supplement. LPN #1 was interviewed on 7/30/24 at 12:53 p.m. LPN #1 said she noticed the resident needed assistance with eating and had asked staff to help her eat. She said if a resident could not state their food preferences, she would ask whoever was caring for them before they were admitted to the facility. The dietary manager (DM) was interviewed on 7/30/24 at 1:44 p.m. The DM said Resident #93's food and drink preferences changed depending on her level of confusion. She said she thought the CNAs chose her meals. The DM said, per the resident's EMR, she started taking a house supplement on 7/23/24 because she had a 7.5% weight loss of 11 lbs. She said the restorative nursing program had requested sandwiches for the resident to help her regain some independence with eating. The DM said she sometimes gave the resident handheld snacks, such as brownies and sweets. RD #2 was interviewed on 7/30/24 at 2:01 p.m. RD #2 said Resident #93 had lost about 10 lbs since April 2024, but was fairly stable until July 2024. RRD #2 said the provider and the resident's daughter were notified of the weight loss, a supplement was ordered and the resident started working with the restorative nursing program. She said originally, the resident refused the supplement, but after losing weight and talking to the resident's daughter, she agreed to take it. RD #2 said if the restorative nursing staff found something a resident liked, they offered that in addition to regular food items on the menu. She said Resident #93's food preferences were discussed at the care conference with the resident's daughter in April 2024. RD #2 said they learned the resident preferred home foods, grilled items, fast food and snacks that the family brought to the facility. RD #2 said the facility did not document consumption of family snacks because those were considered self-administered. The director of rehabilitation (DOR) was interviewed on 7/30/24 at 2:01 p.m. The DOR said when the weight loss was noticed in April 2024, the resident was added to the restorative program for eating and swallowing. She said for the past month (July 2024) the resident needed almost total assistance with eating and cueing, including showing her the motions and providing some touch-assist. She said sometimes the resident ate by herself, but other times she needed full assistance. She said the resident's meal intake stayed consistent between 50 to 75%. CNA #4 was interviewed on 7/30/24 at 3:03 p.m. CNA #4 said Resident #93 could point to pictures of food and say yes or no but could not say verbally what she wanted to eat. She said when she asked the resident what she wanted to eat, she offered the main entree first and showed her pictures so the resident could choose, before offering her a sandwich. She said she had never seen snacks in the resident's room and that her family was rarely there. She said she only saw Resident #93 snacking when occupational therapy was evaluating her. She said some of the CNAs had snacks that residents could eat, but she had not seen Resident #93 eating them and had never seen documentation of snacks eaten. CNA #5 was interviewed on 7/30/24 at 3:14 p.m. CNA #5 said the CNAs took meal orders and circled chosen items on the meal ticket. He said CNAs kept track of how much residents ate, especially residents who received meal assistance or were being watched for weight loss. He said if a resident ordered a sandwich, chips and jello for lunch and they only ate one-fourth of the sandwich, he would document that the resident ate 0 to 25% of the meal. He said if a resident ate that little of a meal, he would write a progress note and tell the nurse. He said if the decreased intake became a trend, it should be documented in the resident's EMR. LPN #3 was interviewed on 7/30/24 at 3:18 p.m. LPN #3 said she never saw snacks in the resident's room that the family had provided. She said she had seen the resident eat snacks before that were provided by one of the CNAs who had snacks for residents. LPN #3 said, in addition to the drinks Resident #93 had at meals, she encouraged fluids throughout the day and tried to give her water from her pitcher. She said the resident had not shown any signs of dehydration. RD #1 was interviewed via the phone on 7/30/24 at 4:16 p.m. RD #1 said she had only been employed at the facility for 24 hours so she did not know Resident #93 personally. She said she reviewed the resident's EMR and said the resident had weight loss of 7.5% since 5/8/24, which she considered significant. She said the resident was around 110 lbs to 111 lbs in April 2024, then had steady weight loss since May 2024. RD #1 said, given that information, she would have done a full assessment, requested the resident's food and liquid intake, and talked to nursing staff. She said if the resident was able, she would talk to the resident. She said she would have written a progress note, particularly if the weight loss occurred between quarterly assessments. RD #1 said in April 2024, the previous RD had recommended adding a nutritional supplement after dinner.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: On 7/23/24, Resident 93 had a house supplement added to resident intake program. Both the care plan and dietary card were updated to reflect changes made to increase intake and attempt to reduce weight loss risk. Meal items to be offered in separate bowls and alternative of equal nutritional value to be offered when indicated. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: On 7/31/24, DON/Designee completed an audit of current weights to ensure no other residents were triggering for significant and avoidable weight loss. No additional residents were identified. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: During the period from 7/31/24 through 8/1/24, staff education was provided to include accurate recording of food intake and timeliness of assistance with meals. In-service training provided by a registered dietician, for all direct care staff, including certified nurse aides, nurses, nursing leadership, and dietary leadership specified to include: -Importance of maintaining nutritional and hydration status in promoting overall resident health and well-being. -Direct care staff's role in identifying, reporting, and addressing changes in a resident's meal and fluid consumption. -Importance of consulting and following care plans when promoting maintenance of resident nutritional and hydration status. -Importance of providing a pleasant and compliant meal experience for those residents requiring set-up, limited, or total assistance with eating. -Techniques for promoting intake for residents that need assistance and encouragement to eat and for those residents eating independently. -How identifying and honoring resident preferences can promote maintenance of nutrition and hydration status. - Accurately documenting resident intakes. All nurses, nurse leaders, dietary management, and facility dietician. - Identifying and implementing orders, recommendations, and care plans to promote resident nutrition and hydration maintenance. - How early identification and intervention in nutrition status changes can prevent significant, avoidable weight/hydration change and decline in health status. -Identifying resident nutrition and intake changes that merit physician consultation/ referral. -Identifying and addressing signs and symptoms of declining nutrition/hydration status. -Understanding avoidable versus unavoidable weight changes. -Accurately documenting supplement intakes. The facility will offer and encourage residents to participate in weekly weights. All weights obtained will be entered into EMR to ensure weight concern triggers are identified. Any identified weight variances concerns will be reported to the Registered Dietician for review. Weekly, the interdisciplinary team will conduct a weight meeting to review active residents current weights, meal intakes, identified weight discrepancies/concerns to ensure appropriate interventions to address concerns are implemented. Results of reviews to be recorded on facility implemented audit tool. Any concerns identified to be addressed upon discovery. Beginning 8/1/24, DON/Designee to complete random weekly observations of resident meals and review percentages recorded in EMR to ensure accurate intakes are recorded. Results of audit to be recorded on facility implemented audit tool. Any concerns identified to be addressed upon discovery. The director of nursing (DON), restorative nurse, dietary manager, therapy manager, and facility dietician and other applicable interdisciplinary team (IDT) members: -Established and implemented a system of measuring, verifying, and documenting resident weights. -Established and implemented a therapy communication to improve resident nutrition and hydration status. -Established and implemented a dietician communication and referral procedure for residents with new or worsening wounds, trending weight changes, and changes in meal consumption that put them at-risk for decline in nutritional status. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: The registered dietician will be responsible for conducting a written, post-training evaluation of staff to ensure all facility staff have an understanding of maintaining resident nutrition and hydration status. By no later than one week after all staff training is completed, the registered dietician the Department the Department with a written report documenting the training's completion and a summary of the outcome of all staff post-training evaluation results. Monthly, the DON/Designee will provide to the Medical Director and Interdisciplinary team a summary report of compliance at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue for 3 months or until sustained compliance is achieved.
4/8/2024Complaint Survey · ID M6FB11No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO35436, #CO35440 and Incident #35474 was conducted on 4/8/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
3/13/2024Complaint Survey · ID FWTD111 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO35268 was conducted on 3/11/24 to 3/13/24. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0760Residents are Free of Significant Med ErrorsS/S J▼
Findings
Based on interviews, observations and record review, the facility failed to ensure one (#3) of three out of six sample residents were free from significant medication errors. Specifically, the facility failed ensure Resident #3 was administered anticoagulant medication (Pradaxa) for atrial fibrillation per physician's orders. The facility failed to ensure the resident's anticoagulant prescription was picked up from a specified pharmacy by facility staff and brought to the facility. This failure resulted in Resident #3 not being administered the anticoagulant medication for a total of nine doses from 11/28/23 to 12/3/23. As a result of the facility's failure, the resident was sent to the hospital with potential signs of a stroke on 12/4/23, was admitted to the hospital and died at the hospital on 12/8/23 due to a cerebral vascular accident (defined as an interruption in the flow of blood to the cells of the brain-stroke). Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 3/11/24 to 3/13/24, resulting in the deficiency being cited as past noncompliance with a correction date of 12/7/23. I. Situation of serious harmThe facility failed to ensure Resident #3's anticoagulant prescription was picked up from a specified pharmacy by facility staff and brought to the facility. This resulted in the facility's failure to ensure Resident #3 received physician ordered anticoagulant therapy for a total of nine doses from 11/28/23 to 12/3/23. The facility's failure led to Resident #3 being sent to the hospital with potential signs of a stroke. Record review and interviews during the complaint investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance at the time of the survey from 3/11/24 to 3/13/24. II. Facility planThe nursing home administrator (NHA) provided the facility's Medication Error Action Plan, dated 12/7/23, on 3/11/23 at 8:28 p.m. Resident #3 was discharged to the emergency department (ED) for evaluation and treatment on 12/4/23. The resident's family and primary care provider (PCP) were notified. The director of nursing (DON) reviewed the resident's clinical record on 12/7/23 and discovered a significant medication error for Pradaxa, an anticoagulant. The DON notified the NHA that the unit manager (UM) had not picked up the Pradaxa from the pharmacy. The NHA notified the physician and the director of clinical services (DCS). The DCS drove to the facility. The UM was immediately suspended and then dismissed on 12/11/23. The UM was reported to the State Board of Nursing. A facility audit was immediately started on 12/7/23 of all residents in the facility that utilized an anticoagulant. Fourteen residents were identified and no concerns were observed. The NHA interviewed the nursing staff on 12/7/23 and discovered the UM had not picked up the resident's Pradaxa from the pharmacy. She had told multiple nursing staff that she would pick up the medication. All 19 nurses who worked for the facility in December 2023 were educated, starting 12/7/23, on anticoagulants, ordering medications and staff communication. The agency, temporary and as needed nursing staff received education prior to their next shift in the facility. The agency and new hire nurse packets were updated to include additional education on anticoagulants, ordering medications and staff communication. Daily medication audits were started on 12/7/23 and continued through 3/8/24. During morning stand up meetings, all newly admitted residents had their medication orders reviewed, care plans reviewed and the availability of the medications was confirmed. Residents admitted on a Saturday or Sunday or a medication change that occurred on Saturday and Sunday had their medications reviewed first at the Monday morning stand up meeting. Due to the severity of the medication error, a quality assurance performance improvement (QAPI) performance improvement plan (PIP) was started on 12/7/23. This PIP was still active at the time of the survey from 3/11/24 to 3/13/24. Interviews and record review during the complaint investigation revealed corrective actions to identify the resident and other residents having the potential to be affected by the deficient practice, systematic changes to prevent its recurrence and monitoring to ensure sustained correction. III. Facility policies and proceduresThe Anticoagulant policy, dated 4/14/23, was provided by the NHA on 3/11/24 at 8:43 p.m. This facility recognized that some medications, including anticoagulants, were associated with greater risks of adverse consequences than other medications. This policy addressed the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety. The term anticoagulant referred to a class of medications that were used to prevent clot extension and formation. They did not dissolve clots. Examples included Warfarin, Heparin, Lovenox, Xarelto, Pradaxa, and Eliquis. Anticoagulants should be prescribed by a provider or other authorized practitioner with clearindications for use. Examples included the prevention and treatment of deep vein thrombosis, pulmonary embolism, atrial fibrillation with embolization, stroke, mechanical heart valve, or management of myocardial infarction. A care plan would be developed for anticoagulants to promote safe use of the medications. The staff would monitor for adverse effects and interventions for prevention, documentation would be completed by exception. The Medication Errors policy, implemented 10/1/21, was provided by the NHA on 3/11/24 at 1:46 p.m. The policy revealed, it was the policy of this facility to provide protections for the health, welfare, rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. A significant medication error meant one which caused the resident discomfort or jeopardizes his/her health and safety. The facility should ensure medications would be administered according to physician's orders; according to the manufacturer's specifications regarding the preparation, and administration of the drug or biological; and in accordance with accepted standards and principles which apply to professionals providing services. III. Significant medication errorA. Resident statusResident #3, age 93, was admitted on 1/26/23 and discharged to the hospital on 12/4/23. According to the December 2023 computerized physician orders (CPO), diagnoses included paroxysmal atrial fibrillation (irregular heartbeat with the heartbeat returns to normal on its own or with medication within seven days), Alzheimer's disease, rhabdomyolysis (damaged muscle tissue releases proteins and electrolytes into the blood, which could damage the heart and kidneys), chronic obstructive pulmonary disease, atherosclerosis (thickening or hardening of the arteries, caused by the buildup of plaque in the inner lining of an artery) of the aorta and non-displaced fracture of the surgical neck of the right humerus. The 11/1/23 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident was administered an anticoagulant medication. It also indicated the resident had hypertension, renal insufficiency, diabetes mellitus and hyperlipidemia (elevated levels of cholesterol and/or triglycerides in the blood). B. Record reviewA physician's order, dated 1/26/23, revealed anticoagulant medication; monitor for discolored urine, black tarry stools, sudden severe headache, nausea/vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath or nose bleeds. Documents yes (Y) if monitored and none of the above observed, document no (N) if monitored and any of the above were observed. Select chart code (Other/See nurse note) and a progress note finding every shift for prevention. A physician's order, dated 1/27/23, revealed Pradaxa oral capsule 110 milligrams (mg), administer one capsule by mouth every 12 hours for atrial fibrillation. The care plan for alteration in health maintenance related to atrial fibrillation, hypertension, chronic obstructive pulmonary disease, renal insufficiency that required anticoagulant therapy was dated 1/27/23. The pertinent inventions were to administer anticoagulant medications as physician ordered. Staff were to monitor for the side effects and adverse effects such as blood tinged urine, black stools, sudden headache, nausea/vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, and/or significant changes in vital signs. Staff were to monitor for signs or symptoms of bleeding, and monitor for vital signs and report to a physician if they are out of parameters. A nurse progress note, dated 11/28/23 at 12:03 p.m., revealed a call was placed to the specified pharmacy for a refill of Pradaxa (anticoagulant). The medication would be ready for pick up later today (11/28/23).-An order administration note, dated 11/28/23 at 6:57 p.m., revealed Pradaxa oral capsule 110 mg, administer one capsule by mouth two times a day for atrial fibrillation was not available.-An order administration note, dated 11/29/23 at 8:07 a.m., revealed Pradaxa oral capsule 110 mg, administer one capsule by mouth two times a day for atrial fibrillation was not available. Medication to be picked up at a specified pharmacy this morning (11/29/23).-An order administration note, dated 11/29/23 at 8:15 a.m., (late entry) revealed the nurse manager was notified that the pharmacist at the pharmacy said the Pradaxa was ready to be picked up. The unit manager said she would pick it up today (11/29/23).