JUNIPER VILLAGE - THE SPEARLY CENTER

A revisit survey was completed on 6/5/25 for all previous deficiencies cited on 4/25/25. The facility is in compliance with all regulations surveyed.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A recertification survey was conducted from 4/7/25 to 4/25/25. Eleven deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/7/25 to 4/25/25. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure residents and their representatives had a right to participate in the development and implementation of their person-centered plan of care for two (#102 and #41) of four residents out of 37 sample residents. Specifically, the facility failed to invite R102's and R41's representatives to participate in the care conferences to review the resident's plan of care. Findings include:I. Facility policy and procedureThe Service Plan policy, undated, was provided by the Health Information Manager (HIM) on 4/10/25 at 4:45 p.m. It read in pertinent part, "Residents will have a service plan developed at move-in and with a change of condition. The purpose is to assist residents in maintaining independence, individuality, dignity and privacy through a written plan of care. The service plan is completed at move-in based upon the resident evaluation and level of care determination and initial wellness evaluation. It is expected that the resident will participate in the development and review of the service plans in all communities. The family, if the resident agrees, may also be present. Participation by the resident, family and all team members will be documented in the medical record."II. Resident #102A. Resident statusR102, age greater than 65, was admitted on 7/29/24. According to the April 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, bipolar disorder (mental illness), post traumatic stress disorder, chronic pain and history of pulmonary embolism (blockage of arteries in the lungs). The 2/22/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score (BIMS) of zero out of 15. The resident was dependent on staff for hygiene, bathing and dressing. The resident needed assistance with eating and was independent with transfers. B. Resident representative interviewThe representative for R102 was interviewed on 4/7/25 at 2:40 p.m. The representative said she was supposed to meet with the resident's care team once a month but did not have any meetings with them. She said the facility had not called to tell her how the resident was doing. She said she was unable to visit due to her recent schedule changes and the facility had not called her for the last care conference. She said she did not remember the last time the facility called her. C. Record reviewThe 11/18/24 quarterly collaborative care review documentation was reviewed and revealed that R102's representative did not attend the care conference. The section of the review that indicated to document the names of people who attended the collaborative care review was left blank. The facility staff that were documented as present during review were clinical services. The 2/22/25 quarterly collaborative care review documentation was reviewed and revealed that R102's representative did not attend the care conference. The facility disciplines that were documented as present during the review were clinical services, social services and therapy. The names of facility staff who attended were listed.-A review of the R102's electronic medical record (EMR) revealed there was no documentation that the resident's representative or the resident was contacted to attend the care conferences on 11/18/24 and 2/22/25. III. Resident #41 A. Resident statusR41, age less than 65, was admitted on 5/19/14. According to the April 2025 CPO, diagnoses included anoxic brain damage and dementia. The 1/8/25 minimum data set (MD) assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15. The resident needed supervision with dressing, hygiene, bathing and transfers. He was independent at mealtime. B. Resident representative interviewR41's representative was interviewed on 4/7/25 at 2:30 p.m. The representative said she used to be involved in the care conferences and had not attended a care conference with the facility in over a year. The representative said she previously joined the care conferences by phone but the facility had not invited her to recent care conferences. The representative said R41 did not know where he was and thought he was still in high school. C. Record reviewThe 7/8/24 quarterly collaborative care review documentation was reviewed and revealed that R41's representative was not documented as present for the meeting. The facility staff documented as present for the meeting were a nurse and social worker. The 10/8/24 quarterly collaborative care review documentation was reviewed and revealed that R41's representative was not documented as present for the meeting and listed the resident's representative as his major decision maker. The facility staff documented as present were a nurse, dietary, connections and social worker. The 1/2/25 quarterly collaborative care review note documentation was reviewed and revealed that R41's representative was not documented as present for the meeting. The facility staff documented as present during review were clinical services and social services. The section of the review available to document the names of people who attended the collaborative care review was left blank.-A review of the R41's electronic medical record (EMR) revealed there was no documentation that the resident's representative was contacted to attend the care conferences on 7/8/24, 10/8/24 and 1/2/25. IV. Staff interviewsThe Social Services Director (SSD) was interviewed on 4/10/25 at approximately 9:00 a.m. The SSD said the care conference schedule was sent to the facility concierge and the concierge informed the resident when their care conference was scheduled. The SSD said most residents did not want to attend the care conference. The SSD said a resident representative could join join a care conference by video, in person or on the phone and were are always given those options. The SSD said the facility could also print the care conference notes and give the notes to the representative. The SSD said the previous social services assistant could have contacted the representatives to attend the care conferences and would try to find documentation of those records.-However, documentation that the resident representatives were notified of the care conferences was not provided. Assistant Director of Nursing (ADON) #1 was interviewed on 4/10/25 at approximately 9:00 a.m. ADON #1 said usually when R102's representative visited the facility a face to face informal meeting was held with her. ADON #1 said the facility provided updates to the representatives if they were unable to attend a care conference. The Director of Nursing (DON) was interviewed on 4/10/25 at 3:00 p.m. The DON said resident representatives should be invited to care conferences and the social services staff invited the representatives.

Based on record review and interviews, the facility failed to provide written notification of room changes for one (#55) of two residents reviewed for notifications out of 37 sample residents. Specifically, the facility failed to:-Provide timely written notification of a room change and the reasoning to R55's; and,-Honor R55's room preferences. Findings include:I. Facility policy and procedureThe Room/Roommate Changes policy and procedure, undated, was provided by the Nursing Home Administrator (NHA) on 4/10/25 at 5:27 p.m. It read in pertinent part, "The social services representative will serve as an advocate for the resident's right to remain in their room placement unless the resident requests a room change, or the move is necessary for improved provision of medical or community life services."If a room change is deemed necessary, the Social Service Representative will obtain verbal consent from the resident and/or responsible party. This is documented in the community life progress notes or on a room change form."If the resident or responsible party refuses to authorize the proposed change, they are given notice five days before the change will occur. The resident or responsible party will be asked to sign the notification. They have the right to appeal the change within those five days. The appeal will be reviewed by the grievance committee and if further appeal is needed, the state health department. "If the resident or responsible party chooses to appeal the proposed change, the room change shall not be made until the appeal has been resolved."The social service representative will complete the room change notice form and distribute to everyone on the notice."II. Resident #55A. Resident status R55, age 81, was admitted on 4/3/24. According to the April 2025 computerized physician orders (CPO), diagnoses included bipolar-type schizoaffective disorder (mental disorder), borderline personality disorder and muscle weakness. The 1/9/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. ObservationsOn 4/9/25 at 2:57 p.m. R55 and the Health Information Manager (HIM) were observed talking in the hallway near the Pinion unit nurse's station. The HIM was holding a room change notification and was explaining what the form was to R55. The HIM said the room change notification was from when R55 had moved rooms in December 2024. The HIM said the facility had forgotten about the room change notification forms and were catching up on them. The HIM said the room change notification document documented the resident wanted to move rooms. R55 said she had not wanted to move rooms and did not want to sign the document. C. Record reviewA progress note, dated 12/14/24 at 11:09 a.m., revealed R55 and her family members complained about the quality, size and placement of the room R55 was being moved to. A progress note, dated 12/14/24 at 11:50 a.m., revealed R55 was involved in a physical altercation with her roommate. Both residents were separated. Plans were underway to relocate one of the residents to a different room to prevent further conflicts. A room change notification form, dated 12/14/24, revealed R55 was moved to a different room on the same unit. The form documented the room change was due to safety. The form was signed by a social services staff member on 12/14/24.-However, the form did not document that the resident was provided written notification of the room change. A room change notification form, dated 3/24/25, revealed R55 was moved to a different room on a different unit. The form documented the room change was due to the resident wanting to move rooms. The form was signed by a social services staff member on 3/24/25.-However, the form did not document whether consent for the room change was obtained and the form was not signed by R55.-Review of R55's electronic medical record (EMR) did not reveal any notes pertaining to R55 requesting to move rooms or the room move itself. D. Staff interviewsNurse Manager (NM) #1 was interviewed on 4/10/25 at 3:26 p.m. NM #1 said the resident or their representative needed to agree to move rooms and sign the room change document prior to the room change occurring. NM #1 said the social services team prepared the room change document. The Social Services Assistant (SSA) was interviewed on 4/10/25 at 3:53 p.m. The SSA said the process for a room change began with talking to the resident or their guardian to see if they wanted to change rooms. The SSA said the facility staff sometimes showed the resident or their guardian the new room would look like in order to get them to agree to the room change. The SSA said the resident or their representative would sign and date the room change notification form. The SSA said information about the room change would be documented in the resident's progress notes. The SSA said they needed to obtain a signature from the resident or representative approving the room change prior to moving rooms. The SSA said the social services team members prepared the room change notification form. The SSA said the facility recently started using the paper room change notification form and were previously writing a progress note in the resident's EMR saying the resident or their guardian agreed to the room change. The SSA said the residents had to agree to sign the room change notification form prior to moving to a new room. The SSA said the room change notifications on 12/14/24 and 3/24/25 should have been signed by R55. The Director of Nursing (DON) was interviewed on 4/10/25 at 4:44 p.m. The DON said room change notifications were done by the social services department. The DON said the social service team members had the resident or their representative sign the room change document or get verbal consent over the phone prior to moving their room to indicate the resident or representative agreed to the room change. The DON said the room change on 12/14/24 was for R55's safety. The DON said when a room change was needed for safety the resident did not get to refuse the room change.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for one (#110) of three residents reviewed for care planning out of 37 sample residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to ensure a comprehensive care plan was developed to address R110's functional abilities and activities of daily living (ADL). Findings include:I. Facility policy and procedureThe Service Plan policy and procedure, undated, was provided by the Nursing Home Administrator (NHA) on 4/10/25 at 5:27 p.m. The policy read in pertinent part, "Residents will have a service plan developed at move-in to assist residents in maintaining independence, individuality, dignity, and privacy through a written plan of care."The service plan is completed at move-in based upon the resident evaluation and level of care determination and initial wellness evaluation."II. Resident #110A. Resident statusR110, age less than 65, was admitted on 12/2/24. According to the April 2025 computerized physicians orders (CPO), diagnoses included quadriplegia (paralysis of all four limbs), legal blindness, encephalopathy (condition that causes dysfunction of the brain, resulting in altered mental state, memory loss, and other neurological symptoms) and chronic pain. The 3/8/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident was dependent on staff for all ADLs. The assessment documented the resident was always incontinent of bowel and bladder. B. Resident representative interviewR110's representative was interviewed on 4/7/25 at 4:10 p.m. The resident representative said she consistently told the nursing staff when R110 needed to have his incontinence briefs changed. The resident representative said she and another family member did most of R110's hygiene care. C. Record review-Review of R110's comprehensive care plan, revised 3/23/25, did not reveal a care plan focus or interventions pertaining to R110's quadriplegia or ADL abilities. A progress note, dated 12/2/24 at 3:19 p.m., revealed R110 was screened for ADL abilities. R110 was found to be totally dependent on staff for all ADLs. A progress note, dated 12/2/24 at 8:20 p.m., revealed R110 needed help with ADLs and was legally blind. Review of R110's Kardex (a staff directive tool) revealed the following directives:-Offer fluids and record intake;-Two-hour turns;-Ensure appropriate visual aides are available to support R110's participation in activities; and,-R110 was able to: (specify strengths).-The Kardex failed to identify what specific strengths the resident had or what he was able to do.-Additionally, there was no information documented on the Kardex regarding R110's ADLs, including the resident's toileting and transfer needs. III. Staff interviewsCertified Nurse Aide (CNA) #2 was interviewed on 4/9/25 at 3:11 p.m. CNA #2 said the staff knew what ADLs the residents needed help with by referring to the residents' electronic medical records (EMR) and by working with the residents and getting to know them. CNA #2 said the EMR indicated whether the resident needed a hoyer lift, if they needed to have their incontinence brief checked or if they needed repositioning. CNA #2 said R110 was fully dependent on staff for assistance with ADLs. CNA #2 said R110 needed to be repositioned at least every two hours and needed to have his brief checked every 30 minutes as he was frequently incontinent of urine. CNA #2 said R110 was not able to tell the nursing staff if he needed to be changed. Licensed Practical Nurse (LPN) #3 was interviewed on 4/10/25 at 10:32 a.m. LPN #3 said the residents' ADL care plans were created by the floor nurses, the restorative and therapy team and the facility's MDS coordinator.-LPN #3 was not able to find an ADL focus documented on R110's comprehensive care plan. LPN #4 was interviewed on 4/10/25 at 11:22 a.m. LPN #4 said residents' ADL information was found in their care plan and on the resident's Kardex. LPN #4 said the ADL care plan was completed by the Director of Nursing (DON) on admission. LPN #4 said R110 was totally dependent on staff for ADLs.-LPN #4 was not able to find an ADL focus documented on R110's comprehensive care plan. Nurse Manager (NM) #1 was interviewed on 4/10/25 at 3:26 p.m. NM #1 said the ADL section of the care plan usually included ability information for residents, including their assistance levels needed for showers, support with eating, grooming, toileting and repositioning. NM #1 said R110 was totally dependent on staff but could communicate his needs verbally. The DON was interviewed on 4/10/25 at 4:44 p.m. The DON said the Assistant Director of Nursing (ADON) completed the ADL care plans. The DON said the ADL care plan typically contained interventions regarding repositioning, toileting and hygiene. The DON reviewed R110's EMR and said the resident did not have an ADL care plan. The DON said R110 was total care and was dependent on staff for ADLs. He said the ADL care plan would normally be used to let the staff know how to meet his needs.

Based on observations, record review and interviews, the facility failed to ensure two (#46 and #98) of three residents received treatment and care in accordance with professional standards of practice out of 37 sample residents. Specifically, the facility failed to:-Ensure physician's orders to treat R46's skin condition on his hands were followed; and,-Ensure R98's skin rash was addressed in a timely manner. Findings include:I. Resident #46A. Resident statusR46, age 69, was admitted on 3/8/21. According to the April 2025 computerized physicians orders (CPO), diagnoses included alcohol dependence with alcohol-induced persisting dementia, dermatitis and psoriasis. The 3/13/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident was independent for all activities of daily living (ADL). The assessment documented the resident did not have any issues with his skin. The assessment documented the resident received applications of ointments/medications to locations other than his feet. B. Resident interview and observationsR46 was interviewed on 4/7/25 at 1:04 p.m. R46 said his skin was itchy and that it hurt to hold a cigarette when he smoked. R46 said the facility staff tried to use different lotions for him but they did not help his skin. R46 said the facility staff were not presently doing anything to fix his skin and he "just had to live with it." R46's palms were covered with patches of thick scaly skin, irritated red skin and there were cracks in the skin between each of his fingers. R46 was itching his hands throughout the interview and had flakes of skin on his pants and his chair. C. Resident representative interviewR46's representative was interviewed on 4/10/25 at 8:24 a.m. The resident representative said he had a care conference with the facility every three months and the facility called him with any changes in R46's condition. The resident representative said he was not aware of any skin issues R46 was having. The resident representative said the facility would call him if they changed any of R46's medications. D. Record reviewThe ADL care plan, revised 3/13/24, revealed R46 had an ADL self-care performance deficit due to his dementia. Pertinent interventions included performing skin inspections, observing for redness, open areas, scratches, cuts and bruises and reporting any changes to the nurse. -Review of R46's comprehensive care plan, revised 4/8/25, did not reveal any focus or interventions related to R46's dermatitis or psoriasis. Review of R46's April 2025 CPO revealed the following physician's orders:Triamcinolone acetonide 0.1% cream (topical steroid) with instructions to apply to the right palm topically three times a day for psoriasis, ordered 2/17/25 and discontinued 4/8/25 (during the survey process). Clobetasol propionate 0.05% cream (topical steroid) with instructions to apply to both hands topically two times a day for dermatitis, ordered 4/8/25 (during the survey process). A progress note, dated 3/7/25 at 4:23 p.m., revealed R46 was seen by the dermatologist that day (3/7/25). The dermatologist said she had performed a biopsy on R46's right hand and instructed the resident to keep his hand dry for 24 hours. The dermatologist said she would discontinue the triamcinolone cream and R46 would need to gently wash his hands and apply vaseline to his hands for ten days.-However, the triamcinolone cream was not discontinued until 4/8/25 (during the survey). A wound note, dated 3/13/25 at 4:29 p.m., revealed R46 had improved palmar psoriasis. R46 refused treatment intermittently, citing discomfort using the cream. The resident's left palmar region was nearly resolved. Treatment included using clobetasol 0.05% ointment as directed.-However, clobetasol was not added to R46's orders until 4/8/25, and the resident continued to receive triamcinolone cream instead. A wound note, dated 3/20/25 at 3:05 p.m., repealed R46 had decreased plaques and dryness, and his left hand had almost resolved. Treatment included using clobetasol 0.05% ointment as directed.-However, clobetasol was not added to R46's orders until 4/8/25, and the resident continued to receive triamcinolone cream instead. An interdisciplinary team (IDT) note, dated 3/26/25, revealed R46 had palmar psoriasis with crusted plaques. R46 was refusing treatment as he said the prescribed cream was uncomfortable. The plaques affected both hands and the left hand had nearly resolved. An IDT note, dated 4/2/25 at 1:45 p.m., revealed R46 had palmar psoriasis with mild crusted plaques and no open lesions. R46 refused treatment intermittently and stated he had discomfort using the prescribed creams. R46 was provided with encouragement to keep up with the treatments but was intermittently noncomplaint, resulting in a slow or stagnant progress. The left palmar area was nearly resolved. R46 underwent a biopsy of both palms to rule out eczema versus psoriasis and the results were pending. Treatment included clobetasol 0.05% cream and vaseline applied twice daily to both hands.-However, clobetasol was not added to R46's orders until 4/8/25, and the resident continued to receive triamcinolone instead. Dermatology notes, dated 4/4/25, revealed R46 was seen to follow up on a previous biopsy. The dermatologist ordered clobetasol propionate 0.05% topical ointment, with instructions to apply to hands twice daily for thirty days. Notes revealed the dermatologist offered to re-biopsy R46's hands as the previous biopsy was lost in the mail, but the resident declined the biopsy. There was concern for psoriasis but a biopsy would be needed to confirm the diagnosis. Clobetasol was re-prescribed as R46 had not been using the ointment.-However, the facility again failed to add the clobetasol order to R46's orders until 4/8/25, and the resident continued to receive triamcinolone cream instead.-Review of R46's electronic medical record (EMR) did not reveal any consent forms for the resident to be seen by the dermatologist or have the biopsy collected (see interviews below). E. Staff interviewsCertified Nurse Aide (CNA) #3 was interviewed on 4/10/25 at 10:10 a.m. CNA #3 said R46 had issues with the skin on his hands. CNA #3 said the wound care team ordered medications for R46, along with a glove to keep his hand moisturized. CNA #3 said R46's skin looked better than it did before as he used to not be able to open his hand without the skin cracking. CNA #3 said R46 was independent and denied lotion whenever it was offered to him because he did not like lotion. CNA #3 said she reported any skin issues to the nurse or the unit manager, who would then alert the wound care team and assess the resident to see if the resident needed any treatment orders. Licensed Practical Nurse (LPN) #3 was interviewed on 4/10/25 at 10:32 a.m. LPN #3 said R46 had psoriasis on his palms and was being followed by wound care. LPN #3 said if a resident received new physician's orders during ancillary appointments, she would call the doctor to verify the order and put it in the EMR before calling the pharmacy to see when the medication would arrive. LPN #3 said R46 had triamcinolone cream ordered twice a day to help his skin and she had just finished administering it to R46. LPN #3 verified R46 was had triamcinolone cream ordered for his hands, and produced a box of triamcinolone cream from her medication cart with R46's name on it and said that was the medication she had administered that morning (4/10/25).-However, the order for triamcinolone cream had been discontinued on 4/8/25, and R46 had a physician's order for clobetasol ointment, initiated 4/8/25. LPN #4 was interviewed on 4/10/25 at 11:22 a.m. LPN #4 said R46 had clobetasol cream in his April 2025 CPO but he did not have triamcinolone cream ordered. LPN #4 said when a resident's medication was discontinued, the remaining medication should be removed from the medication cart and placed in the medication storage room to be picked up by the pharmacy for disposal. LPN #4 said R46 should only be receiving the clobetasol cream that was presently ordered. Nurse Manager (NM) #2 was interviewed on 4/10/25 at 2:45 p.m. NM #2 said residents were sent with a packet each time they received ancillary services for the physicians to fill out regarding what was done and any new orders prescribed for the resident. NM #2 said the packets were often sent back blank, so the facility staff would call the ancillary service physician, request any new orders and add them to the resident's EMR. NM #2 said there were times when there were delays in adding physician's orders if she was not in the facility or there was a new floor nurse. NM #2 said R46 began complaining about issues with his palms starting in February 2025, at which time his hands looked like they had a raised rash. NM #2 said the wound care team at the facility prescribed R46 the triamcinolone cream and did a biopsy on his hands, but the biopsy was lost in the mail. NM #2 said R46 was noncompliant with putting the prescribed creams on his hands as he did not like the creams. NM #2 reviewed R46's chart and said the clobetasol cream was ordered as of 3/13/25. NM #2 said there was a progress note, dated 3/7/25, in the resident's EMR which indicated the triamcinolone cream was discontinued on 3/7/25 (see record review above). NM #2 said she was out of the facility during the period of time in which the new physician's orders were received so that may have affected the facility's processes and the physician's order may have been missed in her absence. NM #2 said clobetasol was ordered for R46 and had been filled by the pharmacy, so R46 should have been receiving that medication as ordered. NM #2 reviewed R46's MAR and said the clobetasol cream had been marked as administered that morning.-However, LPN #3 administered triaminolone cream to R46 on the morning of 4/10/25 (see LPN #3 interview above). NM #2 said R46's representative needed to sign a consent form in order for the resident to be seen by the dermatologist and to have the biopsy performed. NM #2 reviewed R46's EMR and could not find any dermatology or biopsy consent forms in his record (see record review above). The Director of Nursing (DON) was interviewed on 4/10/25 at 4:08 p.m. The DON said there was no reason which should have caused the delay in the switch from triamcinolone cream to clobetasol cream for R46. The DON was interviewed a second time on 4/10/25 at 4:44 p.m. The DON said the facility's medical records staff member started in January 2025 and had a backlog of medical records to input. The DON said the facility had an issue with ancillary physicians writing orders for residents and the facility not receiving them. The DON said the facility did not have a good process for transferring orders when the dermatologist came in and prescribed new orders for residents. II. Resident #98A. Resident statusR98, age 69, was admitted on 6/2/23. According to the April 2025 CPO, diagnoses included bipolar-type schizoaffective disorder and major depressive disorder. The 3/15/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent for all ADLs. The assessment documented the resident did not have any issues with her skin. B. Resident representative interviewR98's representative was interviewed on 4/10/25 at 8:15 a.m. The resident's representative said she learned at the resident's most recent care conference that the resident had rashes on her upper thighs. The resident's representative said the facility thought her rashes were caused by her underwear being too tight due to R98's recent weight gain. The resident's representative said R98 did not have any rashes anywhere else on her body except on her thighs.-However, the resident had additional rashes on her abdomen, chest and buttocks/groin area (see resident interview and record review below). C. Resident interviewR98 was interviewed on 4/10/25 at 11:17 a.m. R98 said she was not sure if there was an issue with the soap she was using, but she had been getting red spots on her chest and stomach due to her itching. R98 said she had some dry spots on her legs as well, but the itch cream that the nursing staff gave her helped with those. D. Record reviewReview of R98's April 2025 CPO revealed the following physician's orders:Lantiseptic skin protectant with instructions to apply to the buttock and groin area to relieve skin rash every shift and after shower, ordered 3/27/25 and discontinued 4/10/25 (during the survey process). Lantiseptic skin protectant with instructions to apply to the abdomen, chest, buttock and groin area to relieve skin rash every shift and after shower, ordered 4/10/25 (during the survey process). Refer to dermatology for skin rash to abdomen, chest, and buttocks/groin area, ordered 4/10/25 (during the survey process). A skin evaluation, dated 3/8/25 at 10:01 a.m., revealed R98's skin was clean, dry and intact. A skin evaluation, dated 3/17/25 at 8:53 a.m., revealed R98 had a generalized rash to her abdomen and her left and right buttocks. R98 had a rash noted to her upper and lower left abdomen and to both glutes (buttocks). -However, the skin evaluation did not reveal whether the physician was informed of the resident's rash. A progress note, dated 3/18/25 at 4:50 p.m., revealed R98 had red spots all over her body and redness between her buttocks. Interventions included performing a skin check to determine the severity of the rash, removing any wet or damp clothing and reviewing recent foods, drinks, and environmental changes for a possible cause.-However, the progress note did not reveal whether the physician was informed of the resident's rash. A skin evaluation, dated 3/25/25 at 9:44 a.m., revealed R98 had a generalized rash to her abdomen, her chest, and her left and right buttocks. Notes revealed R98 had a rash present under both breasts and under each arm. R98 said the rashes itched. A skin check was performed, and the physician and the Assistant Director of Nursing (ADON) were notified.-However, the physician was not notified of R98's rash until 3/25/25, eight days after staff initially noted the rash (see progress notes above).-Additionally, there was no physician's order entered into the resident's EMR for a treatment for the rash until 3/27/25 and the initial physician's order did not include treatment to the resident's abdomen and chest (see physician's orders above). A skin evaluation, dated 4/3/25 at 5:03 a.m., revealed R98 had a generalized rash to her abdomen, her chest, and her left and right buttocks. A progress note, dated 4/10/25 at 5:19 p.m., revealed R98 was receiving Lantiseptic skin protectant to her buttock area for her skin rash. R98's rash appeared to be improving in size, and the resident was encouraged to dry her skin after her shower and apply the cream. R98's skin was otherwise intact and had no signs or symptoms of infection. A progress note, dated 4/10/25 at 5:27 p.m., revealed R98's representative consented to a referral to the dermatologist for the resident's skin rash.-However, the referral for the resident to see a dermatologist for her rash was not obtained until 4/10/25, during the survey, which was over three weeks after the rash was initially noted and spread to other areas on the resident's body. E. Staff interviewsCNA #4 was interviewed on 4/10/25 at 9:16 a.m. CNA #4 said R98 had a rash all over her body the week or two prior. CNA #4 said she notified the nurse right away if she noticed an issue with a resident's skin. LPN #4 was interviewed on 4/10/25 at 10:22 a.m. LPN #4 said R98 had a rash on her buttocks and had a cream prescribed to treat the rash. LPN #4 said whenever she was notified about a skin issue on a resident, she assessed the resident then called their doctor. LPN #4 said the doctor would then give an order based on whatever type of rash the resident had and she would apply the medication as prescribed. NM #1 was interviewed on 4/10/25 at 3:26 p.m. NM #1 said R98 previously had an issue with her skin, so the nursing staff called her physician and received a physician's order for an over-the-counter cream. NM #1 said the cream prescribed to R98 was just to be used after her showers to help with itching, as the resident was generally itchy due to the dryness of her skin. NM #1 was interviewed a second time on 4/10/25 at 4:00 p.m. NM #1 said R98 only had a skin rash on her buttocks. NM #1 said R98 did not have any rashes anywhere else on her body, and that they were only administering the prescribed cream on her buttocks.-However, R98 had rashes covering several areas of her body (see record review and resident interview above). The DON was interviewed on 4/10/25 at 4:44 p.m. The DON said he had spoken with NM #1 to see if the nursing staff had contacted R98's physician about the rash on her chest. The DON said NM #1 told him the nursing staff were administering the prescribed cream to R98's abdominal folds, glutes, and groin region. The DON said he would ask NM #1 to change R98's Lantiseptic order to include administering the cream to her chest. The DON said the facility planned to refer R98 to the dermatologist if her rash was not healed by 4/15/25.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#45) of three residents reviewed for pressure ulcers out of 37 sample residents. Specifically, the facility failed to:-Provide timely assessment by a qualified person;-Provide timely interventions and treatment after new wounds were found; -Notify key individuals (hospice, wound specialist, primary physician) to ensure timely interventions, assessments, and updated care plans, were in place to avoid wounds from worsening; and,-Ensure wound care documentation was thorough and accurate. Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 4/16/25 from https://www.internationalguideline.com/guideline, "Pressure ulcer classification is as follows:"Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk)."Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable"Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover' and should not be removed."Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment." II. Facility policy and procedureThe Pressure Ulcer policy and procedure, undated, was provided by the health information manager (HIM) on 4/10/25 at 4:39 p.m. It documented in pertinent part,"Residents are assessed for skin integrity and wounds upon move-in with documentation in the move-in assessment in the electronic medical record (EMR). Residents with a wound or skin integrity issue at move-in will have weekly skin assessments using the skin integrity evaluation in the EMR until the wound is healed. Residents without wounds or skin integrity issues or recently healed wounds will continue having weekly skin evaluations using the skin integrity evaluation weekly in the EMR. Follow the provider orders for specific wound treatments. Following the identification of wounds, the care plan will be updated to reflect."III. Resident #45A. Resident statusResident #45, age 74, was admitted on 3/28/19. According to the April 2025 computerized physician orders (CPO), diagnoses included major depressive disorder, dementia, overactive bladder, hemiplegia (paralysis to one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke). The 2/19/25 minimum data set (MDS) assessment documented the resident had a short term memory problem based on the staff assessment for mental status. A brief interview for mental status was not conducted due to the resident being rarely/never understood. The assessment documented the resident was dependent on staff for eating, hygiene, bathing, dressing, rolling side to side and transferring. The assessment documented the resident was always incontinent of bowel and bladder. The assessment indicated the resident was at risk for pressure ulcers and did not have any skin conditions at the time of the assessment. The resident had a pressure reducing device for the chair and the bed, turning and repositioning, nutrition or hydration interventions and application of an ointment/medication to somewhere other than to the feet. The assessment indicated the resident did not have rejections of care. B. Resident observationsOn 4/9/25 at 11:30 a.m. Resident #45's wound care was observed with nurse manager (NM) #2, registered nurse (RN) #1 and certified nurse aide (CNA) #5. The resident's left heel had a dark purple/maroon deep tissue injury (DTI) that RN #1 applied skin prep to. Both heels were in soft booties. Resident #45 had a large crater-like wound that was dark brown/black in color at the middle or center of the wound on his sacrum. The skin around the wound was white and red in color. The old dressing NM #2 took off was brown in color with a moderate amount of drainage from the wound. When NM #2 removed the soiled dressing, RN #1 put her shirt up to her nose to mask the scent of the wound. NM #2 said the smell of the wound was from the purulent drainage that was brown in color. She said it was a stage 3 wound. NM #2 cleansed the wound with saline, applied calcium alginate soaked in Dakin ' s solution to the wound bed, applied skin prep around the wound bed and applied a foam dressing to the wound. C. Record reviewThe pressure ulcer plan of care, initiated 3/29/19 and revised 4/8/25 (during the survey), documented that Resident #45 had potential for pressure ulcer development because of his episodes of incontinence, poor nutritional intake and refusals for repositioning. The care plan documented he had an actual wound on his coccyx and a DTI to his left heel. The care plan goal was for Resident #45 to have no significant alteration in skin integrity through the next review period. Interventions included administering supplements as ordered though he often refused supplements (initiated 4/8/25, during the survey), an air mattress (initiated on 4/8/25, during the survey), a Broda chair (initiated 4/8/25, during the survey), coordination with hospice (initiated 4/8/25, during the survey), pain management (initiated 4/8/25, during the survey), wound round checks with the wound care team (initiated 4/2/25), skin prep to heels and heel protectors on while in bed (initiated 4/8/25, during the survey), staff to reposition resident every two to three hours, though he often refused (revised on 4/8/25, during the survey), urinal will be made available at bedside (initiated 3/29/19) and a weekly skin assessment and to notify the physician of any refusals (initiated 3/29/19). -The facility failed to update the skin integrity care plan with interventions related to the actual pressure injuries until 4/8/25, 18 days after the development of the coccyx pressure ulcer and 20 days after the development of the left heel unstageable DTI. -The facility failed to implement timely interventions to prevent Resident #45's facility acquired stage 2 pressure ulcer from progressing to a stage 3 pressure ulcer. A Braden Scale assessment (a tool used for predicting pressure ulcer risk), dated 3/11/25, documented Resident #45 was at risk for developing a pressure injury. The risk factors included not always being able to communicate discomfort, occasionally being moist, his ability to walk was severely limited or non-existent, he had very limited mobility, adequate nutrition and a potential problem for friction and shear (skin slides around). A review of the wound care provider ' s (WCP) note, dated 3/20/25, revealed Resident #45 had an unstageable DTI to the left heel from pressure. It measured 1.2 centimeters (cm) by 1.5 cm. The skin was intact with purple/deep maroon discoloration. Recommendations from the WCP included skin prep to the wound once daily, off-loading the wound and floating the resident ' s heels while in bed. -However, there were no wound care orders for the resident ' s left heel DTI until 4/10/25 (during the survey) after the discrepancy was brought to the attention of the facility (see physician ' s orders below). A review of the nursing progress note, dated 3/22/25 and written by RN #1, documented a new facility-acquired stage 2 pressure ulcer to Resident #45 ' s coccyx with partial thickness skin loss with exposed dermis. It documented that barrier cream was applied and to refer to the wound care team. -However, there was no documentation that the WCP was notified. There was no follow up from the wound care team until 3/27/25, five days later, when the WCP was at the facility and after the resident ' s wound had advanced to a stage 3 pressure ulcer. A review of the WCP note dated 3/27/25, revealed Resident #45 had a stage 3 pressure wound to his coccyx with poor healing potential. The wound measured 2 cm by 2 cm, had moderate to sero-sanguinous exudate and 100% granulation tissue. The treatment was a foam dressing with border three times weekly with skin prep to the peri wound, off load and reposition per facility protocol. A review of CNA documentation for repositioning every two hours revealed Resident #45 refused only one offer to reposition in the 31 days in March 2025. -However, there were 17 days out of the 31 days in March 2025 where it was documented that the resident was repositioned on his back several hours consecutively. A review of Resident #45 ' s April 2025 CPO revealed the following physician's orders for wound care:Clean area of coccyx with wound cleanser, pat dry, apply Medi-honey to open area, skin prep around the wound bed and cover with bordered foam dressing, ordered 3/31/25. -The wound care was ordered 11 days after the development of the pressure ulcer to the coccyx (see progress notes above). Air mattress ordered related to skin integrity/wounds, settings on automatic firm, ordered 4/8/25.-The intervention was ordered 18 days after the development of the pressure ulcer to the coccyx (see progress notes above). Heel protectors on while in bed, ordered 3/17/25. -However, according to NM #1, the facility did not start using booties on the resident until after the development of the unstageable DTI to the left heel (see NM #1 interview below). Clean area with wound cleanser, pat dry, apply skin prep to DTI on inner right heel every shift, ordered on 3/17/25. -However, the DTI was on the resident ' s left heel.-The April 2025 CPO failed to reveal wound care orders for the resident ' s left heel unstageable DTI. E. Staff interviewsCNA #8 was interviewed on 4/9/25 at 10:48 a.m. CNA #8 said Resident #45 would refuse to eat sometimes if he did not like the food. She said the staff tried to offer him alternatives if he did not like the food. She said he was incontinent and needed total assistance for all cares, including eating, repositioning and toileting hygiene. She said he did not refuse to be repositioned or to get his brief changed. NM #2 was interviewed on 4/9/25 at 11:30 a.m. NM #2 said when there was a new skin condition, the nurse who noticed it put a wellness alert in the EMR. She said this alerted the unit manager to get a referral for the WCP to see the resident. She said Resident #45 was at risk for developing pressure ulcers prior to the development of the injuries due to his poor nutrition, refusing repositioning, refusing floating his heels and refusing the booties until recently. She said Resident #45 was dependent on staff for repositioning.-However, review of the CNAs repositioning documentation for Resident #45 revealed he refused only one repositioning attempt in March 2025 (see record review above). CNA #3 was interviewed on 4/10/25 at 9:07 a.m. CNA #3 said Resident #45 did not refuse care. She said the only thing he would refuse at times was eating meals and supplements. She said he got up occasionally out of bed for meals and showers. She said he was incontinent and did not use the call light. CNA #3 said the CNAs went in and repositioned him and checked his brief every two hours. RN #1 was interviewed on 4/10/25 at 9:30 a.m. RN #1 said she was the nurse for Resident #45 on a 3/22/25 when she noticed his coccyx wound worsened. She said she reached out to the resident ' s hospice team to request a visit since the nursing managers were not at the facility on weekends. -However, there was no documentation to indicate that RN #1 reached out to hospice or obtained any new physician's orders for wound care. The WCP was interviewed on 4/10/25 at 10:30 a.m. The WCP said the stage 3 coccyx wound and the left heel DTI wound on Resident #45 were caused by pressure. She said initially she was concerned the coccyx pressure wound was a Kennedy ulcer (end of life wound), but ruled that out. She said he was at risk for developing pressure ulcers due to poor nutritional status, dementia, limited mobility, being bed-bound and refusing nutritional supplements. The director of nursing (DON) and assistant director of nursing (ADON) #1 were interviewed together on 4/10/25 at 11:30 a.m. The DON said when there was a new skin condition discovered, the nurse would write a progress note, the unit manager would review it and put in a referral to the wound care nurse (WCN) and the WCN would reach out to the WCP. The DON said every resident with a new skin condition got a referral to the WCP. He said the primary care physician (PCP) very rarely managed any resident wounds. ADON #1 said she was the wound care nurse at the facility ADON #1 said Resident #45 developed the left heel DTI due to rubbing his feet against the mattress. She said once this was discovered, he started to use soft booties on his heels. She said he was not using the booties prior to the development of the left heel wound. She said he developed his coccyx wound when she was not working so another nurse should have gotten the referral to get the WCP involved. She said she was not aware of the resident ' s coccyx wound until 3/27/25.-However, there was no documentation that another nurse assessed the resident ' s coccyx wound, notified the physician on 3/22/25 or obtained wound care orders (see record review above).

