SIERRA POST ACUTE

A complaint survey, prompted by #CO35326 #CO37318 and Incident #37319 was conducted on 9/4/24 to 9/5/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting one (#1) out of three residents reviewed for accident hazards of three sample residents. The facility failed to provide adequate supervision during a smoking break to a resident, who required the use of oxygen. On 8/21/24 Resident #1 exited the behavioral health secured unit door and entered the smoking patio with his oxygen tank and nasal cannula on his face. Certified nurse aide (CNA) CNA #1 and CNA #2 were present to supervise the resident smoking session. CNA #1 was handing out the cigarettes to the residents and CNA #2 was lighting the cigarette for the residents. Resident #1 reached over other residents for his cigarette and CNA #1 handed him a cigarette. Resident #1 proceed to the line to get his cigarette lit. CNA #2 lit his cigarette but did not observe that the resident's oxygen was in place. Resident #1 proceeded to a chair in the corner of the smoking patio and began smoking his cigarette. CNA #1 and CNA #2 saw another resident running towards Resident #1 and patting his hair which was on fire. Both CNAs ran to Resident #1 and the fire had already been extinguished. CNA #2 immediately removed the resident's nasal cannula and oxygen tank. CNA #2 turned the oxygen off and both CNAs escorted the resident to the nurse's station. The nurse immediately called 911 and sent Resident #1 to the hospital related to the burns on his face. Due to the facilities failure to ensure adequate supervision while residents were smoking, Resident #1 sustained burns to his forehead, tip of his nose, both nostrils, upper and lower lip and his cheeks. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/4/24 to 9/5/24, resulting in the deficiency being cited as past noncompliance with a correction date of 8/21/24. I. Accident investigationThe 8/20/24 accident investigation was provided by the NHA on 9/4/24 at 10:30 a.m. .The investigation documented the nurse was alerted by CNA #1 and CNA #2 that Resident #1 had been burned when his oxygen ignited while he was smoking on 8/20/24 at approximately 4:00 p.m. The nurse completed first aide to Resident #1 while waiting for emergency medical services (EMS) to arrive. The paramedics took over the resident's care of the visible burns and were attempting to keep his airway clear. The resident was sent to the emergency department. The hospital notes revealed that soot (ashes from the fire) was present in the posterior oropharynx (the back wall of the throat). The physician, the police, the nursing home administrator (NHA), the director of nursing (DON), the ombudsman and the resident's guardian were notified of the incident. The staff members that were involved were provided education on the smoking policy and suspended pending an investigation. Resident #1 was interviewed by the nurse and the DON immediately following the incident. Resident #1 said he was sorry that he had forgotten to take his oxygen off before entering the smoking patio. He said he was afraid he had ruined the smoking session for everyone. He said his face hurt. When Resident #1 returned from the hospital, the nurses progress note on 8/22/24, stated he said the staff had saved his life and that he was so happy to be home. II. Facility corrective actionA. Immediate actionThe NHA, the police department, the DON, the ombudsman and the resident's legal guardian were notified of the incident. Resident #1 was immediately transferred to the hospital for evaluation and treatment of his burns. The two employees that were involved were immediately educated on the smoking policy and suspended pending an investigation. All staff working in the facility at the time of the incident were provided reeducation on the smoking policy. The following day (8/21/24) the remainder of facility staff were reeducated on the smoking policy with return demonstration. B. Interventions put into placeThe facility reviewed their current policy 8/20/24, to ensure appropriate procedures were in place to prevent harm /potential harm. The policy met all the criteria of what was needed and all of the staff were reeducated on the smoking policy. The incident was in violation of the policy and procedure, so all of the residents who smoked and all of the staff present at the time of the incident were educated on the policy immediately that day (8/20/24). In addition, all staff that were not present were educated the following day (8/21/24). The NHA would ensure that all newly hired staff would receive education on safe smoking and the facility policy. The education given included the following information:"Smoking while using oxygen can be extremely dangerous and can lead to serious consequences. Oxygen is a medical gas that can increase the risk of fire when used in the presence of smoking. While oxygen itself isn't flammable, an oxygen-rich environment can cause materials to ignite more easily and burn faster. This includes flammable substances like cigarettes, which can burn hotter and faster in an oxygen rich environment. Oxygen molecules can also cling to clothing, hair, skin and ignite if they come into contact with the flame."Smoking while using oxygen can lead to catastrophic consequences, including severe injuries, property damage, and loss of life. Some people have been left with serious facial or upper body burns after smoking while on oxygen."It is our responsibility to ensure that we are protecting our residents from harm. It is our job to ensure that residents who smoke have appropriate personal protective equipment (PPE) if needed and do not have oxygen on. If a known oxygen user is also a smoker, staff is to ensure that the oxygen tank is turned off and left inside the building prior to handing out any cigarettes. Residents smoking times is not a time for staff to be on the phone, texting, or playing games. When supervising a resident smoke break, staff need to be actively supervising the residents."Newly admitted residents would be assessed for history or current smoking upon admission. The facility initiated daily random audits of all three units on 8/21/24 to monitor residents who required supervision for smoking. The monitoring included oxygen use, assistive devices, burn holes in clothing/chair cushions, supervision, that staff had all smoking equipment in their possession and any resident concerns. The DON or designated supervisor was to continue the audits for three months. III. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 5/30/23 and readmitted on 8/22/24. According to the September 2024 computerized physician orders (CPO), the diagnoses included Schizophrenia (mental disorder that causes abnormal behaviors), other psychoactive substance abuse, chronic obstructive pulmonary disease (COPD), dependence on supplemental oxygen and nicotine dependence. The 8/12/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He had no behaviors and did not reject care. He was independent with all of his activities of daily living (ADL). He received oxygen therapy. -The MDS assessment did not indicate the resident smoked. B. Record reviewThe smoking care plan, initiated on 6/19/23 and revised on 8/23/24, revealed Resident #1 currently smoked with direct supervision from a staff member during designated smoking times per facility protocol. Resident #1 was forgetful at times and would ambulate into the smoking designated area with his oxygen present. The interventions included: evaluating the residents ability to smoke safely upon admission, reevaluated quarterly, upon significant change and as determined by qualified staff, instructing and informing Resident #1 about the facility policy on smoking, locations, times, safety concerns and any changes,monitoring for unsafe smoking practices notifying the charge nurse immediately if it was suspected resident had violated the facility smoking policy,providing Resident #1 the required supervision while smoking, storing Resident #1's smoking supplies in the nurse's station, and assisting Resident #1 in removing his oxygen prior to going out into any designated smoking areas. The smoking care plan also documented that the facility could impose smoking restrictions on a resident at any time if it was determined that the resident could not smoke safely with the available levels of support and supervision; and, that the facility maintained the right to confiscate smoking items found in violation of facility smoking policies. A physician's order, dated 5/21/24, revealed the resident was receiving continuous oxygen at three liters per minute (LPM) via a nasal cannula. A readmission progress note dated 8/22/24 at 4:46 p.m. revealed Resident #1 was readmitted to the facility from the hospital post smoking/burn incident. It documented Resident #1 had extensive reddened/burned areas to his nose, cheeks, lips and chin. As well as various small blisters and open/seeping blisters to his face with edema (swelling) throughout. III. Staff interviewsCNA #1 was interviewed on 9/4/24 at 1:15 p.m. CNA #1 said she was one of the CNAs supervising the smoking session at the time of the incident on 8/20/24. She said she had worked at the facility for nine years, but usually worked in the memory care unit. She said she received education on the smoking policy and the needed equipment. such as a smoking apron. She said she was educated to ensure residents were smoking safely. She said that prior to the incident Resident #1 rounded the corner of the dining room without his walker and was carrying his oxygen tank. She said Resident #1 returned to his room to retrieve his walker while she attended to another resident. She said Resident #1 usually had his oxygen tank attached to his walker, left the walker at the door and removed his oxygen from his face. CNA #1 said after she attended to a resident, it was time to take the residents out for their smoking session. She said all of the residents that smoked, lined up to receive their cigarettes. She said she was passing the cigarettes one by one to each resident. She said Resident #1 was eager to smoke and reached over the other residents to retrieve his cigarette. She said she did not see his face and did not know he was still wearing his oxygen. She said Resident #1 had long hair which was in his face and he always left his oxygen tank attached to the walker at the door. CNA #1 said CNA #2 was lighting the cigarettes in a separate line. She said Resident #1 sat down to smoke his cigarette as the staff continued to pass and light cigarettes for the other residents in line. She said she saw another resident run up to Resident #1 and pat his hair to put the fire out. She said she yelled to CNA #2 that Resident #1 was on fire while running to the resident. She said by the time she arrived to Resident #1, the fire was already out. She said CNA #2 immediately grabbed the oxygen tank and turned it off. She said the nasal cannula had burned away. She said her and CNA #2 then escorted Resident #1 inside the nurses station for treatment. She said the nurse called 911 and treated the resident's burns while awaiting EMS. She said the resident was then sent to the hospital. She said the DON immediately reeducated her on the smoking policy and she was suspended pending the investigation. CNA #2 was interviewed on 9/5/24 at 9:51 a.m. CNA #2 said it was the normal smoke session and CNA #1 had heard out to the smoking patio while he ran to do something quickly in the office. He said he hurried outside to assist CNA #1. He said CNA #1 had already begun passing cigarettes out. He said he had his lighter and to make the process faster he started to light the cigarettes. He said he lit Resident #1's cigarette but did not notice he was still wearing his oxygen. He said he was not paying attention as well as he should have been. He said Resident #1 walked over to a chair and sat down to smoke his cigarette while he continued to light other resident's cigarettes. CNA #2 said he then heard another resident yelling that his hair was on fire, He said he looked up and saw a resident patting at Resident #1's hair. He said he ran over to the residents and removed the oxygen tank and turned it off. He said the nasal cannula had burned away. He said he and CNA #1 helped the resident back into the building to the nurse's station. He said Resident #1 usually was good about taking his oxygen off and leaving it at the door on his walker. He said everything moved so quickly he did not pay attention to Resident #1's face and nose area. He said the staff had to constantly keep their eye on everyone. He said he still felts guilty for not observing Resident #1's oxygen and lighting his cigarette. He said he was immediately reeducated on the smoking policy and suspended pending an investigation. The NHA was interviewed on 9/5/24 at 10:43 a.m. The NHA said when the incident occurred two CNAs were present. He said Resident #1 required supervision with supervised smoking and was the only resident receiving oxygen therapy in the behavior health unit that smoked. He said the smoking material was kept at the nurse's station for safety and the residents had scheduled smoking times. The NHA said each resident had been assessed for safe smoking practices. He said if a resident was assessed as safe to light their own cigarette, they were allowed to light it themselves. He said if they were assessed as not safe to light their own cigarette, staff would light it for them. He said on the day of the incident the staff should have been aware of whether the resident was wearing his oxygen or not. He said oxygen should always be removed before smoking. He said both CNA #1 and CNA #2 were reeducated on the smoking policy and procedure and were suspended pending an investigation. He said both of the CNAs returned to working the floor after the suspension and a written performance review was completed. He said the facility immediately reeducated all staff on the smoking policy. He said every resident was reassessed for smoking safety and the smoking policy was revamped to include that the supervised monitor was responsible for removing the oxygen and oxygen tubing at the nurses station before the smoking session. The NHA said in addition to the measures they put in place to prevent the incident from happening again, the facility requested the local fire marshal to assess the smoking area at the facility.

A revisit survey was completed on 5/8/24 for all previous deficiencies cited on 3/20/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO35236 and #CO35300 was conducted on 3/20/24. Two deficiencies were cited.

Based on observations and interviews, the facility failed to ensure residents resided in a sanitary and comfortable environment for three of three units observed for cleanliness. Specifically the facility failed to:-Ensure resident rooms, dining rooms, hallways, kitchen floors and furniture were free from debris, food, and mice droppings (cross reference F925 pest control); and,-Mitigate unpleasant odors on the Legacy unit. Findings include:I. Facility policy and proceduresThe Homelike Environment policy, revised February 2021, was received from the nursing home administrator (NHA) via email on 3/20/24 at 11:58 a.m. It read in pertinent part, "The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: clean, sanitary and orderly environment; pleasant, neutral scents"II. Observations A. Sarvata unitOn 3/20/24 at 10:00 a.m., the Sarvata unit was observed. Observations revealed the following:-There was significant discoloration and staining on the two couches in the main area of the Sarvata unit. An unidentified resident was sitting on the stained couch.-Debris and food crumbs were scattered throughout the hallways, along baseboards and under the radiators. B. KitchenOn 3/20/24 at 10:10 a.m., the kitchen was observed. Observations revealed the following:-There were dried liquid spills and crumbs on the floor throughout the kitchen. -There was a glue-type mouse trap under the rack used to store clean dishes with mouse feces surrounding it. -There was a gap around the window air conditioning (AC) unit with visible daylight. A mouse trap was under a desk in the dry storage room. C. Activities office and storage roomOn 3/20/24 at 10:29 a.m., the activities office and storage room were observed. Observations revealed the following:-There were several chip bags in the activities storage room. The bags had holes where they had been chewed through. -Mouse droppings were in the corners of the room, along with two mouse traps. -Gaps were identified around the window AC unit with daylight showing.-At 10:32 a.m., a mouse ran out of a cabinet and under a desk in the activities office. D. Main dining roomOn 3/20/24 at 10:34 a.m., the main dining room was observed. Observations revealed the following:-There were mouse traps in the corners of the dining room, one of which had mouse urine and visible dirt surrounding it. -Food crumbs were swept under the radiators along the entirety of the dining room. -Large gaps were identified under the doors to the main entrance, allowing daylight to be visible. E. Legacy unitOn 3/20/24 at 10:41 a.m., the Legacy unit was observed. Observations revealed the following:-There were mouse droppings in the corners of the dining room of the Legacy unit and in their kitchenette. -Floors in the dining room were visibly soiled with a dark substance. -Debris and food crumbs were scattered throughout the hallways, along baseboards, and under the radiators. -Daylight was visible under the door leading outside from the unit.-A vinyl chair in the activity room was heavily worn, with areas of the black fabric beneath the vinyl exposed in large multi-inch sections. -Tread strips in the room were heavily worn and peeling up, leaving a dark, sticky residue on the floor. -Mouse droppings were found behind the television (TV) in the activities room.-At 10:51 a.m., the window AC unit in the nurses' station had a gap approximately two to three inches wide around it. A blanket was stuffed into the gap in order to fill the space.-Loose medication capsules, dirt and debris were on the floor behind the crash cart on the unit.-At 10:55 a.m., there was a strong odor of urine throughout the hallways of the unit. An odor eliminator bag was stuffed behind one of the handrails.-At 10:59 a.m., there was a mouse trap in one of the residents' rooms and one of the floor tiles was lifted enough to be a potential tripping hazard. -Food was on the floor in room #59. F. Conference roomOn 3/20/24 at 11:07 a.m., the conference room was observed. Observations revealed the following:-There was daylight visible around the window AC unit in the conference room. III. Record reviewCleaning checklists were provided by the NHA at 11:45 a.m. The checklists included tasks such as cleaning and mopping the floor behind all furniture and cleaning all corners. The tasks were on both the deep cleaning and day-to-day checklists which were to be performed by the housekeeping staff. IV. Staff interviewsThe NHA, maintenance supervisor (MS), and operations manager (OM) were interviewed on 3/20/24 at 11:14 a.m. The MS said the facility had issues with mice coming into the building for the past year. The NHA said they were using one pest control company but switched to another in January 2024. The MS said the pest control company was coming every two weeks in January 2024 and the mice issue was under control at that time. The pest control company had been coming every month since that point. The MS said they had not identified where the mice were coming in but he thought it was due to people leaving the doors open during deliveries. The MS said he had not seen any gaps in the doors nor around the AC units. The MS said he was not sure how the recliners and couches were cleaned. The NHA said the furniture items were on the list to be replaced. She said she was aware that some of the floor tiles were peeling up. The NHA said she had checklists to ensure deep cleaning was ongoing throughout the facility and ensure housekeeping was doing regular cleaning in residents' rooms. The NHA said there were new housekeeping staff members hired in order to keep up with the increase in cleaning. The NHA said she and the OM were cleaning rooms when there was not sufficient housekeeping staff. The NHA said she was not aware of any odor eliminating bags being used. Regarding odors in the facility, the NHA said she was replacing all of the mattresses in the facility, starting with those that belonged to residents that were more resistant to receiving care for activities of daily living. The NHA said she was increasing the frequency of toileting checks for those residents.

Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to:-Take the appropriate measures to mitigate mice populations in the facility including failing to eliminate or minimize food sources; and,-Attempt to eliminate mice from entering the facility through door gaps and holes. Findings include: I. Professional referenceAccording to the Center for Disease Control (CDC), revised July 2019, Guidelines for Environmental Infection Control in Health-Care Facilities, retrieved on 3/25/24 from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, "Mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. "From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on:-Eliminating food sources, indoor habitats, and other conditions that attract pests;-Excluding pests from entering the indoor environments; and-Applying pesticides as needed."Rodents can transmit viruses such as Lymphocytic choriomeningitis, bacteria such as Campylobacteriosis, Leptospirosis, Plague, Salmonellosis, Tularemia, Yersiniosis, and fungi such as Dermatophytosis." II. Facility policy and procedureThe facility's policy on pest control was requested from the nursing home administrator (NHA) on 3/20/24 at 11:45 a.m. -A policy on bed bug prevention was provided by the NHA on 3/20/24 at 11:58 a.m., however, the policy did not have broader guidelines on pest prevention and control in regards to mice. III. ObservationsA. Sarvata unitOn 3/20/24 at 10:00 a.m., the Sarvata unit was observed. Observations revealed the following:-Mouse traps were observed in several locations in the Sarvata unit. -Debris and food crumbs were scattered throughout the hallways, along baseboards, and under the radiators. B. KitchenOn 3/20/24 at 10:10 a.m., the kitchen was observed. Observations revealed the following: -There were dried spills and crumbs on the floor throughout the kitchen. -There was a glue-type mouse trap under the rack used to store clean dishes with mouse feces surrounding it. -There was a gap around the window air conditioning (AC) unit with visible daylight. -A mouse trap was found under a desk in the dry storage room. C. Activities office and storage roomOn 3/20/24 at 10:29 a.m., the activities office and storage room were observed. Observations revealed the following: -A large cart with several open bins of chips and snacks was in the activities storage room.-Several chip bags in the activities storage room had holes in the bags where they had been chewed through. -Mouse droppings were in the corners of the room along with two mouse traps. -Gaps were identified around the window AC unit with daylight showing.-At 10:32 a.m. a mouse ran out of a cabinet and under a desk in the activities office. D. Main dining roomOn 3/20/24 at 10:34 a.m., the main dining room was observed. Observations revealed the following: -There were mouse traps in the corners of the dining room, one of which had mouse urine and visible dirt surrounding it. -Food crumbs were swept under the radiators along the entirety of the dining room. -Large gaps were identified under the doors to the main entrance, allowing daylight to be visible. E. Legacy unitOn 3/20/24 at 10:41 a.m., the Legacy unit was observed. Observations revealed the following: -There were mouse droppings in the corners of the dining room of the Legacy unit and in their kitchenette. -Debris and food crumbs were scattered throughout the hallways, along baseboards, and under the radiators. -Daylight was visible under the door leading outside from this unit. -Mouse droppings were found behind the television (TV) in the activities room.-At 10:51 a.m., the window AC unit in the nurses' station had a gap approximately two to three inches wide around it. A blanket was stuffed into the gap in order to fill the space.-At 10:59 a.m. there was a mouse trap in one of the residents' rooms. -Food was on the floor in room #59. F. Conference roomOn 3/20/24 at 11:07 a.m., the conference room was observed. Observations revealed the following: -There was daylight visible around the window AC unit in the conference room. IV. Record reviewPest control service invoices were provided for the following dates: 12/13/23, 1/2/24, 1/8/24 and 2/12/24.-No details about the services that were provided were revealed in the invoices from the company. Resident council notes from 1/24/24 at 10:10a.m. revealed residents complained about mice running around the facility. V. Staff interviewsThe dietary director (DD) was interviewed on 3/20/24 at 10:20 a.m. The DD said the facility had always struggled with mice. The DD said the facility was having issues with mice eating food in the activities room since the activities department was always getting snacks for the residents. The DD said he found a mouse in one of the traps approximately one to two weeks prior. The DD said the rain and snow drove mice into the facility but he did not know how they were getting into the facility. The activity director (AD) was interviewed on 3/20/24 at 10:26 a.m. The AD said she had recently come back from a leave of absence but she had not seen any snacks that were chewed through since she came back. The activities assistant (AA) was overheard talking to the AD on 3/20/24 at 10:31 a.m. The AA said the reason the snack bins did not have lids was because they did not have enough in the budget to purchase lids for the bins. CNA #1 was interviewed on 3/20/24 at 10:45 a.m. CNA #1 said there were mouse traps in the dining room of the Legacy unit because the facility had a problem with mice in a different area, and the facility did not want the problem to move to the Legacy unit. CNA #1 said she had not seen any mouse activity since she started at the facility in June 2023. The NHA, maintenance supervisor (MS), and operations manager (OM) were interviewed on 3/20/24 at 11:14 a.m. The MS said the facility had issues with mice coming into the building for the past year. The MS said the pest control company was coming every two weeks in January and the mice issue was under control at that time. The pest control company had been coming every month since that point. The MS said a resident found a mouse in their room the day prior (3/19/24), so the MS called the pest control company to expedite their next visit. The MS said the facility had not identified where the mice were coming in but he thought it was due to people leaving the doors open during deliveries. The MS said he had not seen any gaps in the doors nor around the AC units. The NHA said the facility was using one pest control company but had switched to another company in January 2024.

