OAKWOOD CARE AND REHABILITATION

A complaint survey, prompted by #CO1914269 was conducted on 7/14/25. No deficiencies were cited.

A revisit survey was completed on 7/14/25 for all previous deficiencies cited on 6/12/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO39997, #CO40188, #CO40268, #CO40293 was conducted on 6/10/25 to 6/12/25. Three deficiences were cited.

Based on observations and interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, the facility failed to maintain residents' dignity and ensure residents were provided equal access to incontinence care supplies. Findings include:I. Resident interviewsResident #1 was interviewed on 6/11/25 at 3:15 p.m. Resident #1 said he did not have briefs for four days because the facility ran out of briefs. Resident #1 said he asked a nurse manager what to use for briefs if the facility ran out and the nurse manager told him to use a towel instead. Resident #1 said he was not sure what the facility meant by using a towel but there were no briefs available. Resident #1 said the issue started on a Friday and the new briefs were delivered on a Tuesday. Resident #9 was interviewed on 6/12/25 at 9:45 a.m. Resident #9 said a certified nurse aide (CNA) told him the facility did not order briefs. Resident #9 said he only had one pair of briefs left and the facility finally got more briefs in. Resident #9 said the facility was out of briefs at the end of May 2025. Resident #1 was interviewed a second time on 6/12/25 at 10:15 a.m. Resident #1 said the staff told him they were out of briefs and the staff told him the director of nursing (DON) told the facility not to order facility supplies because it was the end of the month. Resident #10 was interviewed on 6/12/ 25 at 10:25 a.m. Resident #10 said he decided to wait to have his brief changed one night because he thought he would run out of briefs in the beginning of June 2025 because he had one brief remaining and he thought the facility was going to run out of briefs again later in the month. Resident #10 said his briefs were wet when he waited to have his briefs changed but it was only for six to seven hours. Resident #10 said when he did not have his briefs changed he did not feel discomfort because he was paraplegic. Resident #10 said he did not like to sit in his briefs too long because he did not want any open sores. Resident #10 said he could not remember who told him the facility was out of briefs but thought it was a CNA. Resident #10 said he was told by a staff member running low on briefs was a money issue and that the facility wanted to order the briefs after the first of the following month. Resident #11 was interviewed on 6/12/25 at 10:37 a.m. Resident #11 said the facility ran out of briefs at the beginning of June 2025 and staff had to use a pull-up garment for him instead. Resident #11 said the pull-up garment leaked into his bed but he did get his wet sheets changed by staff. Resident #11 said he used briefs and needed staff assistance to change his briefs. Resident #12 was interviewed on 6/12/25 at 2:13 p.m. Resident #12 said the facility was constantly running out of necessary supplies the residents needed. Resident #12 said a staff member brought him a package of incorrectly sized incontinence briefs earlier in the day (see observation below). Resident #12 said he normally wore size three extra large (3XL) briefs and the staff member brought him size two extra large (2XL). Resident #12 said the staff member performed incontinence care on him and changed him into the 2XL briefs. Resident #12 said the staff member returned to his room a short while after, with a package of 3XL briefs, and told the resident that the central supply area was full of supplies on 6/11/25 and most of them were gone by 6/12/25. An open package of 2XL briefs and a closed package of 3XL briefs were observed next to Resident #12's bed during the interview. II. Observation On 6/12/25 at 10:28 a.m. an unidentified staff member walked into Resident #12's room. The staff member was holding a package of incontinence briefs. The staff member was heard telling Resident #12 she could not find his size of briefs. The unidentified staff member asked Resident#12 if the smaller size would work and the resident replied that he guessed so. III. Grievance formsFacility grievances were provided by the DON on 6/12/25 at 9:00 a.m. A grievance, dated 6/2/25, documented Resident #1 was concerned he ran out of supplies and only had one brief left and that a night shift CNA told him he was out (of briefs). IV. Staff interviewsA staff member, who wished to remain anonymous, was interviewed on 6/12/25 at 3:10 p.m. The staff member said the facility ran out of briefs at the end of May 2025/beginning of June 2025 and there were pull-up garments available, but the supply of pull-up garments was limited. The staff member said some residents were unable to wear a pull-up garment and briefs were not an option for them based on their build. The staff member said the staff took briefs from residents' rooms to use for other residents. The staff member said a nurse manager instructed the staff to put towels under the residents if the facility ran out of briefs. The staff member said a resident expressed his concerns about the limited supply of briefs to the nurse manager and the nurse manager told the resident to just use towels. A second staff member, who wished to remain anonymous was interviewed on 6/12/25 at 3:13 p.m. The second staff member said the facility ran out of briefs. The second staff member said most of the residents who were offered pull-up garments instead of briefs did not want pull-up garments and some residents did not fit in the pull-up garments. The second staff member said one resident declined to take his medicine and to have his briefs changed because he did not want to go to the bathroom in his briefs. The second staff member said a central supply staff member told the staff that the DON instructed the central supply staff member not to order supplies because the facility was over budget and the facility would probably run out of briefs. A third staff member, who wished to remain anonymous, was interviewed on 6/12/25 at 3:18 p.m. The third staff member said each unit had its own storage closet for supplies and staff would go to the central supply area or other units in the facility if the storage closet on a particular unit was out. The third staff member said they were told by another staff member that on 5/31/25, a member of management told staff to use towels as incontinence briefs for the residents. The third staff member said the staff all had an understanding that there was a lack of resident care supplies in the facility. The third staff member said they felt frustrated and hurt by not having adequate resources necessary for resident care. The nursing home administrator (NHA) and the DON were interviewed together on 6/12/25 at 4:00 p.m. The DON and the NHA said they were not aware of a member of the management telling staff to use towels underneath residents for briefs. The DON said it was not appropriate for staff to be told to use towels instead of incontinence briefs. The NHA said the facility did not run out of briefs for the residents. The DON said she did not instruct the central supply staff not to order supplies, but to order the supplies if needed.

Based on record review and interviews, the facility failed to ensure that the transfer or discharge was documented accurately in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for one (#2) of three residents reviewed for discharge out of 12 sample residents. Specifically, for Resident #2, the facility failed to:-Ensure the resident's discharge summary included the resident's need for two transfer poles; -Ensure the resident's discharge care plan included the resident's medical equipment needs, specifically the two transfer poles-Document communication and responses from the referral sources to confirm the resident's discharge needs; and,-Ensure the resident's discharge date documented in the physician's orders was accurate and the physician's order was obtained timely. Findings include:I. Resident #2A. Resident statusResident #2, age 66, was admitted on 1/24/23 and discharged to home on 5/21/25. According to the June 2025 computerized physician orders (CPO), diagnoses included cervical spinal stenosis (narrowing of the spinal canal in the neck), paroxysmal atrial fibrillation (irregular heart beat), need for assistance with personal care, mixed incontinence, unilateral primary osteoarthritis of unspecified hip (one-sided hip joint condition) and unsteadiness on feet. The 5/21/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required partial assistance with toileting hygiene, bed mobility and transfers. He was dependent on staff for shower/tub transfers. He independently used a motorized wheelchair for locomotion. The MDS assessment documented Resident #2 was discharged from the facility, as planned, on 5/21/25 through a local contact agency. B. Resident interviewResident #2 was interviewed via phone on 6/11/25 at 1:16 p.m. Resident #2 said his apartment was incorrectly set up and his medical equipment was just beginning to be set up. Resident #2 said he was supposed to have two transfer poles in his apartment; one in his bedroom and one in his bathroom. Resident #2 said the transfer pole in his bedroom was not set up in the correct spot and a transfer pole had yet to be installed in his bathroom. During the interview with Resident #2, the resident handed the phone to the transition services agent to answer questions (see interview below). C. Record review A review of the 4/24/25 occupational therapy (OT) and physical therapy (PT) notes documented Resident #2 was waiting for approval for a home visit to install vertical transfer poles for a safe discharge to his community apartment. The nursing discharge summary, dated 5/21/25 at 7:55 a.m., documented Resident #2 had completed therapy services and obtained the highest practical level in a long-term care setting. It documented Resident #2 would require assistance with toileting, bathing and functional transfers upon discharge to the community. It documented Resident #2 was independent with mobility once he was transferred to his power wheelchair. It documented home health nursing and therapy services were arranged to assist Resident #2's transition back to the community. It documented Resident #2 had physician's orders for a specialty bed and mattress and a shower chair with wheels for use at home. -Review of Resident #2's discharge summary revealed there was no documentation regarding the resident's need to have two transfer poles set up in his apartment. The discharge care plan, initiated 2/29/24 and revised 2/10/25, documented Resident #2 intended to be discharged back to the community through a local contact agency. Interventions included reviewing the resident's discharge care plan quarterly and as needed, preparing and providing Resident #2 with contact numbers for all community referrals and staff providing the resident with any needed support. -Review of the discharge care plan revealed there was no documentation addressing Resident #2's specific durable medical equipment needs for a safe discharge, including his need for two transfer poles. Review of Resident #2's May 2025 CPO revealed the following physician's order:Resident to discharge from [facility] to [apartment] on 5/22/25. Resident to discharge with all medications needed, ordered 5/23/25. -The physician's order incorrectly listed Resident #2's date of discharge as 5/22/25, instead of 5/21/25. -Additionally, the physician's order was not obtained until two days after Resident #2 was discharged home from the facility (on 5/21/25). On 6/11/25 at approximately 3:00 p.m., a purchase order for two transfer poles was provided by the SSD. The purchase order indicated the order was placed on 4/8/25 and had not yet shipped. The purchase order was signed by Resident #2, but was not dated as to when the resident signed it. II. Staff interviewsThe social services director (SSD) was interviewed on 6/10/25 at 3:30 p.m. The SSD said the social services assistant (SSA) confirmed with the home health agency over the phone, on 5/20/25, that they had approved home health services for Resident #2. The SSD said the home health agency confirmed Resident #2 would be seen the day following his discharge from the facility on 5/21/25. The SSD said his understanding was that the resident's equipment in his apartment had been set up and the resident's care was successfully transitioned to the home health agency after his discharge from the facility. The director of rehabilitation (DOR) was interviewed on 6/11/25 at 11:27 a.m. The DOR said Resident #2 was assessed prior to his discharge from the facility for a bed to chair transfer with a transfer pole because that was the equipment the resident was going to use at home. The DOR said the transitions services team said Resident #2 would have a transfer pole in his bathroom at his new apartment. The SSA was interviewed on 6/11/25 at 12:07 p.m. The SSA said she spoke to the home health agency contact on 5/20/25 and she said the home health agency confirmed services for Resident #2 that would start on 5/22/25. The SSA said she did not document the conversation in which the home health agency confirmed they would be assuming care for the resident. The SSA said she verbally confirmed with the transition services team on 5/20/25 that Resident #2's two transfer poles were installed at his apartment.-However, only one transfer pole was installed at Resident #2's apartment (see interview below). The transition services agent was interviewed via phone on 6/11/25 at 1:16 p.m. The transition services agent said Resident #2 needed assistance transferring from his bed to his motorized wheelchair. The transition services agent said Resident #2 had one transfer pole installed in his bedroom. The transition services agent said the second transfer pole for Resident #2's bathroom had not been installed yet, but he said he would install the transfer pole in Resident #2's bathroom while he was there (on 6/11/25). The transition services supervisor was interviewed on 6/11/25 at 1:50 p.m. The transition services supervisor said the facility ordered the equipment based on the medical needs of the resident. The transition services supervisor said he knew there was one transfer pole for Resident #2 provided by the facility. The transition services supervisor said the facility did not give the transition team an inventory of the resident's equipment, but during the discharge meeting, via the phone on 5/20/25, the equipment Resident #2 required at discharge had been reviewed. The transition services supervisor was interviewed again on 6/11/25 at 5:45 p.m. The transition services supervisor said a second transfer pole was found in a box at Resident #2's apartment (on 6/11/25) and was going to be installed. The SSD was interviewed a second time on 6/12/25 at 3:37 p.m. The SSD said Resident #2's discharge date was verbalized over the phone to the home health agency but it was not documented in the resident's record.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#9) of five residents reviewed for medications errors out of 12 sample residents. Specifically the facility failed to ensure Resident #9 was administered Farxiga (for chronic kidney disease and diabetes mellitus type 2) per physician's orders. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.sevier, St. Louis Missouri, pp. 606-607, "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. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on 8/12/24. According to the June 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, congestive heart failure, ischemic cardiomyopathy (narrowed arteries reducing blood flow) and chronic kidney disease. The 5/22/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required set up or clean up assistance with his activities of daily living (ADL) and supervision while bathing. B. Resident interviewResident #9 was interviewed on 6/12/25 at 9:45 a.m. Resident #9 said the facility ran out of his medications frequently. He said the facility ran out of two of his medications in May 2025 and he was told a nurse forgot to order the medications. C. Record reviewA review of Resident #9's June 2025 CPO revealed the resident had physician's orders for the following medication:Farxiga oral tablet (dapagliflozin propanediol) 5 milligrams (mg), give two tablets by mouth one time a day for chronic kidney disease and diabetes mellitus type 2, ordered 5/13/25. Resident #9's May 2025 medication administration record (MAR) revealed the resident did not receive the Farxiga as ordered on 5/17/25, 5/18/25 and 5/19/25. A 5/17/2025 at 7:27 a.m. medication administration note documented Resident #9's Farxiga was not administered and the facility was awaiting delivery of the medication from the pharmacy. A 5/18/25 at 9:27 a.m. medication administration note documented to administer Farxiga 5 mg; give two tablets by mouth one time a day for chronic kidney disease and diabetes mellitus type 2.-The note did not indicate why the resident's Farxiga medication was not administered. A 5/19/25 at 11:40 a.m. medication administration note documented to administer Farxiga 5 mg; give two tablets by mouth one time a day for chronic kidney disease and diabetes mellitus type 2 and the medication was on order.-However, there were no progress notes documented to indicate the pharmacy or the physician had been contacted or notified that Resident #9's Farxiga medication was not available and had not been administered to the resident on 5/17/25, 5/18/25 and 5/19/25. III. Staff interviewsThe consultant pharmacist was interviewed on 6/12/25 at 1:48 p.m. The consultant pharmacist said Farxiga was approved for coronary heart failure and studies had shown that it reduced mortality in residents with heart failure. She said the medication was also approved for use with chronic kidney disease. The consultant pharmacist said if the facility were out of a medication, the facility would not contact the pharmacist but should instead contact the pharmacy and could also contact the resident's physician. Licensed practical nurse (LPN) #1 was interviewed on 6/12/25 at 2:58 p.m. LPN #1 said she had had to call the pharmacy after the facility had ordered a medication and sometimes the facility had to order the medication a second time. LPN #1 said she usually documented when she called the pharmacy. LPN #1 said the facility could order medications electronically, and if a medication had to be ordered a second time, she would call the pharmacy for follow up. LPN #1 said if a medication was not available to administer, staff had to notify the physician. The clinical nurse consultant (CNC) was interviewed on 6/12/25 at 4:30 p.m. The CNC said she checked Resident #9's Farxiga medication order and the physician had ordered the medication on 5/13/25. She said the medication showed on the resident's profile but the medication was not filled by the pharmacy. She said the facility reordered the medication on 5/18/25 and it was delivered to the facility on 5/18/25. She said she was not sure why the medication was not administered on 5/19/25. IV. Facility follow-upA provider education document, dated 6/13/25, was provided by the NHA on 6/13/25 at 3:20 p.m., after the survey exit The provider education documented the physician sent an electronic prescription for Resident #9's Farxiga medication to the pharmacy on 5/13/25 and indicated the prescription was for the resident's profile only. Therefore, the pharmacy added the medication to the resident's medication list but did not fill the prescription. The physician was counseled on ensuring that the profile only was not marked on the electronic prescription submission.

A complaint survey, prompted by #CO39635 and Incident #39778 was conducted on 4/17/25. No deficiencies were cited.

A revisit survey was completed on 3/20/25 for all previous deficiencies cited on 1/29/25.. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 3/20/25 for all previous deficiencies cited on 1/29/25.. The facility is in compliance with all regulations surveyed.

A survey prompted by complaint #CO39208 was completed on 1/27/25 to 1/29/25. One deficiency was cited.

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

A complaint survey, prompted by #CO38215, #CO38361, #CO38699, #CO38841, #CO39028, Incident #38650, Incident #38959 and Incident #39031, was conducted 1/27/25 to 1/29/25. Six deficiencies were cited.

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

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification agency in accordance with state law for two (#2 and #24) of 11 residents reviewed for abuse out of 28 sample residents. Specifically, the facility failed to report incidents of potential verbal and physical abuse involving Resident #2 and Resident #24 to the State Survey Agency (SSA). Findings include:I. Facility policy and procedureThe Abuse Prevention and Reporting-Guideline policy, revised August 2021, was provided by the nursing home administrator (NHA) on 1/27/25 at 11:49 a.m. It read in pertinent part, "It is the policy of this facility that all allegations of abuse are investigated. Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect and exploitation. Verbal abuse is any use of oral, written or gestured language that includes knowingly threatening a resident causing fear or imminent, serious bodily injury within hearing distance, to described residents, regardless of their age, ability or disability to comprehend. Physical abuse is the intentional action of inflicting bodily injury including, but not limited to hitting, slapping, pinching, kitchen, etc. It also includes unreasonable confinement, restraint, and bruises of unknown origin. The administrator or designee will complete the investigation and will notify the suspected assailant and victim or responsible party of the conclusions and any corrective actions implemented based on investigative findings."II. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 7/16/24 and discharged on 1/19/25 to the hospital. According to the January 2025 computerized physician orders (CPO), diagnoses included cerebral palsy (disease that affects movement and muscle tone), acute respiratory failure, dementia with behavioral disturbance, violent behavior, depression, need for assistance with personal care and cognitive communication deficit. The 1/24/25 minimum data set (MDS) assessment revealed the resident was moderately impaired regarding tasks of daily life and cues and supervision were required per staff assessment. A review of the residents electronic medical record (EMR) documented on 10/22/24 the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of six out of 15. The assessment documented Resident #2 needed substantial to maximum assistance with oral hygiene, bathing, dressing, and bed mobility. He needed set up assistance with eating. The MDS assessment documented the resident had physical and verbal behaviors directed at others. B. Record reviewA review of Resident #2's electronic medical record (see below) and interviews with the interdisciplinary team (IDT) revealed facility staff incorrectly documented resident to resident altercations involving Resident #2 or failed to report the incidents to the facility abuse coordinator according to the interventions on Resident #2's care plan. These incidents occurred from 7/19/24 until 10/11/24, prior to Resident #2's altercations on 11/3/24 with Resident #8 and 1/19/25 with Resident #1. Resident #2's focused care plan for verbally aggressive behaviors related to dementia, initiated 9/5/24 and revised 11/9/24, documented Resident #2 acted in a playful way toward other residents which could be misconstrued. Pertinent interventions included to document the resident's behavior and attempted interventions (initiated 9/6/24 and revised 11/9/24), and analyze key times, places, circumstances, triggers and what de-escalated the resident's behavior and document; the resident responded to verbal interventions from staff, was placed in a private room (with no roommate) and had potential for unprovoked aggression towards others.-The playful behaviors, which could be misconstrued, were not specified or documented. Resident #2's focused care plan for physical behaviors, initiated 11/4/24, documented he had the potential to demonstrate physical behaviors related to dementia, had exhibited aggression toward staff and other residents and was placed in a private room (with no roommate). Pertinent interventions initiated 11/4/24 included to document observed behavior and attempted interventions, monitor, document and report to the physician if the resident was a danger to himself and others, and analyze key times, places, circumstances, triggers and what de-escalated the behaviors and document the findingsA review of Resident #2's EMR revealed the following documented incidents:On 7/18/24 a nursing progress note, written at 3:55 p.m., documented Resident #2 approached multiple residents screaming and cursing at them for no reason. Staff directed Resident #2 away from other residents. The assistant director of nursing (ADON) and on-call provider were notified.-The facility was unable to provide documentation that the incident had been investigated for potential abuse or that the incident of potential abuse was reported to the State Agency. On 7/19/24 at a nursing progress note written at 5:01 a.m. documented Resident #2 was extremely aggressive and agitated throughout the shift and was calling residents names using explicit language and overall disrupting the "normal" nightly routines. Other residents were fearful of Resident #2 during this shift. Resident #2 began stalking residents and trying to physically trip other residents with his feet. A non-emergent message was left with the director of nursing (DON).-The facility was unable to provide documentation that the incident had been investigated for potential abuse or that the incident of potential abuse was reported to the State Agency. On 7/19/24 a nursing progress note, written at 6:01 p.m., documented Resident #2 was extremely agitated throughout the shift and using profanity. Resident #2 began following other residents and trying to trip them with his feet but did not make contact and was more than ten feet away from the other residents.-The facility was unable to provide documentation that the incident had been investigated for potential abuse or that the incident of potential abuse was reported to the State Agency. On 8/13/24 a nursing progress note, written at 2:27 a.m., documented Resident #2 continued to wander on the secure memory care unit needing one-to-one facility staff care due to increased aggressive behavior and attempting to go in and out of other residents' rooms. After Resident #2 was redirected away from residents' rooms, Resident #2 held a closed fist up to the staff and was swinging and yelling profanities. Several residents got up and returned to their room as they appeared afraid. Reassurance was given to those residents redirected by staff back to their room. Resident #2 continued on one-to-one monitoring for resident safety. The facility placed a call to the provider to send the resident to the emergency department (ED) for evaluation and the ADON was notified. On 8/13/24 at 6:31 p.m. the DON documented a clarification note indicating the DON followed up and the resident was not yelling at any specific residents but residents were redirected into their rooms related to loud noise from Resident #2.-The facility was unable to provide documentation that the potential abuse was reported to the State Agency. On 10/10/24 a nursing progress note, written at 11:47 a.m., documented Resident #2 was screaming at another resident in the hallway. Staff intervened and separated both residents safely. The resident was redirectable and went to participate in activities.-The facility was unable to provide documentation that the incident had been investigated for potential abuse or that the incident of potential abuse was reported to the State Agency. On 10/11/24 a nursing progress note, written at 5:53 a.m., documented Resident #2 continued to scream at a resident and staff and needed to be redirected multiple times. The nurse continued to monitor the resident's behaviors.-The facility was unable to provide documentation that the incident had been investigated for potential abuse or that the incident of potential abuse was reported to the State Agency. III. Resident #24A. Resident statusResident #24, age greater than 65, was admitted on 8/13/24. According to the January 2025 CPO, diagnoses included dementia without behavioral disturbance, high blood pressure, muscle weakness and unsteadiness on his feet. The 11/20/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of two out of 15. Resident #24 required substantial to maximal assistance with bathing, dressing and personal hygiene. He needed set up assistance for meals and was independent with walking up to 150 feet. The MDS assessment documented Resident #24 wandered and the behavior occurred on one to three days during the review period. B. Record reviewResident #24's elopement care plan, initiated 8/16/24, documented he exhibited wandering behavior and resided in the secure unit of the facility due to exit seeking behavior. Pertinent interventions included to document wandering behavior and attempted diversional interventions. Resident #24's self care performance care plan, initiated 8/13/24, documented an activities of daily living (ADL) performance deficit related to his diagnoses of dementia, hyperlipidemia and high blood pressure. Pertinent interventions initiated 8/14/24 included that the resident required one to two staff members for transfers, toileting, repositioning and turning in bed. C. Incident involving Resident #24 and Resident #2 on 12/11/24A review of Resident #2's EMR documented in a behavior note on 12/11/24 at 5:00 a.m. that at approximately 7:00 p.m. on 12/10/24 staff heard a whimpering noise and a male voice call out saying "Get out of here." The staff approached Resident #2's room and observed Resident #2 standing over Resident #24 laying on a metal box spring bedframe in a fetal position. Resident #24 was observed with visible fresh blood from his left eye area/eyebrow, as well as a skin tear to the top of his left hand. Resident #2 said he did not want this male resident in his room or to get in bed with him, and Resident #24 was assisted to a standing position and assisted back to his room ambulating with his walker. Resident #2 said that he felt bad and was sorry, and that he was a nice person. The ADON was notified who then notified the DON. On 12/11/24 a progress note, written at 10:22 a.m., documented a clarification note which indicated there was no physical altercation between the residents (Residents #2 and Residents #24). On 12/11/24 at 12:26 p.m. a provider documented Resident #2 was seen at the request of nursing staff. Nursing staff reported that on the evening of 12/10/24 another resident (Resident #24) laid in the empty bed in Resident #2's room resulting in a resident to resident altercation. On exam this morning (12/11/24) Resident #2 was found lying in his bed alert, calm, and was in no acute distress. Upon seeing the provider enter the room Resident #2 immediately said "I am not going to hurt anyone anymore" and that he was sorry. A review of Resident #24's EMR revealed a provider note on 12/11/24 at 12:27 p.m. documented Resident #24 was seen by the provider at the request of nursing and as a follow up to a resident to resident altercation in which Resident #24 was the victim. A laceration was noted over Resident #24's left eyebrow and left hand of the resident. Emergency medical services was called with concern that Resident #24 needed sutures. Paramedics attended to small lacerations and did not feel hospital transfer was necessary at that time. During the exam on 12/11/24, Resident #24 was found lying in his bed alert, calm, in no acute distress with a social smile. Resident #24 reported chronic back pain but otherwise denied pain and was able to verbalize he was "hurt by someone" but denied being afraid. The resident had a small linear scabbed laceration noted over his left eyebrow and a linear scabbed laceration to his left hand with steri-strips in place.-The facility was unable to provide documentation that the incident of potential abuse was reported to the State Agency, and interviews revealed the facility documented the incident as a fall by Resident #24 (see interviews below). IV. Staff interviewsThe DON and the NHA were interviewed together on 1/29/25 at 11:00 a.m. The DON said the 24-hour nursing report was reviewed daily in the morning meeting. The DON said a note in a resident's EMR could be marked, by the writer, to enable the note to be viewed in the 24-hour report. The DON said the some of the documented incidents in Resident #2's EMR might not have been checked to show in the 24-hour report, making it more difficult to see and review them, so incorrectly documented notes were not followed up on. The NHA and the DON said that incidents on 7/18/24 and 7/19/24 in Resident #2's EMR (see above) should have been reported to the abuse coordinator and the State Agency. The NHA and the DON said they did not see the notes documented on 7/18/24 and 7/19/24. The DON and the NHA said the documented incident on 10/11/24 in Resident #2's EMR should have been reported to the State Agency. The NHA said the facility did not shy away from reporting to the appropriate agencies. The NHA said the facility documented the incident on 12/22/24 between Resident #2 and Resident #24 as a fall because during their investigation, Resident #24 stated he fell. The NHA said Resident #24 was interviewed about the incident in the presence of Resident #2. The NHA said Resident #2 was always truthful about his behavior. The NHA said both residents (#2 and #24) said there was no physical contact and the facility did not have reason to doubt that or they would have reported it. The DON said that Resident #2 had been truthful in the past when he had an altercation with another resident and they believed Resident #2 to be truthful about the incident on 12/11/24.-However, based on the provider documentation, Resident #24 stated post incident on 12/11/24 he was hurt by someone, and Resident #2 said he was not going to hurt anyone anymore and he was sorry. The DON said she was not aware the provider documented on 12/11/24 that Resident #24 had told the provider someone hurt him until 12/16/24. The DON said she did not know why the provider who documented Resident #24's statement on 12/11/24 did not immediately report to the facility. The DON said she asked that the provider's documentation be amended based on the facility's investigation revealing Resident #24 had a fall. The DON said when an agency staff member worked at the facility, the facility staffing coordinator provided the agency staff member information that included the DON's and the NHA's phone numbers. The DON said the facility was working on assembling an information and orientation packet for agency staff that included what incidents to report and whom to report to. The DON said the facility identified agency staff were working when Resident #2's behaviors were not accurately documented or reported. The regional clinical resource (RCR) was interviewed on 1/29/25 at 3:00 p.m. The RCR said after reviewing the documentation in Resident #2's record, the facility recognized the documentation errors in the resident's EMR primarily originated from agency staff. She said after the incident on 1/19/25, the facility implemented a plan to only schedule facility staff in the secured unit (where Residents #1, #2 and #8 resided) instead of agency staff. The RCR said facility staff knew the residents better, could better anticipate a resident's needs and recognize if a resident's behavior began to change and intervene before the behavior escalated.

Based on record review and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#2) of five residents reviewed for mood and behavior out of 28 sample residents. Specifically, the facility failed to a implement person-centered care plan upon admission to address Resident #2's history of physical aggression towards others in order to prevent physical altercations with other residents. Findings include:I. Resident statusResident #2, age greater than 65, was admitted on 7/16/24 and discharged on 1/19/25 to the hospital. According to the January 2025 computerized physician orders (CPO), diagnoses included cerebral palsy (disease that affects movement and muscle tone), acute respiratory failure, dementia with behavioral disturbance, violent behavior, depression, need for assistance with personal care and cognitive communication deficit. The 1/24/25 minimum data set (MDS) assessment revealed the resident was moderately impaired regarding tasks of daily life and cues and supervision were required per staff assessment. A review of the residents electronic medical record (EMR) documented on 10/22/24 the resident had severe cognitive impairments with a brief interview for mental status score (BIMS) of six out of 15. The 1/24/25 assessment documented Resident #2 needed substantial to maximum assistance with oral hygiene, bathing, dressing, and bed mobility. He needed set up assistance with eating. The MDS assessment documented the resident had physical and verbal behaviors directed at others. II. Record reviewThe 7/17/24 provider note documented in Resident #2's EMR revealed the provider documented that Resident #2 was previously admitted to a hospital in April 2024 after assaulting an individual at a facility and being verbally abusive to the staff prior to admission to the facility on 7/16/24. Resident #2's comprehensive care plan, initiated 7/16/24, documented the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to his dementia diagnosis. Pertinent interventions, initiated 7/16/24, included to monitor, document and report to the physician or a nurse any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing himself, difficulty understanding others, level of consciousness and mental status. -However, the facility did not implement any person centered interventions related to the resident's history of physical and verbal aggressions. Resident #2's focused care plan for verbally aggressive behaviors related to dementia, initiated 9/5/24 and revised 11/9/24, documented Resident #2 acted in a playful way toward other residents which could be misconstrued. Pertinent interventions included to document the resident's behavior and attempted interventions (initiated 9/6/24 and revised 11/9/24), and analyzing key times, places, circumstances, triggers and what de-escalated the resident's behavior and document; document observed behavior and attempted interventions; the resident responded to verbal interventions from staff, was placed in a private room (with no roommate) and had potential for unprovoked aggression towards others.-The playful behaviors which could be misconstrued however were not specified or documented in Resident #2's care plan.-The verbally aggressive behavioral care plan was not implemented until 9/5/24, two months after the resident was admitted to the facility with a history of physical aggression. Resident #2's focused care plan for physical behaviors, initiated 11/4/24, documented he had the potential to demonstrate physical behaviors related to dementia, had exhibited aggression toward staff and other residents and was placed in a private room (with no roommate). Pertinent interventions initiated 11/4/24 included to document observed behavior and attempted interventions, monitor, document and report to the physician if the resident was a danger to himself and others, and analyze key times, places, circumstances, triggers and what de-escalated the behaviors and document the findings.-However, the facility failed to update Resident #2's care plan with effective interventions to prevent resident to resident abuse and behaviors upon his admission to the facility based on his documented history behaviors. Cross-reference F600: failure to prevent abuseIII. Staff interviewsThe director of nursing (DON) and nursing home administrator (NHA) were interviewed together on 1/29/25 at 11:00 a.m. The DON said when an agency staff member worked at the facility, the facility staffing coordinator provided the agency staff member information that included the DON's and the NHA's phone numbers. The DON was interviewed on 1/29/25 at 3:00 p.m. The DON said Resident #2 did not immediately have specific behaviors added to his care plan upon admission as the facility tried to establish a baseline for a resident's behavior first. She said the facility would determine if it was a behavior that needed to be care planned. The social services director (SSD) was interviewed on 1/29/25 at 3:30 p.m. The SSD said Resident #2's behavior could escalate quickly with no warning. The SSD said when Resident #2 was talking loudly, it was difficult to determine which behaviors might be directed at staff and which behaviors might be directed at residents. The SSD said the facility monitored Resident #2's behaviors because they were sporadic and it was difficult to identify a trend in his behaviors. The regional clinical resource (RCR) was interviewed on 1/29/25 at 3:00 p.m. The RCR said after reviewing the documentation in Resident #2's record the facility recognized the documentation errors in the resident's EMR primarily originated from agency staff. She said after the incident on 1/19/25 the facility implemented a plan to only schedule facility staff in the secured unit where Resident #2 resided The RCR said facility staff knew the residents better, could better anticipate a resident's needs and recognize if a resident's behavior began to change and intervene before the behavior escalated.

Based on interviews, observations and record review, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value, were palatable in taste and temperature. Specifically, the facility failed to ensure the residents' food was palatable in temperature. I. Facility policy and procedureThe Timely Meal Service and Food Temperature policy, undated, was provided by the nursing home administrator (NHA) on 1/30/25 at 4:00 p.m. It read in pertinent part, "Food will be delivered promptly to ensure safe, palatable and high-quality food served at the proper temperature. Food will be served at preferable temperatures (hot foods hot and cold foods cold) as discerned by the patients/residents and customary practice (not to be confused with proper holding temperatures)."II. Resident interviewsResident #28 was interviewed on 1/27/25 at 11:47 a.m. Resident #28 said the food was bad. Resident #10 was interviewed on 1/27/25 at 3:27 p.m. Resident #10 said food was often served cold and the facility seemed to run out of common food items. Resident #3 was interviewed on 1/28/25 at 11:15 a.m. Resident #3 said every once in a while her food arrived warm to her room, otherwise the food was always cold. Resident #16 was interviewed on 1/28/25 at 11:20 a.m. Resident #16 said the food was notbeing prepared properly, because they microwaved the vegetables. She said the food was always served cold. III. ObservationsDuring a continuous observation on 1/27/25, beginning at 11:30 a.m. and ending at 1:54 p.m., the following was observed during the meal preparation and service in the main kitchen: The posted menu was breaded Italian chicken, penne pasta with marinara, basil zucchini saute and frosted spice cake. At 1:20 p.m. assembly of resident meal trays for the 400 hall room delivery started. At 1:24 p.m. the facility ran out of zucchini and cooked broccoli to serve for the remainder of the meal. At 1:37 p.m. the test tray was assembled and placed in the 400/700 hall room delivery cart. The test tray was covered with a room delivery base instead of a plate cover or insulated dome lid. At 1:43 p.m. the first room tray was delivered to a resident in the 400 hall. The cover had partially fallen off the test tray leaving the food exposed. At 1:51 p.m. the room delivery cart was transported to unit 700 for room delivery. The test tray was partially uncovered leaving the food exposed. At 1:53 p.m. the test tray was removed from the cart. The test tray was immediately evaluated by four surveyors after the last resident had been served their room tray for lunch. The test tray consisted of a breaded chicken breast, penne pasta with marinara sauce, broccoli and cake for dessert. -The broccoli was 102 degrees F.-The chicken breast was 120 degrees F-The penne pasta was 102 degrees FThe cake did not have icing and the pasta was overcooked and soggy. IV. Staff interviewsThe dietitian resource (DR) was interviewed on 1/29/25 at 1:00 p.m. The DR said the plates used for the 400 hall room trays, including the test tray, were not placed in the plate warmer prior to meal assembly. The DR said plates placed in the plate warmer were used for room trays and the plates left on the shelf at room temperature were usually used for the dining room. The DR said the facility did purchase another case of plates (during the survey) so this would not happen again and ensured the plate warmer always had hot plates for room tray service. The DR said she spoke with the dietary staff after meal service and the staff reported to her they do not typically run out of plate covers and lids. The DR said it was possible that not all plate covers and lids were returned to the kitchen after breakfast that morning. The DR said they should have enough plate covers and lids for lunch in case the meal trays are not all returned after breakfast. The DR said she updated the facility dietary improvement plan initiated in October 2024 to include food temperatures. V. Facility follow upThe dietary improvement plan, October 2024 was provided by the DR on 1/29/25 p.m. at 2:00 p.m. The plan was updated to include the following correction action items of food temperatures: purchase more plates, to ensure all food items were covered and to utilize two steam tables for meal service.-However, additional plates were not purchased until the survey (1/27/25 to 1/29/25).