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#77) of five residents reviewed for accident hazards out of 37 sample residents. R77 had severe cognitive impairments. On 3/19/25, the resident took a piece of bread from another resident's plate and ate it. R77 choked and required the Heimlich maneuver (abdominal thrusts used to clear food from a person's airway that is choking) to clear the food from his airway. The resident's care plan directed staff to assist R77 with controlling his rate of eating, monitoring the resident's bite sizes to ensure the resident did not choke and monitoring the resident to avoid the resident stuffing food into his mouth. Additionally, R77 was prescribed a mechanically altered diet. Observations during the survey revealed R77 received menu items that were not consistent with his prescribed diet order. The staff failed to provide supervision during meals to ensure the resident did not take food from other residents' plates or monitor the resident's bite sizes which put the resident at a continued risk of further choking incidents for R77. The failure to provide appropriate supervision during times of resident intake placed residents at risk for serious harm or death if not corrected immediately. On 4/25/25 at 10:11 a.m., immediate jeopardy was identified based on the facility failures above that created a situation of potential serious harm for R77, requiring immediate corrective action. Findings include:I. Immediate JeopardyA. Situation of immediate jeopardyThe facility failed to ensure staff provided appropriate supervision and implemented the identified care-planned interventions for R77 after the resident had a choking incident on 3/19/25. The facility's failure to ensure staff provided appropriate supervision and implemented care-planned interventions led to a continued risk of further choking incidents for R77. B. Imposition of immediate jeopardyOn 4/25/25 at 10:11 a.m., the Nursing Home Administrator (NHA) was notified of the immediate jeopardy situation created by the facility's failure to ensure R77 received appropriate supervision during times of intake. C. Facility plan to remove immediate jeopardyOn 4/25/25 at 4:37 p.m. the facility submitted a plan to remove the Immediate Jeopardy. The removal plan read:1. Corrective action R77 will be served food per the physician's ordered diet of a mechanical soft diet. The Certified Nurse Aide (CNA) and/or nurse will provide R77 with supervision during times of intake to ensure he is eating safely. R77 will be placed on safety checks due to his behavior of taking other residents' food that is not within his prescribed diet texture. Any additional safety concerns or behaviors will be addressed, documented in the behavior log and will be updated on the care plan with appropriate interventions. The care plan and interventions will be reviewed and updated every quarter and with every change of condition. 2. Identification of others An audit was completed on 4/10/25 and determined 14 residents required assistance with intake. Each resident identified will be seated at a designated table in the dining room. The Restorative CNA or designee will provide active monitoring of those residents during each meal. 3. Systemic changesOn 4/11/25 the facility's Diet Orders and Food Services policies were reviewed by leadership to ensure alignment with current best practices and regulatory standards. The DON (Director of Nursing)/designee provided education, starting on 4/11/25 and completed on 4/16/25, to the nursing staff of the requirement for supervision for the at-risk residents that were identified. CNAs and nurses will observe and supervise the at-risk residents identified for choking, appropriate meal texture and process of notification if an incident or concern arises. The Dietary Manager (DM) provided education, starting on 4/10/25 and completed on 4/11/25, to the cooks and servers on diet extensions to ensure proper diet textures, diet types, food procurement and scoop sizes. The kitchen will follow diet extensions at each meal. The cook appropriately prepares the meals following the diet extensions. The server sets up steam tables with all meals prepared by the cook and verifies that menus and extensions are correct. The server will plate the food based on the diet type report that is located on the steam table. The diet type report is updated as needed and with any new orders. The CNA will verify that the meal served matches the diet type report. One CNA and a nurse will be designated to each dining area for the entire meal service. One leadership member is assigned to meals to round and assist as needed. If a resident on eating supervision is given a snack, a CNA or designee must supervise the resident while they consume the snack. 4. MonitoringThe DM/designee will audit the lunch meal on 4/25/25 to ensure extensions are served correctly. Additionally, three meals will be audited daily for one week, then one meal daily for three weeks, then five random meals per week until substantial compliance. The audits will be documented on a written log and concerns will be addressed immediately. The DON/designee will audit resident supervision on 4/25/25. Additionally, three meals will be audited daily for one week, then one meal daily for three weeks, then five random meals per week until substantial compliance. The audits will be documented on a written log and concerns will be addressed immediately. D. Removal of the immediate jeopardyThe NHA was notified the immediate jeopardy was removed on 4/25/25 at 5:17 p.m. based on the facility's removal plan (see above). However, the deficient practice remained at a D level, no actual harm with potential for more than minimal harm that is not immediate jeopardy. II. Facility policy and procedureThe Food Service policy and procedure, undated, was provided by the NHA on 4/25/25 at 3:30 p.m. It read in pertinent part, "Special diets as prescribed by a physician are available. "Mealtime assistance is available as needed, based on the resident service plan."III. Failure to ensure staff provided appropriate supervision and implemented care-planned interventionsA. Resident #77 statusR77, age 68, was admitted on 6/8/23. According to the April 2025 computerized physician orders (CPO), diagnoses included severe dementia with agitation and delusional disorders. The 2/10/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and could never or rarely make decisions regarding tasks of daily life. The resident required partial to moderate staff assistance for eating and was dependent on staff for all other activities of daily living (ADL). The assessment documented the resident was receiving a mechanically altered diet. B. ObservationsDuring a continuous observation of the lunch service on 4/8/25, beginning at 12:11 p.m. and ending at 12:42 p.m., the following was observed:At 12:11 p.m. R77 was sitting at a dining table with several other residents. An unidentified staff member delivered R77's meal to him and the resident began eating independently. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:14 p.m. R77 speared multiple whole baby carrots and sweet potato pieces on his fork and ate them in one bite. No staff member intervened and staff did not provide the resident with supervision to ensure he was eating safely. At 12:19 p.m. multiple staff members were delivering trays of food to residents throughout the dining room and in their rooms. Staff did not provide R77 with supervision to ensure he was eating safely. At 12:22 p.m. an unidentified staff member delivered a second helping of food to R77 and promptly returned to serving trays. The unidentified staff member did not provide the resident with supervision to ensure he was eating safely. At 12:28 p.m. R77 continued eating by himself. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:36 p.m. R77 finished his second helping of food and remained at the dining table with other residents. At 12:42 p.m. an unidentified staff member cleared the plates from the dining table at which R77 was sitting. Staff did not provide the resident with supervision to ensure he did not take food from another resident's plate. During a continuous observation of the lunch service on 4/9/25, beginning at 12:10 p.m. and ending at 12:50 p.m., the following was observed:At 12:24 p.m. R77 was served a slice of pumpkin pie and ate it independently. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:26 p.m. R77 self-propelled to another table in the dining room. R77 grabbed food off of another resident's plate and used that resident's spoon to eat her pumpkin pie. A resident from R77's usual table in the dining room saw what was occurring and yelled out to get the staff's attention. CNA #6 assisted R77 back to his original table and gave him the other resident's remaining pumpkin pie. CNA #6 did not provide the resident with supervision to ensure he was eating safely. At 12:31 p.m. R77 began self-propelling away from the dining room. CNA #6 tried to redirect R77 back to his table and said his food was there. CNA #6 assisted R77 back to his table in the dining room where he was served lunch and began eating. CNA #6 again did not provide the resident with supervision to ensure he was eating safely. At 12:33 p.m. Restorative Nurse Aide (RNA) #1 brought R77 a glass of juice and sat down next to the resident and began providing the resident with supervision and cues for eating more slowly. C. Record reviewThe restorative care plan, initiated 2/26/24, revealed R77 required restorative nursing for dining. Pertinent interventions included assisting R77 with controlling his rate of eating, monitoring bite size to ensure the resident did not choke and monitoring self-feeding to avoid the resident stuffing food into his mouth. The ADL care plan, revised 1/30/24, revealed R77 had a self-care performance deficit due to his dementia. Pertinent interventions included R77 required staff assistance with eating.-Review of the resident's care plan did not reveal the facility identified the resident often took food from other resident's plates. Review of R77's April 2025 CPO revealed a physician's order for a regular diet with a mechanical soft texture, ordered 8/11/24. A progress note, dated 3/7/25 at 4:46 p.m., revealed R77 was observed in the dining room with a plastic soda bottle cap in his mouth. Staff were instructed to remove soda bottles from the dining tables and residents were reminded to throw their trash into the waste receptacles once they were finished with them. A progress note, dated 3/19/25 at 7:26 a.m., revealed R77 had an episode of choking during the previous meal. R77 appeared to be unable to swallow, speak, or cough. Nursing staff assisted R77 with an abdominal thrust and visible food was removed from his mouth. A Registered Nurse (RN) performed an assessment which indicated R77 was able to speak, eat and swallow. No injuries were noted at the time, vital signs were stable. Staff were to continue to observe the resident during meal times and cut his food into smaller pieces. R77's representative and physician were notified. An interdisciplinary team (IDT) note, dated 3/26/25 at 11:34 a.m., revealed R77 choked on an item that was not part of his diet texture. R77 had grabbed food from another resident's plate. R77 was monitored to ensure he was not taking food from other residents' plates. R77 sat at the restorative table while eating. The IDT team suggested the residents in the work therapy program be assigned to pick up plates when other residents were done eating. D. Menu extensionsReview of the menu extensions from 4/7/25 through 4/13/25 revealed the following:The mechanical soft texture lunch meal for 4/9/25 included blackened fish, sweet potato wedges, green beans, and a pureed dinner roll. -However, R77 was served a vegetable blend instead of the green beans on the menu extensions (see observations above). IV. Staff interviewsCNA #4 was interviewed on 4/10/25 at 9:16 a.m. CNA #4 said R77 spent most of his day wandering around the facility. CNA #4 said R77 sometimes tried to grab items from other residents. CNA #4 said R77 was redirectable when he tried to take other residents' items. CNA #4 said the staff had to monitor R77 during meals because he tried to take other residents' meals and drinks. CNA #4 said other residents would yell when R77 took food or drinks from other residents and would redirect him. Licensed Practical Nurse (LPN) #4 was interviewed on 4/10/25 at 9:53 a.m. LPN #4 said R77 liked to grab items and put them in his mouth so the nursing staff had to keep an eye on him. LPN #4 said she was not aware of any choking incidents R77 had. Nurse Manager (NM) #1 was interviewed on 4/10/25 at 3:26 p.m. NM #1 said the nursing staff had to redirect R77 from going into other residents' rooms and grabbing items in the dining room. NM #1 said the nursing staff needed to monitor R77, especially during mealtimes. NM #1 said the nursing staff were good at monitoring R77 and ensuring he did not put anything inappropriate in his mouth. NM #1 said he could not recall if R77 had experienced any choking incidents. The Director of Nursing (DON) was interviewed on 4/10/25 at 4:44 p.m. The DON said R77 had a tendency to grab food from other residents' plates. The DON said R77 had previously grabbed bread from another resident's plate and choked on it. The DON said if the nursing staff saw R77 grabbing food from another resident's plate they redirected him, which in turn made R77 try to eat or get rid of whatever he had grabbed faster than before. The DON said the facility had the resident work therapy program to help clean up the dining room so there were no trays sitting out and thus limiting the amount of food R77 could potentially grab. The DON said the nursing staff increased their monitoring of R77 during meals, and that the resident sat at the restorative dining table so the RNAs could supervise him during meals. The DON said the facility was also utilizing a feeding training program for non-clinical staff so they could help feed and monitor residents during mealtimes.-However, meal observations revealed staff were not supervising R77 when he was eating (see observations above).

Based on observations, record review and interview, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to follow correct portions sizes to ensure adequate nutrition was provided to the residents. Findings include:I. Record reviewThe menu extensions were provided by the Dietary Manager (DM) on 4/10/25 at 4:02 p.m. The menu extensions revealed in pertinent part:-A 1/2 cup serving of seasoned couscous to residents who were prescribed a regular diet, mechanical soft diet and therapeutic diets;-A 1/2 cup serving of pureed seasoned couscous to the residents who were prescribed a pureed diet;-A 1/2 cup serving of Sicilian vegetable blend regular, mechanical soft and therapeutic diets; and,-A 1/2 cup serving of the pureed Sicilian vegetable blend. II. ObservationsDuring a continuous observation of the lunch meal on 4/9/25, beginning at 12:01 p.m. and ending at 1:00 p.m., Dietary Aide (DA) #1 used the following scoop sizes:-A #12 scoop (1/3 cup) for the seasoned couscous for regular, mechanical soft and therapeutic diets;-A #12 scoop (1/3 cup) for the pureed seasoned couscous;-A grey slotted spoon (1/2 cup) for Sicilian vegetable blend regular, mechanical soft and therapeutic diets; and,-A #12 scoop (1/3 cup) for the pureed Sicilian vegetable blend. From 12:22 p.m. to 12:35 p.m. when DA #1 served residents the Sicilian vegetable blend, she filled the #12 scoop (1/3 cup) half to three-quarters full. She did not fill the #12 (1/3 cup) scoop full. DA #1 said she was running out of vegetables in her steam table container.-However, the menu extensions indicated the residents should have received a 1/2 cup scoop of vegetables (see record review above). At 12:35 p.m. DA #1 put approximately 1/8th of a cup of vegetables onto a plate and said "that's all she wrote," as the vegetable blend steam table container was empty. At 12:38 p.m. a container of the Sicilian vegetable blend was delivered. From 12:38 p.m. through the end of service, DA #1 served heaping spoonfuls of the vegetable blend. At 12:58 p.m. DA #1 prepared a mechanically soft texture plate by scooping two #12 scoops of mechanically soft meat and one heaping 1/2 cup scoop of vegetable blend before serving it to the resident. DA #1 said the meal was supposed to include couscous as well, but she had run out of the couscous, so she was just going with it.-The #12 scoop (1/3 cup), measuring 2.67 ounces (oz), was 1.33 oz less than the 1/2 cup (4 oz) specified on the menu extension sheet for the seasoned couscous, pureed seasoned couscous and pureed seasoned vegetable blend. B. Staff interviewsThe DM was interviewed on 4/10/25 at 1:35 p.m. The DM said DA #1 should have been serving a full 1/2 cup scoop of vegetables for each plate. The DM said DA #1 must have thought she was going to run out of vegetables, so she was nervous and overthinking the issue. The DM said the dietary staff were incorrect in using the #12 scoops for each menu item, as they should have been using the #8 (1/2 cup) scoop.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen and one of two nourishment refrigerators. Specifically, the facility failed to:-Ensure safe and appropriate storage of food items in the nourishment room refrigerators;-Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination in the main kitchen; and,-Maintain a clean and sanitary kitchen to prevent the harborage of pests. Findings include:I. Failure to safely and appropriately store food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 4/17/25. It revealed in pertinent part, "Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one."The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety." (3-501.17)The Hormel Code Date and Handling Information 2022, retrieved from https://www.hormelhealthlabs.com/wp-content/uploads/HHL-Code-Date_Handling-Sheet-11_2022.pdf on 4/17/25. It revealed in pertinent part, "Hormel Vital Cuisine Might Shakes, Great Shake Plus, and Nutritious Juice Drink, Shelf Life: unopened: 15 months frozen, refrigerated: 14 days thawed, bedside: up to two hours."B. ObservationsOn 4/7/25 at 9:16 a.m., the following items were observed in the main walk-in refrigerator:-One opened container of half and half, unlabeled and undated;-Three pitchers of lemonade, unlabeled and undated; and,-A plastic bag containing multiple hotdogs and hamburger patties, unlabeled and undated. On 4/8/25 at 1:16 p.m., the following items were observed in the Pinion unit nourishment refrigerator:-An opened jar of sugar-free peach preserves, undated;-A carton of caramel macchiato iced coffee, with an open date of 2/22/25 and an expiration date of 11/29/24;-Four thawed cartons of Mighty Shake (oral nutritional supplement), with a date of 3/12/25; and,-Three thawed cartons of Mighty Shake with dates of 3/8/25, 3/4/25 and 3/15/25. On 4/8/25 at 1:16 p.m. an opened bottle of grape jelly, dated 1/9/25, was sitting on the Pinion nourishment room counter with a container of bread and a jar of peanut butter. The grape jelly was room temperature, and instructions on the bottle ready to refrigerate after opening. On 4/9/25 at 10:39 a.m. two opened bottles of grape jelly were sitting on the main kitchen food preparation counter with a jar of peanut butter. The grape jelly was room temperature and instructions on the bottle ready to refrigerate after opening. C. Staff interviewsThe Dietary Manager (DM) was interviewed on 4/7/25 at 9:35 a.m. The DM said the hotdogs and hamburgers were leftovers from the night before (4/6/25). The DM said the undated lemonade pitchers were from the night before (4/6/25) and the undated half and half container was from that morning (4/7/25). The DM said there was a new dietary aide who served the beverages and was still being trained. The DM said the kitchen staff usually kept leftovers for three to five days before throwing it away. The DM was interviewed a second time on 4/10/25 at 1:35 p.m. The DM said one of the dietary aides went through the nourishment refrigerators throughout the facility, checked their temperatures and went through the refrigerator contents once per day. The DM said the dietary aide recorded the temperatures of the refrigerators daily but did not record that he had gone through the contents of the refrigerators. The DM said Mighty Shakes should be thawed the day they were to be consumed. The DM said she thought the nursing staff were not diligent in looking at the expiration dates for items brought in by the residents or their families. II. Failed to ensure ready-to-eat foods were handled in a sanitary mannerA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 4/17/25. It revealed in pertinent part, "Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment." (3-301.11)B. ObservationsDuring a continuous observation of the lunch meal service on 4/9/25, beginning at 12:01 p.m. and ending at 1:00 p.m. the following was observed:At 12:46 p.m. Certified Nurse Aide (CNA) #7 entered the Pinion unit nourishment room and said she needed to make a sandwich. CNA #7 retrieved a plastic bag of bread, grabbed two slices of bread with her bare hands and placed them on a plate. CNA #7 applied jelly to one slice of bread using a knife, then applied peanut butter to the other slice of bread. CNA #7 used her bare hands to close the sandwich and then used her bare hand to stabilize the sandwich as she cut it in half. C. Staff interviewThe DM was interviewed on 4/10/25 at 1:35 p.m. The DM said ready-to-eat foods should be handled with gloves after performing hand hygiene. The DM said the instance of the CNA preparing the sandwich with her bare hands should not have happened. III. Maintain a clean and sanitary kitchen to prevent the harborage of pestsA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 4/17/25. It revealed in pertinent part, "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 theirpresence on the premises by using methods, if pests are found, such as trapping devices or other means of pest control and eliminating harborage conditions. (6-501.111)"Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. (6-201.11)"In food establishments in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be covered and closed to no larger than one millimeter. The floors in food establishments in which water flush cleaning methods are used shall be provided with drains and be graded to drain, and the floor and wall junctures shall be covered and sealed." (6-201.13)B. ObservationsOn 4/8/25 at 1:16 p.m. the window in the Pinion unit nourishment room was open approximately eight inches and did not have a screen on the window. The window lead to the resident smoking patio. On 4/9/25 at 10:39 a.m. during a follow-up tour of the main kitchen, the following was observed:-The window in the main kitchen was open approximately four inches and did not have a screen;-The dishwashing area floor had an area of several square feet covered with standing water;-The food preparation area had several tiles that were cracked or missing;-There was a gap approximately two inches wide between the floor and the wall in the dishwashing area; -Several holes in the back wall of the dishwashing area;-The bottom five inches of the wall in the dishwashing area had dirt accumulated on it;-A glue trap was positioned below the dishwasher which contained thirteen dead cockroaches; and,-A glue trap was in the trash can next to the dishwashing area which contained more than fifteen dead cockroaches. On 4/9/25 at 12:12 p.m. the following was observed in the Pinion unit nourishment room:-The baseboard was separated from the wall with a gap of approximately 1.5 inches and when pressed, two ants came out from behind the baseboard;-An ant was observed running along the edge of an empty plastic container below the steam table; and,-A hole in the wall below the handwashing sink, approximately twelve inches wide by six inches tall. On 4/10/25 at 12:50 p.m. the glue trap under the dishwasher was no longer in place. C. Staff interviewThe DM was interviewed on 4/9/25 at 10:52 a.m. The DM said the kitchen staff did regular maintenance in the dishwashing area and used a squeegee to push any spilled water into the drain. The DM said the building was older, and any standing water was from water spilling while the kitchen staff were washing dishes. The DM said the windows in the kitchen should not be open. The DM said the facility staff needed to install the window screens and air conditioning units in the kitchen and satellite kitchen. The DM was interviewed a second time on 4/10/25 at 1:35 p.m. The DM said the facility's pest control company installed the glue trap below the dishwasher as a preventative measure and had just serviced the building a few weeks prior. The DM said there were cockroaches on the glue trap because of the trap's proximity to the drain. The DM said she had not seen any cockroaches in the food preparation areas. The DM said the staff may have thrown the glue trap away the night prior as they were cleaning the dishwashing area. The DM said the maintenance staff were aware of the holes in the walls of the dishwashing area and that there were active work orders for them. The DM said the kitchen maintenance work was all in progress. The DM said she was not aware of the hole in the wall below the handwashing sink in the Pinion unit nourishment room. -Pest control records and maintenance records were requested on 4/10/25 at 6:01 p.m. but were not received.

Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standard and principles that applied to individuals providing services in the facility for one (#78) of four residents reviewed for hospice services out of 37 sample residents. Specifically, the facility failed to ensure the hospice agency's notes were easily accessible to the facility staff and had consistent communication and documentation of hospice care visits and updates. Findings include:I. Facility policy and procedureThe Hospice Program policy, undated, was provided by the Nursing Home Administrator (NHA) on 4/7/25 at 11:01 a.m. It read in pertinent part, "When a resident has been diagnosed as terminally ill, the director of wellness will contact a hospice agency and request that a visit/interview with the resident/family be conducted to determine the resident's wishes relative to participate in the hospice program and to review available hospice (services) with the resident and/or responsible party. The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions, which includes, designation of a hospice registered nurse to coordinate the implementation of the plan of care, and provision of substantially all core services that must be routinely provided directly by the hospice associates and cannot be delegated to the community as outlined in current hospice regulations."II. Hospice AgreementThe hospice agreement, dated 1/14/25, was provided by the NHA on 4/10/25 at 3:50 p.m. The agreement read in pertinent part, "Hospice and the facility shall each maintain complete and detailed clinical records concerning each resident receiving facility services and hospice services under the agreement in accordance with prudent record-keeping procedures and as required. Each clinical record shall complete, promptly and accurately document all services provided to, and events concerning each resident, including evaluations, treatments, and progress notes. Hospice and the facility shall have each entry made for services provided to be signed by the person providing the services. Each record shall be readily accessible and systematically organized to facilitate retrieval by either party."II. Resident #78A. Resident statusR78, age greater than 65, was admitted on 1/7/21. According to the April 2025 computerized physician orders (CPO), diagnoses included high blood pressure, psoriatic arthritis (inflammatory disease affecting skin and joints), depression, anxiety, dementia, history of neck and left femur fracture, stage 3 pressure ulcer and senile degeneration of the brain (decline in cognitive function). The 2/25/25 minimum data set (MD) assessment revealed the resident had a short-term and long-term memory problem and his cognitive skills for daily decision making were severely impaired per staff assessment. The resident was dependent on staff for hygiene, bathing, transfers and repositioning in bed. The MDS assessment revealed R78 was receiving hospice services. II. Record reviewThe hospice plan of care, dated 1/15/25, was provided by the NHA on 4/10/25 at 11:32 a.m. The hospice plan of care documented the resident's personal hygiene was to be maintained. Pertinent interventions included care was to be completed by a hospice Certified Nurse Aide (CNA) that included CNA visits twice a week to provide a shower, shampoo, shave, mouth care, assist with dressing and undressing, nail care (file only), and skin observations. R78's hospice binder, was retrieved from a locked room and provided by Assistant Director of Nursing (ADON) #1 on 4/9/25 at 2:20 p.m. The hospice binder contained weekly visit verification forms signed by the hospice nurses. CNA visit notes were present in the binder from a 1/17/25 joint visit with a hospice nurse.-However, no other CNA notes, verification of hospice CNA visits or provisions of activities of daily living (ADL) care by hospice for the resident were present in R78's hospice communication binder or electronic medical record. Hospice nursing assessments were not present in the resident's hospice binder or electronic medical record (see facility follow up below). III. Staff interviewsLicensed Practical Nurse (LPN) #2 was interviewed on 4/10/25 at 11:15 a.m. LPN #2 said the hospice staff saw R78 every Tuesday and Thursday. LPN #2 said the hospice staff checked in with the nurse upon arrival and after providing care for R78. LPN #2 said the hospice staff also provided R78 his shower. LPN #2 said she had not noticed that the hospice staff were not coming according to planned visits. LPN #2 said a hospice nurse and hospice CNA might come the same day or sometimes two nurses came the same day. LPN #2 said a hospice nurse had asked for the facility's hospice binder last week but the hospice staff did not usually ask for the hospice binder. LPN #2 said hospice staff could ask any staff person at the facility for the hospice binder, but she had only been asked for the hospice binder once. Certified Nurse Aide (CNA) #1 was interviewed on 4/10/25 at 11:25 a.m. CNA #1 said hospice staff were frequently at the facility and provided showers twice a week to R78. The Social Services Director (SSD) was interviewed on 4/10/25 at approximately 9:00 a.m. The SSD said that the facility and hospice team met monthly to make sure residents' needs were met and the facility invited the hospice team to the care conferences for the residents assigned hospice care. The SSD said ADL care was the primary responsibility of the facility and hospice was to provide additional ADL support. The SSD said R78's showers were the primary responsibility of the facility staff. ADON #1 was interviewed on 4/10/25 at approximately 9:00 a.m. ADON #1 said hospice CNAs were supposed to come twice a week to see R78 and the hospice CNAs checked in with the nurses when they arrived. ADON #1 said the facility did not have the hospice CNA notes for R78 and were in the process of acquiring those (during the survey). IV. Facility follow upThe Health Information Manager (HIM) provided R78's hospice notes on 4/10/25 at 12:57 p.m. (during the survey). A review of R78's hospice notes revealed a 2/6/25 hospice note that documented that a care conference took place on 2/5/25 without hospice being notified and hospice staff reinforced with the facility staff to include hospice in future care conferences. The hospice notes did not include documented visits twice a week by a hospice CNA.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents, which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include:I. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correctF689 Accidents HazardsDuring the recertification survey on 5/23/24 F689 was cited at a L level scope and severity, immediate jeopardy to resident health or safety, widespread. During the abbreviated survey on 12/11/24 F689 was cited at a L level scope and severity, immediate jeopardy to resident health or safety, widespread. During the recertification survey on 4/25/25 F689 was cited at a J level scope and severity, immediate jeopardy to resident health or safety, isolated. F867 Quality Assurance ProgramDuring the recertification survey on 5/23/24 F867 was cited at a F level scope and severity, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread. During the abbreviated survey on 12/11/24 F867 was cited at a F level scope and severity, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread. During the recertification survey on 4/25/25 F867 was cited at a F level scope and severity, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread. II. Cross-reference citation Cross-reference F689: The facility failed to provide appropriate supervision at meal times for R77, who had a history of choking. The facility's failure to provide supervision and assistance at meal times for a resident with a history of choking created a situation where a serious outcome was likely to occur and created an immediate jeopardy situation. III. Staff interviewsThe Nursing Home Administrator (NHA) was interviewed on 4/10/25 at 4:30 p.m. The NHA said the facility held a monthly QAPI meeting. The NHA said the facility team members, including the interdisciplinary team (IDT), also met daily and discussed potential risks to residents. The NHA said each day during the daily meeting, the team reviewed resident risks identified, how the risks were monitored and the expected outcome. The NHA said the facility developed corrective actions for identified risks that resulted from a collaborative discussion with the IDT. The NHA said there was a documentation binder that contained the problem that was identified, a system put in place or improved upon and how that situation was monitored. The NHA said each day any new issue that was identified was monitored. The NHA said a facility consultant performed an additional review of the facility's plan of correction.-However, the facility failed to identify R77 was not assisted and monitored during meal times, according to his care planned interventions, to ensure R77 did not choke.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to:-Ensure enhanced barrier precautions (EBP) were followed for R45 and R78,-Ensure proper hand hygiene was followed during wound care for R78,-Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms; and,-Ensure high touch surfaces in residents' rooms were cleaned. Findings include:I. EBP and hand hygiene failuresA. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO)'s, (4/2/24), retrieved on 4/15/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html,"Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities."EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO."Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens changing briefs or assisting with toileting, device care or use (central line urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing)."According to the CDC Clinical Safety, Hand Hygiene for Healthcare Worker (2/17/24), retrieved on 4/15/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety,"Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal."B. ObservationsDuring a continuous observation of wound care on 4/9/25, beginning at 11:30 a.m. and ending at 12:00 p.m., the following was observed:Certified Nurse Aide (CNA) #5 donned (put on) gloves and turned R45 on his side. Registered Nurse (RN) #1 donned gloves and applied skin prep to R45's left heel deep tissue injury (DTI). -However, CNA #5 and RN #1 failed to don a gown prior to high contact care for R45. Nurse Manager (NM) #2 washed her hands and gathered supplies. NM #2 donned gloves and removed the old, dirty dressing covering R45's stage 3 pressure ulcer on the sacrum. NM #2 changed gloves and sanitized her hands after removing the dirty dressing. NM #2 cleansed the wound with saline and applied skin prep around the wound. She then applied calcium alginate soaked in Dakin's solution into the wound bed, covered the wound with a Mepilex dressing, dated and initialed the dressing. She changed gloves and performed hand hygiene between each step in the process. -However, NM #2 did not don a gown prior to starting wound care. During a continuous observation on 4/9/25, beginning at 2:37 p.m. and ending at 3:15 p.m., the following was observed: Assistant Director of Nursing (ADON) #1 and Licensed Practical Nurse (LPN) #1 entered R78's room with wound care supplies on a sterile field created on top of a movable table. ADON #1 washed her hands and donned gloves before beginning R78's wound care. LPN #1 also donned gloves and assisted ADON #1 by holding R78 in position. ADON #1 prepared the supplies on the sterile field and then used a sterile swab to remove the soiled packing from within R78's wound. -However, ADON#1 and LPN #1 failed to don a gown prior to starting R78's wound care. ADON #1 grabbed a new sterile swab, folded new packing material over the top and placed it on her sterile field. ADON #1 flushed the wound with saline (salt water), dabbed around the wound with sterile gauze and used the swab to press the new, clean packing into the wound. -However, ADON #1 failed to change gloves after removing the soiled packing from R78's wound. ADON #1 removed her gloves, washed her hands, donned new gloves, and applied a skin protectant around the wound. She placed sterile gauze over the wound and secured all four sides with paper tape. She removed her gloves, wrapped the supplies up within the sterile field, threw out the supplies and sanitized her hands. C. Staff interviewsADON #1 and LPN #1 were interviewed together on 4/9/25 at 3:36 p.m. ADON #1 said normally, only gloves were worn when doing dressing changes, even if the wound was infected. She said EBP was worn when there were weeping wounds or wounds with resistant organisms. She said she did not think she had any training regarding EBP and was not aware that they were supposed to be wearing gowns for dressing changes. She said the wound doctor had not been wearing a gown for dressing changes. She said she should have changed her gloves after taking out the old packing. LPN #1 said she just started orientation at the facility and did not remember learning about EBP precautions. The Director of Nursing (DON), who was also the facility's Infection Preventionist (IP #1), and IP #2 were interviewed together on 4/10/25 at 10:18 a.m. The DON said he educated staff about EBP last summer (2024) when the policy came out. He said there were isolation carts for residents with catheters, wounds and other infections. He said the staff had used EBP for a previous resident that had a fungal infection, but somehow, they had forgotten about the other reasons for EBP precautions. He said EBP was needed for high-contact activities like bathing, dressing, incontinence care and linen changes for those residents. He said face shields were provided for residents with catheters to protect from splashing. He said he did not realize the focus had been lost until yesterday (4/9/25). He said he had started adding orders and care plans for EBP in the residents' electronic medical record (EMR). IP #2 said that she had already started re-educating staff about hand hygiene and EBP. IP #2 said the packet for new employees had information on EBP but somehow it had been forgotten. She said she would also address hand hygiene and EBP at the upcoming skills fair in August 2025. II. Housekeeping failuresA. Professional referenceAccording to Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, retrieved on 3/21/25 fromhttps://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext,"High-touch surfaces are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). "Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment."B. ObservationsDuring a continuous observation on 4/8/25, beginning at 9:13 a.m. and ending at 9:53 a.m., the following was observed:An unidentified Housekeeper (HK) sanitized her hands and donned gloves. She entered room #340, which was a triple occupancy room. The HK sprayed the bathroom toilet with Oxivir 5 sanitizer, wet a clean cloth with water from the sink and wiped the outside, rim of the toilet seat and sides. She scrubbed the inside of the toilet with the toilet brush and flushed the toilet. She wiped the top and outsides of the toilet again with the cloth and then placed the used cloth in a bag on her supply cart outside the room. -The HK failed to change gloves after cleaning a dirty area (the bathroom) before moving to a clean area (the bedroom). The HK then sprayed the mirror and sink with glass and multi-surface cleaner and wiped the area with clean cloths. She placed the used cloths in the bag on the cart and grabbed new ones. She cleaned the surfaces of the bedroom furniture, bed frames and lights for the three resident areas, changing cloths between steps. She cleaned the windows with a new cloth and window cleaner. She swept and then mopped the floor, using new mop heads for each resident area. At 9:53 a.m. the HK removed her gloves, exited room #340 and sanitized her hands.-The HK failed to clean and sanitize the high touch areas in room #340 including door knobs, light switches and the call lights. C. Staff interviewsThe Maintenance Director (MTD) was interviewed on 4/10/25 at 3:45 p.m. The MTD said it was necessary that the housekeeping staff changed their gloves before entering each room for cleaning. He said the staff should remove their gloves before leaving the room and wash or sanitize their hands afterward. The MTD said the housekeeping staff required high touch surfaces like call lights and door knobs to be cleaned at least twice per week unless the resident had an infection. He said he just learned today that gloves should be changed twice during a room clean, so he planned to do education on that.

A licensure survey was completed on 4/7/25 to 4/25/25. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#45) of three residents reviewed for pressure ulcers out of 37 sample residents. R45, who was known to be at risk for pressure injuries, was admitted on 3/28/19. The resident had diagnoses of major depressive disorder, dementia, overactive bladder, hemiplegia (paralysis to one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke). On 3/22/25 R45 developed a facility-acquired stage 2 pressure injury to his coccyx, however, the facility did not notify the physician, initiate further pressure ulcer interventions on the resident's pressure ulcer care plan once the stage 2 pressure injury was identified, or obtain wound care orders until after the wound had worsened. On 3/27/25, the wound care physician documentation indicated R45's pressure wound had worsened to a stage 3 pressure injury. Due to the facility's failures to notify the physician, implement timely additional interventions following pressure injury development and implement orders for wound care until after worsening of the wound, R45 developed a facility-acquired stage 2 pressure injury, which worsened to a stage 3 pressure injury. Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 4/16/25 from https://www.internationalguideline.com/guideline, "Pressure ulcer classification is as follows:"Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk)."Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable"Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover' and should not be removed."Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment." II. Facility policy and procedureThe Pressure Ulcer policy and procedure, undated, was provided by the health information manager (HIM) on 4/10/25 at 4:39 p.m. It documented in pertinent part,"Residents are assessed for skin integrity and wounds upon move-in with documentation in the move-in assessment in the electronic medical record (EMR). Residents with a wound or skin integrity issue at move-in will have weekly skin assessments using the skin integrity evaluation in the EMR until the wound is healed. Residents without wounds or skin integrity issues or recently healed wounds will continue having weekly skin evaluations using the skin integrity evaluation weekly in the EMR. Follow the provider orders for specific wound treatments. Following the identification of wounds, the care plan will be updated to reflect."III. Resident #45A. Resident statusR45, age 74, was admitted on 3/28/19. According to the April 2025 computerized physician orders (CPO), diagnoses included major depressive disorder, dementia, overactive bladder, hemiplegia (paralysis to one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke). The 2/19/25 facility assessment documented the resident had a short term memory problem based on the staff assessment for mental status. A brief interview for mental status was not conducted due to the resident being rarely/never understood. The assessment documented the resident was dependent on staff for eating, hygiene, bathing, dressing, rolling side to side and transferring. The assessment documented the resident was always incontinent of bowel and bladder. The assessment indicated the resident was at risk for pressure ulcers and did not have any skin conditions at the time of the assessment. The resident had a pressure reducing device for the chair and the bed, turning and repositioning, nutrition or hydration interventions and application of an ointment/medication to somewhere other than to the feet. The assessment indicated the resident did not have rejections of care. B. Resident observationsOn 4/9/25 at 11:30 a.m. R45's wound care was observed with Nurse Manager (NM) #2, Registered Nurse (RN) #1 and Certified Nurse Aide (CNA) #5. The resident's left heel had a dark purple/maroon deep tissue injury (DTI) that RN #1 applied skin prep to. Both heels were in soft booties. R45 had a large crater-like wound that was dark brown/black in color at the middle or center of the wound on his sacrum. The skin around the wound was white and red in color. The old dressing NM #2 took off was brown in color with a moderate amount of drainage from the wound. When NM #2 removed the soiled dressing, RN #1 put her shirt up to her nose to mask the scent of the wound. NM #2 said the smell of the wound was from the purulent drainage that was brown in color. She said it was a stage 3 wound. NM #2 cleansed the wound with saline, applied calcium alginate soaked in Dakin's solution to the wound bed, applied skin prep around the wound bed and applied a foam dressing to the wound. C. Record reviewThe pressure ulcer plan of care, initiated 3/29/19 and revised 4/8/25 (during the survey), documented that R45 had potential for pressure ulcer development because of his episodes of incontinence, poor nutritional intake and refusals for repositioning. The care plan documented he had an actual wound on his coccyx and a DTI to his left heel. The care plan goal was for R45 to have no significant alteration in skin integrity through the next review period. Interventions included administering supplements as ordered though he often refused supplements (initiated 4/8/25, during the survey), an air mattress (initiated on 4/8/25, during the survey), a Broda chair (initiated 4/8/25, during the survey), coordination with hospice (initiated 4/8/25, during the survey), pain management (initiated 4/8/25, during the survey), wound round checks with the wound care team (initiated 4/2/25), skin prep to heels and heel protectors on while in bed (initiated 4/8/25, during the survey), staff to reposition resident every two to three hours, though he often refused (revised on 4/8/25, during the survey), urinal will be made available at bedside (initiated 3/29/19) and a weekly skin assessment and to notify the physician of any refusals (initiated 3/29/19). -The facility failed to update the skin integrity care plan with interventions related to the actual pressure injuries until 4/8/25, 18 days after the development of the coccyx pressure ulcer and 20 days after the development of the left heel unstageable DTI. -The facility failed to implement timely interventions to prevent R45's facility acquired stage 2 pressure ulcer from progressing to a stage 2 pressure ulcer. A Braden Scale assessment (a tool used for predicting pressure ulcer risk), dated 3/11/25, documented R45 was at risk for developing a pressure injury. The risk factors included not always being able to communicate discomfort, occasionally being moist, his ability to walk was severely limited or non-existent, he had very limited mobility, adequate nutrition and a potential problem for friction and shear (skin slides around). A review of the wound care physician's (WCP) note, dated 3/20/25, revealed R45 had an unstageable DTI to the left heel from pressure. It measured 1.2 centimeters (cm) by 1.5 cm. The skin was intact with purple/deep maroon discoloration. Recommendations from the WCP included skin prep to the wound once daily, off-loading the wound and floating the resident's heels while in bed. -However, there were no wound care orders for the resident's left heel DTI until 4/10/25 (during the survey) after the discrepancy was brought to the attention of the facility (see physician's orders below). A review of the nursing progress note, dated 3/22/25 and written by RN #1, documented a new facility-acquired stage 2 pressure ulcer to R45's coccyx with partial thickness skin loss with exposed dermis. It documented that barrier cream was applied and to refer to the wound care team. -However, there was no documentation that the WCP was notified. There was no follow up from the wound care team until 3/27/25, five days later, when the WCP was at the facility and after the resident's wound had advanced to a stage 3 pressure ulcer. A review of the WCP note dated 3/27/25, revealed R45 had a stage 3 pressure wound to his coccyx with poor healing potential. The wound measured 2 cm by 2 cm, had moderate to sero-sanguinous exudate and 100% granulation tissue. The treatment was a foam dressing with border three times weekly with skin prep to the peri wound, off load and reposition per facility protocol. A review of CNA documentation for repositioning every two hours revealed R45 refused only one offer to reposition in the 31 days in March 2025. -However, there were 17 days out of the 31 days in March 2025 where it was documented that the resident was repositioned on his back several hours consecutively. A review of R45's April 2025 CPO revealed the following physician's orders for wound care:Clean area of coccyx with wound cleanser, pat dry, apply Medi-honey to open area, skin prep around the wound bed and cover with bordered foam dressing, ordered 3/31/25. -The wound care was ordered 11 days after the development of the pressure ulcer to the coccyx (see progress notes above). Air mattress ordered related to skin integrity/wounds, settings on automatic firm, ordered 4/8/25.-The intervention was ordered 18 days after the development of the pressure ulcer to the coccyx (see progress notes above). Heel protectors on while in bed, ordered 3/17/25. -However, according to NM #1, the facility did not start using booties on the resident until after the development of the unstageable DTI to the left heel (see NM #1 interview below). Clean area with wound cleanser, pat dry, apply skin prep to DTI on inner right heel every shift, ordered on 3/17/25. -However, the DTI was on the resident's left heel.-The April 2025 CPO failed to reveal wound care orders for the resident's left heel unstageable DTI. E. Staff interviewsCNA #8 was interviewed on 4/9/25 at 10:48 a.m. CNA #8 said R45 would refuse to eat sometimes if he did not like the food. She said the staff tried to offer him alternatives if he did not like the food. She said he was incontinent and needed total assistance for all cares, including eating, repositioning and toileting hygiene. She said he did not refuse to be repositioned or to get his brief changed. NM #2 was interviewed on 4/9/25 at 11:30 a.m. NM #2 said when there was a new skin condition, the nurse who noticed it put a wellness alert in the EMR. She said this alerted the unit manager to get a referral for the WCP to see the resident. She said R45 was at risk for developing pressure ulcers prior to the development of the injuries due to his poor nutrition, refusing repositioning, refusing floating his heels and refusing the booties until recently. She said R45 was dependent on staff for repositioning.-However, review of the CNAs repositioning documentation for R45 revealed he refused only one repositioning attempt in March 2025 (see record review above). CNA #3 was interviewed on 4/10/25 at 9:07 a.m. CNA #3 said R45 did not refuse care. She said the only thing he would refuse at times was eating meals and supplements. She said he got up occasionally out of bed for meals and showers. She said he was incontinent and did not use the call light. CNA #3 said the CNAs went in and repositioned him and checked his brief every two hours. RN #1 was interviewed on 4/10/25 at 9:30 a.m. RN #1 said she was the nurse for R45 on a 3/22/25 when she noticed his coccyx wound worsened. She said she reached out to the resident's hospice team to request a visit since the nursing managers were not at the facility on weekends. -However, there was no documentation to indicate that RN #1 reached out to hospice or obtained any new physician's orders for wound care. The WCP was interviewed on 4/10/25 at 10:30 a.m. The WCP said the stage 3 coccyx wound and the left heel DTI wound on R45 were caused by pressure. She said initially she was concerned the coccyx pressure wound was a Kennedy ulcer (end of life wound), but ruled that out. She said he was at risk for developing pressure ulcers due to poor nutritional status, dementia, limited mobility, being bed-bound and refusing nutritional supplements. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) #1 were interviewed together on 4/10/25 at 11:30 a.m. The DON said when there was a new skin condition discovered, the nurse would write a progress note, the unit manager would review it and put in a referral to the Wound Care Nurse (WCN) and the WCN would reach out to the WCP. The DON said every resident with a new skin condition got a referral to the WCP. He said the primary care physician (PCP) very rarely managed any resident wounds. ADON #1 said she was the wound care nurse at the facility ADON #1 said R45 developed the left heel DTI due to rubbing his feet against the mattress. She said once this was discovered, he started to use soft booties on his heels. She said he was not using the booties prior to the development of the left heel wound. She said he developed his coccyx wound when she was not working so another nurse should have gotten the referral to get the WCP involved. She said she was not aware of the resident's coccyx wound until 3/27/25.-However, there was no documentation that another nurse assessed the resident's coccyx wound, notified the physician on 3/22/25 or obtained wound care orders (see record review above).