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 #CO34379 was conducted on 12/7/23-12/13/23. No deficencies were cited.

A revisit survey was completed on 12/13/23 for all previous deficiencies cited on 10/24/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 12/13/23 for all previous deficiencies cited on 10/24/23. The facility is in compliance with all regulations surveyed.

This survey was conducted on November 14, 2023, in accordance with the Federal Register at Section 42 CFR, Subpart 483.90(a), Life Safety from fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 EXISTING Health Care Occupancies. This facility is a two (2) story structure of mixed construction. The two-story is a Type II (111) construction, and the one-story is a Type V (111) construction. There is no 2-hour fire-rated separation; therefore, the entire building is classified as Type V (111). The north section of the one-story structure contains business offices and meeting rooms, and the south portion serves as a secured unit. The lower level of the two-story houses support services and a secured unit. The original facility was constructed in the early 1960s. The facility is licensed for 102 beds, and the census on the date of the survey was 90. This facility is fully protected by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and anti-freeze fire sprinkler systems. The anti-freeze system protects the attic in the one-story structure. The facility is classified as fully-sprinklered. The facility has a natural gas generator. The results of this survey were discussed with the Administrator and Maintenance Director during the exit conference.

Through documentation review, it was determined that the facility failed to meet the Emergency Lighting requirements in accordance with NFPA 101. This was evidenced by: 1) Emergency Lighting: The last documentation states that the inspection was conducted on September 23. An inspection with no date was provided, and the Maintenance Director stated that it was done last month but couldn ' t provide a date. The Maintenance Director stated he did not know it had to be formally documented. Code Citation7.9.3.1.1 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 11/2 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 documentation review, it was determined that the facility failed to meet the Exit Signage requirements in accordance with NFPA 101. This was evidenced by:1) No Exit signage inspection documents were provided for review. 2) In two separate locations, the exit sign is hanging by one screw and is not securely attached to the ceiling. Code citation:NFPA 101: 7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3. NFPA 101: 7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3. 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 survey and documentation review, it was determined that the facility failed to meet the Kitchen Hood Testing requirements in accordance with NFPA 101 and NFPA 96. This was evidenced by: 1) The entire test report dated 11/10/2023 could not be produced. 2) The Kitchen Hood pull station and suppression tank are tagged with red and green tags. The wording indicates "Gas & Electric non-compliant."3) Witnessed an Annual Inspection dated 11/1012023 and one dated 09/29.2023. No semiannual inspection reports were available. Code Citations: 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 96: 11.4 Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 smoke compartment. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Through documentation review, it was determined that the facility failed to meet the Fire Alarm System – Testing and Maintenance requirements in accordance with NFPA 101 and NFPA 72. This was evidenced by: 1) Annual Fire Alarm Test Documents dated 10/02/2023 indicate: 1) Silent Knight Dialer Failed, 2) Detector in O/S Room 16 Address M-4 failed, 2) Ion Detector in O/S Kitchen- Device 20 failed due to tape on device. 2) The sensitivity test report provided was dated 08/26/2021,Code References: 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 72: 14.5.1 System equipment shall be maintained in accordance with the manufacturer ' s published instructions. NFPA 72: 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. NFPA 72: 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. This deficiency could 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.

Through documentation review, it was determined that the facility failed to meet the Portable Fire Extinguishers requirements in accordance with NFPA 101 and NFPA 10. This was evidenced by: 1) Annual Inspection dated 11/10/2023 states that four fire extinguishers need hydrostatic testing. Code Citations: 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 10: 7.3.1.1.2 Fire extinguishers shall be internally examined at intervals not exceeding those specified in Table 7.3.1.1.2. 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 survey, it was determined that the facility failed to meet the Corridor – Doors requirements in accordance with NFPA 101. This was evidenced by:1) The elevator machine room has a gap in the door 3/8 inch that would allow the transfer of smoke. 2) Stairwell door propped open on basement level with a wooden wedge. Code Citation: NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:NFPA 101: 19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled. 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 survey, it was determined that the facility failed to meet the Gas and Electric requirements in accordance with NFPA 101 and NFPA 54. This was evidenced by: 1) The gas pipe supplying natural gas to the warming tables is not properly supported in the kitchen. The gas piping is unsupported for around 8 feet and is a laying appliance, not attached to the wall. 2)In the kitchen, there is no manual shutoff between the quick disconnect devices and the gas piping, as required. 3) An electrical box in the basement boiler room is open, and exposed wiring is showing. A cover needs to be installed. Code Citation: NFPA 54: 7.2.1 Piping installed aboveground shall be securely supported and located where it will be protected from physical damage. Where passing through an exterior wall, the piping shall also be protected from corrosion by coating or wrapping with an inert material approved for such applications. The piping shall be sealed around its circumference at the point of the exterior penetration to prevent the entry of water, insects, and rodents. Where piping is encased in a protective pipe sleeve, the annular spaces between the gas piping and the sleeve and between the sleeve and the wall opening shall be sealedNFPA 54: 7.2.5.1 Piping shall be supported with metal pipe hooks, metal pipe straps, metal bands, metal brackets, metal hangers,or building structural components, suitable for the size of piping, of adequate strength and quality, and located at intervals so as to prevent or damp out excessive vibration. Piping shall be anchored to prevent undue strains on connected appliances and equipment and shall not be supported by other piping. Pipe hangers and supports shall conform to the requirements of ANSI/MSS SP-58, Pipe Hangers and Supports -Materials, Design and ManufactureNFPA 54: 7.2.5.2 Spacings of supports in gas piping installations shall not be greater than shown in Table 7.2.5.2. Spacing of supports of CSST shall be in accordance with the CSST manufacturer ' s instructions. NFPA 54: 9.6.5.2 Where installed indoors, an approved manual shutoff valve with a nondisplaceable valve member shall be installed upstream of the quick-disconnect device. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 smoke compartment. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Through documentation review, it was determined that the facility failed to meet the requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by:1) Fire Damper Inspection record dated 01/19/23 (Fire Inspection Services)states deficiencies were discovered, but no documents show it was corrected. 2) WAIVED TAG- During record review and the walk-through of the facility, it was found that the facility utilizes swamp coolers to provide cooling for the corridors and to provide cooling in resident rooms and adjacent areas, which turns all the corridors into plenum spaces. This deficiency affects all residents and staff in all smoke compartments. NFPA 90A, 4.3.12.1.1* Egress corridors in nursing and long term care facilities shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted. This was discussed during the exit conference. A time limited waiver was granted on March 15, 2023 and is set to expire 10.12.2025. No response necessary. Code Citations: 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 80: 19.5.3 If the damper is not operable, repairs shall begin without delayNFPA 80: 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. NFPA 80: 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. NFPA 80: 19.4.10 All documentation shall be maintained and made available for review by the AHJThis 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 documentation review, it was determined that the facility failed to meet the K914 Electrical Systems – Maintenance and Testing requirements in accordance with NFPA 101, NFPA 99, and NFPA 110 This was evidenced by: 1) Generator testing and inspections haven ' t been conducted since September 28, 2023, since the last Maintenance Director. The current Maintenance Director said he did not know how to test the generator. Code Citations: 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 110: 8.3.2 A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system. NFPA 110: 8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be establishedThis 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.

A recertification survey with complaint #CO30961, #CO33086, #CO33949, #CO33982 and #CO34025 was completed from 10/17/23 to 10/24/23. Twelve deficiencies were cited.

An Emergency Preparedness survey was conducted from 10/17/23 to 10/24/23. One deficiency was cited.

Based on record review and interviews, the facility failed to conduct an annual update of the required facility-based and community-based risk assessment, utilizing an all-hazards approach; and including strategies for addressing emergency events identified by the risk assessment. This failure had the potential to affect 31 residents. Specifically, the facility failed to:-Conduct an annual facility-based and community-based risk assessment; and incorporate the identified risks into the facility emergency preparedness (EP) program; and,-Identify how the identified risk and potential hazards are likely to impact their geographical region, community, facility and patient population. Findings include: The emergency preparedness plan was provided by the corporate nurse consultant on 10/23/23. The plan was last reviewed and updated by the facility in September 2023. The community-based risk assessment was last conducted on 6/15/21 and reviewed on 8/16/22. I. Facility policy The Emergency Management Plan policy revised August 2018, documented in pertinent part: "The purpose of this Emergency Management Plan is to provide an all-hazards approach to guide in the event of an emergency, a crisis, or a disaster scenario that would affect the safety and well-being of our residents and employees as well as community members stricken by the situation. The desired outcome is to protect the residents, employees, families, volunteers and facility from various emergencies. II. Hazard vulnerability analysis (community-based risk assessment) The Hazard Vulnerability Assessment form dated 6/15/21, read in pertinent part: "Facility name conducts a thorough hazard vulnerability analysis to help determine what events or incidents may negatively impact its operations. While it is impossible to forecast every potential threat, it is important to identify as many potential threats as possible to adequately anticipate and prepare to manage a crisis or disaster situation. "Facility name utilizes a quantitative tool, the Hazard Vulnerability Assessment (HVA), which utilizes a rating system for the probability and risk of, as well as preparedness for, various hazards and situations. "Assumptions: For the purpose of this Emergency Management Plan, it is assumed that the following threats may potentially impact all facilities: Fire/explosion, flood, bomb threat, tornado/hurricane/severe weather, power failure/utility disruption, workplace violence/security threat, law enforcement activity, missing resident, internal hazardous materials spill/leak, pandemic episode, and unknown acts of terrorism. III. Staff interview The regional vice president of operations (RVPO) was interviewed on 10/24/23 at 6:05 p.m. The RVPO said the facility had made some key changes in the EPP but were still using some parts of the previous ownership plan as it was specific to the community and still met community needs. The RVPO said corporate leadership had assigned a consultant to work with the community to revise the EPP with updated guidance and in line with the new company's policies.

Based on observations, interviews and record review, the facility failed to provide reasonable accommodation necessary to accommodate mobility and accessibility in the resident's environment for one (#39) out of one resident reviewed for mobility out of 41 sample residents. Specifically, the facility failed to:-Ensure Resident #39 had an appropriate assistive device to aid the resident in proper balance while walking;-Ensure Resident #39 has a clear path in which to walk from her side of the room to the hallway;-Ensure Resident #39's bathroom accommodated her toileting needs by removing her roommate's toilet seat riser from the toilet so she could continue to use the toilet independently without having to wait for staff assistance; and,-Ensuring the resident had an accessible location in the bathroom to place hygiene supplies like wipes and incontinent briefs for her personal and independent use other than to store items on the floor of her small bathroom. Findings include: I. Resident #39 A. Resident status Resident #39, age 65, was admitted on 8/23/19. According to the October 2023 computerized physician orders (CPO), diagnoses included diabetes, glaucoma and anxiety. The 8/25/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status exam score of 14 out of 15. The resident needed supervision assistance with most activities of daily living and (ADL). The resident was usually steady and walked independently without an assistive device. -The assessment of the resident's walking ability was in contradiction to the care plan and other assessments in the resident's record (see below). B. Observations and resident interview Resident #39 was observed walking in her room without an assistive device. The resident had poor balance and was reaching for the walls and almost fell as she tried to navigate around her roommate's unoccupied wheelchair that took up most of the walkway from her side of the room to the hallway door. The unit nurse who was in the hallway nearby was alerted. The nurse stood in the resident's doorway and said there was not much she could do because there was no place else to store the roommate's wheelchair. The nurse then left the resident's room and walked down the hallway. The resident's small bathroom containing only a toilet, as there was no room for a sink or other cabinetry was observed with incontinent supplies lying on the floor adjacent to the toilet. Resident #39 was interviewed on 10/19/23 at 4:09 p.m. Resident #39 said her roommate's wheelchair was always left out in the walkway and it was hard to get around it. Resident #39 said she did not have a walker or a cane; one of her canes was stolen and the other was taken away by the facility because staff said the end was pointy and could cause other residents harm. The resident said she now had a rubber tip for the end of the cane but the facility was unable to find the cane to give back to her. The resident said she would feel more confident walking if she had an appropriate cane. The resident said she liked to take walks outside but the unevenness of the facility sidewalks made it difficult to walk without an assistive device. Resident #39 said staff suggested she use a standard curved top cane to walk but she felt unsafe with such a cane as one had slipped out from under her hand when she last tried to use one. The resident said she was never assessed for the ability to use a walker assistive device. Resident #39 said her roommate was taller than she was and used a toilet seat riser in the bathroom that staff did not remove after the roommate used the bathroom it was left on the toilet most days because her roommate was independent in using the bathroom. The problem was the seat was then too high for her to use and she had to wait for staff to come to remove the riser so she could go to the bathroom. The resident also showed her toileting supplies that she had to store on the floor in the bathroom and said it was hard to bend to reach the item after using the toilet and would have liked a place in the bathroom to store her supplies that were in easy reach and off the floor. C. Record review The resident's comprehensive care plan documented a care focus for impaired mobility and balance. The care focus initiated on 8/28/19 and revised on 6/19/23 read in pertinent part: "The resident has an ADL self-care performance deficit related to impaired balance, limited mobility, and limited ROM (range of motion)." The goal of the care focus was "The resident's risk for decline in ADL function will be minimized." Interventions included the resident required the use of a cane for mobility/stability. Physical and occupational therapy to evaluate and treat as ordered or as needed." Rehab screening form dated 8/11/23 read in pertinent part: "Review of the resident's chart reveals a medical diagnosis or condition that may require therapy intervention: No skilled intervention indicated at this time. Cognitive safety- at baseline with decreased safety due to clutter in her room. ADLs- at baseline, chronic complaints of pain. Fall risk evaluation dated 2/22/23 read in pertinent part: "Gait evaluation: resident has balance problems while walking." D. Staff interviews Certified nurse aide (CNA) #9 was interviewed on 10/23/23 at 12:45 p.m. CNA #9 said Resident #9 was independent with walking and did not use a cane or assistive device; but was unsteady while walking. The resident used the handrails in the hallway to help steady herself. The CNA said the resident's room was small and her roommate's wheelchair was often stored in the walkway when the roommate was in bed this was sometimes a concern because of Resident #39's balance problems. The resident was at risk of falling when the resident was trying to get around the roommate's wheelchair without tripping and falling. The CNA did not know what could be done to give Resident #39 more space to walk around her room. Licensed practical nurse (LPN) #6 was interviewed on 10/23/23 at 1:10 p.m. LPN #6 said it was staff's responsibility to make sure each resident had clutter-free walkways in their rooms and thought the facility. If a resident had unsteady balance and did not use a walker or other assistive device the nurse would make a referral for the resident to be assessed by physical and or occupational therapy to promote safe mobility while enabling the resident to maintain maximal independence. The director of nursing (DON) was interviewed on 10/24/23 at 4:58 p.m. The DON/NHA, who was new to the position, said Resident #39 should have been assessed for her mobility needs due to poor balance, but she was unable to provide a therapy assessment for the assessment of Resident #39's balance, mobility and need for an assistive device. The DON said she was unaware of the status of the resident's cane and did not know any details of when, why or if the previous facility leadership had taken Resident #39's cane away but said she would look into the matter and speak with the leadership team about the resident's walking needs.