Based on observations and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and in three of five nourishment rooms. Specifically, the facility failed to ensure safe and appropriate storage of food items in the kitchen and three of five nourishment room refrigerators. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 2/4/25 read in pertinent part, "The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety." (Chapter 3-25)"Medicines that require refrigeration and are stored in a food refrigerator shall be stored in a package or container and kept inside a covered, leakproof container that is identified as a container for the storage of medicines" (Chapter 7-207.12)II. Facility policy and procedureThe Foods Brought by Family or Visitor/Personal Food Storage, undated, was provided by the nursing home administrator (NHA) on 1/30/25 at 3:00 p.m. It read in pertinent part, "Food or beverage brought in from outside sources for storage in facility pantries or refrigeration units will be monitored by designated facility staff for food safety."III. ObservationsOn 1/27/25 at 11:05 a.m. the following was observed in the main kitchen refrigerator:-Four sealed containers of deli-style potato salad, with use by dates of 1/7/25;-A plastic package of hot dogs, unsealed and dated 1/20/25;-A plastic squeeze bottle containing an unidentified sauce, unlabeled and undated;-Two thawed and individually wrapped raw pork roasts in a clear lexan container. There were no pull dates or expiration dates on the product package or container; and,-Two thawed, individual packages of an orange liquid in a clear container. There were no pull dates or expiration dates on the product package or container. On 1/27/25 at 11:50 a.m. an open bottle of burgundy cooking wine, with an expiration date of 12/13/23 was observed. On 1/27/25 at 11:10 a.m. the following was observed in the drink station refrigerator:-Commercially packaged apple slices with an expiration date of 1/1/25. The package was swollen and bloated;-A slice of cake on a plate in the freezer, unwrapped and unlabeled;-A container of yogurt, with an expiration date of 12/18/24;-A container of yogurt, with an expiration date of 1/18/25;-A container of yogurt, with an expiration date of 1/6/25;-A container of cottage cheese, with an expiration date of 1/24/25;-Five pitchers of juice, unlabeled and undated;-Two containers of milk, with a sell-by date of 11/15/24; and,-The refrigerator and freezer had multiple spills of brown liquid and crumbs throughout. On 1/27/25 at 11:50 a.m. the following was observed in the 400 hall nourishment refrigerator and freezer:-A frozen pasta primavera in the freezer, with a best-before date of July 2024. There was no resident name or date written on the package;-One package of corn tortillas with 9/27 written on the package;-One bag of fresh grapes. There was no resident name or date written on the package;-One half-full jar of green chile sauce. There was a name on the jar but no open date; and,-Two containers of fresh fruit, each dated 1/23/25. A sign on the 400 hall nourishment refrigerator documented the following: "food left past 72 hours would be thrown away. Dietary staff would check food daily and food would be thrown away if there was no name or date or if it was past the three-day limit or best-by date. No exceptions. Food must be labeled with the date, resident name and room number and tightly covered."On 1/28/25 at 11:05 a.m. the items observed in the 400 hall nourishment refrigerator and freezer on 1/27/25 were still present. On 1/27/25 at 12:34 p.m. the following was observed in the 500 hall nourishment refrigerator butter conditioner (a shelf on the inside of the door to the refrigerator with a clear cover):-One dose of Prevnar vaccine labeled with a resident name in a sealed plastic bag; and,-Two doses of tuberculin vaccine labeled with a resident name in a sealed plastic bag. The butter conditioner had a plastic lid that did not completely seal off the contents of the container and did not have any labels or indications that medications were to be stored there. On 1/28/25 at 4:44 p.m. the vaccines (see above) were no longer in the 500 hall nourishment refrigerator. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 1/28/25 at 11:07 a.m. LPN #2 said the jar of green chile (see above) belonged to the resident whose name was on the jar. LPN #2 said she would discard the jar of green chile because it did not have a date written on it, but the printed date on the jar was in 2026. -LPN #2 discarded the jar of green chile. The dietitian resource (DR) was interviewed on 1/29/25 at 1:00 p.m. The DR said it was the responsibility of all the dietary staff to pay attention to the food labels. The DR said the staff should write a pull date on the item when it was removed from the freezer. The DR said typically the label should be put on the tray or container instead of the product itself because the label did not adhere well to the product packaging. The DR said the dietary staff had previously been instructed how to date and label. The DR said cleaning unit refrigerators were on the dietary staff checklist to be completed every week. The DR said the nourishment refrigerators were managed by dietary staff. The DR said if a family member brought in personal food items for a resident, then the staff member who received that food, such as a CNA, was responsible for dating and labeling the food prior to putting the food in the nourishment refrigerators. The director of nursing (DON) was interviewed on 1/29/25 at 1:00 p.m. The DON said medications were not typically stored in the nourishment refrigerators and were removed from the nourishment refrigerator.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on one of six units. Specifically, the facility failed to ensure facility staff followed enhanced barrier precautions (EBP) when performing high contact activity with Resident #12, who had a suprapubic catheter and stage 4 (damage extending through all skin layers, reaching underlying muscle, tendon or bone, often with exposed tissue and high risk of infection) pressure wounds. Findings include:I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precautions in Nursing Homes, updated 7/12/22, retrieved on 2/3/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, "EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care." "Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care (any skin opening requiring a dressing)." II. Facility policy and procedure The Infection Prevention and Control Program (IPCP) On Standard and Transmission-Based Precautions policy, revised April 2024, was provided by the nursing home administrator (NHA) on 1/30/25 at 3:11 p.m. It revealed in pertinent part,"In long term care (LTC), it is appropriate to individualize decisions regarding resident placement (shared or private), balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. Therefore it is appropriate to use the least restrictive approach possible that adequately protects the resident and others." "EBP are used in conjunction with standard precautions (infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status, including hand hygiene, environmental cleaning and disinfection, injection/medication safety, risk assessment with use of appropriate personal protective equipment based on performed activities, minimizing potential exposures, respiratory hygiene, and reprocessing of reusable medical equipment) and expand the use of PPE through the use of gown and gloves during high contact resident care activities that provide opportunities for indirect transfer of multidrug resistant organisms (MDROs) to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. "The use of gown and gloves for high contact resident care activities is indicated when contact precautions (transmission-based precautions, or TBP, used with known infection that is spread by direct or indirect contact with the resident or resident's environment) do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of known MDRO infection or colonization and those with MDRO infection or colonizations. Wounds include, but are not limited to, chronic wounds, pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical devices include, but are not limited to, central venous catheters, peripherally inserted central catheter (PICC) lines, urinary catheters, feeding tubes and tracheostomies."III. Observations On 1/27/25 at 10:15 a.m. an initial observation of unit four was conducted. A droplet precaution (infection control measures used to prevent the spread of respiratory infections) sign was observed on Resident #12's door. His door was open. There was a PPE bin outside of the room. Resident #12 was resting in bed. Resident #12 had an indwelling suprapubic catheter and stage 4 pressure injuries. During a continuous observation of unit four on 1/27/25, beginning at 11:17 a.m. and ending at 2:00 p.m., the following was observed: At 11:17 a.m. the droplet precaution sign had been removed from Resident #12's door and the PPE bin was no longer outside the resident's room. -There was no EBP sign on Resident #12's door or a PPE bin outside the resident's room, was identified by the director of nursing (DON) as the facility's process for making staff aware of which residents required EBP (see DON interview below). At 1:09 p.m. the physical therapist (PT) was observed going into Resident #12's room and asking the resident if he was ready for some exercise. The PT performed hand hygiene and closed the resident's door. -The PT did not put on PPE prior to entering the resident's room to do physical therapy with the resident. At 1:42 p.m. the speech language pathologist (SLP) performed hand hygiene, knocked on Resident #12's door and entered the resident's room. -The SLP did not put on PPE prior to entering the resident's room to do speech therapy with the resident. The PT was still in the resident's room and was adjusting the resident's wheelchair footrests while the resident was sitting up in his chair. The PT, who was not wearing PPE, performed hand hygiene and left the resident's room after the SLP entered the room. -There was no used PPE observed in the resident's trash receptacle to indicate the PT had followed EBP during Resident #12's physical therapy session. During a continuous observation on 1/28/25, beginning at 10:02 a.m. and ending at 1:00 p.m, the following was observed:At 10:02 a.m. Resident #12 was resting in bed and his catheter bag was observed hanging at the foot of the bed. -There was no PPE bin outside of the resident's room and no EBP sign was on the door, which was identified by the DON as the facility's process for making staff aware of which residents required EBP (see DON interview below). At 11:21 a.m. certified nurse aide (CNA) #1 entered Resident #12's room to reposition and toilet him. -CNA #1 donned (applied) gloves but failed to put on a gown before he provided care. CNA #2 entered Resident #12's room with the mechanical lift, shortly after CNA #1, and washed her hands. -CNA #2 did not put on a gown before entering the resident's room but donned gloves once she entered. CNA #1 and CNA #2 provided perianal care to the resident without donning gowns. The resident had a wound dressing on his right ischium (bone in the pelvis that forms the lower and back part of the hip) wound that was pulling up along the edges. The dressing had visible serosanguineous drainage (yellowish-white drainage with streaks of blood) on it. IV. Staff interviewsCNA #2 was interviewed on 1/28/25 at 3:53 p.m. CNA #2 said she was not familiar with any special infection precautions required for Resident #12. CNA #1 was interviewed on 1/28/25 at 3:57 p.m. CNA #1 said he was unaware of any need to wear any special PPE, except for gloves, when performing cares for Resident #12. CNA #3 was interviewed on 1/29/25 at 1:10 p.m. CNA #3 said she only knew of one resident on the unit with a catheter (Resident #12) but she had never seen staff donning PPE during the resident's care except for the wound care team when they changed his wound dressing. The assistant director of nursing (ADON) was interviewed on 1/29/25 at 1:40 p.m. The ADON said he understood if someone had an infection, they would place the appropriate sign on the door as well as a PPE bin to alert staff. The staff utilized the PPE when toileting and helping residents perform activities of daily living (ADL). The ADON did not verbalize understanding of how and why EBPs were utilized or initiated for residents. The director of nursing (DON) was interviewed on 1/29/25 at 2:46 p.m.. The DON said if a resident was on EBP there should be a sign on the resident's door as well as a bin with PPE outside the resident's room. She said Resident #12 should have had an EBP sign on his door and a PPE bin outside his room to alert staff of his high infection risk status. The regional clincial resource (RCR) was interviewed on 1/29/25 at 2:52 p.m. The RCR said she was made aware that Resident #12 was missing an EBP sign and a PPE bin outside of his room to alert staff of his EBP status. She said her plan was to immediately correct this by providing a sign and alerting the nurses to use appropriate PPE when providing high contact care for the resident. She said the facility would conduct an EBP audit (process of reviewing and evaluating a facility's compliance with EBP), including staff education and training. The ADON was interviewed a second time on 1/29/25 at 3:10 p.m. The ADON said he initially removed the droplet precautions sign and PPE bin from Resident #12's door on 1/27/25 because the resident had no current active infections and he was uninformed about EBP. He said staff were made aware of the residents who were on EBP via signage, PPE bins and morning meeting reports. The ADON said he would be more vigilant about ensuring the EBP measures were maintained in the future.

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

A complaint survey, prompted by #CO36118 and #CO36120 was conducted from 6/3/24 to 6/10/24. No deficiencies were cited.

A revisit survey was completed on 6/6/24 for all previous deficiencies cited on 4/10/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 6/6/24 for all previous deficiencies cited on 4/10/24. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on April 30, 2024, for compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies;" NFPA 99, Health Care Facilities Code (2012); and all referenced standards. The facility will meet these requirements when the following deficiencies are corrected. This structure is a one (1) story, Type V (111) (VA) construction. The facility has a partial basement that is used for support services only and there is no resident access. The facility is licensed for 170 beds and the census on the date of the survey was 102.

Based on observation it was found that the facility does not meet mean of egress requirements in accordance with NFPA 101. Activities exit ramp elevation has a change that exceeds ¼". NFPA 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.

Based on observation and staff interviews during the record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101 7.9.3 and 19.2.9.1.1. No documentation was available during the record review of the facility required Exit lights testing of the battery-powered emergency lighting system at 30-day intervals for not less than 30 seconds or annually for not less than 1 ½ hours 2. No documentation was available during the record review of the facility required emergency lights testing of the battery-powered emergency lighting system at 30-day intervals for not less than 30 seconds or annually for not less than 1 ½ hoursNFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

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. Two gauges antifreeze loop need to be replaced 2. Flow switch cover will not stay in the valve 3. Fridge and freezer fire sprinkler head 2004. Shall be replaced every 10 years. 4. The head box needs 3 heads 5. Anchors from the entry sprinkler pipe 6. Mixed standard and quick response heads in 4 hall one head5.3.2* 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. NFPA 25 (2011) 4.1.9.1 Where an impairment to a water-based fire protection system occurs, the procedures outlined in Chapter 15 of this standard shall be followed, including the attachment of a tag to the impaired system. 4.1.9.2 Where a water-based fire protection system is returned to service following an impairment, the system shall be verified to be working properly by means of an appropriate inspection or test. 4.2 Corrective Action. 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. 25 5.3.1.1.1.6 Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervalsNFPA 13 6.2.9.4 Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished. 6.2.9.5 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:(1) For protected facilities having under 300 sprinklers — no fewer than six sprinklers(2) For protected facilities having 300 to 1000 sprinklers — no fewer than 12 sprinklers(3) For protected facilities having over 1000 sprinklers — no fewer than 24 sprinklersNFPA 25 5.2.3Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level. 5.2.3.1 Hangers and seismic braces shall not be damaged or loose. 5.2.3.2 Hangers and seismic braces that are damaged or loose shall be replaced or refastened. 5.2.3.3* Hangers and seismic braces installed in concealed spaces such as above suspended ceilings shall not require inspection. 5.2.3.4 Hangers and seismic bracing installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown8.3.3.2 Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.8.3.3.3 Where there are no listed quick-response sprinklers in the temperature range required, standard-response sprinklers shall be permitted to be used. This deficiency can potentially affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator at the exit conference.

Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. At the time of the survey, documentation showed a record that 6 fire extinguishers throughout the facility were subjected to replacement. 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 can potentially affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Only February, March, and April were available at the time of the inspection. NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 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.

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

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 floorNFPA 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.

A recertification survey with complaint #CO34221, #CO35125, #CO35287, #CO35355, #CO35431, #CO35444 and Incident #CO35115 was completed on 4/3/24 to 4/10/24. Sixteen deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/3/24 to 4/10/24. No deficiencies were cited.

Based on interviews, observations and record review, the facility failed to ensure resident choices for two (#87 and #57) of three residents reviewed for activities of daily living out of 49 sample residents. Specifically, the facility failed to:-Ensure Resident #87 and #57 received showers consistently according to their choice of frequency; and, -Ensure Resident #87 and #57's preferences were included in their plan of care. Findings include:I. Facility policy and procedureThe Bath, Shower policy, revised August 2021, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, "It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation. Residents have the choice between bed bath, shower or bath. "When residents admit please review the preference sheet with the Resident. "Resident may choose the days of the week they choose to bath or shower. "We offer the following options to residents: shower, tub bath or bed bath. "Residents may change their preferences at any time during the stay."The Activities of Daily Living policy, revised October 2022, was provided by the NHA on 4/10/24 at 4:41 p.m. It read in pertinent part, "ADL's (activities of daily living) will be care planned to reflect the resident specific needs."II. Resident #87A. Resident statusResident #87, under the age of 65, was admitted on 6/14/23 and readmitted on 9/12/23. According to the April 2024 computerized physician orders (CPO), diagnoses included morbid obesity, bipolar disorder, post-traumatic stress disorder (PTSD) and need for assistance with personal care and pain. The 1/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a staff interview for cognition. She required supervision for eating and oral hygiene. She required substantial assistance for toileting and personal hygiene. She was dependent for showering. B. Resident interviewResident #87 was interviewed on 4/3/24 at 9:53 a.m. She said she preferred to shower at 7:00 p.m. on Thursdays. She said the facility did not accommodate her shower preferences. Resident #87 said some weeks she missed her shower because the staff did not have time to give her a shower on her preferred day and time. The resident said she preferred to have female caregivers because she had a history of being sexually abused. C. Record reviewThe staff task sheet indicated the resident wanted showers on Thursday nights. The shower documentation from 3/1/24 through 4/7/24 for Resident #87 revealed the resident did not receive a shower on her preferred shower days on 3/7/24, 3/14/24 and 3/21/24. The documentation revealed the resident refused a shower on 3/22/24 at 5:52 p.m. The resident preferred to shower at 7:00 p.m. The ADL care plan, initiated on 3/15/24, revealed the resident had an ADL self care performance deficit related to acute respiratory failure, obesity, bipolar, myopathy (disease affecting the muscles), PTSD, hypertension, contracture to bilateral ankles, gastrostomy status and obstructive sleep apnea. The interventions included in pertinent part: providing one to two staff members for bathing. -The comprehensive care plan did not include the resident's preferred shower days and times or her preference of female caregivers. III. Resident #57A. Resident statusResident #57, age 66, was admitted on 8/7/23 and readmitted on 8/9/23. According to the April 2024 CPO, diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), need for assistance with personal care, anxiety, shortness of breath, alcohol abuse in remission and chronic pain. The 2/15/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of 12 out of 15. He required partial assistance with eating and oral hygiene. He required substantial assistance for toileting, showering and personal hygiene. B. Resident interviewResident #57 was interviewed on 4/3/24 at 2:08 p.m. He said he was not getting his showers when he preferred them. Resident #57 said he had multiple lung issues that caused him to be short of breath. He said when he showered he needed increased oxygen needs. He said the facility told him that they were unable to provide the increase of oxygen needs to him so he had to take bed baths. Resident #57 said he was afraid to take a shower because the facility was not able to provide the increased oxygen. He said the staff provided him with bed baths instead. He said he preferred to shower as bed baths did not make him feel clean. Resident #57 said he was unsure why the facility was unable to provide him the increased oxygen needs because the previous facility he was at could. He said he would prefer to take a shower more than twice a week. He said his normal routine prior to living in a facility was to wake up, take a shower and enjoy a cup of coffee. C. Record reviewThe staff task sheet indicated the resident wanted to shower on Sunday and Wednesday nights. The shower documentation from 3/1/24 through 4/7/24 for Resident #57 revealed the resident did not receive a shower on his preferred shower days on 3/6/24, 3/10/24, 3/13/24, 3/20/24, 3/27/24, 3/31/24 and 4/3/24. The ADL care plan, initiated on 3/14/24, revealed the resident had an ADL self care performance deficit related to acute on chronic respiratory failure, COPD, chronic pain, neuropathy (nerve pain) and limited mobility. The interventions included in pertinent part: encouraging the resident to participate to the fullest extent possible with each interaction.-The comprehensive care plan did not include the resident's shower preferences. IV. Staff interviewsCertified nurse aide (CNA) #9 was interviewed on 4/8/24 at 4:02 p.m. She said there was a binder at the nurses station that had a calendar with each resident's preferred shower days. CNA #9 said Resident #87 preferred to shower Thursday evenings. She said Resident #57 preferred showers on Sunday and Wednesday nights. She said Resident #57 received bed baths because he often got short of breath which caused him anxiety. The assistant director of nursing (ADON) was interviewed on 4/9/24 at 1:35 p.m. The ADON said when a resident admitted to the facility a preference sheet was completed to determine the resident's shower preferences. The ADON said Resident #87 preferred to shower on Thursdays at 7:00 p.m. He said the staff was often busy at that time with meals or assisting other residents. The ADON said sometimes the resident's shower was not always at 7:00 p.m. per her preference. The ADON said they could not always meet her preferences due to staff availability. The ADON said he was not aware of Resident #57's oxygen needs and desire to take a shower over a bed bath. The social services director (SSD) and the corporate social worker (CSW) were interviewed on 4/9/24 at 4:22 p.m. The SSD said the facility had been working with Resident #87 to establish her shower preferences. The SSD said the resident preferred to shower at 2:00 p.m. The SSD said Resident #87 had a very strict schedule that was difficult to work with sometimes. The SSD said he told Resident #87 she needed to have patience with the staff when they were running late on her shower. The SSD said Resident #87 was not thrilled with getting her shower at 2:00 p.m. but she understood that there was more staff available at that time to help her with her shower. The SSD and the CSW said they were not aware Resident #57 had increased oxygen needs when showering. The CSW said they would review the resident's shower preferences to see if they would be able to provide the resident a shower over a bed bath.

Based on observations, interviews and record review, the facility failed to provide a clean, comfortable, homelike environment for residents for one (#93) resident out of 49 sample residents. Specifically, the facility failed to ensure Resident #93's living space was comfortable to him by having access to fresh outside air. Findings include: I. Facility policy and procedureThe Safe, Homelike Environment policy, dated October 2007, was provided by the NHA on 4/10/24 at 4:41 p.m. It read in pertinent part, "Comfortable and safe temperature levels means the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents. "A homelike environment is the one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. "If and when a resident prefers his or her room temperature be kept below 71 degrees fahrenheit, or above 81 degrees fahrenheit, the facility will assess the safety of this practice on the resident and the resident's roommate." II. Resident #93A. Resident statusResident #93, under the age of 65, was admitted on 2/6/24. According to the April 2024 computerized physician order (CPO), diagnoses included quadriplegia (little to no movement in all limbs), need for assistance with personal care, other specified disorders of teeth and supporting structures and adult failure to thrive. The 2/12/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. He was independent while eating. He was dependent on oral hygiene, toileting, showering and personal hygiene. B. Resident interview and observationsResident #93 was interviewed on 4/4/24 at 9:09 a.m. Resident #93 was lying in bed in his room. The resident's room did not have a window. There was a door to enter the resident's room from the hallway and a double door at the back of the room that entered into an atrium (small room enclosed with glass windows). The atrium was an unused space that was locked and inaccessible to the resident. The space has some unused chairs stored inside that could be seen by the resident. The double doors were closed and locked, there was a sign on the door that read not an exit on them. Resident #93 said his room was very hot and he was unable to open the double doors to get fresh air into his room. Resident #93 said the maintenance director (MTD) told the resident he was unable to open the double doors because it was not safe for the resident to be out there. Resident #93 said he wished he was able to open the double doors to the atrium to get fresh air and sunlight into his room. Resident #93 had sweat on his face. He said being hot made him feel sweaty and unclean. The resident's room was hot. He had one fan in the room. He said he got tired of the fan because it was really loud. III. Staff interviews The MTD was interviewed on 4/9/24 at 2:45 p.m. The MTD said the double doors in Resident #93's room opened to an atrium that was not in use and he did not have a key to open the door. The MTD said he could give the resident a fan to cool him down as a solution but said it would be a safety hazard to allow people into the atrium because it could open up the space as a way for unwanted persons to enter the building. The MTD said the resident did not have a window in his room to get fresh air and it was impossible to install a window to the room due to the original structure of the old building. The MTD said he would find a way for the resident to safely open the double doors to the atrium so he would be able to get air circulation in his room.

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

Based on interviews and record review, the facility failed to initiate and complete a thorough investigation of alleged violations and take appropriate corrective action following the investigation. Particularly relevant when the allegation was verified for one (#79) of four residents reviewed for abuse out of 48 sample residents to alleviate after effects contributing to residents experiencing, among other emotions, anxiety, fear, and humiliation. Specifically, the facility failed to, for Resident #79:-Complete thorough investigations of the alleged violation of mental and verbal abuse that included sufficient evidence to allow the nursing home administrator (NHA) to determine what actions were necessary to protect the resident from further abuse that contributed to residents experiencing, among other emotions, anxiety, fear, and humiliation;-Gather all pertinent unbiased observations to identify pertinent facts of the events that occurred before, during and immediately following the incident to determine necessary interventions to prevent further abuse and alleviate after effects felt by the resident victim. This would include observations of the assailant's behavior; words; gestures; facial expression; demeanor; tone and volume of voice; proximity and assailant and victim during the incident; and other applicable responses;-Consider potential bias between alleged abuser(s) and witnesses; and, -Take a timely response to an allegation of mental and verbal abuse and initiate an investigation with a timely response. Findings include:I. Facility PolicyThe Abuse: Prevention of and Prohibition Against Policy, revised October 2022, was provided by the NHA on 4/3/24 at 3:00 p.m. and it read in pertinent part,"All identified events are reported to the Administrator immediately. -A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. -The findings of the examination shall be recorded in the resident's medical record. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee.-Upon receiving a report or allegation of a potential violation of this policy involving the taking, keeping, using, or distributing photos or video recordings, the Administrator or his or her designee will analyze the allegations and determine whether the conduct at issue implicates resident privacy or security as protected by the Health Insurance Portability and Accountability Act ("HIPAA"). Any such actual or potential violation will be managed as per the Facility's HIPAA policies and procedures."The investigation will include the following:-An interview with the person(s) reporting the incident;-An interview with the resident(s);-Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate;-A review of the resident's medical record;-An interview with staff members (on all shifts) who may have information regarding the alleged incident;-Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident;-An interview with staff members (on all shifts) having contact with the accused employee; and-A review of all circumstances surrounding the incident."The investigation, and the results of the investigation, will be documented."If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation:"-Respond immediately to protect the alleged victim and integrity of the investigation;-Examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;-Increase supervision of the alleged victim and residents;-Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;-Protect the involved persons from retaliation; and-Provide emotional support and counseling to the resident during and after the investigation, as needed."If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves an employee, the Facility will:-Immediately remove the employee from the care of any resident.-Suspend the employee during the pendency of the investigation." II. Mental/verbal abuse by staff towards Resident #791. Resident #79A. Resident statusResident #79, age over 65, was admitted on 9/19/22. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, bipolar disorder, post-traumatic stress disorder (PTSD), anxiety and depression. The 3/2/24 minimum data set (MDS) assessment revealed the resident had a mild cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with hygiene, dressing and transferring herself and did not exhibit any behavioral symptoms or refusal of care. B. Resident interviewResident #79 was interviewed on 4/3/24 at 1:35 p.m. Resident #79 was sniffing and wiping tears from her eyes. She grabbed a tissue, sat down on her bed, and apologized for being so upset. Resident #79 then reported she was very upset over a recent interaction with the AD during and after the resident council meeting that morning. Resident #79 said the AD was very mean to her, raised her voice at her, was very rude, and told her the facility's library book program was not a priority and would not be a priority. Resident #79 said she was so upset by the way the AD spoke to her that she began crying. She said two therapy staff witnessed the interaction and helped to console her. Resident #79 said the AD's tone was "snotty and very belittling." She said it made her feel like a "scolded child." C. Facility Investigation (Cross-reference F600 for abuse)An allegation of mental verbal abuse was reported to the facility NHA on 4/3/24 at approximately 12:30 p.m. by facility staff witnessing the activities director (AD) speaking in a mean and belittling manner that caused the resident emotional distress. Although three staff who witnessed the incident promptly reported it to the nursing home administrator (NHA), the facility failed for several hours to initiate an investigation or implement corrective actions to protect Resident #79 from further abuse. The facility investigation documentation and interviews revealed that an investigation into the allegation of mental and verbal abuse was not started timely and the assailant was not suspended until over five hours after the incident of mental verbal abuse occurred. The assailant remained working in the facility with unrestricted access to interact with Resident #79 and other residents in the facility. The investigation documented that Resident #79 was noted by staff who observed the incident to be tearful at time of incident. The witness statements failed to document specific facts of the investigation detailing what the witness observed and heard during the reported incident. Instead of describing location and time of the incident; how close the staff assailant was to Resident #79 during the course of incident; who else was in the immediate area/potential witnesses; the exact words the AD used when communicating with Resident #79; staff assailants demeanor, gestures, tone and volume of voice; resident response; other witnesses names; and any other pertinent details witness statements gave a brief description of the incident. Additionally, the investigation report failed to document the investigators findings, conclusion and recommendations to prevent further abuse and emotional distress towards resident #79.-The investigation did not document who the staff witnesses were or what they observed and/or heard from the initiation and end of the incident. -The investigation did not ask how the alleged perpetrator and victim acted towards one another prior to and after the incident.-The investigation did not document if the alleged assailant and/or victim exhibited any behaviors that would provoke one another.-The facility did document that the investigator asked the resident if she was fearful of the staff assailant (AD) but failed to explore with the resident how the incident affected her emotionally and how the AD's words and behavior made her feel and or explored any other potential emotional factors that might occur after experiencing mental or verbal abuse. -Witness statements further documented the witnesses opinion on whether or not the incident rose to a level of abuse with no justification or evidential facts to support their opinion. D. Witness statementsThe activities assistant (AA) #3 provided a statement on 4/3/24 at 3:15 p.m. It read in pertinent part, "Asked if she witnessed any verbal or emotional abuse towards Resident #79 from the AD? No, felt she answered all the questions. The AD did say that the library is not a priority but they would get to it." -However, the witness statement did not say what the AD's tone of voice was, where the two were positioned during the interaction or if there were any hand gestures by anyone involved. The occupational therapist (OT) #1 provided a witness statement on 4/3/24 no time identified. It read in pertinent part, "The AD's voice was stern and mean. Asked OT #1 if she felt that verbal or emotional abuse happened she stated No, but the interaction was not appropriate. We discussed the word mean during interview and what she felt was mean about the interaction, OT #1 feels it was just stern. She didn't feel that mean met the criteria for reporting abuse."-However, the witness statement did not say the volume of the AD's voice, if there were any interruptions, where the two were positioned during the interaction or if there were any hand gestures by anyone involved. AA #1 provided a witness statement on 4/3/24, no time identified. It read in pertinent part, "Did you feel at any point the AD was verbally or emotionally abuse towards Resident #79 or other residents? No." AA #1 stated the AD apologized for "losing her cool" and that Resident #79 seemed upset. -However, the witness statement did not say if there were any interruptions, or if there were any hand gestures by anyone involved. AA #2 provided a witness statement on 4/3/24, no time identified. It read in pertinent part, "Did you witness the AD being verbally or emotionally abusive? No, AA #2 thought she was professional."-However, the witness statement did not say the volume of the AD's voice, if there were any interruptions, where the two were positioned during the interaction or if there were any hand gestures by anyone involved. The witness statements provided were all typed and signed by the witnesses.-However, the statements were not individualized or unique to the person who witnessed the incident and contained the same first paragraph word for word. E. Staff interviewsThe corporate social worker (CSW) was interviewed on 4/10/24 at 2:45 p.m. The CSW said she interviewed the AD and took some notes in her personal notebook but did not ask the AD to write up her statement or document the interview in the investigation report. The CSW did not provide her note for review. The CSW said she did not interview AA #1 regarding his statement that he overheard the AD apologizing to Resident #79 for "losing her cool." Speech therapist (ST) #1 was interviewed on 4/3/24 at 1:50 p.m. The ST said the incident between the AD and Resident #79 occurred around 11:15 a.m. that morning. ST #1, OT #1 and PT #1 went together to report the incident to NHA around 12:30 p.m.. ST #1 said they felt more comfortable reporting the incident together because they believed their observations would be better received if they all three reported what they observed as a group so the report would not be ignored since the allegation was against a member of the leadership team. PT #1 was interviewed on 4/3/24 at 1:53 p.m. PT #1 said he did not witness the incident but he did see Resident #79 crying so he helped to console her and went with ST #1 and OT #1 to report the incident to the NHA around 12:30 p.m. OT #1 was interviewed on 4/3/24 at 1:55 p.m. OT #1 said she heard the end of the interaction between the AD and resident #79. OT #1 said the interaction was very concerning and felt it needed to be reported to the NHA so she went with PT #1 and ST #1 around 12:30 p.m. to report their concerns. The NHA was interviewed on 4/3/24 at 2:00 p.m. The NHA said the staff that reported the incident between the AD and Resident #79 did not tell him that they thought the incident was verbal abuse so he did not start an investigation or take any action to suspend the AD. -The AD continued to work in the facility without restricted access to interact with Resident #79 or other residents in the facility. The NHA was interviewed on 4/3/24 at 4:30 p.m. The NHA said he had just suspended the AD pending investigation. The NHA was interviewed with the social service director (SSD) on 4/9/24 at 6:18 p.m. The NHA said reports of potential abuse should be fully investigated. The NHA said when abuse was alleged the process was to suspend staff in question; protect the residents from further harm; make notifications to the power of attorney; and start a report to the state agency. -However, the alleged staff assailant was not suspended until over 5 hours after the incident of verbal abuse occurred. The AD was interviewed on 4/10/24 at 3:15 p.m. The AD said the incident began after the resident council meeting when Resident #79 came to her office to talk about the library book program. The AD said she told Resident #79 that it would take time to get it set up as other items had to be relocated first. She said she told Resident #79 that she did not have an immediate solution and the resident became very upset and told the AD that the AD did not care about the library book program. The AD said she did not handle the situation very well and ended the conversation with Resident #79 by saying, "if you don't like any of my solutions then we have nothing else to talk about." The AD said she tried to apologize to Resident #79 but the resident did not want to hear it. The AD said she had reflected on the interaction with Resident #79 and she did not do a good job of de-escalating the resident. The AD said she needed more training and should remember that the facility was home for the residents and she had to respect that. She said if she were in that situation again she would ask the resident for a break to regroup and settle herself down. The AD said Resident #79 kept talking over her and interrupting her so she raised her voice towards the resident because she did not like being interrupted.

Based on observations, record review and interviews, the facility failed to provide the necessary services to maintain personal hygiene for one (#60) of six residents reviewed for services to maintain highest practicable quality of life out of 49 sample residents. Specifically, the facility failed to provide bathing/showering assistance, grooming for nail care, assistance to change and put on clean clothing. Findings include:I. Facility policyThe Activities of Daily living (ADL) policy was provided by the nursing home administrator (NHA) on 4/10/24 at 4:14 pm. It revealed in part, "Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support from staff to maintain: "ADL documentation will be maintained in the electronic health record under tasks, care plan, assessments, and therapy documentation including the following areas of care: eating, grooming, personal hygiene, communication, oral hygiene, transfers and ambulation."ADL's will be carefully planned to reflect the resident's specific needs."II. Resident #60A. Resident statusResident #60, under age 65, was admitted on 7/15/21. According to the April 2024 CPO, diagnoses included schizoaffective disorder, chronic pain, cognitive communication deficit and history of a traumatic brain injury. The 2/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had functional limitations in both lower extremities (hips, knees, ankles and feet) and was fully dependent on staff to complete all ADLs. He was not able to walk and used a wheelchair. B. ObservationsOn 4/3/24 at 2:32 p.m., Resident #60's fingernails were observed to be long and discolored. Resident #60's fingernails were visibly soiled and had a dark substance under several nails. His shirt was dirty and his hair was greasy but pulled back. On 4/4/24 at 11:00 a.m., Resident #60's fingernails were observed to be long and discolored. Resident #60's fingernails were visibly soiled and had a dark substance under several nails. Resident #60's hair was greasy and he was visibly frustrated that he was not receiving showers. On 4/8/24 at 4:30 p.m., Resident #60's fingernails were observed to be long and discolored. Resident #60's fingernails were visibly soiled and had a dark substance under several nails. Resident #60 was in tears and frustrated that he could not bathe until his shower day. C. Resident interviewResident #60 was interviewed on 4/3/24 at 2:32 p.m. Resident #60 said since he arrived at the facility he had not had his fingernails trimmed and had to bite them off to maintain grooming of his fingernails. He said the facility did not offer showers to him on a regular basis and he only received two showers in the past 30 days. He said he received one bed bath but he did not like it because staff was unable to get him clean enough. Resident #60 said his preference and request was specifically to get showers. He said he did not like feeling dirty all the time and wanted the facility to assist him so that his hygiene improved. He said that the facility accused him of refusing showers but he said the refusals were for bed baths not opportunities to get a shower. He said the facility staff did not want to shower him once he got out of bed and complained to him that it was too much work and took too much time because they had to get a second staff member to assist with the hoyer lift getting him undressed and then hoyer lift him to a shower chair and reverse the process once the shower was complete. D. Record reviewA self care performance care plan, revised 3/1/24, documented the resident needed assistance with bathing and grooming needs due to weakness, impaired cognition, hypertension, psychosis and osteoarthritis. Interventions included two staff assistance with bathing and transfers.-The care plan did not document if the resident refused showers. The point of care response chart documented the resident was care planned for receiving shower assistance on Wednesdays and Saturdays during the day shift. The shower documentation from 3/13/24 through 4/6/24 was reviewed for Resident #60. The documentation revealed Resident #60 received a shower on 3/13/24 and 3/16/24 and a bed bath on 4/4/24.-Out of eight opportunities for the resident to receive a shower from 3/13/24 through 4/6/24, Resident #60 only received two showers and one bed bath.-The documentation did not indicate the resident had refused any of his shower opportunities. E. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 4/8/24 at 4:14 p.m. CNA #4 said Resident #60 refused care sometimes and was hard to work with. She said he had long nails that should have been trimmed but she said she was unsure whose responsibility it was to trim his nails. CNA #4 said the resident was offered to be changed but he sometimes refused. -However, the resident's medical record did not document any instances of refusals to have his nails trimmed or cleaned and the resident said he only refused bed baths because they didn't make him feel clean. The resident said it was the staff who were not meeting his need for care planned showers and saying showering would take them too long, they did not have time and if he wanted bathing assistance he would have to take a shower. (see resident interview above.) The NHA was interviewed on 4/9/24 at 11:00. The NHA said when residents required assistance they should have been cared for, especially residents who had visible discomfort and distress. He said any staff member who was unable to assist residents in a timely manner was to notify the charge nurse and reach out to other staff for assistance. The assistant director of nursing (ADON) was interviewed on 4/9/24 at 2:28 p.m. The ADON said Resident #60 had a history of refusals for most cares but he had seen the resident be compliant with staff when approached in the right manner. He said the resident should not have had visibly dirty and ungroomed nails, especially if the resident wanted assistance. He said he would follow up with the resident in the next 24 hours to ensure he received the care he needed.