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#77) of five residents reviewed for accident hazards out of 37 sample residents. R77 had severe cognitive impairments. On 3/19/25, the resident took a piece of bread from another resident's plate and ate it. R77 choked and required the Heimlich maneuver (abdominal thrusts used to clear food from a person's airway that is choking) to clear the food from his airway. The resident's care plan directed staff to assist R77 with controlling his rate of eating, monitoring the resident's bite sizes to ensure the resident did not choke and monitoring the resident to avoid the resident stuffing food into his mouth. Additionally, R77 was prescribed a mechanically altered diet. Observations during the survey revealed R77 received menu items that were not consistent with his prescribed diet order. The staff failed to provide supervision during meals to ensure the resident did not take food from other residents' plates or monitor the resident's bite sizes which put the resident at a continued risk of further choking incidents for R77. The failure to provide appropriate supervision during times of resident intake placed residents at risk for serious harm or death if not corrected immediately. On 4/25/25 at 10:11 a.m., a situation was identified, based on the facility failures above that created a situation of potential serious harm for R77, requiring immediate corrective action. Findings include:I. Choking supervision facility failuresThe facility failed to ensure staff provided appropriate supervision and implemented the identified care-planned interventions for R77 after the resident had a choking incident on 3/19/25. The facility's failure to ensure staff provided appropriate supervision and implemented care-planned interventions led to a continued risk of further choking incidents for R77. On 4/25/25 at 10:11 a.m., the Nursing Home Administrator (NHA) was notified of the situation of potential serious harm created by the facility's failure to ensure R77 received appropriate supervision during times of intake. On 4/25/25 at 4:37 p.m. the facility submitted the following plan:1. Corrective action R77 will be served food per the physician's ordered diet of a mechanical soft diet. The Certified Nurse Aide (CNA) and/or nurse will provide R77 with supervision during times of intake to ensure he is eating safely. R77 will be placed on safety checks due to his behavior of taking other residents' food that is not within his prescribed diet texture. Any additional safety concerns or behaviors will be addressed, documented in the behavior log and will be updated on the care plan with appropriate interventions. The care plan and interventions will be reviewed and updated every quarter and with every change of condition. 2. Identification of others An audit was completed on 4/10/25 and determined 14 residents required assistance with intake. Each resident identified will be seated at a designated table in the dining room. The Restorative CNA or designee will provide active monitoring of those residents during each meal. 3. Systemic changesOn 4/11/25 the facility's Diet Orders and Food Services policies were reviewed by leadership to ensure alignment with current best practices and regulatory standards. The DON (Director of Nursing)/designee provided education, starting on 4/11/25 and completed on 4/16/25, to the nursing staff of the requirement for supervision for the at-risk residents that were identified. CNAs and nurses will observe and supervise the at-risk residents identified for choking, appropriate meal texture and process of notification if an incident or concern arises. The Dietary Manager (DM) provided education, starting on 4/10/25 and completed on 4/11/25, to the cooks and servers on diet extensions to ensure proper diet textures, diet types, food procurement and scoop sizes. The kitchen will follow diet extensions at each meal. The cook appropriately prepares the meals following the diet extensions. The server sets up steam tables with all meals prepared by the cook and verifies that menus and extensions are correct. The server will plate the food based on the diet type report that is located on the steam table. The diet type report is updated as needed and with any new orders. The CNA will verify that the meal served matches the diet type report. One CNA and a nurse will be designated to each dining area for the entire meal service. One leadership member is assigned to meals to round and assist as needed. If a resident on eating supervision is given a snack, a CNA or designee must supervise the resident while they consume the snack. 4. MonitoringThe DM/designee will audit the lunch meal on 4/25/25 to ensure extensions are served correctly. Additionally, three meals will be audited daily for one week, then one meal daily for three weeks, then five random meals per week until substantial compliance. The audits will be documented on a written log and concerns will be addressed immediately. The DON/designee will audit resident supervision on 4/25/25. Additionally, three meals will be audited daily for one week, then one meal daily for three weeks, then five random meals per week until substantial compliance. The audits will be documented on a written log and concerns will be addressed immediately. The NHA was notified the above plan was accepted on 4/25/25 at 5:17 p.m. II. Facility policy and procedureThe Food Service policy and procedure, undated, was provided by the NHA on 4/25/25 at 3:30 p.m. It read in pertinent part, "Special diets as prescribed by a physician are available. "Mealtime assistance is available as needed, based on the resident service plan."III. Failure to ensure staff provided appropriate supervision and implemented care-planned interventionsA. Resident #77 statusR77, age 68, was admitted on 6/8/23. According to the April 2025 computerized physician orders (CPO), diagnoses included severe dementia with agitation and delusional disorders. The 2/10/25 facility assessment revealed the resident was severely cognitively impaired and could never or rarely make decisions regarding tasks of daily life. The resident required partial to moderate staff assistance for eating and was dependent on staff for all other activities of daily living (ADL). The assessment documented the resident was receiving a mechanically altered diet. B. ObservationsDuring a continuous observation of the lunch service on 4/8/25, beginning at 12:11 p.m. and ending at 12:42 p.m., the following was observed:At 12:11 p.m. R77 was sitting at a dining table with several other residents. An unidentified staff member delivered R77's meal to him and the resident began eating independently. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:14 p.m. R77 speared multiple whole baby carrots and sweet potato pieces on his fork and ate them in one bite. No staff member intervened and staff did not provide the resident with supervision to ensure he was eating safely. At 12:19 p.m. multiple staff members were delivering trays of food to residents throughout the dining room and in their rooms. Staff did not provide R77 with supervision to ensure he was eating safely. At 12:22 p.m. an unidentified staff member delivered a second helping of food to R77 and promptly returned to serving trays. The unidentified staff member did not provide the resident with supervision to ensure he was eating safely. At 12:28 p.m. R77 continued eating by himself. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:36 p.m. R77 finished his second helping of food and remained at the dining table with other residents. At 12:42 p.m. an unidentified staff member cleared the plates from the dining table at which R77 was sitting. Staff did not provide the resident with supervision to ensure he did not take food from another resident's plate. During a continuous observation of the lunch service on 4/9/25, beginning at 12:10 p.m. and ending at 12:50 p.m., the following was observed:At 12:24 p.m. R77 was served a slice of pumpkin pie and ate it independently. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:26 p.m. R77 self-propelled to another table in the dining room. R77 grabbed food off of another resident's plate and used that resident's spoon to eat her pumpkin pie. A resident from R77's usual table in the dining room saw what was occurring and yelled out to get the staff's attention. CNA #6 assisted R77 back to his original table and gave him the other resident's remaining pumpkin pie. CNA #6 did not provide the resident with supervision to ensure he was eating safely. At 12:31 p.m. R77 began self-propelling away from the dining room. CNA #6 tried to redirect R77 back to his table and said his food was there. CNA #6 assisted R77 back to his table in the dining room where he was served lunch and began eating. CNA #6 again did not provide the resident with supervision to ensure he was eating safely. At 12:33 p.m. Restorative Nurse Aide (RNA) #1 brought R77 a glass of juice and sat down next to the resident and began providing the resident with supervision and cues for eating more slowly. C. Record reviewThe restorative care plan, initiated 2/26/24, revealed R77 required restorative nursing for dining. Pertinent interventions included assisting R77 with controlling his rate of eating, monitoring bite size to ensure the resident did not choke and monitoring self-feeding to avoid the resident stuffing food into his mouth. The ADL care plan, revised 1/30/24, revealed R77 had a self-care performance deficit due to his dementia. Pertinent interventions included R77 required staff assistance with eating.-Review of the resident's care plan did not reveal the facility identified the resident often took food from other resident's plates. Review of R77's April 2025 CPO revealed a physician's order for a regular diet with a mechanical soft texture, ordered 8/11/24. A progress note, dated 3/7/25 at 4:46 p.m., revealed R77 was observed in the dining room with a plastic soda bottle cap in his mouth. Staff were instructed to remove soda bottles from the dining tables and residents were reminded to throw their trash into the waste receptacles once they were finished with them. A progress note, dated 3/19/25 at 7:26 a.m., revealed R77 had an episode of choking during the previous meal. R77 appeared to be unable to swallow, speak, or cough. Nursing staff assisted R77 with an abdominal thrust and visible food was removed from his mouth. A Registered Nurse (RN) performed an assessment which indicated R77 was able to speak, eat and swallow. No injuries were noted at the time, vital signs were stable. Staff were to continue to observe the resident during meal times and cut his food into smaller pieces. R77's representative and physician were notified. An interdisciplinary team (IDT) note, dated 3/26/25 at 11:34 a.m., revealed R77 choked on an item that was not part of his diet texture. R77 had grabbed food from another resident's plate. R77 was monitored to ensure he was not taking food from other residents' plates. R77 sat at the restorative table while eating. The IDT team suggested the residents in the work therapy program be assigned to pick up plates when other residents were done eating. D. Menu extensionsReview of the menu extensions from 4/7/25 through 4/13/25 revealed the following:The mechanical soft texture lunch meal for 4/9/25 included blackened fish, sweet potato wedges, green beans, and a pureed dinner roll. -However, R77 was served a vegetable blend instead of the green beans on the menu extensions (see observations above). IV. Staff interviewsCNA #4 was interviewed on 4/10/25 at 9:16 a.m. CNA #4 said R77 spent most of his day wandering around the facility. CNA #4 said R77 sometimes tried to grab items from other residents. CNA #4 said R77 was redirectable when he tried to take other residents' items. CNA #4 said the staff had to monitor R77 during meals because he tried to take other residents' meals and drinks. CNA #4 said other residents would yell when R77 took food or drinks from other residents and would redirect him. Licensed Practical Nurse (LPN) #4 was interviewed on 4/10/25 at 9:53 a.m. LPN #4 said R77 liked to grab items and put them in his mouth so the nursing staff had to keep an eye on him. LPN #4 said she was not aware of any choking incidents R77 had. Nurse Manager (NM) #1 was interviewed on 4/10/25 at 3:26 p.m. NM #1 said the nursing staff had to redirect R77 from going into other residents' rooms and grabbing items in the dining room. NM #1 said the nursing staff needed to monitor R77, especially during mealtimes. NM #1 said the nursing staff were good at monitoring R77 and ensuring he did not put anything inappropriate in his mouth. NM #1 said he could not recall if R77 had experienced any choking incidents. The Director of Nursing (DON) was interviewed on 4/10/25 at 4:44 p.m. The DON said R77 had a tendency to grab food from other residents' plates. The DON said R77 had previously grabbed bread from another resident's plate and choked on it. The DON said if the nursing staff saw R77 grabbing food from another resident's plate they redirected him, which in turn made R77 try to eat or get rid of whatever he had grabbed faster than before. The DON said the facility had the resident work therapy program to help clean up the dining room so there were no trays sitting out and thus limiting the amount of food R77 could potentially grab. The DON said the nursing staff increased their monitoring of R77 during meals, and that the resident sat at the restorative dining table so the RNAs could supervise him during meals. The DON said the facility was also utilizing a feeding training program for non-clinical staff so they could help feed and monitor residents during mealtimes.-However, meal observations revealed staff were not supervising R77 when he was eating (see observations above).

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility's general characteristics. The facility consists of two structures separated by a common wall with a two-hour fire rating. The original structure, constructed in 1963, is a two-story, type II (222) structure and has been designated as building A-1 on past surveys. In 1973, the facility constructed a three-story addition to the original structure. The three-story addition is a type II (111) structure and has been designated as building A-2 on past surveys. Because both structures are classified as fully protected with a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, it has been decided to survey the buildings as two separate structures no longer but combine them, with no negative outcome to the facility, to create one building (A-3), classified as a type II(111) structure, based on the lesser of the two construction types The two-hour fire rate separation is considered to be an acceptable horizontal exit, serving either side. The facility is licensed for 135 beds and operated part of it as a secured unit during this survey. This recertification survey was conducted on April 23, 2025 for compliance to fire safety requirements of NFPA 101, Life Safety Code, 2012 edition, Chapter 19 for Existing Health Care Occupancies. Each of the following deficiency items were discussed in the exit conference with the Maintenance Director and facility Administrator during the exit conference.

STANDARD is not met as evidenced by: Through observation and staff interview of the fire alarm system during the survey, the facility failed to install and maintain the Interior wall and ceiling finishes per 2012 NFPA 101 Life Safety Code 19.3.2.1 and 8.7.1. A large section of drywall is missing from the boiler room wall, which does not meet a hazardous area's 1-hour fire resistance rating. 2012 Life Safety Code 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: (1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3 (2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7 (3) Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43Failure to maintain a 1-hour fire resistance rating could affect all occupants, staff, and visitors in the smoke compartment if a fire occurred. During the facility tour, the Director of Maintenance acknowledged the deficient condition of the missing drywall in the boiler room.

STANDARD not met, as evidenced by: Through observation, it was determined that the facility failed to provide proper coverage of the Dry Chemical Extinguishing System as required by NFPA 12 (Chapter 9 and Section 9.3.2). The discharge nozzles are incorrectly positioned compromising the safety of the gas-fired cooktop and grill's cooking surface. NFPA 96-12.1.2.2. Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior re-evaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire-extinguishing system. This non-compliant installation could affect all residents in the smoke department if a fire were to occur, due to the improper positioning of fire suppression nozzles. The following deficient item was discussed in the exit conference with the Maintenance Director and facility Administrator.

STANDARD is not met as evidenced by the: It was determined by record review and staff interview during the survey the facility failed to perform and document the exercising of all fire and smoke dampers at least every four years, per NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This deficient practice could affect all residents, staff, and visitors if the smoke dampers malfunction due to improper maintenance should a fire occur. Records were not available during the survey to document the inspection and testing of the fire dampers installed in the facility every four years. The facility maintenance director believed that no fire dampers were installed in the building; however, during the facility tour, fire and smoke dampers were discovered throughout the premises. NFPA 90A, Chapter 3, Section 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. This practice could impact all patients and staff in every smoke compartment if the smoke dampers fail due to improper maintenance during a fire. The issue of smoke and fire dampers' deficiency was discussed with the Director of Maintenance during the record review of required documentation.

STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to Inspect and Test at frequencies specified by ASMEA17.1 Safety Code for Elevators and Escalators. The facility failed to provide a written report for the monthly Firefighter Service test of the Phase II in-car key operations. 9.4.2.3 Elevators in accordance with ASMEA17.7/CSA B44.7, Performance-Based Safety Code for Elevators and Escalators, shall be deemed to comply with ASME A17.1/CSA B44, Safety Code for Elevators and Escalators, or ASME A17.3, Safety Code for Existing Elevators and Escalators. This deficient practice could affect all residents if the Firefighter' Emergency Operations if a fire emergency occurred on the upper floors. The elevator deficiency item was discussed with the Maintenance Director and Administrator during the exit conference.

STANDARD is not met as evidenced by: Based on record review during the survey; it was determined that the facility failed to conduct fire drills per the Life Safety Code, Section 19.7.1.2 and 4.7. Fire drills are required to be conducted on each shift quarterly; the facility failed to conduct a fire drill on the second shift in the first quarter 2025. Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual conditions that can occur in an actual emergency. The Director of Maintenance acknowledged the conditions of fire drill deficiency during the facility record review.

STANDARD is not met as evidenced by: Based on record review and staff interview during the survey; it was determined that the facility failed to maintain emergency power systems per Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8. The facility failed to provide documentation for weekly inspections of the emergency generator conducted over the last six months. NFPA 110-8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. This deficient practice has the potential to affect all residents throughout the facility in the event of power loss. The emergency generator deficiency item was discussed with the Maintenance Director during the survey and the exit conference with the Administrator.

A survey prompted by Incident #39854 was conducted on 4/22/25. No deficiencies were cited.

A revisit survey was completed on 2/5/25 for all previous deficiencies cited on 12/11/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 2/5/25 for all previous deficiencies cited on 12/11/24. The facility is in compliance with all regulations surveyed.

A survey prompted by Incident #38580 was conducted on 12/10/24 to 12/11/24. Two deficiencies were cited.

Based on observations, record review, and interviews, the facility failed to ensure that one (#1) of three sample residents and other residents residing on the facility's third floor remained as free from accidents as possible. Resident #1 was admitted to the facility on 11/22/24 for long-term care. The resident was severely cognitively impaired and impulsive with poor safety awareness. At the time of admission, he was assessed not to be at risk for elopement. However, after admission, staff reported he was "always on the move," standing near the doors and observing people passing in and out. By 11/30/24, the resident had become increasingly agitated and made several attempts to leave, setting off alarms when he attempted to open the doors. At approximately 1:08 p.m. that day, the resident eloped from the facility. Video surveillance revealed the resident, wearing shorts, a short-sleeved shirt, and flip-flops, followed a staff member through the emergency exit door (kitchen delivery door) on the first floor before the door, which was on a 15-second delay, relocked. Attempts to locate and contact the resident by phone were unsuccessful. He was located by the police two days later (12/2/24), approximately ten miles away from the facility, in critical condition. The resident was transported to the hospital by ambulance where he was pronounced deceased. The facility failed to provide the resident with adequate services and support to prevent his elopement. Despite staff knowledge of the resident's escalating behaviors on 11/30/24, their interviews revealed a conflicting understanding of the resident's level of supervision that day, and progress notes and care plans failed to document interventions to minimize his safety risk. The facility further failed to take adequate steps after 11/30/24 to prevent additional elopements. According to the director of nursing (DON), since the incident on 11/30/24, all staff had received education to wait 15 seconds after exiting the emergency door to ensure the door was locked, and a sign was placed on the doors as a reminder. However, on 12/10/24 at 12:35 p.m. (during the survey), observations revealed an unlocked door to the boiler room next to the emergency exit door. Another door in this room led to the outside. Both doors were unlocked and not secured with an alarm. All residents from the third floor had access to the unlocked doors. According to the nursing home administrator (NHA), the boiler room door was to be locked at all times and she was unclear why it had been left unlocked. The facility failures above created a situation of immediate jeopardy for serious harm, for Resident #1 and widespread potential for serious harm for facility residents on the third floor, that required immediate corrective action. Findings include:IMMEDIATE JEOPARDY I. Immediate Jeopardy A. Findings of immediate jeopardyResident #1 was admitted to the facility on 11/22/24 for long-term care. The resident was severely cognitively impaired and impulsive with poor safety awareness. At the time of admission, he was assessed not to be at risk for elopement. However, after admission, staff reported he was "always on the move," standing near the doors and observing people passing in and out. By mid-day on 11/30/24, the resident had become increasingly agitated and made several attempts to leave, setting off alarms when he attempted to open the doors. At approximately 1:08 p.m. that day, he eloped from the facility. Video surveillance revealed the resident, wearing shorts, a short-sleeved shirt, and flip flops, followed a staff member through the emergency exit door (kitchen delivery door) on the first floor before the door, on a 15-second delay, relocked. Attempts to locate and contact the resident by phone were unsuccessful. He was located by the police two days later, approximately ten miles away from the facility in critical condition. The resident was transported to the hospital by ambulance where he was pronounced deceased. The facility failed to provide the resident with adequate services and support to prevent his elopement. Despite staff knowledge of the resident's escalating behaviors on 11/30/24, their interviews revealed a conflicting understanding of the resident's level of supervision that day and progress notes and care plans failed to reveal interventions to minimize his safety risk. The facility further failed to take adequate steps after 11/30/24 to prevent additional elopements. According to the director of nursing (DON), since the incident on 11/30/24, all staff had received education to wait 15 seconds after exiting the emergency door to ensure the door was locked and a sign was placed on the doors as a reminder. However, on 12/10/24 at 12:35 p.m. (during the survey), observations revealed an unlocked door to the boiler room next to the emergency exit door. Another door in this room led to the outside. Both doors were unlocked and not secured with an alarm. All residents from the third floor had access to these unlocked doors. According to the nursing home administrator (NHA), the boiler room door was to be locked at all times and she was unclear why it had been left unlocked. The facility failures above created a situation of immediate jeopardy for serious harm, for Resident #1 and widespread potential for serious harm for facility residents on the third floor, that required immediate corrective action. B. Facility plan to remove the immediate jeopardy On 12/10/24 at 5:48 p.m., the NHA provided a plan to remove the immediate jeopardy situation. The removal plan read:The boiler door was locked by the NHA on 12/10/2024 at 4:32 p.m. On 12/10/24 at 4:33 p.m. no other doors in the community were found to lead to an exit. The boiler room was verified to be secured at 4:32 p.m. by the NHA. The maintenance director or a designated team member will conduct daily verification of the boiler door lock each morning. All checks will be documented in TELS.Staff were educated that locked doors need to be locked at all times sent via SmartLinx messages on 12/10/24. The NHA reviewed the SmartLinx report to verify that all staff received the education on 12/10/24 at 5:53 p.m. Signs were placed on the boiler room door stating "this door to be always locked" - 12/10/24 at 6 p.m. Education was provided to staff about the elopement procedure and wandering interventions. 12/10/2024 at 5:45 p.m. to 6:30 p.m., and 12/11/2024 at 5:30 a.m. - 06:40 a.m. The staffing coordinator and director of nursing provided the education. The education is recorded on a training sign in sheet. On 12/10/2024 at 5:00 p.m. the social services director reviewed the most recent elopement assessments for all residents to ensure those residents identified as at risk for elopement have interventions in place to prevent elopement. C. Removal of immediate jeopardyThe NHA was notified the immediate jeopardy was removed on 12/11/24 at 2:30 p.m. based on the facility's removal plan (see above). However, the deficient practice remained at a G level, isolated, actual harm. II. Facility PolicyThe Elopement, Wandering, and Wanderguard policy, undated, was received from the NHA on 12/11/24 at 3:30 p.m. It read in pertinent part:"Purpose: To identify residents at risk for wandering and/or elopement attempts and provide systematic approaches to manage these behaviors. Procedure:1. Obtain resident photo. Insert photo in the electronic health record. 2. Each new resident is introduced to associates and data gathering begins on prior history of elopement or wandering through interviews with resident and family members. 3. Elopement Risk Tool will be completed as part of move in, then as needed per quarterly Wellness Re-Evaluation or with a change of condition. 4. Associates will develop the Care Plan for the resident addressing the risk for elopement, through consultation with resident provider, Care Team, and Family for the best practice related to elopement/wandering behaviors. 5. Wanderguard© systems (where available and in use) may be utilized for residents who exhibit wandering and elopement risk behaviors. Wanderguard© is added to the Care Plan for the resident. 6. Door alarms and Wanderguard© systems where applicable, are armed and checked as per policy to maintain them in good working order. 7. Associates will respond to door alarms to identify if an unattended Resident has exited any secure environment. In the event a Resident does elope, see policy for Elopement/Missing Resident policy. 8. Care Plan development may initiate per provider order: 15, 30 or 60 minute checks for physical location monitoring of any high risk resident and document the ordered checks. 9. Associate allows Residents to move freely within the community."III. Resident #1A. Resident statusResident #1, age less than 65, was admitted to the facility on 11/22/24. According to the November 2024 computerized physician orders (CPO), diagnoses included diabetes type 2, metabolic encephalopathy, and schizoaffective disorder. The 11/29/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident was independent with most activities of daily living. He was able to ambulate without a walker or cane. B. Record review 1. Admission assessments and care plans The admission note on 11/22/24 indicated that the resident needed prompts about safety as he "lacked safety awareness in general." The care plan for behaviors initiated on 11/25/24 revealed Resident #1 was verbally aggressive due to schizoaffective disorder. Interventions included administering medications as ordered, providing opportunities for positive interactions, intervening as necessary to protect the safety rights of others, and diverting attention. The care plan for cognition initiated on 11/25/24 revealed Resident #1 had impaired cognitive function and impaired thought process due to schizoaffective disorder. Interventions included engaging the resident in simple structured activities. The care plan indicated that the resident needed supervision and assistance with all decision-making. It did not mention that the resident had a personal phone, and what type of assistance he needed with the maintenance of it, such as charging. The resident did not have a care plan for wandering behaviors. The elopement evaluation completed on 11/25/24 (three days after admission), indicated that the resident did not wander and was not at risk for elopement. A review of the resident's record revealed no documented behaviors before 11/30/24.2. Events on 11/30/24At midnight, a nurse's note documented that the resident was pacing, screaming at others, and wandering. Attempted interventions of offering food and providing a calm environment were not effective. At 5:31 a.m., a note documented the resident was wandering through halls, screaming and making disruptive sounds and upsetting other residents. The resident was offered food, provided a calm environment, and was redirected; however, the resident's behavior did not change. A late entry note completed on 12/4/24 with the effective date of 11/30/24 summarized the events that followed. The note documented:-The resident's physician was contacted in the morning and gave an order for the psychotropic medication (Olanzapine, 5 milligrams, one time only for schizoaffective disorder). The medication was administered at 12:31 p.m., and the resident was observed for effectiveness and was reported by staff as effective. -Around 11:00 a.m., "the resident was asked if he would agree to be placed on the secured unit for temporary placement, and as his own responsible party, he refused. The resident was on increased observation and was noted at the nurses' station around 1:06 p.m."-At 2:00 p.m., staff were not able to locate the resident in the facility. They completed a thorough search of all rooms and closets and were not able to locate the resident. -At 3:05 p.m., the resident was identified as missing. The late entry on 12/4/24 summarized the events above, documenting that Resident #1 became increasingly agitated and made several attempts to leave, setting off alarms when attempting to open the doors. The resident was combative and unable to be redirected. Staff administered psychotropic medication and placed the resident on every 15-minute checks "unofficially to make sure medicine did not cause drowsiness." However, a review of the documentation from 11/30/24 above revealed no documentation of 15-minute checks, and interviews with staff (see below) revealed there was a conflicting understanding of the resident's level of supervision on 11/30/24. In addition, there were no interventions to minimize his safety risk beyond the administration of the psychotropic medication, including no evidence of outreach to the family for information on effective interventions to address his behavior and safety needs. Resident #1's spouse was interviewed on 12/10/24 at 12:16 p.m. She said no one from the facility told her that the resident was at risk for elopement and they did not discuss his safety or options they had to keep him safe. She said on 11/30/24, she was working and she got a call from the facility around 2:30 p.m. The staff on the phone told her they could not find her husband. She said she took time off work and called her husband's brothers who drove from another city and they all went looking for him. She said facility staff advised her to call his cell phone as he might recognize her name and pick up the phone. She said the phone calls did not go through. 3. Facility investigation The facility's investigation of the elopement, initiated on 11/30/24 and completed on 12/4/24, revealed that the resident was located by police on the morning of 12/2/24 outside of the fenced building which was approximately 10 miles away from the facility. The resident was taken to the hospital where he was pronounced deceased. The review of the surveillance video from 11/30/24 revealed Resident #1 was wearing a blue short-sleeved shirt, gray shorts, white socks, and dark flip-flops when he entered the elevator on the third floor at 1:06 p.m. The resident exited the elevator around 1:08 p.m. He turned right into the hallway where a staff member was leaving through the emergency exit (kitchen delivery door). The resident followed the staff member through the door. 4. Police ReportThe police detective was interviewed by phone on 12/12/24 at 9:15 a.m. He said the initial call from the facility was received around 1:30 p.m. on 11/30/24. His report read:On 12/2/24 early in the morning, the resident was located by police about 10 miles away from the facility location. He was in the fenced area that he entered in the morning of 12/1/24 (per the surveillance camera in the area). Upon discovery, the resident was in physical distress, the night temperature in the area was 24-25 degrees Fahrenheit. The resident was wearing a blue hoodie-style shirt, gray shorts, and worn-out socks. He had no shoes. The resident had a flip phone with him which was uncharged. Based on the last signal records from the phone, the battery has been uncharged since 11/28/24. The resident was transported to the hospital by ambulance where he was pronounced deceased. C. Staff interviewsStaff interviews revealed a lack of documentation on the resident's behavior before 11/30/24, conflicting reports on his behavior before 11/30/24, and conflicting understanding of the level of supervision provided on the day he eloped. 1. The director of nursing (DON) was interviewed in the presence of the NHA on 12/10/24 at 9:40 a.m. and again on 12/11/24 at 4:38 p.m. The DON said that on admission Resident #1 was not at risk for elopement. The DON said a comprehensive elopement assessment was completed by social services. Residents were observed for seven days after admission to establish a baseline of their behavior. He said if anything was observed that would require an intervention it was usually discussed in daily meetings. The DON said the resident was on frequent checks because he was started on a new medication and staff were watching for its effectiveness. He said on 11/30/24, the resident left the building around 1:06 p.m. through the emergency exit door by following a staff member. He said staff searched the building and attempted to call the resident as he had a phone with him, but there was no answer. The DON said since the incident, the facility provided education to all staff in the building to wait 15 seconds after exiting the emergency door to ensure the door was locked. In addition, signs were placed on all doors as a reminder. 2. Licensed practical nurse (LPN) #1 was interviewed on 12/10/24 at 12:25 a.m. She said when Resident #1 was admitted, he was physically active and, at times aggressive. He was always on the move and "took the tour of the building." He would usually stand near the doors and observe people passing in and out. She said the resident knew where he was but he did not fully understand why he was here. She said on 11/30/24, she was working on a different unit when she was notified by the nurse that Resident #1 was missing. She said she assisted staff in searching the entire building and after the resident was not located, she contacted the police and the administrator. After that, she reviewed the surveillance video where she observed the resident leave through the emergency exit door on the first floor near the kitchen area. The resident followed a staff member who was leaving through the door. The alarm was not triggered as the staff member used the fob to exit the door and the resident followed right after him. She said she did not know if the resident was on 15-minute checks on that day as she was not working on that unit. She said she received education after the incident to wait 15 seconds before walking away from the emergency door exit as it takes 15 seconds for the alarm to reset. 3. LPN #2 was interviewed on 12/10/24 at 12:50 a.m. He said he was the nurse who admitted the resident on 11/22/24. He said the resident was confused and did not know why he was at the facility. He said the resident had impulsive behaviors and poor safety awareness. He noticed the resident had poor safety awareness when he observed him eating as the resident was putting too much food in his mouth before he was able to chew and swallow. He said the resident's daily routine was to walk throughout the building. He said he was told by other staff that the resident made attempts to open the doors and set off alarms. He said he was told by LPN #1 that it was the responsibility of social services to complete an elopement assessment on admission. He said he completed his nursing assessment but not the elopement assessment. He said his last education on elopement was sometime in October or September 2024. 4. Certified nurse aide (CNA) #1 was interviewed on 12/10/24 at 1:15 a.m. He said he worked with the resident only on one occasion. He said he was working on 11/30/24 and when he returned from lunch he observed other staff around the resident who was attempting to leave through the emergency exit. He said Resident #1 was not his resident and he did not know if he was on 15-minute checks. He said he does not remember when his last education on elopement was. 5. LPN #1 was interviewed a second time on 12/10/24 at 1:45 p.m. She was interviewed in the presence of the assistant director of nursing (ADON). The LPN said the elopement assessment was usually completed by the nurse who admitted the resident and it's usually done within the three days of admission. The ADON said that three days would allow staff to observe the resident and see his baseline behavior. She said all behaviors should be documented in progress notes. She said since the incident on 11/30/24, all staff were educated to wait 15 seconds for the emergency door to lock before walking away from it. She said a reminder sign was placed on every emergency exit door in the facility. 6. CNA #2 was interviewed on 12/10/24 at 1:50 p.m. She said Resident #1 had always wandered since he was admitted. She said at times he would have bizarre behavior such as sitting on the floor. She said the resident was independent and was able to walk everywhere. She said she did not know if he was on 15-minute checks. She said other staff told her that the resident made attempts to leave, but it never happened on her shift. 7. LPN #3 was interviewed on 12/10/24 at 1:55 p.m. She said Resident #1 walked a lot everywhere, he was "constantly up and down the elevator all day long." She said staff kept an eye on the resident since he was always on the move but she did not know if he was on 15-minute checks. She said she did not work with the resident on 11/30/24. 8. The staff member Resident #1 followed out the emergency exit was interviewed on 12/11/24 at 10:45 a.m. He said on 11/30/24 around 1:00 p.m. he stepped away from the kitchen for a smoke. He said he exited the building through the emergency exit door near the kitchen. He said he did not wait 15 seconds for the door to lock. He said he did not see the resident exiting behind him. He said he had been working in the facility for the last three months and upon hire he received education to wait 15 seconds for the door to lock up. He said he did not wait for the door to lock on 11/30/24. He said he was very sorry as he was aware of the incident. He said he was re-educated again after the incident to follow the 15-second rule for the emergency doors. 9. The social service director (SSD) was interviewed on 12/11/24 at 12:10 p.m. She said elopement assessments in the building were completed by social services assistants who were assigned to the unit. She said nurses had a small section on the initial assessment where elopement was mentioned; however, a comprehensive assessment should be completed by social services within seven days of admission. She said the rationale for seven days was that every resident has to be accustomed to the setting of the facility and would be observed for seven days for behaviors. She said observations were made for every newly admitted resident, but they were not documented daily. All observations would be documented in the assessment form on day seven when it was due. She said Resident #1 was admitted as he met the criteria for a mental health diagnosis. She said his initial stay was "perfectly calm and he did not express the desire to leave the building." She said he did not trigger the risk of elopement until 11/30/24 when he was in distress. On 11/30/24, she was a supervisor on call and when she received a call about Resident #1's escalating behaviors she instructed the staff to continue to monitor him. She said the facility offered the resident a move to the secure unit, but he refused. She said even though his cognition was severely impaired and he was not a good advocate for his own safety, the facility was obligated to follow his refusal for a secure unit as respect for his rights. She said the resident's wife was not contacted at this point because the resident was his own responsible party and his wife was only listed as an emergency contact (not power of attorney). She said the facility staff did keep an eye on him; they observed him at the nurse's station, and then in his room later. The resident was on the 15-minute checks, but he left the building within the 10 minutes. She said if staff observed Resident #1 wandering behaviors and attempts to leave the building before 11/30/24, such behaviors should have been documented and the care plan for elopement should have been created. She said the interdisciplinary team met every day to discuss any changes and she did not recall any changes in Resident #1's behavior until 11/30/24. D. Facility response to the 11/30/24 incident. The DON and the NHA were interviewed together on 12/11/24 at 4:38 p.m. The NHA said once the incident was identified on 11/30/24, staff reviewed the resident's record, and the interdisciplinary team met for its daily interdisciplinary meetings and discussed the incident. She said it was identified through the investigation that the staff member did not follow the 15-second rule after exiting through the emergency exit door, and he did not check if anyone was following him. She said the staff member was educated on the 15-second rule upon hire and provided the education log for him. The staff member and all other staff in the building were educated and reminded to wait 15 seconds after exiting through the emergency exit doors. She said signs were placed on all doors throughout the building as a reminder to staff. The DON said starting on 12/10/24, the facility started education for all staff to ensure they were aware of residents at risk for elopement on all units. Binders were created with pictures and care plans of residents who were identified at risk for the elopement. All staff were educated on specific interventions that were in place and the location of the binders at the nurses' station. The NHA said the incident was initially reviewed in the quality assessment performance improvement (QAPI) meeting on 11/30/24. There, the facility identified several missing points from the records, including that detailed behavior with interventions was not documented, the resident was not monitored consistently in the unit, staff on the other units were not aware of residents at risk, and several nursing notes were completed (including skin assessments) after the Resident #1 eloped from the building. The corrective action started on 11/30/24 and continued throughout 12/10/24. IV. The facility's failure to take adequate steps after 11/30/24 to prevent additional elopements. A. Observations on 12/10/24 at 12:35 p.m. On 12/10/24 at 12:35 p.m. (during the survey) observations revealed an unlocked door to the boiler room next to the emergency exit door. Another door in this room led to the outside. Both doors were unlocked and not secured with an alarm. All residents from the third floor had access to the unlocked doors. According to the nursing home administrator (NHA), the boiler room door was to be locked at all times and she was unclear why it had been left unlocked. B. The maintenance director was interviewed on 12/11/24 at 3:41 p.m. He said the boiler required some service on 12/9/24. The service company was in the building on 12/9/24 and after they left he did not check if the boiler door was locked. He said he received an education from the facility on 12/10/24 on ensuring all doors that should be locked are locked. He said he checked the entire building on the evening of 12/10/24 to ensure every locked door in the building was locked and all emergency exits were functioning properly. He said he did not identify any additional unlocked or dysfunctional doors. He said he also placed a sign on the boiler door that it must be locked at all times. He said all emergency exit doors were checked once every week and he provided a log.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents, which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include:I. Facility policy and procedureThe facility's QAPI policy was requested from the nursing home administrator (NHA) on 12/11/24 at 4:50 p.m. -However, the policy was not provided as requested. II. Repeat deficienciesReview of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies in F689 Accidents/Hazards. During a recertification survey on 5/23/24, F689 was cited at a L level scope and severity, immediate jeopardy to resident health or safety, widespread. During an abbreviated survey on 10/23/24, F689 was cited at a G level scope and severity, actual harm, isolated. III. Cross-referenced citationsCross-reference F689: The facility failed to prevent an elopement of the resident. On 11/30/24 Resident #1 left the facility by following a staff member through the back emergency exit door on the first floor. He was located by the police two days (12/2/24) later, approximately ten miles away from the facility, in critical condition. He passed away in the hospital upon arrival. Observations of the facility on 12/10/24 revealed the boiler room door was unlocked. The additional door in the boiler room was unlocked as well and led to the outside. The facility's failure to ensure staff were waiting 15 seconds for the door to lock behind them after exiting through the emergency exit and the failure to keep the boiler door locked at all times, created a situation of immediate jeopardy with widespread potential for serious harm. IV. InterviewsThe director of nursing (DON) and the NHA were interviewed together on 12/11/24 at 4:38 p.m. The DON said a comprehensive elopement assessment was completed by social services. Residents were observed for seven days after admission to establish a baseline of their behavior. He said if anything was observed that would require an intervention, it was usually discussed in daily meetings. The NHA said once the incident with Resident #1 was identified on 11/30/24, staff reviewed the resident's record, and all met for daily interdisciplinary team (IDT) meetings and discussed the incident. She said it was identified throughout the investigation that the staff member that Resident #1 followed through the door did not follow the 15-second rule after exiting through the emergency exit door and he did not check if anyone was following him. She said the staff member was educated on the 15-second rule upon hire and provided the education log for the staff member. The NHA said the staff member and all other staff in the building were educated and reminded to wait 15-seconds after exiting through the emergency exit doors. She said signs were placed on all doors throughout the building as a reminder to staff. The DON said, starting on 12/10/24, the facility started education for all staff to ensure they were aware of residents at risk for elopement on all units. He said binders were created with pictures and care plans of residents who were identified as at risk for elopement. The DON said all staff were educated on specific interventions that were in place and the location of the binders at the nurses station. The NHA said the incident was initially reviewed in QAPI on 11/30/24 and the facility identified several missing points from the records, such as detailed behavior with interventions was not documented, the resident was not monitored consistently in the unit, staff on the other units were not aware of Resident #1's elopement risk and several nursing notes were completed after the resident eloped from the building. The NHA said corrective action in response to Resident #1's elopement started on 11/30/24 and continued throughout 12/10/24. V. Facility follow upOn 12/11/24 at 4:50 p.m., during the survey, the NHA provided a copy of the quality measure report. The report was initiated on 11/30/24 after Resident #1 eloped from the building. The report indicated that the facility identified poor documentation for timeline of events, delay in obtaining as needed medications, failure to monitor resident on the unit, staff from other units being unaware of residents who were at risk for elopement and staff not waiting for the exit door to alarm before walking away. The education to all staff on ensuring exit alarms reengaged before walking away doors was completed on 12/3/24. The protocol was initiated to share information between units on residents unable to leave units on 12/5/24.