Based on observations and interviews, the facility failed to provide a comfortable environment and homelike environment in three out of three units. Specifically, the facility failed to ensure: -Residents were not subjected to foul odors in their rooms and common hallways for two of three units; -Resident rooms were clean and in good repair on two of three units;-Common areas and dining room were clean and maintained in good repair; and, -Outside areas were maintained. Findings include: I. Facility policy The Homelike Environment policy, revised February 2021, was provided by corporate nurse consultant (CNC) #1 on 10/25/23 at 11:05 a.m. It read in pertinent part: "Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include institutional odors."II. Ensure residents were not subjected to foul odors A. ObservationsOn 10/17/23 to 10/19/23 and 10/23/23 to 10/24/23, the skilled and long-term care unit hallway and resident rooms were observed throughout the day between approximately 9:00 a.m. to 6:00 p.m., the unit had lingering odors comprised of body odor, urine and feces. The urine smell was stronger at several times throughout the observation and lingered throughout the day at times other than the normal rounding time when staff were assisting residents with routine incontinence care. On 10/23/23 to 10/24/23, the memory care unit was observed etween approximately 9:00 a.m. to 6:00 p.m. to have a lingering odor of urine throughout both days of observation. III. Ensure resident rooms were clean On 10/18/23 and 10/23/23 resident rooms in the skilled and long-term care unit were observed. Observations revealed the floors in resident rooms #38, #39 #40, #30, #41, #25 and #16 were soiled with dust, dirt and food crumbs debris particularly under the beds and around the edges of the room. Room #38 at the resident space closest to the door was particularly soiled with dust and debires. The floor under the bed was covered with a thick layer of debris, crumbs and dust; the nightstand which held a television was heavily soiled with a thick whitish-gray layer of dust. The floor in room #39 was heavily soiled with dried liquid food spills and food crumbs. On 10/24/23 at 1:30 p.m., housekeeping services were observed. Housekeeper #1 was observed cleaning room #16. HSKP #1 swept the resident's room starting on the far side of the room; the HSKP swept partially under both residents' beds leaving a layer of debris behind failing to thoroughly sweep all food and dust/dirt debris from the resident's room floor particularly in the corners of the room, at the edge of the wall and under the resident's beds (cross-reference to F925 failure to maintain effective pest control). B. Resident interviewResident #8 was interviewed on 10/17/23 at 3:10 p.m. Resident #8 said the facility did not keep up with housekeeping and several resident rooms had food debris on the floors and under their beds. He had assisted several residents to bring this to the attention of leadership but the problem had not been resolved. This was also contributing to the facility having mice in the building (cross-reference F925). IV. Ensure resident common areas (inside and outside) and dining room were clean and maintained in good conditionA. Resident interviews Resident #59 was interviewed on 10/18/23 at 2:05 p.m. Resident #59 said she reportedthe baseboards in the dining room and her television were falling apart. Resident #66 was interviewed on 10/18/23 at 2:55 p.m. Resident #66 said he reported there was a hole in the wall in his room, but no one repaired the damage. He pointed to the wall behind the front door of his room. Residents #8 and #39 were interviewed on 10/23/23 at 1:30 p.m. The residents said the dining room ceiling had prior leakage and the ceiling tiles were dropping white debris on the table where they ate and they were concerned that the ceiling debris would get into their food. Resident #8 said the outside ramp leaving the building was cracked and uneven and the landscaping outside of the building made the sidewalk narrow and he was worried that he or someone would get injured. B. ObservationsOn 10/18/23 at 2:55 p.m., room #10 had a hole on the wall behind the front door of the room that was patched and not painted. It was a white color while the rest of the room was a cream color. On 10/19/23 at 2:07 p.m. the common area, television room and dining room in the behavioral secured unit were observed. The baseboards underneath the sink in the dining room were falling apart. The baseboards on the left side of the entrance to the television room were falling apart. The baseboard on the left side of the door in the dining room to the unit's patio was falling apart. At 3:18 p.m. the patio for the behavior secured unit was observed. There were approximately eight black patio chairs against three walls in the patio. Every single chair had white pigeon droppings on the patio chairs. There were several pigeons sitting on the top of the fence in the patio area. At 4:45 p.m. the outside ramp at the main entrance was cracked and uneven. On 10/23/23 at 1:38 p.m. the ceiling tiles in the main dining room were worn and shedding debris. V. Staff interviews The operations manager (OM) was interviewed on 10/17/23 at 4:21 p.m. The OM said he was responsible for troubleshooting and observing day-to-day activities and when problems were discovered he brought the concerns to the attention of the nursing home administrator (NHA) for a solution and further direction. The OM said since the new ownership transition several months ago the facility started a project to improve the look of the building. The outside of the building was repainted and they were now looking into making cosmetic improvements inside of the building. The OM did not have a specific list of improvements yet to be addressed but said leadership was still looking into it. Licensed practical nurse (LPN) #2 was interviewed on 10/24/23 at 12:51 p.m. He said the baseboards were falling apart because there was a female resident who picked at the baseboards until they started to fall apart. LPN #2 said the staff tried to redirect the resident from picking at the baseboards. LPN #2 said he was aware of the patch in resident room #10 and said the wall had to be repaired a month ago after the resident in that room punched a hole in the wall. He was not able to speak to the pigeon feces on the chairs on the patio but said there were a lot of pigeons around the building, so he would not be surprised if there was pigeon feces on the patio chairs on the patio. LPN #2 said he would tell the maintenance staff verbally and through their work order software system if something needed to be fixed. The maintenance director (MTD), the regional corporate consultant (RCC) #2 were interviewed on 10/24/23 at 9:05 a.m. The MTD was not aware that the baseboards in the secured unit needed to be repaired. He was aware that the wall in resident room #10 needed to be sanded and painted. After the interview, a walk-through was completed with the MTD and RCC #2. The RCC said the chairs in the patio should be power washed. The MTD said the chairs should be wiped and cleaned daily.

Based on record review and interview, the facility failed to ensure all grievances were followed up on and resolved timely and appropriately. Specifically, the facility failed to investigate and provide feedback for grievances made by residents and their family members. Findings include:I. Facility policy and proceduresThe Grievance policy, updated 12/17/06, was received from the corporate nurse consultant (CNC) on 10/25/23 at 11:30 a.m. It read in pertinent part: "Accordingly, a formal system known as the Resident and Family Concern/Grievance Program is in place to review and act upon concerns or grievances expressed. Any resident has the right to voice grievances without discrimination or reprisal."The Resident Concern/ Grievance Program is intended to reflect the facility policy which acknowledges the right of residents to voice concerns and the expectation of prompt effects by the facility to resolve them. This program is supported by the Resident Council. Any resident, family member or staff member may generate a Resident Concern/ Grievance Report in response to a concern or grievance identified as a result of an individual concern or grievance from a resident, family member and/or staff member."Procedure: The Social Service Director (SSD) is designated for collecting, reviewing, andcommunicating concerns or grievances to the Administrator. These shall be completed within one business day. Responses and results will be completed within five business days. It is the policy of the facility to handle any complaints or grievances relating to abuse immediately and according to the facility Abuse Prohibition and Control Manual.-Concerns or grievances shall be communicated in writing. The SSD may be called upon to assist in writing these and to complete any necessary forms.-The SSD will complete an investigation and confer with the Administrator. The Administrator may or may not be involved in the actual investigation. Responses will be communicated within 72 hours of completion of the investigation.-The SSD will complete a follow-up interview within 7-10 days to ensure that the approach taken by the facility has resolved the concern. If the concern remains unresolved the SSD will confer with the Administrator and Department Director to develop a revised approach, which is to be implemented immediately upon development (no more than 72 hours following identification that the initial resolution was not satisfactory). The SSD will complete an additional follow-up interview within 7-10 days to ensure that the corrective action taken by the facility has resolved the concern.-The SSD will bring all Resident Concern Reports to the Quality Assurance Committee meeting to review with the team to assess the need for possible further action."II. Resident interviews Resident #28 was interviewed on 10/17/23 at 1:33 p.m. Resident #28 said he voiced concerns to the facility staff but nothing ever changed. He was most concerned about his therapy services and the quality of the service. Since nothing was resolved he just stopped accepting services. Resident #28 said he knew that was not the best idea to not participate in his therapy services; however, he wanted changes in the quality of the services before he resumed services and was waiting for the facility to do something about his concerns. Resident #49 was interviewed on 10/17/23 at 1:50 p.m. Redisnet #49 said it was useless to file a grievance because the facility did not fix anything. Resident #49 said he had complained about the lack of hot water for the past couple of weeks and the facility still had not corrected the problem and he was not always able to take showers because to the problem. Cross-reference F908 essential equipment, safe operating condition. Resident #8 was interviewed on 10/18/23 at 3:27 p.m. Resident #8 said he was not satisfied with the facility's response to grievances. There had been no follow-up to himself or his peers who had filed grievances and there was no resolution to the grievances. Resident #8 said he and his peer had several discussions about their dissatisfaction regarding the way the facility was operating with both the past and new administration and neither was resolving the resident grievance or changing the way the facility was being managed. Resident #8 said these private discussions with his peers were carried over to resident council meetings and voiced to facility leadership. The leadership did not maintain grievance records and did not report back to the resident council group on how the resident grievance/concerns would be fully addressed and resolved. Resident #8 said he encouraged his peers to keep copies of grievance forms they filed as records because the facility never had any documentation of filed grievances to present at the resident council group meetings. Resident #31 was interviewed on 10/19/23 at 1:33 p.m. Resident #31 said he had been complaining of the same things over and over again for months and there had been no resolution. Resident #31 said even if he wrote the complaint on a grievance form the complaint was not addressed. Resident #31 and Resident #39 were interviewed on 10/19/23 at 1:55 p.m. The residents said they had filed a grievance about loud noises on the overnight shift. Some resident played their televisions loudly late at night and some staff talked loudly in the hallway which was interfering with their sleep. The residents said this had been a topic of concern at several resident council meetings but it still had not been resolved. III. Resident group interview Five alert and oriented residents (#8, #38, #39, #49 and #85) who usually attended the resident council and one resident representative were interviewed on 10/24/23 at 10:15 a.m. The resident group said a the start of each resident council meeting they always opened with past business and the invited staff did take that opportunity to go over each concern present at the prior resident council meeting and they were no able to have a discussion about past grievances and hear the facility's response to grievance and the resolution. Past grievances seemed to have been forgotten. Resident #8 said he used to be the resident council president but he resigned because the facility did not take the grievance procedure seriously. Facility staff did not write up grievance forms at the resident council meetings and then did not document or present back on resolution. The resident group said they felt that resident grievances were ignored. The group said the facility did not fix past grievances and the resident council members and other residents had the same concerts over and over again. The resident representative said she and her friend had filed several grievances with facility staff and had received some verbal response at the moment of filing the grievance but had not received a written response on any of the filed grievances and none of the grievances raised had been resolved. IV. Record reviewA review of resident council minutes for July 2023 through October 2023 revealed the resident in attendance voiced several grievances; however, the minutes field to document the facility's response to the resident grievance and the resident response. All resident council minutes document "All grievances can be received and or written by any staff member. All grievances were returned to the department head to ensure grievances are followed up on and resolved."The 7/20/23 resident council minutes revealed the residents voiced grievances included:-Loud noise levels: Ongoing complaints about residents and staff not following quiet hours. These complaints have been a topic of discussion since 4/20/23. Concerns included loud television volumes, and nighttime staff having loud conversations while residents were trying to sleep. -Request for less agency nursing staff. Good nursing care was dependent upon the staff on duty. -Other individualized personal grievances were voiced as well. The 8/17/23 resident council minutes revealed the resident voiced grievances included:-Loud noise levels were better but not resolved.-Requests for less agency nursing staff.-Requests for staff to wear their nametag so it is visible to residents and to have a larger font so the staff names are more readable. -Presence of mice in the facility (cross-reference F925 pest control).-Request for the facility to provide more consistent therapy and restorative nursing services.-Request for maintenance to repair outside landscaping and sidewalks. Residents were concerned about outside walkways being uneven, cracked and hazardous to residents traveling on on the sidewalks to local community areas (cross-reference F584 safe, clean home-like environment). -Laundry delays.-Request for hot meals to be served at dinner instead of sandwiches and other cold foods.-Request for activities programming to resume and for the facility to provide activities based on resident preferences (Cross-reference F679 activities).-Request for the grievance procedure to be followed including completion of grievance forms. Observation during the survey from 10/17/23 to 10/24/23 between the hours of 8:30 a.m. and 2:30 p.m. revealed several staff members were not wearing name tags and many name tags were not placed in a visible location on the staff's person. The 9/21/23 resident council minutes revealed the resident voiced grievances included:-Request for more regular and consistent nursing staff (less agency staff).-Request for the activities program to resume shopping trips and provide more consistent activities programming. -Request for hot meals to be served at dinner instead of sandwiches and other cold foods.-Request for the grievance procedure to be followed including completion of grievance forms.-General maintenance grievance (no specific details documented).-Other individualized personal grievances were voiced as well. The 10/19/23 resident council minutes revealed the resident voiced grievances included:-There were still too many agency nursing staff.-The new therapy staff is off to a slow start. -Mice were still being seen in resident rooms. -Request for an update on the lack of consistent hot water for resident showering (Cross-reference F908).-Request for hot meals to be served at dinner instead of sandwiches and other cold foods.-Request for the activities program to resume shopping trips and provide more consistent activities programming. -However, the resident council minutes failed to document a full discussion on the voiced grievance of the resident council; the facility's attempts to resolve the resident grievances; or the resident's response to the facility's actions to address resident grievances/concerns. -Additionally, the 10/19/23 resident council minutes documented the name of the facility's grievance official as the previous social services director. The form was not updated and many of the entries on the document were not consistently completed. A request was made to the director of nursing/nursing home administrator (DON/NHA) for documentation on individual resident grievances and resident council grievances for the past three months. The DON/NHA provided one individual grievance form. -The DON/NHA was unable to locate any other grievance forms for the grievance voiced during resident council meetings for either the group concerns or the individual personal resident concerns voiced during resident council meetings (see interviews below). V. Staff interviews Licensed practical nurse (LPN) #5 was interviewed on 10/24/23 at 1:00 p.m. LPN #5 said some of the residents knew how to file a grievance and if they did not know how to or could not complete a grievance form, their complaint could not be resolved at the time of complaint and staff should help then fill out a grievance form. Completed grievance forms were sent to the manager on duty so they could be addressed timely. The LPN said the social services department was responsible for monitoring the grievance procedure and for discussing the results of the grievances with the residents. The activities director (AD) was interviewed on 10/24/23 at 3:03 p.m. The AD said the first resident council meeting she attended in her new role was 10/19/23, she learned the residents were not happy, particularly about activities programming. The AD said she was not told she needed to complete grievance forms for the resident's voiced concerns. The AD said she would offer to assist residents in filling out grievance forms after the meeting if they wanted help but no resident asked for her assistance with a grievance form. The AD said most of the department directors attended the resident council meetings so they were aware of the resident council members' grievances and they were responsible for coming up with a resolution to the grievance voiced during the resident council meeting. That same department director was responsible for reporting back to the resident council on any action taken to resolve the group's grievance. The AD said the grievances and resolutions should be documented in the resident council minutes. The social services director (SSD) was interviewed on 10/24/23 at 3:47 p.m. The SSD said the was the new SSD and was in the role of grievance official. The SSD said in starting her position she noticed there was a lack of documentation on resident council grievances and grievance resolution and had identified it as a system oversight. The SSD said moving forward she will start a grievance log to record all resident grievances and monitor complaints to resolution. The SSD said the grievance procedure was for a resident to complete a grievance form or for staff to assist a resident in completing a grievance form for all unresolved grievances/complaints. Each grievance was submitted to the applicable department director for investigation and follow-up this occurred within 72 hours of the grievance being received. Once the department director investigated and addressed the resident's grievance the SSD said she was responsible for conducting a follow-up interview with the resident. The SSD said she let the AD know to bring several blank grievance forms to the resident council meetings and to fill them out for each resident(s) grievance voiced during the meeting. The SSD said she and the AD would make sure that each voiced grievance would be present at the following resident council meeting and determined as resolved or if it needed to be held over as still outstanding additional follow-up. The grievance would be held open until the resident council was satisfied with the facility's actions. The CNC was interviewed on 10/24/23 at 4:10 p.m. The CNC said the facility did not have any documentation of a resident grievance form either individual grievances or from the resident council other than the one individual resident grievance for September 2023 that was already provided. The CNC was not sure why the facility had not documented grievances. The CNC said going forward the facility would provide the staff including the AD and SSD on the facility's grievance policy and the expectations for documenting and addressing all resident grievances.