-An order administration note dated 11/29/23 at 8:45 a.m. (late entry) revealed the provider was notified.-An order administration note dated, 11/29/23 at 8:37 p.m., revealed Pradaxa oral capsule 110 mg, administer one capsule by mouth two times a day for atrial fibrillation was not available.-An order administration note, dated 11/30/23 at 8:07 p.m., revealed Pradaxa oral capsule 110 mg, administer one capsule by mouth two times a day for atrial fibrillation was not available. The November 2023 medication administration record (MAR) revealed the resident was not administered the physician ordered anticoagulant a total of four times on:-11/28/23 at 7:00 p.m.;-11/29/23 at 6:00 a.m. and 7:00 p.m.; and,-11/30/23 at 7:00 p.m.-An order administration note dated, 12/1/23 at 7:03 a.m., revealed Pradaxa oral capsule 110 mg, administer one capsule by mouth two times a day for atrial fibrillation. The facility was waiting for the delivery of the medication.-An order administration note, dated 12/2/23 at 7:58 a.m., revealed Pradaxa oral capsule 110 mg, administer one capsule by mouth two times a day for atrial fibrillation was not available.-An order administration note, dated 12/2/23 at 9:00 p.m., revealed Pradaxa oral capsule 110 mg, administer one capsule by mouth two times a day for atrial fibrillation was not available.-An order administration note, dated 12/3/23 at 9:35 a.m., revealed Pradaxa oral capsule 110 mg, administer one capsule by mouth two times a day for atrial fibrillation was on order.-An order administration note, dated 12/3/23 at 10:05 p.m., revealed Pradaxa oral capsule 110 mg, administer one capsule by mouth two times a day for atrial fibrillation. There was notation that the medication was given or not given. The medication was never picked up from the pharmacy. The December 2023 MAR revealed the resident was not administered the physician ordered anticoagulant a total of five times on:-12/1/23 at 6:00 a.m.;-12/2/23 at 6:00 a.m. and 7:00 p.m.; and,-12/3/23 at 6:00 a.m. and 7:00 p.m. A weekly nursing note, dated 12/3/23, revealed the reason for the visit was due to mentation (mental activity). The resident was alert andoriented to his person only. The resident's pulses were within normal limits. The resident's hydration status revealed recent poor oral intake. No edema (swelling) was observed and the resident's respirations were within normal limits. The resident had shortness of breath with excretion and utilized oxygen via a nasal cannula. The resident required extensive assistance with one staff member for activities of daily living and transfers. The resident's skin turgor (skin elasticity) was three seconds. The resident's mucous membranes, lips and tongue were moist. A social services note, dated 12/4/23, revealed the clinical care manager (CCM) was informed by nursing staff that the resident had potential signs of a stroke. The resident was a do not resuscitate (DNR). The resident's representative was called and he wanted the resident to be sent to the hospital for an evaluation. Emergency medical services (EMS) was called and the CCM remained with the resident until EMS arrived. The Aspen unit manager contacted the resident's physician office and advised them that the resident was sent out emergently. The hospital records dated 12/7/23 revealed the resident presented on 12/4/23 with altered mental status, was found to have urosepsis (infection spread in the bloodstream caused by urinary tract infection) and a new subacute posterior left middle cerebral artery (MCA) infarct (stroke) according to the computed tomographic angiography (CTA) performed on 12/4/23. The resident had seizures and required intubation (the insertion of a tube through a person's mouth or nose and down the windpipe to keep the airway open) on admission due to apneic (involuntarily and temporality stops breathing) episodes. The resident was transferred to comfort care. The assessment revealed ischemic stroke, acute encephalopathy (change in brain function) seizures and sepsis. The hospital records revealed the resident was pronounced as deceased on 12/8/23 at 8:53 a.m. The cause of death was a cerebral vascular accident (CVA). IV. Staff interviewsThe NHA, director of nursing (DON), director of clinical Sciences (DCS) and the chief clinical officer (CCO) were interviewed on 3/11/24 at 1:00 p.m. They said the nurse progress note dated 11/28/23 at 12:03 p.m. revealed a call was placed to the specified pharmacy for a refill of Pradaxa and the medication would be ready for pick up later that day. The UM told the three nursing staff that she would go and pick up the medication from the specified pharmacy and she did not do it. The nursing staff discussed with the UM the resident's Pradaxa was not in the facility, they were waiting for her to pick up and bring the medication to the facility. The UM did not tell anyone that she had not gone to pick up the medication. The pharmacy did not call the facility to let them know the medication still had not been picked up. The facility did have an automated medication dispensing cabinet and it did not contain Pradaxa. The UM said she went to the pharmacy on 11/28/23 to pick up the medication, the medication was not ready at that time and she left the pharmacy. The UM should have waited on the medication. The UM said she would return to the pharmacy to pick up the medication and she did not. Other staff had offered to go pick up the medication and she told them that she would go get the medication. The UM was suspended, terminated and the State Board of Nursing (BON) was notified. -The date the BON was notified was not provided when requested. They said the November 2023 MAR revealed the resident did not receive the Pradaxa four times. They said the December 2023 MAR revealed the resident did not receive the Pradaxa five times. The resident should have been administered as his physician ordered. The DCS said the resident was administered one dose of Pradaxa on 11/30/23 at 6:00 a.m. The facility nurse found a single capsule in a blister packet. The DCS said the December 2023 MAR revealed the resident was administered the medication on12/1/23 at 7:00 p.m. by an agency nurse. The nurse did not reveal where the medication came from. The DCS said the resident was examined on 12/3/23 at 7:13 a.m. and there were no signs or symptoms of anticoagulant problems. There were no signs or symptoms of a stroke, however the social services note dated 12/4/23 at 9:09 a.m. did reveal the resident was sent to the hospital for the potential signs of a stroke. They said 12/7/23 was the first time the issue was identified by the DON. The resident was already at the hospital. The DON called the NHA and told him that a medication error had occurred. An immediate house audit of residents who used an anticoagulant was conducted/completed for verification of orders and that the facility had plenty of anticoagulant medications in the facility. No additional issues were found and the medical director (MD) was notified. All nurses in the facility, at that time, were interviewed and the UM admitted she was responsible. On 12/7/23 nurses were educated on anticoagulants, on the procedures to follow when medications were not available and communication. The facility started daily audits to ensure all resident medications were available. They said the social services note, dated 12/4/23 at 9:09 a.m., revealed the resident was sent to the hospital for the potential signs of a stroke. Licensed practical nurse (LPN) #1 was interviewed on 3/12/24 at 10:15 a.m. She said she was in-serviced on anticoagulants, reordering of medications and staff communication on 12/7/23. She said medications were ordered with the pharmacy using the facility's computerized system. She said medications in a blister package were arranged in rows. She said when the medication was on the last row of the blister package, she would order the medication from the pharmacy. She said this would be the same system she would use to order anticoagulant medications. She said if a medication was not available, she would notify the DON, the pharmacy, the resident's physician and the NHA. She said the resident's physician would tell the nurse what to do, such as hold the medication or make a change to a different medication. She said if a medication was unavailable and not in the automated medication dispensing cabinet, a STAT (immediate) medication script order could be sent to the pharmacy and they would deliver the medication as quickly as they could. She said if she observed that a medication had not been administered, she would notify the unit manager. She said nursing staff should follow physician orders. The pharmacist (PH) was interviewed on 3/12/24 at 10:31 a.m. She said Resident #3's physician order read Pradaxa oral capsule 110 mg, administer one capsule by mouth every 12 hours for atrial fibrillation. She said the November 2023 MAR revealed the resident was not administered this medication four times and the December 2023 MAR revealed the resident was not administered this medication five times. The PH said the resident should have been administered the medication as the physician ordered. Registered nurse (RN) #1 was interviewed on 3/12/24 at 11:57 a.m. He said he was in-serviced on 12/7/23 on anticoagulants, reordering of medications and staff communication. He said he ordered medications when there were eight or less medications in the medication blister package. He said during shift change, it would be best practice to communicate that a medication was in low supply or not available. He said Pradaxa was not in the facility's automated medication dispensing cabinet. He said if a medication was not available, he would notify the UM, the DON, the resident's physician, the resident's family and the pharmacy. He said when he talked with the resident's physician regarding a medication that was not administered the physician would tell him what to do. The physician might want the medication to be held, change to a substitute medication for one dose or write a script for a different medication. He said if the physician wrote a script for a medication, a STAT (immediate) order would be placed with the pharmacy. The medical director (MD) was interviewed on 3/11/24 at 1:17 p.m. He said he was made aware of this issue on 12/7/23, as soon as the facility became aware of the problem. He said he was unable to recall the interventions the facility put in place. He said medications should be given per physician orders. He said if a medication such as Pradaxa was not given, the resident's primary care physician (PCP) should be notified. The NHA was interviewed again on 3/12/24 at 2:18 p.m. He said he first became aware of this issue on 12/7/23. The DON called him to let him know she had found a mistake by the UM related to Resident #3. He then called the DCS. An immediate facility wide medication audit was started and the UM was suspended. The NHA called the regional director of operations (RDO) and the corporate human resources department. The NHA said the DCS drove to the facility immediately and completed a review of all residents who utilized an anticoagulant. No additional issues were identified. The NHA said on 12/7/23, he called the facility's medical director (MD). He said he started interviewing nursing staff that had interacted with the UM to ensure the Pradaxa medication was available. He said after interviewing the nursing staff on the morning and afternoon of 12/7/23, the failure to pick up the Pradaxa medication was further understood. He said on the afternoon of 12/7/23, in-services were started with the nursing staff about anticoagulants, ordering medications and staff communication. He said throughout December 2023, the facility only had 19 full or part time nurses. He said the nurses that were working in the facility at that time and newly hired nurses were educated on the anticoagulants, ordering medications and staff communication before they worked on the floor. He said the nursing staff in the facility had been educated on anticoagulant administration. He said the new nurse orientation packet and the agency staff packet were updated to include additional information on anticoagulants, ordering medications and staff communication. He said the facility provided quarterly training to the nursing staff on medication administration, which included anticoagulant medication. He said the facility completed weekly clinical reports that included the number of residents that utilized anticoagulant medications and any that had international normalized ratio (INR) or the amount of time it takes blood to clot concerns. He said the medication Pradaxa did not require an INR.The NHA said daily medication audits started on 12/7/23 and continued through 3/8/24. He said during the morning stand up meetings, all newly admitted residents had their medication orders reviewed and the availability of the medications was confirmed. He said any resident medication order that was changed or a medication was added, were reviewed in the daily morning meeting. He said if any resident was admitted or a medication change occurred on Saturday and Sunday, those individuals or medications were reviewed first at the Monday morning stand up meeting. No other concerns have been identified. The NHA said given the severity of the medication error, a quality assurance performance improvement (QAPI) performance improvement plan (PIP) was started on 12/7/23. He said the PIP was developed and was being reviewed each month in the QAPI committee meeting. He said the PIP was a fluid and dynamic document. If the audits did not demonstrate they were achieving the specified goals, the audit and/or the goals could be changed as necessary. Changes could be made as needed and the facility did not have to wait for the next monthly QAPI committee meeting which typically occurred on the first Wednesday of each month. The NHA provided the QAPI minutes for January 2024 and February 2024. The minutes reflected the review of PIP for anticoagulants. He said the January 2024 meeting reflected December 2023 and the February 2024 meeting reflected January 2024. To reiterate the timeline for this medication error, the NHA said Resident #3's Pradaxa order had been sent to the pharmacy. He said the resident's representative had been contacted by the pharmacy to complete the necessary paperwork for the pharmacy to deliver medications to the facility. At the time of the medication error, the representative had not signed the document. The NHA said the facility staff had to go and pick up the medication. He said the pharmacy was about a 20-minute drive from the facility. The UM said she would go and pick up the medication at the pharmacy. The NHA said the UM told him that she went to the pharmacy to pick up the medication, however, it was not ready at that time. The NHA said the UM told him that she planned to pick up the medication on her way home from work and when it was not available, she planned to pick it up the next morning. He said the UM never picked up the medication. He said when the other nurses noticed this Pradaxa medication was not available, they discussed this issue with the UM. The UM assured the nurses that she would take care of this problem and go pick up the Pradaxa. He said the UM never told the DON or himself that she had not picked up the medication. The NHA said 12/7/23 was when he first learned of the concern after Resident #3 was sent to the hospital on 12/4/23. The NHA said the DON did an audit of Resident #3's clinical record after he went to the hospital. The DON discovered the resident's Pradaxa had not been given as the physician ordered. The DON then called him. Resident #3's PCP was called on 3/12/24 at 3:55 p.m. A message and return phone number was left on a voicemail machine. The PCP did not respond.
Plan of correction
The state did not require a plan of correction for this citation.
1/25/2024Complaint Survey · ID GJPX11No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO32092, #CO34664 and Incident #31590 was completed on 1/25/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
6/20/2023Focused Infection Control, Other-Fed Survey · ID 902R111 deficiency▼
0884Reporting - National Health Safety NetworkS/S F▼
Findings
Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/12/2023 and 06/18/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.
Plan of correction
The state did not require a plan of correction for this citation.
6/12/2023Focused Infection Control, Other-Fed Survey · ID KPQC111 deficiency▼
0884Reporting - National Health Safety NetworkS/S F▼
Findings
Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/05/2023 and 06/11/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.
Plan of correction
The state did not require a plan of correction for this citation.
6/5/2023Focused Infection Control, Other-Fed Survey · ID 0Q4D111 deficiency▼
0884Reporting - National Health Safety NetworkS/S F▼
Findings
Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/29/2023 and 06/04/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.
Plan of correction
The state did not require a plan of correction for this citation.
5/16/2023Revisit: Recertification Survey · ID O9GV22No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A revisit to the 4/6/2023 survey was completed on 5/16/2023. The facility was in compliance with the regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
5/3/2023Revisit: State Licensure Survey · ID LWDO12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 5/3/23 for all previous deficiencies cited on 3/16/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
5/3/2023Revisit: Recertification Survey · ID O9GV12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 5/3/23 for all previous deficiencies cited on 3/16/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
4/6/2023Recertification Survey · ID O9GV211 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (000) (VB) construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1978 and is license for110 beds. This re-certification survey conducted on April 6, 2023, was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey. The Administrator reported the daily census to be 100 residents on April 6, 2023.
Plan of correction
The state did not require a plan of correction for this citation.
0353Sprinkler System - Maintenance and TestingS/S F▼
Findings
STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following. -Pendent sprinkler shows signs of foreign materials (including paint) around the working parts of the head. The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility. NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5
Plan of correction · submitted by the facility
353PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSION SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THE RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R 488.18 AND SECTION 7317A OF THE STATES OPERATIONS MANUAL. No specific resident was identified for this deficient practice. All residents, staff and visitors have the potential to be affected by the deficient practice. The sprinkler heads that were loaded were cleaned on 4/6/2023 during the walk through and the one painted head was cleaned, and confirmation from Sentinal was received they will be out to replace on 4/13/23. The Maintenance Director or Designee will report monthly to the Quality Assurance team for the next 3 months or until substantial compliance is achieved.