A survey prompted by complaint #CO38735 was completed on 12/10/24 to 12/11/24. One deficiency was cited.

Based on observations, record review, and interviews, the facility failed to ensure that one (#1) of three sample residents and other residents residing on the facility's third floor remained as free from accidents as possible. Resident #1 was admitted to the facility on 11/22/24 for long-term care. The resident was severely cognitively impaired and impulsive with poor safety awareness. At the time of admission, he was assessed not to be at risk for elopement. However, after admission, staff reported he was "always on the move," standing near the doors and observing people passing in and out. By 11/30/24, the resident had become increasingly agitated and made several attempts to leave, setting off alarms when he attempted to open the doors. At approximately 1:08 p.m. that day, the resident eloped from the facility. Video surveillance revealed the resident, wearing shorts, a short-sleeved shirt, and flip-flops, followed a staff member through the emergency exit door (kitchen delivery door) on the first floor before the door, which was on a 15-second delay, relocked. Attempts to locate and contact the resident by phone were unsuccessful. He was located by the police two days later (12/2/24), approximately ten miles away from the facility, in critical condition. The resident was transported to the hospital by ambulance where he was pronounced deceased. The facility failed to provide the resident with adequate services and support to prevent his elopement. Despite staff knowledge of the resident's escalating behaviors on 11/30/24, their interviews revealed a conflicting understanding of the resident's level of supervision that day, and progress notes and care plans failed to document interventions to minimize his safety risk. The facility further failed to take adequate steps after 11/30/24 to prevent additional elopements. According to the director of nursing (DON), since the incident on 11/30/24, all staff had received education to wait 15 seconds after exiting the emergency door to ensure the door was locked, and a sign was placed on the doors as a reminder. However, on 12/10/24 at 12:35 p.m. (during the survey), observations revealed an unlocked door to the boiler room next to the emergency exit door. Another door in this room led to the outside. Both doors were unlocked and not secured with an alarm. All residents from the third floor had access to the unlocked doors. According to the nursing home administrator (NHA), the boiler room door was to be locked at all times and she was unclear why it had been left unlocked. The facility failures above created a situation of serious harm, for Resident #1 and widespread potential for serious harm for facility residents on the third floor, that required immediate corrective action. Findings include:I. Elopement facility failures Resident #1 was admitted to the facility on 11/22/24 for long-term care. The resident was severely cognitively impaired and impulsive with poor safety awareness. At the time of admission, he was assessed not to be at risk for elopement. However, after admission, staff reported he was "always on the move," standing near the doors and observing people passing in and out. By mid-day on 11/30/24, the resident had become increasingly agitated and made several attempts to leave, setting off alarms when he attempted to open the doors. At approximately 1:08 p.m. that day, he eloped from the facility. Video surveillance revealed the resident, wearing shorts, a short-sleeved shirt, and flip flops, followed a staff member through the emergency exit door (kitchen delivery door) on the first floor before the door, on a 15-second delay, relocked. Attempts to locate and contact the resident by phone were unsuccessful. He was located by the police two days later, approximately ten miles away from the facility in critical condition. The resident was transported to the hospital by ambulance where he was pronounced deceased. The facility failed to provide the resident with adequate services and support to prevent his elopement. Despite staff knowledge of the resident's escalating behaviors on 11/30/24, their interviews revealed a conflicting understanding of the resident's level of supervision that day and progress notes and care plans failed to reveal interventions to minimize his safety risk. The facility further failed to take adequate steps after 11/30/24 to prevent additional elopements. According to the director of nursing (DON), since the incident on 11/30/24, all staff had received education to wait 15 seconds after exiting the emergency door to ensure the door was locked and a sign was placed on the doors as a reminder. However, on 12/10/24 at 12:35 p.m. (during the survey), observations revealed an unlocked door to the boiler room next to the emergency exit door. Another door in this room led to the outside. Both doors were unlocked and not secured with an alarm. All residents from the third floor had access to these unlocked doors. According to the nursing home administrator (NHA), the boiler room door was to be locked at all times and she was unclear why it had been left unlocked. The facility failures above created a situation of serious harm, for Resident #1 and widespread potential for serious harm for facility residents on the third floor, that required immediate corrective action. On 12/10/24 at 5:48 p.m., the NHA provided the following planThe boiler door was locked by the NHA on 12/10/2024 at 4:32 p.m. On 12/10/24 at 4:33 p.m. no other doors in the community were found to lead to an exit. The boiler room was verified to be secured at 4:32 p.m. by the NHA. The maintenance director or a designated team member will conduct daily verification of the boiler door lock each morning. All checks will be documented in TELS.Staff were educated that locked doors need to be locked at all times sent via SmartLinx messages on 12/10/24. The NHA reviewed the SmartLinx report to verify that all staff received the education on 12/10/24 at 5:53 p.m. Signs were placed on the boiler room door stating "this door to be always locked" - 12/10/24 at 6 p.m. Education was provided to staff about the elopement procedure and wandering interventions. 12/10/2024 at 5:45 p.m. to 6:30 p.m., and 12/11/2024 at 5:30 a.m. - 06:40 a.m. The staffing coordinator and director of nursing provided the education. The education is recorded on a training sign in sheet. On 12/10/2024 at 5:00 p.m. the social services director reviewed the most recent elopement assessments for all residents to ensure those residents identified as at risk for elopement have interventions in place to prevent elopement. The NHA was notified the above plan was accepted on 12/11/24 at 2:30 p.m. II. Facility PolicyThe Elopement, Wandering, and Wanderguard policy, undated, was received from the NHA on 12/11/24 at 3:30 p.m. It read in pertinent part:"Purpose: To identify residents at risk for wandering and/or elopement attempts and provide systematic approaches to manage these behaviors. Procedure:1. Obtain resident photo. Insert photo in the electronic health record. 2. Each new resident is introduced to associates and data gathering begins on prior history of elopement or wandering through interviews with resident and family members. 3. Elopement Risk Tool will be completed as part of move in, then as needed per quarterly Wellness Re-Evaluation or with a change of condition. 4. Associates will develop the Care Plan for the resident addressing the risk for elopement, through consultation with resident provider, Care Team, and Family for the best practice related to elopement/wandering behaviors. 5. Wanderguard© systems (where available and in use) may be utilized for residents who exhibit wandering and elopement risk behaviors. Wanderguard© is added to the Care Plan for the resident. 6. Door alarms and Wanderguard© systems where applicable, are armed and checked as per policy to maintain them in good working order. 7. Associates will respond to door alarms to identify if an unattended Resident has exited any secure environment. In the event a Resident does elope, see policy for Elopement/Missing Resident policy. 8. Care Plan development may initiate per provider order: 15, 30 or 60 minute checks for physical location monitoring of any high risk resident and document the ordered checks. 9. Associate allows Residents to move freely within the community."III. Resident #1A. Resident statusResident #1, age less than 65, was admitted to the facility on 11/22/24. According to the November 2024 computerized physician orders (CPO), diagnoses included diabetes type 2, metabolic encephalopathy, and schizoaffective disorder. The 11/29/24 facility assessment revealed the resident was severely cognitively impaired. The resident was independent with most activities of daily living. He was able to ambulate without a walker or cane. B. Record review 1. Admission assessments and care plans The admission note on 11/22/24 indicated that the resident needed prompts about safety as he "lacked safety awareness in general." The care plan for behaviors initiated on 11/25/24 revealed Resident #1 was verbally aggressive due to schizoaffective disorder. Interventions included administering medications as ordered, providing opportunities for positive interactions, intervening as necessary to protect the safety rights of others, and diverting attention. The care plan for cognition initiated on 11/25/24 revealed Resident #1 had impaired cognitive function and impaired thought process due to schizoaffective disorder. Interventions included engaging the resident in simple structured activities. The care plan indicated that the resident needed supervision and assistance with all decision-making. It did not mention that the resident had a personal phone, and what type of assistance he needed with the maintenance of it, such as charging. The resident did not have a care plan for wandering behaviors. The elopement evaluation completed on 11/25/24 (three days after admission), indicated that the resident did not wander and was not at risk for elopement. A review of the resident's record revealed no documented behaviors before 11/30/24.2. Events on 11/30/24At midnight, a nurse's note documented that the resident was pacing, screaming at others, and wandering. Attempted interventions of offering food and providing a calm environment were not effective. At 5:31 a.m., a note documented the resident was wandering through halls, screaming and making disruptive sounds and upsetting other residents. The resident was offered food, provided a calm environment, and was redirected; however, the resident's behavior did not change. A late entry note completed on 12/4/24 with the effective date of 11/30/24 summarized the events that followed. The note documented:-The resident's physician was contacted in the morning and gave an order for the psychotropic medication (Olanzapine, 5 milligrams, one time only for schizoaffective disorder). The medication was administered at 12:31 p.m., and the resident was observed for effectiveness and was reported by staff as effective. -Around 11:00 a.m., "the resident was asked if he would agree to be placed on the secured unit for temporary placement, and as his own responsible party, he refused. The resident was on increased observation and was noted at the nurses' station around 1:06 p.m."-At 2:00 p.m., staff were not able to locate the resident in the facility. They completed a thorough search of all rooms and closets and were not able to locate the resident. -At 3:05 p.m., the resident was identified as missing. The late entry on 12/4/24 summarized the events above, documenting that Resident #1 became increasingly agitated and made several attempts to leave, setting off alarms when attempting to open the doors. The resident was combative and unable to be redirected. Staff administered psychotropic medication and placed the resident on every 15-minute checks "unofficially to make sure medicine did not cause drowsiness." However, a review of the documentation from 11/30/24 above revealed no documentation of 15-minute checks, and interviews with staff (see below) revealed there was a conflicting understanding of the resident's level of supervision on 11/30/24. In addition, there were no interventions to minimize his safety risk beyond the administration of the psychotropic medication, including no evidence of outreach to the family for information on effective interventions to address his behavior and safety needs. Resident #1's spouse was interviewed on 12/10/24 at 12:16 p.m. She said no one from the facility told her that the resident was at risk for elopement and they did not discuss his safety or options they had to keep him safe. She said on 11/30/24, she was working and she got a call from the facility around 2:30 p.m. The staff on the phone told her they could not find her husband. She said she took time off work and called her husband's brothers who drove from another city and they all went looking for him. She said facility staff advised her to call his cell phone as he might recognize her name and pick up the phone. She said the phone calls did not go through. 3. Facility investigation The facility's investigation of the elopement, initiated on 11/30/24 and completed on 12/4/24, revealed that the resident was located by police on the morning of 12/2/24 outside of the fenced building which was approximately 10 miles away from the facility. The resident was taken to the hospital where he was pronounced deceased. The review of the surveillance video from 11/30/24 revealed Resident #1 was wearing a blue short-sleeved shirt, gray shorts, white socks, and dark flip-flops when he entered the elevator on the third floor at 1:06 p.m. The resident exited the elevator around 1:08 p.m. He turned right into the hallway where a staff member was leaving through the emergency exit (kitchen delivery door). The resident followed the staff member through the door. 4. Police ReportThe police detective was interviewed by phone on 12/12/24 at 9:15 a.m. He said the initial call from the facility was received around 1:30 p.m. on 11/30/24. His report read:On 12/2/24 early in the morning, the resident was located by police about 10 miles away from the facility location. He was in the fenced area that he entered in the morning of 12/1/24 (per the surveillance camera in the area). Upon discovery, the resident was in physical distress, the night temperature in the area was 24-25 degrees Fahrenheit. The resident was wearing a blue hoodie-style shirt, gray shorts, and worn-out socks. He had no shoes. The resident had a flip phone with him which was uncharged. Based on the last signal records from the phone, the battery has been uncharged since 11/28/24. The resident was transported to the hospital by ambulance where he was pronounced deceased. C. Staff interviewsStaff interviews revealed a lack of documentation on the resident's behavior before 11/30/24, conflicting reports on his behavior before 11/30/24, and conflicting understanding of the level of supervision provided on the day he eloped. 1. The director of nursing (DON) was interviewed in the presence of the NHA on 12/10/24 at 9:40 a.m. and again on 12/11/24 at 4:38 p.m. The DON said that on admission Resident #1 was not at risk for elopement. The DON said a comprehensive elopement assessment was completed by social services. Residents were observed for seven days after admission to establish a baseline of their behavior. He said if anything was observed that would require an intervention it was usually discussed in daily meetings. The DON said the resident was on frequent checks because he was started on a new medication and staff were watching for its effectiveness. He said on 11/30/24, the resident left the building around 1:06 p.m. through the emergency exit door by following a staff member. He said staff searched the building and attempted to call the resident as he had a phone with him, but there was no answer. The DON said since the incident, the facility provided education to all staff in the building to wait 15 seconds after exiting the emergency door to ensure the door was locked. In addition, signs were placed on all doors as a reminder. 2. Licensed practical nurse (LPN) #1 was interviewed on 12/10/24 at 12:25 a.m. She said when Resident #1 was admitted, he was physically active and, at times aggressive. He was always on the move and "took the tour of the building." He would usually stand near the doors and observe people passing in and out. She said the resident knew where he was but he did not fully understand why he was here. She said on 11/30/24, she was working on a different unit when she was notified by the nurse that Resident #1 was missing. She said she assisted staff in searching the entire building and after the resident was not located, she contacted the police and the administrator. After that, she reviewed the surveillance video where she observed the resident leave through the emergency exit door on the first floor near the kitchen area. The resident followed a staff member who was leaving through the door. The alarm was not triggered as the staff member used the fob to exit the door and the resident followed right after him. She said she did not know if the resident was on 15-minute checks on that day as she was not working on that unit. She said she received education after the incident to wait 15 seconds before walking away from the emergency door exit as it takes 15 seconds for the alarm to reset. 3. LPN #2 was interviewed on 12/10/24 at 12:50 a.m. He said he was the nurse who admitted the resident on 11/22/24. He said the resident was confused and did not know why he was at the facility. He said the resident had impulsive behaviors and poor safety awareness. He noticed the resident had poor safety awareness when he observed him eating as the resident was putting too much food in his mouth before he was able to chew and swallow. He said the resident's daily routine was to walk throughout the building. He said he was told by other staff that the resident made attempts to open the doors and set off alarms. He said he was told by LPN #1 that it was the responsibility of social services to complete an elopement assessment on admission. He said he completed his nursing assessment but not the elopement assessment. He said his last education on elopement was sometime in October or September 2024. 4. Certified nurse aide (CNA) #1 was interviewed on 12/10/24 at 1:15 a.m. He said he worked with the resident only on one occasion. He said he was working on 11/30/24 and when he returned from lunch he observed other staff around the resident who was attempting to leave through the emergency exit. He said Resident #1 was not his resident and he did not know if he was on 15-minute checks. He said he does not remember when his last education on elopement was. 5. LPN #1 was interviewed a second time on 12/10/24 at 1:45 p.m. She was interviewed in the presence of the assistant director of nursing (ADON). The LPN said the elopement assessment was usually completed by the nurse who admitted the resident and it's usually done within the three days of admission. The ADON said that three days would allow staff to observe the resident and see his baseline behavior. She said all behaviors should be documented in progress notes. She said since the incident on 11/30/24, all staff were educated to wait 15 seconds for the emergency door to lock before walking away from it. She said a reminder sign was placed on every emergency exit door in the facility. 6. CNA #2 was interviewed on 12/10/24 at 1:50 p.m. She said Resident #1 had always wandered since he was admitted. She said at times he would have bizarre behavior such as sitting on the floor. She said the resident was independent and was able to walk everywhere. She said she did not know if he was on 15-minute checks. She said other staff told her that the resident made attempts to leave, but it never happened on her shift. 7. LPN #3 was interviewed on 12/10/24 at 1:55 p.m. She said Resident #1 walked a lot everywhere, he was "constantly up and down the elevator all day long." She said staff kept an eye on the resident since he was always on the move but she did not know if he was on 15-minute checks. She said she did not work with the resident on 11/30/24. 8. The staff member Resident #1 followed out the emergency exit was interviewed on 12/11/24 at 10:45 a.m. He said on 11/30/24 around 1:00 p.m. he stepped away from the kitchen for a smoke. He said he exited the building through the emergency exit door near the kitchen. He said he did not wait 15 seconds for the door to lock. He said he did not see the resident exiting behind him. He said he had been working in the facility for the last three months and upon hire he received education to wait 15 seconds for the door to lock up. He said he did not wait for the door to lock on 11/30/24. He said he was very sorry as he was aware of the incident. He said he was re-educated again after the incident to follow the 15-second rule for the emergency doors. 9. The social service director (SSD) was interviewed on 12/11/24 at 12:10 p.m. She said elopement assessments in the building were completed by social services assistants who were assigned to the unit. She said nurses had a small section on the initial assessment where elopement was mentioned; however, a comprehensive assessment should be completed by social services within seven days of admission. She said the rationale for seven days was that every resident has to be accustomed to the setting of the facility and would be observed for seven days for behaviors. She said observations were made for every newly admitted resident, but they were not documented daily. All observations would be documented in the assessment form on day seven when it was due. She said Resident #1 was admitted as he met the criteria for a mental health diagnosis. She said his initial stay was "perfectly calm and he did not express the desire to leave the building." She said he did not trigger the risk of elopement until 11/30/24 when he was in distress. On 11/30/24, she was a supervisor on call and when she received a call about Resident #1's escalating behaviors she instructed the staff to continue to monitor him. She said the facility offered the resident a move to the secure unit, but he refused. She said even though his cognition was severely impaired and he was not a good advocate for his own safety, the facility was obligated to follow his refusal for a secure unit as respect for his rights. She said the resident's wife was not contacted at this point because the resident was his own responsible party and his wife was only listed as an emergency contact (not power of attorney). She said the facility staff did keep an eye on him; they observed him at the nurse's station, and then in his room later. The resident was on the 15-minute checks, but he left the building within the 10 minutes. She said if staff observed Resident #1 wandering behaviors and attempts to leave the building before 11/30/24, such behaviors should have been documented and the care plan for elopement should have been created. She said the interdisciplinary team met every day to discuss any changes and she did not recall any changes in Resident #1's behavior until 11/30/24. D. Facility response to the 11/30/24 incident. The DON and the NHA were interviewed together on 12/11/24 at 4:38 p.m. The NHA said once the incident was identified on 11/30/24, staff reviewed the resident's record, and the interdisciplinary team met for its daily interdisciplinary meetings and discussed the incident. She said it was identified through the investigation that the staff member did not follow the 15-second rule after exiting through the emergency exit door, and he did not check if anyone was following him. She said the staff member was educated on the 15-second rule upon hire and provided the education log for him. The staff member and all other staff in the building were educated and reminded to wait 15 seconds after exiting through the emergency exit doors. She said signs were placed on all doors throughout the building as a reminder to staff. The DON said starting on 12/10/24, the facility started education for all staff to ensure they were aware of residents at risk for elopement on all units. Binders were created with pictures and care plans of residents who were identified at risk for the elopement. All staff were educated on specific interventions that were in place and the location of the binders at the nurses' station. The NHA said the incident was initially reviewed in the quality assessment performance improvement (QAPI) meeting on 11/30/24. There, the facility identified several missing points from the records, including that detailed behavior with interventions was not documented, the resident was not monitored consistently in the unit, staff on the other units were not aware of residents at risk, and several nursing notes were completed (including skin assessments) after the Resident #1 eloped from the building. The corrective action started on 11/30/24 and continued throughout 12/10/24. IV. The facility's failure to take adequate steps after 11/30/24 to prevent additional elopements. A. Observations on 12/10/24 at 12:35 p.m. On 12/10/24 at 12:35 p.m. (during the survey) observations revealed an unlocked door to the boiler room next to the emergency exit door. Another door in this room led to the outside. Both doors were unlocked and not secured with an alarm. All residents from the third floor had access to the unlocked doors. According to the nursing home administrator (NHA), the boiler room door was to be locked at all times and she was unclear why it had been left unlocked. B. The maintenance director was interviewed on 12/11/24 at 3:41 p.m. He said the boiler required some service on 12/9/24. The service company was in the building on 12/9/24 and after they left he did not check if the boiler door was locked. He said he received an education from the facility on 12/10/24 on ensuring all doors that should be locked are locked. He said he checked the entire building on the evening of 12/10/24 to ensure every locked door in the building was locked and all emergency exits were functioning properly. He said he did not identify any additional unlocked or dysfunctional doors. He said he also placed a sign on the boiler door that it must be locked at all times. He said all emergency exit doors were checked once every week and he provided a log.