Based on record review and interviews, the facility failed to ensure one (#87) of two sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan out of 49 sample residents. Specifically, the facility failed to assess and document Resident #87's blood pressure consistently prior to administering blood pressure medications. Findings include:I. Professional referenceAccording to Khashayar, F., Arif, J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine, retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK532906 on 4/11/24."Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockage of these receptors with beta-blocker medications can lead to many adverse effects. Bradycarida (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur."The patient's heart rate and blood pressure require monitoring while using beta-blockers."According to Kizior, R. J., Hodgson, K. J. (2023). Metoprolol. Saunders Nursing Drug Handbook. Elsevier, p. 770."Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse is 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician."II. Facility policy and procedureThe Medication Administration policy, revised August 2021, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, "Medications must be administered in accordance with the written orders of the attending physician."III. Resident #87Resident #87, under the age of 65, was admitted on 6/14/23 and readmitted on 9/12/23. According to the April 2024 computerized physician orders (CPO), diagnoses included morbid obesity, bipolar disorder, post-traumatic stress disorder (PTSD), mood disorder with depressive episodes, dysphonia (decreased voice production), cognitive communication deficit and need for assistance with personal care and pain. The 1/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a staff interview for cognition. She required supervision for eating and oral hygiene. She required substantial assistance for toileting and personal hygiene. She was dependent for showering. IV. Record reviewThe April 2024 CPO documented a physician order of Prazosin HCI Oral Capsule five mg (Prazosin HCI), give two capsule by mouth at bedtime for hypertension, hold for SBP (systolic blood pressure) <110 (less than 110), ordered 7/31/24 and discontinued on 4/3/24. On 4/3/24 the physician order was changed to Prazosin HCI Oral Capsule five mg (Prazosin HCI), give one capsule by mouth at bedtime for hypertension, hold for SBP (systolic blood pressure) <110 (less than 110). The April 2024 vital signs summary revealed the resident's blood pressure was not assessed for the medication on 4/1/24 to 4/8/24. A review of the April 2024 (4/1/24 to 4/8/24) medication administration record (MAR) revealed no documentation that the resident's blood pressure was taken 4/1/24 to 4/8/24 when the Prazosin HCL oral capsule had been administered to the resident. V. Staff interviewsRegistered nurse (RN) #3 was interviewed on 4/9/24 at 12:14 p.m. RN #3 said Resident #87 was on a medication that required the licensed nurses to assess the residents blood pressure prior to administering the medications. RN #3 said the resident's MAR typically populated and required the blood pressure to be taken prior to administering the medication. RN #3 said Resident #87's physician order for Prazosin was not prompting the nurses to document the blood pressure. RN #3 said the resident's blood pressure had not been documented in the medical record since 3/11/24. The assistant director of nursing (ADON) was interviewed on 4/9/24 at 1:35 p.m. The ADON said Resident #87 was prescribed Prazosin for high blood pressure. The ADON said the physician orders instructed the licensed nurses to take the resident's blood pressure and hold the medication if the blood pressure was less than 110. The ADON said he did not see Resident #87's blood pressure had been documented since 3/11/24 but he trusted the nurses to take the blood pressure prior to administering the medication.

Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for three (#93, #40 and #57) of four residents out of 49 sample residents. Specifically, the facility failed to arrange optometry services timely for Resident #93, #40 and #57. Findings include:I. Facility policy and procedureThe Hearing and Vision Services policy, revised March 2024, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, "It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. "The social worker/social services designee is responsible for assisting residents, and their families, in locating and utilizing available resources (Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community), for the provision of vision and hearing services."Once vision or hearing services have been identified, the social worker/social service designee will assist the resident by making appointments and arranging for transportation."II. Resident #93A. Resident statusResident #93, under the age of 65, was admitted on 2/6/24. According to the April 2024 computerized physician orders (CPO), diagnoses included quadriplegia (little to no movement in all limbs), need for assistance with personal care, other specified disorders of teeth and supporting structures and adult failure to thrive. The 2/12/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. He was independent for eating. He was dependent for oral hygiene, toileting, showering and personal hygiene. The assessment indicated the resident had adequate vision and did not have corrective lenses. B. Resident interviewResident #93 was interviewed on 4/4/24 at 9:08 a.m. Resident #93 said he had astigmatism in his eyes. Resident #93 said he needed glasses. He said his vision made it difficult for him to read. Resident #93 said he had asked several staff members since he admitted to see the eye doctor. He said the eye doctor was at the facility in March 2024 and he tried to see the eye doctor at that time. Resident #93 said he was not allowed to see the eye doctor since he was not on the list that day. C. Record reviewA request was made for vision visit notes for Resident #93 on 4/5/24. The social services director (SSD) said the resident had not been seen by the eye doctor since he was admitted to the facility (see interview below). -A review of the resident's comprehensive care plan on 4/5/24 did not reveal the resident's vision needs were addressed. III. Resident #40A. Resident statusResident #40, under the age of 65, was admitted on 1/19/23 and readmitted on 5/29/23. According to the April 2024 CPO, diagnoses included need for assistance with personal care, depression and hypertension (high blood pressure). The 1/28/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of 11 out of 15. She required supervision for eating and oral hygiene. The assessment indicated the resident had adequate vision and did not have corrective lenses. B. Resident interviewResident #40 was interviewed on 4/3/24 at 10:18 a.m. She said she needed to see the eye doctor because she had not seen an eye doctor in a long time and she lost her glasses. She said the facility had not offered for her to see the eye doctor. C. Record review-A review of the resident's comprehensive care plan on 4/5/24 did not reveal the residents vision needs were addressed. A request was made for vision visit notes for Resident #40 on 4/5/24. The SSD said the resident had not been seen by the eye doctor in the past year (see interview below). IV. Resident #57A. Resident statusResident #57, age 66, was admitted on 8/7/23 and readmitted on 8/9/23. According to the April 2024 CPO, diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), need for assistance with personal care, anxiety, shortness of breath, alcohol abuse in remission and chronic pain. The 2/15/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of 12 out of 15. He required partial assistance with eating and oral hygiene. He required substantial assistance for toileting, showering and personal hygiene. The assessment indicated the resident had adequate vision and did not have corrective lenses. -However, according to the optometrist note the resident had worsening vision and needed corrective lenses (see below). B. Resident interviewResident #57 was interviewed on 4/3/24 at 2:07 p.m. He said he saw the eye doctor several months ago to get new glasses and still had not received them. He said he currently did not have any glasses and he needed some. C. Record reviewThe 2/15/24 eye exam summary report documented the resident had a complaint his distant vision was blurry. The eye doctor documented both eyes were worsening but his distant vision was more affected. The plan was to get clear lenses, monitor for progression and update the prescription. -However, the resident had not received glasses yet or the facility was unaware of the status (see interview below). The vision care plan, initiated on 3/27/24, revealed the resident was at risk for impaired vision function related to poor vision. The resident wore glasses. The interventions included: arranging a consultation with an eye care practitioner as required and reviewing medications for side effects which affect his vision. V. Staff interviewsThe SSD was interviewed on 4/8/24 at 4:18 p.m. The SSD said he had worked at the facility since November 2023. The SSD said the ancillary services were very inconsistent at the facility. The SSD said he terminated the contract with the vision services and obtained a contract with a new eye doctor to provide services to the residents. The SSD said Resident #93 had not been seen by the eye doctor since he was admitted to the facility in February 2024. The SSD said the resident was not seen the last time the previous doctor was here in March 2024 because he did not want to have the resident establish a baseline with the previous doctor and then have to switch providers. The SSD said he would ensure Resident #93 was added to the list when the new eye doctor came to the facility. The SSD said Resident #57 was assessed for glasses in February 2024 and he had not received them yet. The SSD said he had not received any updates regarding the resident's glasses or updated the resident regarding progress made towards obtaining the resident's new glasses. The SSD was interviewed again on 4/10/24 at 10:56 a.m. He said Resident #40 had not been seen by the eye doctor for the past year. The SSD said he would add her to the list to be seen by the new eye doctor.

Based on observations, staff interviews, and record review, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#13 and #83) of two residents reviewed for catheter care out of 49 sample residents. Specifically, the facility failed to ensure there were orders for catheter care and maintenance for Resident #13 and #83. Findings include:I. Facility policy and procedureThe Catheter care policy and procedure, revised November 2017, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part: "It is the policy of this facility that each resident with an indwelling urinary catheter will receive the necessary care and services related to minimizing the risks and promoting the highest practicable well-being. This includes but is not limited to physician's order for medical necessity, care planning the specific catheter size with resident specific interventions, daily catheter care, monitoring urine output, and replacing or changing the catheter when it is directed by the resident's physician."II. Resident #13A. Resident statusResident #13,under the age of 65, was admitted on 2/1/23 and readmitted on 2/14/24. According to the April 2024 computerized physician orders (CPO), diagnoses included paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), type 2 diabetes mellitus, cognitive communication deficit and flaccid neuropathic bladder (underactive bladder that does not contract enough to empty). The 2/19/24 admission minimum data set (MDS) assessment revealed the resident had intact cognition and scored a 14 out of 15 on the brief interview for mental status (BIMS) assessment. The resident showed no signs of delusions or psychosis and had no aggressive behaviors. The resident did not reject care or assistance. The resident upon admission was able to complete some activities of daily living with only set up assistance from staff. The resident needed supervision or touching assistance from staff for bed mobility and upper body dressing. The resident needed partial to moderate assistance for transferring, lower body dressing and with personal hygiene. The resident had a suprapubic catheter. B. Resident interviewResident #13 was interviewed on 4/8/24 at 3:10 p.m. He said he was in pain from his catheter. He said he had been asking nursing staff for over a week to replace it but it had not been done. He said he was considering calling 911 to go to the hospital because he knew the hospital would take care of him. Resident #13 said he was aware of the different types of pain in his body and he knew this pain was caused by his catheter needing changed. He could not remember the last time it was changed but said it had been a while. C. Record reviewReview of the resident's medical record revealed the resident was readmitted on 2/14/24 with a suprapubic catheter. Review of the resident's April 2024 physician's orders, medication and treatment administration record (MAR/TAR) revealed there were no orders for routine catheter care, maintenance or monitoring of the resident catheter. The comprehensive care plan initiated 3/7/24 had a focus for suprapubic catheter with interventions to change the catheter bag and tubing as ordered, provide catheter care every shift and as needed, monitor for signs and symptoms of discomfort and to report to the doctor signs or symptoms of urinary tract infection. A long term care follow up note entered by the physician on 3/13/24 revealed Resident #13 had recurrent catheter associated urinary tract infections (CAUTI) dating back to 2/15/23 shortly after his initial admission. The catheter was changed and he was started on antibiotics. The next catheter change was 9/25/23 after he was sent to the emergency department (ED) and found to have another CAUTI. On 1/7/24 Resident #13 was sent back to the hospital and found to have bilateral hydronephrosis (urine unable to leave the kidneys) with a distended bladder due to a clogged catheter. The catheter was replaced at that time. On 2/1/24 the resident returned to the ED and was found to have another CAUTI. -There was not any documentation regarding suprapubic catheter care or replacement being performed. III. Resident #83A. Resident statusResident #83,under the age of 65, was admitted on 8/28/23 and readmitted on 9/23/23. According to the April 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, cognitive communication deficit and neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problem). The 3/4/24 MDS assessment revealed the resident had intact cognition and scored a 13 out of 15 on the BIMS assessment. The resident showed no signs of delusions or psychosis and had no aggressive behaviors. The resident did not reject care or assistance. The resident was able to complete some activities of daily living independently. The resident was dependent on staff for perineal care, bathing, lower body dressing and transfers. The resident had an indwelling catheter. B. Resident interviewResident #83 was interviewed on 4/9/24 at 3:45 p.m. She said she could not remember how long it had been since her catheter was changed. C. Record reviewReview of the resident's April 2024 physician's orders, medication and treatment administration record (MAR/TAR) revealed no orders for routine catheter care, maintenance or monitoring of the resident catheter. Review of the comprehensive care plan initiated 3/1/24 revealed a focus for indwelling catheter with interventions to change catheter bag and tubing as ordered, monitor and document for pain or discomfort, report to doctor for signs and symptoms of urinary tract infection and provide catheter care every shift and as needed. A long term care follow up note entered by the physician on 3/1/24 revealed the resident had a chronic indwelling catheter and had failed a void trial prior to admission. The physician documented the resident requested to continue use of the indwelling catheter. The physician documented to attempt another void trial on Monday. -There was not any documentation of a void trial after the physicians note. IV. Staff interviewsThe assistant director of nursing (ADON) was interviewed on 4/8/24 at 3:30 p.m. The ADON said residents with catheters should have orders for care and monitoring. He said it was important to follow the orders to prevent infection. The ADON was not able to locate orders for Resident #13 or Resident #83 and said he would look into it. He was not aware of Resident #13's complaints of pain or requests to have his catheter changed. Licensed practical nurse (LPN) #4 was interviewed on 4/9/24 at 4:00 p.m. She said residents with catheters should have orders to change the catheter if it was irritated or painful. She said routine orders for changing a catheter were usually every three months. LPN #4 said all residents who have any type of catheter should have physician orders for care.

Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#57 and #87) of two residents reviewed for pain out of 49 sample residents. Specifically, the facility failed to:-Offer person-centered non-pharmacological pain interventions for Resident #57; and,-Follow physician orders for pain parameters when administering as needed pain medications for Resident #57 and Resident #87. Findings include:I. Facility policy and procedureThe Pain Management policy, revised November 2019, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, "It is the policy of this facility to provide an environment and programs that assist each resident o attain or maintain the resident's highest practicable physical, mental and psychosocial well being. Residents are provided and receive the care services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. "Purpose: the facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by: screening to determine if the resident has been or is experiencing pain; comprehensively evaluation of the pain. Licenses nurse will complete the Pain evaluation in (electronic medical record system); and, using pharmacological and/or non-pharmacologic interventions to manage the pain and/or try to prevent the pain consistent with the resident's goals. "Monitor pain status and treatment effects on a regular basis. "Consult physician for additional interventions if indicated."II. Resident #57A. Resident statusResident #57, age 66, was admitted on 8/7/23 and readmitted on 8/9/23. According to the April 2024 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), need for assistance with personal care, anxiety, shortness of breath, alcohol abuse in remission and chronic pain. The 2/15/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) with a score of 12 out of 15. He required partial assistance with eating and oral hygiene. He required substantial assistance for toileting, showering and personal hygiene. The resident received scheduled pain medication. The resident had received as needed pain medication or was offered as needed pain medication and declined. The resident had not received non-medication interventions for pain. The resident reported he frequently had pain. He said his pain frequently made it difficult for him to sleep at night, made it difficult to participate in therapy activities and limited his day-to-day activities. The resident reported his pain level as an 8 out of 10. B. Resident interview and observationResident #57 was interviewed on 4/3/24 at 2:11 p.m. Resident #57 said he had chronic pain throughout most of his body. The resident said he took pain medications. He said he preferred to have non-pharmacological pain interventions since he was a recovering drug and alcohol addict. Resident #57 said heat packs would help his pain significantly but the facility did not offer that to him. Resident #57 was in pain during the interview. He was grimacing and trying to reposition himself in his wheelchair. Resident #57 requested the interview to stop due to his pain level and it was immediately reported to the nurse. C. Record reviewThe February 2024 CPO revealed Resident #57 had the following as needed physician orders for pain management:-Acetaminophen Oral Tablet 325 milligrams (mg) (Acetaminophen, give two tablet by mouth every four hours as needed for mild pain 5-10, ordered 8/7/23; and, -Hyrdocodone-Acetaminophen Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen), give one tablet by mouth every six hours as needed for pain 8-10, ordered 8/7/23. A review of Resident #57's February 2024 medication administration record (MAR) (2/1/24 to 2/29/24) documented the resident was administered Hydrocodone-Acetaminophen Oral Tablet 5-325 mg when he reported his pain level at a 3 on 2/9/24 and 2/15/24. The resident was administered Hydrocoodone-Acetaminophen Oral Tablet 5-325 mg when he reported his pain level at a 6 on 2/8/24, 2/19/24, 2/20/24, 2/21/4, 2/26/24 and 2/28/24. The resident was administered Hydrocodone-Acetaminophen Oral Tablet 5-325 mg when he reported his pain level at a 7 on 2/4/24 and 2/9/24.-The pain parameters specified in the physician orders for the Acetaminophen and the Hydrocodone-Acetaminophen overlapped. The Acetaminophen Oral Tablet 325 mg specified for a pain level of 5-10 and the Hydrocodone-Acetaminophen Oral Tablet 5-325 mg specified for a pain level of 8-10. The physician orders did not have an as needed pain medication for a pain level less than 5. The March 2024 CPO revealed Resident #57 had the following as needed physician orders for pain management:-Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen), give one tablet by mouth every six hours as needed for pain level of 5-10 out of 10, ordered on 8/7/23; and,-Tylenol Tablet 325 mg (Acetaminophen), give two tablets by mouth every four hours as needed for pain level of 1-4 out of 10, not to exceed three grams in 23 hours, ordered 8/7/23. A review of Resident #57's March 2024 MAR (3/1/24 to 3/31/24) documented the resident was administered Hydrocodone-Acetaminophen Oral Tablet 5-325 mg when he reported his pain level at a 2 on 3/4/24, 3/5/24 and 3/6/24. The resident was administered Hydrocodone-Acetaminophen Oral Tablet 5-325 mg when he reported his pain level at a 3 on 3/30/24. The resident was administered Tylenol Tablet 325 mg when he reported his pain level as a 6 on 3/8/24. The resident was administered Tylenol Tablet 325 mg when he reported his pain level at a 7 on 3/21/24 and 3/25/24. The resident was administered Tylenol Tablet 325 mg when he reported his pain level at a 9 on 3/29/24. The April 2024 CPO revealed Resident #57 had the following as needed physician orders for pain management:-Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen), give one tablet by mouth every six hours as needed for pain level of 5-10 out of 10, ordered on 8/7/23; and,-Tylenol Tablet 325 mg (Acetaminophen), give two tablets by mouth every four hours as needed for pain level of 1-4 out of 10, not to exceed three grams in 23 hours, ordered 8/7/23. A review of Resident #57's April 2024 MAR (4/1/24 to 4/8/24) documented the resident was administered Hydrocodone-Acetaminophen Oral Tablet 5-325 mg when he reported his pain level at a 2 on 4/2/24 and 4/4/24. The 3/5/24 pain management review assessment documented the resident had complaints of pain to his back. The resident did not have pain during the interview or had pain in the last five days -However, Resident #57 was administered Hydrocodone-Acetaminophen Oral Tablet 5-325 mg on 3/4/24 for a pain level of 2). The resident reported his pain was worse in the afternoon and it was an aching pain. The resident reported the pain affected his sleep and emotions. Feeling fatigued and physical exercise made the residents' pain worse. The resident reported warm packs, distraction, repositioning and rest would help his pain. The resident reported his pain was well managed. The resident reported his acceptable pain level as a 3. The resident made negative verbalizations and vocalizations, facial expressions and had behaviors when he had pain. The staff would continue with the residents current plan of care. -However a review of the resident's EMR did not reveal the resident had been offered warm packs to assist with his pain. The 3/5/24 pain interview documented the resident had frequent pain within the lastfive days. The resident reported pain occasionally affected his sleep and interfered with his day-to-day activities. The resident reported his pain as moderate. The pain care plan, initiated on 3/14/24, revealed the resident had acute and chronic pain related to neuropathy and chronic pain. The interventions included: monitoring and documenting for the probable cause of each pain episode, removing causes of pain when possible monitoring and document for side effects of pain medication, monitoring and recording pain characteristics, monitoring and recording signs and symptoms of non-verbal pain, notifying the physician if interventions are unsuccessful or if current complain is a significant change from residents past experience of pain, observing and reporting changes in usual routine, conducting a pain assessment every shift and reporting to the nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain.-However, the person-centered non-pharmacological pain intervention of heat packs was not included in the comprehensive plan of care. III. Resident #87A. Resident statusResident #87, under the age of 65, was admitted on 6/14/23 and readmitted on 9/12/23. According to the April 2024 CPO, diagnoses included morbid obesity, bipolar disorder, post-traumatic stress disorder (PTSD), need for assistance with personal care and pain. The 1/14/24 MDS assessment revealed the resident was cognitively intact with a staff interview for cognition. She required supervision for eating and oral hygiene. She required substantial assistance for toileting and personal hygiene. She was dependent for showering. The resident was on a scheduled pain medication regimen. She received as needed pain medications or was offered as needed pain medications and declined. She did not receive non-medication interventions for pain. The resident had frequent pain. Pain frequently interfered with therapy activities and her day-to-day activities. The resident reported her pain at a 9 out of 10. B. Record reviewThe February 2024 CPO revealed Resident #87 had the following as needed physician orders for pain management:-Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI), give 5 mg by mouth every four hours as needed for pain rated 3-5 out of 10, ordered 1/19/24;-Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI), give 10 mg by mouth every four hours as needed for pain rated 6-8 out of 10, ordered 1/19/24; and,-Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI), give 15 mg by mouth every four hours as needed for pain rated 9-10 out of 10, ordered 1/19/24. A review of Resident #87 February 2024 MAR (2/1/24 to 2/29/24) documented the resident was administered Oxycodone 5 mg when she reported her pain level at a 6 on 2/16/24, 2/22/24 and 2/25/24. The resident was administered Oxycodone 5 mg when she reported her pain level at a 7 on 2/11/24, 2/12/24, 2/17/24, 2/23/24 and 2/27/24. The resident was administered Oxycodone 5 mg when she reported her pain level at an 8 on 2/8/24. The resident was administered Oxycodone 5 mg when she reported her pain level at a 9 twice on 2/8/24. The resident was administered Oxycodone 10 mg when she reported her pain level at a 0 on 2/16/24. The resident was administered Oxycodone 10 mg when she reported her pain level at a 3 on 2/3/24, 2/9/24, 2/15/24 and 2/17/24. The resident was administered Oxycodone 10 mg when she reported her pain level at a 4 on 2/3/24. The resident was administered Oxycodone 10 mg when she reported her pain level at a 9 on 21/24 and 2/3/24. The resident was administered Oxycodone 15 mg when she reported her pain level at a 0 on 2/24/24. The resident was administered Oxycodone 15 mg when she reported her pain level at a 5 on 2/16/24. The resident was administered Oxycodone 15 mg when she reported her pain level at a 7 on 2/21/24. The resident was administered Oxycodone 15 mg when she reported her pain level at an 8 on 2/15/24. The March 2024 CPO revealed Resident #87 had the following as needed physician orders for pain management:-Tylenol Tablet 325 mg (Acetaminophen), give two tablet by mouth every four hours as needed for pain level of 1-4 out of 10, not to exceed three grams in 24 hours;-Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI), give 5 mg by mouth every four hours as needed for pain rated 6-7 out of 10, ordered 1/19/24;-Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI), give 10 mg by mouth every four hours as needed for pain rated 8-9 out of 10, ordered 1/19/24; and,-Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI), give 15 mg by mouth every four hours as needed for pain rated 10 out of 10, ordered 1/19/24. A review of Resident #87 March 2024 MAR (3/1/24 to 3/31/24) documented the resident was administered Tylenol 325 mg when she reported her pain level as a 5 twice on 3/17/24. The resident was administered Tylenol 325 mg when she reported her pain level at a 7 on 3/23/24. The resident was administered Oxycodone 5 mg when she reported her pain level at a 5 on 3/30/24. The resident was administered Oxycodone 10 mg when she reported her pain level at a 4 on 3/30/24. The resident was administered Oxycodone 10 mg when she reported her pain level at a 6 on 3/31/24. The resident was administered Oxycodone 10 mg when she reported her pain level at a 7 on 3/21/24, three times on 3/22/24, 3/23/24, 3/24/24 and 3/26/24. The resident was administered Oxycodone 10 mg when she reported her pain level at a 10 on 3/27/24. The resident was administered Oxycodone 15 mg when she reported her pain level at an 8 on 3/25/24. The resident was administered Oxycodone 15 mg when she reported her pain level at a 9 on 3/27/24 and 3/31/24. The April 2024 CPO revealed Resident #87 had the following as needed physician orders for pain management:-Tylenol Tablet 325 mg (Acetaminophen), give two tablet by mouth every four hours as needed for pain level of 1-4 out of 10, not to exceed three grams in 24 hours;-Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI), give 5 mg by mouth every four hours as needed for pain rated 6-7 out of 10, ordered 1/19/24;-Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI), give 10 mg by mouth every four hours as needed for pain rated 8-9 out of 10, ordered 1/19/24; and,-Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI), give 15 mg by mouth every four hours as needed for pain rated 10 out of 10, ordered 1/19/24. A review of Resident #87 April 2024 MAR (4/1/24 to 4/8/24) documented the resident was administered Tylenol 325 mg when she reported her pain level as a 5 on 4/8/24. The resident was administered Tylenol 325 mg when she reported her pain level at a 6 on 4/8/24. The resident was administered Oxycodone 5 mg when she reported her pain level at a 5 on 4/4/24, 4/5/24 and 4/7/24. The resident was administered Oxycodone 10 mg when she reported her pain level at a 4 on 4/4/24. The resident was administered Oxycodone 10 mg when she reported her pain level at a 5 on 4/5/24 and 4/7/24. The resident was administered Oxycodone 15 mg when she reported her pain level at an 8 on 4/1/24.-A review of the March 2024 and April 2024 CPO revealed the resident did not have an as needed pain medication for when she reported her pain level at a 5. The 10/8/23 monthly medication review completed by the pharmacist documented the resident had received Oxycodone for pain level of 3-6 out of 10 or pain documented as a 0 and 2, please check documentation as this is a medication error and needs to be addressed. The 3/4/24 Pain Management Review assessment documented the resident complaint of pain to her back and legs. The resident reported she did not currently have pain but had pain within the last day. The resident had daily pain or pain several times a day. The resident had back and muscle pain that was worst in the early morning, mid-morning, afternoon and late evening. The resident described her pain as aching. The resident said her pain affected her sleep and emotions. The resident said physical activity and feeling fatigued made her pain worse. The resident said warm packs, breathing and relaxation, distraction and rest helped. The resident said Oxycodone and Tylenol helped her pain. The resident said her pain was very well managed. The resident reported her acceptable pain level as a 3. The resident made negative verbalizations and vocalizations, facial expressions and had behaviors when he had pain. The staff would continue with the residents current plan of care. The 3/25/24 Pain Interview assessment documented the resident frequently had pain that occasionally affected her sleep, therapy activities and day-to-day activities. The resident reported her pain as moderate. The pain care plan, initiated on 3/15/24, revealed the resident had potential for acute and chronic pain related to neuritis (nerve inflammation) and neuralgia (sharp nerve pain). The residents' acceptable level of pain was 2 out of 10. The interventions included: anticipating and meeting the residents need for pain relief and responding immediately to any complaint of pain, following the pain scale to medicate as ordered, providing non-pharmacological interventions, notifying the physician if interventions were unsuccessful, observing and reporting changes in usual routine and completing a pain assessment every shift. IV. Staff interviewsCertified nurse aide (CNA) #9 was interviewed on 4/8/24 at 4:02 p.m. She said Resident #57 often complained of generalized pain. CNA #9 said when the resident reported pain she told the licensed nurse on duty. Registered nurse (RN) #3 was interviewed on 4/9/24 at 12:14 p.m. RN #3 said if a resident had multiple as needed pain medications the physician would put specified pain parameters within the physician's order. RN #3 said the licensed nurses had to follow the pain parameters for as needed pain medications. The assistant director of nursing (ADON) was interviewed on 4/9/24 at 1:35 p.m. The ADON said Resident #57 had pain and Resident #87 had chronic pain. The ADON said person-centered pain parameters should be offered to the residents. The ADON said the licensed nurses had to follow the pain parameters for administering as needed pain medications specified in the physician's order. The ADON said he would complete education with the staff on administering pain medications per physician's orders. The ADON said the director of nursing (DON) completed the pain assessment for Resident #57 regarding the heat packs being helpful for the resident's pain. The ADON said he would follow-up with the DON regarding the residents' preferred non-pharmacological pain interventions. V. Facility follow-upThe facility provided documentation indicating licensed practical nurse (LPN) #5 was provided education on 10/17/23 regarding administering pain medications per the CPO pain parameters for follow-up regarding the pharmacist altering the facility of the medication error for Resident #87. -However, the facility continued to administer as needed pain medications outside the physician ordered pain parameters for Resident #87's pain medications.

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

Based on observations, record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#87) of five residents reviewed for psychotropic medications out of 49 sample residents. Specifically, the facility failed to attempt a gradual dose reduction (GDR) for Resident #87's use of antidepressant medication, sedative medication and antipsychotic medication or provide substantial documentation by the prescribing physician on why a GDR of the resident's medication was contraindicated. Findings include:I. Facility policy and procedureThe Psychotropic Drug Use policy, revised November 2016, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, "Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. "Quarterly thereafter, or with any significant change in condition, the residents will be calendared by the SSD (social services director) for referral to the Psychotropic Drug Review Committee to assess for continued need/justification of the medication and possible Gradual Dose Reduction."II. Resident #87Resident #87, under the age of 65, was admitted on 6/14/23 and readmitted on 9/12/23. According to the April 2024 computerized physician orders (CPO), diagnoses included morbid obesity, bipolar disorder, post-traumatic stress disorder (PTSD), mood disorder with depressive episodes, dysphonia (decreased voice production), cognitive communication deficit and need for assistance with personal care and pain. The 1/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a staff interview for cognition. She required supervision for eating and oral hygiene. She required substantial assistance for toileting and personal hygiene. She was dependent for showering. III. Record reviewThe April 2024 CPO revealed the following orders for psychotropic medications:-Citalopram Hydrobromide oral tablet 20 milligrams (mg) (Citalopram Hydrobromide), give one table by mouth one time a day for bipolar disorder, ordered 7/31/21;-Latuda oral tablet 60 mg (Lurasidone HCI), give one tablet by mouth one time a day for bipolar disordered, ordered 7/31/23;-Zolpidem Tartrate oral tablet five mg (Zolpidem Tartrate), give one tablet by mouth at bedtime for insomnia, ordered 7/31/23; and,-Valproic Acid oral capsule 250 mg (Valproic Acid), give 750 mg by mouth three times a day for depression, ordered 11/10/23.-Review of the CPO did not reveal the resident had a diagnosis of insomnia or depression. The 7/3/23 interdisciplinary team (IDT) psychotropic review documented the resident had a current diagnosis of bipolar disorder, (PTSD), dysphonia and mood disorder. The resident was receiving Valproic Acid for seizures, Latuda for schizophrenia and citalopram for depression. The resident was on sleep tracking, had loss of interest and lost two pounds. The resident was not on any as needed psychotropics. It was documented on the assessment that the last dose reduction was not applicable. The resident was on as needed Tylenol and Oxycdone. The resident was cognitively intact with a BIMS score of 15 out of 15. The resident scored a three out of 19 on a patient health questionnaire (PHQ-9) indicating none or minimal signs of depression. The resident was consuming 25% of her meals and was on a regular diet with small portions due to history of bariatric surgery. The resident received oral nutritional supplements and enteral feedings. The resident was tolerating the enteral feedings. The resident participated in independent and group activities. The IDT met on 7/11/24. The resident had no reported behaviors, was doing well with her current medications and there were no recommendations at that time. The 10/3/23 IDT psychotropic review documented the resident had a diagnosis of bipolar disorder, PTSD and mood disorder. The resident had a physician's order for Citalopram for bipolar disorder and Latuda for bipolar disorder. The resident had a history of loss of interest. The resident weighed 230 pounds which was an increase from 229.5 pounds on 9/7/23. The resident was not prescribed any as needed psychotropic medications. It was documented on the assessment that the last dose reduction was not applicable. The resident was on as needed Oxycodone and tylenol for pain. The resident was cognitively intact with a BIMS score of 15 out of 15. The resident scored a three out of 19 on a PHQ-9 indicating none or minimal signs of depression. The resident was consuming 50-75% of meals and was ordered small portions due to history of bariatric surgery. The resident was ordered oral nutritional supplements and was receiving water flushes through her gastric tube. The resident's weight had remained stable since admission. The resident continued to participate in independent activities and would occasionally attend a social gathering. The IDT met on 10/17/24. The resident expressed depression and passive suicidal ideations with no plan. The psychiatric nurse practitioner was consulted to meet with the resident. The 1/7/24 IDT psychotropic review documented the resident had a diagnosis of bipolar disorder, PTSD, cognitive communication deficit, mood disorder and dysphonia. The resident was on Valproic Acid for depression, Citalopram for bipolar disorder and Latuda for bipolar disorder. The resident had a history of mood swings in the last quarter. The resident had no recent weight loss and was not on any as needed psychotropic medications. The assessment was not filled out when asked about the last gradual dose reduction for the resident's psychotropic medication use. The resident was on as needed Oxycodone and did not have uncontrolled pain. The resident was on as needed Oxycodone and tylenol for pain. The resident was cognitively intact with a BIMS score of 13 out of 15. The resident scored a four out of 19 on a PHQ-9 indicating none or minimal signs of depression. The resident had low oral intake and was consuming 26-50% of her meals and snacks daily. The resident received small portions due to preference and desire to lose weight. The resident was receiving and oral nutritional supplement, her weight was stable and her body mass index (BMI) indicated she was morbidly obese. The IDT recommended for the physician to complete a risk versus benefit on medication as the resident was planning to discharge. The 4/3/24 physician note documented in pertinent part the resident was not appropriate for a gradual dose reduction at that time as she was likely discharging soon so the resident would be unable to follow-up for these medications. -However, the facility requested a risk versus benefit statement to be completed on 1/7/24. A review of the medical record did not indicate a risk versus benefit had been completed. The insomnia care plan, initiated on 3/15/24, revealed the resident was on hypnotic therapy related to insomnia. The interventions included: not exceeding the recommended daily dose thresholds for hypnotic medications, informing the resident about the risks and benefits of the medications, observing for possible side effects every shift, providing non-pharmacological interventions, preceding or accompanying hypnotic use by other interventions to try and improve sleep and reporting pertinent lab results to the physician. The mood care plan, initiated on 3/15/24 and revised on 3/24/24, revealed the resident had potential for mood problems related to life circumstances, history of vegetative depression, passive suicidal ideations and mood swings. The interventions included: assisting the resident in identifying strengths and positive coping skills, providing behavioral health consults as needed and encouraging the resident to express her feelings. The antipsychotic medication care plan, initiated on 3/15/24 and revised on 3/24/24, revealed the residentwas using antipsychotic medications related to bipolar disorder. The interventions included: documenting episodes of behavior, documenting non-pharmacological interventions, documenting side effects of the medications, monitoring the residents blood pressure monthly and completing an abnormal involuntary movement screen quarterly. The antidepressant care plan, initiated on 3/15/24, revealed the resident was on an antidepressant medication related to bipolar disorder. The interventions included: educating the resident on the risks, benefits and side effects of the medication, administering the medication as ordered, monitoring the residents behaviors, providing non-pharmacological interventions and observing for side effects of the medications. IV. Staff interviews The SSD was interviewed on 4/8/24 at 4:18 p.m. The SSD said residents who were on psychotropic medications were reviewed in the IDT psychotropic medication review meeting quarterly. The SSD said Resident #87 was last reviewed in January 2024. The SSD said the past three psychotropic medication review notes did not indicate that the resident had been attempted for a gradual dose reduction. The SSD said she was unsure the last time Resident #87 was trailed for a dose reduction on any of her psychotropic medications based on the IDT psychotropic medication reviews.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of two medication refrigerators and one medication cart. Specifically, the facility failed to; -Ensure controlled medications were in a locked storage container that was permanently affixed to the refrigerator; -Ensure medications were not left in a medication cup on top of the medication cart when not in direct line of sight with the nurse; and,-Ensure that the medication cart was locked when not in direct line of sight of the nurse. Findings include: I. ObservationsOn 4/4/24 at 2:42 p.m., the medication refrigerator was observed with licensed practical nurse (LPN) #2. Six vials of liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) were in a ziploc bag on the bottom shelf and one bottle of oral Ativan was on the bottom shelf in the refrigerator. -The storage box was being installed in the refrigerator but it was not permanently affixed to the inside of the refrigerator as the shelves were able to slide out. On 4/8/24 at 8:51 a.m. LPN #2 left a medication cup containing cardiac medications on top of the medication cart while she stepped away to administer medications to a resident. LPN #2 was not in direct line of sight of the medication cart. -The assistant director of nursing (ADON) was immediately notified. On 4/8/24 at 1:09 p.m. the medication cart assigned to LPN #1 was observed. The medication cart was unlocked and the nurse was not in sight (see interview below). There were other facility staff passing meal trays to residents. -The ADON was immediately notified. II. Staff interviewsThe nursing home administrator in training (NHAIT) was interviewed on 4/4/24 at 2:42 p.m. The NHAIT said he was aware that the locked storage box needed to be permanently affixed to the refrigerator but securing it to the removable shelf with zip ties was his solution until he could do something more permanent. The ADON was interviewed on 4/8/24 at 8:52 a.m. He said medications should not be left on top of the medication cart. He said residents could easily take the medication and ingest them causing harm to themselves. LPN #1 was interviewed on 4/8/24 at 1:11p.m. She opened the top drawer of the medication cart and realized it had not been locked. LPN #1 said she thought she locked it when she left to get food from the break room. LPN #1 said the medication cart should be locked at all times when unattended. The ADON was interviewed on 4/8/24 at 1:30 p.m. He said LPN #1 had come to him and told him that she left the medication cart unlocked when she went to get food from the break room. At 1:45 p.m. the ADON said he sent LPN #1 home. The director of nursing (DON) was interviewed on 4/10/24 at 2:15 p.m. She said nurses should always lock the medication cart when they step away. She said if the medication cart was left unlocked other staff or residents could get into it and take medications that were not prescribed for them. The DON said medications should always be destroyed if they were not needed or refused. She said they should not be left on top of the medication cart because staff or residents could take them.