3/16/2023State Licensure Survey · ID LWDO111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure survey was completed on 3/13/23 to 3/16/23. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0709Resident Care - Weight Changes▼
Findings
Based on observations, record review and interviews, the facility failed to implement nutritional interventions for one (#89) of four residents reviewed for nutritional parameters out of 37 sample residents to maintain acceptable parameters of nutritional status. Resident #89, age 78, was admitted to the facility on 12/30/22 with diagnoses of dementia, post traumatic stress disorder, chronic kidney disease stage three, previous head injury with loss of consciousness, left side paralysis following a stroke, epilepsy, prostate enlargement, vitamin D deficiency, urinary incontinence, restlessness and agitation, depression and influenza (flu). Resident #89 sustained a weight loss of 9.9% (17.6 lbs) from admission on 12/30/22 through 2/26/23, and an 11% (20.2 lbs) weight loss from admission to 3/12/23, which was considered significant. He also lost more than three lbs weekly from 1/18/23 to 1/25/23 (4.3 lbs loss), 2/16/23 to 2/19/23 (4 lbs loss) and from 2/19/23 to 2/26/23 (6.9 lbs loss). According to Resident #89's nutrition care plan, pertinent interventions initiated 12/30/22 included to monitor, record and report to the physician as needed any signs and symptoms of malnutrition such as significant weight loss. There was no documentation a physician was notified of any weight loss until 3/1/23 physician progress note revealed the resident's weight of 160.4 (a 9.9% decrease from admit). There was no documentation on expected or unplanned weight loss, or updated care plan goals and interventions. Findings include:I. Facility policy and procedureThe Weight Management Policy, dated 10/24/22, was provided by the regional clinical resource (RCR) on 3/16/23 at 10:10 a.m. The policy read in pertinent part, "All residents were weighed upon admission, then weekly or as indicated by physician orders. The results were documented in the resident record in the medical record. Residents were monitored (per physician orders) for significant weight change on a regular basis. The results were reviewed and analyzed by the facility for interventions as appropriate. Residents identified with significant weight change were assessed by the interdisciplinary team (IDT); and further interventions were implemented to minimize the risk for further weight change where possible and promote weight stability. Residents were screened for their risk of weight change on admission, quarterly, annually, and with significant change of condition with completion of the MDS (minimum data set assessment). Residents with a significant weight variance (loss or gain) were reweighed. Significant weight variance was defined as: 5% in one month; 7.5% in 3 months; or 10% in 6 months. Residents identified at risk for weight change had interventions implemented to minimize the risk for additional weight change included in their plan of care. This may have included supplements, registered dietitian (RD) evaluation, and assisted dining. The IDT met weekly to review residents with identified weight change, developed a plan, implemented, evaluated, and re-evaluated interventions to minimize the risk for weight change. Nursing staff were responsible to communicate weight changes to the attending physician and resident's family. The nurse documented the notification in the medical record. Nursing staff was to notify food and nutrition services and the registered dietitian (RD) of a resident's weight change. The RD further assessed the resident and made recommendations as indicated to reduce or stabilize the weight change."II. Resident #89Resident #89, age 78, was admitted on 12/30/22. According to the March 2023 computerized physician orders (CPO), the diagnoses included dementia, post traumatic stress disorder, chronic kidney disease stage three, previous head injury with loss of consciousness, left side paralysis following a stroke, epilepsy, prostate enlargement, vitamin D deficiency, urinary incontinence, restlessness and agitation, depression and influenza (flu). The 2/7/23 facility assessment revealed the Resident #89 was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. No rejection of care was documented. He required extensive assistance with bed mobility, transfers, dressing, toilet and use and personal hygiene. The resident required limited assistance with eating. The swallowing and nutritional status of the facility assessment revealed the resident height was 74 inches, and weight was 173 pounds (the most recent weight in the last 30 days), and that the resident had not lost weight (either 5% or more in the last month or 10% or more in the last 30 days). Resident #89 was observed at mealtime on 3/15/23 at 5:15 p.m. He ate in the main dining room without staff assistance. III. Record reviewA. Resident care planResident #89's nutrition care plan, initiated 12/30/22 and revised 1/5/23, was to have minimal nutrition risk evidenced by having a meal intake greater than 50% and a stable weight. He required some assistance at meal time and could make his preferences known, and was medically managed by a local senior care provider. The care plan goal, initiated 1/5/23 and revised 2/14/23, was to maintain adequate nutrition status evidenced by maintaining weight and consuming an average of greater than 50% at meals. Pertinent interventions initiated 12/30/22 included to monitor, record and report to the physician as needed any signs and symptoms of malnutrition such as emaciation, muscle wasting or significant weight loss: three lbs in one week, more than 5% in one month, more than 7.5% in three months, and more than 10% in six months; monitor weights as ordered; obtain food preferences and offer as able; provide and serve the resident's diet as ordered and monitor intake and record with his meal; monitor, document, and report as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and if the resident appeared concerned during meals. An intervention was added on 1/5/23 for the RD to evaluate and make diet change recommendations as needed (prn). The chronic kidney disease care plan initiated 12/30/22 included the pertinent intervention to monitor, record and report to a nurse a loss of appetite, refusal to eat and weight loss. B. Resident weightsResident #89's weights were documented in the resident's record as follows:-On 1/5/23 the resident weighed 178.0 lbs-On 1/18/23 the resident weighed 177.9 lbs-On 1/25/23 the resident weighed 173.2 lbs-On 2/16/23 the resident weighed 171.3 lbs-On 2/19/23 the resident weighed 167.3 lbs-On 2/26/23 the resident weighed 160.4 lbs -On 3/5/23 the resident weighed 157.8 lbs-On 3/7/23 the resident weighed 157.6 lbs-On 3/12/23 the resident weighed 157.6 lbs-On 3/15/23 the resident weighed 158.3 lbsResident #89 lost more than 3 lbs during the following weeks:1/18/23 to 1/25/23 (177.9 to 173.2 for a 4.3 lb loss); there was no record of the physician being notified. 2/16/23 to 2/19/23 (171.3 to 167.3 for a 4 lb loss); there was no record of the physician being notified. 2/19/23 to 2/26/23 ( from 167.3 to 160.4 for a 6.9 lb loss); there was no record of the physician being notified. Resident #89 sustained a weight loss of 9.9% (17.6 lbs) from admission through 2/26/23, and an 11% (20.4 lb) weight loss from admission to 3/12/23, which was considered significant weight loss. Re-weighs were ordered for Resident #89 on 2/3/23, 2/9/23 and 2/16/23 and marked as completed in the February 2023 administration record but not recorded. C. Physician ordersThe March 2023 computerized physician orders revealed the resident had the following orders related to nutrition:-Weekly weights every day shift every Sunday, ordered 2/26/23;-Regular diet, regular texture, and thin liquids. D. Nutrition assessments and progress notesResident #89's admission weight on 1/5/23 was 178 lbs. His initial 1/5/23 admission nutritional assessment signed 1/16/23 did not list a usual body weight or previous weight within the last 30 days. The assessment revealed the resident's fluid intake was 240-360 millimeters (ml) each meal, and food intake was 51-75% at each meal and snacks were offered as needed. Resident #89's estimated nutrition needs were 1789 calories (kcal), 65 grams (g) of protein, and 2023 ml of fluids a day. His estimated needs were calculated by using 81 kilograms (kg) of body weight, caloric needs at 22 kcal per kg of body weight, protein at 0.8 g per kg of body weight and fluids at 25 ml per kg of body weight. The assessment also revealed the resident was at minimal nutrition risk due to consistent intake greater than 50% and a stable weight, with the care plan to maintain weight during admission. The 2/22/23 weight change note revealed the resident weighed 167.3 lb, an 11lb decrease since admission. The note also revealed the resident had a decreased intake the past couple of days "per documentation" and recommended to discharge the resident from the weight management meeting.-At the time of the documented weight note Resident #89 had two instances of a 3lb weight loss or more within one week's time (reference resident weights above). The note did not indicate if the RD or physician were notified of the weight changes. An explanation of why the admission weight was inaccurate and an updated weight or re-weigh for the resident was not documented. The 3/1/23 physician note contained the resident's most recent weight on 2/26/23 of 160.4 lbs. The note also revealed the resident denied complaints and stated he was doing well. The physician note also revealed that the facility had no nutritional concerns to report.-At the time of the physician note the resident had a 17.6 lb and 9.9% weight loss since admission on 12/30/22. No additional weight loss notes, interventions or updates to the care plan were documented. The 3/2/23 weight change note revealed the resident's most recent weight of 160.4 lbs and a re-weigh was pending. Resident #89's intake was reported to be 51-100%. -At the time of the weight change note it was not documented that the RD was present for the meeting or whether she was notified of the weight change. This weight was a 6.3% decrease in 10 days and a 9.9% weight decrease since admission. There was no new weight or re-weigh documented until 3/5/23, which was the next day the resident was to be weighed per the CPO. No additional weight loss notes, interventions or updates to the care plan were documented. The 3/8/23 weight change note revealed Resident #89's weight was 157.8 lbs, a loss of 15 lbs in 30 days. The resident was eating 51-100% at meals and the resident was active. This weight change was recommended to be referred to the RD.-At the time of the weight change note the resident had a 20.2 lb and 11.3% weight decrease since admission on 12/30/22 and a 5.6% decrease since 2/19/23. The weight on 3/5/23 was 157.8 lbs, and an additional weight was obtained on 3/7/23 of 157.6 lbs. No additional weight loss notes, interventions or updates to the care plan were documented. The 3/15/23 weight change note (added during survey) revealed the facility RD discussed weight loss with Resident #89's medical provider RD with a supplement order requested on 3/9/23. The provider had yet to send the order as documented in the note and the resident was noted to have a meal intake of 76-100% on a regular diet, with a regular texture and thin liquids. Nursing was to offer snacks between meals and record the task in the electronic charting system. The note also revealed the resident had a weight of 157.8 on 3/15/23.-There was no documentation after 3/9/23 that the facility followed up on the status of the supplement order. A 3/16/23 nutritional/dietary note (added during survey) included a follow up by the facility RD on Resident #89's weight change. The resident's chart was reviewed by the facility RD. The note revealed the provider notes indicated a progressive cough and respiratory illness in late January with a diagnosis of flu, then a late February diagnosis of COVID-19. The nursing notes indicated increasing agitation and urinary retention during this period. The meal records indicated he continued to consume greater than 75% of his meals. This resident has history of transcatheter aortic valve replacement (TAVR) which some research indicates is associated with a higher risk of malnutrition (https://www.ahajournals.org/doi/full/10.1161/CIRCINTERVENTIONS.121.010483). The resident's weight loss appeared to have a component related to his progressive overall decline. Nutritional supplements twice a day were ordered and the facility RD recommended a thyroid stimulating hormone (TSH) test in discussion with the medical provider's RD. The recommendation was to continue to monitor for the effect of extra calories provided. The updated estimated needs were 2150 kcals per day (30 kcals/kg), 86 g/day protein (1.2g/kg), and 2150 mLs/day of fluids (30mLs/kg).-A review of the CPO revealed a pending order placed 3/16/23 by the facility RD for a Boost plus supplement to be offered twice a day ( in the morning and evening) to Resident #89 and the resident could choose the flavor. A 3/16/23 IDT note (added during survey) revealed Resident #89 ate his meals on the unit where he received supervision and was eating well at that time with a meal intake of 76-100%. His weight of 158.3 lbs appeared to be stabilizing between 157-160 lbs since 2/26/23 following a loss of 13 lbs from 2/16/23. The facility RD discussed the resident's weight loss with the medical provider who agreed to adding a supplement. The resident often accepted snacks. The facility discussed Resident #89's weight with his wife and she stated she saw him at lunch and he was eating well, and likes ice cream in the evening.-A copy of the nutritional value provided by the regular menu was requested on 3/16/23 and not received. E. Meal and snack intakesMeal intake records were reviewed for 30 days from 2/13/23 to 3/13/23. Meal intake records from 2/23/23, 2/27/23, 3/1/23, 3/5/23, were missing for breakfast and lunch. Meal intake records from 3/7/23 were missing breakfast and dinner intake records, and the third intake record was marked 76-100% at 2:10 p.m. and then the resident was marked not available at 2:11 p.m. -The 3/7/23 progress note revealed the resident was out of the facility to see his medical provider but did not indicate how long. Meal intake records from 3/9/23 were missing breakfast and dinner intake records and lunch intake was recorded as 76-100% at 12:11 p.m. and also marked the resident was not available at 12:11 p.m. There was nothing marked to indicate the resident refused a meal or was not available. Meal intake records from 3/10/23 were missing for breakfast and lunch. Meal intake records from 3/13/23 were missing breakfast intake records. Lunch intake was recorded at 1:15 p.m. as 76-100% and then at 1:15 p.m. as the resident was not available.-The 3/13/23 progress note at 1:10 p.m revealed the resident left the facility for an appointment but did not indicate for how long. The snacks offered record was reviewed for 30 days from 2/13/23 to 3/13/23. The staff recorded when a snack was offered to Resident #89 for morning, evening, and before bedtime and PRN snacks. The snack amount consumed was reviewed for 30 days from 2/13/23 to 3/13/23. The recorded amount of snack consumed by the resident varied from 1-480 when the resident accepted the snack.-Neither the snacks offered record or the amount of snack consumed indicated what snack was offered or what unit of measurement was recorded for the resident snack intake. IV. Staff interviewsThe dietary director (DD) was interviewed on 3/15/23 at 3:52 p.m. She stated she did not see Resident #89 a lot but when she did he was usually eating and seated at that time. The facility reviewed him in the weight meeting and usually reviewed his intake. The facility did reach out to the medical provider about a supplement and the order was not approved yet. She said the supplement was immediately available for the resident once the order was approved and in the meantime the staff offered him snacks from the dry snack closet, which she had observed staff offering a couple times. She said sometimes with the medical provider there was a frustration waiting for the provider to respond. Resident #89's wife and medical power of attorney (MPOA) was interviewed on 3/16/23 at 9:26 a.m. by phone. She said she could tell Resident #89 was getting thinner, but he did seem to eat when she was there. She said she was at the facility almost daily but she did not go to the medical provider appointments with him. She said his usual body weight was 185, and she thought right now his height was six foot or six foot one inch , and that he used to be six foot two inches but was shorter as he has gotten older. She said she was not contacted about a recent weight loss. She said she was not contacted by the facility about the resident's food preferences and likes. She said she did not see the staff offer snacks but that did not mean the staff did not offer the snacks, but the staff did ask the resident what he wanted at meal time. The facility RD was interviewed on 3/16/23 at 10:00 a.m. over the phone. Also present by phone during the interview were the nursing home administrator (NHA), the director of nursing (DON), the DD, and the consulting registered dietitian (CRD). The RD stated resident #89 had a history of decline and multiple falls which led to his admission to the facility. She said he also had a history of a valve replacement and that was noted in the RD notes from that day (3/16/23) and there was an association with poor outcomes from that surgery. The resident developed a cough in mid January 2023 and was admitted with respiratory distress that was later diagnosed with flu and COVID. She said the resident had increased agitation and the staff had a difficult time keeping him from wandering into other resident rooms. The resident had been brought up in the weight meeting because of the shift in his weight. The facility determined at one point that maybe the weight loss was because the resident was settling in at the facility, but there could have been some progressive decline that was popping up and this was in the notes. She said the resident had maintained his appetite and his meal intake, and the facility did a monthly meeting with the medical provider's RD, and she told the provider's RD she was seeing weight loss progressing rapidly, and that the medical provider's RD said he would speak to the provider's physician, and the RD just followed up with medical provider RD regarding the supplement. The RD said she made the recommendation to the medical provider for a Boost plus because it was calorie dense and if staff gave the resident 4 oz, the supplement was still a nice partial serving and the resident would get a nice calorie intake. She said she spoke with the medical provider's RD on 3/9/23 by phone about Resident #89's weight loss and supplement. She said it was not typical to wait a week for the provider to fulfill the order. The RD said she did not receive a notification when an order was filled, but that she frequently signed on onto the database due to her preparation for the weekly weight meeting a day or two in advance. She said the challenge was that she was waiting and there was a possible machine glitch somewhere. She said she would put the supplement order in herself if she felt she needed to speed up the process. The RD said the facility menu regular diet provides about 2000-2300 kcal and she used the resident's body weight and kcal per kg to calculate his estimated nutritional needs. She said she used different numbers for his new estimated needs calculation and said that the resident had increased protein and calorie needs at this point because of his agitation. She said the nursing notes described his agitation and inthe nursing notes it appeared he called out frequently for family members and that he had decreased ability to remain seated. The DON said Resident #89 had dementia and was advancing fairly rapidly and was impulsive, had poor safety awareness and was trying to ambulate independently. She said she had seen confusion but not agitation and maybe a little bit of anxiety and he had wandered off the unit. She felt the current unit the resident resided on was too stimulating and he needed a smaller, quieter, unit and she had requested that transfer but had not received a response from the medical provider. The DD said she did have an idea of what snacks the staff offered Resident #89, but could not say what snacks he was accepting. She said he was offered nutrigrain bars, granola bars, ice cream, pudding, cheese and peanut butter crackers. The CRD said adding a nutrition intervention was more of a sense of when the resident was ready for something like the recommended supplement and that he was ready the previous week. She said the facility tried to look at the whole person and with the COVID diagnosis, the valve replacement and with the increased anxiety, there were multiple factors to consider with the resident. She said if supplements were overused it would take away the resident's appetite and desire to eat.-However, the resident's weight was not addressed when he was losing weight regardless of supplements being ordered when he lost 11 lbs and was not to have a decreased intake 2/23/23. The NHA said the resident had gained weight this week, and said it was important to note that the COVID diagnosis meant the resident's intake was diminished and it was the resident's choice to have a supplement or anything else. Now that the resident was in a spot on the upswing, the NHA had seen the resident's weight come back a little bit. The facility RD said Resident #89 did have extensive hospitalization prior to admission at the facility and the hospital weight was slightly less at 174 lbs. When she saw some weight differences, and when she saw the weight decrease in about a 20 day period he also had urinary retention that was pretty profound but maybe not overt at that time. The medical provider's physician (MPP) was interviewed by phone on 3/16/23 at 11:25 a.m. The physician was not aware the facility RD put in a supplement order the previous week. He reviewed Resident #89's chart and did not see a supplement on the medication list or a recommendation for one. He said the electronic charting system the facility used did not communicate very well with their system and typically relied on faxes back and forth. He said an 11% weight loss was usually flagged by the medical provider. The RD who reviewed resident charts on a routine basis would notify him (the physician) and the provider RD usually did a recommendation then and signed the order. He said if the facility noticed the weight loss, the facility contacted the medical provider RD or the provider physician directly. He said the facility RD absolutely could make supplement recommendations and it was typically done through fax. He said the recommendation also could be done over the phone and he would sign the order. The medical provider RD was interviewed on 3/16/23 1:50 p.m. He said he did not see a supplement recommendation in Resident #89's chart from the previous week. He said he talked to the facility RD on 3/9/23 and he did not remember going over a supplement recommendation with her. He said if the facility RD felt a supplement was appropriate she could order a supplement and he would approve it. He said while reviewing his notes from his call with the facility RD last week that his notes did not indicate that he or the facility RD discussed a supplement for Resident #89. He said the facility RD stated Resident #89 was eating well and that the resident's weight was down quite a bit. He said the facility RD did not mention a supplement at the time because the resident was still eating well. He said he was happy to start the supplement and said it would certainly be appropriate. He said a supplement could be recommended and approved and it should take a little less than 24 hours. He said the facility should place a courtesy call to him (the medical provider RD) if an order is placed at the facility level. The DON was interviewed on 3/16/23 at 1:00 p.m. She said she was unsure how staff were documenting Resident #89's intake when he ate at the medical provider's building. She was also unsure of the unit of measure for the snack amount consumed record. She said if a resident was out of the building the staff should be marked unavailable and if a meal intake was missing it was likely the staff missed recording it in the electronic charting system. She said as a facility recording resident meal intakes had improved. CNA #3 was interviewed on 3/16/23 at 2:00 p.m. She said if a resident was out of the building she would not document a meal intake for the resident and instead she would make a note in the electronic charting system that the resident was out of the building or the meal was left in the room. V. Facility follow upAdditional notes corresponding to Resident #89's weights were provided 3/17/23 by CRD at 1:04 p.m.-1/5/23 178 lbs: Resident #89 was admitted to the facility with a flu diagnosis, and received tamiflu; the resident's family requested a locked unit.-1/18/23 177.9 lbs: Haldol (antipsychotic medication) was discontinued on 1/12/23.-2/16/23 171.3 lbs: Resident #89 was diagnosed with COVID and treated with paxlovid (COVID medication); trazodone (psychotropic medication) was discontinued on 2/14/23.-2/19/23 167.3 lbs (no notes provided).-2/26/23 160.4 lbs (no notes provided).-3/5/23 157.8 lbs: the facility RD called the medical provider on 3/9/23 for a supplement order, with an email sent to DON and DD for status.-3/7/223 157.6 lbs: Progress notes from 3/10/23 summarized, Resident #89 was noted to be increasing impulsiveness and inability to sleep, attempted to stand without assistance, required frequent redirection.-3/15/23 158.3 lbs: The facility RD followed up with the medical provider to advise on the supplement ordered by facility RD.Two additional progress notes were provided on Resident #89's agitation. The 3/6/23 progress note revealed Resident #89 yelled out his wife's name multiple times during this shift. The resident's wife called and spoke with the resident over the phone and he was able to calm down for a while. The care partners able to redirect the resident temporarily but he started yelling out again shortly after. The provider was notified and updated with the resident's behavior. The 3/10/23 progress note revealed Resident #89 was by nursing station most of shift for being an high fall risk; he was confused at times, screamed throughout the shift and frequently redirected. Additional weight committee notes were provided from 1/4/23 to 2/22/23. The notes revealed on 1/11/23 Resident #89 refused to be weighed. Weight committee notes from 2/22/23 and 3/1/23 revealed the admission weight was determined to be inaccurate but did not include a new weight, updated weight or source of documentation. Weight committee notes from 3/15/23 revealed a supplement was discussed for Resident #89 on 3/9/23 and a fax was to be sent over. A follow up note on 3/16/23 regarding a coordination of care call with the medical provider revealed the resident was admitted under the care of the medical provider in April 2022 however a nutrition assessment was not completed by the medical provider for the resident until January 2023. The provider informed the facility on that call the resident had a weight of 190 lbs in the fall of 2022. Resident #89 ate two days a week at the medical provider facility with no documentation available from the meal site regarding his intake. The conclusion was the resident was admitted with high risk factors and noted decline in mental status from admission, a decrease in medicationand compounded by infection. The facility could improve with increased notes and establishing a baseline weight.