A survey prompted by #CO37813 and #CO37815 was conducted 10/23/24 to 10/23/24. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure one (#2) of four residents reviewed for accidents out of seven sample residents remained free from accidents. Resident #2, who was non-weight bearing with a history of osteoporosis and was known to be at risk for pathological fractures (fractures caused by disease processes rather than trauma), sustained bilateral distal femoral fractures (thigh bone above the knee) during a transfer with a mechanical (Hoyer) lift into a wheelchair. During the facility's investigation, it was identified that the type of Hoyer sling being used was a split leg sling which required the sling straps to be placed under and crossed around the thighs while the resident was being lifted out of bed and being transferred to the wheelchair. It was identified that the placement of the straps caused pressure and external rotation on the resident's thighs while being lifted with the Hoyer lift and was consistent with the location of Resident #2's fractures. Due to the facility's failure to ensure Resident #2's lower extremities were handled without undue pressure and alignment was maintained during a hoyer transfer, Resident #2 sustained bilateral femoral fractures on 9/13/24 which resulted in hospitalization and an open reduction internal fixation (surgical repair) of the fractures. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 10/23/24, resulting in the deficiency being cited as past noncompliance with a correction date of 9/25/24. I. Incident on 9/13/24The facility failed to ensure Resident #2's lower extremities were handled appropriately, without undue pressure and in alignment of her lower extremities during a hoyer transfer into a wheelchair. Due to the facility's failure, Resident #2 sustained bilateral distal femoral fractures on 9/13/24 which resulted in hospitalization and surgery to repair the fractures. Record review and interviews during the onsite investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance at the time of the investigation on 10/23/24. II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #2The 9/13/24 facility incident report identified Resident #2 was being transferred from her bed to her wheelchair by a Hoyer lift. Resident #2 was being lowered into her wheelchair when a popping noise was heard and Resident #2 complained of pain in her lower extremities. Resident #2 was evaluated by nursing staff and given Tylenol and a lidocaine patch (topical pain patch). After lunch on 9/13/24, the resident continued to complain of pain and the physician was notified. An x-ray of her right knee was ordered. A fracture of the right femur was confirmed and the resident was transported to the hospital for further evaluation. On 9/16/24 (three days after the incident), the facility conducted an investigation of Resident #2's accident. The facility interviewed all staff on duty who were involved in care for the resident on the day of the accident (9/13/24). All interviewed staff said Resident #2 was being moved from her bed to her wheelchair using a Hoyer lift and as she was being lowered into the wheelchair a popping noise from the resident's lower extremities was heard. She was evaluated by the nurse and given Tylenol and a lidocaine patch. Resident #2 continued to complain of pain and the physician was notified and a right knee x-ray was ordered. The 9/16/24 investigation documented Hoyer lift safety education and repeat demonstration, last calibration and safety inspection were performed on 6/28/24. The 9/18/24 interdisciplinary (IDT) risk management note identified during Resident #2's Hoyer lift transfer from bed to wheelchair, the resident complained of increased pain in her right knee. No deviations in the transfer or care were identified. The note documented that upon Resident #2's returnfrom the hospital to the facility, the use of a full body sling would be implemented during Hoyer transfers for the resident to prevent pressure on the lower extremities. Additionally, the facility would report the resident's transfer injury to the sling manufacturer. The 9/18/24 vendor mechanical lift calibration log identified the facility's mechanical lifts passed the safety inspection on that date. The 9/25/24 inservice documented Hoyer lift transfer competency with full body sling and geri chair. The September 2024 quality assurance and performance improvement (QAPI) report in response to Resident #2's accident while being transferred on 9/13/24 was provided by the nursing home administrator (NHA) on 10/23/24 at 4:12 p.m. The QAPI report identified Resident #2's bilateral femoral fractures during a hoyer lift transfer and the use of a full body sling as an intervention upon her transfer back to the facility. It discussed training for staff on Hoyer lift transfers and the use of full body slings. The root cause analysis, undated, identified a review into staff education regarding Hoyer lifts and transfer training prior to incident and Hoyer and transfer training post incident. It identified Hoyer and mechanical lift calibration preventative maintenance before and after the incident. It identified an audit of damaged slings with none identified and to increase sling par level. It indicated a review of documentation of preexisting health conditions, medication and diagnosis list and physician documentation. B. Identification of other residentsThe facility completed an audit and identified other residents in the building who were at risk due to using the Hoyer lift for transfers. A total of four other residents were identified and assessed for appropriate Hoyer lift slings. C. Systemic changesNursing leadership re-educated the nursing staff in regards to Hoyer lift safety and the use of full body slings in an effort to prevent further accidents with Hoyer lifts for facility residents on 9/16/24 and 9/25/24. D. MonitoringThe IDT, the director of nursing (DON) and the assistant director of nursing (ADON) were responsible for identifying and ensuring all residents that required Hoyer lifts for transfers had the appropriate sling. They were additionally responsible for ensuring all nursing staff were provided the education and reeducation on the correct use of Hoyer lifts and full body slings. III. Professional referenceAccording to the Food and Drug Administration (FDA) Patient Lifts Safety Guide (10/1/24), retrieved on 10/24/24 from https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/patient-lifts,"To increase patient safety, use the correct type and size of sling for your patient. Select sling and sling bar based on manufacturer recommendations for the following criteria: type of transfer task, patient's medical condition, patient's size and weight, pressure sensitivity, need for full back support, need for head support, need for padding, patient' preferred or medically appropriate position."IV. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 1/3/22 and readmitted on 10/1/24. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia, fractures of left and right femur and osteoporosis. The 10/8/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. She was dependent with toileting, personal hygiene, bed mobility, transfers and required setup assistance with eating. B. Record reviewThe osteoporosis care plan, initiated 11/14/23 and revised 9/23/24, revealed Resident #2 had osteoporosis related to non-weight bearing status, being female and elderly. Interventions included monitoring, documenting and reporting complications related to osteoporosis, including fracture, loss of height, kyphosis (thoracic curvature of spine) and pain. The pathological bone fracture care plan, initiated 1/10/24, indicated Resident #2 was at risk for pathological bone fractures due to osteoporosis and severe demineralization of bones. Interventions included handling the resident gently when moving her and maintaining body alignment. The Hoyer lift care plan, initiated 10/9/23 and revised 9/23/24, revealed Resident #2 required the Hoyer lift the all transfers.-However, the care plan failed to identify the new intervention of using a full body sling for all of Resident #2's transfers following the 9/13/24 incident where the split leg sling was identified as a causative factor of the resident's bilateral femoral fractures. According to the accident incident report, on 9/13/24 Resident #2 was being transferred from her bed to her wheelchair by a Hoyer lift. As the resident was clearing the bed and being lowered to the wheelchair, an audible popping sound was heard. Resident #2 began expressing more pain than normal and said that it was in her right leg. The certified nurse aide (CNA) notified the nurse to evaluate the resident's pain. Resident #2 was administered Tylenol and a lidocaine patch. The resident continued to complain of pain, the physician was notified and an x-ray of her right knee was ordered. The x-ray confirmed a fracture of her right femur and the resident was transported to the hospital for further treatment. According to the hospital discharge summary, dated 10/1/24, Resident #2 was admitted to the hospital on 9/13/24, after she experienced a right distal femoral fracture during a Hoyer lift transfer. The discharge summary further revealed it was discovered after the resident was admitted to the hospital and that she also had a left distal femoral fracture. Resident #2 underwent surgery on 9/15/24 for an open reduction internal fixation of her bilateral femur fractures. Resident #2 was readmitted to the facility on 10/1/24. V. Staff interviewsCNA #1 was interviewed on 10/23/24 at 1:42 p.m. CNA #1 said she and CNA #2 were transferring Resident #2 from the bed using a hoyer lift with a split leg sling that had straps that crossed under the thighs. She said as they were lowering her into her wheelchair they heard a popping sound. She said they finished lowering her into the wheelchair and she went to get the nurse to evaluate the pain that the resident was experiencing in her leg. Licensed practical nurse (LPN) #1 was interviewed on 10/23/24 at 1:45 p.m. LPN #1 said Resident #2 usually complained of pain while being transferred but 9/13/24 was the first day she continued to express pain after she was transferred into her wheelchair. She said Resident #2 continued to complain of leg pain after they had taken her to the dining room. She said she was given Tylenol and a lidocaine patch. She said Resident #2 continued to complain of pain and the facility contacted the physician and obtained physician's orders for an x-ray of the resident's right leg. She said after the x-ray was done, it was confirmed that there was a fracture in the resident's right femur. LPN #1 said Resident #2 was transported to the hospital via ambulance for further evaluation. She said after the resident was transported to the hospital, the facility found out that Resident #2 had fractures in both femurs. The DON was interviewed on 10/23/24 at 1:45 p.m. The DON said nursing staff, along with restorative nursing staff, had a meeting the following morning (9/14/24) after they found out that Resident #2 had bilateral femur fractures after being transferred into a wheelchair with a Hoyer lift. He said the staff did a demonstration using a split leg sling for a Hoyer lift during the investigation. He said during the demonstration, the Hoyer lift transfer, they identified that the straps from the sling that crossed under the resident's thighs caused the thighs to externally rotate and, depending on placement, could rest under the thighs above the knee. He said Resident #2 had a history of osteoporosis, was non-weight bearing and was at a high risk for fractures. The DONsaid the facility contacted the mechanical lift company to report the incident and the company told them they were not aware of a similarly reported incident. He said one intervention that was identified during the root cause analysis was to use only a full body sling to help keep Resident #4's legs in alignment and prevent contortion or pressure on the legs once she returned from the hospital. He said the other intervention the IDT identified was to conduct nursing staff reeducation on the use of Hoyer lifts and on the correct placement of the mechanical lift slings. He said they had enough full body slings in the facility to give to the four residents identified in the audit as using Hoyer lifts for transfers. VI. Facility follow upOn 10/24/24 at 2:27 p.m., after the survey exit, the NHA sent a follow up email. In the email, the NHA said the IDT team, the DON and the ADON were responsible for ensuring the interventions identified were completed. She said reeducation with CNAs about Hoyer lift and proper slings began on 9/13/24 and continued 9/16/24, once the facility was updated from the hospital regarding Resident #2's bilateral femoral fractures. She said, to date, all nursing staff had been educated on the Hoyer lifts and slings. She said all identified residents that required the Hoyer full body slings had been distributed to the identified residents and the facility had a sufficient par level of the full body slings. The NHA said the facility was in the process of ordering additional full body slings to have on hand if needed.-However, despite the NHA's email indicating staff education for the Hoyer lifts started on 9/13/24 and continued on 9/16/24, according to the inservice education documents provided by the facility during the survey, the dates of the staff education were 9/16/24 and 9/25/24 (see facility plan of correction above).

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.

An onsite revisit was completed on 8/1/2024. Five deficiencies were cited. The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and represent the facility's general characteristics. The facility consists of two structures separated by a common wall with a two-hour fire rating. The original structure, constructed in 1963, is a two-story, type II (222) structure and has been designated as building A-1 on past surveys. In 1973, the facility constructed a three-story addition to the original structure. The three-story addition is a type II (111) structure designated building A-2 on past surveys. Due to the fact that both structures are classified as fully protected with a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, it has been decided to no longer survey the buildings as two separate structures but combine them, with no negative outcome to the facility, to create one building (A-3), classified as a type II(111) structure, based on the lesser of the two construction types. The two-hour fire rate separation is an acceptable horizontal exit serving either side. An onsite revisit was conducted, and deficiencies K-353 and K-918 were not corrected. A response is required. An onsite revisit was conducted, and new deficiencies K-345. All waived deficiencies will be corrected at a later date as per the approved waiver.

A revisit survey was completed on 7/24/24 for all previous deficiencies cited on 5/23/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 7/24/24 for all previous deficiencies cited on 5/23/24. The facility is in compliance with all regulations surveyed.

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and represent the facility's general characteristics. The facility consists of two structures separated by a common wall with a two-hour fire rating. The original structure, constructed in 1963, is a two-story, type II (222) structure and has been designated as building A-1 on past surveys. In 1973, the facility constructed a three-story addition to the original structure. The three-story addition is a type II (111) structure designated building A-2 on past surveys. Due to the fact that both structures are classified as fully protected with a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, it has been decided to no longer survey the buildings as two separate structures but combine them, with no negative outcome to the facility, to create one building (A-3), classified as a type II(111) structure, based on the lesser of the two construction types. The two-hour fire rate separation is an acceptable horizontal exit serving either side.

Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Means of egress shall be put back to their original state and sent in for plan review 2. Car blocking exit from therapy 3. Exterior exit gates shall be one motion 4. North third floor, three dead in corridors exceeding 30ft 5. Exit doors need proper signage NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101, 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 77.5.1.1 Exits shall be located, and exit access shall be arranged so that exits are readily accessible at all times. 7.5.1.2.1 Approved existing corridors that require passage through a room to access an exit shall be permitted to continue to be used, provided that all of the following criteria are met:(1) The path of travel is marked in accordance with Section 7.10.(2) Doors to such rooms comply with 7.2.1.(3) Such arrangement is not prohibited by the applicable occupancy chapter. 7.5.1.3.7 The balance of the exits, exit accesses, or exit discharges specified in 7.5.1.3.6 shall be located so that, if one becomes blocked, the others are available. 19.2.5.2* Dead-End Corridors. Existing dead-end corridors not exceeding 30 ft (9.1 m) shall be permitted. Existing dead-end corridors exceeding 30 ft (9.1 m) shall be permitted to continue in use if it is impractical and unfeasible to alter them. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.

Based on observation, it was found that the facility does not meet the mean of egress requirements in accordance with NFPA 101. Egress concrete exceeds ¼ elevation closet needs to be repaired. Next to Rm 333NFPA 101 7.5.4.3 Each required accessible means of egress shall be continuous from each accessible occupied area to a public way or area of refuge in accordance with 7.2.12.2.2. NFPA 101 7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 in. (6.3 mm), but not exceeding 1/2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1/2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and Maintenance director discussed deficient items at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. This was evidenced by:1. Exit doors need proper signage 3rd floor north, east exit, therapy exit, and therapy patio exit. 2. The third floor does not have exit signs through the path of travel to the exitsLife Safety Code 19.2.10.1. Means of egress shall have signs in accordance with section 7.10. The directional indicator shall be located outside of the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated. 7.10.1.2 Exits. 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. 7.10.1.3 Exit Door Tactile Signage. Tactile signage shall be provided to meet all of the following criteria, unless otherwise provided in 7.10.1.4:(1) Tactile signage shall be located at each exit door requiring an exit sign.(2) Tactile signage shall read as follows: EXIT.(3) Tactile signage shall comply with ICC/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities. 7.10.1.2.2* Horizontal components of the egress path within an exit enclosure shall be marked by approved exit or directional exit signs where the continuation of the egress path is not obvious. 7.10.1.5.1 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. 7.10.1.9 Mounting Location. The bottom of new egress markings shall be located at a vertical distance of not more than 6 ft 8 in. (2030 mm) above the top edge of the egress opening intended for designation by that marking. Egress markings shall be located at a horizontal distance of not more than the required width of the egress opening, as measured from the edge of the egress opening intended for designation by that marking to the nearest edge of the marking. 7.10.2 Directional Signs. 7.10.2.1* A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 7.10.5 Illumination of Signs. 7.10.5.1* General. Every sign required by 7.10.1.2, 7.10.1.5, or 7.10.8.1, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The maintenance director discussed deficient items during the survey and with the maintenance director and Administrator at the exit conference.

Based on observation, interviews, and record review, the facility failed to maintain an adequate and functional kitchen hood and ensure wheeled cooking equipment had blocks installed maintain the equipment's correct placement for the kitchen hood's designated coverage area. Specifically, the kitchen hood's fire suppression system coverage was not directed over applicable appliances; the kitchen hood's carbon dioxide (CO2) cylinder was stripped, rendering it unable to initiate the dry chemical to suppress fire, and, the wheeled cooking appliances lacked wheel blocks, in accordance with NFPA 17 and NFPA 96. These failures created the likelihood of serious adverse outcome for all residents, staff, and visitors in if there were a fire event within the facility. The findings include:Cross reference K0211 for observations of means of egress concerns that could prevent or hamper building exit in the event of a fire. Cross reference to K0293 for observations of exit signage deficient practices that could hamper or delay building exit in the event of a fire. Cross reference to K0372 for observations penetrations in all smoke compartments throughout the facility that would allow smoke travel to other smoke compartments in the event of a fire. 1. 1. Immediate JeopardyA. Findings of Immediate JeopardyRegulatory Requirements:NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to the approved design location prior to cooking operations. NFPA 17 11.2.2 If any deficiencies are found, appropriate corrective action shall be taken immediately. 11.3.1.5 Where the maintenance of the system(s) reveals defective parts that could cause an impairment or failure of proper operation of the system(s), the defective parts shall be replaced or repaired in accordance with the manufacturer's recommendations. 11.3.1.5.1 Until such repairs are accomplished, the system(s) shall be tagged as noncompliant, and the owner or owner's representative responsible for the system and the authority having jurisdiction shall be notified of the impairment. Record Review:An inspection, testing, and maintenance report, dated 01/23/2024, provided by the director of maintenance (DOM) on 6/4/2024, documented the hood's dry fire suppression system was not functional and that the coverage piping and nozzles were not correctly placed for the designated coverage area. January 2024 kitchen hood inspection report stated the control head of the kitchen hood system was stripped where the CO2 cartridge attaches to it. Observations:On 6/4/2024 at approximately 1:00 p.m., the kitchen fire suppression system was observed with the DOM. Observation revealed:-The kitchen was in current use and staff been preparing cooked food for resident meals.-The nozzles on the kitchen hood positioned in a way that failed to provide coverage for the appliances under the hood. -The CO2 cylinder's threads were stripped, rendering the cylinder unable function to extinguish a grease fire. -The inspection tag for the kitchen hood was white; however, the tag directed the reader to review the January 2024 inspection report (see record review above) which stated the hood was malfunctioning. The white tag did not document that the hood had passed its inspection.-The stove and oven under the hood had wheels to allow for movement of the appliance during cleaning. -There were no wheel chocks/blocks or other means in place to ensure the cooking equipment was replaced in the designated location for hood coverage. Interviews:On 6/4/2024 at approximately 1:00 p.m., the DOM confirmed the problems with the hood piping and nozzle placement. The DOM agreed the CO2 cylinder's threading was stripped. The DOM reviewed the hood inspection report and agreed that the hood was not in working order to suppress a grease fire. The DOM said there wheeled cooking equipment did not have chocks/blocks or other suitable guides as required. On 6/4/2024, the nursing home administrator (NHA) was interviewed regarding the repair and maintenance of the cooking facilities. The NHA said the systems control head PO was approved. They are waiting on Johnson Controls to get the part in stock to repair their system. B. Notification of Immediate JeopardyOn 6/4/2024 at 2:49 p.m., the NHA and the corporate representative were informed the failures above created the likelihood for serious harm to all staff, residents, and visitors within building. C. Facility Plan to Remove Immediate JeopardyOn 6/4/2024 at 4:15 p.m., the facility provided a revised plan to remove immediate jeopardy. The plan read:"On 6/4/24 a emergency request was placed with a vendor to service the hood suppression system. The vendor will be onsite 6/4/24 to repair the system. All sprinkler heads will be correctly placed by the certified vendor. The kitchen has been placed on fire watch until the fire suppression system is repaired. Fire watch sheets have been explained given to assigned staff. DPFC (division of fire prevention and control) have been notified of the communities Fires watch status."D. Removal of Immediate JeopardyOn 6/5/2024 at 9:57 a.m., the NHA was notified the immediate jeopardy was removed. However, the deficient practice remained at scope and severity "F" - widespread potential for more than minimal harm.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Semi Annual need2. 3-year dry valve test report 3. Quick repose and standard response heads expired 4. The facility has a mix of standard and quick-response heads 5. The main drain needs to be monitored or chained to be non-operable 6. The head box has 9 7. Loading on fire sprinkler head outside of third imagery cart RM 8. Painted head In closet wellness office, Connection office 9. Eyewash center, RM 224 painted sprinkler head 10. RM 345 sprinkler escutcheon broken 11. 319 needs an escutcheon 12. Second-floor resident storage shall be below 18" from the fire sprinkler head 13. Taped fire sprinkler head in connections office 14. 217 fire sprinkler line needs to be supported 15. Hazardous material storage above the sprinkler outside the boiler room 16. Maintenance shop storage too high on rack storage 17. Antifreeze backflow leakingNFPA 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 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12NFPA 25, 5.2.1.1.5 Escutcheons and coverplates for recessed, flush, and concealed sprinklers shall be replaced with their listed escutcheon or coverplate if found missing during the inspection. 8.8.6Clearance to Storage (Extended Coverage Upright and Pendent Spray Sprinklers). 8.8.6.1 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater. 19.3.5.5NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 13 6.2.9.4 Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished. 6.2.9.5 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:(1) For protected facilities having under 300 sprinklers — no fewer than six sprinklers(2) For protected facilities having 300 to 1000 sprinklers — no fewer than 12 sprinklers(3) For protected facilities having over 1000 sprinklers — no fewer than 24 sprinklers8.3.3.2 Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.8.5.6.4 Where sprinklers penetrate a single membrane of a fire resistance–rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 1/2 in. (13 mm), measured between the edge of the membrane and the sprinkler. 5.3.1.1.1.3 Sprinklers manufactured using fast-response elements that have been in service for 20 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals. NFPA 25 5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested. 13.4.4.2.2.2* Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. 13.6.2.1.2 Where water rationing is enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be permitted in lieu of conducting the annual forward flow test. 13.6.3.1 Maintenance of all backflow prevention assemblies shall be conducted by a trained individual following the manufacturer ' s instructions in accordance with the procedure and policies of the authority having jurisdictionA.816.1.1.2 The management is responsible for the supervision of valves controlling water supply for fire protection and should exert every effort to see that the valves are maintained in the normally open position. This effort includes special precautions to ensure that protection is promptly restored by completely opening valves that are necessarily closed during repairs or alterations. The precautions apply equally to valves controlling sprinklers and other fixed water-based fire suppression systems, hydrants, tanks, standpipes, pumps, street connections, and sectional valves. The standard method of locking, sealing, and tagging valves to prevent, so far as possible, their unnecessary closing, to obtain notification of such closing, and to aid in restoring the valve to normal condition is a satisfactory alternative to valve supervision. The authority having jurisdiction should be consulted regarding details for specific cases. Where electrical supervision is not provided, locks or seals should be provided on all valves and should be of a type acceptable to the authority having jurisdiction. Seals can be marked to indicate the organization under whose jurisdiction the sealing is conducted. All seals should be attached to the valve in such a manner that the valves cannot be operated without breaking the seals. Seals should be of a character to prevent injury in handling and to prevent reassembly when broken. When seals are used, valves should be inspected weekly. The authority having jurisdiction can require a valve tag to be used in conjunction with the sealing. A padlock, with a chain where necessary, is especially desirable to prevent unauthorized closing of valves in areas where valves are subject to tampering. When such locks are employed, valves should be inspected monthly. If valves are locked, any distribution of keys should be restricted to only those directly responsible for the fire protection system. Multiple valves should not be locked together; they should be individually locked. The individual performing the inspections should determine that each valve is in the normal position, properly locked or sealed, and so note on an appropriate record form while still at the valve. The authority having jurisdiction should be consulted for assistance in preparing a suitable report form for this activity. Identification signs should be provided at each valve to indicate its function and what it controls. If it becomes necessary to break a seal for emergency reasons, the valve, following the emergency, should be opened by the person responsible for the fire protection of the plant, or his or her designated representative, and this person should apply a seal at the time of the valve opening. This seal should be maintained in place until such time as the authority having jurisdiction can replace it with one of its own. Seals or locks should not be applied to valves reopened after closure until such time as the inspection procedure is carried out. Where water is shut off to the sprinkler or other fixed water-based fire suppression systems, a guard or other qualified person should be placed on duty and required to continuously patrol the affected sections of the premises until such time as protection is restored. During specific critical situations, a person should be stationed at the valve so that the valve can be reopened promptly if necessary. It is the intent of this section that the person remain within sight of the valve and have no other duties beyond this responsibility. This procedure is considered imperative when fire protection is shut off immediately following a fire. An inspection of all other fire protection equipment should be made prior to shutting off water in order to make sure it is in operative condition. In case of changes to fire protection equipment, all possible work should be done in advance of shutting off the water so that final connections can be made quickly and protection restored promptly. Many times it will be found that by careful planning open outlets can be plugged and protection restored on a portion of the equipment while the alterations are being made. Where changes are being made in underground piping, all possible piping should be laid before shutting off the water for final connections. Where possible, temporary feed lines, such as temporary piping for reconnection of risers by hose lines, and so forth, should be used to afford maximum protection. The plant, public fire department, and other authorities having jurisdiction should be notified of all impairments to fire protection equipment. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.

Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. 1. Kitchen - extinguisher mounted above 3.5 feet 2. At the time of the survey, there was no documentation or record that all fire extinguishers throughout the facility were subjected to monthly and annual inspections. 3. Fire extinguisher to exceed 5ft near room 300 4. Blocked fire extinguisher therapy rm 5. Blocked fire extinguisher patio 6. The fire extinguisher in the maintenance office is sitting on the desk. It shall be mounted. Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire ExtinguishersNFPA 10, Section 6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. 6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem. 6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage. 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. 6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. This deficiency can potentially affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1. Penetration throughout the whole facility. 2. Ceiling tiles throughout the facility have gaps larger than ½" NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to maintain wiring in accordance with NFPA 101 and NFPA 70.1. Utility Rm 2nd and third floor have exposed wires 2. 344. outlet coming out 3. Delayed egress next to 333 exposed wires 4. Open junction box restroom RM 224 NFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and workmanlike manner. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference

Based on observation and staff interviews, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105, 101, and 54.1. The open plenum in the third-floor exits needs to shut on the fire alarm or need to be removed. 2. Gas leak boiler 28.2.3Piping systems should be tested for leaks immediately after gas is turned on to a new system or after an interruption of service. 8.5.5.2 Smoke Dampers. Where a smoke barrier is penetrated by a duct or air-transfer opening, a smoke damper designed and tested in accordance with the requirements of ANSI/UL 555S, Standard for Smoke Dampers, shall be installed. Where a smoke barrier is also constructed as a fire barrier, a combination fire/smoke damper designed and tested in accordance with the requirements of ANSI/UL 555, Standard for Fire Dampers, and ANSI/UL 555S, Standard for Smoke Dampers, shall be installed. NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shallbe every 6 years. 6.5.3 Care shall be exercised to ensure that all tests are completed safely, wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator discussed deficient items at the exit conference.

Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills closer than an hour apart, not at varied times. NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.

Based on observations and records review, it was determined that the facility did not maintain oxygen storage in accordance with NFPA 99. Condenser stored near salon in the corridor. 11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference

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

Based on observation and record review during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 ofthe Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8.1. Inspection Weekly 110-2010; 8.4.1- Not available at time of inspection 2. Monthly load test 20 days to 40 days 110-2010; 8.4.2 and 99-2012; 6.4.4.1.1.4 - missing months, July. 3. Transfer Switch: Monthly test with generator 20 days to 40 days 110-2010; 8.4.6 and 99-2012; 6.4.4.1.1.4 - Not available at time of inspection NFPA 110-8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 8.4.6 Transfer switch shall be operated monthly. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by: 1. 339 Daisy chaining power strips 2. Appliance plugged into power strip 319 3. Connection office daisy chaining of fridge 4. Appliances in the power strip in the central supply 5. The fridge in the maintenance office plugged into a power stripFlexible cords and cables in accordance with Chapter 4 of NFPA 70, Section 400.8(1), in part, flexible cords and cables shall not be used as a substitute for the fixed wiring of a structure. Furthermore, Health Care Facilities Code section 10.2.3.6 (2), "The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets."This deficiency has the potential to affect the occupants, who might include the residents, staff, and visitors within affected smoke compartments. The maintenance staff and facility administrator discussed deficient items during the exit conference.

Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99 and 55. This was evidenced by the following:1. Oxygen Transfill rooms need a vent 12" off the floor 2. Full and empty containers were not separated. NFPA 556.15.7 Inlets to the Exhaust System. 6.15.7.1 The exhaust ventilation system design shall take into account the density of the potential gases released. 6.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor. 6.15.7.3 For gases that are lighter than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the ceiling. NFPA 99 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and Maintenance director discussed deficient items at the exit conference.

A recertification survey with complaints #CO35597, #CO35736, #CO36010, #CO36024, #CO36051 and Incident #35539 was completed on 5/13/24 to 5/23/24. Fourteen deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/13/24 to 5/23/24. One deficiency was cited.

Based on record review and interview, the facility failed to develop and maintain an up-to-date emergency preparedness training and testing program that was based on the facility's emergency preparedness (EP) program plan, annual risk assessment, facility EP policies and procedures and the communication plan that was delivered to all staff annually. Specifically, the facility failed to:-Ensure all staff were trained in procedures to emergently evacuate residents from the facility;-Develop a written training and testing program based on the facility's updated EP program;-Provide education and instruction to staff, contractors, and facility volunteers to ensure all individuals are aware of the facility's EP program;-Ensure the EP training included the facility's expected response to the annual risk and all hazards risk assessment; and, -Ensure EP training included, at a minimum, training related to the facility's EP policies and procedures. Findings include: I. Facility policy The Disaster/Emergency Plan policy and procedure, revised 8/1/14, was provided by the NHA on 5/21/24 at 2:26 pm. It read in pertinent part, "To establish a method of systematic and orderly repose to disasters. The following emergency situations will be considered disasters: fire and explosions, severe weather situations, utility failure, hazardous material and radiological emergency, a medical emergency involving more than two persons, any other emergencies that may directly impact the community. Evacuation and relocation to alternate living arrangements will be made based upon scope of disaster and determination of leadership team and emergency personnel decision and consensus."The Evacuation Plan policy and procedure, revised 1/16/2009 was provided by the NHA on 5/21/24 at 2:26 p.m. It read in pertinent part, "A community specific evacuation plan is developed and posted. Residents and staff are trained on evacuation routes and procedures on a monthly basis during scheduled drills."-However, there was no evidence that evacuation drills were conducted or that all staff were trained in procedures to emergently evacuate residents from the facility (see below). II. Facility planThe EP program binder was provided by the nursing home administrator (NHA) and the environmental services director (ESD) on 5/21/24 at 1:31 p.m. Review of the EP program binder revealed the facility did not have any documented training and testing program that reflected the risks identified in the facility's risk assessment. The facility did not have a written training and testing program with provisions to ensure all staff, contractors and facility volunteers received EP training specific to the facility's updated EP program. III. Staff interviewsThe NHA and ESD were interviewed together on 5/21/24 at 1:31 p.m. They said their all hazard vulnerability analysis identified flooding as their greatest risk followed by loss of power and epidemic. The NHA said the annual EP program was reviewed on 1/17/24 and updates were completed. The NHA said the interdisciplinary team (IDT) was responsible for the overall plan. The NHA said the facility conducted a training and testing exercise for entire building evacuation on 5/16/24 (during the survey). The NHA said they used an outside director to help with the drill and exercises. The NHA said prior to the training and testing on 5/16/24, the facility had not conducted a testing and training program that trained residents and staff on evacuation routes and procedures or other training and testing programs based on the all hazards risk assessment.

Based on observations and interviews the facility failed to ensure residents on one of three units had the right to a dignified existence. Specifically, the facility failed to answer call lights in a timely manner on the second floor. Findings include:I. Facility policyThe Call light policy, undated, was provided by the nursing home administrator on 5/20/24 at 3:16 p.m. It read in pertinent part, "Purpose: To respond promptly to resident's call for assistance. All community personnel must be aware of call lights at all times. Answer all call lights in a timely manner. In some instances, it may be necessary to leave the call light illuminated/activated in order to alert other staff or care team. Never make the resident feel you are too busy to give assistance."II. Resident group interviewThe resident group interview was conducted on 5/15/24 at 11:00 a.m. with seven residents (#76, #75, #115, #68, #7, #77 and #112) who were members of the resident council. The residents were identified as interviewable by the facility and assessments. The residents said they often had to wait over an hour for their call lights to be answered. Resident #68 reported she recently had to wait one hour and 45 minutes for her call light to be answered. She said it made her feel like no one cared about her. III. Additional resident interviewResident #8 was interviewed on 5/16/24 at 10:15 a.m. Resident #8 said she did not think her call light worked. She said when she activated the light it usually took an hour or more before staff came to assist her. Resident #8 said it made her feel like no one cared when she had to wait so long for assistance. -The resident's call light was observed to be in working order on multiple occasions during the survey. IV. ObservationsDuring a continuous observation on 5/14/24, beginning at 11:54 a.m. and ending at 12:18 p.m., the following was observed:At 11:54 a.m. two call lights on the second floor were blinking. At 12:18 p.m. an unidentified staff member came up from the first floor to check on the first light. At the time, there were two certified nurse aides (CNA) in the dining area serving beverages, a nurse at the medication cart near the nurses' station and a nurse sitting at the nurses' station. There was not an audible tone or call light panel alerting staff that a call light had been activated. During a continuous observation on 5/15/24, beginning at 9:37 a.m. and ending at 10:15 a.m., the following was observed:At 9:37 a.m. the call light for room 215 was blinking. At 9:49 a.m., Assistant director of nursing (ADON) #2 walked past room #215, entered her office and did not check on the resident. At 9:56 a.m. ADON #2 left her office, walked past room #215 again and did not check on the resident. At 10:03 a.m. ADON #2 passed room #215 to return to her office and did not check on the resident. At 10:15 a.m. an unidentified CNA entered room #215 and turned off the call light. There was not an audible tone or call light panel alerting staff that a call light had been activated. During a continuous observation on 5/19/24, beginning at 5:13 p.m. and ending at 5:29 p.m., the following was observed: At 5:13 p.m. call lights were activated for rooms #200, #201 and #206. At the time, three employees were observed sitting behind the desk at the nurses' station. One nurse was using her personal cell phone. At 5:29 p.m. the lights remained unanswered for all three rooms. V. Staff interviewsCNA #8 was interviewed on 5/16/24 at 9:30 a.m. on the Juniper unit. CNA #8 said the call lights beeped at the nurses'station and listed the room number and bed number on the tablet. She said there was also a light above the resident's door to indicate the resident had activated the call light.-However, observations on the Juniper unit on 5/17/23 revealed that the sound on the tablet was so low at the nurses' station that it could not be heard. The nursing home administrator (NHA) was interviewed on 5/22/24 at 6:53 p.m. The NHA said all staff members were expected to answer call lights. She said there was an audible tone and a tablet behind the nurses' stations that alerted staff to call light activation. The NHA said staff were expected to respond to call lights in less than seven minutes. -The NHA was not aware the audible tone had been turned down and was not audible unless standing within one foot of the tablet on the wall.

Based on interviews and record review, the facility failed to ensure one (#181) of three residents out of 56 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a satisfactory resolution to Resident #181's grievance, which the resident representative had communicated to staff on multiple occasions, regarding the resident's missing glasses. Findings include:I. Facility policy and procedureThe Grievance policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/14/24 at 1:35 p.m. It read in pertinent part, "When a grievance exists, residents, family members, and/or resident advocates may submit the grievance to the administrator or designee. Within two business days after the submission of a grievance, a status report will be provided by the director of the department to who the grievance was directed, to the individual who filed the grievance. "The resident or person acting on behalf of the resident will be informed of the findings of the investigation within seven working days of the filing date and have the right to obtain a written decision regarding the grievance. A copy of the initial grievance and the associative action will be filed in the social services office for no less than three years."II. Resident #181A. Resident statusResident #181, age 78, was admitted on 6/16/23, readmitted 11/15/23 and discharged 11/17/23. According to the November 2023 computerized physician orders (CPO), diagnoses included dementia, Parkinson's disease (brain disorder causing involuntary movements), sepsis (infection of the blood), post-traumatic stress disorder (PTSD) and depressive episodes. The 11/17/23 discharge minimum data set (MDS) assessment revealed the staff assessment for mental status was conducted and documented the resident had short-term memory problems and was moderately impaired for daily decision making. He was dependent on staff assistance with shower/bathing, upper body dressing, personal hygiene, putting on/taking off footwear, rolling left/right, transfering from sitting to lying, transfering from sitting to standing and transferring from bed to chair. The assessment documented the resident had no behavioral symptoms present and no rejection of care. B. Resident representative interviewThe resident representative was interviewed on 5/20/24 at 3:49 p.m. She said after the resident was discharged, the facility mailed Resident #181 plastic reader glasses which were not his. The resident's representative said she had already told the facility those glasses were not his. She said in the box that was shipped from the facility she had received items that went missing during Resident #181's stay at the facility. She said she continued to miss Resident #181's blue prescription glasses which the facility did not replace. She said she did not receive any other boxes from the facility. The resident representative said she filed a written grievance on 11/30/23 and received an email from the facility on 12/13/24 addressing the other missing items but not the blue prescription glasses. The resident representative said the glasses were listed on the intake inventory sheet on admissions. C. Record reviewThe admissions inventory list dated 6/20/23 (date of admission 6/16/23) revealed the resident was admitted with glasses. -The inventory sheet did not document the color of the resident's glasses. The 11/30/23 grievance form, completed by the resident's representative, was provided by the NHA on 5/16/24 at 1:35 p.m. It revealed the following:The description of the grievance section documented the resident and his representative needed to be reimbursed for several items including blue prescription eyeglasses. Receipts and photos were included for replacement. The section for facility follow-up was not filled out. The section for the resolution of the grievance section was not filled out. There was additional information documented on the grievance form that indicated on 12/5/23 a few items were located and an email was attached to the form. The NHA signed the grievance form indicating it was resolved. -However, the form was not dated when the NHA approved the resolution . -The grievance form failed to address the resident's missing blue prescription glasses. Invoice documents for a vision and eye clinic were provided to the facility by the resident's representative upon filing the grievance. The first document, dated 11/3/22, was for the purchase of a pair of blue eyeglasses (which the resident had upon admission to the facility on 6/16/23). The invoice amount was $424.20. The second document, dated 11/27/23, was for the purchase of a pair of blue eyeglasses to replace the previous pair. The invoice amount was $424.20. The 12/13/23 email, sent at 11:00 a.m., from the facility to the resident's representative documented the facility recovered several of Resident #181's missing items, which included one cream colored slipper with fur, one medium gray zip-up jacket, one hearing aid with batteries and filters in a clear box, one bag of hearing aid cleaning tools, one gray zip-up case and one clear box. A picture of the box contents that was shipped to the resident's representative was attached to the grievance form.-However the email did not address the missing blue prescription glasses and was not in the picture of the box shipped by the facility. A review of the Resident #181's electronic medical record (EMR) revealed the following progress notes: The 10/6/2023 social services note documented at 10:45 a.m. documented a telephone call was made to the resident's representative to inform her that Resident #181 had his glasses. The 11/15 23 (late entry) physician progress note documented the resident had glasses and dentures. The 11/20/23 wellness progress note documented the nurse spoke with the resident's representative to get an update on Resident #181 and to ensure that the resident's representative was doing okay. The resident's representative stated Resident #181's glasses needed to be found. The writer's contact information was given to the resident's representative in case the resident's representative needed anything.-Resident #181 was discharged to the hospital on 11/17/23. The 11/23/23 progress note documented the resident's representative came to the facility to pick up some of Resident #181's belongings, which included his dentures, hearing aids and glasses that were found with the residents' possessions. Upon receiving the glasses in question, the resident's representative told the concierge that the glasses were not the resident's glasses and threw them at the concierge. The resident's representative then asked if she would be able to grab some clothes and other items to take to the resident in the hospital. The resident's representative took the residents' hearing aids, dentures, cowboy hat and a pack of gloves with her upon leaving the facility. The NHA provided an email communication between the facility and the resident's representative on 5/20/24 at 4:39 p.m. The resident's representative emailed the facility on 1/26/24 at 10:36 a.m. The email to the NHA read the resident's representative had not heard from the facility in regards to Resident #181's missing blue prescription glasses nor had she received reimbursement for their replacement. The resident's representative said she provided receipts and photos to the facility when the Veterans administration liaison met there with her about two months ago (November 2023). The resident's representative said she would like to resolve the issue. The facility responded to the resident's representative email on 1/26/24 at 11:54 a.m. The facility attached the personal belongings agreement signed by the resident's representative upon Resident #181's admission outlining the policy regarding lost, stolen, damaged items. The facility informed the representative they were not able to find the glasses on any of Resident #181's inventory sheets. As a result of the facility's investigation, the facility was not approved to refund the amount for the glasses. -However, the admissions inventory list dated 6/20/23 (date of admission 6/16/23) revealed the resident was admitted with glasses, but the color of the glasses was not specified on the inventory list. A review of Resident #181's electronic medical record (EMR) on 5/20/24 at 4:27 p.m. revealed the resident's glasses were an auxiliary device (supplementary). The profile picture in the resident's EMR revealed the resident was wearing glasses. III. Staff interviewThe NHA was interviewed on 5/20/24 at 3:07 p.m. The NHA said the facility attempted to return the glasses to the resident's representative but she threw the glasses at the concierge. The NHA said all of the other missing items were shipped to the family including the glasses.-However the plastic reading glasses were not the blue prescription glasses that the resident's representative was requesting. The NHA was interviewed again on 5/20/24 at 4:36 p.m. The NHA reviewed the written grievance. The NHA said she would look for evidence that the blue prescription glasses were sent to the resident. The NHA said the facility had mailed a second box to the resident however they did not take a picture of the second box sent to the resident. -The NHA did not provide evidence that the facility found, replaced or reimbursed the resident's representative for the missing blue prescription glasses. The social services director (SSD) was interviewed on 5/23/24 at 10:30 a.m. The SSD saidthat once a grievance was filed the turnaround time was about two days to proceed with a response/resolution. She said items listed on an inventory list that were not returned were reimbursed by the facility.

Based on record review and interviews, the facility failed to ensure four (#118, #32, #49 and #90) of four residents reviewed for abuse out of 56 sample residents were kept free from abuse. Specifically, the facility failed to:-Implement person-centered interventions to prevent a resident to resident altercation between Resident #118 and Resident #32; and,-Implement person-centered interventions to prevent a resident to resident altercation between Resident #90 and Resident #49. Findings include:I. Facility policy and procedure The Abuse Policy, undated, was provided by the nursing home administrator (NHA) on 5/13/24 at 2:22 p.m. It read in pertinent part: "This policy is intended to provide guidance on investigating and reporting suspected resident rights violations and abuse, neglect, and misappropriation of resident property. "To assist our community's associate members in recognizing abuse, the following definitions of abuse are provided. Abuse is defined as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Neglect is defined as "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The facility staff and agency supplemental personnel will be trained regarding abuse prevention, reporting and investigation upon orientation and annually. Strategies for dealing with difficult and/or aggressive behavior."Prevention of abuse, neglect or misappropriation of property will be implemented through: ongoing associate, resident and family training monthly safety committee meetings ongoing rounds and quarterly staff meetings that focus on possible root causes."An immediate investigation will be conducted. Wellness Director or designee will complete the investigative form. The physician and Executive Director will review and sign the form. The resident will be provided with an interview to determine how and what situations provide comfort and a feeling of well-being. The Administrator will analyze all occurrences to determine if changes are needed to policies and procedures to prevent further occurrences."The Managing Challenging Behaviors policy and procedure, undated, was provided by the NHA on 5/13/24 at 2:22 p.m. It read in pertinent part: "Policy: Staff employee therapeutic approach with residents that will minimize the occurrence of challenging behaviors and maximize successful management of such behaviors should they occur."Purpose: To foster the creation of a harmonious community and to minimize behavioral distress for each resident."Procedure: Staff may assist in preventing challenging behaviors by knowing and appreciating the background, values, preferences and abilities of the resident and engaging the resident in activities based on needs."II. Resident to resident physical abuse between Resident #118 and Resident #32 on 5/8/24. The abuse investigation, dated 5/8/24, revealed Resident #118 entered the room of Resident #32 and laid in her bed. Resident #32 asked Resident #118 to leave her room. Resident #118 allegedly responded by pushing Resident #32 and Resident #32 responded by pushing Resident #118 back. Staff responded and assisted Resident #118 to leave the room. The abuse investigation indicated Resident #32 was interviewed and said Resident #118 was in her bed and she wanted him out of her room. Resident #118 was non interviewable due to his cognitive status. The abuse investigation indicated both residents were placed on 15 minute checks, the police were notified, along with the family/guardian and the physician. The abuse investigation indicated neither Resident #32 or Resident #118 had injuries. The abuse investigation revealed Resident #118's and Resident #32's care plans were updated regarding the incident. Resident #32 was seen by an existing community mental health provider and Resident #118 was referred to a community mental health provider. The abuse investigation indicated other staff and residents were interviewed and expressed no concern. -A request for the other staff and resident interviews was made on 5/13/24, however the facility did not provide them by the survey exit on 5/23/24.-A review of Resident #118's and Resident #32's comprehensive care plans did not reveal updated person-centered interventions to prevent future resident to resident altercations following the incident on 5/8/24. III. Resident #118A. Resident statusResident #118, age 73, was admitted on 8/17/23. According to the May 2024 computerized physicians orders (CPO), diagnoses included Alzheimer's disease, bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and post traumatic stress disorder (PTSD). According to the 3/24/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He was independent with eating, toileting, bed mobility and transferring. He did not use any mobility devices. B. Record reviewThe maladaptive behavior care plan, initiated on 12/1/23, indicated Resident #118 had maladaptive behaviors secondary to his dementia and occasionally became verbally aggressive and swatted at caregivers during care. The pertinent interventions included administering medications and monitoring for side effects, anticipating and meeting Resident #118's needs, providing an opportunity for positive interactions and attention and stopping to talk with the resident while passing by. -A review of the resident's comprehensive care plan revealed the facility did not implement an intervention after Resident #118 was involved in a resident to resident altercation. A review of Resident #118's electronic medical record (EMR) revealed the resident had a history of behaviors directed towards staff and residents. The 5/9/24 progress note indicated Resident #118 wandered into the room of Resident #32's room and laid in her bed. When Resident #32 asked Resident #118 to get out of her bed, Resident #118 pushed Resident #32 in the stomach which resulted in the two residents engaging in a physical altercation that staff had to break up. (see resident to resident physical abuse above). IV. Resident #32A. Resident statusResident #32, age less than 65, was admitted on 11/6/13. According to the May 2024 CPO, diagnoses included schizoaffective disorder (mental health condition characterized by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), personality disorder, anxiety and insomnia. According to the 4/29/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with all activities of daily living (ADL). B. Record reviewThe behavior care plan, initiated on 11/15/13 and revised on 11/2/22, revealed Resident #32 had a history of hitting a staff member at a previous facility, experienced auditory and visual hallucinations and had a history of yelling and crying. It indicated Resident #32 would have a reduction and stabilization of behaviors and symptoms that necessitated facility placement and maintain psychiatric stabilization. The pertinent interventions included Resident #32 being supported by her community mental health case manager. -A review of the resident's comprehensive care plan revealed the facility did not implement an intervention after Resident #32 was involved in a resident to resident altercation. V. Incident of resident to resident altercation between Resident #49 and Resident #90 on 12/30/23The facility reported event, dated 12/30/23, revealed Resident #49 was walking through the communal dining area and was gesturing to Resident #90 with his middle finger. Resident #90 responded by slapping resident Resident #49 on the left cheek. The facility responded by separating the two residents from each other and both were assessed for injuries. The facility report noted Resident #49 had a reddened area on the left cheek. The report indicated both residents were put on 15 minute checks and the police were notified. The facility report indicated Resident #90 was unable to participate in an interview related to cognition and Resident #49 stated, "I'm just mad" when interviewed. The facility report indicated other staff and residents were interviewed and there were no other concerns expressed. Resident #49 would be referred to a community mental health provider. The abuse investigation indicated other staff and residents were interviewed and expressed no concern. -However, none of the interviews were provided during the survey -Resident #90's care plan was not updated after he was involved in a resident to resident altercation on 12/30/23.-Resident #49 was not referred for community mental health services. On 5/15/24 the NHA provided the following facility investigation for another resident to resident altercation between Resident #90 and Resident #49 on 4/10/24: On 4/10/24 Resident #90 was being aggressive towards Resident #49 in the dining room of their shared unit. Resident #49 attempted to physically hit Resident #90 in the face without success. The investigation revealed the facility had reviewed surveillance video and witnessed Resident #49 did not physically hit Resident #90 as staff were able to successfully prevent a resident to resident altercation. It indicated Resident #49 would be referred to a community mental health agency and Resident #90 would be seen by an existing mental health provider. -A review of Resident #49's EMR during the survey revealed he still had not been referred to receive services from a community mental health agency even though it had been recommended following the resident to resident altercations on 12/30/23 and again on 4/10/24.. VI. Resident #49A. Resident statusResident #49, age less than 65, was admitted on 5/19/14. According to the May 2024 CPO, diagnoses included anoxic brain damage (brain damage due to lack of oxygen), dementia, mood disorder (mental illnesses that cause a person's emotional state to be persistently disturbed) and major depressive disorder. According to the 4/5/24 MDS assessment, the resident had severe cognitive impairment with a BIMS score of nine out of 15. He required set-up assistant for eating, toileting and personal hygiene. He was independent with mobility. The assessment revealed Resident #49 displayed verbal behavioral symptoms directed at others, such as, threatening, screaming or cursing at others. The resident displayed other behavioral symptoms, such as, hitting or scratching self, pacing, rummaging, public sexual acts and disrobing in public. B. Record reviewThe mood and behavior care plan, initiated on 5/21/14 and revised 12/14/16 revealed Resident #49 had a history of gesturing to others with his middle finger and was cognitively unaware he was doing so related to his diagnosis of an anoxic brain injury. He frequently used profanity and offensive language and had a history of provoking peers due to this behavior in which it had caused his peers to become verbally/physically aggressive with him. The pertinent interventions included encouraging Resident #49 to make a peace sign when gesturing with his middle finger. -A review of the comprehensive care plan did not reveal the care plan had been updated after Resident #49 was involved in a resident to resident altercation on 12/30/23 or 4/10/24. VII. Resident #90A. Resident status Resident #90, age less than 65, was admitted on 7/24/20. According to the May 2024 CPO, diagnoses included major depressive disorder, anxiety and a traumatic brain injury (TBI). According to the 4/22/24 MDS assessment, the resident was cognitively intact with a BIMS of 13 out of 15. He required supervision with all ADLs and was independent with mobility. The assessment revealed Resident #90 had displayed verbal behavioral symptoms directed towards others to include threatening, screaming or cursing at others. B. Record reviewA review Resident #90's electronic medical record (EMR) revealed the resident had a history of behaviors directed towards staff and residents. VIII. Staff interviewsOn 5/13/24 at 2:22 p.m. the NHA said the facility entered facility reportable events directly into the state agency portal. The NHA said the facility was not using a separate investigation form for information gathering by the facility. The NHA said resident to resident altercations were discussed daily in morning meetings and interventions to avoid continued altercations were decided as an interdisciplinary team (IDT). The director of nursing (DON) was interviewed on 5/21/24 at 11:30 a.m. The DON said behaviors were documented in the EMR or the 24-hour report binder. The DON said any of the IDT members could put in an order for a mental health referral if it was warranted. The DON said Resident #118 was not seen by a community mental health provider sooner because of scheduling constraints with the mental health provider. Registered nurse (RN) #3 was interviewed on 5/21/24 at 4:40 p.m. RN #3 said staff had to get to know the residents to work with resident behaviors and anticipate needs. RN #3 said she did not work with Residents #118, #32, #49 and #90 on a regular basis. RN #3 said every resident on the second floor had behaviors. RN #3 said the staff used verbal redirection if an altercation occurred. CNA #4 was interviewed on 5/21/24 at 4:40 p.m. CNA #4 said she did not know where to locate resident centered behaviors or interventions. CNA #4 said she used verbal redirection of asking or telling a resident to stop doing something that had the potential to cause an altercation. CNA #4 said the facility trained direct care staff on crisis prevention intervention one time annually. CNA #4 said she started as an employee after an annual training but knew of crisis prevention interventions from a different community she had worked at. The social services director (SSD) and the social services assistance (SSA) were interviewed together on 5/21/24 at 5:30 p.m. The SSD said resident to resident incidents were discussed during the daily interdisciplinary (IDT) meeting. The SSD said resident to resident altercations and resident's displaying behaviors were considered an occurrence that were discussed. The SSD said behaviors and interventions were not necessarily care planned and were mainly communicated verbally from staff to staff. The SSD said she did not know if this was an effective method for tracking resident specific behaviors and interventions. The SSD said Resident #49 was not a good candidate for community mental health because of his brain injury and the SSD did not know why this was being recommended as an intervention.