Based on interviews and record review, the facility failed to assist residents in obtaining routine or emergency dental services, as needed for four (#57, #40, #93 and #84) of four residents reviewed for dental services out of 49 sample residents. Specifically, the facility failed to ensure:-Resident #57 was provided follow-up dental services recommended by the dentist;-Resident #40 was provided dentures in a timely manner;-Dental services were offered to Resident #93; and, -Refer Resident #84 to a dental specialist as recommended by the facility dentist for follow up on the resident's dental issues. Findings include:I. Facility policy and procedureThe Dental Services policy, dated November 2007, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, "It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. 'Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairts), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, taking impressions for dentures and fitting dentures. "Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. "Residents and/or resident representatives, during the admission process, are notified of dental services available under the State plan (state-run programs), and of the potential charges that may apply in the case of routine or emergency dental care provided by outside resources. The facility will assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. "The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location. "All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record."II. Resident #57A. Resident statusResident #57, age 66, was admitted on 8/7/23 and readmitted on 8/9/23. According to the April 2024 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), need for assistance with personal care, anxiety, shortness of breath, alcohol abuse in remission and chronic pain. The 2/15/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) with a score of 12 out of 15. He required partial assistance with eating and oral hygiene. He required substantial assistance for toileting, showering and personal hygiene. The MDS assessment indicated the resident had no dental issues. -However, the resident had broken teeth and had been recommended to have all teeth extracted. B. Resident interview and observationResident #57 was interviewed on 4/3/24 at 2:05 p.m. He said he saw the dentist a few months ago for a full work-up. He said it was determined he needed all of his teeth pulled and to have dentures made. Resident #57 said his teeth caused him some discomfort. He said he had not received any follow-up from the facility as to when his next appointment would be. Resident #57's teeth were broken. C. Record reviewThe 11/2/23 dental note documented the resident had a cleaning completed. The dentist recommended brushing gently with a soft or extra soft toothbrush. The resident had cavities in almost every tooth. The resident had poor oral hygiene. The dentist spoke to the resident and informed him that dentures would be a good idea. The resident was having sensitivity and agreed on getting full dentures. The 11/20/23 dental note documented the resident had not had extractions yet but was interested because the teeth were causing him pain. The resident had spreading cavities. The 11/22/23 dental done documented the resident had the option to save the teeth. The resident said he would rather pull the teeth and get dentures. The note documented to consult the dentist for extractions and dentures. The 1/12/24 dental consult note documented the resident was in pain and wanted his teeth extracted. The note documented the resident's nurse was concerned for the patient due to the pain and would like to know how soon the resident could get the work done on his teeth. The note said to rush the residents status with the social worker to get the work done before the resident got an infection. The note documented the social worker was talked to about the situation and the social worker said they were trying to get the resident back on Medicaid services so he could get the work done as soon as possible. The 1/18/24 dental re-evaluation note documented the resident was partially edentulous, had poor oral hygiene, the tissue was inflamed and red, he had heavy amounts of plaque. The note documented the resident had chronic cavities throughout his mouth. The treatment plan documented debridement was completed via hand scaling. Silver diamine fluoride was added to several teeth. The resident was having pain in his teeth and was bed bound. The dentist prescribed amoxicillin 500 milligrams (mg) once a day and 20% Benzocaine to all teeth to get ride of sensitivity. The next visit was to send a pre authorization for treatment and to complete extractions. The 1/25/24 dental note documented the resident's nurse was asking if the resident was supposed to continue on antibiotics until the resident got the teeth extractions. The dentist said to finish the course of antibiotics. The dentist gave the resident topical Benzocaine to keep the pain under control and referred the resident to a dentist for extractions. The 2/15/24 dental note documented the resident was seen by another dentist for full mouth extractions and when that was finished he needed dentures made immediately. -The resident was interviewed on 4/3/24 and was still waiting on follow-up to have his teeth extracted. The resident had been waiting five months since the dentist recommended to have his teeth pulled and dentures made due to the resident having multiple cavities and pain. -A review of the resident's comprehensive care plan revealed the resident's dental issues were not addressed in the resident's plan of care. The resident had a physician order for Orajel Mouth/Throat Gel 10% (Benzocaine -Dental), apply to affected teeth topically every four hours as needed for dental pain, ordered 1/25/24. -The resident did not receive the Orajel from 4/1/24 through 4/8/24. III. Resident #40A. Resident statusResident #40, under the age of 65, was admitted on 1/19/23 and readmitted on 5/29/23. According to the April 2024 CPO diagnoses, included need for assistance with personal care, depression and hypertension (high blood pressure). The 1/28/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of 11 out of 15. She required supervision for eating and oral hygiene. The assessment indicated the resident had no dental issues. -However, the resident was edentulous (had no teeth). B. Resident interviewResident #40 was interviewed on 4/3/24 at 10:16 a.m. The resident said she had no teeth. The resident said she was waiting for her dentures to be made. The resident said it was difficult for her to eat with no teeth. The resident said she had not received any follow-up regarding the progress of her dentures being made. C. Record reviewThe 9/19/23 dental note documented the resident was healing from teeth extractions well. The next visit would include full mouth x-rays and first impressions if the insurance approved. The 11/16/23 dental note documented the residents first impressions were completed for upper and lower dentures. The resident was fully healed post dental extractions. The resident was notified it would take several visits for dentures to be made and fit properly. The 1/3/24 dental note documented the resident was fully edentulous. The dentist documented the next visit was for the residents' bite registration.-There were no additional dental visits after 1/3/24 regarding follow-up for Resident #40's dentures. -A review of the resident's comprehensive care plan revealed the resident's dental issues were not addressed in the resident's plan of care. IV. Resident #93A. Resident statusResident #93, under the age of 65, was admitted on 2/6/24. According to the April 2024 CPO, diagnoses included quadriplegia (little to no movement in all limbs), need for assistance with personal care, other specified disorders of teeth and supporting structures and adult failure to thrive. The 2/12/24 MDS assessment revealed the resident was cognitively intact with a BIMS with a score of 15 out of 15. He was independent for eating. He was dependent for oral hygiene, toileting, showering and personal hygiene. The assessment indicated the resident had no dental issues. B. Resident interviewResident #93 was interviewed on 4/4/24 at 9:05 a.m. He said he had tooth pain. He said one of his teeth on the right side of his mouth broke off several years ago and the nerve was poking through which made it very sensitive. The resident said he chewed on the left side of his mouth to help with the pain. Resident #93 said he had asked the nurses and the social services director (SSD) to see the dentist on many occasions. Resident #93 said he had not seen the dentist since he was admitted to the facility on 2/6/24 despite him asking several times. C. Record reviewA request was made for dental visit notes for Resident #9 on 4/5/24. The SSD said the resident had not been seen by the dentist since he was admitted to the facility (see interview below). -A review of the resident's comprehensive care plan revealed the resident's dental needs were not addressed in the resident's plan of care. The resident had a physician order for Orajel 3X Toothache and Gum Mouth/Throat Gel 20-0.26-0.15% (Benzocaine-Menthol-Zinc Chloride), apply to upper right tooth/bum topically every six hours as needed for pain apply to affected area while awake before meals, ordered 2/6/24. -The resident had not received the medication from 4/1/24 through 4/8/24. V. Staff interviewsCertified nurse aide (CNA) #9 was interviewed on 4/8/24 at 4:02 p.m. CNA #9 said Resident #57 had several missing and broken teeth. CNA #9 said the resident's teeth were rotting. CNA #9 said the resident reported pain to his teeth at times. CNA #9 said Resident #93 reported mouth pain but was good at brushing his teeth when the staff assisted him in getting the toothbrush ready. The SSD was interviewed on 4/8/24 at 4:18 p.m. The SSD said he had worked at the facility since November 2023. The SSD said the ancillary services were very inconsistent at the facility. The SSD said he terminated the contract with the dental services and obtained a contract with a new dentist to provide services to the residents. The SSD said Resident #57 did not qualify for emergency dental services because he did not have severe pain. The SSD said the previous dentist would not visit residents in their rooms and Resident #57 preferred to stay in his room. The SSD said Resident #57 was awaiting tooth extractions. The SSD said Resident #40 was supposed to have dentures being made. The SSD said the resident had been waiting several months for the dentures. The SSD said he was not sure when the resident would receive her dentures. The SSD said Resident #93 admitted to the facility in February 2024. The SSD said Resident #93 had not been seen by the dentist since he was admitted. The SSD said the resident had not been seen by the dentist since he was trying to transition to a new facility dentist. The SSD said he had not considered assisting Resident #93 in visiting a dentist outside the facility since he did not express the pain was that bad to him. The SSD was interviewed again on 4/10/24 at 10:56 a.m. The SSD said there was not a plan in place for residents to receive dental services while the facility was transitioning to a new facility dentist. VI. Resident #84A. Resident statusResident #84, age 78, was admitted on 3/14/23. According to the April 2024 CPO, diagnoses included dementia with behavioral disturbance, anxiety and a need for assistance with personal care. The 3/20/24 MDS assessment revealed the resident usually understood conversations but missed some or parts of the intent of the message and was able to make herself understood. The resident was assessed to have severely impaired cognition as evidenced by a BIMS score of three out of 15. The MDS did not document any dental concerns. The resident presented with physical and verbal behavioral symptoms directed toward others, wandered daily and rejected care evaluation and care daily assistance with activities of daily living (ADL). The resident and or resident representative said it was important to the resident to choose her clothing, receive a shower, care for personal belongings and participate in favorite activities. B. Resident representative interviewResident #84's representative was interviewed on 4/8/24 at 3:06 p.m., The resident representative said the facility was not assisting with setting up a dental appointment for Resident #84. Resident #84 was in need of dental services and she had been calling the facility social worker for several months. The social services worker never called her back. The resident representative said she planned to be present for Resident #84's dentist appointment so the resident would cooperate with care, but she needed the facility to communicate with her to get the appointment set up. C. Record reviewA dental note dated 11/16/23 read: "Today's Note: Tooth #9 has not been extracted. The patient does not want to get an extraction done at this time. We will keep the root tip treated regularly with SDF (a colorless liquid that is applied to teeth with a small brush. It contains silver, which kills germs that can cause tooth decay, as well as fluoride to prevent, slow down, or stop decay) and keeps an eye for infection."A dental note dated 12/4/23 read: "Today's Note: Tooth #7 needs a filling, root tip for tooth #9 needs extraction. The patient wants work done, refer to (name of dental specialist)."A dental note dated 1/25/24 read: "Today's Note: Silver diamine was applied to tooth #7 and tooth #9 root tip to arrest caries process. The pulp vitality test was negative for tooth #7 and #9 was negative. (Resident #84 wants to get tooth #7 treated and tooth #9 root tip extracted. Refer to (name of dental specialist) to get tooth #7 treated and tooth #9 extracted. The patient would not let us do the treatment." -A review of the resident's medical record and progress note failed to show documentation of the recommended referral to the dental specialist being made. D. Staff interviewsCNA #3 was interviewed on 4/8/24 at 1:02 p.m. CNA #3 said Resident #84 was not a good eater and sometimes complained of tooth and mouth pain. She was reluctant to let staff assist her with ADLs, especially oral care, so staff did not know the condition of her teeth. CNA #3 said the resident's family was able to get her to take a shower and perform grooming tasks when they visited but their visits were infrequent. The SSD was interviewed on 4/8/24 at 4:18 p.m. The SSD said he was having trouble for over five months getting consistent dental services from the existing provider the facility was contracted to use. The SSD said he worked with the dental provider to rotate services to the various residents so each resident could be seen and they did have access to emergency dental care when needed. The SSD said he was aware of Resident #84 need for dental services and had discussed this with the resident's guardian and additionally talked to the resident earlier that morning. Licensed practical nurse (LPN) #3 was interviewed on 4/8//24 at 3:42 p.m. LPN #3 said Resident #84 had expressed a desire to get her tooth fixed so he did put her on the dental list and he was not sure when she would see the dentist. LPN #3 said the resident had her dental issue for a few months. LPN #3 said the resident did not let staff do much for her or look at her teeth so he was not sure of the extent of her dental needs but knew she needed dental work completed.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to:-Ensure housekeeping staff changed gloves and performed hand hygiene consistently when appropriate;-Ensure housekeeping staff performed hand hygiene appropriately when performed;-Ensure housekeeping staff properly used a disinfectant chemical when cleaning resident rooms and bathrooms;-Ensure tracking, offering and administration of the COVID-19 vaccination;-Follow infection control practices during wound care; and,-Ensure proper hand hygiene was conducted during medication administration. Findings include:I. HousekeepingA. Facility policy and procedureThe Infection Control Policy and Procedure for Housekeeping services, dated January 2009, was provided by the maintenance director (MTD) on 4/9/24 at 2:22 p.m. It read in pertinent part, "It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the facility's interior will aid in physically removing and reducing microorganisms' potential contribution to the incidence of health-associated infections (HAI)."Personnel working in resident areas will follow strict hand washing procedures."A hospital-grade disinfectant/detergent registered by the federal EPA (Environmental Protection Agency) will be used."The Hand Hygiene policy, dated October 2022, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, "Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associated infection. "All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. "Wash hands with soap and water for the following situations: when hands are visibly soiled and after caring fo ra resident with known or suspected Clostridiales (c.) difficile or Norovirus infection during an outbreak, or if infection rates of C. Difficile Infection."Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after coming on duty; before and after direct contact with residents; before preparing or handling medications; before performing any non-surgical invasive procedures; before donning (putting on) sterile gloves; before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment, etc.; after removing gloves; before and after eating or handling food; before and after assisting a resident with meals; after personal use of the toilet or conducting your personal hygiene; and, after removing and disposing of personal protective equipment."Washing hands: vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under moderate stream of running water, at a comfortable temperature. How water is unnecessarily rough on hands; rinse hands thoroughly under running water; hold hands lower than wrists; do not touch fingertips to inside of sink; dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel; discard towels into trash; use lotions throughout the day to protect the integrity of the skin."Using Alcohol-Based Hand Rubs: apply generous amount of product to palm of hand and rub hands together; cover all surfaces of hands and fingers until hands are dry; and follow manufacturers' directions for volume of product to use."B. Disinfectants used in the facilityThe BNC-15 instructions were retrieved from https://www.spartanchemical.com/about/news/bnc-15/ on 4/16/24. It read in pertinent part, "BNC-15 offers three minutes disinfection for most common bacteria and viruses."The NABC Concentrate Non-Acid Disinfectant Bathroom Cleaner instructions were retrieved from https://www.spartanchemical.com/about/news/bnc-15/ on 4/16/24. It read in pertinent part, "Contact time: Leave surfaces wet for 10 minutes." C. Observations of housekeeping staff on 4/9/24At 8:52 a.m. housekeeper (HSKP) #1 was observed cleaning room 707. She used alcohol based hand rub for nine seconds. Her hands were still visibly wet when put on a pair of gloves. HSKP #1 spray a couple squirts of the BNC-15 chemical on a towel. HSKP #1 entered the room and began wiping off the bedside table. The bedside table did not appear wet. HSKP #1 returned to the housekeeping cart and disposed of the dirty towel. HSKP #1 got another towel and sprayed a couple squirts of the BNC-15 chemical on the towel. HSKP #1 entered the room and used the towel to wipe off the sink, the counter surrounding the sink and the mirror. HSKP #1 picked up the resident's tooth brush and other toiletry items to clean under with the same towel. The surfaces were not visibly wet after HSKP #1 wiped them down with the towel. HSKP #1 returned to the housekeeping cart and disposed of the dirty towel. HSKP #1 got another towel and sprayed a couple squirts of the BNC-15 chemical on the towel. HSKP #1 did not change her gloves or perform hand hygiene. HSKP #1 grabbed a bucket with a toilet brush that was filled with bathroom cleaner. HSKP #1 entered the room and used the towel to wipe off the toilet and grab bar in the bathroom. The surfaces were not visibly wet after she wiped the surfaces with the towel. HSKP #1 used the toilet brush to clean the inside of the toilet. At 8:56 a.m. returned to the housekeeping cart. She disposed of the towel and put the toilet brush bucket on the cart. Without changing gloves or performing hand hygiene, HSKP #1 grabbed the broom and began sweeping the bathroom and the room. HSKP #1 got the dustpan and swept the debris into it. HSKP #1 returned to the housekeeping cart and put the dustpan and the broom away. HSKP #1 got a mop head and began mopping the room. HSKP #1 picked up the resident's shoes and the trash can to mop underneath them. HSKP #1 returned to the cart and disposed of the mop head. HSKP #1 got another mop head and mopped the bathroom. HSKP #1 touched door knob to the room with her gloved hands. HSKP #1 disposed of the mop head and put the mop head back on the housekeeping cart. HSKP #1 removed her gloves and entered the room. HSKP #1 turned on the sink and washed her hands. HSKP #1 used her clean hands to turn off the sink. HSKP #1 turned the sink back on and got a paper towel to dry her hands. HSKP #1 used the paper towel she dried her hands with to turn off the sink. HSKP #1 then used the same paper towel to wipe off the sink and the counter surrounding the sink. HSKP #1 returned to the housekeeping cart and said she was done cleaning the room. At 10:59 a.m. HSKP #2 exited room 203 with gloves on. HSKP #2 disposed of a dirty mop head, got a new mop head and returned to room 203 to mop. HSKP #2 took the mop head off the mop and disposed of it. HSKP #2 applied hand sanitizer on her hands and began rubbing them together. With visibly wet hands HSKP #2 picked up a towel on her cart and dried her hands on the towel. HSKP #2 put gloves on and entered room 201. HSKP #2 flushed the toilet and moved the toilet riser out of the bathroom. HSKP #2 took the trash out of two trash cans and then put new trash bags in the trash cans. HSKP #2 said she was hot and opened the window with the same gloved hands. HSKP #2 went around the room and began picking up trash that was on the bedside table and the counter near the sink. HSKP #1 touched the resident's newspaper with the same gloved hands and then put it back on the counter next to the sink. HSKP #2 got the toilet brush bucket from the housekeeping cart and began using the toilet brush to clean the inside of the toilet bowl, the outside of the toilet, the base of the toilet near the ground and the ground surrounding the toilet. HSKP #2 then used the same toilet brush without placing it back in the bucket of sanitizer and used it to clean the toilet riser. HSKP #2 said she was unsure what the blue chemical was that she used to clean the toilet and toilet riser. HSKP #2 returned to the housekeeping cart. HSKP #2 got the BNC-15 chemical and sprayed the sink, toilet and other high touch areas. HSKP #2 immediately began wiping off the surfaces she sprayed. HSKP #2 was utilizing the towel she used to wipe her hands off prior to entering the room to wipe off the surfaces in the resident room and bathroom. HSKP #2 said the BNC-15 chemical had to remain on the surface for one minute prior to wiping it off. -However, the BNC-15 chemical has a three minute surface disinfectant time. HSKP #2 got another towel and began wiping off the toilet riser then the toilet. HSKP #2 used the same towel to wipe off the grab bar in the bathroom. HSKP #2 returned to the cart and disposed of the dirty towel. Without changing gloves or performing hand hygiene, HSKP #2 got the broom and began sweeping the room. HSKP #2 got the dustpan and swept up the debris. HSKP #2 returned the broom and dustpan to the housekeeping cart. HSKP #2 said she had to go get the wet floor signs. Without changing gloves or performing hand hygiene HSKP #2 locked the housekeeping cart and walked to the previous room to get the wet floor sign and put it in front of room 201. Without changing gloves or performing hand hygiene HSKP #1 unlocked the cart and got the glass cleaner. HSKP #2 entered the room and sprayed the glass cleaner on the mirror. HSKP #2 wiped the mirror off with a towel and used the towel to wipe off the sink area. HSKP #2 returned to the cart and disposed of the towel and put the glass cleaner back. HSKP #2 got a clean mop head and began mopping the bathroom. HSKP #2 returned to the cart and disposed of the dirty mop head. Without changing gloves or performing hand hygiene, HSKP #2 got another clean mop head and then mopped the resident's room. HSKP #2 picked up a hairball off the ground and put it into the trash can and continued mopping the room. With the same gloves hands HSKP #2 closed the window and turned off the bathroom light and the room light. HSKP #2 got air freshener and sprayed the curtains in the room. HSKP #2 finished mopping the room and disposed of the mop head. HSKP #2 got a new towel and sprayed BNC-15 on it and began wiping the grab bar outside of room 201 with the same gloved hands. At 11:19 a.m. HSKP #2 disposed of the towel and took her gloves off. HSKP #2 applied hand sanitizer and rubbed her hands together for four seconds. HSKP #2 hands were visibly wet when she put on a new pair of gloves. D. Staff interviewsHSKP #2 was interviewed on 2/9/24 at 11:20 a.m. HSKP #2 said she was instructed to wash her hands and put gloves on when she started cleaning a room. HSKP #2 said she only changed her gloves and performed hand hygiene when she was done cleaning a room prior to cleaning the next room. The MTD and the housekeeping supervisor (HSKS) were interviewed on 4/9/24 at 12:48 a.m. The MTD said hand hygiene should be conducted frequently. The MTD said gloves should be changed and hand hygiene should be performed when going from a dirty item to a clean item. The MTD said the BNC-15 chemical and a one to three minute surface disinfectant time. The MTD said the surface needed to be wet for the entire duration. The MTD said HSKP #1 was not effectively cleaning and sanitizing the rooms when she was spraying the towels with the cleaner. The MTD said the surface would not remain wet for the correct duration that way. The HSKS said when using hand sanitizer the staff needed to rub their hands together until the hand sanitizer was dry. The MTD said he would immediately conduct an in-service with all housekeeping staff on hand hygiene and the proper surface disinfectant times of the chemicals. The MTD said the bathroom cleaner did not have a surface disinfectant time. -However, according to the manufacturer guidelines it has a 10 minute surface disinfectant time. II. COVID-19 immunization trackingA. Facility policy and procedureThe COVID Management policy, revised November 2022 was provided by the NHA on 4/3/24 at approximately 11:00 a.m. It read in pertinent part, "The facility will assess and track the vaccination status of all residents and staff. "The facility will do on-going education to promote vaccine confidence. "Vaccination clinics will be held at the facility within 60 days of any update to CDC's COVID-19 vaccination recommendations."The COVID Resident Vaccination policy, revised November 2022, was provided by the NHA on 4/3/24 at approximately 11:00 a.m. It read in pertinent part, "Residents who have no medical contraindications to the vaccine will be encouraged to receive the COVID-19 vaccine per the frequently recommended by the Centers for Disease Control and Prevention (CDC), to encourage and promote the benefits associated with COVID-19 infection prevention. "The facility shall provide education about the risks, benefits and potential side effects of the COVID-19 vaccine to residents and or responsible party including the Food and Drug Administration (FDA) Emergency Use Authorization (EUA) Fact Sheet. "Residents and/or POA (power of attorney) will be offered the COVID-19 vaccine if available for administration by the facility or in the community. "If a Resident is already vaccinated, the facility will obtain a copy of their vaccination record and maintain it in the medical record. "Administration of the COVID-19 vaccine will be made in accordance with Centers for Disease Control and Prevention (CDC) recommendations in effect at the time of the vaccination."If the resident and/or responsible party would prefer to get the vaccine in the community or if there is no facility clinic available, the facility will assist the resident in making the appointment at their chosen community pharmacy and will transport resident to and from appointment."B. Record reviewAccording to the electronic medical record (EMR) of Resident #3 (admitted 1/5/15 and readmitted 2/25/22), the resident had not been offered or received the 2023/2024 COVID-19 booster. According to the EMR of Resident #84 (admitted 3/14/23), the resident had not been offered or received the 2023/2024 COVID-19 booster. According to the EMR of Resident #63 (admitted 78/21), the resident had not been offered or received the 2023/2024 COVID-19 booster. According to the EMR of Resident #31 (admitted 9/2/2020 and readmitted 1/27/23), the resident had not been offered or received the 2023/2024 COVID-19 booster. According to the EMR of Resident #68 (admitted 11/11/22), the resident had not been offered or received the 2023/2024 COVID-19 booster. C. Staff interviewsThe IP was interviewed on 4/4/24 at 12:31 p.m. The IP said she had worked at the facility for almost one year. The IP said the facility had not held a COVID-19 vaccination clinic since she started working at the facility. The IP said the pharmacy they used previously did not have access to the COVID-19 booster. The IP said the facility began using a new pharmacy on 3/1/24 and she was hoping to hold a COVID-19 vaccination clinic soon. III. Infection control during wound careA. ObservationsOn 4/3/24 at 10:44 a.m., registered nurse (RN) #1 prepared to perform wound care for Resident #13. RN #1 gathered the supplies and entered the resident ' s room. She placed the supplies on the bedside table. She did not sanitize the table or lay down a barrier to place the supplies on. RN #1went to the sink and washed her hands with soap and water for six seconds. She turned around and moved the resident ' s wheelchair, moved the bedside table and then put gloves on. RN #1 sprayed wound cleanser on the wound, wiped the wound with gauze, applied calcium alginate and removed her gloves. She opened the abdominal pad with her bare hands, applied the abdominal pad to the wound and covered the abdominal pad with tape. -RN #1 did not perform hand hygiene after touching dirty items in the room and prior to providing wound care. B. Staff interviewsThe director of nursing (DON) was interviewed on 4/10/24 at 2:15 p.m. She said the proper steps of wound care were to check the orders, gather the supplies, use hand sanitizer or wash hands, put the supplies on the bedside table, wash hands and put gloves on, remove the old dressing, clean the wound, wash hands and put on new gloves and apply the new dressing. She said failure to follow proper infection control practices during wound care could cause the wound to become infected which would prolong healing. IV. Hand hygiene during medication administrationA. ObservationsOn 4/8/24 at 7:26 a.m., medication administration was observed with licensed practical nurse (LPN) #1. She opened the medication cart and began preparing the medications for Resident #7. -She did not wash or sanitize her hands. LPN #1 administered the medications to Resident #7 in his room and returned to the medication cart. At 7:32 a.m. LPN #1 prepared the medications for Resident #39 and walked to the resident ' s room to give the medications. At 7:37 a.m. she exited the residents room. LPN #1 put hand sanitizer in her right hand only and rubbed that hand by itself. At 7:43 a.m. LPN #1 began preparing medications for Resident #23. LPN #1 dropped a medication on the floor, put on one glove, picked it up with the gloved hand and put the medication in a medication cup. She covered the medication cup with her glove and put it in the top drawer of the medication cart. LPN #1 walked to the main medication room to look for medication. She did not find the medication and returned to the medication cart. At 8:04 a.m. LPN #1 finished preparing the medications and administered them in the resident ' s room. At 8:07 a.m. LPN #1 exited the resident ' s room. -She did not perform hand hygiene when she exited the room or when she returned to the medication cart. At 8:15 a.m. LPN #1 began preparing medications for Resident #32. She walked to the resident ' s room and administered the medications. At 8:32 a.m. LPN #1 finished administering the medications to the resident and walked to the sink in the resident ' s room to wash her hands. She washed her hands with soap and water, however it was only for six seconds. B. Staff interviewsThe corporate clinical consultant (CNC) was interviewed on 4/9/24 at 3:20 p.m. She said staff should wash their hands with soap and water for 20 seconds or rub their hands together for 20 seconds with hand sanitizer between each resident during medication administration. She said failure to do so could spread germs and cause residents to get sick. The DON was interviewed on 4/10/24 at 3:15 p.m. She said it was important for staff to wash their hands with soap and water or use hand sanitizer for 20 seconds between each resident during medication administration. She said failure to do so could spread infection among residents.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#63, #68, #84, #3 and #31) of five residents reviewed for immunizations out of 49 sample residents. Specifically, the facility failed to:-Ensure Resident #63, #68, #84, #3 and #31's electronic medical record (EMR) was up to date with their vaccination history; and,-Determine which pneumococcal vaccine was given to Resident #63, #68, #84, #3 and #31 and determine if additional doses were needed. Findings include:I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2022, retrieved on 4/16/24, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: "Routine vaccination - pneumococcal-For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20)." (see notes)-For those "over the age of 65 who meet age requirement and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20." "Special situations: Age 19-64 years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups.-Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies.-Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies."II. Facility policy and procedureThe Immunizations-Influenza and Pneumococcal policy, revised October 2022, was provided by the nursing home administrator (NHA) on 4/3/24 at approximately 11:00 a.m. It read in pertinent part, "It is the policy of this facility to offer and administer influenza and pneumococcal immunization to eligible residents after providing education the risks and potential side effects of the vaccine(s) and obtaining consent. Eligibility to receive the vaccines may include, but is not limited to current vaccine status, season/time of year, medical contraindications, or resident preference/choice."To minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and pneumococcal disease by ensuring that each resident is informed about the benefits and risks of immunizations; and has the opportunity to receive the influenza and pneumococcal vaccine(s), unless medically contraindicated, declined or was already immunized. "Receipt of vaccinations is essential to the health and well-being of long-term care residents. Establishing an immunization program against influenza and pneumococcal disease facilitates achievement of this objective. Influenza outbreaks place both the residents and staff at risk of infection. Pneumococcal pneumonia, a type of bacteria pneumonia, is a common cause of hospitalization and death. "Residents will be screened at the time of admission to determine vaccine status and eligibility, using current CDC (Centers for Disease Control)/ACIP (Advisory Committee on Immunization Practices) guidelines, to receive either/both the influenza or pneumococcal vaccine. "Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized. "Information related to education provided regarding the benefits and risks of immunization and the administration or refusal of or medical contraindications to the vaccines will be documented in the resident's medical record. Document that the resident either received the influenza and/or pneumococcal immunization or did not received the influenza and/or pneumococcal immunization due to medical contraindications or declination. Documentation will also include any adverse effects experienced by the resident related to vaccination(s)."III. Resident #63A. Resident statusResident #63, age 70, was admitted on 7/8/21. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia and abnormal weight loss. The 3/11/24 minimum data set (MDS) assessment revealed the resident was not up to date on her pneumococcal vaccination and she had not been offered the pneumococcal vaccination. B. Record review-A review of the resident's EMR on 4/4/24 revealed there was no documentation indicating the resident had received or been offered a pneumococcal vaccination. IV. Resident #68A. Resident statusResident #68, age 70, was admitted on 11/11/22. According to the April 2024 CPO, diagnoses included hypertension (high blood pressure), Alzheimer's disease and depression. The 2/16/24 MDS did not indicate if the resident was up to date on his pneumococcal vaccination. The MDS assessment indicated the pneumococcal vaccination had not been offered. B. Record review-A review of the resident's EMR on 4/4/24 revealed the resident had not received the pneumococcal vaccination after the resident's representative consented for the resident to receive the vacation on 11/11/22. V. Resident #84A. Resident statusResident #84, age 78, was admitted on 3/14/23. According to the April 2024 CPO, diagnoses included heart disease, chronic obstructive pulmonary disease (COPD), need for assistance with personal care and dementia. The 3/20/24 MDS assessment indicated the resident was not up to date on the pneumococcal vaccination and had not been offered the vaccination. B. Record review-A review of the resident's immunization record in the EMR on 4/4/24 revealed the resident had not been offered or received a pneumococcal vaccination. The infection preventionist (IP) said the immunization tab in the EMR was the facility's system on tracking if immunizations had been offered, refused and/or given. The IP said the immunization tab should be up to date with all of the information (see interview below). VI. Resident #3A. Resident statusResident #3, age 72, was admitted on 1/5/15 and readmitted on 2/25/22. According to the April 2024 CPO, diagnosis included dementia and multiple sclerosis (deterioration of the muscles). The 1/31/24 MDS assessment indicated the resident was not up to date on the pneumococcal vaccination and did not state a reason why. B. Resident representative interviewResident #3's power of attorney (POA) was interviewed on 4/8/24 at 9:26 a.m. She said she wanted the resident to be vaccinated for pneumonia every year. She said the facility had not contacted her recently to obtain consent. The POA said she had requested the IP to administer the pneumococcal vaccination several times and hadnever received follow-up. C. Record review-A review of Resident #3's EMR on 4/4/24 revealed the resident had received the Pnuemovax dose one on 1/11/19. The POA declined an additional dose of the Peumovax on 9/16/21. VII. Resident #31A. Resident statusResident #31, age 65, was admitted on 9/2/2020 and readmitted on 1/27/23. According to the April 2024 CPO, diagnoses included multiple sclerosis. The 2/28/24 MDS assessment did not indicate if the resident was up to date on the pneumococcal vaccination. The assessment documented the resident had not been offered the pneumococcal vaccination. B. Record review-A review of the resident's EMR on 4/4/24 revealed the resident had not received the pneumococcal vaccination after the resident consented for the resident to receive the vacation on 1/30/23. VIII. Staff interviewsThe IP was interviewed on 4/4/24 at 12:32 p.m. The IP said had worked at the facility for almost a year and had been in the IP and director of nursing (DON) role. The IP said she was responsible for looking up the resident's immunization history upon admission. The IP said she used the state immunization system to determine which immunizations the resident had received. The IP said she would input the information into the resident's EMR under the immunization tab. The IP said she utilized the immunization tab in the EMR to track immunizations. She said the immunization tab should indicate when a resident had received or refused all immunizations. The IP said she identified the resident's EMR was not up to date on 3/31/24. The IP said she implemented a process improvement plan (PIP). The IP said she had begun going through all of the resident's medical records and reviewing the state immunization system to determine which vaccinations the residents had received and which residents were due for vaccinations. The IP said the PIP would include an audit of all of the residents that resided at the facility. The IP said she had not been reoffering the pneumonia vaccination after a resident had refused but going forward she was going to re-offer the vaccination quarterly at the care conferences. The IP said Resident #63, #68, #84, #3 and #31's EMR was not up to date with the correct information. The IP said she would conduct research to determine if the resident had received the pneumonia vaccination and if they were due for additional doses of the vaccination. The IP said she was aware the current immunization tracking system was not effective and that was why she implemented the PIP.The IP was interviewed again on 4/4/24 at 4:27 p.m. The IP said she did some research and determined Resident #63 had received a dose of the pneumonia vaccination in 2018 and 2020. The IP said this needed to be included in the resident's EMR. The IP said she Resident #31 had consented to receive the pneumonia vaccination and never received it. The IP said the consent forms did not indicate which pneumonia vaccination they were offering the residents. The IP said she would update the consent forms and add it to the PIP. The IP was interviewed again on 4/4/24 at 5:11 p.m. The IP said a new company took over the facility on 3/1/24. The IP said she had lost access to the state immunization system. The IP said she realized this week that the immunization system needed to be updated. The IP was interviewed again on 4/8/24 at 12:01 p.m. The IP said she did a whole house audit over the weekend to determine who needed to be offered the pneumonia vaccination. The IP said she began updating the resident's EMR with the correct vaccination history. The IP said there was a systematic issue that was causing immunizations not to be offered, given and documented in the medical record. The IP said the PIP had not been finished. She said there were eight to 10 more residents that needed to be offered the pneumonia vaccination. IX. Facility follow-up The facility provided additional information 4/5/24. The information indicated Resident #63 had received the Prevnar 13 on 11/9/18 and the PPSV23 vaccination on 10/28/2020. The resident was not eligible for a vaccination. -However, the facility had not identified that the resident had received the vaccinations and included the information in her medical record. The information indicated the facility could not confirm Resident #68 had received the pneumococcal vaccination after consent was provided on 11/11/22. The facility said they reoffered the vaccination and the resident declined on 4/5/24 (during the survey process). The information indicated the facility re-offered the pneumococcal vaccination to Resident #84's POA on 4/5/24 and the POA consented for Resident #84 to receive the pneumococcal vaccination. The information indicated the facility re-offered the pneumococcal vaccination to Resident #31 on 4/5/24 and the resident declined the vaccination (during the survey process).

Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the laundry room was free from multiple environmental concerns observed during tours of the facility. Findings include: I. Facility policies and procedures The Laundry policy and procedure, dated November 2007, was provided by the maintenance director (MTD) on 2/9/24 at 2:22 p.m. It revealed in pertinent part, "The facility launders linens and clothing in accordance with current CDC (Centers for Disease Control) guidelines to prevent transmission of pathogens."Laundry equipment will be used and maintained according to manufacturer's instructions." II. Observations of the laundry room on 4/9/24 At 10:16 a.m. the laundry room floor was wet. There was a large drain on the floor that did not have a drain cover on it. There was water leaking from the ceiling onto the floor and the washing machines. The laundry room was wet and slippery. There was a container of sharps next to the washing machine. On top of two of the washing machines there was water build-up. The water build-up was thick and raised off of the top and sides of the washing machines. There were pieces of equipment on top of the washing machines. The housekeeping supervisor (HSKS) said she was unsure what those items were. There was a glove sticking out of the top of the washing machine on the right side of the room where the detergent entered the machine. The HSKS said she was unsure what those items were. The HSKS said only two of the three washing machines worked and only one of the three dryers worked. The HSKS said there was a pipe in the ceiling that was leaking onto the washing machines and the floor of the laundry room. The HSKS said she was unsure what was causing the leak. The maintenance director (MTD) was interviewed on 4/9/24 at approximately 10:30 a.m. The MTD said he began working at the facility in February 2024. He said when he saw the laundry room when he started it needed attention. He said the laundry room had not been cleaned. The MTD said he would have staff clean the laundry room to ensure it was safer and more sanitary to conduct laundry services in. During the interview the MTD pointed to the large drain on the floor that was without a cover. He said he was unsure how no one had fallen or tripped on the drain. He said it was a big area to be left uncovered and it needed to be covered with a grate to prevent an accident from happening. The MTD said there was a leak somewhere in the building that was leaking onto a pipe that was near the ceiling in the laundry room above the washing machine. He said he had done some investigating into where the leak was coming from but had not figured it out. The MTD said the floor of the laundry room was wet and slippery. The MTD said the container of sharps should not be in the laundry room. The MTD said there were covers from the washing machine that were stacked on top of the washing machines. The MTD said there should not be a glove in the top of the washing machine. The MTD said he heard the washing machine that did not work had been broken for several years. The MTD said one of the dryers stopped working prior to him working at the facility but he was unsure how long it had been broken for. The MTD said there was another dryer that recently stopped working and he was in the process of getting it fixed. The MTD said he was in the process of getting quotes to replace and repair the machines.

A licensure survey was completed on 4/3/24 to 4/10/24. One deficiency was cited.

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

A survey for Incident #34733 was conducted 2/1/24 to 2/5/24. No deficiencies were cited.

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 12/11/2023 and 12/17/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit survey was completed on 12/7/23 for all previous deficiencies cited on 10/9/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 12/7/23 for all previous deficiencies cited on 10/9/23. The facility is in compliance with all regulations surveyed.

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

A survey prompted by complaint #CO34002 was completed 9/26/23 to 10/9/23. Five deficiencies were cited.

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Based on observation, interview, and record review the facility failed to ensure three (#14, #20 and #22) of three residents reviewed for dementia care of 22 sample residents, received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Resident #14 was admitted to the facility for long term care on 5/25/23 with diagnoses of Alzheimer's disease, senile degeneration of the brain, anxiety disorder, depressive episodes, and cognitive communication deficit. The resident required supervision with one person physical assistance with walking in the room and corridors. The resident required extensive one person assistance with dressing. Since admission on 5/25/23 the resident had increasing wandering, agitation and physically aggressive behaviors. Due to the facility failures, Resident #14 wandered into other residents' rooms. The facility failed to determine and prevent triggers that caused agitation and physical aggression toward other residents. The facility failed to maintain the ability for the resident to communicate with staff with the translator machine that required the internet to operate. These failures resulted in Resident #14 was involved in four resident to resident altercations with three other residents, one resident twice over an eight day period. Additionally, the facility failed to implement personalized interventions for Resident #20 and Resident #22, who wandered into other resident rooms. Cross-reference S1509 the facility failed to prevent resident to resident altercations by implementing appropriate safety measures for Residents #14 and #20. Findings include I. Census and conditions demographicThe 9/26/23 Census and Condition form documented 111 residents resided at the facility. There were 62 residents with dementia or Alzheimer's disease and 28 with behavioral health needs. The facility had one long-term secured memory care unit open with 25 residents in the unit. II. Facility policy and proceduresThe Dementia - Clinical protocol, revised April 2021, was delivered by the director of nursing (DON) on 9/27/23 at 2:05 p.m. It read in pertinent part, "As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition. "The staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes."As needed the physician will help verify or reconsider the diagnosis of dementia and identify other possible causes and coexisting psychiatric conditions."Individuals with dementia can also have personality disorder, mental illness, psychosis, delirium, depression, adverse drug reactions (ADRs), or other conditions causing or contributing to impaired cognition and problematic behavior. "As needed, the physician may obtain a psychiatrist or neurologist consultation to assist with diagnosis, treatment selection, monitoring of responses to treatment, and adjustment of medications. "The staff and physician will determine any relationship between the resident's level of pain and cognitive loss. "For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. "Nursing assistants will receive initial training in care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the reviews. "If a psychiatric consultation is called to help manage behavioral or psychiatric symptoms in the individual with dementia, the IDT team will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition, and function, monitoring for complications related to treatment, and evaluating progress."III. Resident #14A. Resident status Resident #14, over age 65, was admitted to the facility on 5/25/23 and lived in the secured memory care unit. According to the September 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, senile degeneration of the brain, anxiety disorder, depressive episodes and cognitive communication deficit. The 8/17/23 facility assessment documented the resident had a severe cognitive deficit with a brief interview for mental status (BIMS) score of three out of 15. The resident required supervision with one person physical assistance with bed mobility, personal hygiene, and toileting, and supervision with set up assistance with transfers between surfaces, walking in the room and corridors, locomotion on and off the unit, and eating. The resident required extensive one person assistance with dressing. -The facility failed to assess the resident's behaviors. B. Record reviewThe care plan for the secured unit, initiated on 5/25/23 and revised on 8/29/23, documented the resident resides on the secured unit related to wandering. Interventions included staff to redirect the resident to safe wandering area as needed. The care plan for communication, no initiation date and revised on 8/29/23, documented the resident had impaired communication due to a diagnosis of Alzheimer's and was Russian speaking. The resident can communicate effectively via a translating machine. Interventions include communicate through identified communication method; staff used a translator to communicate. The care plan for mood, revised on 8/31/23, documented the resident got nervous and anxious at times. Interventions included to approach the resident from the front and address him or her by name, touch/hold his or her hand, avoid things that make the resident more anxious, and if the resident was upset to redirect the conversation or task. The care plan for activities, revised on 9/1/23 documented the resident had a language barrier and the staff was able to use a translator when needed, he enjoyed watching the news, going outside in warm weather, gardening, and listening to Russian music. Interventions included to provide an activity calendar, provide independent leisure as requested and speak to the resident with the translator machine. -The care plan did not have personalized interventions for dementia care. The admission and baseline care plan summary dated 5/25/23 at 7:38 p.m. documented communication and difficulty understanding others due to language barrier, wandering, anxiousness and restlessness concerns. Social services progress note dated 6/22/23 at 1:50 p.m. documented the IDT team met to discuss resident wandering and secure unit placement. The social services director (SSD) and assistant director of nursing (ADON) found a wander guard bracelet in the resident's bedside drawer. -The facility documented moving the resident to the secure memory care unit on 6/22/23, the facility failed to initiate safety measures to prevent the resident from wandering into other residents rooms to prevent physical abuse (cross-reference S1509). Administrator progress note dated 6/22/23 at 1:51 p.m. documented the resident was admitted to the secure unit due to wandering and going into other residents rooms. Nursing progress note dated 7/3/23 at 12:15 a.m, documented the resident had increased agitation and intruded into all residents rooms one-by-one, taking their belongings and attempting to hit other residents with wheelchairs, walkers and other items believing the other residents were in his room. The resident attempted to break the windows on the double doors, attempted to crawl over the nurses station half door and attempted to hit staff with a chair. After being redirected to his room he attempted to break the window. Staff called 911. Administrator progress note dated 7/3/23 at 8:52 a.m. documented the resident was sent to the hospital on an M1 (mental health) hold. Nursing progress note dated 7/3/23 at 8:32 p.m. documented the resident returned to the facility from the hospital. The resident displayed aggressive behaviors toward staff by grabbing, pinching, and hitting and taking a CNA's (certified nurse aide) jacket and wallet. Physician progress note dated 7/5/23 at 8:00 a.m. documented a psychiatric consultation was sent but had not been received and were not able to see the resident. Physician progress note dated 7/12/23 at 5:54 a.m. documented the psychiatric consultation was pending. Nursing progress note dated 7/16/23 at 11:09 a.m. documented the resident was digging in the trash and found bread and put it in his pocket. Physician progress note dated 7/31/23 at 1:57 a.m. documented the psychiatric consultation was still pending. Nursing progress note dated 8/14/23 at 3:01 a.m. documented the resident was going in and out of other resident's rooms and was unable to be redirected. The resident was picking up chairs, walker and "wet floor" signs and attempting to hit staff and other residents. The resident said "this is my house, and they all need to leave." He attempted to hit residents who were walking in the hallway. The resident spit at the nurse. Staff called 911, officers calmed the resident but when the officers departed the resident became aggressive again. The staff placed other residents who were ambulating in the halls in the nurses station for their safety while the resident banged on the door with his fists and other objects. IDT follow up progress note dated 8/31/23 at 10:31 a.m. documented a review of resident targeted behaviors. Interventions included offer lower stimulating behavior, utilize translator machine and offer to go outside. IDT follow up progress note dated 9/25/23 at 10:16 a.m. documented the review of the resident to resident altercation interventions included resident to be redirected into a safe wandering area. Nursing progress note dated 10/1/23 at 11:35 p.m. documented the resident continued to wander in and out of other resident's rooms and was difficult to redirect. IDT event review progress noted dated 10/2/23 at 9:45 a.m. documented following the current IDT review no new interventions suggested at this time. Social services progress note dated 10/6/23 at 11:30 a.m. social services director (SSD) reached out to the psychiatric services provider for a female provider, the provider stated they do not have female providers. Nursing progress note dated 10/6/23 at 2:48 p.m. documented the IDT met to review the resident to resident incident. Interventions included for staff to utilize translator for resident to be able to communicate with other residents due to language barrier. C.Altercations Event initial progress note dated 9/25/23 at 9:46 a.m. documented on 9/24/23 at 4:20 p.m. Resident #14 was arguing with Resident #7 and Resident #7 threw a two inch cowbell and hit Resident #14 in the face causing a reddened area to the left cheek. Event initial progress note dated 9/26/23 at 3:15 p.m. documented a resident to resident altercation on 9/26/23 at 3:00 p.m. between Resident #14 and Resident #20. Resident #14 was walking toward Resident #20 with a closed fist and shoved him in the shoulder. Resident #20 then hit Resident #14 in the face causing a small swelling on the left cheek. Nursing progress note dated 9/30/23 at 7:30 p.m. documented a witnessed resident to resident altercation between Resident #14 and Resident #21. Resident #14 was walking in the hallway when Resident #21 came out of his room yelling at Resident #14, #14 responded in a foreign language and Resident #21 punched #14 on the left side of his face. No injury noted at the time. IDT event initial progress note dated 10/1/23 at 2:17 p.m. documented a resident to resident altercation between Resident #14 and Resident #20. The RN heard a plate break in the dining room and found Resident #14 standing over Resident #20, who was seated, hitting him in the face. Resident #20 suffered a cut on the left eyelid.-The facility failed to provide person-centered approaches to Resident #14's dementia care services to address triggered physical aggressive behavior in order to prevent physical altercations (cross-reference S1509). D. Observation During a brief tour of the memory care unit on 9/26/23 at approximately 3:00 p.m. it was observed two male residents coming face-to-face and their tempers started to rise. The memory care coordinator (MCC) and two CNAs were present and intervened. The MCC redirected Resident #14 away from the dining area since he was agitated. Many of the resident rooms did not have personal appearing items such as pictures, to make the room homelike. Resident #14's room had bare walls and an empty, stripped second bed. The rooms had shadow boxes outside each door that were empty. Some of the doors had stop signs taped to the door, not fabric/velcro across the entry way to prevent wandering into resident rooms. During a brief tour of the memory care unit on 10/1/23 at approximately 4:30 p.m. it was observed the Activities Director (AD) was in the dining area with activities and speaking with Resident #14 in Russian. The AD said the resident is calm when the staff can communicate with him. IV. Resident #20A. Resident statusResident #20 who lived in the secured memory care unit, over age 65, was admitted to the facility on 8/4/23. According to the September 2023 CPO, diagnoses included dementia, muscle weakness, cognitive communication deficit, anxiety disorder, depressive episodes and chronic obstructive pulmonary disease. The 8/10/23 facility assessment documented the resident had severe cognitive deficit with a BIMS score of zero out of 15. The resident required supervision with one person physical assistance with bed mobility, transfers, walking in the room, walking in corridors, and dressing. He required supervision with set up assistance for eating, and limited one person physical assistance with toileting and personal hygiene. The resident did not exhibit any behavior symptoms. B. Record review The mood care plan, revised on 8/22/23, documented the resident exhibited signs and symptoms of depression related to life circumstances. Interventions included utilizing antidepressant (medication) for depression, encourage resident to participate in activities outside of room, including meal and other social activities, involve resident it IDT and care planning and one-to-one validation of feelings and concerns as needed. The care plan for cognition, revised on 8/22/23, documented the resident had cognitive impairments as evidenced by impaired decision making and orientation. Interventions included encouraging resident to make daily decisions, reassure resident as needed if confused, and reorient resident to situations as needed. The care plan for activities revised on 9/8/23 documented the resident enjoyed listening to music, watching tv, and going outside in warm weather. Interventions included to provide an activity calendar and independent leisure materials as requested. -The care plan did not indicate personalized interventions for dementia care. Nursing progress note dated 9/14/23 at 3:32 a.m. documented the resident continued to pace and be intrusive into other resident's rooms. Physician progress note dated 9/27/23 at 3:43 a.m. documented the resident punched another resident on 9/26/23 and grasped other residents and staff. IDT event review progress note dated 10/2/23 at 9:47 a.m. documented a review of the resident to resident altercation; no new interventions were suggested at that time. C. Altercations Event initial note progress dated 9/26/23 at 3:40 p.m. documented a resident to resident altercation between Resident #20 and Resident #14. Resident #14 was walking toward Resident #20 in the hallway, Resident #14 had a closed fist and shoved Resident #20 in the shoulder, Resident #20 hit Resident #14 in the face. Resident #14 had swelling to the left cheek. Event initial progress note dated 10/1/23 at2:51 p.m. documented a resident to resident altercation between Resident #14 and Resident #20. The RN heard a plate fall on the floor, she went to investigate and found Resident #14 standing over Resident #20, who was sitting, punching him in the face.-The facility failed to provide person-centered approaches to Resident #20's dementia care services to address his behaviors, to include wandering, in order to prevent physical altercations (cross-reference S1509). V. Staff interviewCertified nurse aide (CNA) #2 was interviewed on 9/27/23 at 11:44 a.m. The CNA said Resident #14 had a language barrier, the staff used the translator phone to talk to him. The CNA said the resident thought he was security for the building and he did not want these people in it. He is under the impression this was his building and they were trespassing. The MCC was interviewed on 9/27/23 at 11:52 a.m. The MCC said interventions in the memory care unit include stop signs on doors. She said the main intervention that was used by staff to prevent resident altercations was redirection. She said Resident #14 had been having behaviors for the past several days. The DON was interviewed on 10/3/23 at 11:45 a.m. She said Resident #14 was on the secure unit and he had a few resident to resident altercations that involved someone hitting him or him hitting someone else. She said his behaviors include getting agitated. She said he had gotten better. She said he was often non-redirectable. She said Resident #14 had four altercations since 9/24/23 and these were more geared toward other residents rather than the staff. She said when he was not redirectable then the staff put him on a one-to-one observation, mainly when he was agitated and not redirectable. She said the facility tried to send him out on the M1 hold due to behaviors but he was sent back. She said to keep other residents safe the staff directed him to his room. The nursing home administrator (NHA) and the social services director (SSD) were interviewed on 10/3/23 at 12:20 p.m. The NHA said there were two instances where Resident #14 was the aggressor. He said the staff put him on a one-to-one observation. He said one-to-one staff was assigned to him as long as needed or the end of the shift. He said the NHA or the DON could initiate the one-to-one observation if needed. He said the facility did not have documentation for one-to-one observations. The NHA said nurses, CNAs or the staff who saw Resident #14 with behaviors should be monitoring him. The NHA said Resident #14 liked to use the translator machine. Registered nurse (RN) #1 was interviewed on 10/3/23 at 12:45 p.m. The RN said the internet was not working and the translator machine was not working. Licensed practical nurse (LPN) #1 was interviewed on 10/5/23 at 12:00 p.m. The LPN said the facility had not had internet service for a while, it had been down. The LPN said the internet had not worked the previous week, yesterday or today. The LPN said the translator machine did not work if the internet was down so the staff has not been able to use it. -The facility failed to ensure the translator machine, which required internet access, was working. The staff was unable to communicate with the resident which caused agitation to the resident. VI. Resident #22A. Resident #15's interview and record review about Resident #22's wanderingResident #15 was interviewed on 9/26/23 at 12:27 p.m. She said Resident #22 was confused and wandered into her room and rummaged through things in her room, including the trash. She said the nursing staff said the resident had a history of wandering, rummaging and aggression. Resident #15 said Resident #22 had recently come into her room and taken a blanket. She said she did not say anything to Resident #22 when she came in her room because she was afraid Resident #22 would get upset and physically hurt her. Resident #15 said she had no way to defend herself due to the inability to move her legs and arms. She said she felthelpless, with increased feelings of anxiety and fear of physical harm from Resident #22 if she said anything to her. Resident #15 said she had spoken to the assistant director of nursing (ADON) #1 about her fear and concern with Resident #22 coming into her room, but nothing had changed and the resident continued to come into her room. Additionally, Resident #15 said she was concerned when she had seen Resident #22 in the lobby area, eating out of the trash can. Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes from the resident's representative regarding the events since the resident admitted. The notes documented in pertinent part that Resident #15 has said she was "scared" because a resident with known to be violent wheels herself into her room and Resident #15 had no way to defend herself. Additionally, the notes documented that Resident #22 had been observed by the resident representative eating out of the trash can in the lobby on 9/22/23. B. Resident statusResident #22, age 83, was admitted on 2/23/23. According to the October 2023 CPO diagnoses included dementia and major depression. The 7/14/23 facility assessment indicated the resident had severe cognitive impairment and could not complete a BIMS evaluation. She had short and long term memory loss and did not recognize faces, names, rooms, seasons, or the facility. She required two persons extensive assistance with transfers, dressing, toileting and personal hygiene. She required extensive one person assistance with personal hygiene and eating. The assessment documented the resident had wandered daily and had no behaviors. The assessment documented the resident was on antipsychotic medication. C. Record reviewThe care plan related to behavior, revised 9/12/23 did not indicate when it was initiated. It documented, Resident #22 was confused and forgetful and took others belongings. She became physically aggressive towards others. She was observed by staff eating non edible items like paper and flowers. The goal was that the resident would be able to be redirected when she became physically and verbally aggressive. Interventions were to offer her a snack if she was seen eating non edible items. If the resident could not be redirected or calmed, staff should attempt to do care at a later time. Staff to explain was to the resident prior to and during the process of cares. Staff to redirect the resident to other activities. Staff to reorient the resident to place and situation as appropriate to their cognitive level. The care plan for wandering, revised 9/16/23 did not indicate when it was initiated. It documented Resident #22 was at risk for injury due to wandering throughout the building and attempting to go toward the front door. The care plan documented the resident had a wanderguard and to redirect her when wandering. Ensure all basic needs are met such as if the resident has gone to the bathroom, is hungry or thirsty. Invite the resident to activities. The progress notes documented in pertinent part,On 2/27/23 at 4:16 p.m. the nursing note document the resident was moved off the secure unit to a room two doors down from Resident #15. On 4/11/23 at 4:38 p.m. the progress notes documented that on 4/10/23 between 7:00 p.m. and 7:30 p.m. Resident #22 had gotten into an argument with her roommate when Resident #22 tried to take her roommate's pillow. The roommate resisted and Resident #22 slapped her roommate in the face. On 6/21/23 at 4:35 p.m. and 6/20/23 at 10:03 p.m. the progress notes documented Resident #22 was on monitoring for wandering and invading others privacy. -The progress notes did not document when or why the resident had been placed on this monitoring. On 7/11/23 at 3:59 p.m. assistant director of nursing (ADON) #1 documented that Resident #22 was in Resident #15's room again and Resident #15's spouse wheeled Resident #22 out ofResident #15's room. On 8/18/23 at 11:31 a.m. the director of nursing (DON) documented an IDT (interdisciplinary team) note. The note documented the resident was impulsive. The resident grabbed and rummaged through things like furniture. On 9/19/23 at 2:10 p.m. the provider documented the resident was on seroquel due to delusions and aggression. The provider documented the resident had been eating paint chips. The provider documented it was unclear how long this behavior had been occurring. D. Staff interviewsADON #1 was interviewed via telephone on 9/28/23 at 2:10 p.m. He said Resident #22 propelled around in her wheelchair and wandered into other resident rooms and rummaged. He said she had dementia and recently stole a blanket from a room. He said she was confused and recently stole a blanket from a room. The ADON said Resident #22 was usually looking for something to eat, and he tried to give her snacks. He said Resident #15 had reported to him that Resident #22 had been in her room. He said the plan to prevent Resident #22 from going into other rooms was to continue to try to give Resident #22 snacks. The DON was interviewed on 10/3/23 at 9:30 a.m. She said she was not aware of Resident #22 wandering into Resident #15's room and rummaging. She said she knew Resident #22 had wandered into other resident's rooms. She said Resident #22 was very confused and had done this since she admitted. The DON said she only heard Resident #22 wandered into other resident rooms, not that she rummaged in other resident rooms. The DON said she felt that someone would have said something if Resident #22 was really going into Resident rooms and rummaging. However, Resident #22's care plan documented she wandered throughout the building and took others belongings.(see above). Additionally, ADON #1 said Resident #15 had reported to him Resident #22 had been in her room. The DON acknowledged that this behavior could cause Resident #15 to be fearful due to her inability to move, or defend herself. She said a plan to prevent this would be to maybe put a stop sign on Resident #15's door. Certified nurse aide (CNA) #12 was interviewed on 10/9/23 at 1:00 p.m. She said Resident #22 wandered into other resident's rooms. She said she was usually looking for food and digging in the trash cans of other resident rooms or the lobby trash can. She said the resident ate inappropriate things such as recently trying to eat a blanket. CNA #10 said Resident #22 was frequently physically and verbally aggressive, at least two to three times per shift. CNA #10 said Resident #22 would scream, pinch, grab and kick the staff when they attempted to redirect her.

Based on record review and interviews, the facility failed to provide medically related social services to two (#12 and #15) of two residents reviewed out of 22 sample residents. Specifically, the facility failed to assist Resident #12 in making a dental extraction appointment timely after she reported pain and the dentist recommended extractions resulting in infection. Resident #12 was seen by the mobile dentist at the facility on 3/2/23. The mobile dentist recommended sending a referral to a dentist in the community for five tooth extractions. At this time the resident was in pain. The facility did not obtain consent from the resident until 4/4/23 to send the referral. The facility failed to schedule an appointment for Resident #12's teeth extractions for four and a half months. On 7/19/23 Resident #12 had her teeth extracted and was put on an antibiotic because she had developed an oral infection. Resident #15, who required assistance from staff, had five medical appointments that still had not been scheduled. Due to the lack of following up with scheduling her appointments, the resident felt anxious and frustrated due to her ongoing pain, unexplained muscle weakness and voice issues. Findings include:I. Facility policy and procedureThe Dental Services policy, revised December 2016, was provided by the director of nursing (DON) on 10/3/23 at 10:28 a.m. It read in pertinent part, "Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. "Social services representatives/designee will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible."II. Resident #12A. Resident statusResident #12, age 67, admitted on 10/26/22, readmitted on 8/3/23 and passed away on 8/30/23. According to the August 2023 computerized physician orders the diagnoses included: neurocognitive disorder with Lewy bodies (dementia), dysphagia (difficulty swallowing), dementia, Parkinson's disease (deterioration of the brain), anxiety and depression. The 8/22/23 facility assessment revealed she had severe cognitive impairments with short-term and long-term memory deficits according to staff interview. She required extensive assistance of two people for bed mobility, transfers, personal hygiene, walking in her room and in the corridor, locomotion on and off the unit and dressing. She required extensive assistance of one person for eating. The facility assessment documented the resident had no mouth problems. The facility assessment documented the resident was on a scheduled pain medication regimen, received as needed pain medications and did not receive non-medication pain interventions. B. Record review 1. Comprehensive care plan-dentalA review of Resident #12's electronic medical record, revealed Resident #12's comprehensive care plan did not address her oral/dental needs. 2. Dental progress notesThe 11/10/22 dental examination note documented the resident's mouth tissue was inflamed and red. The dentist recommended having all remaining lower teeth extracted and then get upper and lower dentures. The dentist documented to send a referral to another dentist for full lower extractions. The 1/24/23 dental examination note documented the resident refused to see the mobile dentist. The 3/2/23 dental examination note documented the resident was having pain on her lower right side of her mouth. The resident needed to have teeth extracted. The dentist requested a referral to be sent to another dentist for lower teeth extractions. The 6/2/23 dental examination note documented the resident had not gone to the local dentist for teeth extraction. The note documented the resident wanted the work done and was in pain. The dentist requested a referral to be sent to another dentist. The 7/19/23 dental progress note documented the resident had eight teeth extracted. The dentist ordered an antibiotic as the resident had a dental infection. -The facility failed to send a referral to the dentist to get the resident's teeth extracted till July 2023, although the resident started reporting pain in March 2023. 3. Progress notesThe 3/6/23 care conference note documented the social services director (SSD), assistant director of nursing (ADON) #2, the activities director (AD) and the resident met. The power of attorney (POA) was invited and said she would be there, but did not arrive. The SSD called the POA and left a voicemail. -The note did not indicate if an attempt was made to obtain dental consents (see SSD interview below). The 3/27/23 care conference note documented the resident, nursing home administrator (NHA), SSD, speech therapist, activities assistant, DON, ADON #2, the ombudsman and the doctor were present. The daughter was invited to come, but did not attend. -The note did not indicate if an attempt was made to obtain dental consents (see SSD interview below). The 4/4/23 social services progress note documented the dentist made recommendations to follow-up for extractions. The resident gave consent and an appointment request was sent to transportation. -The dentist recommended a referral to be sent on 11/10/22 and 3/2/23. The facility did not obtain consent to send a referral until 4/4/23. The 7/20/23 nursing progress note documented the resident was on an antibiotic for eight teeth extractions. The resident was on a soft diet until her mouth was healed. The licensed nurse documented she would continue to monitor. C. Staff interviewsThe SSD was interviewed on 9/27/23 at 2:54 p.m. The SSD said the mobile dentist saw Resident #12 in November 2022 and recommended for the resident to be seen by a community dentist for teeth extractions. The SSD said the mobile dentist attempted to see the resident in January 2023 and February 2023 and the resident refused to be seen. The SSD said Resident #12 was seen by the mobile dentist again on 3/2/23 and recommended to have the teeth removed. The SSD said the resident then had her teeth extracted in June 2023. -Resident #12 did not have her teeth extracted until 7/19/23. The SSD was interviewed again on 9/27/23 at 2:54 p.m. The SSD said she did not obtain consent from the resident to send a referral to the community dentist until 4/4/23. The van driver (VD) was interviewed on 9/28/23 at 4:03 p.m. The VD said he was responsible for scheduling appointments for all residents and transporting them to their appointments. The VD said typically dentist referrals were emailed to him from the SSD and he would make the appointment. The VD said sometimes referrals were not communicated to him. The VD said he called the doctor's office within a day or two from receiving a referral to calling the physician offices to make appointments. The VD said he was unsure the exact date he sent a referral for Resident #12 to have her teeth extracted. The VD said he did not document or keep record of when he received or sent referrals to doctors. The VD said he was unsure why it took several months to get Resident #12 an appointment to have her teeth extracted. The VD was interviewed again on 9/28/23 at 4:03 p.m. The VD said he spoke with the DON regarding documenting in resident medical records regarding sending referrals for medical records. The DON was interviewed on 9/28/23 at approximately 3:15 p.m. The DON said the nursing staff were responsible for placing referral orders into the electronic medical record and notifying the VD that an appointment needed to be scheduled.. The DON said the VD was responsible for calling the doctor's office, making an appointment and transporting the resident to the appointment. The DON said at times it took awhile to get certain appointments related to doctors availability. The SSD was interviewed again on 9/28/23 at 9:40 a.m. The SSD said she attempted to reach out to Resident #12's daughter who was the residents proxy (decision maker) and get consent to send a referral to an outside dentist for Resident #12's teeth extractions. The SSD said the VD was responsible for making appointments and transporting the residents to the appointments. The SSD said she was not involved in scheduling Resident #12's dental extraction appointment. The SSD was interviewed again on 9/28/23 at 9:53 a.m. The SSD provided two care conference notes from March 2023. The SSD said she attempted to reach out to the resident's daughter to obtain consent to send a referral to the community dentist. The SSD said the daughter did not call her back. The SSD said a month after the mobile dentist saw Resident #12 and recommended to have teeth extracted she asked the resident for consent to send the referral. The SSD said Resident #12 was able to make her own choices. The SSD said she was unsure why she did not ask the resident for consent sooner than 4/4/23. The NHA was interviewed on 10/3/23 at 11:35 a.m. The NHA said the VD was responsible for scheduling appointments and transporting residents to their appointments. The NHA said the facility had attempted to get her into the dentist that accepted her insurance. The NHA said pain is very subjective and if the facility felt it was an emergency then they would have had Resident #12 seen immediately. The NHA said the resident was not in that much pain. -However, the mobile dentist documentation revealed Resident #12 was in pain and wanted her teeth extracted. The NHA was interviewed again on 10/3/23 at 1:25 p.m. The NHA said the facility had referred the resident to the dentist, but the 7/19/23 date was the soonest available appointment. The NHA said the SSD tried to confirm the appointment with Resident #12's family, but she did not call her back. -However, the care conference notes do not indicate that the SSD attempted to speak to the daughter or the resident regarding consent to send a referral to a community dentist. The NHA said the VD was unable to document in the resident's medical records when he sent referrals. The NHA said the VD was given permission to document in medical records when he sends referrals and schedules appointments for the residents. III. Resident #15A. Resident statusResident #15, under age 65, was admitted on 6/14/23. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity, myopathy (disease affects muscles causing muscle weakness, neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection) and chronic pain. The 6/20/23 facility assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. The assessment documented the Resident#15 had pain frequently which affected her day to day activities. She was on scheduled and PRN (as needed) pain medication and had no non pharmacological pain interventions. B. Resident interviewResident #15 was interviewed on 9/26/23 at 12:27 p.m. She said she was still waiting on five appointments to be scheduled by the facility. She said she was suppose to see an ENT (ear, nose and throat) doctor related to changes in her voice, a gynecologist related to pelvic pain which during a urinary tract infection on 9/8/23, a neurology appointment related to ongoing pain from neuropathy (weakness, numbness, pain due to nerve damage), a sleep study for concerns for sleep apnea (sleep disorder where breathing stops and starts during sleep) and a pain clinic related to her chronic pain. Resident #15 said she had not received any follow up from the nursing staff as to when the appointments were scheduled for. Resident #15 said she was frustrated and anxious regarding the lack of follow up on appointments for her pain, her unexplained muscle weakness and voice issues. C. Record reviewThe September 2023 CPO was reviewed on 9/26/23 at 1:25 p.m. The orders documented the following. 7/27/23, Referral to ENT for voice change, needs vocal cords visualized. 8/11/23, Consult pain management and rehab for chronic pain syndrome. 8/15/23, Referral to neurology to establish care and get EMG (muscle response to electrical activity) done. 8/24/23, Schedule outpatient EMG for generalized weakness and concern for myopathy. 8/24/23, Please schedule sleep study for concern for OSA (obstructive sleep apnea). 9/15/23, Referral to pain management for diagnosis of chronic pain. 9/15/23, Referral to OB-GYN (obstetric gynecologist) for vaginal burning. Twice the provider wrote orders for an EMG and a referral for pain management (see above) and no appointments were scheduled. The provider notes revealed the following:On 7/25/23 at 12:53 p.m. the provider documented in the progress notes the resident had "not gotten an EMG as previously discussed. Refer to neurology. The resident would like a referral to ENT. She has had a permanent voice change since intubation."On 7/27/23 at 9:23 a.m. the provider documented in the progress notes "confirmed that orders forreferrals have been placed to ENT, and neurology for EMG."On 8/3/23 at 12:51 p.m. the provider documented in the progress notes, "follow up on neurology referral, if not for some time, plan neuropathy labs, see if EMG can be done elsewhere without neurology appointment."On 8/29/2023 at 1:17 p.m. the provider documented in the progress notes, the resident has still not yet had an EMG.On 9/14/23 at 9:15 a.m. the provider documented in the progress notes, EMG and sleep study pending. On 9/15/23 at 11:11 a.m. the provider documented in the progress notes the referral to gynecology pain management clinic for chronic pain syndrome were still pending. On 9/22/23 at 2:26 p.m. the provider documented in the progress notes the referral to gynecology and pain management clinic were still pending.-However, once the survey began on 9/25/23, appointments began to get scheduled (see below). D. Staff interviewsThe director of nursing (DON) was interviewed on 9/28/23 at 9:30 a.m. She said if there was a referral in the physician orders the DON or nurse manager sent the referral to the van driver (VD) to schedule the appointment. The DON said the VD schedules and provided transportation to appointments for residents. The assistant director of nursing (ADON) #1 was interviewed on 9/28/23 at 2:10 p.m. He said he was in charge of nursing oversight on the hall Resident #15 resided on. ADON #1 said he did not know if an OB-GYN, neurology, pain, sleep study or ENT appointments had been scheduled. He said he was new at this, being the ADON, and it had been a struggle for him to keep everything straight. He said the VD was responsible for appointments. The nursing home administrator (NHA) was interviewed on 10/3/23 at 11:35 a.m. He said the VD scheduled appointments and transported the residents to the appointments. He said if it was a bariatric resident, the facility would use an outside agency to transport because they would not fit in the facility van. The NHA said he was not sure how the VD was notified of a referral and appointment that needed to be scheduled. The VD was interviewed on 10/5/23 at 10:28 a.m. He said he scheduled appointments, found specialty physicians for referral orders and drove the facility van for appointments. The VD said providers will text him if a resident needs an appointment. He said appointment needs were usually "word of mouth." The provider will test him that they put in a referral for a resident and the diagnosis. He said he would then go into the electronic medical record (EMR) and print off the order. The VD said he was just learning how to use the EMR system. He said once he printed the order he would call the physician office to see if they accepted the residents insurance and faxed them the referral order. He said once the appointment was made he gave a copy of the appointment to the resident and the resident's nurse. The VD said he did not go through the medical record to look for new orders for referrals. He said someone had to notify him if there was a new referral order. He said it could take three to seven days to get the appointment once he sent the specialist the fax with resident information and insurance. The VD said he had been working on scheduling appointments for Resident #15. He said she had all her appointments scheduled. -However, this was not completed until after the survey began on 9/25/23 (see below). He said the neurology appointment was scheduled when the referral was made by the provider. The VD said the sleep study had been hard to schedule because the resident needed to fill out a questionnaire for the referral. He said he was not medical so he could not do the questionnaire with the resident. He said the director of nursing (DON) would need to do the phone call and questionnaire together. The VD said he did not keep records of when a specialist office was contacted with a referral or appointment attempts he had made. The VD said he did not want to say why there was a delay. He said there was a delay in getting referrals in the residents chart as orders. E. Facility follow-upOn 10/5/23 at 11:00 a.m. the VD provided copies of appointments scheduled for Resident #15. All the appointments were scheduled after the survey began on 9/25/23. The documentation provided by the VD revealed:A pain management clinic referral was dated as ordered 9/28/23, due to chronic pain. There was still no documentation about when this appointment was scheduled for. The original orders for a pain clinic were written on 8/11/23 and 9/15/23 (see above). A neurology referral was dated as ordered 9/28/23 for an EMG. The appointment was scheduled for 12/6/23. The original orders for a neurology referral were written on 8/15/23 and 8/24/23 (see above). An ENT referral was dated as ordered 9/28/23, no diagnosis was listed. The appointment was scheduled for 10/5/23. The original orders for an ENT referral were written on 7/27/23. The VD was interviewed again on 10/9/23 at 11:11 a.m. The VD said the resident did not go to her ENT appointment on 10/5/23 because her wheelchair did not fit in the van from the transport agency. He said the appointment would need to be rescheduled when the transport agency had their larger transport van available. The OB-GYN appointment documented it was ordered on 10/3/23, and was scheduled for 10/24/23 at 1:15 p.m. However, the order for the OB-GYN was written on 9/15/23. -There was no documentation provided regarding an appointment for a sleep study.