Plan of correction · submitted by the facility
F-692I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: On 3/16/23, Registered Dietician completed a nutritional review of Resident 89 and contacted primary care providers for additional supplement order. Nurses were notified of new supplement order. Resident experienced a change in overall condition and was discharged to the hospital on 3.19.23 with family notification. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: On 3/20/23, Corporate Food and Nutrition consultant completed an audit of all active residents to identify residents with triggered weight loss and ensure appropriate interventions in place. All residents were assessed for weight loss with twenty residents identified for additional review. Of these residents, two were noted for additional follow up:-Resident had experienced slow weight change and dentition concerns. RD reviewed and noted no mouth pain and stable weight, resident was determined to being meeting estimated needs with no further interventions needed.-Resident was reviewed due to genetic low body weight secondary to Asian ethnicity and determined to be meeting estimated needs. No further interventions were indicated. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: During the period from 3/17/23 through 3/20/23, staff were provided education on weight management process to identify potential weight loss concerns and ensure interventions are in place as indicated. Additionally, education included following interventions as ordered. Beginning the week of 3/19/23, FNM/Designee to review any resident triggering for weight loss in IDT weight meeting to ensure appropriate interventions and documentation in place. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly the DON/Designee will provide the Medical Director and Interdisciplinary team a summary report at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue until 90 days of sustained compliance is identified.
3/16/2023Complaint, Recertification Survey · ID O9GV115 deficiencies▼
0000Initial CommentsSurveyor note2 building records▼
Findings · record 1 of 2
A recertification survey with complaint #CO31012 was completed from 3/13/23 to 3/16/23. Five deficiencies were cited.
Findings · record 2 of 2
An Emergency Preparedness survey was conducted from 3/13/23 to 3/16/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0580Notify of Changes (Injury/Decline/Room, etc.)S/S D▼
Findings
Based on record review, and interviews, the facility failed to ensure the resident representative was notified for one (#89) of five residents reviewed out of 37 sample residents. Specifically, the facility failed to ensure Resident #89's representative was notified of his significant weight loss. Findings include: I. Facility policyThe Weight Management policy, dated 10/24/22, was provided by the regional clinical resource (RCR) on 3/16/23 at 10:10 a.m. The policy read in pertinent part, "Nursing staff were responsible to communicate weight changes to the attending physician and resident's family. The nurse documented the notification in the medical record. Nursing staff was to notify food and nutrition services and the registered dietitian (RD) of a resident's weight change."The Changes in Resident Condition Policy, revised 11/23/19 was provided by the RCR on 3/16/23 at 10:10 a.m. The policy read in pertinent part, "The resident, attending physician and legal representative or interested family member were notified when changes in condition or certain events occurred. A facility immediately informed the resident; consulted with the resident's physician; and if known, notified the resident's legal representative or an interested family member when there was: A significant change in the resident's physical, mental, or psychosocial status (such a deterioration in health, mental, or psychosocial status in either life - threatening conditions or clinical); a need that altered treatment significantly ( a need that discontinued an existing form of treatment due to adverse consequences, or to commence a new form of treatment); change in the resident status that affect the problem(s)/goal(s) or approach on the resident's plan of care were documented as revisions and communicated to the interdisciplinary team (IDT) team."Examples of clinical condition changes were such things as a stage II pressure injury, onset orrecurrent delirium, recent urinary tract infections, significant weight loss, falls, a significant change in behaviors, a resident was started on antibiotics for any type of infection, any change in the resident from resident's baseline such as an onset of a new concern/incident (such as a skin tear, or bruise). The documentation in the resident's medical record was to include:-The date and time of the change of condition and who (physician/family member/responsible party) was notified regarding the condition change-The information communicated.-The response and/or orders received.-The assessment of the resident's condition and ongoing monitoring of resident condition.-The care provided.-The care plan was updated as needed.-Documented on the 24 Hour report the was resident's name and the condition change and any other pertinent information."II. Resident #89Resident #89, age 78, was admitted on 12/30/22. According to the March 2023 computerized physician orders (CPO), the diagnoses included dementia, post traumatic stress disorder, chronic kidney disease stage three, previous head injury with loss of consciousness, left side paralysis following a stroke, epilepsy, prostate enlargement, vitamin D deficiency, urinary incontinence, restlessness and agitation, depression and influenza (flu). The 2/7/23 minimum data set (MDS) assessment revealed the Resident #89 was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The MDS assessment revealed the resident needed one person assistance for bed mobility, ambulating in his room, corridor, and on and off the unit, dressing, eating, toilet use and hygiene. He needed two person assistance for transfers. The resident's profile revealed Resident #89's wife was his medical power of attorney (MPOA). III. Resident representative interviewResident #89's wife and MPOA was interviewed on 3/16/23 at 9:26 a.m. She said she could tell Resident #89 was getting thinner, but he did seem to eat when she was there. She said she was at the facility almost daily but she did not go to the medical provider appointments with him. She said she was not contacted about a recent weight loss, and when informed of his weight loss since his admission, she stated she had no idea he had lost so much weight. She stated she was not going to be at the facility later that day or the remainder of the week due to a medical appointment she had planned. IV. Record reviewResident #89's admission weight on 1/5/23 was 178 lbs. The initial 1/5/23 admission nutritional assessment signed 1/16/23 did not list a usual body weight or previous weight within the last 30 days. The assessment also revealed the resident was at minimal nutrition risk due to consistent meal intake greater than 50% and a stable weight, with the care plan goal of the resident to maintain weight during admission. Resident #89 showed progressive weight loss through 3/12/23. On 2/26/23 Resident #89 weighed 160.4 lbs, a 17.6 lb and 9.9% weight decrease since admission. On 3/5/23 Resident #89 weighed 157.8 lbs, a 20.2 lb and 11.3% weight decrease since admission. Cross-reference F692 for nutritional status. The 3/2/23 weight change note revealed the resident's most recent weight was 160.4 lbs on 2/26/23 and a re-weigh was pending. -There was no documentation Resident #89's MPOA was notified or was attempted to be notified of the resident's significant weight decrease which was a 9.9% decrease since his admission. The 3/6/23 progress notes revealed Resident #89's MPOA was in the building to visit him. -There was no documentation Resident #89's MPOA was notified or was attempted to be notified of the resident's significant weight decrease. The 3/8/23 weight change note revealed Resident #89's weight was 157.8 lbs on 3/5/23, a loss of 15 lbs in 30 days. This weight change was recommended to be referred to the RD. -There was no documentation the MPOA was notified or attempted to be notified of the resident's significant weight decrease which was an 11.3% decrease since admission and 7.9% decrease in less than 30 days. The 3/15/23 social services progress notes revealed staff attempted to contact Resident #89's spouse to advise her of the care conference on 3/16/23 at11:30 a m. Staff left a voicemail, requested a call back and provided a contact number for a return call. V. InterviewsThe facility RD, nursing home administrator (NHA), director of nursing (DON and dietary director (DD) were interviewed on 3/16/23 at 10:00 a.m. The facility staff were unable to confirm the MPOA was informed of Resident #89's weight loss. The DON stated she had reached out to the MPOA a couple times but the MPOA did not call her back and the MPOA had some memory issues. The RD stated she thought she saw a note about a care conference and an unidentified staff member stated the care conference was happening that afternoon and there was an attempt to reach his wife. The RD then stated the care conference was happening that day and there had been an attempt to reach his wife. -Care conference notes or sign in sheet were requested for documentation regarding the MPOA being notified of Resident #89's weight loss but was not received by the exit of survey on 3/16/23. V. Facility follow upA 3/16/23 interdisciplinary team (IDT) note was entered and revealed the DD discussed Resident #89's weight with his MPOA.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: On 3/17/23, the facility held a care conference with the responsible party to review the change in condition. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: All residents were assessed for weight loss with twenty residents identified for additional review. Of these residents, two were noted for additional follow up with no further interventions indicated. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: During the period from 3/17/23 through 3/20/23, staff were provided education on appropriate notification and documentation to responsible parties when a resident is experiencing a change in condition. Beginning the week of 3/19/23, DON/Designee to complete random weekly audits to ensure appropriate notifications completed for any resident noted with significant weight loss. Any discrepancies to be corrected upon discovery. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly the DON/Designee will provide the Medical Director and Interdisciplinary team a summary report at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue until 90 days of sustained compliance is identified.