Based on observations, interviews and record review, the facility failed to provide activities designed to support residents' physical, mental and psychosocial well-being were provided for the resident on the behavioral secured unit and four (#59, #39, #1 and #54) of five residents reviewed for meaningful activity programming activities out of 41 sample residents. Specifically, the facility failed to ensure:-Consistent meaningful activity programming to include group activities, individual activities and one-to-one visits were provided to resident on the secured behavioral unit;-Resident #59 was provided meaningful activities; and, -That activities on the skilled/long-term care were not canceled without advanced notice; were provided as scheduled; and as requested by residents affecting Resident #39, #1 and #54. Findings include: I. Facility policyThe Activity Program policy, revised August 2006, was provided by the corporate nurse consultant (CNC) on 10/25/23 at 11:05 a.m. It read in pertinent part: "Activity programs are designed to meet the needs of each resident are available on a daily basis. Our activity program consists of individual and small and large group activities that are designed to meet the needs and interest of each resident."II. Secured behavioral unit activities A. ObservationsThe secured behavior unit was observed on 10/19/23 at 3:16 pm. The activities calendar was posted on the wall next to the nurse's station. The wall to the left of the door to the unit's patio had a bulletin board that covered approximately eighty percent of the wall. It had four columns with the following titles: important contacts, ancillary services, outings this month, and shopping days. Underneath each title, there was nothing except for important contacts which had the phone number for the nurse manager on call's phone number. The secured behavior unit was observed during continuous observation on 10/19/23 from 2:00 p.m. to 3:30 p.m. The activities calendar revealed that at 2:00 p.m. resident council was scheduled. There was no staff gathering residents to attend the event. The residents were observed sitting at the dining room tables, on the couches in the common area or on the couches in the television room. There were no leisure materials available on the table, no leisure activities were offered to any of the residents and there were no organized group activities offered during the observation period. -At 2:07 p.m. a male resident complained that the television was not working. The television was turned on with the main menu of television programs to select from, and there was no sound coming from the television. A staff member came out of the locked nurse's station at 2:13 p.m. to try to fix the television, but was unable to tune in to any television program. The staff went back to the nurse's station. The same male resident went to the nurse's station window to ask about the status of the television. The staff response was unintelligible. -At 2:23 p.m., the male resident talked in a loud manner and appeared irritated about the television status. -At 3:18 p.m., Resident #59 fixed the television so the other residents could watch television. Staff did not engage with residents unless the residents walked to the nurse's station to request assistance for things such as to request ice, a soda or their medication. The secured behavior unit was observed during continuous observation on 10/23/23 from 2:13 p.m. to 3:23 p.m. The residents were observed sitting at the dining room tables, on the couches in the common area or on the couches in the television room. There were no leisure materials available and no staff offered any leisure activities to the resident. There were no organized group activities offered during the observation period. The activities calendar revealed that Bingo was scheduled for 3:00 p.m. Staff did not engage with residents unless the residents walked to the nurse's station to request assistance for things such as ice, a soda or their medication. B. Record reviewThe August 2023 resident council meeting minutes for the secured behavioral unit were reviewed. The minutes revealed that all of the residents present expressed a concern that the facility needed an activities director and wanted more outings like going to the dollar store, bowling and shopping. It revealed the facility hired an activities director who would start in a week and a half. The September 2023 resident council meeting minutes for the secure behavioral unit were reviewed. The minutes revealed that one resident asked for more outings with the bus. The minutes revealed that activities would schedule more outings. One resident asked for more activities like arts, crafts and beads. It revealed a new activities employee was starting the following week. The activities calendar was reviewed. It revealed that every day of the week at 9:30 a.m. there was daily chronicle newsletter and daily check ins. Other activities included manicures, decorate coffee mugs, praise and worship, football games, store orders due, snack shack, movie night and one-on-one visits. Each day of the week had at least two activities scheduled. C. Resident #59 1. Resident status Resident #59, age less than 65 years old, was admitted on 2/1/21. According to the October 2023 computerized physician order (CPO) the diagnoses included diffuse traumatic brain injury, post traumatic seizures, insomnia, chronic pain, major depressive disorder, hypothyroidism, delusional disorder, tremor and asthma. The 9/18/23 minimum data sheet (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. The resident required set up assistance with bed mobility, transfer, toileting, personal hygiene and eating. The MDS assessment did not document the resident's activities preference. The 1/10/23 MDS assessment documented that the resident said it was very important to listen to music that she liked, to be around animals like pets, to do things with groups of people, to do her favorite activities, to go outside to get fresh air and participate in religious services. She said it was somewhat important to read books, newspapers and magazine and to keep up with the news. 2. Resident interview Resident #59 was interviewed on 10/18/23 at 1:57 p.m. She said the facility did not take her and other residents in their secured behavioral unit out of the facility like they use to the store for shopping. She liked going on outings like the grocery store because she felt like she could take care of herself. 3. Record review The 6/30/23 care plan revealed the resident had an activities care plan. It revealed the resident enjoyed independent activities such as singing, writing, listening to music, playing the piano, doing word searches, getting manicures, and reading books, newspapers, and magazines. She enjoyed group activities such as Bingo, food socials, resident shopping, outings, arts and crafts, music groups, live music performances, exercise group, movies, outdoor activities, and painting. She also enjoyed cooking, baking and other outings of interest. Interventions included to offer the resident an activities calendar each month and notify her of any changes, staff to invite the resident to scheduled activities and for staff to offer and supply the resident with materials for independent leisure activities. The resident's activity record revealed she attended 14 activities from 9/24/23 to 10/24/23. She attended Bingo one time. The record did not document that she attended outings. III. Skilled and long-term care unit activities A. Observation On 10/23/23 from 1:30 p.m. to 3:45 p.m., the unit was observed the scheduled activity including bingo did not occur. B. Residents 1. Resident #39 a. Resident status Resident #39, age 65, was admitted on 8/23/19. According to the October 2023 computerized physician orders (CPO), diagnoses included diabetes, glaucoma and anxiety. The 8/25/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status exam score (BIMS) of 14 out of 15. The resident required supervision support from staff with activities of daily living and (ADL) but was totally dependent while completing bathing tasks. The resident was usually steady and walked independently without an assistive device. -The assessment did not document the resident's activity preferences. b. Resident interview Resident #39 was interviewed on 10/19/23 at 1:59 p.m. Resident #39 said the facility had canceled and no longer provided her preferred activity for shopping outings. Resident #39 said that she relied on those shopping trips to pick out personal items she needed. Once they canceled the shopping trips, the activities program did the shopping for the residents, but that was not working because the store the facility shopped at was too expensive. The resident said it was important to be able to pick out her own items based on the store's inventory. The resident said she like to get out of the facility and into the community but that was not possible because the activities department called all outings. On rare occasions when the facility scheduled an outing, the same residents always went and she was left out. Resident #39 said she was not alone in her frustration with the activities department. There were several other residents who wanted to go out on shopping trips to the store and also be able to go on other outings in the community. Resident #39 was interviewed on 10/23/23 at 4:18 p.m. Resident #39 said she enjoyed bingo but the facility canceled today's bingo without giving any explanation. Resident #39 said she and other residents went to the activity but the activities staff did not show up. Resident #39 said this happened a lot and no explanation was given. c. Record review The resident activities assessment dated 6/6/23 documented that the resident activities preference review revealed that it was very important to the resident to make her own choice about daily activity preferences and be able to take care of and keep her belongings safe. The resident also said that it was very important to have books, newspapers and magazines to read; be able to listen to music that she liked; be around animals such as pets; and keep up with the news. The resident also said it was very important to be able to do her favorite activities; be able to go outside and get fresh air when the weather is good; and be able to participate in religious services or practices. The resident said it was somewhat important to do things with groups of people. In summary, the assessment document Resident #39 enjoyed group activities of interest, independent leisure activities, outings of interest, and in-room visits from staff, bingo, resident council and other community meetings, resident shopping, trivia, food/holiday socials, various arts and crafts (tie-dye, crafts, jewelry making, painting), music groups and live entertainers, community outings, outdoor activities and walks, socializing with peers and staff, reading, practicing her faith (reading the bible, praying), watching television, playing card games (solitaire), utilizing the resident computer for various things, coloring, and hanging out in the common areas. The resident accepts social visits from staff and enjoys the daily chronicle newsletter. The comprehensive care plan documented a care focus for activities and social needs, revised 6/19/23. The care focus revealed Resident #39 goal was to participate in therapeutic, social, cognitive and creative activities one to three times a week and pursue her own independent activity interests five to seven times a week. A care focus, revised 4/9/2020, related to the resident preadmission screening resident review (PASRR) recommendations included assisting the resident in developing and providing the resident with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise. 2. Resident #1 a. Resident status Resident #1, age 70, was admitted on 1/16/07. According to the October 2023 CPO, diagnoses included epilepsy, arthritis and congestive heart failure. The 9/13/23 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. The resident was dependent on staff to complete most ADLs; and used a manual wheelchair with staff for mobility. -The assessment did not document the resident's activity preferences. b. Resident interview Resident #1 was interviewed on 10/18/23 at 4:19 p.m. Resident #1 said the facility had not provided many activities in a long time. The activities staff were constantly canceling activities without notice. The department used to bring a cart around and provide her with things to do on her own if she did not want to leave her room, but there was no staff in activities to bring the cart around and the residents were told there was no budget for the activities supply cart. "They (the activities department) don't have things to do and people don't go out in the community anymore." Resident #1 said if there were activities worth going to, she would go. She was interested in clergy visits and attending an activity when an outside entertainment group came in to present. Resident #1 said the facility staff no longer asked her what she was interested in doing. There was supposed to be a new activities director in the facility but nothing has changed with activities programming. c. Record review The resident activities assessment dated 1/6/23 documented that the resident activities preference review revealed that it was very important to the resident to make her own choice about daily activity preferences. The resident also said that it was very important to be able to listen to music that she liked and be able to do her favorite activities. The resident said it was somewhat important to keep up with the news and be able to go outside and get fresh air when the weather is good. The resident's comprehensive care plan documented a care plan focused on activities and leisure recreation needs last reviewed 102/23. The care focus revealed the resident enjoyed watching television, doing puzzles participating in snack shack, going outside and chatting with friends and peers. The resident enjoyed shopping and doing independent leisure activities that included watching television reading the daily chronicle newsletter and socializing with staff. The care focus documented that the resident spent most of her time in bed therefore staff were to prioritize one-to-one visits with increased socialization and companionship as well as other assistance with Snack Shack and other independent activities of interest. Interventions included providing the monthly activities calendar and offering periodic social visits, providing independent activity supplies, as well as assistance with the snack shack, inviting the resident to group activities and providing transportation assistance to and from the preferred activity when the resident agreed to attend. 3. Resident #54 a. Resident status Resident #54, age 67, was admitted on 6/1/2020. According to the October 2023 CPO, diagnoses included respiratory failure, mild cognitive impairment and major depression. The 8/31/23 MDS assessment revealed the resident had intact cognition with a brief interview for mental status exam score of 15 out of 15. The resident was dependent on staff to complete some more complex ADLs and used a manual wheelchair with staff assistance for mobility. -The assessment did not document the resident's activity preferences. b. Resident interview Resident #54 was interviewed on 10/19/23 at 11:15 a.m. Resident #54 said the facility did not offer any activities that met his general interests. Activities offered included various arts and crafts and bingo. No staff had asked him what activities he would like to see provided. Resident #54 said if they improved the activities program with activities, he was interested he would get involved. He was interested in group activities such as trivia and activities that involved getting out of the facility into the community. Resident #54 pointed to the bus just outside his window and said that bus had not moved since last spring 2023. c. Record review The resident activities assessment dated 11/16/23 documented that the resident activities preference review revealed that it was somewhat important to the resident to make his own choice about daily activity preferences. The resident also said that it was very important to be able to listen to music that he liked; keep up with the news and be able to do his favorite activities. The resident said it was somewhat important to have books, newspapers, and magazines to read. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 10/24/23 at 12:51 p.m. He said the residents went on outings before the COVID pandemic and it did not return after the pandemic. He said the activities staff were responsible to carry out the activities schedule. He said nurses would participate in activities but there was no time. He said the secure behavior unit used to have concierge staff that would help residents with tasks that were not related to direct patient care but the position had been vacant and not replaced for several months. The activities director (AD) was interviewed on 10/24/23 at 3:02 p.m. The AD said she was initially hired as a certified nurse aide in August 2023 and was promoted to the AD position about a month ago. She was working on completing the State-approved activities training course to become a qualified activities professional. She said there were currently three activity staff including herself to provide activities for the entire facility. It was difficult to provide unique programming to each unit simultaneously because each unit had a different activities calendar due to the different needs and abilities of the three units; the secured behavioral unit, and the skilled and long-term care unit. The AD said she was full-time and had one other full item and one part-time activities assistant working with her. The AD said she had requested one additional full-time activity assistant to meet the needs of the residents but the request was denied. The AD said sometimes activities had to be rescheduled or pushed back because of the activity staffing schedules, and it was hard for her team to execute group activities consecutively on all three units as scheduled since the nursing staff did not assist with activities programming. The AD said the activity staff were able to provide the residents with word search, puzzle packets, coloring pages and painting activities that could be done independently when the staff was providing activities elsewhere in the building. The AD was not able to explain why Bingo was canceled on 10/23/23 or why no activities were provided on the secured behavioral unit because she was out of the building on those days. The AD said activities programming was important to residents' mental health. Recreation and leisure time activities helped mellow out resident behaviors and help them calm when something upset them. The AD said for residents, particularly in the secured behavioral unit activities could provide them with meaningful activities to reduce boredom, especially when they sat around with nothing to do. Independent activity supplies were very important to the residents. The AD said that each resident in the secured units had a leisure card that provided staff with a list of meaningful independent activities that the resident could do. The AD said she could not speak to what activities were supposed to have been offered during the continuous observation times on 10/19/23 and 10/23/23 (see above). The AD said she was not in the building on 10/23/23 but that one of the other activities staff was scheduled to be working on a different unit providing a group activity. The AD said other benefits of activities were to help the resident feel welcome and secure. If a resident was upset and her team noticed, they could offer the resident to go on a walk or to participate in another preferred activity. She said activities helped reduce the resident's stress and helped their overall well-being. The AD said she attended the resident council for the first time on 10/19/23. The resident had a lot of complaints about activities and the activities calendar. The residents provided a lot of suggestions for the types of activities they wanted to see and wanted shopping trips and outings to start up again. The AD said plans for November 2023 activities programming were going to have to be a lot different. The AD said she was up for changing the activities program to meet the needs and wants of the residents in each of the three units. The AD said it would be a challenge to provide sufficient programming around the lunch meal because the lunch meal was never on time it was usually late or early and that made it difficult to plan and carry out activities. The nursing home administrator (NHA)/director of nursing (DON) and the CNC were interviewed on 10/24/23 at 4:28 p.m. The NHA/DON said the activities department was fully staffed with three activity employees; two full-time and one part-time employee. The NHA/DON said the residents were not offered outings but she could accommodate outing activities next month (November 2023). The NHA/DON said residents in the secured behavioral unit had independent activity supplies such as magazines, board games and adult coloring page activities. The CNC said that nursing staff and other staff should engage with residents who were not engaged in activity to promote leisure time enjoyment. The NHA/DON was not aware that activities programming was not offered during the times of the continuous observations in the secured behavioral unit on 10/19/23 and 10/23/23 and was not sure why bingo on the skilled and long-term was canceled but said she would check what activities were offered during the continuous observation times. The NHA/DON did not follow up to confirm what activities were offered. The CNC said activities were important for a secured behavior unit because activities helped keep the residents engaged and could reduce negative behaviors. She said activities for all residents were critical to the residents and the unit.

Based on record review and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for two (#61and #75) of four residents out of 41 sample residents. Specifically, the facility failed to -Ensure the ordered medication was held when Resident #61's blood pressure and heart rate were out of range of the ordered parameters; and, -Ensure Resident #75 received a prescribed medication for treatment of a pressure injury. Findings include I. Physician's orders for blood pressure medicationA. Professional reference According to Saunders Nursing Drug Handbook 2020, Kizior, R. J. and Hodgson, K.J., St. Louis Missouri 2020, revealed the following pharmaceutical information:-Page (pp). 706 - 709 read in part: "Lisinopril use treatment of hypertension to reduce signs and symptoms of systolic health failure. Alert: in adults and the elderly for patients with systolic blood pressure greater than 100 to 120 millimeters of mercury (mmHg) discontinue if systolic blood pressure is less than 90 mmHg for more than one hour. Side effects dizziness, headache, and postural hypotension. Nursing considerations - Baseline assessment: Obtain blood pressure and apical pulse immediately before each dose in addition to regular monitoring ot be alert of fluctuations." According to the National Library of Medicine, Terazosin, 3/13/23, retrieved on line 11/2/23 from: https://www.ncbi.nlm.nih.gov/books/NBK545208/ "Terazosin is a medication used in the management and treatment of essential hypertension. The nurse is responsible for administering the medication to the patient requires vigilance and awareness of the potential hypotension associated with Terazosin and should be meticulous in their measurement of vital orthostatic signs after administration." B. Resident #61 1. Resident status Resident #61, age 67, was admitted on 12/13/21. According to the October 2023 computerized physician orders (CPO), diagnoses included dementia, diabetes and hypertension. The 8/25/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) exam score of 15 out of 15. 2. Record review Medication orders The October CPO revealed the following orders:-Lisinopril Tablet 5 milligrams (mg), give one tablet by mouth one time a day for hypertension related to essential primary hypertension, hold for systolic blood pressure less than 100, start date 3/8/23.-Terazosin HCl Capsule 2 mg, give one capsule by mouth at bedtime related to essential primary hypertension, hold for systolic blood pressure less than 100 and heart rate less than 60, start date start 9/15/23. Vital signs assessment The May 2023 medication administration record (MAR) and treatment administration record (TAR) recorded daily vital signs that included blood pressure and heart rate. -The record did not document the time of the vital signs assessment in relation to the administration of the resident's Lisinopril or terazosin medications. There was no documentation to show that the resident's vital signs were assessed prior to the administration of the resident's Lisinopril or terazosin medication. The May 2023 TAR and the vital signs assessment summary record documented that the resident systolic blood pressure was assessed once a day and was under 100 on five days of the month.-On 5/10/23 at 11:25 a.m., the resident's blood pressure was 99/67. Neither the Lisinopril or terazosin medication were held-On 5/14/23 at 10:43 a.m., the resident's blood pressure was 94/54. Only the terazosin medication was held.-On 5/18/23 at 3:35 p.m. the resident's blood pressure was 99/60. Neither the Lisinopril or terazosin medication were held-On 5/24/23 at 9:43 a.m. the resident's blood pressure was 81/56. Neither the Lisinopril nor terazosin medication was held.-On 5/27/23 at 4:59 p.m. the resident's blood pressure was 98/62. Only the terazosin medication was held. The June 2023 MAR and TAR recorded daily vital signs that included blood pressure and heart rate for only 6/1/23 to 6/7/23. -The record did not document the time of the vital signs assessment in relation to the administration of the resident's Lisinopril or terazosin medications. The June 2023 MAR, TAR and the vital signs assessment summary record documented that the resident systolic blood pressure was not assessed daily. No vital signs assessment occurred on 6/4/23, 6/13/23 to 6/15/23, 6/17/23 to 6/19/23, 6/22/23 to 6/25/23 and 6/26/23 to 6/30/23. -Due to the lack of blood pressure assessment in the month of June 2023 there was no way to verify if the resident required the administration of Lisinopril or terazosin medication. A review of the July 2023 to October 2023 MAR or TAR revealed no documentation of the resident's blood pressure or heart rate being assessed prior to the administration of either medication Lisinopril or terazosin. The July 2023 MAR, TAR and the vital signs assessment summary record documented that the resident systolic blood pressure was not assessed daily. No vital signs assessment occurred on 7/2/23, 7/4/23 to 7/6/23, 7/12/23. 7/19/23 to 7/20/23, 7/26/23 and 7/30/23. The August 2023 MAR, TAR, and the vital signs assessment summary record documented that the resident systolic blood pressure was not assessed daily. No vital signs assessment occurred on 8/1/23 to 8/2/23, 8/9/23, 8/16/23, 8/23/23 and 8/30/23 to 8/31/23. The September 2023 MAR, TAR, and the vital signs assessment summary record documented that the resident systolic blood pressure was not assessed daily. No vital signs assessment occurred on 9/1/23 to 9/6/23, 9/10/23 to 9/11/23, 9/13/23 to 9/25/23 and 9/27/23 to 9/30/23. The October 2023 MAR, TAR, and the vital signs assessment summary record documented that the resident systolic blood pressure was not assessed daily. No vital signs assessment occurred on 10/1/23 to 10/2/23, 10/4/23 to 10/9/23 to 10/16/23, and 10/18/23 to 10/24/23. -Due to the lack of blood pressure assessment on the above dates from July 2023 to October 2023 there was no way to verify if the resident required the administration of Lisinopril or terazosin medication. The resident comprehensive care plan, last reviewed on 9/4/23 failed to document care focus for the resident's use of antihypertensive medication to control blood pressure. 3. Staff interviewsLicensed practical nurse (LPN) #6 was interviewed on 10/23/23 at 1:02 p.m. LPN #6 said the administration nurse was responsible for following physician orders for assessing the resident blood pressure prior to administering an antihypertensive medication and holding the mediation when the resident's was below 100 and or the heart rate was less than 60 beats per minute. LPN #6 said the resident's blood pressure and heart rate assessment should be documented in the resident's medical record and or on the MAR. The director of nursing (DON) was interviewed on 10/24/23 at 4:58 p.m. The DON said physician's orders for medication administration should always be followed. If the medication orders document that a mediation should be held when the blood pressure or heart rate wereUnder a specific assessed number and out of the prescribed parameter the nurse should hold the medication and notify the resident's physician to determine if there was a need for alternative orders. The nurse should then document all findings, communication with the physician and any subsequent orders. II. Physician's order for medication supplement for wound healing A. Professional reference According to Song YP, Wang L, Yu HR, Yuan BF, Shen HW, Du L, Cai JY, Chen HL. December 2020, Zinc Therapy Is a Reasonable Choice for Patients With Pressure Injuries: A Systematic Review and Meta-Analysis. Nutrition in Clinical Practice, 35(6):1001-1009. DOI: 10.1002/ncp. 10485. Retrieved online 11/2/23 from https://pubmed.ncbi.nlm.nih.gov/32166790/#:~:text=Our%20systematic%20review%20and%20meta,ulcer%3B%20wound%20healing%3B%20zinc. "Our systematic review and meta-analysis from clinical research confirmed that zinc therapy can promote wound healing and suggest that medical staff should consider providing patients with zinc during PI (pressure injury) treatment. B. Facility policy The Medication Orders policy, revised November 2014, was provided by the corporate nurse consultant (CNC) on 10/25/23 at 11:30 a.m. The policy read in pertinent part: "The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders." C. Resident #75 1. Resident status Resident #75, age 86, was admitted on 7/7/23. According to the October 2023 CPO, diagnoses included pressure injury, failure to thrive, and depression. The 8/25/23 MDS assessment revealed the resident had severely impaired cognition with a BIMS exam score of four out of 15. The resident needed extensive assistance from staff to complete activities of daily living. The resident was at risk for pressure injuries and had unhealed pressure injuries, stage 4 pressure injury present upon admission. 2. Record review The comprehensive care plan documented a care focus for pressure ulcers due to immobility revised 7/13/23. Interventions included: Administer medications as ordered. Monitor and document for side effects and effectiveness. Physician's progress note dated 10/6/23: "Medical necessity of visit: Recent medication changes. Nursing requested that I see the patient today. History of present illness: right trochanter stage 4 ulcer discussed with wound care nurse. When the patient fell the wound opened up due to significant undermining. She is being seen by a wound care physician. The reports today that the wound currently does not have any undermining on dressing change today. History: adult failure to thrive. Assessment and Plan: Pressure ulcer of right hip, Stage 4: continue wound care. Order zinc and vitamin C supplements added for healing."The resident's CPO documented a physician's order for zinc 15 milligrams (MG) oral tablet, give one tablet one time a day for wound treatment, start date 10/6/23. -The order was later discontinued (see the director of nursing interview below). There were no notes in the resident medical record to document why the order was discontinued. There were no notes in the resident medical record to document that the prescribing physician was notified that the medication was discontinued and unavailable. 3. Staff interviews The resident physician was interviewed on 10/23/23 at 11:18 a.m. The resident's physician said the resident had a wound that had worsened after a fall and the resident's health condition warranted the addition of zinc supplementation. The physician said she entered an order for a zinc supplement on 10/6/23 into the resident medication administration record but was not notified until today that the resident had not started on the medication. The physician said this was concerning because the resident had poor nutrition and poor healing and needed the zinc supplement in addition to current interventions to promote effective wound healing. The physician said over-the-counter medication did not come from the regular pharmacy; instead, facility staff went to a local retail store to purchase the medicine. The physician said she was unaware of why the zinc medication was not obtained. LPN #6 was interviewed on 10/23/23 at 1:02 p.m. LPN #6 said the resident's physician entered medication orders into the resident's medical administration record and the order was sent to the pharmacy. If there was a problem with the order the pharmacy would usually contact the facility and the nurse should contact the physician for alternative orders. The nurse was responsible for documenting this communication and any new orders. LPN #6 said there were times when the physician would provide a written or telephone order and the nurse would enter the order into the resident's record The DON was interviewed on 10/24/23 at 3:47 p.m. The DON said she was aware that the resident's physician had ordered a low dose of zinc and said the pharmacy did not have the dose in stock that the physician had ordered and the physician did not want to give the resident a higher dose due to the resident's poor kidney function. For that reason, the order was discontinued from the resident's medical record. The DON checked the medical record and said she did not see any notes to show that the resident's physician was notified or a note documenting why the zinc order had been discontinued.