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

Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one (#15) of one resident reviewed for dignity out of 22 sample residents. Specifically, the facility failed to ensure staff were not using their personal cell phones while providing incontinence care, assisting a resident with eating and while in resident care areas. The use of employee cell phones during care resulted in Resident #15 reporting anxiety, humiliation, embarrassment and frustration. Findings include: I. Facility policy and procedureThe Resident Rights policy, revised February 2021, as received from the nursing home administrator (NHA) on 10/9/23 at 9:53 a.m. The policy documented in pertinent part, "the resident has the right to a dignified existence, to be treated with respect, kindness and dignity, to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal, and have the facility respond to his or her grievance." A policy on employee cell phone use while providing resident care was requested from the NHA on 10/9/23 at 3:17 p.m. and not received by the end of the survey 10/9/23. II. Resident #15A. Resident statusResident #15, under age 65, was admitted on 6/14/23. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity, myopathy (disease affects muscles causing muscle weakness, neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection) and chronic pain. The 6/20/23 facility assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. B. Resident interviewResident #15 was interviewed on 9/26/23 at 12:27 p.m. She said CNA #8 had been in her room on her cell phone on 8/3/23 while changing the resident and providing incontinence care. The resident said the CNA had her earphones in and was talking. Resident #15 said she was humiliated, frustrated and embarrassed the CNA would be on the phone while providing personal care. The resident said she had no use of her arms or legs and felt helpless. The resident said she reported it to the other CNA on duty. Resident #15 said CNA #8 came back to her room a short time later and got within an inch of the resident's face. The resident said the CNA gritted her teeth and said sarcastically "we're gonna be friends." The CNA said she was not on her cellphone and accused the resident of lying. (Cross-reference S1509). Resident #15 said she reported it to the nursing staff on duty at the time. She said she reported it again to assistant director of nursing (ADON) #1 on 8/7/23. The resident said the CNA continued to work on the resident's hall until her employment was ended on 9/22/23. Additionally, Resident #15 reported CNA #9 was texting on her phone while assisting the resident to eat on the first week of September 2023 and two days in a row at the end of August 2023. She said the CNA denied it and spoke to the resident as if the resident were confused. Resident #15 said she reported this to ADON #1. Resident #15 stated she continued to have anxiety and frustration over the staff use of cellphones while providing care. Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. III. Record reviewThe resident council notes were received from the director of nursing (DON) on 9/26/23 at 10:55 a.m. On 7/11/23 (for June 2023), the resident council notes documented in pertinent part, old business, CNAs were ontheir phones at the nurse's station while call lights were going off. The resident council notes document the NHA and DON were present at the meeting. Resident #15 was not at the resident council meeting and did not report the concern. There was no documentation as to which resident reported the concern. The resident council form documented the staff was educated. All grievance reports related to staff cell phone use were requested from the DON on 9/26/23 at 4:00 p.m. There were no grievance reports for June or July 2023 related to staff cell phone use, despite the concern in resident council. A grievance report dated 8/4/23 for Resident #15 documented the resident complained that CNA #8 was on her cell phone in her room. The DON documented verbal education was provided to the CNA and the resident did not want the CNA in her room again. The grievance form documented the CNA said she was using the flashlight on her phone in the resident's room. -There was no further information as to why the resident did not want the CNA in her room again. It did not address the use of a personal cell phone while providing incontinence care. A grievance report dated 9/10/23 documented Resident #15 complained a staff member was on her phone in her room. The grievance form documented the staff said they were just texting about the schedule. The form documented the DON provided verbal education. The name of the CNA was not documented. The grievance was signed by the NHA on 9/11/23.-There were no grievance forms regarding the staff the cellphone use for the end of August 2023 despite the concern reported by Resident #15. On 9/12/23 the resident council notes documented new business, residents were concerned the CNA's were on their cell phones. The resident council notes documented the NHA and DON were present at the meeting. -It did not document when or where the staff were on their cell phones. A Resident Council Concern Follow Up note dated 9/12/23 documented "CNA's on their phones at nurses station." The grievance form documented that signs were posted at nurse stations and bathrooms that phones were not allowed at nurses stations or care areas. -The form was blank under was action sufficient and was action effective. However no signs were posted (see below). The personnel file for CNA #8 was reviewed on 10/3/23 at 10:00 a.m. There was no counseling regarding personal cell phone use while providing incontinence care. The file documented CNA #8 was terminated on 9/22/23 for sleeping on the job as seen on video. She had been previously given a final written warning for sleeping on the job 7/18/23 and racial misconduct having to do with pictures taken. The personnel file for CNA #9 was reviewed on 10/3/23 at 10:00 a.m. The file contained verbal counseling for cell phone use in a resident room on 9/11/23. There was no education or counseling in August 2023 for the concern reported by Resident #15. On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes from the resident's representative regarding the events since the resident admitted. The notes documented in pertinent part on a number of occasions the resident's representative had walked by the nurses' station and the CNA staff were sitting at the nurses' station on their cell phones. It further documented that a number of times, CNA #9 was on her cell phone while assisting the resident with eating. The notes further documented there were a number of incidents of the CNAs taking personal calls while assisting the resident with eating and changing her, violating her confidentiality. The representative documented he felt the resident was beginning to withdraw and shut down due to the concerns above. Education regarding cell phone use with resident care for September 2023 was requested from the DON on 10/3/23. No documentation was received by the end of the survey on 10/9/23 or within 24 hours after the survey. IV. Staff interviewsThe DON was interviewed on 10/3/23 at 9:30 a.m. She said she was not awareof CNA #8 getting in Resident #15's face after Resident #15 had reported the CNA for being on her cellphone during care. The DON said she was aware of the concerns with staff use of cellphones at the nurses station and while providing care for Resident #15. She said had written a grievance on it. She could not explain why the grievance on 8/4/23 documented Resident #15 no longer wanted CNA #8 in her room. -The DON provided no further information. The NHA was interviewed on 10/9/23 at 3:17 p.m. He said he was not aware of the concern with staff use of cellphones while providing care. -However, the resident council minutes documented the NHA was present, and some of the grievance forms related to staff cell phone use were signed by the NHA (see above). He said if the concern had been brought up at resident council then he would have looked into it. V. ObservationsOn 10/9/23 at 10:08 a.m., the nurse station and staff bathroom on the hall where Resident #15 resided was observed with ADON #1. The ADON confirmed there were no postings regarding staff cellphone use. ADON #1 said he had not seen any postings. At 2:00 p.m. two CNAs were observed at the nurses' station viewing something on a cellphone together.

A complaint survey, prompted by #CO32483, #CO32355, #CO33678, #CO33679, #CO33698, #CO33693, #CO33694, #CO33701, #CO33758 and Incident #32180, #32165, #33172 was completed on 9/26/23 to 10/9/23. Thirteen deficiencies were cited.

Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one (#15) of one resident reviewed for dignity out of 22 sample residents. Specifically, the facility failed to ensure staff were not using their personal cell phones while providing incontinence care, assisting a resident with eating and while in resident care areas. The use of employee cell phones during care resulted in Resident #15 reporting anxiety, humiliation, embarrassment and frustration. Findings include: I. Facility policy and procedureThe Resident Rights policy, revised February 2021, as received from the nursing home administrator (NHA) on 10/9/23 at 9:53 a.m. The policy documented in pertinent part, "the resident has the right to a dignified existence, to be treated with respect, kindness and dignity, to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal, and have the facility respond to his or her grievance." A policy on employee cell phone use while providing resident care was requested from the NHA on 10/9/23 at 3:17 p.m. and not received by the end of the survey 10/9/23. II. Resident #15A. Resident statusResident #15, under age 65, was admitted on 6/14/23. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity, myopathy (disease affects muscles causing muscle weakness, neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. B. Resident interviewResident #15 was interviewed on 9/26/23 at 12:27 p.m. She said CNA #8 had been in her room on her cell phone on 8/3/23 while changing the resident and providing incontinence care. The resident said the CNA had her earphones in and was talking. Resident #15 said she was humiliated, frustrated and embarrassed the CNA would be on the phone while providing personal care. The resident said she had no use of her arms or legs and felt helpless. The resident said she reported it to the other CNA on duty. Resident #15 said CNA #8 came back to her room a short time later and got within an inch of the resident's face. The resident said the CNA gritted her teeth and said sarcastically "we're gonna be friends." The CNA said she was not on her cellphone and accused the resident of lying. (Cross-reference F600). Resident #15 said she reported it to the nursing staff on duty at the time. She said she reported it again to assistant director of nursing (ADON) #1 on 8/7/23. The resident said the CNA continued to work on the resident's hall until her employment was ended on 9/22/23. Additionally, Resident #15 reported CNA #9 was texting on her phone while assisting the resident to eat on the first week of September 2023 and two days in a row at the end of August 2023. She said the CNA denied it and spoke to the resident as if the resident were confused. Resident #15 said she reported this to ADON #1. Resident #15 stated she continued to have anxiety and frustration over the staff use of cellphones while providing care. Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. III. Record reviewThe resident council notes were received from the director of nursing (DON) on 9/26/23 at 10:55 a.m. On 7/11/23 (for June 2023), the resident council notes documented in pertinent part, old business,CNAs were on their phones at the nurse's station while call lights were going off. The resident council notes document the NHA and DON were present at the meeting. Resident #15 was not at the resident council meeting and did not report the concern. There was no documentation as to which resident reported the concern. The resident council form documented the staff was educated. All grievance reports related to staff cell phone use were requested from the DON on 9/26/23 at 4:00 p.m. There were no grievance reports for June or July 2023 related to staff cell phone use, despite the concern in resident council. A grievance report dated 8/4/23 for Resident #15 documented the resident complained that CNA #8 was on her cell phone in her room. The DON documented verbal education was provided to the CNA and the resident did not want the CNA in her room again. The grievance form documented the CNA said she was using the flashlight on her phone in the resident's room. -There was no further information as to why the resident did not want the CNA in her room again. It did not address the use of a personal cell phone while providing incontinence care. A grievance report dated 9/10/23 documented Resident #15 complained a staff member was on her phone in her room. The grievance form documented the staff said they were just texting about the schedule. The form documented the DON provided verbal education. The name of the CNA was not documented. The grievance was signed by the NHA on 9/11/23.-There were no grievance forms regarding the staff the cellphone use for the end of August 2023 despite the concern reported by Resident #15. On 9/12/23 the resident council notes documented new business, residents were concerned the CNA's were on their cell phones. The resident council notes documented the NHA and DON were present at the meeting. -It did not document when or where the staff were on their cell phones. A Resident Council Concern Follow Up note dated 9/12/23 documented "CNA's on their phones at nurses station." The grievance form documented that signs were posted at nurse stations and bathrooms that phones were not allowed at nurses stations or care areas. -The form was blank under was action sufficient and was action effective. However no signs were posted (see below). The personnel file for CNA #8 was reviewed on 10/3/23 at 10:00 a.m. There was no counseling regarding personal cell phone use while providing incontinence care. The file documented CNA #8 was terminated on 9/22/23 for sleeping on the job as seen on video. She had been previously given a final written warning for sleeping on the job 7/18/23 and racial misconduct having to do with pictures taken. The personnel file for CNA #9 was reviewed on 10/3/23 at 10:00 a.m. The file contained verbal counseling for cell phone use in a resident room on 9/11/23. There was no education or counseling in August 2023 for the concern reported by Resident #15. On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes from the resident's representative regarding the events since the resident admitted. The notes documented in pertinent part on a number of occasions the resident's representative had walked by the nurses' station and the CNA staff were sitting at the nurses' station on their cell phones. It further documented that a number of times, CNA #9 was on her cell phone while assisting the resident with eating. The notes further documented there were a number of incidents of the CNAs taking personal calls while assisting the resident with eating and changing her, violating her confidentiality. The representative documented he felt the resident was beginning to withdraw and shut down due to the concerns above. Education regarding cell phone use with resident care for September 2023 was requested from the DON on 10/3/23. No documentation was received by the end of the survey on 10/9/23 or within 24 hours after the survey. IV. Staff interviewsThe DON was interviewed on 10/3/23 at 9:30 a.m. She said she was not aware of CNA #8 getting in Resident #15's face after Resident #15 had reported the CNA for being on her cellphone during care. The DON said she was aware of the concerns with staff use of cellphones at the nurses station and while providing care for Resident #15. She said had written a grievance on it. She could not explain why the grievance on 8/4/23 documented Resident #15 no longer wanted CNA #8 in her room. -The DON provided no further information. The NHA was interviewed on 10/9/23 at 3:17 p.m. He said he was not aware of the concern with staff use of cellphones while providing care. -However, the resident council minutes documented the NHA was present, and some of the grievance forms related to staff cell phone use were signed by the NHA (see above). He said if the concern had been brought up at resident council then he would have looked into it. V. ObservationsOn 10/9/23 at 10:08 a.m., the nurse station and staff bathroom on the hall where Resident #15 resided was observed with ADON #1. The ADON confirmed there were no postings regarding staff cellphone use. ADON #1 said he had not seen any postings. At 2:00 p.m. two CNAs were observed at the nurses' station viewing something on a cellphone together.

Based on observations, record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years. Specifically, the facility failed to provide three years worth of survey and investigation findings in a prominent location for public viewing. Findings include:I. ObservationsOn 10/5/23 at 3:08 p.m. the facility's survey results binder was located behind the front desk, there was no notice of availability of federal survey information in any prominent location. Front receptionist (FR) #1 said the survey results binder was stored behind the front desk. FR #1 said the only additional copy of the survey results binder was stored in the nursing home administrator's office (NHA). On 10/9/23 at 9:40 a.m. the facility's survey results binder was located behind the front desk, there was no notice of availability of federal survey information in any prominent location. FR #2 said the survey results binder was stored behind the front desk. FR #2 said the only additional copy of the survey results binder was stored in the NHA's office. The survey results binder failed to include the following surveys: 11/5/2020, 11/23/2020, 1/12/21, 3/3/21, 9/8/21, 2/24/22, 6/9/22, 7/5/22 and 8/18/22. II. Interviews The NHA was interviewed on 10/9/23 at 10:43 a.m. The NHA said the survey results binder needed to be accessible to the residents and their families. The NHA said the survey results binder was moved behind the front receptionist desk when they had the entryway painted a couple weeks ago. The NHA said the survey results binder needed to have three years worth of survey results accessible to the residents and family members.

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

Based on record review and interviews, the facility failed to report an allegation of potential abuse to the State Agency in accordance with State law for one (#15) resident of three residents reviewed for abuse out of 22 sample residents. Specifically, the facility leadership failed to report an allegation of verbal abuse of Resident #15 by facility a staff member to the facility administrator, local law enforcement or the State Agency. Findings include: I. Facility policyThe Abuse, Neglect, Exploitation and Misappropriation and Prevention Program policy, revised April 2021, was received from the director of nursing (DON) on 9/28/23 at 2:00 p.m. The policy documented in pertinent part, "The Abuse, Neglect, Exploitation and Misappropriation and Prevention Program consists of a facility wide commitment and resource allocation to support the following objectives, provide staff orientation and training programs that include topics such as abuse prevention and reporting of abuse, and investigate and report any allegations within timeframes required by federal requirements." II. Resident #15Resident statusResident #15, under age 65, was admitted on 6/14/23. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity, myopathy (disease affects muscles causing muscle weakness, neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. III. Resident interviewResident #15 was interviewed on 9/26/23 at 12:27 p.m. She said on 8/3/23, she had reported certified nurse aide (CNA) #8 for being on her cellphone while providing care. She said she reported the behavior to CNA #6. Resident #15 said CNA #8 came back into her room later that day and got within an inch of the resident's face. She said she had an angry expression and gritted teeth. CNA #8 told the resident she was not on her cellphone in the resident's room and the resident was lying. She then said to the resident within an inch of her face, "We are going to be friends" sarcastically. The resident said she was afraid and felt like she was in physical danger of harm without being able to defend herself. She said felt CNA #8 was retaliating against her for reporting her. The resident said she has no movement in her arms and legs. She said she was helpless. The CNA continued to work on the resident ' s hall until a couple of weeks ago. Resident #15 said she could not sleep at night due to fear CNA #8 might hurt her. Resident #15 said she reported the CNA ' s threatening behavior to assistant director of nursing (ADON) #1 on 8/7/23. Resident #15 said the ADON told her he would move the CNA off her halfway until she felt comfortable with the CNA again. Cross-reference F600, failure to protect the resident from abuse and F610, failure to investigate alleged abuse. III. Record reviewOn 8/7/23 at 10:50 a.m., ADON #1 documented in the progress notes, "Resident #15 said she felt threatened by the CNA last Thursday night because [the CNA] got into the resident ' s face about an inch or two away from her and was aggressively speaking to her." The progress notes documented the CNA was restricted from going into the resident's room indefinitely or until the resident feels comfortable with her again. "No further action needed."Review of the State Agency portal for August 2023 failed to reveal the allegation had been reported. IV. Staff interviewsADON #1 was interviewed on 9/28/23 at 2:10 p.m. He said on 8/7/23, Resident #15 told him that the night CNA (CNA #8) had gotten in her face and spoke aggressivelyto her.. He said he did not know if there was an investigation, but he spoke to the CNA about what she did. He said he reported the allegation to the director of nursing (DON). ADON #1 said he would have to ask the DON why the allegation was never reported to the State Agency. The DON was interviewed on 10/3/23 at 9:30 a.m. The DON said she had not been aware of the allegation prior to the survey. She said ADON #1 had not informed her of the allegation. The DON then said she just found out about the incident from ADON #1 last night (10/2/23) and she reported the allegation last night to the State Agency portal. The nursing home administrator (NHA) was interviewed on 10/9/23 at 9:54 a.m. He said the allegation a CNA threatened Resident #15 should have been reported to him immediately. He said he planned to do abuse reporting education with the staff. He said the allegation came to light during the survey and was reported to the State Agency last week. V. Facility follow upThe facility reported the allegation of verbal abuse on 8/3/23 to the State Agency portal on 10/2/23 at 8:43 p.m. during the survey.

Based on record review, resident and staff interviews, the facility failed to investigate an allegation of abuse for one (#15) of four residents reviewed for abuse out of 22 sample residents. Specifically, the facility failed to thoroughly investigate an allegation of staff to resident physical abuse involving Resident #15. Findings include: I. Facility policyThe Abuse, Neglect, Exploitation and Misappropriation and Prevention Program policy, revised April 2021, was received from the director of nursing (DON) on 9/28/23 at 2:00 p.m. The policy documented in pertinent part, "The Abuse, Neglect, Exploitation and Misappropriation and Prevention Program consists of a facility wide commitment and resource allocation to support the following objectives,identify and investigate all possible incidents of abuse, neglect mistreatment or misappropriation of resident property. Investigate and report any allegations within time frames required by federal requirements. Protect residents from any further harm during investigation." II. Resident #15Resident statusResident #15, under age 65, was admitted on 6/14/23. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity, myopathy (disease affects muscles causing muscle weakness, neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. III. Resident interviewResident #15 was interviewed on 9/26/23 at 12:27 p.m. She said on 8/3/23, she had reported certified nurse aide (CNA) #8 for being on her cellphone while providing care. She said she reported the behavior to CNA #6. Resident #15 said CNA #8 came back into her room later that day and got within an inch of the resident's face. She said the CNA had an angry expression and gritted teeth. CNA #8 told the resident she was not on her cellphone in the resident's room and the resident was lying. She then said to the resident within an inch of her face, "We are going to be friends" sarcastically. The resident said she was afraid and felt like she was in physical danger of harm without being able to defend herself. She said felt CNA #8 was retaliating against her for reporting her. The resident said she has no movement in her arms and legs. She said she was helpless. The CNA continued to work on the resident ' s hall until a couple of weeks ago. Resident #15 said she could not sleep at night due to fear CNA #8 might hurt her. Resident #15 said she reported the CNA ' s threatening behavior to assistant director of nursing (ADON) #1 on 8/7/23. Resident #15 said the ADON told her he would move the CNA off her halfway until she felt comfortable with the CNA again. Cross-reference F600, failure to protect the resident from abuse and F609, failure to report alleged abuse. III. Record reviewOn 8/7/23 at 10:50 a.m., ADON #1 documented in the progress notes that Resident #15 said she felt threatened by CNA #8 last Thursday night because the CNA got into the resident ' s face about an inch or two away from her and was aggressively speaking to her. The progress notes documented the CNA was restricted from going into the resident's room indefinitely or until the resident feels comfortable with her again. "No further action needed."IV. Staff interviewsADON #1 was interviewed on 9/28/23 at 2:10 p.m. He said on 8/7/23, Resident #15 told him that the night CNA had gotten in her face and spoke aggressively to her. He said he wrote what the resident told him in her medical record under progress notes. He said the CNA was told not to go in the resident's room anymore. He said he did not know if there was an investigation, but he spoke to the CNA about what she did. He said he reported the occurrence to the director of nursing (DON). The DON was interviewed on 10/3/23 at 9:30 a.m. The DON said she had not been aware of the allegation of staff to resident verbal abuse of Resident #15 in August 2023 prior to the survey. She said ADON #1 had not informed her of the allegation. The DON said CNA #8 was terminated on 9/22/23 for sleeping on her shift. She said CNA #8 was not moved to a different hall after the incident with Resident #15 in August 2023. The DON said she was told CNA #8 was not to work with Resident #15. The DON acknowledged that she was aware CNA #8 was told not to provide care to Resident #15 in August 2023; however, she said she did not recall why and and she could not recall if the reason for the removal of CNA #8 from Resident #15 ' s care was investigated. The DON said the facility was beginning an investigation of the allegation today. V. Facility follow-upThe facility investigation revealed the allegation was unsubstantiated because no other residents complained of staff aggression and Resident #15 only reported the CNA was on her phone in her room, not that she had been aggressive. -However, the aggression was reported ADON #1 on 8/7/23 and documented in the resident ' s progress notes.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#10) of three residents reviewed for professional standard out of 22 sample residents. Specifically, the facility failed to ensure Resident #10 received the care and services to treat a surgical wound and prevent the development of severe cellulitis (skin infection). Resident #10 was admitted on 12/14/21, readmitted on 6/15/22 and discharged on 4/5/23. Resident #10 had a diagnosis of chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, dementia, need for assistance with personal care and gastro-esophageal reflux disease (GERD). Resident #10 had a dermatological surgical procedure on 3/30/23 to remove a cancer lesion from her left upper arm. The dermatologist prescribed oral antibiotics, topical antibiotics, dressing changes and pain medications. The facility failed to complete all physician ordered dressing changes and accurately assess Resident #10's surgical incision to her left upper arm for infection. According to the follow-up appointment note on 4/5/23 from the dermatologist, the wound was grossly infected and had severe cellulitis. The dermatologist drained 30 cubic centimeters (CC) of drainage, cleaned the wound and sent the resident to the hospital to receive intravenous (IV) antibiotics. Findings include:I. Resident #10A. Resident statusResident #10, age 76, was admitted on 12/14/21, readmitted on 6/15/22 and discharged on 4/5/23. According to the April 2023 computerized physician orders (CPO) the diagnoses included type two diabetes mellitus, dementia, dysphagia (swallowing difficulty) and gastro-esophageal reflux disease (GERD). The 1/25/23 minimum data set (MDS) assessment revealed Resident #10 was cognitively intact with a brief interview for mental status (BIMS) with a score of 13 out of 15. She required extensive assistance of one person for bed mobility, locomotion on and off the unit, dressing, toileting and personal hygiene. She required extensive assistance of two people for transfers. She required supervision of one person assistance for walking in her room and in the corridor, eating. B. Record reviewThe pain management care plan, initiated on 1/18/23, revealed Resident #10 needed pain management and monitoring related to limited mobility. The interventions included: administering pain medication as ordered, coordinating with the patient and family to identify patient's favorite items and activities that could serve to distract from pain, evaluating and establishing a level of pain on a numeric scale, evaluating characteristics and frequently of pain, evaluating need to provide medications prior to treatment, implementing the patient's preferred non-pharmacological pain relief strategies, observing for potential medication side effects, repositioning as needed and utilizing a pain monitoring tool to evaluating effectiveness of interventions. The March and April 2023 CPO revealed Resident #10 had the following physician orders for post operative skin care:-Post-surgery instructions left upper arm: light activity, keep dressing on for 72 hours, then remove and apply bacitracin ointment twice a day, do not get incision wet until follow-up, every shift for incision for 14 days, ordered 3/30/23.-Cleanse wound area to left upper arm with wound cleanser and cover with xeroform and dry dressing once a day and as needed, one time a day for wound care, ordered 3/18/23 and discontinued on 4/3/23. -Left upper arm: apply bacitracin ointment twice a day and cover with a bandage every shift for incision site for 14 days, ordered 4/3/23. -According to the April 2023 treatment administration record (TAR), the licensed nurses completed cleansing the wound area to left upper arm with wound cleanser and cover with xeroform and dry dressing on 4/1/23 and 4/2/23. -However, the dermatologist had ordered a new treatment to the wound after the surgery on 3/30/23. The physician's order was to leave the dressing on the surgical incision for 72 hours. The dressing should have remained intact to the surgical site until 4/2/23.-According to the April 2023 TAR, the facility failed to provide treatment as ordered to the residents left upper extremity on the night shift on 4/3/23. The resident refused treatment on 4/4/23 due to pain. The facility did not notify the physician of the increased pain to the area, resulting in the resident refusing treatment. Cross-reference: F697 the facility failed to provide pain medications as ordered by the physician for post operative pain management. The 3/30/23 nursing progress note documented Resident #10 returned to the facility after having a surgery to her left upper arm at 5:26 p.m. The resident's vital signs were within normal limits, she denied pain and had not acute distress. The post-surgery orders were entered. Resident #10 was eating dinner and the licensed nurse documented she would continue to monitor the resident. The 3/30/23 weekly wound assessment documented the resident had a surgical incision to her left arm that was 3.6 centimeters (cm) in length by 3.6 cm in width and 0.1 cm in depth. The wound had 30% epithelial, 45% granulation, 5% sloth and 20% dermis. The wound had scant serous drainage. -The physician ordered the dressing to stay intact for 72 hours after surgery. The dressing should have remained intact from 3/30/23 until 4/2/23. The licensed nurse removed the dressing to assess the wound (see wound assessment above). The licensed nurse did not follow the physician's post operative instructions. The 3/30/23 operative report documented by the dermatologist (DERM) revealed in pertinent part, Resident #10 had surgery to remove a soft tissue mass on her left upper arm. The 3/31/23 nurse practitioner progress note documented in pertinent part, Resident #10 saw the dermatologist yesterday (3/30/23) and had a left arm lesion removed. Resident #10 was placed on as needed Norco for pain management. Resident #10 reported she had pain to her left arm. The 3/31/23 nursing progress note documented Resident #10 had surgery on 3/30/23 to remove a lesion from her left upper arm. A dressing was placed to the surgical area and was not to be removed for 72 hours. The nursing progress note documented the resident had two new orders for medications, which were entered. The family provided the medications from an outside pharmacy and the medications were in the medication cart. The 3/31/23 nursing progress note documented Resident #10 continued on monitoring for antibiotic use related to her recent surgery to her left upper extremity. The resident's vital signs were within normal limits. Resident #10 complained of pain and as needed pain medications were administered. The progress note documented the pain medications were effective. The resident was at her baseline. The 3/31/23 nursing progress note documented the resident was alert and oriented at baseline. The resident ate all of her meals and was taking her medications as ordered. The resident's vital signs were within normal limits. The resident complained of pain and as needed pain medication was administered. The pain medication was effective. The dressing to the residents left upper arm was clean, dry and intact. According to the April 2023 MAR the licensed nurse completed a weekly head to toe skin assessment on 4/3/23. -However, a review of Resident #10's electronic medical record revealed there was no documented head to toe skin assessment on 4/3/23 (see interview below). The 4/2/23 nursing progress note documented the resident's surgical dressing was clean, dry and intact. There were no signs or symptoms of infection. The resident had no allergic reactions to the antibiotic. The licensed nurse documented she would continue to monitor. The 4/2/23 nursing progress note documented the resident remained on antibiotics post surgery. The resident's dressing remained in place per physician orders. The dressing was clean, dry and intact. The resident complained of pain and there were no further concerns. The 4/3/23 nursing progress note documented the resident remained on increased observation due to her recent surgery to remove a cancer legion from her left upper arm. The resident was on an oral and topical antibiotic for infection prevention. The skin was warm and dry to touch. The nursing progress note documented there was trace edema to the resident's left upper arm. The resident denied pain or discomfort. The licensed nursing encouraged fluid. The note documented facility staff would continue to monitor the resident. The 4/4/23 nurse practitioner progress note documented in pertinent part, Resident #10 was seen lying in bed. Resident #10 reported ongoing pain to her left arm and has relief from the prescribed as needed Norco. The 4/4/23 nursing progress note documented at 11:38 p.m. revealed the resident was on an antibiotic after a surgery to her left upper arm. Resident #10 refused to have her dressing changed to her arm due to pain. The progress note documented the nurse administered the scheduled pain medication. The nurse attempted to change the dressing to the resident's arm later that shift and the resident declined the dressing change and said she did not want the dressing touched. The 4/5/23 head to toe skin assessment documented the resident had skin issues. The assessment documented the licensed nurse was unable to assess the resident as she was at the hospital. The 4/5/23 nursing progress note documented the resident remained on an antibiotic after a surgical procedure to remove a mass from her left upper arm. The dressing remained clean, dry and intact. There was no draining or warmth. The resident's upper arm was slightly red and swollen. The resident complained of pain and as needed pain medication was administered. The 4/5/23 dermatology note documented the resident had an excision of a left upper arm lesion on 3/30/23. The dermatologist documented the area was grossly infected, painful and the nursing home was not taking care of the site. The note documented the resident had severe cellulitis and 40 cubic centimeters (CC) of purulence (puss) was drained from the site. Cultures were taken, the wound was irrigated and cleaned and a clean dressing was placed. Resident #10 was transferred to the hospital for intravenous (IV) antibiotics related to the gross cellulitis and infection. The 4/5/23 incident report documented Resident #10's granddaughter alleged the facility did not treat Resident #10's arm and identify infection. Resident #10 was sent to the hospital from the dermatologist appointment. Resident #10 received intravenous (IV) antibiotics when she arrived at the hospital. The incident report documented the facility reviewed resident notes, care plan diagnosis and medications. Through staff interviews the facility concluded that the redness on Resident #10's arm was at baseline and there were no signs or symptoms of infection. The facility determined the 4/5/23 allegation was not substantiated due to staff providing dressing changes consistently. -However, according to the April 2023 MAR and skin assessments, the licensed nurses did not follow the physician orders and removed the dressing prior to the 72 hour order. According to the April 2023 TAR the facility did not provide the physician prescribed topical antibiotic or a dressing change on the night shift of 4/3/23. A review of the 4/5/23 hospitalist note documented the resident had increased pain, erythema (redness), heat, pain and edema. The resident was admitted to the hospital and started on IV Vancomycin (antibiotic) and IV Ceftriaxone (antibiotic) to treat the infection. II. Interviews The dermatologist was interviewed on 9/28/23 at 2:10 p.m. The dermatologist said Resident #10 had a follow-up appointment on 4/5/23. The dermatologist said upon assessing the surgical incision to the resident's left upper arm he knew it was infected. The dermatologist said the surgical incision was dried out, crusted over, extremely swollen, warm to the touch, tender and fluid filled, which were all signs of infection. The dermatologist said he cleaned the wound and drained fluid from the wound. The dermatologist said it was clear the infection had been developing for several days and not just a few hours. The dermatologist said the wound was in very bad shape and needed immediate attention. The dermatologist said he cleaned the wound and packed it. The dermatologist said the best course of action was to send the resident to the hospital to get IV antibiotics. The dermatologist said he had to clean the wound out two or three more times to help with the infection. The dermatologist said he had ordered the licensed nurses at the nursing home to leave the dressing on for 72 hours after the surgery. He said after 72 hours the licensed nurses were supposed to clean the wound, place an antibiotic ointment on the wound and place a clean dry dressing over the wound. The dermatologist said the licensed nurses should have noticed the infection and called him for further orders. The dermatologist said he ordered an oral and topical antibiotic prior to the surgery prophylactically. The dermatologist said the resident was at a high risk for infection related to her comorbidities. Registered nurse (RN) #2 was interviewed on 10/3/23 at 10:29 a.m. RN #2 said signs of infection include red, oozing and painful. The director of nursing (DON) was interviewed 10/9/23 at 11:48 a.m. The DON said Resident #10 had a surgical procedure to remove a cancer lesion from her left upper arm on 3/30/23. The DON said the resident attended a follow-up appointment on 4/5/23 as was sent to the hospital. The DON said the granddaughter alleged the facility did not care for the resident's surgical incision.. The DON said the facility completed an investigation by interviewing staff members and determined the resident did not have signs of infection. The DON said she did not review the dermatologist notes that indicated the facility was not caring for the resident's surgical incision. The DON said she briefly spoke to the dermatologist assistant on 4/5/23 when they notified the DON that the resident was being transferred to the hospital. The DON said the licensed nurse signed off on the MAR that she completed a head to toe skin assessment, but there was not a skin assessment documented in the resident's medical record. The DON said she would have expected the resident's arm to be a little swollen and red, since the resident recently had surgery. The DON said she was not aware that Resident #10 had not received her dressing change on 4/3/23. The DON said the facility typically notified the resident's primary care physician if the resident was refusing medications or treatments. -However, a review of the resident's medical record revealed the facility had not notified the physician of the resident's dressing change refusal related to pain on 4/3/23.

Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#15 and #10) of three residents reviewed out of 18 sample residents. Resident #15 admitted on 6/14/23 with chronic pain and neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection). According to record review and interviews, the facility failed to ensure the Resident #15's Oxycodone pain medication was available on three separate occasions resulting in increased pain. Additionally, the facility failed to administer Resident #10 the correct pain medication per physician order after a surgical procedure. Findings include:I. Facility policy and procedureThe Pain Assessment and Management policy, revised October 2022, was received from the director of nursing (DON) on 9/28/23 at 2:00 p.m. The policy documented in pertinent part, "Contact the prescriber immediately if the residents pain or medication side effects are not adequately controlled, report the following information to the physician or practitioner, significant changes in the level of residents pain, prolonged unrelieved pain. II. Resident #15A. Resident statusResident #15, under age 65, was admitted on 6/14/23. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity and myopathy (disease affects muscles causing muscle weakness), neuritis (nerve pain) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated Resident #15 was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. The assessment documented the resident reported her worst pain level on a 0 to 10 scale (with 10 being the worst pain on the scale) was 8 out of 10. The assessment documented Resident#15 had pain frequently which affected her day -to-day activities. She was on scheduled and PRN (as needed) pain medication and had no non-pharmacological pain interventions. B. Resident interviewResident #15 was interviewed on 9/26/23 at 12:27 p.m. She said the nursing staff did not have her Oxycodone pain medication at least three times since she was admitted in July 2023. Resident #15 said there was no Oxycodone pain medication available for her on admission for the first two days, and then twice in July 2023. She said on admission she only received Tylenol for pain. She said the staff would have it for two weeks and then run out on the weekend. The resident said this happened twice. She said she had chronic nerve pain all over and new pelvic pain. Resident #15 said the pain was tolerable at level 3 out of 10 if she did not move. . She said when the nursing staff ran out of Oxycodone she had pain all over from 9 to 10 out of 10. Resident #15 said her pain was usually around a f5, but often could get up to an 8 before she received her pain medication. She said when the facility ran out of the Oxycodone pain medication she experienced anxiety and her mind began racing. She said she worried all the time about the staff running out of her pain medication now. Resident #15 said the lack of pain medication affected her ability to get out of bed and sleep. Resident #15 described the pain as throbbing to her back, knees and arms. Resident #15 said she had new pelvic pain since she had a urinary tract infection in the beginning of September 2023. The resident said the facility was supposed to have scheduled a follow up appointment with a gynecological physician related to the pelvic pain, and a neurologist for her nerve pain but she had not heard from the facility regarding either appointment (cross-reference F745 provision of social services). Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. C. Record reviewOn Saturday 7/1/23 at 7:03 p.m. the nursing notes documented the resident was out of Oxycodone. The nurse spoke to the pharmacy this morning about it and the pharmacy said they would deliver it. The note documented no oxycodone had been delivered. The nurse attempted to get it from the facility's emergency kit, but there was no second nurse at the facility available with username access to the kit to get the medication. The nurse documented she called the provider, but the provider was unreachable and she left a message. -There was no further documentation. On 7/16/23 at 6:00 p.m. the nurse's notes document the resident was having pain 10 out of 10 and the resident's Oxycodone had not arrived from the pharmacy. The nurses note documented the medication had been ordered on 7/15/23 from the pharmacy. The pharmacy said they were waiting on information from the physician. The progress notes documented the resident requested the nurse call the provider to get a one time order for Oxycodone 10 mg, twice the amount the resident normally took for pain. The nurse obtained a one time order for Oxycodone 10 mg and administered the medication from the emergency kit. On 7/17/23 at 1:21 p.m. the progress notes documented a one time order was received for Oxycodone 5 mg times two. This was twice the amount Resident #15 normally took again. On 7/18/23 at 4:03 p.m. the nursing progress notes documented the resident wanted her Oxycodone at 5:00 p.m. She said she had previously been in pain for a long time. She said it was fine now but it had taken her a long time to recover. On 7/25/23 at 12:53 p.m. the provider documented the resident had chronic pain. She complained the facility had run out of her Oxycodone the weekend before the fourth of July holiday. The note documented the resident was back on her routine dosing. The provider note further documented that the nursing staff had asked to discontinue the nighttime Oxycodone because they have to wake up the resident. The provider documented the resident did not want to discontinue the Oxycodone at that time because that was when she received incontinence care and she did not want to have any decrease in care. On 7/27/23 at 2:00 p.m. the nursing progress notes documented Resident #15 was concerned about her medication and wanted to make sure she had enough Oxycodone for the weekend. The June 2023 medication administration record (MAR) was reviewed. The MAR documented after the resident was admitted on 6/14/23, the Resident #15 received Acetaminophen (Tylenol) 325mg two tablets via PEG tube (percutaneous endoscopic gastrostomy) twice on 6/15/23 for pain levels of 5 and 6. She received Tylenol at the end of the month for pain levels of 4 to 6. -There were no parameters for what pain level the tylenol was to be given. The June 2023 MAR was blank for Oxycodone 5 mg tablet one tablet via PEG every four hours as needed for pain for the day of admission 6/14/23 and 6/15/23. After 6/15/23 the Oxycodone was given three to four times per day for pain ranging from 4 to 8.-There were no parameters for when to give the OxycodoneThe July 2023 MAR was reviewed. The July MAR revealed the resident received Oxycodone on 7/1/23 at 4:30 a.m. for pain level of 4 and then not again until 7/3/21 at 2;17 p.m. for pain level of 8. -The resident did not have any Oxycodone available (see above). After 7/3/21 the July MAR revealed the resident received Oxycodone between two and four times daily for pain levels between 4 and 10. -However, another gap in the MAR indicated the resident had no Oxycodone 5mg after Saturday 7/15/23 at 5:00 p.m. for pain level of 7 until Monday 7/17/23 at 10:00 p.m for pain level of 7. The resident again had ran out of Oxycodone on the weekend again from 7/15/23 until Monday 7/17/23 (see above). The resident continued to receive Oxycodone as needed up to five times per day for pain levels up to 8 after 7/17/23. The resident was administered a one time dose of Oxycodone 10mg on 7/16/23 at 2:47 p.m. and one time on 7/17/23 at 1:26 p.m. (see above). On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes the resident's representative had typed for her regarding the events since the resident admitted. The notes documented in pertinent part that on a number of occasions the facility had run out of the residents pain medication on the weekends. The resident had to go the weekend and most of Monday without her pain medication. D. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 9/28/23 at 9:12 a.m. She said medication reordering was done through a computer program with the pharmacy. She said when medications are reordered or ordered for a new admission the medication was usually delivered the same day or the next day. LPN #2 said there was no formal process for reordering medications. She said the nurses reordered medications when they noticed they were getting low. She said if the nurses ran out of medication they would call the pharmacy or get the medication out of the emergency medication kit. Assistant director of nursing (ADON) #1 was interviewed on 9/28/23 at 2:10 p.m. He said Resident #15's pain was manageable with pain medication. He said the facility had an order for a pain clinic and the facility was going to get her an appointment. ADON #1 said the resident took Oxycodone as needed for pain. He said Resident #15 had new pelvic pain and the facility was going to get the resident an appointment with a specialist. ADON #1 said if the nurse did not have a prescribed pain medication they should call the pharmacy and notify the physician of the missed dose or request new orders for something else for pain. ADON #1 said regarding the missed Oxycocodne medication for Resident #15, he was not in charge of ensuring narcotics were ordered. The DON was interviewed on 10/3/23 at 9:30 a.m. She said when a new resident admitted to the facility, orders were faxed over to the pharmacy. She said medications arrive that night or the next day. The DON said if the resident needed medication on the day of admission the nurse could get the medication from the facility's emergency supply machine. She said Oxycodone was in the machine. She said the nurse would have had to call the pharmacy for a code to open the machine and have a second nurse present. She said barriers to this have been the pharmacy not answering the phone. The DON said the nurse could have called the physician and received an order for a different pain medication. The DON said the nurse could call the on-call nurse for help or the medical director when they did not get a hold of the physician. She said the on call number the nurse called on 7/1/23 was the number for the medical director. She said the number for the medical director did not answer when called. She said the nurses did not have access to any other number for the medical director. The nursing home administrator (NHA) was interviewed on 10/9/23 at 3:17 p.m. The NHA said the unavailability of pain medication was brought up during the facility's clinical meetings in the morning but the facility had no process improvement plan for the concern. III. Resident #10 A. Facility policy and procedure The Medications Brought to the Facility by the Resident/Family, revised April 2007, was provided by the DON on 10/9/23 at 12:44 p.m. It revealed in pertinent part, "The facility shall ordinarily not permit residents and families to bring medications into the facility. "If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician and Consultant Pharmacist, shall check to ensure that: state law and regulations allow such use; themedications have been ordered by the resident's Attending Physician, and documented on the physician's ordered sheet; the contents of each container are labeled in accordance with established policies; the contents of each container have been verified by a licensed pharmacist; and signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP (representative) and receiving staff member is completed."B. Resident statusResident #10, age 76, was admitted on 12/14/21, readmitted on 6/15/22 and discharged on 4/5/23. According to the April 2023 CPO the diagnoses included type two diabetes mellitus, dementia, dysphagia (swallowing difficulty) and gastro-esophageal reflux disease (GERD). The 1/25/23 MDS assessment revealed Resident #10 was cognitively intact with a brief interview for mental status with a score of 13 out of 15. She required extensive assistance of one person for bed mobility, locomotion on and off the unit, dressing, toileting and personal hygiene. She required extensive assistance of two people for transfers. She required supervision of one person assistance for walking in her room and in the corridor, eating. The MDS assessment indicated the resident was on a scheduled pain medication regimen and had not received non-medication interventions for pain during the review period. According to staff assessment, Resident #10 displayed non-verbal sounds of pain and showed evidence of pain daily. C. Record review 1. Comprehensive care plan-painThe pain management care plan, initiated on 1/18/23, revealed Resident #10 needed pain management and monitoring related to limited mobility. The interventions included: administering pain medication as ordered, coordinating with the patient and family to identify patient's favorite items and activities that could serve to distract from pain, evaluating and establishing a level of pain on a numeric scale, evaluating characteristics and frequently of pain, evaluating need to provide medications prior to treatment, implementing the patient's preferred non-pharmacological pain relief strategies, observing for potential medication side effects, repositioning as needed and utilizing a pain monitoring tool to evaluating effectiveness of interventions. 2. Physician orders related to painThe March 2023 CPO revealed Resident #10 had the following physician orders for pain management:-Acetaminophen Tablet 325 MG (milligrams), give two tablets by mouth three times a day for chronic pain syndrome, ordered 10/6/22.-Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), give one tablet by mouth every four hours as needed for pain, ordered 3/30/23 and discontinued on 4/5/23. According to the March 2023 medication administration record (MAR), Resident #10 received the Norco Oral Tablet 5-325 MG on 3/31/23 at 9:11 a.m. when she reported her pain level as a 5 and on 3/31/23 at 4:35 p.m. when she reported her pain level as a 7.-However, Resident #10 was prescribed Percocet for pain. The April 2023 CPO revealed Resident #10 had the following physician orders for pain management and skin treatments:-Acetaminophen Tablet 325 MG, give two tablets by mouth three times a day for chronic pain syndrome, ordered 10/6/23.-Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), give one tablet by mouth every four hours as needed for pain, ordered 3/30/23, discontinued on 4/5/23.-Left upper arm: apply bacitracin ointment twice a day and cover with a bandage every shift for incision site for 14 days, ordered on 4/3/23. -Percocet Oral Tablet 5-325 MG (Oxycodone with Acetaminophen), give one tablet by mouth every four hours as needed for pain, ordered 4/5/23 and discontinued on 4/6/23. According to the April 2023 MAR, Resident #10 received the Norco Oral Tablet 5/325 MG on 4/1/23 at 8:18 a.m. when she reported her pain level as a 5, on 4/2/23 at 8:45 a.m. when she reported her pain level as a 4, on 4/3/23 when she reported her pain level as a 5, on 4/5/23 at 5:36 a.m. when she reported her pain level as a 9 and on 4/5/23 at 9:59 a.m. when she reported her pain level as a 5. -However, Resident #10 was prescribed Percocet for pain. 3. Controlled drug recordsThe health information manager (HIM) provided a copy of two controlled drug records on 10/5/23 at 4:30 p.m. The controlled drug record documented Resident #10 received Norco 5/325 MG 1 tablet every 4 to 6 hours as needed for pain on 3/3/23, 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/4/23 and 4/5/23. The second controlled drug record documented Resident #10 received Hydrocodone/APAP 5 (Norco) on 4/5/23. -According the the April 2023 MAR, Resident #10 did not receive the Norco 5/325 MG on 4/4/23. However, the nurse signed the controlled drug record on 4/4/23 at 10:00 a.m. Norco 5/325 MG was administered. 4. Progress notes The 3/30/23 operative report documented by the dermatologist (DERM) revealed in pertinent part, Resident #10 had surgery to remove a soft tissue mass on her left upper arm. The 3/31/23 nurse practitioner progress note documented in pertinent part, Resident #10 saw the dermatologist yesterday (3/30/23) and had a left arm lesion removed. Resident #10 was placed on as needed Norco for pain management. Resident #10 reported she had pain to her left arm. The 4/4/23 nurse practitioner progress note documented in pertinent part, Resident #10 was seen lying in bed. Resident #10 reported ongoing pain to her left arm and has relief from the prescribed as needed Norco. The 4/4/23 nursing progress note documented at 11:38 p.m. revealed the resident was on an antibiotic after a surgery to her left upper arm. Resident #10 refused to have her dressing changed to her arm due to pain. The progress note documented the nurse administered the scheduled pain medication. The nurse attempted to change the dressing to the resident's arm later that shift and the resident declined the dressing change and said she did not want the dressing touched. -The licensed nurse administered the scheduled Acetaminophen Tablet 325 MG when the resident reported pain to her dressing site. Resident #10 did not receive the as needed Norco Oral Tablet 5-325 MG as needed pain medication when she refused to have her dressing changed related to pain. The 4/5/23 nursing progress note documented by the DON revealed Resident #10 had a dermatology appointment last week. The dermatologist prescribed Percocet for pain. The note documented Resident #10 had been receiving Percocet. The order was incorrect in the MAR. The progress note documented the order was under Norco instead of Percocet. The note documented the resident had been receiving the correct medication. The note documented the facility would continue to monitor. -However, according to the March 2023 and April 2023 MAR and the controlled substance records Resident #10 received Norco on 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/4/23 and 4/5/23 (see interviews below). The 4/5/23 dermatology note documented the resident had an excision of a left upper arm lesion on 3/30/23. The dermatologist documented the area was grossly infected, painful and the nursing home was not taking care of the site. The note documented the resident had severe cellulitis and 40 cubic centimeters (CC) of purulence (puss) was drained from the site. Cultures were taken, the wound was irrigated and cleaned and a clean dressing was placed. Resident #10 was transferred to the hospital for intravenous (IV) antibiotics related to the gross cellulitis and infection. D. InterviewsThe dermatologist was interviewed on 9/28/23 at 2:10 p.m. The dermatologist said Resident #10 had surgery to remove a cancer lesion on 3/30/23. The dermatologist said Resident #10 had cognitive impairment and was not able to always accurately voice her pain. The dermatologist said he would have expected Resident #10 to have pain, as the surgery covered a big area. The dermatologist assistant (DA) was interviewed on 9/28/23 at 2:10 p.m. The DA said the dermatologist prescribed Percocet for pain management following the surgical procedure on 3/30/23. The DA said the doctor called the facility and gave the order to the nurse on duty. The DON was interviewed on 10/9/23 at 11:48 a.m. The DON said Resident #10 was prescribed Percocet for pain management following a surgical procedure on 3/30/23. The DON said the dermatologist called the facility and verbally gave the order to the nurse on duty. The DON said Resident #10's granddaughter provided the medication from an outside pharmacy. The DON said the facility relied on the outside pharmacy to verify the medication was correct and accurate. The DON said the physician's order was entered incorrectly into the resident's electronic medical record. The DON said the physician's order read to give the resident Norco instead of Percocet for pain management. The DON said the controlled substance sheets and MAR documented the resident had received Norco. The DON said the resident's physician notified the DON that the order in the electronic medical record was not accurate. The DON said Resident #10 received Percocet. The DON said multiple licensed nurses signed off on the MAR and the controlled substance record sheets that they administered Norco.-However, according to Resident #10's MAR and the controlled substance record sheets, Resident #10 received Norco.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for five of eight staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA), #13, CNA #14, CNA #15, CNA #9 and CNA #16. Findings include:I. Facility policyThe Nurse Aide Qualifications and Training Requirements policy, revised August 2022, was provided by the director of nursing (DON) on 10/9/23 at approximately 1:30 p.m. It revealed in pertinent part, "Nurse aides will have a minimum of 12 hours of training in the following areas prior to direct contact with residents: communication and interpersonal skills; infection control, safety/emergency procedures; promoting residents ' independence; respecting residents ' rights; basic nursing skills; personal care skills; mental health and social service needs; care of cognitively impaired residents and resident rights."II. Record reviewA request for CNA #13 (hired 10/3/21), CNA #14 (hired 10/13/21), CNA #15 (hired 3/23/22), CNA #9 (hired 7/6/22) and CNA #16 (hired 6/15/21) annual performance review and inservice education based on the outcome of the reviews on 9/28/23. The human resources director (HRD) said CNA #13, CNA #14, CNA #15, CNA #9 and CNA #16 did not have a performance review. CNA #13, CNA #14, CNA #15, CNA #9 and CNA #16 had not completed annual inservice education based on the outcome of their reviews. III. Staff interviewsThe DON was interviewed on 10/9/23 at 11:48 a.m. The DON said she was going to hold a skills competency class for CNAs in November 2023. The DON said she was not sure who was responsible for monitoring the CNA's annual training. The DON said she would work with the HRD to develop a plan to ensure all CNAs received required training. The DON said CNAs needed annual reviews. The HRD was interviewed on 10/9/23 at 1:40 p.m. The HRD said she was unsure who was responsible for annual reviews and training. The HRD said she would check with the DON to ensure the annual reviews and training were done for all CNAs. The HRD said CNA #13, CNA #14, CNA #15, CNA #9 and CNA #16 did not have annual reviews or completed training based on their annual reviews.

Based on observation, interview, and record review the facility failed to ensure three (#14, #20 and #22) of three residents reviewed for dementia care of 22 sample residents, received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Resident #14 was admitted to the facility for long term care on 5/25/23 with diagnoses of Alzheimer's disease, senile degeneration of the brain, anxiety disorder, depressive episodes, and cognitive communication deficit. The resident required supervision with one person physical assistance with walking in the room and corridors. The resident required extensive one person assistance with dressing. Since admission on 5/25/23 the resident had increasing wandering, agitation and physically aggressive behaviors. Due to the facility failures, Resident #14 wandered into other residents' rooms. The facility failed to determine and prevent triggers that caused agitation and physical aggression toward other residents. The facility failed to maintain the ability for the resident to communicate with staff with the translator machine that required the internet to operate. These failures resulted in Resident #14 was involved in four resident to resident altercations with three other residents, one resident twice over an eight day period. Additionally, the facility failed to implement personalized interventions for Resident #20 and Resident #22, who wandered into other resident rooms. Cross-reference F600 the facility failed to prevent resident to resident altercations by implementing appropriate safety measures for Residents #14 and #20. Findings include I. Census and conditions demographicThe 9/26/23 Census and Condition form documented 111 residents resided at the facility. There were 62 residents with dementia or Alzheimer's disease and 28 with behavioral health needs. The facility had one long-term secured memory care unit open with 25 residents in the unit. II. Facility policy and proceduresThe Dementia - Clinical protocol, revised April 2021, was delivered by the director of nursing (DON) on 9/27/23 at 2:05 p.m. It read in pertinent part, "As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition. "The staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes."As needed the physician will help verify or reconsider the diagnosis of dementia and identify other possible causes and coexisting psychiatric conditions."Individuals with dementia can also have personality disorder, mental illness, psychosis, delirium, depression, adverse drug reactions (ADRs), or other conditions causing or contributing to impaired cognition and problematic behavior. "As needed, the physician may obtain a psychiatrist or neurologist consultation to assist with diagnosis, treatment selection, monitoring of responses to treatment, and adjustment of medications. "The staff and physician will determine any relationship between the resident's level of pain and cognitive loss. "For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. "Nursing assistants will receive initial training in care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the reviews. "If a psychiatric consultation is called to help manage behavioral or psychiatric symptoms in the individual with dementia, the IDT team will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition, and function, monitoring for complications related to treatment, and evaluating progress."III. Resident #14A. Resident status Resident #14, over age 65, was admitted to the facility on 5/25/23 and lived in the secured memory care unit. According to the September 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, senile degeneration of the brain, anxiety disorder, depressive episodes and cognitive communication deficit. The 8/17/23 minimum data set (MDS) assessment documented the resident had a severe cognitive deficit with a brief interview for mental status (BIMS) score of three out of 15. The resident required supervision with one person physical assistance with bed mobility, personal hygiene, and toileting, and supervision with set up assistance with transfers between surfaces, walking in the room and corridors, locomotion on and off the unit, and eating. The resident required extensive one person assistance with dressing. -The facility failed to assess the resident's behaviors. B. Record reviewThe care plan for the secured unit, initiated on 5/25/23 and revised on 8/29/23, documented the resident resides on the secured unit related to wandering. Interventions included staff to redirect the resident to safe wandering area as needed. The care plan for communication, no initiation date and revised on 8/29/23, documented the resident had impaired communication due to a diagnosis of Alzheimer's and was Russian speaking. The resident can communicate effectively via a translating machine. Interventions include communicate through identified communication method; staff used a translator to communicate. The care plan for mood, revised on 8/31/23, documented the resident got nervous and anxious at times. Interventions included to approach the resident from the front and address him or her by name, touch/hold his or her hand, avoid things that make the resident more anxious, and if the resident was upset to redirect the conversation or task. The care plan for activities, revised on 9/1/23 documented the resident had a language barrier and the staff was able to use a translator when needed, he enjoyed watching the news, going outside in warm weather, gardening, and listening to Russian music. Interventions included to provide an activity calendar, provide independent leisure as requested and speak to the resident with the translator machine. -The care plan did not have personalized interventions for dementia care. The admission and baseline care plan summary dated 5/25/23 at 7:38 p.m. documented communication and difficulty understanding others due to language barrier, wandering, anxiousness and restlessness concerns. Social services progress note dated 6/22/23 at 1:50 p.m. documented the IDT team met to discuss resident wandering and secure unit placement. The social services director (SSD) and assistant director of nursing (ADON) found a wander guard bracelet in the resident's bedside drawer. -The facility documented moving the resident to the secure memory care unit on 6/22/23, the facility failed to initiate safety measures to prevent the resident from wandering into other residents rooms to prevent physical abuse (cross-reference F600). Administrator progress note dated 6/22/23 at 1:51 p.m. documented the resident was admitted to the secure unit due to wandering and going into other residents rooms. Nursing progress note dated 7/3/23 at 12:15 a.m, documented the resident had increased agitation and intruded into all residents rooms one-by-one, taking their belongings and attempting to hit other residents with wheelchairs, walkers and other items believing the other residents were in his room. The resident attempted to break the windows on the double doors, attempted to crawl over the nurses station half door and attempted to hit staff with a chair. After being redirected to his room he attempted to break the window. Staff called 911. Administrator progress note dated 7/3/23 at 8:52 a.m. documented the resident was sent to the hospital on an M1 (mental health) hold. Nursing progress note dated 7/3/23 at 8:32 p.m. documented the resident returned to the facility from the hospital. The resident displayed aggressive behaviors toward staff by grabbing, pinching, and hitting and taking a CNA's (certified nurse aide) jacket and wallet. Physician progress note dated 7/5/23 at 8:00 a.m. documented a psychiatric consultation was sent but had not been received and were not able to see the resident. Physician progress note dated 7/12/23 at 5:54 a.m. documented the psychiatric consultation was pending. Nursing progress note dated 7/16/23 at 11:09 a.m. documented the resident was digging in the trash and found bread and put it in his pocket. Physician progress note dated 7/31/23 at 1:57 a.m. documented the psychiatric consultation was still pending. Nursing progress note dated 8/14/23 at 3:01 a.m. documented the resident was going in and out of other resident's rooms and was unable to be redirected. The resident was picking up chairs, walker and "wet floor" signs and attempting to hit staff and other residents. The resident said "this is my house, and they all need to leave." He attempted to hit residents who were walking in the hallway. The resident spit at the nurse. Staff called 911, officers calmed the resident but when the officers departed the resident became aggressive again. The staff placed other residents who were ambulating in the halls in the nurses station for their safety while the resident banged on the door with his fists and other objects. IDT follow up progress note dated 8/31/23 at 10:31 a.m. documented a review of resident targeted behaviors. Interventions included offer lower stimulating behavior, utilize translator machine and offer to go outside. IDT follow up progress note dated 9/25/23 at 10:16 a.m. documented the review of the resident to resident altercation interventions included resident to be redirected into a safe wandering area. Nursing progress note dated 10/1/23 at 11:35 p.m. documented the resident continued to wander in and out of other resident's rooms and was difficult to redirect. IDT event review progress noted dated 10/2/23 at 9:45 a.m. documented following the current IDT review no new interventions suggested at this time. Social services progress note dated 10/6/23 at 11:30 a.m. social services director (SSD) reached out to the psychiatric services provider for a female provider, the provider stated they do not have female providers. Nursing progress note dated 10/6/23 at 2:48 p.m. documented the IDT met to review the resident to resident incident. Interventions included for staff to utilize translator for resident to be able to communicate with other residents due to language barrier. C.Altercations Event initial progress note dated 9/25/23 at 9:46 a.m. documented on 9/24/23 at 4:20 p.m. Resident #14 was arguing with Resident #7 and Resident #7 threw a two inch cowbell and hit Resident #14 in the face causing a reddened area to the left cheek. Event initial progress note dated 9/26/23 at 3:15 p.m. documented a resident to resident altercation on 9/26/23 at 3:00 p.m. between Resident #14 and Resident #20. Resident #14 was walking toward Resident #20 with a closed fist and shoved him in the shoulder. Resident #20 then hit Resident #14 in the face causing a small swelling on the left cheek. Nursing progress note dated 9/30/23 at 7:30 p.m. documented a witnessed resident to resident altercation between Resident #14 and Resident #21. Resident #14 was walking in the hallway when Resident #21 came out of his room yelling at Resident #14, #14 responded in a foreign language and Resident #21 punched #14 on the left side of his face. No injury noted at the time. IDT event initial progress note dated 10/1/23 at 2:17 p.m. documented a resident to resident altercation between Resident #14 and Resident #20. The RN heard a plate break in the dining room and found Resident #14 standing over Resident #20, who was seated, hitting him in the face. Resident #20 suffered a cut on the left eyelid.-The facility failed to provide person-centered approaches to Resident #14's dementia care services to address triggered physical aggressive behavior in order to prevent physical altercations (cross-reference F600). D. Observation During a brief tour of the memory care unit on 9/26/23 at approximately 3:00 p.m. it was observed two male residents coming face-to-face and their tempers started to rise. The memory care coordinator (MCC) and two CNAs were present and intervened. The MCC redirected Resident #14 away from the dining area since he was agitated. Many of the resident rooms did not have personal appearing items such as pictures, to make the room homelike. Resident #14's room had bare walls and an empty, stripped second bed. The rooms had shadow boxes outside each door that were empty. Some of the doors had stop signs taped to the door, not fabric/velcro across the entry way to prevent wandering into resident rooms. During a brief tour of the memory care unit on 10/1/23 at approximately 4:30 p.m. it was observed the Activities Director (AD) was in the dining area with activities and speaking with Resident #14 in Russian. The AD said the resident is calm when the staff can communicate with him. IV. Resident #20A. Resident statusResident #20 who lived in the secured memory care unit, over age 65, was admitted to the facility on 8/4/23. According to the September 2023 CPO, diagnoses included dementia, muscle weakness, cognitive communication deficit, anxiety disorder, depressive episodes and chronic obstructive pulmonary disease. The 8/10/23 MDS assessment documented the resident had severe cognitive deficit with a BIMS score of zero out of 15. The resident required supervision with one person physical assistance with bed mobility, transfers, walking in the room, walking in corridors, and dressing. He required supervision with set up assistance for eating, and limited one person physical assistance with toileting and personal hygiene. The resident did not exhibit any behavior symptoms. B. Record review The mood care plan, revised on 8/22/23, documented the resident exhibited signs and symptoms of depression related to life circumstances. Interventions included utilizing antidepressant (medication) for depression, encourage resident to participate in activities outside of room, including meal and other social activities, involve resident it IDT and care planning and one-to-one validation of feelings and concerns as needed. The care plan for cognition, revised on 8/22/23, documented the resident had cognitive impairments as evidenced by impaired decision making and orientation. Interventions included encouraging resident to make daily decisions, reassure resident as needed if confused, and reorient resident to situations as needed. The care plan for activities revised on 9/8/23 documented the resident enjoyed listening to music, watching tv, and going outside in warm weather. Interventions included to provide an activity calendar and independent leisure materials as requested. -The care plan did not indicate personalized interventions for dementia care. Nursing progress note dated 9/14/23 at 3:32 a.m. documented the resident continued to pace and be intrusive into other resident's rooms. Physician progress note dated 9/27/23 at 3:43 a.m. documented the resident punched another resident on 9/26/23 and grasped other residents and staff. IDT event review progress note dated 10/2/23 at 9:47 a.m. documented a review of the resident to resident altercation; no new interventions were suggested at that time. C. Altercations Event initial note progress dated 9/26/23 at 3:40 p.m. documented a resident to resident altercation between Resident #20 and Resident #14. Resident #14 was walking toward Resident #20 in the hallway, Resident #14 had a closed fist and shoved Resident #20 in the shoulder, Resident #20 hit Resident #14 in the face. Resident #14 had swelling to the left cheek. Event initial progress note dated 10/1/23 at 2:51 p.m. documented a resident to resident altercation between Resident #14 and Resident #20. The RN heard a plate fall on the floor, she went to investigate and found Resident #14 standing over Resident #20, who was sitting, punching him in the face.-The facility failed to provide person-centered approaches to Resident #20's dementia care services to address his behaviors, to include wandering, in order to prevent physical altercations (cross-reference F600). V. Staff interviewCertified nurse aide (CNA) #2 was interviewed on 9/27/23 at 11:44 a.m. The CNA said Resident #14 had a language barrier, the staff used the translator phone to talk to him. The CNA said the resident thought he was security for the building and he did not want these people in it. He is under the impression this was his building and they were trespassing. The MCC was interviewed on 9/27/23 at 11:52 a.m. The MCC said interventions in the memory care unit include stop signs on doors. She said the main intervention that was used by staff to prevent resident altercations was redirection. She said Resident #14 had been having behaviors for the past several days. The DON was interviewed on 10/3/23 at 11:45 a.m. She said Resident #14 was on the secure unit and he had a few resident to resident altercations that involved someone hitting him or him hitting someone else. She said his behaviors include getting agitated. She said he had gotten better. She said he was often non-redirectable. She said Resident #14 had four altercations since 9/24/23 and these were more geared toward other residents rather than the staff. She said when he was not redirectable then the staff put him on a one-to-one observation, mainly when he was agitated and not redirectable. She said the facility tried to send him out on the M1 hold due to behaviors but he was sent back. She said to keep other residents safe the staff directed him to his room. The nursing home administrator (NHA) and the social services director (SSD) were interviewed on 10/3/23 at 12:20 p.m. The NHA said there were two instances where Resident #14 was the aggressor. He said the staff put him on a one-to-one observation. He said one-to-one staff was assigned to him as long as needed or the end of the shift. He said the NHA or the DON could initiate the one-to-one observation if needed. He said the facility did not have documentation for one-to-one observations. The NHA said nurses, CNAs or the staff who saw Resident #14 with behaviors should be monitoring him. The NHA said Resident #14 liked to use the translator machine. Registered nurse (RN) #1 was interviewed on 10/3/23 at 12:45 p.m. The RN said the internet was not working and the translator machine was not working. Licensed practical nurse (LPN) #1 was interviewed on 10/5/23 at 12:00 p.m. The LPN said the facility had not had internet service for a while, it had been down. The LPN said the internet had not worked the previous week, yesterday or today. The LPN said the translator machine did not work if the internet was down so the staff has not been able to use it. -The facility failed to ensure the translator machine, which required internet access, was working. The staff was unable to communicate with the resident which caused agitation to the resident. VI. Resident #22A. Resident #15's interview and record review about Resident #22's wanderingResident #15 was interviewed on 9/26/23 at 12:27 p.m. She said Resident #22 was confused and wandered into her room and rummaged through things in her room, including the trash. She said the nursing staff said the resident had a history of wandering, rummaging and aggression. Resident #15 said Resident #22 had recently come into her room and taken a blanket. She said she did not say anything to Resident #22 when she came in her room because she was afraid Resident #22 would get upset and physically hurt her. Resident #15 said she had no way to defend herself due to the inability to move her legs and arms. She said shefelt helpless, with increased feelings of anxiety and fear of physical harm from Resident #22 if she said anything to her. Resident #15 said she had spoken to the assistant director of nursing (ADON) #1 about her fear and concern with Resident #22 coming into her room, but nothing had changed and the resident continued to come into her room. Additionally, Resident #15 said she was concerned when she had seen Resident #22 in the lobby area, eating out of the trash can. Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes from the resident's representative regarding the events since the resident admitted. The notes documented in pertinent part that Resident #15 has said she was "scared" because a resident with known to be violent wheels herself into her room and Resident #15 had no way to defend herself. Additionally, the notes documented that Resident #22 had been observed by the resident representative eating out of the trash can in the lobby on 9/22/23. B. Resident statusResident #22, age 83, was admitted on 2/23/23. According to the October 2023 CPO diagnoses included dementia and major depression. The 7/14/23 MDS assessment indicated the resident had severe cognitive impairment and could not complete a BIMS evaluation. She had short and long term memory loss and did not recognize faces, names, rooms, seasons, or the facility. She required two persons extensive assistance with transfers, dressing, toileting and personal hygiene. She required extensive one person assistance with personal hygiene and eating. The assessment documented the resident had wandered daily and had no behaviors. The assessment documented the resident was on antipsychotic medication. C. Record reviewThe care plan related to behavior, revised 9/12/23 did not indicate when it was initiated. It documented, Resident #22 was confused and forgetful and took others belongings. She became physically aggressive towards others. She was observed by staff eating non edible items like paper and flowers. The goal was that the resident would be able to be redirected when she became physically and verbally aggressive. Interventions were to offer her a snack if she was seen eating non edible items. If the resident could not be redirected or calmed, staff should attempt to do care at a later time. Staff to explain was to the resident prior to and during the process of cares. Staff to redirect the resident to other activities. Staff to reorient the resident to place and situation as appropriate to their cognitive level. The care plan for wandering, revised 9/16/23 did not indicate when it was initiated. It documented Resident #22 was at risk for injury due to wandering throughout the building and attempting to go toward the front door. The care plan documented the resident had a wanderguard and to redirect her when wandering. Ensure all basic needs are met such as if the resident has gone to the bathroom, is hungry or thirsty. Invite the resident to activities. The progress notes documented in pertinent part,On 2/27/23 at 4:16 p.m. the nursing note document the resident was moved off the secure unit to a room two doors down from Resident #15. On 4/11/23 at 4:38 p.m. the progress notes documented that on 4/10/23 between 7:00 p.m. and 7:30 p.m. Resident #22 had gotten into an argument with her roommate when Resident #22 tried to take her roommate's pillow. The roommate resisted and Resident #22 slapped her roommate in the face. On 6/21/23 at 4:35 p.m. and 6/20/23 at 10:03 p.m. the progress notes documented Resident #22 was on monitoring for wandering and invading others privacy. -The progress notes did not document when or why the resident had been placed on this monitoring. On 7/11/23 at 3:59 p.m. assistant director of nursing (ADON) #1 documented that Resident #22 was in Resident #15's room again and Resident #15's spouse wheeled Resident #22 out ofResident #15's room. On 8/18/23 at 11:31 a.m. the director of nursing (DON) documented an IDT (interdisciplinary team) note. The note documented the resident was impulsive. The resident grabbed and rummaged through things like furniture. On 9/19/23 at 2:10 p.m. the provider documented the resident was on seroquel due to delusions and aggression. The provider documented the resident had been eating paint chips. The provider documented it was unclear how long this behavior had been occurring. D. Staff interviewsADON #1 was interviewed via telephone on 9/28/23 at 2:10 p.m. He said Resident #22 propelled around in her wheelchair and wandered into other resident rooms and rummaged. He said she had dementia and recently stole a blanket from a room. He said she was confused and recently stole a blanket from a room. The ADON said Resident #22 was usually looking for something to eat, and he tried to give her snacks. He said Resident #15 had reported to him that Resident #22 had been in her room. He said the plan to prevent Resident #22 from going into other rooms was to continue to try to give Resident #22 snacks. The DON was interviewed on 10/3/23 at 9:30 a.m. She said she was not aware of Resident #22 wandering into Resident #15's room and rummaging. She said she knew Resident #22 had wandered into other resident's rooms. She said Resident #22 was very confused and had done this since she admitted. The DON said she only heard Resident #22 wandered into other resident rooms, not that she rummaged in other resident rooms. The DON said she felt that someone would have said something if Resident #22 was really going into Resident rooms and rummaging. However, Resident #22's care plan documented she wandered throughout the building and took others belongings.(see above). Additionally, ADON #1 said Resident #15 had reported to him Resident #22 had been in her room. The DON acknowledged that this behavior could cause Resident #15 to be fearful due to her inability to move, or defend herself. She said a plan to prevent this would be to maybe put a stop sign on Resident #15's door. Certified nurse aide (CNA) #12 was interviewed on 10/9/23 at 1:00 p.m. She said Resident #22 wandered into other resident's rooms. She said she was usually looking for food and digging in the trash cans of other resident rooms or the lobby trash can. She said the resident ate inappropriate things such as recently trying to eat a blanket. CNA #10 said Resident #22 was frequently physically and verbally aggressive, at least two to three times per shift. CNA #10 said Resident #22 would scream, pinch, grab and kick the staff when they attempted to redirect her.