0685Treatment/Devices to Maintain Hearing/VisionS/S D▼
Findings
Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive device to maintain hearing and vision abilities for two (#32 and #29) of three residents reviewed for vision and hearing out of 37 sample residents. Specifically, the facility failed to:-Provide working hearing aids and repair glasses for Resident #32; and, -Offer Resident #29 audiology services. Findings include:I. Facility policy and procedureThe Ancillary policy and procedure, dated 8/19/14, were provided by the nursing home administrator (NHA) on 3/15/23 at 11:35 a.m. It read in pertinent part, "Ancillary services, including, but not limited to, dental, vision, audiology, and podiatry will be provided to the resident per state and federal regulatory guidelines; at the resident/responsible family member's request; and as needed."Any resident needing or requesting ancillary services such as dental, vision, audiology or podiatry will have their needs met timely. The facility will keep available a provider for ancillary services and/or assist the resident with utilizing the provider of their choice."Ancillary services are available to all residents requiring routine and emergency ancillary services care."Social services/designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner."II. Resident #32A. Resident statusResident #32, over age 65, was admitted on 9/13/22. According to the March 2023 computerized physician orders (CPO), diagnoses include stable burst fracture of unspecified lumbar vertebra (back bone), shortness of breath, chronic obstructive pulmonary disease and depression. The 12/21/22 minimum data set (MDS) assessment revealed the resident had no cognitive deficit impairment with a brief interview for mental status (BIMS) with a score of 14 out of 15. The resident required extensive assistance of one person with bed mobility, transfers, how the resident moved between surfaces, walking in the room, walking in the corridor, dressing, toileting, and personal hygiene. B. Resident interview and observationResident #32 was interviewed on 3/13/23 at 10:20 a.m. The resident said her hearing aids did not work and she could not hear very well and she said that her glasses did not fit, and that she could not see out of them. She said the staff were supposed to schedule her for another hearing test but it had not happened. The resident was interviewed in the presence of her son on 3/13/23 at 4:26 p.m. The son said the resident was very hard of hearing and her hearing aids were not working. He said he had brought in amplifying headphones for her so she would be able to watch television. He said that the staff had to speak very loudly in order for her to be able to hear. Resident #32 was interviewed again on 3/15/23 at 11:32 a.m. The resident said she did not put the hearing aids on unless she had to. She said the hearing aids were not working right and they had not worked right for a while. She said she felt she should be able to hear better with the hearing aids in than she did. She said she could hear about the same with the hearing aids as she does without them. She said that she had asked the facility to have the hearing aids checked, she was told they would look into it and then nothing happened. The resident said she needed to have her glasses looked at too, she was unsure if they were not fitting right or if the prescription was wrong but she did not feel she could see with them. The resident proceeded to put her hearing aids in both ears after taking them out of the charger and putting on her glasses that appeared ill-fitting and smashed onto her face. The resident had difficulty hearing with the aids in. C. Record reviewThe care plan for communication initiated and revised on 9/19/22 documented the resident had a communication problem related to a hearing deficit. Interventions included anticipating and meeting the resident's needs, when communicating allow adequate time to respond and repeat if necessary, and do not rush, monitor effectiveness of communication strategies and assistive devices. Monitor, document and report any changes in ability to communicate. The care plan for ancillary services initiated and revised on 9/19/22 documented the resident will receive ancillary services as needed and required for dental, vision, audiology, and podiatry. Interventions include: coordinate arrangements for dental care; transportation as needed/as ordered. Diet as ordered. Monitor, document, report any sign or symptoms of oral/dental problems needing attention. The nursing admission note dated 9/13/23 at 4:35 p.m. documented the resident was mildly to moderately hearing impaired with difficulty hearing in some environments or the speaker may need to increase volume and the resident had hearing aids for both ears. The social services note dated 1/31/23 at 9:16 a.m. documented an email from an outside agency involved with the resident's care regarding the need for ancillary services, optometry and audiology appointments. -There were no other social services notes regarding the need for ancillary services. The nursing note dated 3/10/23 at 8:44 a.m. documented the resident wore glasses and was very hard of hearing. -The facility failed to document providing or the resident receiving ancillary services at the facility or with the outside agency involved with her care. D. Staff interviewsThe social services director (SSD) was interviewed on 3/15/23 at 3:53 p.m. The SSD said the facility utilized visiting services for long term care residents including dental, audiology, and podiatry. An initial assessment was performed when the resident was admitted to the facility to learn what services they needed. . He said the providers of ancillary services did not take outside insurances. He said the outside agency involved with Resident #32's care had their own preferred provider for ancillary services. He said if he was notified by a nurse that a resident needed services he would investigate to see what the residents' needs were then he would reach out to a scheduler to make appointments for those residents with outside agencies involved with their care. Licensed practical nurse (LPN) #1 was interviewed on 3/16/23 at 10:12 a.m. The nurse said Resident #32 was admitted to be hard of hearing. She said she tried to get the residents to see the facility providers. She said the nurses could put in requests for care and they did not report it to anyone else. The SSD was interviewed again on 3/16/23 at 10:16 a.m. He said he had received an email from the outside agency on 1/31/23 regarding Resident #32 going for appointments for her hearing and vision. There were no follow up emails regarding appointments. Certified nursing assistant (CNA) #1 was interviewed on 3/16/23 at 10:57 a.m. The CNA said Resident #32 was hard of hearing and had hearing aids. He said the resident had stated she was not sure if she could hear better with them or without them. He said if the resident were to say there was a problem the staff would tell the nurse. The CNA said he did not know if there was an appointment for hearing aids, glasses or other services. The NHA was interviewed on 3/16/23 at 11:03 a.m. in the presence of the regional clinical resource (RCR) and the director of nursing (DON). He said if it was found that a resident was supposed to get services through the resident's preferred provider and had not, the facility would follow up with them. He said the facility could call their center director and schedule them for services or follow up with the doctor directly. The NHA said the outside agencies said they would provide services at their centers. The NHA said that if it was found that a resident was not getting the service they needed the facility could call the medical director and have the facility providers give the care the residents need. III. Resident #29A. Resident statusResident #29, over theage 90, was admitted on 9/29/22. According to the January 2023 computerized physician orders (CPO), diagnoses included dementia, history of COVID-19, history of urinary tract infections, chronic kidney disease stage three, high blood pressure, aphasia (speech difficulties), weakness, anemia, gout, vitamin D deficiency, gastroesophageal disease, osteoarthritis, and history of falls. The 2/13/23 minimum data set (MDS) assessment revealed the Resident #29 was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. She needed two person assistance for bed mobility and one person assistance for transfers, walking in her room and corridor, ambulating on and off the unit, dressing, eating, toileting and hygiene. The MDS assessment revealed Resident #29 did not use a hearing aid or other hearing appliance, usually understood or missed some pertinent parts of the message but comprehended most conversation. B. Resident interview and observationResident #29 was interviewed on 3/13/23 at 10:22 a.m. She said at the start of the interview she was hard of hearing. The resident was unable to hear some questions, and specifically unable to hear questions regarding her use of hearing aids in the past or if she had hearing aids currently. There were no hearing aids or hearing devices observed in the resident's room. The resident appeared to hear better if this speaker was standing within a foot of her while talking. The resident said she was interested in hearing aids. C. Record reviewA consent form for ancillary services was signed on 6/7/22 by Resident #29's legal representative and a facility representative. Resident #29's care plan for ancillary services was initiated and revised on 6/21/22 for dental, vision, audiology and podiatry. Pertinent interventions initiated 6/21/22 included coordination of arrangements for dental care, and transportation as needed and as ordered. Resident #29's care plan for falls initiated on 6/8/22 and revised on 6/21/22 revealed she was at moderate risk for falls due to generalized weakness, gait and balance problems, a history of falls, incontinence, vision and hearing problems. Resident #29's activities care plan initiated on 6/15/22 and revised on 3/11/23 revealed she enjoyed watching court tv and the news on tv, listening to German and polka music and was hard of hearing. Pertinent interventions included to encourage the resident to sit near a visiting speaker or presenter due to her being hard of hearing. The 9/6/22 provider note revealed Resident #29 had conductive hearing loss of both ears. The 9/11/22 activities progress note revealed Resident #29 was extremely hard of hearing and adaptations were needed for successful participation due to hearing limitations. The 11/21/22 provider notes revealed Resident #29 had conductive hearing loss of both ears. The 12/26/22 activities progress note revealed Resident #29 was extremely hard of hearing and adaptations were needed for successful participation due to hearing limitationsThe 2/8/23 psychosocial progress note revealed Resident #29 had poor hearing and ancillary needs that needed addressed including dental, visual, auditory and podiatry.-The resident had documented appointments for vision services on 1/24/23 and podiatry on 9/21/22. There was no documentation for audiology services. The 2/10/23 activities progress note revealed Resident #29 was extremely hard of hearing and needed to sit next to speakers. D. Staff interviewsThe nursing home administrator (NHA) and director of nursing (DON) were interviewed 3/14/23 at 3:35 p.m. The DON said she was not familiar with Resident #29's desire for hearing aids. The NHA said he thought the facility had previously followed up with the resident on a request for hearing aids, but he was going to verify documentation was present that indicated the audiology ancillary services were offered and the resident refused. Certified nurses aide (CNA) #5 was interviewed on 3/15/23 10:00 a.m. She stated shehad previously taken care of Resident #29 and she was hard of hearing and did not use hearing aids. The DON was interviewed on 3/16/23 1:00 p.m. She said if a resident requested hearing aids, then a social worker would follow up with the resident. The social services director (SSD) was interviewed on 3/16/23 at 2:20 p.m. He said audiology ancillary services fell under visiting audiology at the facility. He said if the resident benefited the facility offered testing to the resident, but it was up to the resident if they wanted to or not. He said he thought Resident #29 had been offered to see an audiologist in the past but said it might not be documented. He said if he found the documentation he would provide it. E. Facility follow-upThe SSD met with Resident #29 on 3/14/23 and placed the resident on a waiting list for an audiology appointment.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: On 3/17/23, CCM contacted the daughter of Resident 29 to receive authorization and consent for audiology evaluation and treatment. On 3/20/23, CCM contacted the primary care provider of Resident 32 and received confirmation that hearing aides were ordered. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: During the period from 3/16/23 through 3/23/23, Social Service Director/Designee completed an audit of all current residents to identify any ancillary service needs. Any needs identified were addressed. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: During the period from 3/17/23 through 3/20/23, staff were provided education on resident right to ancillary services and need to refer any resident concerns for ancillary services to social services. Beginning the week of 3/19/23, SSD/Designee to complete random weekly audits to ensure ancillary needs are met. Any issues identified to be corrected upon discovery. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly the DON/Designee will provide the Medical Director and Interdisciplinary team a summary report at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue until 90 days of sustained compliance is identified.
0688Increase/Prevent Decrease in ROM/MobilityS/S D▼
Findings
Based on observations, record review, and interviews, the facility failed to ensure a resident with limited mobility receives appropriate equipment, and assistance to maintain or improve mobility for one (#26) of three residents reviewed for limited range of motion out of 37 sample residents. Specifically, the facility failed to provide the resident with a hand splint and assistance for right hand contracture. Findings include:I. Facility policy and procedureThe Resident Mobility and Range of Motion policy and procedure, 2001 and revised in July 2017, was provided by the director of clinical operations (DCO) on 3/16/23 at 2:48 p.m. In pertinent part, it read:"-Residents will not experience an avoidable reduction in range of motion (ROM).-Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.-Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.-The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed.-The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion."II. Resident #26A. Resident #26 statusResident #26, age 68, was admitted to the facility on 2/27/21. According to the March 2023 computerized physician orders (CPO), diagnoses included epilepsy, unspecified traumatic brain injury, hemiplegia (paralysis one side) unspecified affecting right dominant side, contracture of right hand and muscle weakness. The 2/2/23 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 had no behavioral problems, psychosis, or rejection of care. He required extensive assistance of two people with bed mobility, transfers, toilet use and personal hygiene and extensive assistance of one person with dressing. The resident had functional limitations on his right side of both upper and lower extremities. He was receiving restorative nursing services for passive range of motion and transfers. B. Resident interview and observations Resident #26 was interviewed on 3/13/23 at 4:07 p.m. He said he had the contracture to his right hand ever since he had a motorcycle accident over 30 years ago. He said he had a right hand splint that he was supposed to be using. The resident was observed in his room watching television (TV) and visiting with his wife. His right hand was in his lap which had a contracture, his hand was in a fist with his wrist bent inward towards his body. His hand contracture was without a hand splint or washcloth, and he was leaning to his right side. On 3/15/23 at 11:02 a.m., the resident was observed propelling himself down the hall to the dining area. He was leaning to the right side with his right hand in lap; he was using his left hand to propel his wheelchair. Resident #26 was interviewed on 3/15/23 at 1:22 p.m. The resident said he had a splint for his right hand but he did not know where it was. He said the staff should be putting it on him at night but they had not done so recently. He said there was a sign in his room that reminded staff to put his splint on at night. The resident was in his wheelchair. His right hand was in his lap, it was without a hand splint/brace or washcloth, and he was leaning to his right side. On his wall was a sign that reminded staff to put his hand splint on his right hand at night. The hand splint was not observed in the room. Resident #26 was interviewed on 3/16/23 at 10:32 a.m. Resident #26 said staff found his hand splint on the table in his room. He said someone saw him yesterday to look at his hand splint and said they were going to order a new one because "this one was worn out." The resident's right hand was in his lap, it was without a hand splint/brace or washcloth. His hand splint was on a small table in the room. C. Record review Occupational therapy evaluation and plan dated 4/28/22 revealed the following:-Resident #26 to work with the occupational therapist (OT) to determine appropriate hand/wrist splint to decrease discomfort and risk of skin breakdown. The resident has a soft, moldable hand splint recently provided by restorative.-Resident #26 will wear a hand/wrist splint for the right hand. OT will determine a wear schedule with staff assistance for 90% of the time. Target date 5/27/22.-Education and training completed for primary caregivers and Resident #26 for positioning/pressure relieving techniques, positioning maneuvers, proper body mechanics and self-care/skin checks, use of assistive devices and use of adaptive equipment. OT treatment encounter notes:-5/6/22 Resident #26 said he was wearing his hand splint when he could remember to remind staff to put it on. OT created a sign to remind staff to put on his hand splint, and placed it on the bulletin board next to his bed.-5/7/22 Resident #26 right hand splint wearing schedule developed and provided to patient and nursing. The recommendation was for him to wear this at night with use of rolled up washcloth as needed for day time.-5/10/22 Resident #26 said he has been using the resting hand splint at night and it was comfortable.-5/19/22 Resident #26 said that the resting hand splint was comfortable and working well. The occupational therapist determined the resident could wear the hand splint at night with a rolled up washcloth in palm during the day.-5/26/22 Resident #26 reported his hand splint program was going well. Goal met. The care plan updated on 5/10/22 identified the resident had self-care performance deficit, right impaired balance, activity intolerance, decreased mobility, weakness, and shortness of breath. Interventions included: wear resting right hand splint, night staff to assist the resident to take off in the morning. Use a rolled washcloth in the palm of his right hand and check hand for potential skin issues. The OT evaluation and plan dated 3/1/23 evaluated toileting skills and did not address range of motion (ROM) or use of hand splint. The resident's treatment administration record from 3/1/23-3/16/23 (TAR) did not include application of hand splint. E. Staff interviewsCertified nurses aide (CNA) #4 was interviewed on 3/16/23 at 10:36 a.m. She said worked periodically with the resident on the day shift. She said she had not seen the resident wearing the hand splint and did not think he was using it. Registered nurse #2 was interviewed on 3/15/23 at 1:38 p.m. She said she did not know if Resident #26 had a right hand splint or if he was supposed to be using one. The restorative therapist (RT) was interviewed on 3/15/23 at 1:16 p.m. The RT said Resident #26 loved doing the passive range of motion (PROM) exercises. The RT said he provided massages to the resident's right hand and focused on the resident's right side. He said he did not know anything about a right hand splint or if the resident was using one. The OT was interviewed on 3/16/23 at 10:12 a.m. She said Resident #26 was admitted with a splint for a right hand contracture and had been using it for a long time. She said he was on her caseload in 2022 for his right hand contracture and wheelchair management. About a year ago she assessed the splint for him, monitored his skin and set up a schedule for use of the splint to be applied during the night. The nurses and CNAs were trained on the use of the splint with the resident. As far as she knew it had not been discontinued. The director of rehabilitation (DOR) was interviewed on 3/16/23 at 10:19 a.m. She said an evaluation was completed on 3/15/23 for his contracture. The resident's splint was found on his dresser. The assessment would include determining why the resident was not using his splint; if he was refusing to wear it or if it did not fit properly. The director of nursing (DON) was interviewed on 3/16/23 at 1:12 p.m. She said Resident #26 had used a hand splint since last spring but when he was placed on hospice last year, he declined to wear it. He was discharged from hospice on 4/18/22. The DON said the care plan should have been updated to reflect that he declined to use the hand splint. The posted sign in his room was a reminder to the CNAs, especially the agency staff, to apply the splint nightly. She said the CNAs were primarily responsible for the application of the splint and it should be documented on the resident's TAR. The CNA and nursing staff should have been trained on the application and use of the splint for the resident.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: Resident 26 was evaluated and treated by occupational therapists. Resident 26 had a brace created by orthotic provider. Occupational therapist completed a staff education regarding the brace use and the care plan has been updated. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: On 3/17/23, DON/Designee completed an audit of all current residents with contractures to ensure interventions to include splints/braces are in place and appropriate. No additional findings noted. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: During the period from 3/17/23 through 3/20/23, staff were provided education on contractures and appropriate interventions to include range of motion and providing splints as ordered. Beginning the week of 3/19/23, DON/Designee to complete random weekly audits for a period of 90 days to ensure interventions are in place and followed appropriately for residents receiving splint/range of motion services. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly the DON/Designee will provide the Medical Director and Interdisciplinary team a summary report at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue until 90 days of sustained compliance is identified.