Based on observation, interview and record review, the facility failed to ensure that residents who require urostomy, services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. for one (#293) of one resident reviewed for urostomy care out of 41 sample residents. Specifically, the facility failed to ensure:-Resident #293's urostomy bag was maintained per physician's guidance and professional standards of practice; -Ensure orders for Resident #293's urostomy care; and, -Ensure the comprehensive care plan documented a care plan focus for urostomy care with interventions for Resident #293's urostomy care needs. Findings include: I. Failure to provide urostomy care as ordered A. Professional reference According to Medline Plus, Changing your Urostomy Stoma and Skin Care, 4/10/22, retrieved online 11/2/23 from https://medlineplus.gov/ency/patientinstructions/000477.htm "Urostomy pouches are special bags that are used to collect urine after some types of bladder surgery. Caring for your stoma and the skin around it is very important to prevent infection of your skin and kidneys. A stoma is very delicate."Caring for the skin around your stoma: After surgery, the skin around your stoma should look like it did before surgery. The best way to protect your skin is by taking good care of the skin around your stoma. Wash your skin with warm water and dry it well before you attach the pouch. Avoid skin care products that contain alcohol. These can make your skin too dry. Do not use products on the skin around your stoma that contain oil. These can make it hard to attach the pouch to your skin. Use special skin care products. This will make problems with your skin less likely. Be sure to treat any skin redness or skin changes right away, when the problem is minor. Do not allow the problem area to become larger or more irritated before asking your provider about it."The skin around your stoma can become sensitive to the supplies you use, such as the skin barrier, tape, adhesive, or the pouch itself. This could happen slowly over time and not occur for weeks, months, or even years after using a product."According to Medline Plus, Changing your Urostomy Pouch, 4/10/22, retrieved online 11/2/23 from https://medlineplus.gov/ency/patientinstructions/000478.htm "Urostomy pouches are special bags that are used to collect urine after some types of bladder surgery. You will need to change your urostomy pouch often."Most urostomy pouches need to be changed 1 to 2 times a week. It is important to follow a schedule for changing your pouch. Do not wait until it leaks because urine leaks can harm your skin. You may need to change your pouch more often. Always change your pouch if there are signs that it is leaking. Signs include itching, burning, or if changes in the appearance of the stoma or the skin around the stoma."B. Facility policy The Ureterostomy Care policy, revised October 2010, was provided by the corporate nurse consultant (CNC) on 10/25/23 at 11:30 a.m. The policy read in pertinent part: "The purposes of this procedure are to promote cleanliness and to protect peristomal skin from irritation, breakdown, and infection. Review the resident's care plan to assess for any special needs of the resident." C. Resident #293 1. Resident status Resident #293, age 78, was admitted on 10/5/23. According to the October 2023 computerized physician orders (CPO), diagnoses included cancer of the urethra, abdominal aortic aneurysm (swelling of the tube that carries blood from the heart to the stomach) and absence of a spleen. The minimum data set (MDS) assessment had not yet been completed due to the resident being newly admitted. Per the hospital referral packet dated 10/4/23, Resident #293 was alerted and oriented to person, place, time and situation. The resident had been admitted to the hospitalfor a procedure to treat aortic aneurism/atherosclerosis and underwent surgery. Following surgery and recovery, the resident was discharged to the facility for skilled nursing services including occupation, physical therapy and speech-language therapy. 2. Observations and resident interview Resident #293 was interviewed on 10/23/23 at 10:33 a.m. Resident #293 said the staff emptied the urine bag and had not changed his urostomy bag. Observation of the resident's urostomy revealed the ostomy bag setup was dated 10/4/23. There was a urine drainage bag connected to the urostomy bag to drain the urine. 3. Record review Hospital ostomy note dated 10/2/23, labeled as referral packet in the resident's medical record documented. "Stoma assessment. Type: Urostomy. Date of stoma creation: 8/23/23. Stoma size: 19 millimeters (mm). Stoma shape: round. Stoma appearance: pale pink, no bleeding noted. Stoma output type: urine, mucous present. Stoma skin pain zero of 10. Current ostomy products use a 1.75 inch wafer and bag, barrier ring and skin prep. "Appliance change frequency Tuesday and Friday."Treatment plan and plan of care: removed soiled appliance and discarded. Cleansed peristomal skin, and dried. Applied skin prep to peristoma. Applied barrier ring. Wafer cut to fit, attached. Bag applied and ached to night bag (for drainage)." The hospital referral documents containing therapy, nutrition and wound care orders, faxed to the facility on 10/4/23 read in pertinent part: "Precautions: Ostomy- 1.75 wafer and bag, barrier ring and skin prep- change T/F (Tuesday and Friday). Coming with the patient one week of ostomy supplies. -Active outpatient mediation orders included: Pouches, urostomy, (brand name and order number listed) pouches, three times a week for urostomy."-The following supply was processed to be filled, per request of facility/case management:Pouches, urostomy, (brand name and order number listed). D. Staff interviews The resident physician was interviewed on 10/23/23 at 11:18 a.m. The resident's physician said it was concerning that Resident #293's urostomy bag had not been changed since admission and that the bag needed to be changed a couple of times a week. Licensed practical nurse (LPN) #6 was interviewed on 10/23/23 at 1:02 p.m. LPN #6 said Resident #293's urostomy bag was changed as needed and there was no order to change it on any regular schedule. The LPN said there was no special care for the urostomy. The nurses were responsible for checking the urostomy setup, changing the bag if the urine was not flowing or if the setup was not staying on the resident's skin, monitoring and documenting the urine output and emptying the resident drainage bag as needed. The director of nursing (DON) was interviewed on 10/24/23 at 3:47 p.m. The DON said the nurses were responsible for all care related to Resident #293's urostomy. Urostomy care included monitoring and documenting the condition of the urostomy and urine output six times a day, every day. Changing and cleaning the stoma site once a week. The DON said there should be in order for the resident urostomy care on the medication or treatment administration record (MAR/TAR) and was not sure why the order was not in the record.

Based on observations, record review and interviews, the facility failed to ensure one (#15) of one resident reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 41 sample residents. Resident #15 was admitted to the facility on 9/30/19. His admission weight on 9/30/19 was188.4 pounds (lbs). The resident maintained a weight between 180 lbs to 200 lbs between January 2022 and June 2023. The resident was hospitalized in July 2023. When he returned to the facility, the facility failed to weigh the resident until August 2023. The facility did not attempt to weigh the resident after he refused one weight. The registered dietitian (RD) recommended weekly weights in July 2023 and no weights were obtained. Per staff interviews, the resident was not eating, refusing meals and often skipped breakfast and no preventative measures were implemented to address his eating patterns to ensure his intake was adequate. Due to the facility's failure to implement nutritional interventions, Resident #15 sustained a severe weight loss of 32.8 pound weight loss or a 17.09 percent weight loss in 60 days. Findings include: I. Facility policy The Food and Nutrition Services policy, revised October 2017, was provided by the corporate nurse consultant (CNC) #1 on 10/25/23 at 11:05 a.m. It read in pertinent part: "Each resident is provided with a nourishing, palatable, well balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each diet. The multidisciplinary staff will assess each resident's nutritional needs, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment." II. Resident #15 A. Resident status Resident #15, age 70 years old, was admitted on 9/30/19. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia, schizophrenia, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, psychotic disturbance, psychosis, hypertension, hypertensive chronic kidney disease and osteoarthritis. The 7/19/23 minimum data set (MDS) assessment documented that the resident was unable to complete the brief interview for mental status (BIMS). The staff assessment for mental status was completed. It documented the resident had a memory problem and was moderately impaired, made poor decisions and supervision or cues was required. The resident required supervision with bed mobility and transfers. He required one person assistance with toileting, grooming and personal hygiene. The assessment documented the resident required set up assistance with eating and the resident had not experienced any weight loss. His height was 5 foot 8 inches. B. Record review Resident #15's medical record revealed he experienced a significant unplanned weight loss of 23 pounds; 11.93 percent in six months, from April 2023 to 10/17/23. The resident was discharged on 7/12/23 and was readmitted on 7/14/23. Prior to the discharge, the resident was in the secured memory unit. When the resident returned, the resident was moved to the secured behavioral unit. The facility attempted to weigh the resident one time at readmission but the resident refused and the staff did not reattempt a weight despite the resident being known to be at risk for weight loss. According to the hospital documentation on 7/12/23, the resident weight was 195 lbs. 1. Resident #15 nutritional status The unintended weight changed care plan, initiated on 9/30/19 and revised 8/4/23, documented the resident had potential for unplanned weight loss related to dementia, psychotropic medication, variable meal intakes, declining health status secondary to numerous comorbidities. Interventions included a health supplement shake due to the resident skipping breakfast; monitor weightweekly; and monitor for significant changes. The cognitive care plan, initiated on 11/16/19 and revised on 10/8/21, documented the resident had impaired cognitive function/dementia or impaired thought processes related to disease process. The activities of daily living (ADL) care plan, initiated on 10/3/19 and revised on 3/8/23, documented the resident had a self-care performance. It documented the resident did not require supervision and he was independent with eating. 2. Resident #15 weight loss history revealed significant weight loss as follows: -On 4/19/23, the resident weighed 195.3 pounds -On 5/3/23, the resident weighed 195.4 pounds-On 6/2/23, the resident weighed 195.4 pounds-The facility failed to obtain a weight for July 2023 -On 8/1/23, the resident weighed 162.6 pounds, a 32.8 pound weight loss or a 17.09 percent weight loss in 60 days -On 8/4/23, the resident weighed 165.8 pounds-On 8/18/23, the resident weighed 168.4 pounds-On 8/22/23, the resident weighed 172.8 pounds -On 9/1/23, the resident weighed 168.8 pounds -On 9/5/23, the resident weighed 175.2 pounds-On 9/12/23, the resident weighed 176.6 pounds -On 9/16/23, the resident weighed 173 pounds -On 9/19/23, the resident weighed 176.4 pounds-On 9/26/23, the resident weighed 171.8 pounds -On 10/3/23, the resident weighed 175.2 pounds -On 10/14/23, the resident weighed 168.6 pounds-On 10/17/23, the resident weighted 172 pounds -On 10/21/23, the resident weighed 168.2 pounds -On 10/24/23, the resident weighed 168.6 pounds The 7/14/23 readmission nutritional assessment, completed by a registered dietitian (RD), documented Resident #15 was on a regular diet with a regular texture and a thin liquid diet. It indicated the resident weighed 195.4 pounds on 6/2/23. The RD documentd the resident's intake was erratic at meals with refusals and skipped breakfast due to sleeping. The RD recommended monitoring intake and to obtain weekly weights. -However, the RD did not add any measures for his meal refusals and skipping breakfast. In addition, the RD was aware the resident was not eating prior to hospitalization in July 2023 and losing weight and no preventative measures were put in place to address his nutritional risk. In addition, the resident was not weighed weekly as the RD recommended to help monitor his nutritional status. The 8/4/23 interdisciplinary team weight variance assessment revealed that the resident had a 15.1 percent weight loss in eight weeks. A new intervention was to add mighty shakes in the morning. It revealed that potential medical factors were a recent illness within 30 days, recent significant changes in medication and psychotropic medications. The summary revealed that a nurse on the secure memory unit said the resident stopped eating prior to his hospitalization due to increased behaviors and aggression. -A supplement was added after the resident sustained a 32.8 pound weight loss with no preventative measures in place. The August 2023 CPO documented the following physician order for mighty shake one time a day for weight loss. Provide once the resident wakes up. The start date was 8/5/23. The September 2023 CPO documented the mighty shake was discontinued on 9/8/23. The 10/14/23 interdisciplinary team weight variance assessment revealed that the resident had a 13.7 percent weight loss in six months. The summary revealed the resident intake improved and mostly consumes 76-100 percent of meals. It documented with the weight trending down, mighty shakes were added. The October 2023 CPO documented the following physician order for mighty shake one time a day. The start date was 10/17/23. The October 2023 meal intake records documented the resident consumed the following from 9/20/23 to 10/19/23 the records revealed the resident ate 76-100 percent on 49 occasions; 51-75 percent on two occasions; 26-50 percent on four occasions; and, refused meals on six occasions (10/1/23, 10/3/23, 10/4/23, 10/5/23, 10/8/23 and 10/10/23). Additionally, the residenthad less than three meals in a day recorded for several days between 9/20/23 to 10/19/23. The record revealed the resident ate only two meals on three days (9/23/23, 10/15/23 and 10/16//23); and only one meal on two days (9/26/23 and 9/30/23). III. ObservationsOn 10/23/23 from 12:05 p.m. to 12:35 p.m., Resident #15's lunch meal was observed. Registered nurse (RN #1)and an unidentified certified nurse assistant (CNA) delivered the lunch meal tray and beverages to residents who ate meals in their room. The nurse went into Resident #15's room at 12:05 p.m., to deliver his lunch, the resident was lying on his bed and looked asleep. She asked him if he was hungry and he said no; she told him she would come back. The nurse went back at 12:15 p.m. to set up his meal. The nurse cut up the resident's chicken and left the food for him. The resident was lying on his bed and still looked asleep. At 12:35 p.m., Resident #15 did not start to eat his food. Resident #15 was interviewed on 10/23/23 at 1:35 p.m. The resident was unable to communicate why he did not eat his meal or even if he received a lunch time meal. The scales in all units were observed on 10/24/23 between 1:00 p.m. and 1:30 p.m. The secured memory unit had a commercial scale that a resident could stand on, in their television room. The non secured unit had a commercial scale in a locked scale room. It was a scale for residents who could not stand independently. The secured behavioral unit scale had a regular scale. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 10/24/23 at 12:51 p.m. LPN #2 said the resident lost weight because he liked to sleep in instead of getting up for breakfast. LPN #2 showed the scale that was used to weigh residents on the unit. It was a home weight scale and was not a medical weight scale. The RD was interviewed on 10/24/23 at 10:05 a.m. She was familiar with Resident #15. She said the resident stopped eating completely prior to the resident's hospitalization and lost a lot of weight. Upon the resident's return and throughout August 2023, the resident lost a significant amount of weight. The physician ordered a mighty shake nutritional supplement then by September 2023 the resident started to gain some weight and the mighty shakes were discontinued so the resident did not gain too much weight. The resident was prescribed mighty shakes again in October 2023. The RD said the scale in the secured behavioral unit was not as accurate as the scale in the secured memory unit. She weighed herself in both units and said the difference was approximately five pounds and found that the scale in the secured memory care unit was more accurate. The RD said she would add interventions if a resident lost five percent in three months and 10 percent in six months. -However, nutritional interventions should be proactively added and not when the resident sustains a significant weight loss. The intervention would depend upon the resident individualized needs. She said if a resident was not weighed on the day of readmission, then the facility should weigh the resident within three days. She said it was important to have an accurate weight so she could complete an accurate nutritional assessment. She said all residents should be weighed monthly to ensure the resident was not losing weight and to provide a complete nutritional picture of the residents nutritional needs. Resident #15 who had a significant weight loss should have been weighed weekly. The director of nursing (DON) was interviewed on 10/24/23 at 2:00 p.m. She was familiar with Resident #15. The DON said Resident #15's dementia was progressing in addition to his mental illness which both contributed to his weight loss. Additionally, Resident #15 was a picky eater and did not have a hunger drive. The DON said Resident #15 refused to be weighed in July 2023 when he returned from the hospital. The DON said when a resident refused to be weighed the nursing staff should attempt to weigh the resident within three days and document the results. The DON said residents should be weighed weekly for the first weeks after admission and then monthly thereafter. She said there would be times the resident would not be weighed monthly based on the RD's recommendation. She said it was important to weigh resident's monthly because it was indicative of other things that happened to the resident. Monthly weight history helped with the whole picture of the resident health and could trigger concern for other care areas like medication review. The DON said the CNAs weighed the resident and reported to the nurse who would record and report any weight concerns. The DON said the facility offered Resident #15 meal alternatives, like a supplement shake to help with the resident's weight loss; and would recommend adding additional interventions if the resident lost five percent of his weight in three months and 10 percent in six months. The DON said that a two month gap of no weights for a resident would be too long. If the resident refused to be weighed, she would follow up with the interdisciplinary team to develop other interventions. The DON said she placed an order for a medical weight scale to be placed in the resident's unit to reduce weight discrepancies.

Based on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis. Specifically, the facility named the DON to also function in the role of the facility ' s nurse home administrator (NHA) and the infection preventionist (IP); delegating all three responsibilities to one individual employee in a facility with an average census of 92 residents. Findings include: I. Facility policy The Director of Nursing Services policy, revised August 2022, was provided by the corporate nurse consultant (CNC) on 10/25/23 at 11:30 a.m. It read in pertinent part: "The nursing services department is managed by the director of nursing services (DNS). The director is a registered nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing. The director is employed full-time (40 hours per week)." II. Staff interviews A frequent visitor to the building was interviewed on 10/17/23 at 2:30 p.m. The frequent visitor said the facility was struggling to provide good care to residents and residents were observed to be cared for under poor conditions. The frequent visitor said both the staff and the residents reported poor care and poor ability to provide competent care due to a lack of proper leadership. The frequent visitor said that staff reported running out of supplies, poor coordination with lab services and having to sometimes work with agency staff who were less than motivated or knowledgeable enough to provide competent care. The operations manager (OM) was interviewed on 7/19/23 at 4:21 p.m. The OM said he recently earned a bachelor's degree in financial planning and previous to this position he managed a local chain restaurant. He did not attend the facility quality assurance quality improvement (QAPI) meeting but did provide data for the DON to present. The OM said in the role of OM he was responsible for troubleshooting resident satisfaction. In this role, he talked with residents and staff to make sure everything was in place and things were operating and functioning properly. The OM said when he learned of facility concerns whether it be a clinical or physical environment issue he would investigate and bring the information to the DON who was also acting as the full-time NHA and the DON would make the decision on how to handle the concern/problem. The OM said he did not make any managerial or operational decisions; he was in his role to assist the DON in day-to-day activities as directed. The OM said his other duties include running shift change meetings and making sure staff were answering call lights timely. The OM said the facility had been looking for a full-time permanent NHA since the previous NHA resigned from the position. The building has had a number of temporary NHAs in the position but (at the time of the survey from 10/17/23 to 10/24/23) the DON was performing both the role of DON and NHA and was fully responsible for fulfilling both roles since 9/25/23. The OM said the roles of assistant director of nursing (ADON) and infection preventionist were vacant but they had offered the position and expected the ADON candidate to start on 11/2/23. Corporate leadership provided support by phone and in person once a week when possible. The DON/NHA was interviewed on 10/18/23 at 9:30 a.m. The DON said she was hired as the facility ' s full-time DON on 9/25/23. When the facility was unable to find and hire an NHA she applied for an emergency NHA licensure and was granted a temporary permit for an emergency situation on 10/3/23, in order to assume the role of the facility ' s NHA position. The DON/NHA said she assumed the roles of the facility ' s full-time DON, NHA and was acting as the facility ' s infection preventionist. The facility had a plan to start a new nurse in the role of ADON and infection preventionist starting the first Monday of November 2023. The DON/NHA said a typical day in her position included making rounds, reviewing shift reports, examining reported resident health concerns like falls, medication issues, new illnesses, new and readmissions and other clinical concerns. After that, the DON said she attended morning meetings with other members of leadership to discuss clinical and administrative concerns then she met with floor staff and other managerial staff to pass along needed information for daily care matters. The DON/NHA also met with the interdisciplinary team to discuss QAPI plans for service improvement areas, attended weekly nutrition and sometimes helped with admissions and monitored wound rounds. The DON/NHA said the OM worked under her direction and assisted with investigating day-to-day concerns from residents and staff. Once identified the OM manager brought the findings to her attention and she made all of the clinical and administrative decisions and delegated resolution actions to the OM and other key staff. The DON/NHA said corporate leadership provides additional support by phone and with occasion onsite visits. There was no set onsite visit schedule and most support was provided by phone. The CNC was interviewed on 10/19/23 at 842 a.m. The CNC said the facility underwent an ownership change in February 2023, the previous NHA left soon after the new acquisition. Corporate leadership then hired a temporary NHA and started a search for a permanent full-time NHA but had difficulty getting candidates approved through the State licensing board due to a number of extenuating circumstances. The CNC said finding a permanent NHA was the facility's top priority. In the interim, the CNC said she was helping as needed with operational tasks and providing additional training for the OM who was new to the long-term care industry. The regional vice president of operations (RVPO) was interviewed on 10/19/23 at 5:15 p.m. The RVPO said the corporation had been in touch with the State licensing board but was having difficulty getting a consistent response from the licensing board. The corporation had submitted a number of candidates for application to sit for the NHA State licensure exam but several applications were denied for various different reasons and it was difficult to determine a consistent factor in the licensing board's decision making. The RVPO said the corporation continued to seek candidates for the facility NHA position and had a positive interview with a potential candidate who was currently licensed in the State as an NHA and was hopeful that the candidate would accept and start in the position in the next couple of weeks. Once an NHA candidate started in the position; the plan was to relieve the DON of the NHA duties.