Based on record review and interviews, the facility failed to provide medically related social services to two (#12 and #15) of two residents reviewed out of 22 sample residents. Specifically, the facility failed to assist Resident #12 in making a dental extraction appointment timely after she reported pain and the dentist recommended extractions resulting in infection. Resident #12 was seen by the mobile dentist at the facility on 3/2/23. The mobile dentist recommended sending a referral to a dentist in the community for five tooth extractions. At this time the resident was in pain. The facility did not obtain consent from the resident until 4/4/23 to send the referral. The facility failed to schedule an appointment for Resident #12's teeth extractions for four and a half months. On 7/19/23 Resident #12 had her teeth extracted and was put on an antibiotic because she had developed an oral infection. Resident #15, who required assistance from staff, had five medical appointments that still had not been scheduled. Due to the lack of following up with scheduling her appointments, the resident felt anxious and frustrated due to her ongoing pain, unexplained muscle weakness and voice issues. Findings include:I. Facility policy and procedureThe Dental Services policy, revised December 2016, was provided by the director of nursing (DON) on 10/3/23 at 10:28 a.m. It read in pertinent part, "Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. "Social services representatives/designee will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible."II. Resident #12A. Resident statusResident #12, age 67, admitted on 10/26/22, readmitted on 8/3/23 and passed away on 8/30/23. According to the August 2023 computerized physician orders the diagnoses included: neurocognitive disorder with Lewy bodies (dementia), dysphagia (difficulty swallowing), dementia, Parkinson's disease (deterioration of the brain), anxiety and depression. The 8/22/23 minimum data set (MDS) assessment revealed she had severe cognitive impairments with short-term and long-term memory deficits according to staff interview. She required extensive assistance of two people for bed mobility, transfers, personal hygiene, walking in her room and in the corridor, locomotion on and off the unit and dressing. She required extensive assistance of one person for eating. The MDS documented the resident had no mouth problems. The MDS documented the resident was on a scheduled pain medication regimen, received as needed pain medications and did not receive non-medication pain interventions. B. Record review 1. Comprehensive care plan-dentalA review of Resident #12's electronic medical record, revealed Resident #12's comprehensive care plan did not address her oral/dental needs. 2. Dental progress notesThe 11/10/22 dental examination note documented the resident's mouth tissue was inflamed and red. The dentist recommended having all remaining lower teeth extracted and then get upper and lower dentures. The dentist documented to send a referral to another dentist for full lower extractions. The 1/24/23 dental examination note documented the resident refused to see the mobile dentist. The 3/2/23 dental examination note documented the resident was having pain on her lower right side of her mouth. The resident needed to have teeth extracted. The dentist requested a referral to be sent to another dentist for lower teeth extractions. The 6/2/23 dental examination note documented the resident had not gone to the local dentist for teeth extraction. The note documented the resident wanted the work done and was in pain. The dentist requested a referral to be sent to another dentist. The 7/19/23 dental progress note documented the resident had eight teeth extracted. The dentist ordered an antibiotic as the resident had a dental infection. -The facility failed to send a referral to the dentist to get the resident's teeth extracted till July 2023, although the resident started reporting pain in March 2023. 3. Progress notesThe 3/6/23 care conference note documented the social services director (SSD), assistant director of nursing (ADON) #2, the activities director (AD) and the resident met. The power of attorney (POA) was invited and said she would be there, but did not arrive. The SSD called the POA and left a voicemail. -The note did not indicate if an attempt was made to obtain dental consents (see SSD interview below). The 3/27/23 care conference note documented the resident, nursing home administrator (NHA), SSD, speech therapist, activities assistant, DON, ADON #2, the ombudsman and the doctor were present. The daughter was invited to come, but did not attend. -The note did not indicate if an attempt was made to obtain dental consents (see SSD interview below). The 4/4/23 social services progress note documented the dentist made recommendations to follow-up for extractions. The resident gave consent and an appointment request was sent to transportation. -The dentist recommended a referral to be sent on 11/10/22 and 3/2/23. The facility did not obtain consent to send a referral until 4/4/23. The 7/20/23 nursing progress note documented the resident was on an antibiotic for eight teeth extractions. The resident was on a soft diet until her mouth was healed. The licensed nurse documented she would continue to monitor. C. Staff interviewsThe SSD was interviewed on 9/27/23 at 2:54 p.m. The SSD said the mobile dentist saw Resident #12 in November 2022 and recommended for the resident to be seen by a community dentist for teeth extractions. The SSD said the mobile dentist attempted to see the resident in January 2023 and February 2023 and the resident refused to be seen. The SSD said Resident #12 was seen by the mobile dentist again on 3/2/23 and recommended to have the teeth removed. The SSD said the resident then had her teeth extracted in June 2023. -Resident #12 did not have her teeth extracted until 7/19/23. The SSD was interviewed again on 9/27/23 at 2:54 p.m. The SSD said she did not obtain consent from the resident to send a referral to the community dentist until 4/4/23. The van driver (VD) was interviewed on 9/28/23 at 4:03 p.m. The VD said he was responsible for scheduling appointments for all residents and transporting them to their appointments. The VD said typically dentist referrals were emailed to him from the SSD and he would make the appointment. The VD said sometimes referrals were not communicated to him. The VD said he called the doctor's office within a day or two from receiving a referral to calling the physician offices to make appointments. The VD said he was unsure the exact date he sent a referral for Resident #12 to have her teeth extracted. The VD said he did not document or keep record of when he received or sent referrals to doctors. The VD said he was unsure why it took several months to get Resident #12 an appointment to have her teeth extracted. The VD was interviewed again on 9/28/23 at 4:03 p.m. The VD said he spoke with the DON regarding documenting in resident medical records regarding sending referrals for medical records. The DON was interviewed on 9/28/23 at approximately 3:15 p.m. The DON said the nursing staff were responsible for placing referral orders into the electronic medical record and notifying the VD that an appointment needed to be scheduled.. The DON said the VD was responsible for calling the doctor's office, making an appointment and transporting the resident to the appointment. The DON said at times it took awhile to get certain appointments related to doctors availability. The SSD was interviewed again on 9/28/23 at 9:40 a.m. The SSD said she attempted to reach out to Resident #12's daughter who was the residents proxy (decision maker) and get consent to send a referral to an outside dentist for Resident #12's teeth extractions. The SSD said the VD was responsible for making appointments and transporting the residents to the appointments. The SSD said she was not involved in scheduling Resident #12's dental extraction appointment. The SSD was interviewed again on 9/28/23 at 9:53 a.m. The SSD provided two care conference notes from March 2023. The SSD said she attempted to reach out to the resident's daughter to obtain consent to send a referral to the community dentist. The SSD said the daughter did not call her back. The SSD said a month after the mobile dentist saw Resident #12 and recommended to have teeth extracted she asked the resident for consent to send the referral. The SSD said Resident #12 was able to make her own choices. The SSD said she was unsure why she did not ask the resident for consent sooner than 4/4/23. The NHA was interviewed on 10/3/23 at 11:35 a.m. The NHA said the VD was responsible for scheduling appointments and transporting residents to their appointments. The NHA said the facility had attempted to get her into the dentist that accepted her insurance. The NHA said pain is very subjective and if the facility felt it was an emergency then they would have had Resident #12 seen immediately. The NHA said the resident was not in that much pain. -However, the mobile dentist documentation revealed Resident #12 was in pain and wanted her teeth extracted. The NHA was interviewed again on 10/3/23 at 1:25 p.m. The NHA said the facility had referred the resident to the dentist, but the 7/19/23 date was the soonest available appointment. The NHA said the SSD tried to confirm the appointment with Resident #12's family, but she did not call her back. -However, the care conference notes do not indicate that the SSD attempted to speak to the daughter or the resident regarding consent to send a referral to a community dentist. The NHA said the VD was unable to document in the resident's medical records when he sent referrals. The NHA said the VD was given permission to document in medical records when he sends referrals and schedules appointments for the residents. III. Resident #15A. Resident statusResident #15, under age 65, was admitted on 6/14/23. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity, myopathy (disease affects muscles causing muscle weakness, neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. The assessment documented the Resident#15 had pain frequently which affected her day to day activities. She was on scheduled and PRN (as needed) pain medication and had no non pharmacological pain interventions. B. Resident interviewResident #15 was interviewed on 9/26/23 at 12:27 p.m. She said she was still waiting on five appointments to be scheduled by the facility. She said she was suppose to see an ENT (ear, nose and throat) doctor related to changes in her voice, a gynecologist related to pelvic pain which during a urinary tract infection on 9/8/23, a neurology appointment related to ongoing pain from neuropathy (weakness, numbness, pain due to nerve damage), a sleep study for concerns for sleep apnea (sleep disorder where breathing stops and starts during sleep) and a pain clinic related to her chronic pain. Resident #15 said she had not received any follow up from the nursing staff as to when the appointments were scheduled for. Resident #15 said she was frustrated and anxious regarding the lack of follow up on appointments for her pain, her unexplained muscle weakness and voice issues. C. Record reviewThe September 2023 CPO was reviewed on 9/26/23 at 1:25 p.m. The orders documented the following. 7/27/23, Referral to ENT for voice change, needs vocal cords visualized. 8/11/23, Consult pain management and rehab for chronic pain syndrome. 8/15/23, Referral to neurology to establish care and get EMG (muscle response to electrical activity) done. 8/24/23, Schedule outpatient EMG for generalized weakness and concern for myopathy. 8/24/23, Please schedule sleep study for concern for OSA (obstructive sleep apnea). 9/15/23, Referral to pain management for diagnosis of chronic pain. 9/15/23, Referral to OB-GYN (obstetric gynecologist) for vaginal burning. Twice the provider wrote orders for an EMG and a referral for pain management (see above) and no appointments were scheduled. The provider notes revealed the following:On 7/25/23 at 12:53 p.m. the provider documented in the progress notes the resident had "not gotten an EMG as previously discussed. Refer to neurology. The resident would like a referral to ENT. She has had a permanent voice change since intubation."On 7/27/23 at 9:23 a.m. the provider documented in the progress notes "confirmed that orders forreferrals have been placed to ENT, and neurology for EMG."On 8/3/23 at 12:51 p.m. the provider documented in the progress notes, "follow up on neurology referral, if not for some time, plan neuropathy labs, see if EMG can be done elsewhere without neurology appointment."On 8/29/2023 at 1:17 p.m. the provider documented in the progress notes, the resident has still not yet had an EMG.On 9/14/23 at 9:15 a.m. the provider documented in the progress notes, EMG and sleep study pending. On 9/15/23 at 11:11 a.m. the provider documented in the progress notes the referral to gynecology pain management clinic for chronic pain syndrome were still pending. On 9/22/23 at 2:26 p.m. the provider documented in the progress notes the referral to gynecology and pain management clinic were still pending.-However, once the survey began on 9/25/23, appointments began to get scheduled (see below). D. Staff interviewsThe director of nursing (DON) was interviewed on 9/28/23 at 9:30 a.m. She said if there was a referral in the physician orders the DON or nurse manager sent the referral to the van driver (VD) to schedule the appointment. The DON said the VD schedules and provided transportation to appointments for residents. The assistant director of nursing (ADON) #1 was interviewed on 9/28/23 at 2:10 p.m. He said he was in charge of nursing oversight on the hall Resident #15 resided on. ADON #1 said he did not know if an OB-GYN, neurology, pain, sleep study or ENT appointments had been scheduled. He said he was new at this, being the ADON, and it had been a struggle for him to keep everything straight. He said the VD was responsible for appointments. The nursing home administrator (NHA) was interviewed on 10/3/23 at 11:35 a.m. He said the VD scheduled appointments and transported the residents to the appointments. He said if it was a bariatric resident, the facility would use an outside agency to transport because they would not fit in the facility van. The NHA said he was not sure how the VD was notified of a referral and appointment that needed to be scheduled. The VD was interviewed on 10/5/23 at 10:28 a.m. He said he scheduled appointments, found specialty physicians for referral orders and drove the facility van for appointments. The VD said providers will text him if a resident needs an appointment. He said appointment needs were usually "word of mouth." The provider will test him that they put in a referral for a resident and the diagnosis. He said he would then go into the electronic medical record (EMR) and print off the order. The VD said he was just learning how to use the EMR system. He said once he printed the order he would call the physician office to see if they accepted the residents insurance and faxed them the referral order. He said once the appointment was made he gave a copy of the appointment to the resident and the resident's nurse. The VD said he did not go through the medical record to look for new orders for referrals. He said someone had to notify him if there was a new referral order. He said it could take three to seven days to get the appointment once he sent the specialist the fax with resident information and insurance. The VD said he had been working on scheduling appointments for Resident #15. He said she had all her appointments scheduled. -However, this was not completed until after the survey began on 9/25/23 (see below). He said the neurology appointment was scheduled when the referral was made by the provider. The VD said the sleep study had been hard to schedule because the resident needed to fill out a questionnaire for the referral. He said he was not medical so he could not do the questionnaire with the resident. He said the director of nursing (DON) would need to do the phone call and questionnaire together. The VD said he did not keep records of when a specialist office was contacted with a referral or appointment attempts he had made. The VD said he did not want to say why there was a delay. He said there was a delay in getting referrals in the residents chart as orders. E. Facility follow-upOn 10/5/23 at 11:00 a.m. the VD provided copies of appointments scheduled for Resident #15. All the appointments were scheduled after the survey began on 9/25/23. The documentation provided by the VD revealed:A pain management clinic referral was dated as ordered 9/28/23, due to chronic pain. There was still no documentation about when this appointment was scheduled for. The original orders for a pain clinic were written on 8/11/23 and 9/15/23 (see above). A neurology referral was dated as ordered 9/28/23 for an EMG. The appointment was scheduled for 12/6/23. The original orders for a neurology referral were written on 8/15/23 and 8/24/23 (see above). An ENT referral was dated as ordered 9/28/23, no diagnosis was listed. The appointment was scheduled for 10/5/23. The original orders for an ENT referral were written on 7/27/23. The VD was interviewed again on 10/9/23 at 11:11 a.m. The VD said the resident did not go to her ENT appointment on 10/5/23 because her wheelchair did not fit in the van from the transport agency. He said the appointment would need to be rescheduled when the transport agency had their larger transport van available. The OB-GYN appointment documented it was ordered on 10/3/23, and was scheduled for 10/24/23 at 1:15 p.m. However, the order for the OB-GYN was written on 9/15/23. -There was no documentation provided regarding an appointment for a sleep study.

Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included facility and community based risk assessments, facility resources, types of staff medical practitioners needed, staff training and competency information, and contract and memorandum of understanding information for third party providers in normal and emergency situations. Findings include: I. Record reviewThe facility assessment, reviewed 12/9/22, was received from the nursing home administrator (NHA) on 10/5/23 at 10:50 a.m. The facility assessment failed to include:-The facility-based and community-based risk assessment, utilizing an all-hazards approach;-Identify the facility resources including a 25 bed secure unit and wanderguard system;-Identify the type of staff, health care professionals, medical providers needed to provide care and support for the resident population including the secure unit coordinator and assistant directors of nursing (ADON);-Identify specific trainings, competencies and education needed for the types of professional staff providing resident support and care needed; -Identification of all contracts, memorandum of understanding and other agreements to provide services or equipment to the facility during day to day operations and emergencies; and, -Accurate calculations of the number of hours of direct care provided per resident per day. The assessment documented the facility provided 36.5 registered nurse (RN) hours per resident per day; 56 hours of licensed practical nurse (LPN) per resident per day; and 172.5 hours of certified nurse aide (CNA) hours per resident per day with an average census of 103 residents. The assessment documented the facility provided 16 CNAs per day (12 hour shifts) for a total of 192 hours per day for all residents not per resident and a total of eight nurses (RN or LPN) per day (12 hour shifts) 96 hours per day for all residents not per resident. With an average census of 103, this was approximately 1.86 hours of CNAs per resident per day, and 0.93 hours of licensed nurses per resident per day. II. InterviewThe NHA was interviewed on 10/9/23 at 10:27 a.m. He said the facility's nurse consultant wrote the facility assessment in December 2022. He said he reviewed it briefly when he started in April 2023. He said he had not identified the lack of a complete list of staff needed and education, competency and training needed. The NHA said he had not identified the missing information regarding the facility vans, the secure unit or wanderguard system. He said he was not aware that facility risk assessment information needed to be included in the facility assessment. The NHA said the facility assessment did not include all contract information or any information on facility memorandum of understandings. He said the direct care staff hours were not calculated accurately.

Based on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#12) out of 22 sample residents. Specifically, the facility failed to contain an accurate representation of incontinence care and meals provided to Resident #12. Findings include:I. Resident #12A. Resident statusResident #12, age 67, admitted on 10/26/22, readmitted on 8/3/23 and passed away on 8/30/23. According to the August 2023 computerized physician orders the diagnoses included: neurocognitive disorder with Lewy bodies (dementia), dysphagia (difficulty swallowing), dementia, Parkinson ' s disease (deterioration of the brain), anxiety and depression. The 8/22/23 minimum data set (MDS) assessment revealed she had severe cognitive impairments with short-term and long-term memory deficits according to staff interview. She required extensive assistance of two people for bed mobility, transfers, personal hygiene, walking in her room and in the corridor, locomotion on and off the unit and dressing. She required extensive assistance of one person for eating. C. Record reviewThe ADL care plan, initiated on 8/4/23, revealed Resident #12 had a physical functioning deficit. The interventions included in pertinent part, providing assistance with personal hygiene and toileting. A review of Resident #12's toileting log was provided by the director of nursing (DON) on 9/27/23 revealed the resident was toileted once on 8/12/23 at 7:36 p.m., once on 8/13/23 at 11:09 a.m., twice on 8/14/23 at 5:59 a.m. and 9:22 a.m., once on 8/15/23 at 11:07 a.m., twice on 8/16/23 at 6:24 a.m. and 8:09 p.m., twice on 8/17/23 at 6:45 a.m. and 8:09 p.m., twice on 8/18/23 at 10:02 a.m. and 11:23 p.m. and twice on 8/19/23 at 8:56 a.m. and 10:35 p.m.-It indicated the resident was not toileted for 16 hours on 8/12/23 to 8/13/23, 19 hours from 8/13/23 to 8/14/23, three and a half hours on 8/14/23, 26 hours from 8/14/23 to 8/15/23, 19 hours from 8/15/23 to 8/16/23, 14 hours on 8/16/23, 10 hours from 8/16/23 to 8/17/23, 16 hours on 8/17/23, 11 hours from 8/17/23 to 8/18/23, 13 hours on 8/18/23, nine hours from 8/18/23 to 8/19/23 and 14 hours on 8/19/23-It indicated the resident was not toileted for 13 hours on 9/11/23, 13 hours on 9/12/23, 12 hours on 9/13/23 and five hours on 9/14/23. A review of Resident #12 ' s meal intake log from 6/19/23 through 8/30/23 was provided by the DON on 9/27/23 revealed Resident #12 was provided two meals on 7/1, 7/2, 7/12, 7/13, 7/19, 7/22 and 8/17/23. It revealed Resident #12 was provided one meal on 8/7/23. It revealed Resident #12 was not provided a meal on 8/4/23. II. Staff interviewsCertified nurse aide (CNA) #7 was interviewed on 9/28/23 at 12:51 p.m. CNA #7 said the CNAs were responsible for assisting residents to the bathroom. CNA #7 said when she assisted a resident with toileting, she was responsible for documenting the resident was toileted in the resident ' s medical record. CNA #7 said if she toileted a resident and did not document it, there was no proof that the resident was toileted. CNA #7 said she worked from 6:00 a.m. to 6:00 p.m. CNA #7 said she assisted incontinent residents after breakfast, lunch and dinner. CNA #7 said after a resident consumed their meal, it was the CNA ' s responsibility to document the amount each resident consumed in their medical record. CNA #7 said she refused if the resident did not want to eat after multiple offers. CNA #7 said every resident should have three documented meals each day. The registered dietitian (RD) was interviewed on 10/3/23 at 10:30 a.m. The RD said Resident #13 ' s meal intake log had blank entries. The RD said she was unsure what the blank entries meant. The RD said every resident should have received three meals a day. The RD said she utilized the meal ticket system to ensure all residents got their meals. The RD said she was not aware that some residents had occasionally missed meals. The DONwas interviewed on 10/3/23 at 10:55 a.m. The DON said nursing staff were responsible for documenting each time they assisted a resident to the bathroom. The DON said residents should be toileted every two hours. The DON said there were several days Resident #13 had one or two documented toileting episodes. The DON said staff were responsible for documenting how much residents consumed of their meals or if they refused their meals three times a day. The DON said Resident #13 had missing entries on her meal intake log.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident rights, abuse and neglect, quality of life and quality of care. Findings include:I. Facility policy and procedureThe Quality Assurance can Performance improvement (QAPI) policy, revised February 2020, was received from the nursing home administrator (NHA) on 10/9/23 at 9:53 a.m. The policy documented in pertinent part, "Provide a means to measure current and potential indicators for outcomes of care and quality of life. The QAPI plan describes a process for identifying and correcting qualified deficiencies. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators."II. Cross-reference citationsCross-reference F600: The facility failed to ensure residents were protected from resident to resident physical abuse. The facility's failure to protect residents from resident to resident physical abuse created an immediate jeopardy situation. Additionally, the facility failed to investigate an allegation of staff to resident verbal abuse and multiple allegations of neglect. Cross-reference F550: The facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Cross-reference F609: The facility failed to report to the state agency an allegation of staff to resident verbal abuse. Cross-reference F610: The facility failed to thoroughly investigate an allegation of staff to resident verbal abuse. Cross-reference F684: The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices. Cross-reference F697: The facility failed to ensure pain was managed adequately. Cross-reference F730: The facility failed to ensure staff competencies and training were completed. Cross-reference F744: The facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Cross-reference F745: The facility failed to assist residents with timely offsite medical appointments as ordered. Cross-reference F838: The facility failed to conduct a thorough facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergency situations. III. Staff InterviewThe NHA was interviewed on 10/9/23 at 3:17 p.m. The NHA said he was not aware of concerns with staff using their cell phones in resident care areas. He said the facility had looked at medication changes for the resident who had been involved in the resident to resident altercations (cross-reference F600) but had not looked at non-pharmacological interventions for his behavior. He said the resident ' s room did not need personal items, or items and pictures on the walls. He said every secure unit he had been to when he worked as a physical therapist (PT), did not have personal items on the wall or in the room. He said the residents on secure units would just end up moving or taking the items. He said the QAPI committee had not identified the lack of non-pharmacological interventions for the secure dementia care unit (cross-reference F744). The NHA said the memory care coordinator (MCC) completed the dementia training for newly hired staff. He said she did not know what was included in the training or how the training was presented, whether it was paper to read, verbal or by video. He said the QAPI committee did not identify dementia training as a concern because the MCC did not present it as a concern to the committee. .The NHA said the allegation of verbal abuse by staff was not reported or investigated from August 2023 because many things were just coming to light during the survey (9/26/23 to 10/9/23). He said he could not recall the specifics about the staff to resident neglect was substantiated or why the previous allegations of neglect had been unsubstantiated (cross-reference F600). He said the QAPI committee reviewed allegations of abuse and neglect but did not identify the allegations of neglect. The NHA said the unavailability of pain medication was brought up during the facility clinical meetings in the morning, but the QAPI committee had not reviewed the concern. The NHA said the QAPI committee had not identified the multiple delays in scheduling outside medical appointments, the missing information from the facility assessment or the lack of staff competencies. He said the competencies needed to be addressed.

A revisit survey was completed on 9/5/23 for all previous deficiencies cited on 7/20/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO32883 was conducted on 7/20/23. Two deficiencies were cited.

Based on observations and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects for two of three dumpster areas. Specifically, the facility failed to ensure garbage and potentially hazardous medical waste was disposed of in the proper receptacles or dumpster. Findings include:I. Facility policy and proceduresThe Food and Related Garbage and Refuse Disposal policy, revised October 2017, was received from the director of nursing (DON) on 7/20/23 at 12:25 p.m. The policy documented in pertinent part, "Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. Storage areas will be kept clean at all times, and shall not constitute a nuisance. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter."The Medical Waste policy, dated 2018, was received from the DON on 7/20/23 at 12:23 p.m. The policy documented in pertinent part, "For the purpose of this policy, medical waste includes human blood and blood-soiled articles, contaminated items (soiled dressings), items contaminated with feces from a person diagnosed as having a disease that is transmitted through feces, and disposable sharps (needles, scalpels). Disposable items, which are contaminated with excretions or secretions from residents believed to be infectious, must be placed in red plastic bags and sealed; stored until removal from the premises. Outside of the compactor and dumpster must be locked when not in use and at night. Only authorized vendors are permitted to collect regulated wastes."II. Observations and interviews On 7/20/23 at 10:49 a garbage dumpster could be observed from the common area, through a window, on the 700 hall. From the window the dumpster toward the back of the parking lot had garbage and two red bins on the ground in front of it, broken equipment on the side of it and a thick layer of garbage in front of it. At 11:39 a.m., the dumpster seen from the 700 hall window was observed outside up close with the maintenance supervisor (MS) and the nursing home administrator (NHA). While walking to the dumpsters, the MS said the facility had three garbage containers. He said the facility had one large roll off dumpster for garbage outside the 400 hall, one garbage compactor with recycle bin across from the 400 hall dumpster and one roll off dumpster that had been used to dispose of old equipment outside of the 700 hall. He said the two roll off dumpsters were not emptied routinely, the facility had to call to have them emptied. The MS said the garbage compactor and recycle bin were emptied three times per week. He said he did not know if anyone routinely checked the garbage areas to ensure the garbage and refuse was contained and not on the ground. The garbage compactor and recycle bin in the facility parking lot were observed first with the NHA and the MS. On the ground surrounding the garbage compactor were five pairs of disposable gloves, empty water bottles, empty drink cans, multiple napkins, pieces of aluminum foil, food wrappers, disposable silverware and other pieces of paper. The roll off garbage dumpster outside the 700 hall was then observed with the NHA and the MS. The dumpster was at the back of the parking lot. There were two cars parked near the dumpster. The ground in front of the dumpster had layers of garbage about 10 to 12 inches high. Garbage on the ground included empty test tube vials, approximately 10 vials with an orange cap and 10 with a red cap; layers of yard waste, old food, multiple soiled disposable incontinence briefs, food wrappers, water bottles, plastic cups, plastic silverware, food cans, styrofoam cups, 10 or more plastic bags white and black plastic bags with unknown contents, an old dormitory size refrigerator, old boxes, old plastic urinals, bed pillows and gloves. The garbage was piled several inches high on the ground. The ground could not be seen under most of the area surrounding the front of the dumpster. There was an empty brown glass bottle approximately three inches tall by 1.5 inches in diameter, with a dropper. The bottle appeared to be a medication bottle used for liquid morphine (Roxanol). The label was peeled off. The bottle appeared empty. To the left side of the dumpster were two red bins labeled biohazard. Both bins were observed from the top. They were full of papers and yard debris. One had a large white plastic bag in it, hanging halfway out. The contents of the bag were unknown. The contents of the red bins was unknown except for what could be observed from the top. Cross-reference: F880 infection prevention and control. The gate in front of the dumpster would not close due to the layers of garbage. The NHA said "it was not like that yesterday, the kitchen must have done it." Upon further observation of the items on the ground the NHA acknowledged there were multiple layers of garbage and unknown possible medical waste. The MS said the outside garbage company was on their way to pick up the dumpster. However, upon clarification he said the garbage company was not coming today and he was not sure when they would be there. The NHA said all the garbage around the dumpster should be treated as if it were biohazardous waste because there was no way to tell which garbage might be hazardous medical waste and which was not. The NHA said there were homeless persons in the area and maybe they had caused all the garbage to be on the ground.-However, this did not explain why the biohazardous bins were outside next to a dumpster, with vials on the ground. The NHA and MS said they did not know where the facility's biohazardous waste was stored for pick up. The NHA said he was not sure who was in charge of monitoring the dumpster areas to ensure all refuse and garbage was contained in the dumpsters. The MS said the dumpster areas should have been monitored to ensure they did not have garbage on the ground around them. He said she would assign someone to monitor the areas daily moving forward. The dumpster in the parking lot behind the 700 hall was observed with the director of nursing at 11:56 a.m. She said the vials with the orange and red tops looked like COVID test tubes. She said she did not know how they got there. The DON said the facility had not used that type of testing vial for many months. The DON said biohazardous medical waste should not be stored out by the dumpster. She said it was stored in the soiled utility rooms until picked up by the biohazard vendor. The area was observed again at 1:30 p.m. There was no change to the garbage on the ground or around the dumpsters.

Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of three hallways and the facility parking lot. Specifically, the facility failed to: -Ensure soiled linen and garbage was contained in a manner to prevent the spread of infection; and,-Ensure potentially biohazardous materials were stored in a manner to prevent the spread of infection. Findings include:I. Facility policies and proceduresThe Medical Waste policy, dated 2018, was received from the DON on 7/20/23 at 12:23 p.m. The policy documented in pertinent part, "For the purpose of this policy, medical waste includes human blood and blood-soiled articles, contaminated items (soiled dressings), items contaminated with feces from a person diagnosed as having a disease that is transmitted through feces, and disposable sharps (needles/scalpels). Disposable items, which are contaminated with excretions or secretions from residents believed to be infectious, must be placed in red plastic bags and sealed; stored until removal from the premises. Outside of the compactor and dumpster must be locked when not in use and at night. Only authorized vendors are permitted to collect regulated wastes."The Laundry and Bedding, Soiled policy, revised September 2022, was received from the director of nursing (DON) on 7/20/23 at 3:38 p.m. The policy documented in pertinent part, "All used laundry is handled as potentially contaminated using standard precautions. Contaminated laundry is bagged or contained at the point of collection (location where it was used). Clean linen is stored separately, away from soiled linens, at all times. Clean linen is kept separate from contaminated linen."II. Potentially contaminated soiled linenOn 7/20/23 at 10:40 a.m. certified nurse aide (CNA) #1 was observed walking down the 700 hall with a bag of trash in her left hand and a pile of dirty linen in her right hand. She went to the soiled utility room and came back out in less than a minute. She was no longer carrying the linen or trash. She walked down the hallway halfway and entered a resident's room. At 10:49 a.m. the soiled utility room on the 700 hall was observed with licensed practical nurse (LPN) #1. LPN #1 said she did not know where the biohazardous waste was disposed of in the facility. On the counter in the soiled utility room were four sharps containers filled to the top with needles, syringes and other items. At 10:55 a.m. on the 400 hall, a soiled linen cart was observed. There was no bag in the cart and it was zipped all the way open to the bottom. There were multiple soiled linens including sheets and towels hanging out of the cart and onto the floor. The hamper was resting against the clean linen cart. Registered nurse (RN) #1 was interviewed on 7/20/23 at 10:56 a.m. He observed the soiled linen cart. RN #1 said the soiled linen cart should have a bag in it. He said the soiled linen should have been bagged before it was brought out of a room. RN #1 said soiled linen was bagged before it was removed from a resident room to prevent the spread of infection. He said clean linen should not be stored next to soiled linen due to the risk of contamination. RN #1 said he did not know who was responsible for ensuring the soiled linen cart had a bag in it. At 11:00 a.m. the 400 hall soiled utility room was observed. The door was unlocked. A trash bin was overflowing with trash. There were bags of trash on the floor, paper wrappers and used gloves rolled together. There were no biohazard bins in the room. At 1:40 p.m. the 700 hall was observed. Midway on the hall was a trash bag on the ground in the hall with used incontinent briefs. At 2:02 p.m. the 400 hall soiled utility room was observed with the assistant director of nursing (ADON). The door was unlocked. The trash bin was still overflowing with trash. There were bags of trash on the floor, paper wrappers and used gloves rolled together. The ADON said the trash should have been emptied. There were no biohazard disposal containers in the room. A sharps container, full to the top, was on the counter. The ADON said she did not know where the biohazardous waste was disposed of in the facility. The DON was interviewed on 7/20/23 at 1:32 p.m. The DON said sharps containers should be placed in a biohazardous waste bin when three fourths full. She said linen should have been bagged in the resident room before it was brought out into the hall to prevent any transmission of infectious material. The DON said the linen barrels should have liners and no linen should be thrown in the bin unbagged and hanging onto the hall floor to prevent contamination. III. Potentially hazardous medical waste (cross-reference F814 garbage and refuse)A roll off garbage dumpster outside the 700 hall, in the facility parking lot, was observed with the nursing home administrator (NHA) and the maintenance supervisor (MS). The dumpster was at the back of the parking lot. There were two cars parked to the left of the dumpster. The ground in front of the dumpster had layers of garbage about 10 to 12 inches high. Garbage on the ground included empty test tube vials, approximately 10 vials with an orange cap, and 10 with a red cap; layers of yard waste, old food, multiple soiled disposable incontinence briefs, food wrappers, water bottles, plastic cups, plastic silverware, food cans, styrofoam cups, 10 or more plastic bags white and black plastic bags with unknown contents, an old dormitory size refrigerator, old boxes, old plastic urinals, bed pillows and gloves. The garbage was piled several inches high on the ground. The ground could not be seen under most of the area surrounding the front of the dumpster. To the left side of the dumpster were two red bins labeled biohazard. Both bins were observed from the top. They were full of papers and yard debris. One had a large white plastic bag in it, hanging halfway out. The contents of the bag were unknown. The contents of the red bins was unknown except for what could be observed from the top. The gate in front of the dumpster would not close due to the layers of garbage. The NHA said "it was not like that yesterday, the kitchen must have done it." Upon further observation of the items on the ground, the NHA acknowledged there were multiple layers of garbage and unknown possible medical waste. The NHA said all the garbage around the dumpster should be treated as if it were biohazardous waste because there was no way to tell which garbage might be hazardous medical waste and which was not. The NHA said there were homeless persons in the area and maybe they had caused all the garbage to be on the ground. Additionally, staff, visitors and residents had access to the parking area. The dumpster in the parking lot behind the 700 hall was observed with the director of nursing (DON) at 11:56 a.m. She said the vials with the orange and red tops looked like COVID test tubes. She said she did not know how they got there. The DON said the facility had not used that type of testing vial for many months. The DON said biohazardous medical waste should not be stored out by the dumpster. She said it was stored in the soiled utility rooms until picked up by the biohazard vendor.

A revisit survey was completed on 6/26/23 for all previous deficiencies cited on 5/4/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 6/26/23 for all previous deficiencies cited on 5/4/23. The facility is in compliance with all regulations surveyed.

A survey for Incidents #31636 and #31871 was conducted on 5/1/23-5/4//23. One deficiency was cited.

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

A survey prompted by complaint #CO32118 was completed 5/1/23 to 5/4/23. One deficiency was cited.

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

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required. Waived tags include 222, 341,345, 351, 371, 521.

A complaint survey, prompted by #CO31290 and Incidents #30823, #31145, #31164 and #31438 was conducted on 3/16/23 to 3/29/23. No deficiencies were cited.

A revisit survey was completed on 1/19/23 for all previous deficiencies cited on 11/17/22. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/19/23 for all previous deficiencies cited on 11/17/22. The facility is in compliance with all regulations surveyed.