0692Nutrition/Hydration Status MaintenanceS/S G▼
Findings
Based on observations, record review and interviews, the facility failed to implement nutritional interventions for one (#89) of four residents reviewed for nutritional parameters out of 37 sample residents to maintain acceptable parameters of nutritional status. Resident #89, age 78, was admitted to the facility on 12/30/22 with diagnoses of dementia, post traumatic stress disorder, chronic kidney disease stage three, previous head injury with loss of consciousness, left side paralysis following a stroke, epilepsy, prostate enlargement, vitamin D deficiency, urinary incontinence, restlessness and agitation, depression and influenza (flu). Resident #89 sustained a weight loss of 9.9% (17.6 lbs) from admission on 12/30/22 through 2/26/23, and an 11% (20.2 lbs) weight loss from admission to 3/12/23, which was considered significant. He also lost more than three lbs weekly from 1/18/23 to 1/25/23 (4.3 lbs loss), 2/16/23 to 2/19/23 (4 lbs loss) and from 2/19/23 to 2/26/23 (6.9 lbs loss). According to Resident #89's nutrition care plan, pertinent interventions initiated 12/30/22 included to monitor, record and report to the physician as needed any signs and symptoms of malnutrition such as significant weight loss. There was no documentation a physician was notified of any weight loss until 3/1/23 physician progress note revealed the resident's weight of 160.4 (a 9.9% decrease from admit). There was no documentation on expected or unplanned weight loss, or updated care plan goals and interventions. Findings include:I. Facility policy and procedureThe Weight Management Policy, dated 10/24/22, was provided by the regional clinical resource (RCR) on 3/16/23 at 10:10 a.m. The policy read in pertinent part, "All residents were weighed upon admission, then weekly or as indicated by physician orders. The results were documented in the resident record in the medical record. Residents were monitored (per physician orders) for significant weight change on a regular basis. The results were reviewed and analyzed by the facility for interventions as appropriate. Residents identified with significant weight change were assessed by the interdisciplinary team (IDT); and further interventions were implemented to minimize the risk for further weight change where possible and promote weight stability. Residents were screened for their risk of weight change on admission, quarterly, annually, and with significant change of condition with completion of the MDS (minimum data set assessment). Residents with a significant weight variance (loss or gain) were reweighed. Significant weight variance was defined as: 5% in one month; 7.5% in 3 months; or 10% in 6 months. Residents identified at risk for weight change had interventions implemented to minimize the risk for additional weight change included in their plan of care. This may have included supplements, registered dietitian (RD) evaluation, and assisted dining. The IDT met weekly to review residents with identified weight change, developed a plan, implemented, evaluated, and re-evaluated interventions to minimize the risk for weight change. Nursing staff were responsible to communicate weight changes to the attending physician and resident's family. The nurse documented the notification in the medical record. Nursing staff was to notify food and nutrition services and the registered dietitian (RD) of a resident's weight change. The RD further assessed the resident and made recommendations as indicated to reduce or stabilize the weight change."II. Resident #89Resident #89, age 78, was admitted on 12/30/22. According to the March 2023 computerized physician orders (CPO), the diagnoses included dementia, post traumatic stress disorder, chronic kidney disease stage three, previous head injury with loss of consciousness, left side paralysis following a stroke, epilepsy, prostate enlargement, vitamin D deficiency, urinary incontinence, restlessness and agitation, depression and influenza (flu). The 2/7/23 minimum data set (MDS) assessment revealed the Resident #89 was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. No rejection of care was documented. He required extensive assistance with bed mobility, transfers, dressing, toilet and use and personal hygiene. The resident required limited assistance with eating. The swallowing and nutritional status of the MDS assessment revealed the resident height was 74 inches, and weight was 173 pounds (the most recent weight in the last 30 days), and that the resident had not lost weight (either 5% or more in the last month or 10% or more in the last 30 days). Resident #89 was observed at mealtime on 3/15/23 at 5:15 p.m. He ate in the main dining room without staff assistance. III. Record reviewA. Resident care planResident #89's nutrition care plan, initiated 12/30/22 and revised 1/5/23, was to have minimal nutrition risk evidenced by having a meal intake greater than 50% and a stable weight. He required some assistance at meal time and could make his preferences known, and was medically managed by a local senior care provider. The care plan goal, initiated 1/5/23 and revised 2/14/23, was to maintain adequate nutrition status evidenced by maintaining weight and consuming an average of greater than 50% at meals. Pertinent interventions initiated 12/30/22 included to monitor, record and report to the physician as needed any signs and symptoms of malnutrition such as emaciation, muscle wasting or significant weight loss: three lbs in one week, more than 5% in one month, more than 7.5% in three months, and more than 10% in six months; monitor weights as ordered; obtain food preferences and offer as able; provide and serve the resident's diet as ordered and monitor intake and record with his meal; monitor, document, and report as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and if the resident appeared concerned during meals. An intervention was added on 1/5/23 for the RD to evaluate and make diet change recommendations as needed (prn). The chronic kidney disease care plan initiated 12/30/22 included the pertinent intervention to monitor, record and report to a nurse a loss of appetite, refusal to eat and weight loss. B. Resident weightsResident #89's weights were documented in the resident's record as follows:-On 1/5/23 the resident weighed 178.0 lbs-On 1/18/23 the resident weighed 177.9 lbs-On 1/25/23 the resident weighed 173.2 lbs-On 2/16/23 the resident weighed 171.3 lbs-On 2/19/23 the resident weighed 167.3 lbs-On 2/26/23 the resident weighed 160.4 lbs -On 3/5/23 the resident weighed 157.8 lbs-On 3/7/23 the resident weighed 157.6 lbs-On 3/12/23 the resident weighed 157.6 lbs-On 3/15/23 the resident weighed 158.3 lbsResident #89 lost more than 3 lbs during the following weeks:1/18/23 to 1/25/23 (177.9 to 173.2 for a 4.3 lb loss); there was no record of the physician being notified. 2/16/23 to 2/19/23 (171.3 to 167.3 for a 4 lb loss); there was no record of the physician being notified. 2/19/23 to 2/26/23 ( from 167.3 to 160.4 for a 6.9 lb loss); there was no record of the physician being notified. Resident #89 sustained a weight loss of 9.9% (17.6 lbs) from admission through 2/26/23, and an 11% (20.4 lb) weight loss from admission to 3/12/23, which was considered significant weight loss. Re-weighs were ordered for Resident #89 on 2/3/23, 2/9/23 and 2/16/23 and marked as completed in the February 2023 administration record but not recorded. C. Physician ordersThe March 2023 computerized physician orders revealed the resident had the following orders related to nutrition:-Weekly weights every day shift every Sunday, ordered 2/26/23;-Regular diet, regular texture, and thin liquids. D. Nutrition assessments and progress notesResident #89's admission weight on 1/5/23 was 178 lbs. His initial 1/5/23 admission nutritional assessment signed1/16/23 did not list a usual body weight or previous weight within the last 30 days. The assessment revealed the resident's fluid intake was 240-360 millimeters (ml) each meal, and food intake was 51-75% at each meal and snacks were offered as needed. Resident #89's estimated nutrition needs were 1789 calories (kcal), 65 grams (g) of protein, and 2023 ml of fluids a day. His estimated needs were calculated by using 81 kilograms (kg) of body weight, caloric needs at 22 kcal per kg of body weight, protein at 0.8 g per kg of body weight and fluids at 25 ml per kg of body weight. The assessment also revealed the resident was at minimal nutrition risk due to consistent intake greater than 50% and a stable weight, with the care plan to maintain weight during admission. The 2/22/23 weight change note revealed the resident weighed 167.3 lb, an 11lb decrease since admission. The note also revealed the resident had a decreased intake the past couple of days "per documentation" and recommended to discharge the resident from the weight management meeting.-At the time of the documented weight note Resident #89 had two instances of a 3lb weight loss or more within one week's time (reference resident weights above). The note did not indicate if the RD or physician were notified of the weight changes. An explanation of why the admission weight was inaccurate and an updated weight or re-weigh for the resident was not documented. The 3/1/23 physician note contained the resident's most recent weight on 2/26/23 of 160.4 lbs. The note also revealed the resident denied complaints and stated he was doing well. The physician note also revealed that the facility had no nutritional concerns to report.-At the time of the physician note the resident had a 17.6 lb and 9.9% weight loss since admission on 12/30/22. No additional weight loss notes, interventions or updates to the care plan were documented. The 3/2/23 weight change note revealed the resident's most recent weight of 160.4 lbs and a re-weigh was pending. Resident #89's intake was reported to be 51-100%. -At the time of the weight change note it was not documented that the RD was present for the meeting or whether she was notified of the weight change. This weight was a 6.3% decrease in 10 days and a 9.9% weight decrease since admission. There was no new weight or re-weigh documented until 3/5/23, which was the next day the resident was to be weighed per the CPO. No additional weight loss notes, interventions or updates to the care plan were documented. The 3/8/23 weight change note revealed Resident #89's weight was 157.8 lbs, a loss of 15 lbs in 30 days. The resident was eating 51-100% at meals and the resident was active. This weight change was recommended to be referred to the RD.-At the time of the weight change note the resident had a 20.2 lb and 11.3% weight decrease since admission on 12/30/22 and a 5.6% decrease since 2/19/23. The weight on 3/5/23 was 157.8 lbs, and an additional weight was obtained on 3/7/23 of 157.6 lbs. No additional weight loss notes, interventions or updates to the care plan were documented. The 3/15/23 weight change note (added during survey) revealed the facility RD discussed weight loss with Resident #89's medical provider RD with a supplement order requested on 3/9/23. The provider had yet to send the order as documented in the note and the resident was noted to have a meal intake of 76-100% on a regular diet, with a regular texture and thin liquids. Nursing was to offer snacks between meals and record the task in the electronic charting system. The note also revealed the resident had a weight of 157.8 on 3/15/23.-There was no documentation after 3/9/23 that the facility followed up on the status of the supplement order. A 3/16/23 nutritional/dietary note (added during survey) included a follow up by the facility RD on Resident #89's weight change. The resident's chart was reviewed by the facility RD. The note revealed the provider notes indicated a progressive cough and respiratory illness in late January with a diagnosis of flu, then a late February diagnosis of COVID-19. The nursing notes indicated increasing agitation and urinary retention during this period. The meal records indicated he continued to consume greater than 75% of his meals. This resident has history of transcatheter aortic valve replacement (TAVR) which some research indicates is associated with a higher risk of malnutrition (https://www.ahajournals.org/doi/full/10.1161/CIRCINTERVENTIONS.121.010483). The resident's weight loss appeared to have a component related to his progressive overall decline. Nutritional supplements twice a day were ordered and the facility RD recommended a thyroid stimulating hormone (TSH) test in discussion with the medical provider's RD. The recommendation was to continue to monitor for the effect of extra calories provided. The updated estimated needs were 2150 kcals per day (30 kcals/kg), 86 g/day protein (1.2g/kg), and 2150 mLs/day of fluids (30mLs/kg).-A review of the CPO revealed a pending order placed 3/16/23 by the facility RD for a Boost plus supplement to be offered twice a day ( in the morning and evening) to Resident #89 and the resident could choose the flavor. A 3/16/23 IDT note (added during survey) revealed Resident #89 ate his meals on the unit where he received supervision and was eating well at that time with a meal intake of 76-100%. His weight of 158.3 lbs appeared to be stabilizing between 157-160 lbs since 2/26/23 following a loss of 13 lbs from 2/16/23. The facility RD discussed the resident's weight loss with the medical provider who agreed to adding a supplement. The resident often accepted snacks. The facility discussed Resident #89's weight with his wife and she stated she saw him at lunch and he was eating well, and likes ice cream in the evening.-A copy of the nutritional value provided by the regular menu was requested on 3/16/23 and not received. E. Meal and snack intakesMeal intake records were reviewed for 30 days from 2/13/23 to 3/13/23. Meal intake records from 2/23/23, 2/27/23, 3/1/23, 3/5/23, were missing for breakfast and lunch. Meal intake records from 3/7/23 were missing breakfast and dinner intake records, and the third intake record was marked 76-100% at 2:10 p.m. and then the resident was marked not available at 2:11 p.m. -The 3/7/23 progress note revealed the resident was out of the facility to see his medical provider but did not indicate how long. Meal intake records from 3/9/23 were missing breakfast and dinner intake records and lunch intake was recorded as 76-100% at 12:11 p.m. and also marked the resident was not available at 12:11 p.m. There was nothing marked to indicate the resident refused a meal or was not available. Meal intake records from 3/10/23 were missing for breakfast and lunch. Meal intake records from 3/13/23 were missing breakfast intake records. Lunch intake was recorded at 1:15 p.m. as 76-100% and then at 1:15 p.m. as the resident was not available.-The 3/13/23 progress note at 1:10 p.m revealed the resident left the facility for an appointment but did not indicate for how long. The snacks offered record was reviewed for 30 days from 2/13/23 to 3/13/23. The staff recorded when a snack was offered to Resident #89 for morning, evening, and before bedtime and PRN snacks. The snack amount consumed was reviewed for 30 days from 2/13/23 to 3/13/23. The recorded amount of snack consumed by the resident varied from 1-480 when the resident accepted the snack.-Neither the snacks offered record or the amount of snack consumed indicated what snack was offered or what unit of measurement was recorded for the resident snack intake. IV. Staff interviewsThe dietary director (DD) was interviewed on 3/15/23 at 3:52 p.m. She stated she did not see Resident #89 a lot but when she did he was usually eating and seated at that time. The facility reviewed him in the weight meeting and usually reviewed his intake. The facility did reach out to the medical provider about a supplement and the order was not approved yet. She said the supplement was immediately available for the resident once the order was approved and in the meantime the staff offered him snacks from the dry snack closet, which she had observed staff offering a couple times. She said sometimes with the medical provider there was a frustration waiting for the provider to respond. Resident #89's wife and medical power of attorney (MPOA) was interviewed on 3/16/23 at 9:26 a.m. by phone. She said she could tell Resident #89 was getting thinner, but he did seem to eat when she was there. She said she was at the facility almost daily but she did not go to the medical provider appointments with him. She said his usual body weight was 185, and she thought right now his height was six foot or six foot one inch , and that he used to be six foot two inches but was shorter as he has gotten older. She said she was not contacted about a recent weight loss. She said she was not contacted by the facility about the resident's food preferences and likes. She said she did not see the staff offer snacks but that did not mean the staff did not offer the snacks, but the staff did ask the resident what he wanted at meal time. The facility RD was interviewed on 3/16/23 at 10:00 a.m. over the phone. Also present by phone during the interview were the nursing home administrator (NHA), the director of nursing (DON), the DD, and the consulting registered dietitian (CRD). The RD stated resident #89 had a history of decline and multiple falls which led to his admission to the facility. She said he also had a history of a valve replacement and that was noted in the RD notes from that day (3/16/23) and there was an association with poor outcomes from that surgery. The resident developed a cough in mid January 2023 and was admitted with respiratory distress that was later diagnosed with flu and COVID. She said the resident had increased agitation and the staff had a difficult time keeping him from wandering into other resident rooms. The resident had been brought up in the weight meeting because of the shift in his weight. The facility determined at one point that maybe the weight loss was because the resident was settling in at the facility, but there could have been some progressive decline that was popping up and this was in the notes. She said the resident had maintained his appetite and his meal intake, and the facility did a monthly meeting with the medical provider's RD, and she told the provider's RD she was seeing weight loss progressing rapidly, and that the medical provider's RD said he would speak to the provider's physician, and the RD just followed up with medical provider RD regarding the supplement. The RD said she made the recommendation to the medical provider for a Boost plus because it was calorie dense and if staff gave the resident 4 oz, the supplement was still a nice partial serving and the resident would get a nice calorie intake. She said she spoke with the medical provider's RD on 3/9/23 by phone about Resident #89's weight loss and supplement. She said it was not typical to wait a week for the provider to fulfill the order. The RD said she did not receive a notification when an order was filled, but that she frequently signed on onto the database due to her preparation for the weekly weight meeting a day or two in advance. She said the challenge was that she was waiting and there was a possible machine glitch somewhere. She said she would put the supplement order in herself if she felt she needed to speed up the process. The RD said the facility menu regular diet provides about 2000-2300 kcal and she used the resident's body weight and kcal per kg to calculate his estimated nutritional needs. She said she used different numbers for his new estimated needs calculation and said that the resident had increased protein and calorie needs at this point because of his agitation. She said the nursing notes described his agitation and in the nursing notes it appeared he called out frequently for family members and that he had decreased ability to remain seated. The DON said Resident #89 had dementia and was advancing fairly rapidly and was impulsive, had poor safety awareness and was trying to ambulate independently. She said she had seen confusion but not agitation and maybe a little bit of anxiety and he had wandered off the unit. She felt the current unit the resident resided on was too stimulating and he needed a smaller, quieter, unit and she had requested that transfer but had not received a response from the medical provider. The DD said she did have an idea of what snacks the staff offered Resident #89, but could not say what snacks he was accepting. She said he was offered nutrigrain bars, granola bars, ice cream, pudding, cheese and peanut butter crackers. The CRD said adding a nutrition intervention was more of a sense of when the resident was ready for something like the recommended supplement and that he was ready the previous week. She said the facility tried to look at the whole person and with the COVID diagnosis, the valve replacement and with the increased anxiety, there were multiple factors to consider with the resident. She said if supplements were overused it would take away the resident's appetite and desire to eat.-However, the resident's weight was not addressed when he was losing weight regardless of supplements being ordered when he lost 11 lbs and was not to have a decreased intake 2/23/23. The NHA said the resident had gained weight this week, and said it was important to note that the COVID diagnosis meant the resident's intake was diminished and it was the resident's choice to have a supplement or anything else. Now that the resident was in a spot on the upswing, the NHA had seen the resident's weight come back a little bit. The facility RD said Resident #89 did have extensive hospitalization prior to admission at the facility and the hospital weight was slightly less at 174 lbs. When she saw some weight differences, and when she saw the weight decrease in about a 20 day period he also had urinary retention that was pretty profound but maybe not overt at that time. The medical provider's physician (MPP) was interviewed by phone on 3/16/23 at 11:25 a.m. The physician was not aware the facility RD put in a supplement order the previous week. He reviewed Resident #89's chart and did not see a supplement on the medication list or a recommendation for one. He said the electronic charting system the facility used did not communicate very well with their system and typically relied on faxes back and forth. He said an 11% weight loss was usually flagged by the medical provider. The RD who reviewed resident charts on a routine basis would notify him (the physician) and the provider RD usually did a recommendation then and signed the order. He said if the facility noticed the weight loss, the facility contacted the medical provider RD or the provider physician directly. He said the facility RD absolutely could make supplement recommendations and it was typically done through fax. He said the recommendation also could be done over the phone and he would sign the order. The medical provider RD was interviewed on 3/16/23 1:50 p.m. He said he did not see a supplement recommendation in Resident #89's chart from the previous week. He said he talked to the facility RD on 3/9/23 and he did not remember going over a supplement recommendation with her. He said if the facility RD felt a supplement was appropriate she could order a supplement and he would approve it. He said while reviewing his notes from his call with the facility RD last week that his notes did not indicate that he or the facility RD discussed a supplement for Resident #89. He said the facility RD stated Resident #89 was eating well and that the resident's weight was down quite a bit. He said the facility RD did not mention a supplement at the time because the resident was still eating well. He said he was happy to start the supplement and said it would certainly be appropriate. He said a supplement could be recommended and approved and it should take a little less than 24 hours. He said the facility should place a courtesy call to him (the medical provider RD) if an order is placed at the facility level. The DON was interviewed on 3/16/23 at 1:00 p.m. She said she was unsure how staff were documenting Resident #89's intake when he ate at the medical provider's building. She was also unsure of the unit of measure for the snack amount consumed record. She said if a resident was out of the building the staff should be marked unavailable and if a meal intake was missing it was likely the staff missed recording it in the electronic charting system. She said as a facility recording resident meal intakes had improved. CNA #3 was interviewed on 3/16/23 at 2:00 p.m. She said if a resident was out of the building she would not document a meal intake for the resident and instead she would make a note in the electronic charting system that the resident was out of the building or the meal was left in the room. V. Facility follow upAdditional notes corresponding to Resident #89's weights were provided 3/17/23 by CRD at 1:04 p.m.-1/5/23 178 lbs: Resident #89 was admitted to the facility with a flu diagnosis, and received tamiflu; the resident's family requested a locked unit.-1/18/23 177.9 lbs: Haldol (antipsychotic medication) was discontinued on 1/12/23.-2/16/23 171.3 lbs: Resident #89 was diagnosed with COVID and treated with paxlovid (COVID medication); trazodone (psychotropic medication) was discontinued on 2/14/23.-2/19/23 167.3 lbs (no notes provided).-2/26/23 160.4 lbs (no notes provided).-3/5/23 157.8 lbs: the facility RD called the medical provider on 3/9/23 for a supplement order, with an email sent to DON and DD for status.-3/7/223 157.6 lbs: Progress notes from 3/10/23 summarized, Resident #89 was noted to be increasing impulsiveness and inability to sleep, attempted to stand without assistance, required frequent redirection.-3/15/23 158.3 lbs: The facility RD followed up with the medical provider to advise on the supplement ordered by facility RD.Two additional progress notes were provided on Resident #89's agitation. The 3/6/23 progress note revealed Resident #89 yelled out his wife's name multiple times during this shift. The resident's wife called and spoke with the resident over the phone and he was able to calm down for a while. The care partners able to redirect the resident temporarily but he started yelling out again shortly after. The provider was notified and updated with the resident's behavior. The 3/10/23 progress note revealed Resident #89 was by nursing station most of shift for being an high fall risk; he was confused at times, screamed throughout the shift and frequently redirected. Additional weight committee notes were provided from 1/4/23 to 2/22/23. The notes revealed on 1/11/23 Resident #89 refused to be weighed. Weight committee notes from 2/22/23 and 3/1/23 revealed the admission weight was determined to be inaccurate but did not include a new weight, updated weight or source of documentation. Weight committee notes from 3/15/23 revealed a supplement was discussed for Resident #89 on 3/9/23 and a fax was to be sent over. A follow up note on 3/16/23 regarding a coordination of care call with the medical provider revealed the resident was admitted under the care of the medical provider in April 2022 however a nutrition assessment was not completed by the medical provider for the resident until January 2023. The provider informed the facility on that call the resident had a weight of 190 lbs in the fall of 2022. Resident #89 ate two days a week at the medical provider facility with no documentation available from the meal site regarding his intake. The conclusion was the resident was admitted with high risk factors and noted decline in mental status from admission, a decrease in medication and compounded by infection. The facility could improve with increased notes and establishing a baseline weight.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: On 3/16/23, Registered Dietician completed a nutritional review of Resident 89 and contacted primary care providers for additional supplement order. Nurses were notified of new supplement order. Resident experienced a change in overall condition and was discharged to the hospital on 3.19.23 with family notification. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: On 3/20/23, Corporate Food and Nutrition consultant completed an audit of all active residents to identify residents with triggered weight loss and ensure appropriate interventions in place. All residents were assessed for weight loss with twenty residents identified for additional review. Of these residents, two were noted for additional follow up:-Resident had experienced slow weight change and dentition concerns. RD reviewed and noted no mouth pain and stable weight, resident was determined to being meeting estimated needs with no further interventions needed.-Resident was reviewed due to genetic low body weight secondary to Asian ethnicity and determined to be meeting estimated needs. No further interventions were indicated. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: During the period from 3/17/23 through 3/20/23, staff were provided education on weight management process to identify potential weight loss concerns and ensure interventions are in place as indicated. Additionally, education included following interventions as ordered. Beginning the week of 3/19/23, FNM/Designee to review any resident triggering for weight loss in IDT weight meeting to ensure appropriate interventions and documentation in place. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly the DON/Designee will provide the Medical Director and Interdisciplinary team a summary report at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue until 90 days of sustained compliance is identified.