Based on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#392) of two residents reviewed for medication errors out of 41 sample residents. Specifically, the facility failed to ensure that Resident #392 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Finding includeI. Professional referenceAccording to the Lantus (glargine) manufacturer guidelines, last updated 2022, retrieved fromhttps://www.lantus.com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8aba629a/lantus-solostar-pen-guide.pdf on 10/30/23 included the following recommendations,"Perform a safety test. Dial a test dose of two units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Never use the pen if no insulin comes out after using a second needle."II ObservationsOn 10/24/23 at 7:40 a.m. licensed practical nurse (LPN) #6 was checked Resident #392's insulin order of glargine insulin 30 units before breakfast. She obtained Resident #392's labeled insulin pen and dialed in 31 units. She did not prime the pen with insulin before dialing in the dose to be administered. She then entered Resident #392's room and administered insulin to the resident. She returned to the medication cart and disposed of the needle cap into the sharps container. III. Staff interviewsLPN #6 was interviewed on 10/24/23 at 8:15 a.m. She said she was told by the pharmacy to dial an additional one unit of insulin in addition to the ordered dosage of insulin to help prime the pen during administration so that they did not get the incorrect doseLPN #4 was interviewed on 10/24/23 at 8:30 a.m. She said all insulin pens should have two units primed through the insulin pen prior to administration. If the insulin pen was not primed prior to administration that air could be injected and potentially an incorrect dose could be administered. The director of nursing (DON) was interviewed on 10/24/23 at 8:45 a.m. She said insulin pens should be primed with two units prior to administration to prevent injection of air and prevent the incorrect dose of insulin to be administered.

Based on observations, record reviews, and interviews, the facility failed to ensure that drugs/biologicals were stored and disposed properly upon expiration in one of two medication storage refrigerators. Specifically, the facility failed to dispose of expired medications. Findings include:I. Professional reference According to Konvomep manufacturer's instructions for healthcare professionals (August 2022), retrieved from https://konvomep.com/hcp/about-omeprazole on 10/26/23, advised to discard unused reconstituted suspension after 30 days. II. Facility policy and proceduresA. The Storage of Medications policy, revised November 2020, was provided by the director of nursing (DON) on 10/24/23 at 10:50 a.m. It read, in pertinent part: "The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed." B. The Nursing Responsibilities checklist, not dated, was provided by the nursing home administrator (NHA) on 10/24/23 at 10:00 a.m. It read in pertinent part:"Check for expired medications and place them in the medication room."III. Observations On 10/19/23 at 3:30 p.m. the medication storage room (Omnicell room on Sarvata unit) was reviewed with licensed practical nurse (LPN) #3. The refrigerator contained liquid medication Konvomep. The medication had been opened and the label affixed to back of the bottle had an expiration date of 8/25/23. In the same refrigerator, Veltassa 8.4 gm seven packets were labeled with the manufacturer's expiration date 2/20/23. IV. Staff Interviews LPN #3 was interviewed on 10/19/23 at 3:35 p.m. She said the resident who had taken Konvomep had been discharged and both the Konvomep and Veltassa medications in the refrigerator should have been discarded by the expiration date. LPN #4 was interviewed on 10/24/23 at 9:20 a.m. She said the pharmacy came in monthly to review the medication carts and remove expired meds. She said all staff were responsible for checking the medication refrigerators. She said there was no set process and she was not aware of any staff specifically being responsible to check for expired medications. She said giving expired medications could mean giving a medication that was no longer effective or could have potential side effects. The DON was interviewed on 10/24/23 at 9:50 a.m. She said the medication carts were checked by the pharmacy and were on a rotating schedule with the medication carts in the storage room. She said the medication refrigerators in the storage rooms were checked by staff for expired medications at the same time refrigerator temperatures were checked. The DON said that expired medications should never be given because medications should be checked for the five rights prior to administration. She said giving expired medications could potentially be administering ineffective medications or have side effects.

Based on observation and staff interviews, the facility failed to ensure essential equipment was in proper working order. Specifically, the facility failed to maintain the water system boiler in working order to ensure the resident had hot water for showering and the kitchen dishwasher maintained proper water temperature to clean and sanitize resident dishware. Findings include:I. Resident interviews Resident #8 was interviewed on 10/18/23 at 2:26 p.m. Resident #8 said he had not taken a shower in the past two weeks because the water was not hot. Resident #8 said the problem with the hot water had been ongoing for the past four weeks. Resident #59 was interviewed on 10/18/23 at 2:55 p.m. Resident #59 said that she took showers but the water temperature was too cold. The last time she took a shower was the night before. She said she took cold showers for the past two weeks. She said that when the cold waters hit her back, it took her breath away and she felt like she would faint. Resident #28 was interviewed on 10/18/23 at 3:01 p.m. Resident #28 said he wanted showers more regularly but was not comfortable taking showers because the shower water was not hot enough to take a comfortable shower because the water was too cold. Resident #28 said the hot water had not been working properly for the past couple of weeks the water temperature was inconsistent, some days the shower water was hot but most of the time the water was cold. Resident #83 was interviewed on 10/18/23 at 3:57 p.m. Resident #83 said that the water in his room was cold and not hot enough. Resident #49 was interviewed on 10/18/23 at 3:01 p.m. Resident #49 said the water was not enough. He said since the water was not hot, he had not had a shower but wanted one. II. ObservationsOn 10/18/23 at 1:15 p.m., the nutrition services director (NSD) was observed performing a temperature check for the dishwasher. The temperature of the water in the hot temperature dishwasher was 99.6 degrees Fahrenheit (F). The NSD said the temperature should be between 120 degrees F and 140 degrees F to effectively sanitize the dishes for resident use. He said he told the maintenance staff about the problem, but it was not fixed. The NSD did not know how long the dishwasher was having problems keeping a consistent appropriate temperature but said it had been for a while. The NSD said the kitchen planned to use disposable plates, cups and utensils until the temperature was fixed. On 10/18/23 from 2:26 p.m. to 2:56 p.m. the sink water temperature in resident rooms #30, #28, and #40 were tested and the water was neither hot nor cold to the touch with the hot water faucet opened fully and the cold water faucet completely off. III. Staff interviews The regional corporate consultation (RCC) #2 was interviewed on 10/18/23 at 3:30 p.m. RCC #2 said the maintenance department conducted an assessment (during the survey between 10/18/23 and 10/19/23) and identified that the boiler unit serving two of three units and the kitchen was not working properly. The facility ' s immediate corrective action was to serve meals on paper plates and have residents shower in the Legacy unit where there were no issues with the hot water. The regional vice president of operations (RVPO) was interviewed on 10/19/23 at 5:15 p.m. The RVPO said the boiler/hot water tank was installed incorrectly. The facility contacted a contractor earlier this day (10/19/23) and the contractor said the boiler system had to be replaced due to plumbing inaccuracy and code errors. The facility was setting up a contract and securing corporate funding for the project to have the boiler system replaced. The next step was to apply for a city permit to complete the job. The repair required the installation of a new hot water tank with polyvinyl chloride (PVC) piping in the appropriate configuration. Licensed practical nurse (LPN) #2 was interviewed on 10/24/23 at 12:51 p.m. LPN #2 said some residents complained about the water not being hot enough to take a shower. He said he recently heard it was a boiler issue and the residents had been complaining about the problem for about a week. LPN #2 said if the water was not hot enough, he would tell the maintenance staff verbally and through their work order software system. The maintenance director (MTD), RCC #2 and the operations manager (OM) were interviewed on 10/24/23 at 9:05 a.m. The MTD said the motor to the boiler was not working properly which caused the two units and kitchen to not have hot water. They fixed the boiler's motor but the boiler still had a pressure issue which was what caused the system to struggle to provide consistent hot water for resident showering and kitchen dishwashing. The MTD said the boiler was now working and providing hot water but it was a temporary fix. He said the facility needed to order additional parts to ensure the boiler could maintain hot water long-term when needed. The additional parts were being delivered on 10/25/23. The MTD said he was responsible for taking the water temperatures in the resident room sinks, the three shower rooms, the kitchen water and the dining kitchenette. There had not been any concerts on the days when the maintenance department had tested the water in the past several weeks. If the temperature were not in range, he would troubleshoot and fix the issue. He said he would document what did not work and notify the administrator of the problem. The OM said there were some residents who reported the temperature not being hot enough for showers.

Based on observations and interviews, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to implement a method for pest control to control the rodent population throughout the facility that was effective and sanitary. Cross-reference F584 failure to maintain a clean and sanitary homelike environment. I. Professional referencesAccording to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (1/1/19) page 186, retrieved on 10/25/23, from https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view "The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: Routinely inspecting the premises for evidence of pests;-Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and,-Eliminating harborage conditions." According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, (July 2019), pp. 95-96, retrieved on 10/25/23, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf"From a public health and hygiene perspective, arthropods (insects) and vertebrate pests (rodents) should be eradicated from all indoor environments, including health-care facilities."II. Facility policyThe Pest Control policy, revised May 2008, was provided by the corporate nurse consultant (CNC) #1 on 10/24/23 at 9:35 a.m. It revealed in pertinent part, "Facility shall maintain an effective pest control program. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Garbage and trash are not permitted to accumulate and are removed from the facility daily."III. ObservationsThe outdoor patio on the Legacy unit was observed on 10/15/23 at 11:38 a.m. The patio had a large amount of tree leaves and debris in the patio area piled up close to the building. The skilled unit was observed on 10/18/23 at 11:30 a.m. A large mouse was observed running along the edge of the hallway near resident room #25. The mouse ran into room #25 and into a crack in the wall at the back corner of the room. The behavioral health unit was observed on 10/23/23 at 3:26 p.m. A live small juvenile mouse was inside the unit running back and forth by the door that led to the unit patio. The mouse went into a cracked section of the baseboard and then to underneath the heating unit. IV. Resident/resident representative interviewsA. Resident group interviewA group of five alert and oriented residents (#8, #38, #39, #49 and #85) who usually attended the resident council meetings in the facility were interviewed on 10/24/23 at 10:30 a.m. The residents all said they had problems with mice in their rooms. The residents said there were a lot of mice running around the facility and they felt it was a big problem. The rodent infestation had been a problem for the last year. The resident group said they believed the cause of the mice problem was related to residents eating meals and snacks in their rooms and poor housekeeping. The resident group said they had brought the mouse problem to the facility leadership but the problem has not been resolved. Resident #39 and Resident #8 said a woman down the hall ate all meals and snacks in her room and there was a constant pile of crumbs and other food spills on the floor by her bed and under the bed. The residents said the housekeeping staff were not cleaning well under the beds. Both residents said they had observed mice running around under that resident's bed. Those mice would leave that room and travel down the hall stopping in a number of other resident rooms along a path towards the nurses station. Resident #38 said she had a similar problem in her room. Resident #38 said her roommate had a lot of items under her bed and she had seen mice under that bed. Resident #38's representative who was also in attendance at the meeting said Resident #38 had mice in her room and she had reported these sightings to the nursing staff but Resident #38 continued to have mice in her room. B. Resident individual interviews Resident #7 and Resident #44 were interviewed on 10/18/23 at 11:30 a.m. Resident #7 said there was a mouse problem in the facility. She said they were in her room because her roommate kept food in their room. Resident #44 said she sometimes saw mice in her room. Resident #44 did not have containers for her food stash. Resident #8 was interviewed on 10/18/23 at 2:26 p.m. Resident #8 said he had mice in his room. On one occasion Resident #8 said he was woken up by the sound of rustling and when he opened his eyes he saw a large mouse sitting on the seat of his wheelchair staring back at him. Resident #8 said the mouse left excrement on his wheelchair seat; staff just brushed it off but no staff cleaned or sanitized his wheelchair cushion. Resident #8 said he was concerned that a mouse could crawl up into his bed so if staff did not get him up for meals he usually did not eat out of concern that crumbs in his bed would attract the mice. Resident #31 was interviewed on 10/19/23 at 1:30 p.m. Resident #31 said the facility had placed silver box closed mouse traps in his and several other resident rooms. In the last week, the trap in his room caught six mice. Last week "I saw a mouse crawling on my dresser." The mouse left feces dropping behind. Resident #31 said he believed the problem was made worse by residents eating in their rooms with the crumbs and food debris not being cleaned up. Resident #39 was interviewed on 10/19/23 at 1:45 p.m. Resident #39 said she saw mice in her room and running down the hall on a number of occasions. Resident #31 was interviewed on 10/24/23 at 3:30 p.m. Resident #31 said Resident #28's family removed her from the facility the day prior (10/23/23) because a mouse got on her bed while she was in bed watching television (see resident representative interview below). Resident #31 said this was upsetting because he also had a mouse in his room that morning. He got up to open his blinds when he heard rustling. He said he observed a mouse crawling down the blinds. Resident #31 said he did not want to get bit so he watched the mouse crawl down the blinds and then behind the heating unit. The mouse disappeared under the heating unit. C. Resident representative interviewResident #28's representative was interviewed on 10/25/23 at 11:24 a.m. The resident representative said the resident's caretaker removed the resident from the facility after the resident called her to say that a mouse had crawled up on her bed while she was watching television. The resident's representative said he was very concerned about the resident's welfare. V. Record review The 8/17/23 resident council minutes were reviewed. The minutes revealed two residents reported they saw mice in their rooms. The staff reported the reason for the mice was that residents left food in their rooms. The 9/21/23 resident council minutes were reviewed. The minutes revealed the old business was "reviewed, positive response, resolved." -There was no specific information on what the old business was or how the old business was resolved. The 10/19/23 resident council minutes were reviewed. The minutes revealed residents said the maintenance staff needed to work on the mice problem and place more traps throughout the facility and in resident rooms. The most recent pest control service report was provided by the regional corporate consultant (RCC) #2 on 10/24/23 at 9:28 a.m. The record revealed that the pest control company's last service date for the facility was on 10/11/23. The report revealed that the service provider did not observe pest activity and no staff reported pest activity at the time of service. The service representative documented the replacement of five glue boards for mice control mainly in the employee break room and advised ongoing monitoring, as needed. The service report documented the facility was serviced for mice/rodent control on 6/15/23. During that visit, the services provided recommended that the facility clear debris and piles of mulch and dirt for the alley behind the facility to help control the rodent population. VI. Staff interviewLicensed practical nurse (LPN) #1 was interviewed on 10/23/23 at 4:41 p.m. LPN #1 said she saw mice in the behavioral secure unit. She could not remember how long it had been going on but said it had been a while. She said there were mice traps in the unit but she was unable to locate them. She said she mostly saw mice near the heating units and baseboard that was located near the wall to the unit's patio. She did not see pest control come because of the shift she worked. She saw mice more when the weather was colder because mice would try to find warm areas. LPN #2 was interviewed on 10/24/23 at 12:51 p.m. LPN #2 said he saw mice a couple of months ago. He could not remember how long the mice had been in the building but said it had been a while. He said there were mice traps in the unit but he was unable to locate them. He saw mice in the resident's room and told the maintenance staff verbally and through their work order software system about the mouse sightings. He recently saw the pest control company on the unit. The maintenance director (MTD), RCC #2 and operations manager (OM) were interviewed on 10/24/23 at 9:05 a.m. The MTD said the pest control program included having the pest control company scheduled to come monthly. The OM said sometimes the pest control vendor came more than once a month. He said in September 2023, the vendor serviced the facility two times. All three staff members reported they had not seen any mice in the facility. The MTD said the staff and residents reported mice in the dining area and in the resident's room. The OM and the MTD said they believed the cause of mice being in the resident's room was because the resident's rooms were cluttered and there were crumbs and food littering the floor spaces. The OM said the resident's rooms were cleaned every day.

A licensure survey was completed on 10/17/23 to 10/24/23. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure one (#15) of one resident reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 41 sample residents. Resident #15 was admitted to the facility on 9/30/19. His admission weight on 9/30/19 was188.4 pounds (lbs). The resident maintained a weight between 180 lbs to 200 lbs between January 2022 and June 2023. The resident was hospitalized in July 2023. When he returned to the facility, the facility failed to weigh the resident until August 2023. The facility did not attempt to weigh the resident after he refused one weight. The registered dietitian (RD) recommended weekly weights in July 2023 and no weights were obtained. Per staff interviews, the resident was not eating, refusing meals and often skipped breakfast and no preventative measures were implemented to address his eating patterns to ensure his intake was adequate. Due to the facility's failure to implement nutritional interventions, Resident #15 sustained a severe weight loss of 32.8 pound weight loss or a 17.09 percent weight loss in 60 days. Findings include: I. Facility policy The Food and Nutrition Services policy, revised October 2017, was provided by the corporate nurse consultant (CNC) #1 on 10/25/23 at 11:05 a.m. It read in pertinent part: "Each resident is provided with a nourishing, palatable, well balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each diet. The multidisciplinary staff will assess each resident's nutritional needs, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment." II. Resident #15 A. Resident status Resident #15, age 70 years old, was admitted on 9/30/19. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia, schizophrenia, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, psychotic disturbance, psychosis, hypertension, hypertensive chronic kidney disease and osteoarthritis. The 7/19/23 facility assessment documented that the resident was unable to complete the brief interview for mental status (BIMS). The staff assessment for mental status was completed. It documented the resident had a memory problem and was moderately impaired, made poor decisions and supervision or cues was required. The resident required supervision with bed mobility and transfers. He required one person assistance with toileting, grooming and personal hygiene. The assessment documented the resident required set up assistance with eating and the resident had not experienced any weight loss. His height was 5 foot 8 inches. B. Record review Resident #15's medical record revealed he experienced a significant unplanned weight loss of 23 pounds; 11.93 percent in six months, from April 2023 to 10/17/23. The resident was discharged on 7/12/23 and was readmitted on 7/14/23. Prior to the discharge, the resident was in the secured memory unit. When the resident returned, the resident was moved to the secured behavioral unit. The facility attempted to weigh the resident one time at readmission but the resident refused and the staff did not reattempt a weight despite the resident being known to be at risk for weight loss. According to the hospital documentation on 7/12/23, the resident weight was 195 lbs. 1. Resident #15 nutritional status The unintended weight changed care plan, initiated on 9/30/19 and revised 8/4/23, documented the resident had potential for unplanned weight loss related to dementia, psychotropic medication, variable meal intakes, declining health status secondary to numerous comorbidities. Interventions included a health supplement shake due to the resident skipping breakfast; monitor weight weekly; and monitor for significant changes. The cognitive care plan, initiated on 11/16/19 and revised on 10/8/21, documented the resident had impaired cognitive function/dementia or impaired thought processes related to disease process. The activities of daily living (ADL) care plan, initiated on 10/3/19 and revised on 3/8/23, documented the resident had a self-care performance. It documented the resident did not require supervision and he was independent with eating. 2. Resident #15 weight loss history revealed significant weight loss as follows: -On 4/19/23, the resident weighed 195.3 pounds -On 5/3/23, the resident weighed 195.4 pounds-On 6/2/23, the resident weighed 195.4 pounds-The facility failed to obtain a weight for July 2023 -On 8/1/23, the resident weighed 162.6 pounds, a 32.8 pound weight loss or a 17.09 percent weight loss in 60 days -On 8/4/23, the resident weighed 165.8 pounds-On 8/18/23, the resident weighed 168.4 pounds-On 8/22/23, the resident weighed 172.8 pounds -On 9/1/23, the resident weighed 168.8 pounds -On 9/5/23, the resident weighed 175.2 pounds-On 9/12/23, the resident weighed 176.6 pounds -On 9/16/23, the resident weighed 173 pounds -On 9/19/23, the resident weighed 176.4 pounds-On 9/26/23, the resident weighed 171.8 pounds -On 10/3/23, the resident weighed 175.2 pounds -On 10/14/23, the resident weighed 168.6 pounds-On 10/17/23, the resident weighted 172 pounds -On 10/21/23, the resident weighed 168.2 pounds -On 10/24/23, the resident weighed 168.6 pounds The 7/14/23 readmission nutritional assessment, completed by a registered dietitian (RD), documented Resident #15 was on a regular diet with a regular texture and a thin liquid diet. It indicated the resident weighed 195.4 pounds on 6/2/23. The RD documentd the resident's intake was erratic at meals with refusals and skipped breakfast due to sleeping. The RD recommended monitoring intake and to obtain weekly weights. -However, the RD did not add any measures for his meal refusals and skipping breakfast. In addition, the RD was aware the resident was not eating prior to hospitalization in July 2023 and losing weight and no preventative measures were put in place to address his nutritional risk. In addition, the resident was not weighed weekly as the RD recommended to help monitor his nutritional status. The 8/4/23 interdisciplinary team weight variance assessment revealed that the resident had a 15.1 percent weight loss in eight weeks. A new intervention was to add mighty shakes in the morning. It revealed that potential medical factors were a recent illness within 30 days, recent significant changes in medication and psychotropic medications. The summary revealed that a nurse on the secure memory unit said the resident stopped eating prior to his hospitalization due to increased behaviors and aggression. -A supplement was added after the resident sustained a 32.8 pound weight loss with no preventative measures in place. The August 2023 CPO documented the following physician order for mighty shake one time a day for weight loss. Provide once the resident wakes up. The start date was 8/5/23. The September 2023 CPO documented the mighty shake was discontinued on 9/8/23. The 10/14/23 interdisciplinary team weight variance assessment revealed that the resident had a 13.7 percent weight loss in six months. The summary revealed the resident intake improved and mostly consumes 76-100 percent of meals. It documented with the weight trending down, mighty shakes were added. The October 2023 CPO documented the following physician order for mighty shake one time a day. The start date was 10/17/23. The October 2023 meal intake records documented the resident consumed the following from 9/20/23 to 10/19/23 the records revealed the resident ate 76-100 percent on 49 occasions; 51-75 percent on two occasions; 26-50 percent on four occasions; and, refused meals on six occasions (10/1/23, 10/3/23, 10/4/23, 10/5/23, 10/8/23 and 10/10/23). Additionally, the resident had less thanthree meals in a day recorded for several days between 9/20/23 to 10/19/23. The record revealed the resident ate only two meals on three days (9/23/23, 10/15/23 and 10/16//23); and only one meal on two days (9/26/23 and 9/30/23). III. ObservationsOn 10/23/23 from 12:05 p.m. to 12:35 p.m., Resident #15's lunch meal was observed. Registered nurse (RN #1)and an unidentified certified nurse assistant (CNA) delivered the lunch meal tray and beverages to residents who ate meals in their room. The nurse went into Resident #15's room at 12:05 p.m., to deliver his lunch, the resident was lying on his bed and looked asleep. She asked him if he was hungry and he said no; she told him she would come back. The nurse went back at 12:15 p.m. to set up his meal. The nurse cut up the resident's chicken and left the food for him. The resident was lying on his bed and still looked asleep. At 12:35 p.m., Resident #15 did not start to eat his food. Resident #15 was interviewed on 10/23/23 at 1:35 p.m. The resident was unable to communicate why he did not eat his meal or even if he received a lunch time meal. The scales in all units were observed on 10/24/23 between 1:00 p.m. and 1:30 p.m. The secured memory unit had a commercial scale that a resident could stand on, in their television room. The non secured unit had a commercial scale in a locked scale room. It was a scale for residents who could not stand independently. The secured behavioral unit scale had a regular scale. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 10/24/23 at 12:51 p.m. LPN #2 said the resident lost weight because he liked to sleep in instead of getting up for breakfast. LPN #2 showed the scale that was used to weigh residents on the unit. It was a home weight scale and was not a medical weight scale. The RD was interviewed on 10/24/23 at 10:05 a.m. She was familiar with Resident #15. She said the resident stopped eating completely prior to the resident's hospitalization and lost a lot of weight. Upon the resident's return and throughout August 2023, the resident lost a significant amount of weight. The physician ordered a mighty shake nutritional supplement then by September 2023 the resident started to gain some weight and the mighty shakes were discontinued so the resident did not gain too much weight. The resident was prescribed mighty shakes again in October 2023. The RD said the scale in the secured behavioral unit was not as accurate as the scale in the secured memory unit. She weighed herself in both units and said the difference was approximately five pounds and found that the scale in the secured memory care unit was more accurate. The RD said she would add interventions if a resident lost five percent in three months and 10 percent in six months. -However, nutritional interventions should be proactively added and not when the resident sustains a significant weight loss. The intervention would depend upon the resident individualized needs. She said if a resident was not weighed on the day of readmission, then the facility should weigh the resident within three days. She said it was important to have an accurate weight so she could complete an accurate nutritional assessment. She said all residents should be weighed monthly to ensure the resident was not losing weight and to provide a complete nutritional picture of the residents nutritional needs. Resident #15 who had a significant weight loss should have been weighed weekly. The director of nursing (DON) was interviewed on 10/24/23 at 2:00 p.m. She was familiar with Resident #15. The DON said Resident #15's dementia was progressing in addition to his mental illness which both contributed to his weight loss. Additionally, Resident #15 was a picky eater and did not have a hunger drive. The DON said Resident #15 refused to be weighed in July 2023 when he returned from the hospital. The DON said when a resident refused to be weighed the nursing staff should attempt to weigh the resident within three days and document the results. The DON said residents should be weighed weekly for the first weeks after admission and then monthly thereafter. She said there would be times the resident would not be weighed monthly based on the RD's recommendation. She said it was important to weigh resident's monthly because it was indicative of other things that happened to the resident. Monthly weight history helped with the whole picture of the resident health and could trigger concern for other care areas like medication review. The DON said the CNAs weighed the resident and reported to the nurse who would record and report any weight concerns. The DON said the facility offered Resident #15 meal alternatives, like a supplement shake to help with the resident's weight loss; and would recommend adding additional interventions if the resident lost five percent of his weight in three months and 10 percent in six months. The DON said that a two month gap of no weights for a resident would be too long. If the resident refused to be weighed, she would follow up with the interdisciplinary team to develop other interventions. The DON said she placed an order for a medical weight scale to be placed in the resident's unit to reduce weight discrepancies.

A complaint survey, prompted by #CO32361 was conducted on 6/12/23 and 6/20/23. No deficiencies were cited.

A revisit survey was completed on 6/20/23 for all previous deficiencies cited on 5/4/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 6/20/23 for all previous deficiencies cited on 5/4/23. The facility is in compliance with all regulations surveyed.

A survey prompted by complaint #CO32142 was completed 5/3/23 to 5/4/23. One deficiency was cited.

Based on record review and interviews the facility failed to keep two residents (#1 and #2) free from resident to resident physical abuse of five sample residents. The facility failed to protect Resident #2 from resident to resident physical abuse from Resident #1 and then failed to protect approximately one hour later, Resident #1 from retaliatory physical abuse from Resident #2 on 4/19/23. During the first altercation, Resident #1 tapped Resident #2 on the shoulder and put up his balled fists. Resident #2 lunged at Resident #1, put his hands on Resident #1's neck and a fight began which required nursing staff to separate the two men. The police were called to come to the facility due to the first altercation. Within approximately one hour after the first altercation, Resident #2 left his room and walked to the dining room where he found Resident #1. Resident #2 then began another fight with Resident #1 and the nursing staff separated the men again. After the first altercation both men had documented that the facility staff checked on them every 15 minutes. The nursing home administrator (NHA) in an email (see facility follow-up) wrote that because police were in the building staff had their physical presence and attention removed from the residents and the retaliatory incident happened as a result. Resident #1 and Resident #2 both lived in a secured unit, and both men had histories of verbal and physical aggression. Findings include:I. Resident census and conditions demographicThe Resident Census and Condition was provided by the nursing home administrator (NHA) on 5/4/23 at 3:15 p.m. It revealed that 90 residents resided in the facility. The form further documented that 47 residents had a psychiatric diagnosis, 44 had dementia, and 18 had behavioral healthcare needs. The facility had two secured units. The secured unit called Legacy was where Resident #1 and Resident #2 lived. II. Professional referenceAccording to the Centers for Disease Control (CDC) website, Preventing Elder Abusehttps://www.cdc.gov/violenceprevention/elderabuse/fastfact.html 6/2/21, (Retrieved 5/9/23),"Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial abuse."Physical abuse is when an elder experiences illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning."III. Facility policies and procedures Three different abuse policies were provided by the nursing home administrator (NHA) on 5/4/23 at 3:00 p.m. Each policy contained pertinent information. The Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 revealed in pertinent part,"Residents have the right to be free from abuse. This includes physical abuse."The resident abuse, neglect, and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: Protect residents from abuse by anyone including, other residents."Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents."Protect residents from further harm during investigations."The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy, September 2022, revealed in pertinent part,"The administrator ensures that the resident and the person(s) reporting violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility."The Abuse and Neglect Clinical Protocol, March 2018, revealed in pertinent part,"Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish."IV. Resident to resident physical abuses between Resident #1 and Resident #2 on 4/19/23 at approximately 4:00 p.m and on 4/19/23 approximately one hour later. The 4/19/23 facility incident report which involved Resident #1 and Resident #2 was provided by the NHA on 5/4/23 at 10:00 a.m. It revealed in pertinent part,On 4/19/23 at approximately 4:00 p.m. Resident #1 walked up to Resident #2 and tapped him on the back of his shoulder and put his hands up with balled fists. Resident #2 then lunged at Resident #1 and the two men began striking each other. Staff responded and put the two men on 15 minute checks for monitoring. Within approximately one hour Resident #2 came out of his room and found Resident #1 who was in a common area and slapped him. The facility put Resident #1 on one-to-one monitoring at that time (See social services assistant interview below that there was no one-to-one tracking documentation from this monitoring). Resident #1 had slight redness and a small abrasion to his arm. Resident #2 had slight redness to his neck which was no longer visible within a few hours (The report did not say how many hours until the redness was gone). The facility staff said they heard the two men yelling, and observed Resident #1 strike Resident #2, and Resident #2 put his hands on Resident #1's neck. The staff said about an hour later Resident #2 entered a common area where Resident #1 was seated and struck him with an open hand. Resident #1 was placed on one-to-one monitoring and Resident #2 was redirected to his room. The incident report documented the video footage was reviewed which revealed Resident #1 tapped Resident #2 on the shoulder. Resident #1 put up balled fists at Resident #2 who responded by hitting Resident #1. Then about one hour later Resident #2 struck Resident #1. Resident #1 was placed on every 15 minute monitoring which progressed to one-to-one care by staff. -The facility documented 15 minute checks for both men but not one-to-one care for Resident #1 as was documented in the medical records. The facility concluded there was insufficient evidence to substantiate resident to resident physical abuse because there was no willful infliction of injury including physical harm, pain, or mental anguish. The facility documented willful was characterized by an awareness of consequences which Resident #1 was unable to understand due to dementia with severe agitation and a traumatic brain injury (TBI). There was nothing in the facility's conclusion about Resident #2 who retaliated and was the aggressor in the second incident. Agency staff were interviewed on the day of the investigation which revealed,Agency LPN (licensed practical nurse) said she saw Resident #1 choking Resident #2 but did not see the event leading up to it. She separated the two residents immediately. She said about one hour later Resident #2 approached Resident #1 who was in the dining room and slapped him from behind. The agency certified nurse aide (CNA) said she saw the first altercation when Resident #1 put his fists up and then Resident #2 started to hit Resident #1. The documentation of 15 minute checks was provided by the NHA on 5/4/23 at 3:30 p.m. which revealed, -Resident #1 was placed on 15 minute checks at 4:00 p.m. During this time the second incident occurred. The initials which verified he was observed every 15 minutes were not clear enough to determine who signed the 15 minute checks. The NHA said the initials did not look like the agency LPN that was on duty that day. The NHA said he would look at the employee time cards and verify the initials. -The facility did not provide who the initials represented for facility staff who did the 15 minute checks. The facility documented Resident #1 was on 15 minute checks for the next three days but did not have any documentation of Resident #1 with a one-to-one person or sitter. -Resident #2 was put on 15 minute checks which began at 3:00 p.m. according to the documentation, which was an hour before the altercation. The initials were the same on the staff checks as with Resident #1, which was not verified as to who initialed the 15 minute checks for the next several hours. The 4/19/23 nursing progress note revealed that Resident #1 approached Resident #2 when he raised his fists and hit Resident #2 in the chest. Before the nurse could intervene to separate the two men Resident #2 responded with physical violence by a swing which hit Resident #1. Then Resident #1 began to choke Resident #2. The nurse was able to get Resident #1 to release his hand grip from around Resident #2's neck. At 5:09 p.m. Resident #2 hit Resident #1 in the face. The NHA notified that the resident was to be put on one-to-one care. One of the residents said, "He hit me, he shouldn't have hit me. I'll beat his (expletive)." The social services assistant (SSA) video camera footage description was provided by the SSA on 5/4/23 at 4:05 p.m. It revealed that the SSA watched the video footage of the incident. It was observed Resident #1 walked up to Resident #2 in the hallway, tap him on the shoulder, and put up his balled fists. Resident #2 lunged at Resident #1 and started to hit him, leaving visible scratches on Resident #1's arm. She documented Resident #2 said Resident #1 choked him. The SSA told the staff on the unit to place the two residents on 15 minute checks. Resident #2 said he hit Resident #1 because "he was mouthing off." The SSA was notified of the second incident at 5:20 p.m. Resident #1 was to be placed on one-to-ones with an agency nurse. V. Resident #1 A. Resident status (perpetrator in the first incident and victim in the second incident)Resident #1, age under 65, was admitted on 3/17/22 and readmitted on 5/3/23. According to the May 2023 computerized physician orders (CPO) the diagnoses included unspecified dementia, severe, with agitation, traumatic brain injury (TBI), cognitive communication deficit, chronic obstructive pulmonary disease (COPD) and altered mental status. The 3/8/23 facility assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He had disorganized thinking. He did not reject care from staff. He required supervision with bed mobility, transfers, walking in his room and in the corridors, dressing, eating, toilet use, and personal hygiene. B. Record reviewThe 7/18/22 suicide homicide risk evaluation for Resident #1 revealed the resident had made homicidal remarks. (See social service assistant was unaware of the note in the electronic medical records EMR). The resident reported "I am going to kill someone." Social service interviewed him and he said he was not going to hurt anyone. He said he made statements like this when joking. The comprehensive care plan on 3/20/22 and revised on 8/29/22 revealed in pertinent part,Focus: The resident had impaired cognitive function/dementia or impaired thought process with dementia. The resident had dementia with behavioral disturbances. The resident had physically aggressive behaviors.-Resident had a history of being verbally aggressive towards peers and staff. Also history of antagonizing peers. At times resident makes threatening statements and balls fists though reports he was joking.-Resident had a history of hitting other residents. Goal: Resident will not harm self or others through the review date. (Revised on 4/10/23, nine days before the incident) He will verbalize the need to control physical aggressive behaviors through the review date. Interventions: Behavior monitoring revised on 2/18/23. Identify/document potential causative factors and eliminate/resolve where possible. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff will redirect if (the) resident becomes verbally aggressive. The behavior progress notes documented,-On 3/22/23 the resident was on frequent checks due to a recent altercation with another resident.-On 4/7/23 the resident threatened to hit another resident two times on the same day while walking past the resident.-On 4/19/23 the resident made (a) physical altercation with another resident in the hallway, obtained bruising/abrasion to lower left arm and above the elbow. Resident was to remain on one-to-one supervision with staff until he could be evaluated the next morning. (See interviews below that the resident was not placed on one to one supervision)The April 2023 treatment administration record (TAR) documented a daily tracking of the following:-Target behavior (physical aggression, strikes out) at the end of each shift, mark frequency how often behavior occurred and intensity. How (the) resident responded to redirection. Intensity code: zero equaled did not occur, one equaled easily altered, and two equaled difficult to redirect every shift. -On 4/19/23 the day of the altercation, the facility did not record any intensity codes on the TAR about behaviors for physical aggression. The nurse practitioner (NP) progress note on 4/15/23 (four days before the physical abuse incident) revealed in pertinent part that staff reported he had a history of seeking out more vulnerable residents and physically assaulting/attempting to physically assault them. The nurse practitioner (NP) progress note on 4/20/23 revealed in pertinent part, the resident had an altercation with another resident on 4/19/23 and had a bruise and abrasion to the left lower arm above the elbow. The NP documented the resident was in another skilled nursing facility and went to the hospital on 10/2/22 where he was aggressive and required restraints. The resident previously had heavy alcohol use and he used crack cocaine. VI. Resident #2A. Resident status (victim in the first incident, and perpetrator in the second incident)Resident #2, age 70, was admitted on 3/6/23. According to the May 2023 computerized physician orders (CPO), the diagnoses included unspecified dementia, moderate, without mood disturbances, cerebral infarction (stroke), hypertension (high blood pressure), stage 4 chronic kidney disease, anxiety disorders, alcohol abuse in remission, depression, cognitive communication deficit and difficulty in walking. The 3/13/23 facility assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. The resident had verbal behavioral symptoms directed toward others. The resident did not reject care from staff. The resident required supervision with bed mobility, transfers, walking in his room and corridors, dressing, eating, and toilet use. He needed limited assistance with personal hygiene. B. Record reviewThe comprehensive care plan 4/11/23 revealed in pertinent part,Focus: Resident had a history of being verbally aggressive. Had a potential for injury to self or others which was manifested by constant yelling, kicking, verbal outbursts, and delusional behaviors. Interventions: Monitor/record occurrences of target behavior symptoms, inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol. The April 2023 TAR documented a daily tracking of the following:-Target behavior (physical aggression, strikes out) at the end of each shift, mark frequency how often behavior occurred and intensity. How (the) resident responded to redirection. Intensity code: zero equaled did not occur, one equaled easily altered, and two equaled difficult to redirect every shift. -On 4/19/23 the day of the altercation, the facility did not record any intensity codes on the TAR about behaviors for physical aggression. The NP progress note on 4/20/23 revealed in pertinent part, the resident (had) fingerprint markings on his neck from an altercation with another resident on 4/19/23. The NP documented when the resident went to a hospital on 2/24/23 he punched a security guard in the face. The behavior progress note on 4/20/23 documented Resident #2 said "That guy is dangerous."-The note did not document whom the resident said was dangerous. (See SSA interview below) VII. Staff interviewsLPN #1 was interviewed on 5/4/23 at 12:10 p.m. She said she worked on the Legacy unit where Resident #1 and Resident #2 lived. She said she had complained prior about the agency nurses that were on the unit the day of the incident. She said the agency CNA the day of the incident had prior told her that she did not get involved with fights between residents. She said if the men were being watched after the first altercation there would not have been a second altercation. She said Resident #2 may not remember the incident but he still gets nervous and agitated when he sees Resident #1 in the hallway. She said the staff tried to keep Resident #2 from seeing Resident #1 but it was difficult on a small secured unit. The SSA was interviewed on 5/4/23 at 4:00 p.m. The SSA said she said she was the social worker responsible for the Legacy unit. She said after the second incident she told the agency nurse on the unit to start one-to-one staff supervision with Resident #1. She said she had no documentation that she told the nurse and there was no documentation any staff had provided one-to-one supervision with Resident #1. She said he needed to be watched 24/7 by nursing staff until he could be medically evaluated the next day. She was unaware only 15 minute checks were done for three days. She said Resident #1 had altercations with others prior to the incident. She said because Resident #2 had not had altercations with others prior to the incident he was not put on one-to-one supervision. She said she was unaware that there was a homicide/suicide evaluation done for Resident #1 in the electronic medical records (EMR). She said after the first incident with Resident #1, Resident #2 retaliated. She said she did not know why the staff on the unit did not notice Resident #2 had left his room to go to the dining room to seek out Resident #1. She said Resident #2's intervention after the incident was to be discharged to another state to go live with his former wife. She said she was unaware of a note in the medical record on 4/20/23 the day after the incident which documented Resident #2 had said that guy was dangerous. The social service director (SSD) was interviewed on 5/4/23 at 4:10 p.m. She said Resident #1 had other altercations with other residents on the unit. She said Resident #1 balled up his fists at others to be funny. She said some residents understand his humor and others hit him. She said after the first altercation the two men were separated. She said Resident #2 came out of his room and found Resident #1 and retaliated for what happened about an hour prior. She said she did not know what other interventions could have been put in place to protect the two residents except 15 minute checks because that usually worked. She did not know how the two men were not watched closely enough that a second incident happened. The NHA was interviewed on 5/4/23 at 4:20 p.m. He said he would read the employee time cards and if he found who initialed the 15 minute checks for Resident #1 and Resident #2 and he would provide the documentation. -No documentation was provided during or after the survey on 5/5/23. He said there was no documentation that Resident #1 was put on one-to-one care after the second incident. He said the nurse on duty documented the events in the resident's medical records. He said he was not sure the agency nurse that day viewed the altercation correctly. VIII. Facility follow-upOn 5/5/23 at 4:34 p.m. the NHA emailed the following information. Resident #1 had aggressive behaviors in the past, and the facility had tried with no success to refer him to get accepted by other facilities to care for his needs. After the first altercation on 4/19/23 police were called and refused to transport Resident #1 on assault charges. The NHA said after viewing the video footage of the first incident he felt the nurse on duty that day had her back to the residents and did not see the incident correctly. The NHA requested the police department who responded to the event in the facility to send their report and a copy of the video footage. The facility had not received a response from the police department as of 5/5/23 (16 days after the incident). The NHA also wrote that when the police were in the building within an hour of the first altercation, the staff had "removed their physical presence and attention to monitoring that would have otherwise been in place. The presence of the police and the proximity of the residents during the police interviews led to the retaliatory incident."