0700BedrailsS/S D▼
Findings
Based on observation, interview and record review, the facility failed to ensure inspection and maintenance of a halo safety ring (fixed bed rail assistive device) for one (#29) of two residents using bed halo (type of bed rail) for positioning out of 37 sample residents. Specifically, for Resident #29, the facility failed to:-Inspect and regularly check the mattress and halo safety ring for areas of possible entrapment;-Check bed rail/halo safety ring regularly for ongoing maintenance to make sure device was still installed correctly as rails may shift or loosen over time; and, -Ensured the bedrail/halo safety ring was securely attached to the resident bed frame and prevented unstable movement and wobbling of the assistive device. Findings include:I. Professional standardThe U.S. Food and Drug Administration (FDA) Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, last updated 2/27/23 and pulled 3/22/23 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails included bed rail safety guidelines:-Bed rail use for patient's mobility and/or transferring, for example turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan. -The equipment (beds/mattresses/bed rails) should be inspected, evaluated, maintained, and upgraded to identify and remove potential fall and entrapment hazards and appropriately match the equipment to patient needs, considering all relevant risk factors. -The patient's needs should be re-assessed and the equipment re-evaluated if an episode of entrapment or near-entrapment occurred, with or without serious injury; this was done immediately because fatal "repeat" events can occur within minutes of the first episode. -The bed, mattress and any accessories should be monitored and maintained on an ongoing basis. II. Facility policy and procedureThe Assisted Devices Policy Timeline, revised 2/28/19, was provided by the regional clinical resource (RCR) on 3/16/23 at 10:00 a.m. The policy read in pertinent part, "The purpose of this policy is to establish timelines in which assistive devices were reassessed. The facility completed a reassessment of any assistive devices at least annually and with any significant change in resident status. The facility completed quarterly reviews of the assistive device with quarterly MDS (minimum data set) and plan of care reviews. The facility will obtain a written consent for the use of an assistive device at the time the device is initiated and annually thereafter."-The policy did not document that a bed rail/bed halo was assessed for proper fit and safety, or that the bed rail/bed halo was regularly monitored and inspected per the manufacturer's recommendations. III. Assistive device manualThe manufacturer's instructions for Resident #29's bed rail/halo ring was provided by the RCR on 3/15/23 at 10:59 a.m. for model number 77121. The manufacturer's instructions provided the information:-Proper patient assessment and monitoring, and proper maintenance and use of equipment was required to reduce the risk of entrapment.-The bed rail/halo ring and bed system should be measured, tested and evaluated for each user individually. -The halo safety ring should be returned to the original position parallel to the bed with the detent (quick release) pins engaged before each use.-The mattress must remain in firm contact with the halo safety ring with no gap on both sides of the bed. If a halo safety ring was only installed on one side of the bed, ensure the mattress remained in firm contact with mounted bracket on the other side of the bed.-The halo device was regularly checked to identify areas of possible entrapment, and immediately ceased use of the device until the bed until entrapment risk was fixed. A gap allowed a resident to become wedged between the bed rail and the mattress. Continuous movement in bed increased mattress compression, gap spaces, and the possibility of injury or death. IV. Resident #29A. Resident statusResident #29, over the age 65, was admitted on 9/29/22. According to the January 2023 computerized physician orders (CPO) diagnoses included dementia, history of COVID-19, history of urinary tract infections, chronic kidney disease stage three, high blood pressure, aphasia (speech difficulties), weakness, anemia, gout, vitamin D deficiency, gastroesophageal disease, osteoarthritis and history of falls. The 2/13/23 minimum data set (MDS) assessment revealed the Resident #29's cognition was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. She needed two person assistance for bed mobility and one person assistance for transfers, walking in her room and corridor, ambulating on and off the unit, dressing, eating, toileting and hygiene. She was noted as not steady during transfers from the bed to the chair. The MDS assessment was not marked to indicate a bed rail/halo ring was used. B. Resident observation and interviewResident #29 was interviewed on 3/13/23 at 10:22 a.m. She stated she used the bed rail/halo ring to lift herself up in bed. She stated she was concerned the bed rail/halo ring was loose. Resident #29 was interviewed on 3/14/23 at 1:30 p.m. She said she did not think anyone checked the bed rail/halo ring or tightened it. The bed rail/halo ring turned approximately one inch to the right while parallel to the bed when moved. C. Record reviewA review of the Resident #29's March 2023 computerized physician orders (CPO) showed an order on 10/24/22 for a bed halo added to the resident's bed and checked for placement and functionality every shift, which was to occur three times daily. The resident's care plan activities of daily living (ADL) care plan self-care performance deficit with impaired balance and limited mobility was initiated on 6/8/22 and revised on 6/21/22. The bed mobility intervention initiated 6/21/22 revealed the resident needed two person assistance and halos on the bed for mobility was added 10/24/22. Resident #29's treatment administration record (TAR) revealed an order to check the bed rail/halo rings placement every shift including placement and functionality, which was to occur three times daily. V. Staff interviewsThe nursing home administrator (NHA) was interviewed on 3/14/23 at 2:35 p.m. The NHA said that maintenance would check the bed rail/halo ring to see if the halo rings needed to be replaced because due to age but the maintenance staff did not check for stability. The NHA was observed checking both halo rings on Resident #29's bed and stated the halo rings were in the correct position and moved appropriately. Licensed practical nurse (LPN) #2 was interviewed on 3/14/23 at 3:44 p.m. as she was working on Resident #29's hallway. She said she was not aware she needed to check the resident's bed rail/halo ring and was unsure what she was looking for, and she had not checked them at the building previously. Registered nurse (RN) #3 was interviewed on 3/15/23 at 3:30 p.m. as she was working on Resident #29's hallway. She stated she worked as needed at the facility, and did not check the resident's bed rail/halo ring and was not sure what a halo ring was, and was not aware of what to do. The director of nursing (DON) was interviewed on 3/16/23 at 1:00 p.m. in the presence of the NHA and RCR. She stated the nursing staff checking the bed rail/halo ring should be making sure the halo ring was secure to the bed frame and that the halo ring was functional, and the staff would be educated on what that meant. VI. Facility follow upThe NHA stated on 3/15/23 at 10:30 a.m. that the bed rail/halo ring was replaced on Resident #29's bed and the resident was very happy with the replacement. The NHA provided a grievance form on 3/15/23 at 12:00 p.m. that a different bed rail/halo ring was installed on Resident #29's bed that the resident was comfortable with. The matching manufacturer's instructions were provided and the instructions for maintenance matched the maintenance instructions on the previous bed rail/halo ring.
Plan of correction · submitted by the facility
I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: On 3/16/23, minor adjustments were completed to halo on Resident 29’s bed. The device was inspected and noted to be securely fashioned to the bed frame. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: On 3/20/23, DON/Designee completed an audit of all current assistive devices in use to ensure appropriate function and placement as well as order in place to check each shift. No additional concerns noted. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: During the period from 3/17/23 through 3/20/23, staff were provided education on assistive devices to include checking for appropriate function and placement each shift. Beginning the week of 3/19/23, DON/Designee to complete random weekly audits to ensure assistive devices are in place and functional. Any discrepancies to be corrected upon discovery. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED: Monthly the DON/Designee will provide the Medical Director and Interdisciplinary team a summary report at Quality Assurance Process Improvement which summarizes the monitoring of the plan of correction. This will continue until 90 days of sustained compliance is identified.
Reportable Occurrences
28 records11/20/2025Verbal Abuse · ID 25020414021Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/20/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a verbal abuse event. Reportedly, staff (1) and client (A) heard client (B) threaten to hurt him (client A). The two clients were roommates. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, notified the police and implemented a monitoring plan for peer safety. Management moved client (A) to a new room, and he reported that he liked his new room away from client (B). Later during follow-up interviews with the staff witness and clients, all of them deny hearing a verbal threat. The event could not be substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 1/20/2026 · released to the public 1/27/2026.
10/11/2025Physical Abuse · ID 25020414020Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/11/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, as client (B) attempted to wheel around client (A), client (A) grabbed client (B)’s blanket off their lap. In response, client (B) grabbed client (A)’s arm causing scattered bruises. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, notified the police and implemented a monitoring plan for peer safety. The dining area furniture was moved to provide clearer pathways. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 1/6/2026 · released to the public 1/14/2026.
8/21/2025Diverted Drugs · ID 25020414018Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/21/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a diverted drug event. Staff discovered a narcotic count discrepancy during shift change. One card containing 26 tablets of Oxycodone and the associated count sheet was missing from the locked medication cart. The medications had been prescribed to client (B). During the course of the investigation, the healthcare entity conducted additional medication audits, checked on clients and conducted interviews. There were no reported adverse outcomes to clients. All staff denied being involved or having knowledge of the missing medication. An alleged assailant could not be identified; however, medications were deliberately removed and missing. The event was substantiated. Management implemented a new process for handling discontinued medications. Staff received education on the process changes to help with the accountability of medication handling. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 11/6/2025 · released to the public 11/13/2025.
5/12/2025Neglect · ID 25020414016Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/12/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a neglect event. Staff (1) notified the facility to report a complaint had been filed against their license for alleged neglect involving client (B). A representative from Adult Protective Services opened an external investigation about the complaint. The facility administration indicated they were not provided the specifics of this neglect allegation but only heard that it was tied to the previous case of alleged verbal abuse involving staff (1) and client (B). For specifics on the verbal abuse report, refer to event ID #25020414015. Currently, staff (1) was on suspension while the verbal abuse investigation was ongoing. During the course of the investigation, the healthcare entity conducted an assessment and interviews and reviewed records. Nursing staff reported no adverse findings with client (B)’s assessment. The facility indicated client (B) did not express any concerns about neglect during their interview. There was a report that client (B) started to refuse care and staff (1) had left the room to allow client (B) time to calm down. Staff (1) had then been suspended and was unable to continue providing care to client (B). However, other staff stepped in to complete client (B) care needs. At the facility level, the facility did not substantiate an allegation of staff neglect. Staff (1) did not return to the client's floor. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 9/3/2025 · released to the public 9/10/2025.
5/12/2025Verbal Abuse · ID 25020414015Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/12/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a verbal abuse event involving staff (1) and a client. During the course of the investigation, the healthcare entity suspended staff (1), conducted interviews, provided emotional support to the client and notified the police. Although the incident was reported by staff (2), the client denied being verbally mistreated. The facility concluded at times, staff (1) communicated with a loud voice; however, an abuse event was not substantiated. Staff (1) received additional education regarding their approach and returned to work. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 8/12/2025 · released to the public 8/19/2025.
1/29/2025Brain Injury · ID 25020414005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 1/29/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury event. Reportedly, client (B) stumbled and fell striking her head. There was a loss of consciousness and change of condition. During the course of the investigation, the healthcare entity conducted assessments and reassessed the safety plan. The family chose to continue comfort care measures in the facility. No diagnostic tests were completed. However as she experienced a neurological change post fall, the event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/2/2025 · released to the public 6/9/2025.
1/19/2025Physical Abuse · ID 25020414004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 1/19/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (A) entered client (B)’s room. They started holding hands and talking. When staff attempted to separate the clients, client (A) grabbed client (B)’s wrist causing redness and bruising to the area. During the course of the investigation, the healthcare entity safely separated the clients, conducted an assessment and interviews, and started safety monitoring. Both clients had a cognitive impairment and could not participate in a follow-up interview about the interaction. The facility determine staff attempted to separate the clients when they were enjoying each other’s company. Staff’s actions triggered client (A)’s physical reaction. Despite the outcome of redness and bruising, management concluded the incident was not abuse. Education was provided to staff regarding interventions. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/28/2025 · released to the public 6/4/2025.