A focused infection control survey with Incident #31901 was conducted 5/3/23 to 5/4/23. One deficiency was cited.

An Emergency Preparedness focused infection control survey was conducted 5/3/23 to 5/4/23. No deficiencies were cited.

Based on record review and interviews the facility failed to keep two residents (#1 and #2) free from resident to resident physical abuse of five sample residents. The facility failed to protect Resident #2 from resident to resident physical abuse from Resident #1 and then failed to protect approximately one hour later, Resident #1 from retaliatory physical abuse from Resident #2 on 4/19/23. During the first altercation, Resident #1 tapped Resident #2 on the shoulder and put up his balled fists. Resident #2 lunged at Resident #1, put his hands on Resident #1's neck and a fight began which required nursing staff to separate the two men. The police were called to come to the facility due to the first altercation. Within approximately one hour after the first altercation, Resident #2 left his room and walked to the dining room where he found Resident #1. Resident #2 then began another fight with Resident #1 and the nursing staff separated the men again. After the first altercation both men had documented that the facility staff checked on them every 15 minutes. The nursing home administrator (NHA) in an email (see facility follow-up) wrote that because police were in the building staff had their physical presence and attention removed from the residents and the retaliatory incident happened as a result. Resident #1 and Resident #2 both lived in a secured unit, and both men had histories of verbal and physical aggression. Findings include:I. Resident census and conditions demographicThe Resident Census and Condition was provided by the nursing home administrator (NHA) on 5/4/23 at 3:15 p.m. It revealed that 90 residents resided in the facility. The form further documented that 47 residents had a psychiatric diagnosis, 44 had dementia, and 18 had behavioral healthcare needs. The facility had two secured units. The secured unit called Legacy was where Resident #1 and Resident #2 lived. II. Professional referenceAccording to the Centers for Disease Control (CDC) website, Preventing Elder Abusehttps://www.cdc.gov/violenceprevention/elderabuse/fastfact.html 6/2/21, (Retrieved 5/9/23),"Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial abuse."Physical abuse is when an elder experiences illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning."III. Facility policies and procedures Three different abuse policies were provided by the nursing home administrator (NHA) on 5/4/23 at 3:00 p.m. Each policy contained pertinent information. The Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 revealed in pertinent part,"Residents have the right to be free from abuse. This includes physical abuse."The resident abuse, neglect, and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: Protect residents from abuse by anyone including, other residents."Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents."Protect residents from further harm during investigations."The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy, September 2022, revealed in pertinent part,"The administrator ensures that the resident and the person(s) reporting violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility."The Abuse and Neglect Clinical Protocol, March 2018, revealed in pertinent part,"Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish."IV. Resident to resident physical abuses between Resident #1 and Resident #2 on 4/19/23 at approximately 4:00 p.m and on 4/19/23 approximately one hour later. The 4/19/23 facility incident report which involved Resident #1 and Resident #2 was provided by the NHA on 5/4/23 at 10:00 a.m. It revealed in pertinent part,On 4/19/23 at approximately 4:00 p.m. Resident #1 walked up to Resident #2 and tapped him on the back of his shoulder and put his hands up with balled fists. Resident #2 then lunged at Resident #1 and the two men began striking each other. Staff responded and put the two men on 15 minute checks for monitoring. Within approximately one hour Resident #2 came out of his room and found Resident #1 who was in a common area and slapped him. The facility put Resident #1 on one-to-one monitoring at that time (See social services assistant interview below that there was no one-to-one tracking documentation from this monitoring). Resident #1 had slight redness and a small abrasion to his arm. Resident #2 had slight redness to his neck which was no longer visible within a few hours (The report did not say how many hours until the redness was gone). The facility staff said they heard the two men yelling, and observed Resident #1 strike Resident #2, and Resident #2 put his hands on Resident #1's neck. The staff said about an hour later Resident #2 entered a common area where Resident #1 was seated and struck him with an open hand. Resident #1 was placed on one-to-one monitoring and Resident #2 was redirected to his room. The incident report documented the video footage was reviewed which revealed Resident #1 tapped Resident #2 on the shoulder. Resident #1 put up balled fists at Resident #2 who responded by hitting Resident #1. Then about one hour later Resident #2 struck Resident #1. Resident #1 was placed on every 15 minute monitoring which progressed to one-to-one care by staff. -The facility documented 15 minute checks for both men but not one-to-one care for Resident #1 as was documented in the medical records. The facility concluded there was insufficient evidence to substantiate resident to resident physical abuse because there was no willful infliction of injury including physical harm, pain, or mental anguish. The facility documented willful was characterized by an awareness of consequences which Resident #1 was unable to understand due to dementia with severe agitation and a traumatic brain injury (TBI). There was nothing in the facility's conclusion about Resident #2 who retaliated and was the aggressor in the second incident. Agency staff were interviewed on the day of the investigation which revealed,Agency LPN (licensed practical nurse) said she saw Resident #1 choking Resident #2 but did not see the event leading up to it. She separated the two residents immediately. She said about one hour later Resident #2 approached Resident #1 who was in the dining room and slapped him from behind. The agency certified nurse aide (CNA) said she saw the first altercation when Resident #1 put his fists up and then Resident #2 started to hit Resident #1. The documentation of 15 minute checks was provided by the NHA on 5/4/23 at 3:30 p.m. which revealed, -Resident #1 was placed on 15 minute checks at 4:00 p.m. During this time the second incident occurred. The initials which verified he was observed every 15 minutes were not clear enough to determine who signed the 15 minute checks. The NHA said the initials did not look like the agency LPN that was on duty that day. The NHA said he would look at the employee time cards and verify the initials. -The facility did not provide who the initials represented for facility staff who did the 15 minute checks. The facility documented Resident #1 was on 15 minute checks for the next three days but did not have any documentation of Resident #1 with a one-to-one person or sitter. -Resident #2 was put on 15 minute checks which began at 3:00 p.m. according to the documentation, which was an hour before the altercation. The initials were the same on the staff checks as with Resident #1, which was not verified as to who initialed the 15 minute checks for the next several hours. The 4/19/23 nursing progress note revealed that Resident #1 approached Resident #2 when he raised his fists and hit Resident #2 in the chest. Before the nurse could intervene to separate the two men Resident #2 responded with physical violence by a swing which hit Resident #1. Then Resident #1 began to choke Resident #2. The nurse was able to get Resident #1 to release his hand grip from around Resident #2's neck. At 5:09 p.m. Resident #2 hit Resident #1 in the face. The NHA notified that the resident was to be put on one-to-one care. One of the residents said, "He hit me, he shouldn't have hit me. I'll beat his (expletive)." The social services assistant (SSA) video camera footage description was provided by the SSA on 5/4/23 at 4:05 p.m. It revealed that the SSA watched the video footage of the incident. It was observed Resident #1 walked up to Resident #2 in the hallway, tap him on the shoulder, and put up his balled fists. Resident #2 lunged at Resident #1 and started to hit him, leaving visible scratches on Resident #1's arm. She documented Resident #2 said Resident #1 choked him. The SSA told the staff on the unit to place the two residents on 15 minute checks. Resident #2 said he hit Resident #1 because "he was mouthing off." The SSA was notified of the second incident at 5:20 p.m. Resident #1 was to be placed on one-to-ones with an agency nurse. V. Resident #1 A. Resident status (perpetrator in the first incident and victim in the second incident)Resident #1, age under 65, was admitted on 3/17/22 and readmitted on 5/3/23. According to the May 2023 computerized physician orders (CPO) the diagnoses included unspecified dementia, severe, with agitation, traumatic brain injury (TBI), cognitive communication deficit, chronic obstructive pulmonary disease (COPD) and altered mental status. The 3/8/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He had disorganized thinking. He did not reject care from staff. He required supervision with bed mobility, transfers, walking in his room and in the corridors, dressing, eating, toilet use, and personal hygiene. B. Record reviewThe 7/18/22 suicide homicide risk evaluation for Resident #1 revealed the resident had made homicidal remarks. (See social service assistant was unaware of the note in the electronic medical records EMR). The resident reported "I am going to kill someone." Social service interviewed him and he said he was not going to hurt anyone. He said he made statements like this when joking. The comprehensive care plan on 3/20/22 and revised on 8/29/22 revealed in pertinent part,Focus: The resident had impaired cognitive function/dementia or impaired thought process with dementia. The resident had dementia with behavioral disturbances. The resident had physically aggressive behaviors.-Resident had a history of being verbally aggressive towards peers and staff. Also history of antagonizing peers. At times resident makes threatening statements and balls fists though reports he was joking.-Resident had a history of hitting other residents. Goal: Resident will not harm self or others through the review date. (Revised on 4/10/23, nine days before the incident) He will verbalize the need to control physical aggressive behaviors through the review date. Interventions: Behavior monitoring revised on 2/18/23. Identify/document potential causative factors and eliminate/resolve where possible. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff will redirect if (the) resident becomes verbally aggressive. The behaviorprogress notes documented,-On 3/22/23 the resident was on frequent checks due to a recent altercation with another resident.-On 4/7/23 the resident threatened to hit another resident two times on the same day while walking past the resident.-On 4/19/23 the resident made (a) physical altercation with another resident in the hallway, obtained bruising/abrasion to lower left arm and above the elbow. Resident was to remain on one-to-one supervision with staff until he could be evaluated the next morning. (See interviews below that the resident was not placed on one to one supervision)The April 2023 treatment administration record (TAR) documented a daily tracking of the following:-Target behavior (physical aggression, strikes out) at the end of each shift, mark frequency how often behavior occurred and intensity. How (the) resident responded to redirection. Intensity code: zero equaled did not occur, one equaled easily altered, and two equaled difficult to redirect every shift. -On 4/19/23 the day of the altercation, the facility did not record any intensity codes on the TAR about behaviors for physical aggression. The nurse practitioner (NP) progress note on 4/15/23 (four days before the physical abuse incident) revealed in pertinent part that staff reported he had a history of seeking out more vulnerable residents and physically assaulting/attempting to physically assault them. The nurse practitioner (NP) progress note on 4/20/23 revealed in pertinent part, the resident had an altercation with another resident on 4/19/23 and had a bruise and abrasion to the left lower arm above the elbow. The NP documented the resident was in another skilled nursing facility and went to the hospital on 10/2/22 where he was aggressive and required restraints. The resident previously had heavy alcohol use and he used crack cocaine. VI. Resident #2A. Resident status (victim in the first incident, and perpetrator in the second incident)Resident #2, age 70, was admitted on 3/6/23. According to the May 2023 computerized physician orders (CPO), the diagnoses included unspecified dementia, moderate, without mood disturbances, cerebral infarction (stroke), hypertension (high blood pressure), stage 4 chronic kidney disease, anxiety disorders, alcohol abuse in remission, depression, cognitive communication deficit and difficulty in walking. The 3/13/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. The resident had verbal behavioral symptoms directed toward others. The resident did not reject care from staff. The resident required supervision with bed mobility, transfers, walking in his room and corridors, dressing, eating, and toilet use. He needed limited assistance with personal hygiene. B. Record reviewThe comprehensive care plan 4/11/23 revealed in pertinent part,Focus: Resident had a history of being verbally aggressive. Had a potential for injury to self or others which was manifested by constant yelling, kicking, verbal outbursts, and delusional behaviors. Interventions: Monitor/record occurrences of target behavior symptoms, inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol. The April 2023 TAR documented a daily tracking of the following:-Target behavior (physical aggression, strikes out) at the end of each shift, mark frequency how often behavior occurred and intensity. How (the) resident responded to redirection. Intensity code: zero equaled did not occur, one equaled easily altered, and two equaled difficult to redirect every shift. -On 4/19/23 the day of the altercation, the facility did not record any intensity codes on the TAR about behaviors for physical aggression. The NP progress note on 4/20/23 revealed in pertinent part, the resident (had) fingerprint markings on his neck from an altercation with another resident on 4/19/23. The NP documented when the resident went to a hospital on 2/24/23 he punched a security guard in the face. The behavior progress note on 4/20/23 documented Resident #2 said "That guy is dangerous."-The note did not document whom the resident said was dangerous. (See SSA interview below) VII. Staff interviewsLPN #1 was interviewed on 5/4/23 at 12:10 p.m. She said she worked on the Legacy unit where Resident #1 and Resident #2 lived. She said she had complained prior about the agency nurses that were on the unit the day of the incident. She said the agency CNA the day of the incident had prior told her that she did not get involved with fights between residents. She said if the men were being watched after the first altercation there would not have been a second altercation. She said Resident #2 may not remember the incident but he still gets nervous and agitated when he sees Resident #1 in the hallway. She said the staff tried to keep Resident #2 from seeing Resident #1 but it was difficult on a small secured unit. The SSA was interviewed on 5/4/23 at 4:00 p.m. The SSA said she said she was the social worker responsible for the Legacy unit. She said after the second incident she told the agency nurse on the unit to start one-to-one staff supervision with Resident #1. She said she had no documentation that she told the nurse and there was no documentation any staff had provided one-to-one supervision with Resident #1. She said he needed to be watched 24/7 by nursing staff until he could be medically evaluated the next day. She was unaware only 15 minute checks were done for three days. She said Resident #1 had altercations with others prior to the incident. She said because Resident #2 had not had altercations with others prior to the incident he was not put on one-to-one supervision. She said she was unaware that there was a homicide/suicide evaluation done for Resident #1 in the electronic medical records (EMR). She said after the first incident with Resident #1, Resident #2 retaliated. She said she did not know why the staff on the unit did not notice Resident #2 had left his room to go to the dining room to seek out Resident #1. She said Resident #2's intervention after the incident was to be discharged to another state to go live with his former wife. She said she was unaware of a note in the medical record on 4/20/23 the day after the incident which documented Resident #2 had said that guy was dangerous. The social service director (SSD) was interviewed on 5/4/23 at 4:10 p.m. She said Resident #1 had other altercations with other residents on the unit. She said Resident #1 balled up his fists at others to be funny. She said some residents understand his humor and others hit him. She said after the first altercation the two men were separated. She said Resident #2 came out of his room and found Resident #1 and retaliated for what happened about an hour prior. She said she did not know what other interventions could have been put in place to protect the two residents except 15 minute checks because that usually worked. She did not know how the two men were not watched closely enough that a second incident happened. The NHA was interviewed on 5/4/23 at 4:20 p.m. He said he would read the employee time cards and if he found who initialed the 15 minute checks for Resident #1 and Resident #2 and he would provide the documentation. -No documentation was provided during or after the survey on 5/5/23. He said there was no documentation that Resident #1 was put on one-to-one care after the second incident. He said the nurse on duty documented the events in the resident's medical records. He said he was not sure the agency nurse that day viewed the altercation correctly. VIII. Facility follow-upOn 5/5/23 at 4:34 p.m. the NHA emailed the following information. Resident #1 had aggressive behaviors in the past, and the facility had tried with no success to refer him to get accepted by other facilities to care for his needs. After the first altercation on 4/19/23 police were called and refused to transport Resident #1 on assault charges. The NHA said after viewing the video footage of the first incident he felt the nurse on duty that day had her back to the residents and did not see the incident correctly. The NHA requested the police department who responded to the event in the facility to send their report and a copy of the video footage. The facility had not received a response from the police department as of 5/5/23 (16 days after the incident). The NHA also wrote that when the police were in the building within an hour of the first altercation, the staff had "removed their physical presence and attention to monitoring that would have otherwise been in place. The presence of the police and the proximity of the residents during the police interviews led to the retaliatory incident."

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

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/23/2023 and 01/29/2023, 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.