12/22/2024Physical Abuse · ID 24020414035Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 12/22/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (B) alleged client (A) made physical contact with her upper body causing pain. During the course of the investigation, the healthcare entity kept the clients separated, conducted an assessment, and started frequent safety checks. No visible injury was observed with client (B), and her pain complaint varied with follow up interviews. Client (A) denied touching client (B). As there were no witnesses and due to conflicting statements, the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/31/2025 · released to the public 4/7/2025.
12/14/2024Verbal Abuse · ID 24020414034Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS: On 12/16/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a verbal abuse event. Reportedly, client (B) alleged client (A) was in their room in an agitated state while yelling and throwing things. Client (B) reported she did not feel safe. During the course of the investigation, the healthcare entity moved client (B) to a new room and provided emotional support. Through additional interviews, client (B) stated the items were not thrown at her, so there was no direct threat of harm. Client (A) could not report what triggered her agitation. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 3/31/2025 · released to the public 4/7/2025.
9/28/2024Missing Person · ID 24020414028Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 9/28/24, the healthcare entity investigated a reportable event of a missing person. Reportedly, staff discovered the at-risk client (B) missing during early morning rounds. During the course of the investigation, the healthcare entity conducted a search and notified the appropriate parties. Client (B) was located eight hours later in the community. As she refused to return, she was transported to the hospital for further evaluation. There were no reported adverse findings, and she did not return per her wishes. The facility concluded the client left the facility without notifying staff, and the event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 10/2/24, Event ID 8X8J11.
Publication
Sent to facility 4/29/2025 · released to the public 5/6/2025.
7/16/2024Physical Abuse · ID 24020414021Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/18/24, resident (B)’s family member contacted the facility to report resident (B) alleged resident (A) strangled her with an oxygen cord. The residents were roommates, and the alleged incident occurred a few nights earlier. Management moved resident (B) to a new room per her request and started frequent safety checks with both residents. Currently, resident (B) had no complaint of pain and no visible injuries were observed. During a police interview, resident (B) did not recall making the allegation. Resident (A) had no recall of any alleged incidents. Both residents had memory impairments. The facility was unable to substantiate resident (B)’s allegation. Staff continued monitoring the residents with safety checks.
DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 12/19/2024 · released to the public 12/26/2024.
6/29/2024Physical Abuse · ID 24020414019Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 6/29/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event involving two clients. During the course of the investigation, the healthcare entity reported two clients engaged in a verbal argument over Bingo cards when client (A) took one of them and made physical contact with client (B)’s face. Redness was observed to client (B)’s face and she complained of pain. Staff kept the clients separated, conducted an assessment, and started frequent safety checks. Pain medications were provided. Staff ensured the clients did not sit close to one another during activities. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 2/16/2025 · released to the public 2/23/2025.
6/10/2024Neglect · ID 24020414018Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 6/10/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a neglect event. During the course of the investigation, the healthcare entity received a complaint of neglect involving client (B). A family member stated one of the medications was not given timely that morning. The client was near end of life under hospice care. Review of records showed the medication was given 30 minutes outside of the window for medication delivery. However, with staff #1’s assessment of the client, the facility reported staff #1 waited for the hospice nurse to arrive and assess first before administering any additional sedating medications to the client. The family was upset at the situation and alleged neglect. Staff interviews indicated the client was not displaying signs nor symptoms of pain or discomfort. Additional education was provided to nursing staff regarding medication policies. Despite the medication error, the facility concluded the allegation of staff neglect event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/3/2025 · released to the public 3/10/2025.
6/3/2024Physical Abuse · ID 24020414016Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/30/24, staff observed resident (B) lying on the floor of resident (A)’s room. Resident (A) was observed holding the handles of resident (B)’s wheelchair saying resident (B) needed to “get out.” Staff separated the residents and assessed resident (B). No visible injuries were observed and she had no current complaint of pain. Both residents had a cognitive impairment and could not participate in a follow up interview about the incident. Management was unable to determine the circumstances of how resident (B) ended up on the floor. Staff educated resident (A) to ask for staff assistance to redirect other residents out of her room. Resident (B) was referred to therapy services to help with fall prevention.
DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 12/19/2024 · released to the public 12/26/2024.
5/28/2024Misappropriation of Property · ID 24020414015Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/28/24, resident (B)’s family member alleged a SIM card was stolen from the resident’s cell phone. The family member contacted the mobile carrier. The facility reported the name provided on the SIM card did not match any employee or agency staff working in the facility. Management was unable to determine what might have happened. No other residents expressed concerns about their belongings. Staff helped the resident keep track of her new phone to ensure it was not missing and functioning properly.
DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 12/19/2024 · released to the public 12/26/2024.
5/22/2024Physical Abuse · ID 24020414014Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 5/22/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. During the course of the investigation, the healthcare entity reported client (A) approached client (B) and swatted at her hand for no reason. Client (B) yelled out for staff help. Staff separated the clients, conducted an assessment, and started frequent safety checks. No visible injury was observed on client (B), and she had no current complaint of pain. Both clients had cognitive impairments and could not participate in a follow up interview about the incident. The facility determined client (A) became confused with client (B)’s movements and struck out. However, as there was no injury, the facility concluded the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/3/2025 · released to the public 3/10/2025.
4/21/2024Physical Abuse · ID 24020414013Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/24/24 resident (A) alleged physical abuse by staff #1 that occurred on 4/21/24. Reportedly, resident (A) said staff #1 had grabbed them by both wrists and pushed them back to sitting on their bed. Resident (A) was assessed and no injuries or concerns were found. Resident (A) said they were upset with the treatment by staff #1. The record review showed resident (A) had recent back surgery and s/he was sent out to the hospital for an unrelated change of condition. The facility’s investigation showed through staff interviews the resident had a fall on the date of the event and they had encouraged him not to attempt to walk alone. The facility concluded that resident (A) had fallen and was experiencing pain and likely misinterpreted the interaction of staff #1 in keeping them from falling again. The facility unsubstantiated the allegation of physical abuse. Staff will provide care in teams of two and the resident’s care plan will be updated to include preferences upon their return.
DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 1/27/2025 · released to the public 2/3/2025.
3/29/2024Physical Abuse · ID 24020414008Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS: On 3/29/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported an alleged physical abuse event involving two clients. During the course of the investigation, the healthcare entity reported client (A) entered client (B)’s room uninvited. Client (B) yelled for help when client (A) grabbed client (B)’s arm causing a skin tear. Staff separated the clients, provided first aid treatment, and started frequent safety checks. A stop sign was placed across client (B)’s doorway to deter others from entering and staff monitored client (A)’s wandering. Although the event happened, the facility concluded the allegation of abuse event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 2/12/2025 · released to the public 2/19/2025.
3/2/2024Neglect · ID 24020414005Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The agency/facility's response to this occurrence violated licensing standards by failing to report the occurrence within the required timeframes.
Publication
Sent to facility 5/12/2025 · released to the public 5/19/2025.
12/26/2023Physical Abuse · ID 23020414023Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/26/23, staff observed resident (B) lying on the floor in another resident’s room. She complained of hip pain. Resident (B) alleged she had been pushed by resident (A). Resident (A) denied pushing resident (B) and alleged she was pushed by resident (B). Staff separated the residents and followed the post fall protocol with resident (B). Safety checks were implemented. X-ray results showed resident (B) suffered a right hip fracture. She was transferred to the hospital for treatment and admitted. The facility was unable to determine the cause of the fall due to conflicting resident statements. Resident (B) wandered into resident (A)'s room. Resident (A) was educated and encouraged to call for staff assistance with any resident situation. When resident (B) returned, staff planned to reassess her safety needs.
DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 11/25/2024 · released to the public 12/2/2024.
12/21/2023Misappropriation of Property · ID 23020414022Reported on time: Yes▼
Occurrence summary
Summary of Findings:On 12/21/23, while resident (B) was in the hospital, he asked a family member to pick up his money. Reportedly, the family was unable to locate the $3500. Resident (B) stated he last saw the money on day of discharge to the hospital, which occurred on 12/11/23. However, the facility his story changed about where he was storing the money. The money had not been secured in the room. Management searched the room and no money was found. The facility was unable to determine if the resident had that amount of money in the facility or determine what might have happened. Lock boxes were available for resident use along with a locked drawer. In addition, residents can store money in a resident fund account. A lock box was offered. Department Findings:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 11/20/2024 · released to the public 11/27/2024.
10/19/2023Physical Abuse · ID 23020414018Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 10/19/23, Resident A in her 100’s left her room and propelled herself towards Resident B in her 80’s who was seated in her chair in the dining room. Resident A attempted to talk to Resident B, but Resident B turned her body away and waved her hand dismissively. Resident A yelled at Resident B and then grabbed her right upper arm. Resident B suffered a superficial scratch and redness.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified police, family/guardians, ombudsman, physician and adult protective services. The residents were separated and placed on fifteen minute checks. Resident B was assessed by a facility registered nurse and no additional treatment was provided. Resident B did not recall the incident but stated she was grabbed, it did not hurt and she was unsure of how it happened. Resident B then stated it may have been caused by different residents in different neighborhoods in the facility. The resident was not fearful. Resident A did not recall the incident. Staff #1 stated she witnessed the incident but was unable to reach them in time. Staff #1 stated both residents appeared fine following the incident and expressed no pain or fear. From the investigation, the facility unsubstantiated an allegation of Resident A physically abusing Resident B. To help prevent a recurrence, the facility updated the care plan and educated staff to encourage and assist Resident A to walk away from another resident to prevent misunderstandings in communication. The facility updated the care plan and educated staff to encourage and assist Resident B with communication with another resident to help prevent misunderstandings in communication.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The occurrence report indicated the facility/agency acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 12/28/2023 · released to the public 1/4/2024.
9/20/2023Physical Abuse · ID 23020414017Reported on time: No▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 9/22/23, the facility submitted a report of an alleged abuse incident occurring back on 9/20/23. Staff heard resident (B), in her 90s, yelling from her room. Staff entered the room to find her on the ground near the foot of her bed. A second resident (A), in her 80s, was observed standing near the head of resident (B)’s bed. Resident (B) alleged resident (A) hit her and pushed her, which caused her to fall.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, physician, Adult Protective Services, families/guardians and ombudsman. Staff removed resident (A) from the room and provided direct monitoring. A nurse assessed resident (B) and found no visible injuries. She had no current complaint of pain. Post fall monitoring remained in place. Resident (A) had a history of wandering into other resident rooms. Staff said she often thought she was the caretaker for other residents and made attempts to help them. She could be aggressive towards other residents at times. With resident (A)’s cognitive impairment, she was not able to participate in a follow up interview about the incident. From the findings, the facility was unable to determine what truly happened in the room. The fall could have been a result of being pushed or it was possible she tripped. Staff noted one of the chairs had been moved from its original location, which could have been a factor in her fall. Modifications were made to the room to help prevent movement of chairs. A stop sign was added to resident (B)’s door to help deter others from entering the room without permission. Staff continued monitoring and redirecting the residents per their individualized plans of care.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The agency/facility's response to this occurrence violated licensing standards by failing to report the occurrence within the required timeframes.
Publication
Sent to facility 11/27/2023 · released to the public 12/4/2023.
7/1/2023Neglect · ID 23020414013Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 7/3/23, a staff member made an allegation of staff neglect involving nurse (1)’s care of a resident post fall. The staff member alleged nurse (1) did not complete a post fall assessment. The resident, in her 80s, rolled out of bed onto her floormat. She had a severe cognitive impairment. The fall occurred on 7/1/23 in the early morning hours.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. Nurse (1) was suspended pending investigation. On 7/3/23, a new nursing head to toe assessment was completed. This nurse noted the resident was found to be at baseline with no complaints of pain, and a small scrape was noted over her left eye. A nurse manager reviewed nursing notes that showed a nursing entry (nurse 1) reporting a fall out of bed with no injury. Four hours later, staff observed an abrasion on the resident’s head. Nurse (1) assessed the resident again and noted no other issues. Nurse (1) reported s/he was under the assumption the fall was witnessed when actually it was an unwitnessed fall. This was the reason the neurological checks had not been started per a certain policy. Once staff noticed the hematoma on her forehead later that morning, neurological checks were started. After her fall, a second mattress was placed by the bed for additional safety measures. Statements from staff members indicated no instances of neglect. Staff working at the time stated that they witnessed nurse (1) complete an assessment and s/he directed them to complete vital signs post fall. The resident had a cognitive impairment and was unable to participate in a follow up interview. From the findings, the facility was unable to substantiate a claim of staff neglect. Nurse (1) had been misinformed about the circumstances of the fall but an assessment occurred.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 11/20/2023 · released to the public 11/27/2023.
7/1/2023Missing Person · ID 23020414012Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 7/1/23 at 1:45 a.m., a staff member observed a resident, in her 80s, ambulating in the parking lot. She left the facility without staff awareness. Staff helped the resident return. She had a severe cognitive impairment and was identified to be at-risk to self.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, family/guardian, physician, and ombudsman. A nurse assessed the resident and no adverse outcomes were noted. The nurse indicated there were no changes to the resident's cognitive baseline. She was unable to state what prompted her to leave. Fifteen-minute safety checks were started. Staff reported last checking on the resident in bed one hour earlier. Staff checked exit doors and found one door on the unit had malfunctioned. The locking feature was not receiving power. Staff initiated direct monitoring of the exit door until the power was restored. From the findings, the resident eloped without staff awareness when a secured exit door malfunctioned. The resident’s care plan was updated to reflect a risk of elopement. Safety checks remained in place.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 9/25/2023 · released to the public 10/2/2023.
4/13/2023Misappropriation of Property · ID 23020414005Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 4/14/23, the facility became aware of an allegation of financial exploitation involving a family member and one resident, who was in his 80s. The resident was identified as an at-risk adult with a noted severe cognitive impairment. An unauthorized transaction occurred from the resident’s bank account on 4/23/23. A safety plan was put in place to deny this particular family member entry into the building during the investigation.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, family/guardian, ombudsman, and Adult Protective Services. A family member that was not identified to be the resident’s financial power of attorney took the resident to the bank. A transaction in the amount $2800 was withdrawn from the resident’s account, which closed the account. The money was then deposited into the family member’s account. The resident said he was under the impression of withdrawing $100 with the intention of going to lunch with family. The bank was made aware of the unauthorized transaction to assist in the matter of reversing the fund transaction. An outside investigation was ongoing with the appropriate authorities regarding the allegation of misappropriation of property and financial exploitation. Staff continued monitoring visitors and now only authorized persons could take the resident out of the facility.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 6/12/2023 · released to the public 6/19/2023.
3/31/2023Physical Abuse · ID 23020414004Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 3/31/23, there was a report of a physical altercation between two female residents, whom resided in the memory care unit. Review of video footage showed resident (A), in her 80s, entering a common area and starting a verbal argument with resident (B), in her 80s, without an apparent root cause or instigation. The verbal argument turned into a physical altercation of the residents striking one another. Staff intervened and separated the residents. Resident (B) complained of pain and suffered several injuries.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. A nurse assessed both residents. Resident (B) suffered several small bruises on one arm and facial red marks with slight swelling. First aid treatment was provided. Resident (A) did not suffer any injuries. Resident (A) told staff that when she exited her room, resident (B) started screaming and hollering at her first. She then reported resident (B) grabbed her first. However, camera footage showed resident (A) instigated the physical altercation for an unknown reason. A medication review occurred for resident (A) due to her agitation, and her medications were increased to help with behavioral management. Staff continued monitoring the residents through frequent checks.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 11/14/2023 · released to the public 11/14/2023.
2/26/2023Physical Abuse · ID 23020414001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 2/26/23, there was a report of a resident dispute in the memory care unit. Resident (B), in her 70s, attempted to enter resident (A)’s room and resident (A), in her 80s, started yelling at resident (B). As staff approached to separate the residents, resident (B) grabbed resident (A)’s arm. In response, resident (A) swung at resident (B)’s face. Staff successfully separated them at this point.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. Frequent safety checks were started. A nurse assessed resident (B) and observed a small abrasion to her left cheek/upper mouth. First aid treatment was provided. She denied having any current pain. Resident (B) appeared confused about what happened and thought it was a man that hit her. Resident (A) could not recall the specifics of what happened except for saying people tried to enter her room. Video footage showed the incident happened as described. The facility substantiated the allegation of resident (A) hitting resident (B) after she attempted to enter her room without permission. A stop sign was placed across resident (A)’s doorway to deter others from entering her room. Staff was tasked to continue monitoring the residents per their individualized plans of care. In addition, the facility was looking for an alternative placement for resident (A).
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 9/18/2023 · released to the public 9/25/2023.