Based on record review, observations, and interviews, the facility failed to ensure that six (#118, #126, #121, #115, #72 and #20) of nine residents out of 56 sample residents were free from involuntary seclusion and were receiving the least restrictive approach for their needs. Specifically, the facility failed to ensure Residents #118, #126, #121, #115, #72 and #20, who resided on the secure locked unit, had the required documentation to justify such restrictions. Findings include:I. Resident #118A. Resident statusResident #118, age 73, was admitted on 8/17/23. According to the May 2024 computerized physicians orders (CPO), diagnoses included post traumatic stress disorder (PTSD), Alzheimer's disease and bipolar disorder. According to the 3/24/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He was independent with eating, toileting, bed mobility and transferring. He did not use any mobility devices. The assessment indicated Resident #118 had not exhibited wandering behavior. B. Record reviewA review of Resident #118's electronic medical record (EMR) failed to reveal a pre-admission evaluation for secure unit placement, a physician's order for secure unit placement, a care plan for secure unit placement or any ongoing evaluations for secure unit placement. C. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 5/21/24 at 4:40 p.m. CNA #4 said Resident #118 mainly stayed in his room and did not wander. CNA #4 said Resident #118 was able to walk on his own but not more than 10 to 15 steps without getting tired and needing to sit down. II. Resident #126A. Resident statusResident #126, over the age of 65, was admitted on 3/29/24. According to the May 2024 CPO, diagnoses included bipolar disorder, dementia, post-traumatic stress disorder (PTSD) and anxiety disorder. The 4/5/24 MDS assessment revealed the resident had a moderate cognitive impairment with a BIMS score of nine out of 15. He required supervision and assistance with activities of daily living (ADLs). B. Record review-A review of Resident #126's May 2024 CPO did not reveal a physician's order for secure unit placement. -A review of Resident #126's elopement risk evaluation revealed it was initiated on 4/1/24 but was not complete at the time of the survey and did not contain a score. -A review of Resident #126's comprehensive care plan, initiated 4/3/24, revealed there was not a care plan focus related to Resident #126's secure unit placement to include person-centered individualized interventions, personalized triggers, or personalized signs and symptoms.-The semi-secure neighborhood placement evaluation for Resident #126 did not specify why the resident needed placement in a secure unit. The evaluation documented Resident #126 benefited from the structure of the semi secure unit and had a guardian for major decisions. The evaluation was signed by the nursing home administrator (NHA), a social worker, the assistant director of nursing (ADON), the director of nursing (DON) and the legally responsible party. The referral for secured unit placement from the Veterans Administration (VA) documented the residents' need for secure unit placement or a wander guard system. -However, the facility did not perform its own admission assessment or a 30-day post-admission assessment with input from an individual with mental health or social work training who was not a staff member. III. Resident #121A. Resident statusResident #121, over the age of 65, was admitted on 10/27/23. According to the May 2024 CPO, diagnoses included secondary malignant neoplasm of unspecified kidney and renal pelvis (kidney cancer), type II diabetes mellitus, hypertension (high blood pressure), and atrial flutter (abnormal heart beat). -There were not any mental health or dementia diagnoses identified. The 4/5/24 MDS assessment revealed the resident had a mild cognitive impairment with a BIMS score of 12 out of 15. He was independent in mobility with the use of a cane. He did not have any behaviors or refusal of care. B. Record Review-A review of Resident #121's May 2024 CPO did not reveal a physician's order for secure unit placement. A review of Resident #121's elopement risk evaluation was completed on 2/2/24 and it documented a low risk of wandering with a score of two. -A review of Resident #121's comprehensive care plan, revised on 2/13/24, revealed there was not a care plan focus related to Resident #121's secure unit placement to include person-centered individualized interventions, personalized triggers, or personalized signs and symptoms.-The semi-secure neighborhood placement evaluation for Resident #121 did not specify why the resident needed placement in a secure unit. The evaluation documented Resident #121 benefited from the secure unit due to dementia and had a guardian for major decisions. The evaluation was signed by the NHA, a social worker, a member of the nursing department, DON and verbal consent from the legally responsible party. -However, the facility did not perform its own admission assessment or a 30-day post-admission assessment with input from an individual with mental health or social work training who was not a staff member. -The referral from a hospice service provider and family did not document a need for secure unit placement. -The semi secure unit placement evaluation included in Resident #121's pre admission packet was not completed. C. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 5/20/24 at 2:05 p.m. LPN #4 said it was his first day working at the facility. He could not locate any information in Resident #121's EMR that justified the need for secured unit placement for Resident #121. LPN #4 said there should be orders in the CPO for secured unit placement based on his experience at other nursing facilities. Registered nurse (RN) #3 was interviewed on 5/20/24 at 3:48 p.m. RN #3 said Resident #121 was placed in the secured unit due to his behaviors, however she could not locate any documented information in the resident's EMR. She said sometimes family members were involved in the decision to place a resident on the secured unit. RN #3 said the facility did not have wander guards and the secure unit was the least restrictive alternative available at the facility. RN #3 said the social workers and the DON were responsible for ensuring the secure unit placement was in the care plans for each resident placed there. RN #3 said diagnoses alone did not justify placement on the secure unit, but in the case of Resident #121 no one ever knew when he was going to blow up and have behavioral issues. IV. Resident #115A. Resident statusResident #115, under the age of 65, was admitted on 7/28/23. According to the May 2024 CPO, diagnoses included Wernicke's encephalopathy (an acute neurological condition characterized by a clinical triad of ophthalmoparesis with nystagmus, ataxia, and confusion), type one diabetes mellitus, anxiety disorder and alcohol dependence with alcohol-induced persisting dementia. The 4/22/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with all ADLs. She did not have any behaviors or refusals of care. B. Resident interviewResident #115 was interviewed on 5/16/24 at 9:48 a.m. The resident resided on the second floor and said she did not want to live at the facility and she felt trapped. She said she could not leave the second floor without an escort and did not know why. C. Record Review-A review of Resident #115's May 2024 CPO did not reveal a physician's order for secure unit placement. A review of Resident #115's elopement risk evaluation was completed on 10/25/23 and documented a high risk of wandering with a score of 13. -A review of Resident #115's comprehensive care plan, revised on 4/23/24, revealed there was not a care plan focus related to Resident #115's secure unit placement to include person-centered individualized interventions, personalized triggers, or personalized signs and symptoms.-The semi-secure neighborhood placement evaluation for Resident #115 did not specify why the resident needed placement in a secure unit. The evaluation documented Resident #115 benefited from the structure of the secure unit due and the guardian supports placement on the semi secure unit. The evaluation was signed by the NHA, a social worker, the DON and verbal consent from the legally responsible party. -However, the facility did not perform its own admission assessment or a 30-day post-admission assessment with input from an individual with mental health or social work training who was not a staff member. V. Resident #72A. Resident statusResident #72, under the age of 65, was admitted on 7/29/2020 and readmitted on 3/12/24. According to the May 2024 CPO, diagnoses included Ahlzeimers disease with early onset, unspecified dementia, generalized anxiety disorder and a cognitive communication deficit. The 3/15/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of zero out of 15. She did not have any behaviors or refusal of care. She required setup or clean up assistance with ADLs and partial to moderate assistance with toileting hygiene. B. Record Review-The semi-secure neighborhood placement evaluation for Resident #72 did not specify why the resident needed placement in a secure unit. The evaluation documented Resident #72 benefited from the structure of the secure unit due and the proxy gave verbal consent for semi secure unit placement. The evaluation was signed by the NHA, a social worker , an ADON and the DON. -However, the facility did not perform its own admission assessment or a 30-day post-admission assessment with input from an individual with mental health or social work training who was not a staff member. VI. Resident #20A. Resident statusResident #20, under the age of 65, was readmitted on 10/5/23. According to the May 2024 CPO, diagnoses included unspecified intracranial injury, mood disorder with depressive features, brief psychotic disorder, and unspecified psychosis not due to a substance or known physiological condition. The 4/16/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of zero out of 15. He had experienced hallucinations and delusions but did not refuse care. He required supervision and assistance with ADLs and was dependent on staff for bathing. B. Record Review-A review of Resident #20's May 2024 CPO did not reveal a physician's order for secure unit placement. A review of Resident #20's elopement risk evaluation was completed on 4/15/24 and it documented a high risk of wandering with a score of 11. -The semi-secure neighborhood placement evaluation for Resident #20 did not specify why the resident needed placement in a secure unit. The evaluation documented Resident #20 benefited from the structure of the secure unit and the guardian agreed to placement on the semi secure unit. The evaluation was signed by the NHA, a social worker , a nursing department representative, the DON and verbal consent from the legally responsible party. -However, the facility did not perform its own admission assessment or a 30-day post-admission assessment with input from an individual with mental health or social work training who was not a staff member. VII. Staff interviewsThe social services director (SSD) was interviewed on 5/16/24 at 2:00 p.m. The SSD said the second floor was considered semi secured so it was not really a secure unit. The SSD said the unit had egress doors that would open when pushed on for more than 15 seconds. The SSD said residents were re-evaluated for a move from the semi secured unit to the non secured third floor on an ongoing basis and it depended on the residents' ability and motivation to leave the facility and input from the interdisciplinary team, the physician, family or guardian. The SSD said therewas not an official assessment that occurred for evaluation. ADON #2 was interviewed on 5/20/24 at 3:51 p.m. ADON #2 said when a resident was admitted to the secure unit she went through the resident's record to ensure there was justification for placement. She said the assessment was done prior to admission. ADON #2 said the team assessed each resident after admission for appropriateness of the secure unit placement. She said every resident on the secure unit had a physician's order for placement which would be located in the CPO and it would be identified in the residents' care plans. The DON was interviewed on 5/20/24 at 3:56 p.m. The DON said a resident qualified for secure unit placement if there was an elopement risk or if the resident had behavior risks that compromised safety to themselves or others. He said resident placement on the secure unit was discussed in care conferences on a quarterly basis. The DON said social services was responsible for ensuring the care plan reflected the secure unit placement. He said if a resident or guardian requested a resident to move off of the unit, the team would reassess, but if things were going well they would just keep the resident on the secured unit. The NHA was interviewed on 5/20/24 at 4:03 p.m. The NHA said a resident qualified for secure unit placement if there was a safety concern to the resident themself or others, if it was deemed by court order or if the resident or family/guardian preferred secure unit placement. She said the residents on the secured unit were reassessed every six months by staff and the initial assessment was in the residents' EMRs. She said all recurrent assessments were a hard copy and kept by the SSD. The NHA said it was the responsibility of social services and anyone in the nursing department to ensure an order was in the EMR for secure unit placement. She said if a resident showed evidence of exit seeking they were placed on the secured unit. The NHA said the facility did not have a wander guard system. The medical director (MD) was interviewed on 5/21/24 at 1:04 p.m. The MD said he always recommended to the staff that they include the need for secure placement in the care plan and notes. He said the primary care provider needed to complete paperwork to attest that each resident had failed in less restrictive environments and the attending physician would sign that document. The MD said the second floor was considered a secure unit because everyone had to have a key fob to access or leave the floor.

Based on record review and interviews, the facility failed to thoroughly investigate an allegation of neglect involving one (#8) of two residents reviewed for neglect out of 56 sample residents. Specifically, the facility failed to conduct a thorough investigation to determine the cause of reddened skin and blisters found on Resident #8's left and right thigh. Findings include:I. Facility policyThe Abuse and Neglect policy, undated, was provided by the nursing home administrator (NHA) on 5/13/24 at 2:17 p.m. It documented in pertinent part,"This policy is intended to provide guidance on investigating and reporting suspected resident rights violations and abuse, neglect, and misappropriation of resident property."This policy will be accomplished through the following:a. Pre-Screening of all facility associates and agency supplemental personnel.b. Training and documentation of training for all associates and agency supplemental personnelthrough orientation and on-going sessions.c. Prevention through training of all residentsd. Identification of suspected cases of abusee. Investigation of all incidents and allegations by qualified and trained individualsf. Protection of residents during investigations.g. Reporting of abuse as required by law/regulations."To assist our community's associate members in recognizing abuse, the following definitions ofabuse are provided.a. Abuse is defined as "the willful infliction of injury, unreasonable confinement, intimidation, orpunishment with resulting physical harm or pain or mental anguish.b. Neglect is defined as "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness."An immediate investigation will be conducted.a. Wellness Director or designee will complete the investigative form. The physician and Executive Director will review and sign the form.b. The following action will be taken regarding the employee involved. 1. The associate will be suspended without pay pending a full investigation 2. The associate will have thirty days to request a hearing to present evidence, either in person,in writing, or through witness to refute the allegation. 3. The associate may have an attorney present at the hearing. 4. In the event, it is determined that the associate did not neglect, abuse, and/or misappropriateresident property, they will be reinstated and paid for all days lost from work.c. A final report will be submitted to the Administrator within five working days of occurrence."II. Resident #8A. Resident statusResident #8, under the age of 65, was admitted on 7/27/23 and readmitted on 9/12/23. According to the May 2024 computerized physicians orders (CPO), diagnoses included personality disorder, paraplegia, systemic sclerosis, type 2 diabetes mellitus and anxiety disorder. The 4/24/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no behaviors and did not reject care. The resident was dependent on staff for toileting, dressing, personal hygiene and bathing. B. Resident interviewResident #8 was interviewed on 5/15/24 at 2:15 p.m. Resident #8 said she was recently readmitted to the facility in the late afternoon on 12/27/23. She said she was given a shower in the morning on 12/28/23 and when she went to bed that night staff found red skin and blisters on both of her thighs. Resident #8 said she requested to go to the hospital again for treatment but the staff refused to call an ambulance so she called 911 from her personal cell phone. She said she did not have much feeling in her legs so she did not know the water in the shower was too hot for her fragile skin. C. Record reviewA nursing note dated 12/27/23 at 5:08 p.m. documented Resident #8 returned from the hospital at 4:15 p.m. accompanied by paramedics. It documented the resident was stable and cooperative and there were no new skin issues. A skin integrity evaluation dated 12/27/23 at 4:38 p.m. revealed an existing wound on the residents right buttock and left knee that was improved. There were not any other wounds or skin integrity issues documented. A nursing note dated 12/28/23 at 10:59 p.m. revealed that certified nurse aides (CNA) had provided care to the resident at 8:30 p.m. and discovered blisters between the resident's inner right and left thigh. It documented that the skin was open and not intact with the left wound measuring 15 centimeters (cm) long and 13 cm wide and the right wound measuring 6.5 cm long and 4 cm wide. The note documented the supervisor was informed and instructed the nurse to clean the wounds and apply abdominal pads. The note revealed the resident informed the nurse she wanted to go to the hospital. The note also documented that the resident called emergency medical services (EMS) from her cell phone without informing staff and was picked up by EMS at 11:06 p.m. An injury/incident report was dated 12/28/24 at 8:40 p.m. and was completed by assistant director of nursing (ADON) #2. The report documented the resident had blisters on her left and right inner thighs, the resident was alert and oriented to person, place, time and situation and there were no witnesses found. The discharge summary, dated 12/29/23 from a local hospital, documented the resident had 4% total body surface area (TBSA) partial thickness burns (second degree burns) sustained when she was in the shower at the resident's facility on 12/28/23. She was transferred to a burn center for autografting (skin transfer from one part of the body to another) of the burns. A nursing note dated 1/15/24 at 5:34 p.m. documented the resident returned to the facility from the hospital. It revealed the resident had discoloration to both of her thighs due to healing partial thickness second degree burns with autograft. D. Failure to investigate the 2nd degree burnsThe facility failed to complete a thorough investigation as to how the resident had sustained 2nd degree burns to both of her left and right thigh. The facility failed to interview the CNA who performed the shower on 12/28/23, failed to show that water temperatures in the the showers were monitored on a regular basis and failed to ensure other residents and staff were interviewed in regards to the water temperatures in the shower and the burns to Resident #8's thighs. -The facility investigation was requested. However, the DON said they had only done a soft investigation of the allegation (see interviews below). The DON provided a document he referred to as his soft investigation. It read in pertinent part,"Soft file Resident #8 investigation -CNA reported to nurse blisters on legs on 12/28/23 -Resident sent out to hospital 12/28/23 -Wound nurse notified to have wound doctor assess on next rounds 12/29/23 -Documentation from hospital identified the source of blisters as minor burns. -On 12/29/23 notified adult protective services (APS) was involved and investigating source of burns -Facility asked to temperature check water in Spruce Spa on 12/29/23 -Shared it was 100 degrees consistent with two previous readings in December -Suspicion of self-inflicted origin related to previous periods when wound was improving and developed infection with no changes in wound care. -Facility notified guardian we would not take her back due to open APS case. -Resident stated at hospital to police department it was not intentional and did not want to hold individual at fault. -Guardians and APS determined facility is the best place for Resident #8. -Resident #8 returned on 1/15/24."An email dated 1/4/24 at 9:23 a.m., from the social worker at the burn center, documented the guardians for Resident #8 were trying to brainstorm what could have caused the burns to the resident's thighs. It revealed the guardians had several theories but did not specify any interviews conducted or witness statements.-The facility did not investigate further by interviewing Resident #8 once she returned to the facility. D. InterviewsCNA #9 was interviewed on 5/15/24 at 3:40 p.m . CNA #9 said she had worked at the facility for three months and had showered residents. She said she checked the temperature with her hand and then asked the residents if the water felt okay. She said she did not use a thermometer to check the temperature of the water and thought she had learned the technique of checking the temperature with her hand before applying it to a resident in CNA school. CNA #9 said if a resident had delicate skin, she would check with the nurse before showering the resident. The DON was interviewed on 5/20/24 at 9:25 a.m. The DON said he did an internal soft investigation and had notes on what he discovered regarding Resident #8's wounds. He said the facility did not have a formal form that was used for investigations. The DON said he thought APS took over the investigation so he did not continue investigating further and just "let it go". He said the water in the shower was temperature checked and it was fine. The environmental service director (ESD) was interviewed on 5/20/24 at 3:39 p.m. The ESD said he checked the water temperature in the facility showers weekly and expected the temperature to read a minimum of 100 degrees fahrenheit. He said he was aware of an incident where a resident reported being burned in the shower but he was not sure what the facility had done when the resident reported that or if it had been determined to be true. The ESD said,to his knowledge, no residents had ever gotten burned in the facility showers.

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

Based on observations, interviews, and record review, the facility failed to have a plan to ensure staff were trained and had the necessary equipment to emergently evacuate residents from the facility, affecting the safety of all 130 facility residents. Review of the facility floor plans, observations, and interviews revealed three facility emergency exits that led to two outdoor courtyards. Each exit had an EXIT sign that pointed to the courtyard doors. Observation of the outdoor courtyards revealed one of the courtyards had three exits through gates secured with padlocks that required a key to unlock. Staff reported they did not know where to locate a key to release the padlocks on the gates. The second outdoor courtyard revealed one exit through a gate. This gate was secured with a C clamp (device to hold objects together), that required a tool to remove it. Staff reported they did not know how to remove the C clamp on the gate. The facility's failure to have a plan to ensure staff were trained and had the necessary equipment to evacuate residents from the facility emergently created a situation of immediate jeopardy with widespread potential for serious harm. Further review, observation, and interviews revealed the facility failed to take sufficient steps to prevent Resident #45's fall with injury and failed to develop and implement appropriate and effective fall interventions given the resident's known cognitive and functional limitations and behaviors. Findings include:IMMEDIATE JEOPARDY I. Immediate Jeopardy A. Findings of immediate jeopardyStaff interviews revealed the facility failed to have a plan that ensured the safe evacuation of residents from the facility in an emergency. Observations revealed the facility had three floors. Forty-six residents resided on the second floor and 84 residents resided on the third floor. Evacuation floor plans were posted on the wall on each floor. Directional arrows showed the path to follow in the event of evacuation. Review of the facility evacuation plans, observations, and interviews revealed the second floor plan had two stairwell exits and two ramp exits with egress doors that led to a courtyard with an egress gate. The gate was equipped with a broken magnetic lock and secured with a C clamp that required a socket wrench for removal so that staff and residents could evacuate from the second floor. Review of the facility evacuation plans, observations, and interviews revealed the third floor plan had an emergency exit through the recreation area (patio) that opened into a gated courtyard. The main exit from the courtyard had a padlock on the gate. The secondary path to exit the courtyard had a padlock on the gate, which led to another small fenced-in area with a padlock on the gate. Another path showed direction out another door, which led to the gated patio. The staff interviewed were unaware of any process to evacuate residents and reported they did not have access to keys to unlock the padlocks on the gates or knew how to remove the C clamp. The environmental services director (ESD) said he held the only key to all three padlocks and the C clamp required a socket wrench for removal. He said the C clamp was temporary but the padlocks on the gates were placed at the direction of the previous nursing home administrator (NHA) to keep outside people from getting in and keeping residents from leaving the community. Staff demonstrated a lack of understanding and training with the plan for evacuation and observations revealed the presence of physical barriers (padlocks and C clamp) that prevented staff and residents from evacuating the premises. The facility's failure to have a plan that ensured the safe evacuation of residents created a hazardous environment with the potential for serious harm, affecting 130 facility residents. B. Facility plan to remove the immediate jeopardy On 5/15/24 at 2:18 p.m., NHA provided a plan to remove the immediate jeopardy situation. The removal plan read:Plan of Correction:-All padlocks have been removed on 5/14/24 at 2:00 p.m. C clamp was removed on 5/14/24 at 3:30 p.m. The consultants provided interdisciplinary team (IDT) members training and education on never placing padlocks on emergency egress gates.-The ESD and consultants completed a walkthrough of the community on 5/15/24. Verified all locks were removed. Recommendations were made to change the layout of primary exit doors on 5/15/24. The ESD updated the emergency exit floor plan to reflect the necessary changes to the emergency exits on 5/15/24. Additionally, the ESD updated the emergency exit signage and removed emergency exit signs that will no longer be emergency exits on 5/15/24. All staff were re-educated on looking for emergency exit signs and new emergency exits on 5/15/24.-The community is purchasing a new emergency preparedness (EP) manual. This manual will arrive 5/16/24. The consultants will provide education and training with the NHA/ESD on the content of the EP manual 5/15/24.-All community staff (IDT members, licensed nursing, nursing assistants, dietary, housekeeping/maintenance) have been educated on the procedure to evacuate a resident in case of an emergency on 5/14/24 and 5/15/24 between 6:00 a.m. and 2:00 p.m. for first shift, second shift between 2:00 p.m. to 10:00 p.m. and between 10:00 p.m. to 6:00 a.m. for third shift. Specifically, staff received additional training and education on 5/15/24 on the following:Evacuation Procedure -1. Staff members have been trained to pull fire alarm in the event of an emergency that would require potential evacuation / call 911.2. Designate staff member to complete and maintain resident tracking 3. Evacuation exit doors /community evacuation floor plan 4. Phases of evacuation includingPhase 1 ambulatoryPhase 2 wheelchair dependentPhase 3 bed bound.-The community ordered five evacuation sleds for emergency exits with stairs. The emergency sled will be stored in the stairwell. When the sleds arrive the ESD will provide education and training with staff on how to use the emergency sleds. In the meantime, the ESD trained community staff on the use of a mattress to transport wheelchair or bed bound residents.-All community staff (IDT members, licensed nursing, nursing assistants, dietary, housekeeping/maintenance) have been educated on the location of the disaster preparedness binders and where to find them on 5/14/24 and 5/15/24 between 6:00 a.m. and 2:00 p.m. for first shift, second shift between 2:00 p.m. to 10:00 p.m. and between 10:00 p.m. to 6:00 a.m. for third shift. All departments have been provided the education with signatures. -When the new emergency manual arrives the community will remove old manuals.-The ESD /NHA confirms no other doors or exits have physical barriers. All secured /locked evacuation routes can be quickly opened to safely evacuate residents.-Emergency doors will be checked daily by the ESD or designee for one week for functioning and accessibility. The ESD or designee will check the emergency door weekly for a month and report to the QAPI committee for review and recommendations. Recommendations made by the QAPI committee will be executed by the ESD or designee.-Facility staff will continue to be trained on evacuation routes and procedures monthly during scheduled drills.-The IDT team will complete visual door checks on emergency exits to ensure there are no barriers present daily. The checks will be documented on an audit sheet. These visual checks will be conducted daily for 30 days. Findings of the audits will be reported to the QAPI committee for review and recommendations. The Administrator will beresponsible to execute findings of the QAPI committee related to ongoing audits and frequency of the audits.-Emergency Preparedness will be reviewed monthly in QAPI and Safety Committee monthly for three months and quarterly thereafter. C. Removal of immediate jeopardyThe NHA was notified the immediate jeopardy was removed on 5/16/23 at 5:07 p.m. based on the facility's removal plan (see above). However, deficient practice remained at a G level, with a potential for more than minimal harm that is widespread. II. Facility PolicyThe facility's evacuation plan was received from the NHA on 5/14/24 at 1:30 p.m. It read in pertinent part:"-A Community specific Evacuation plan is developed and posted.-Residents and staff are trained on evacuation routes and procedures on a monthly basis during scheduled drills.-Routes for evacuation may change due to the location, therefore use the nearest exits, avoiding the fire, as directed by the individual in command. Evacuation is made to a fire safe area. The fire safe areas for the community are the parking lot across from the church which is located on the northeast corner of 30th and Vallejo. -­The procedure for building evacuation is as follows.a. Residents in immediate danger shall be evacuated first.b. Residents closest to danger will be evacuated next (adjacent, across and above fire).c. Ambulatory residents shall then be assistedd. Residents who are unable to evacuate independently (due to cognitive, psychological, or physical reasons) shall be assisted next.-Evacuation, if necessary, is conducted under the direction of the Executive Director prior to the arrival of the Fire Department."III. Observations, interviews, and record review revealed the facility failed to have a plan to ensure staff were trained and had the necessary equipment to evacuate residents from the facility emergently. A. ObservationsObservations revealed the facility had three floors. Forty-six residents resided on the second floor and 84 residents resided on the third floor. Evacuation floor plans were posted on the wall on each floor. Directional arrows showed the path to follow in the event of evacuation. Three facility emergency exits led to two outdoor courtyards. Observation of the second floor courtyard emergency exit on 5/14/24 at 1:45 p.m. revealed the gate which allowed exit from the courtyard in the event of an emergency was secured with a C clamp and two screws. There was an illuminated exit sign above the door leading to the courtyard and an emergency exit route map posted on the wall that directed people to exit through the courtyard. Observation of the third floor courtyard emergency exit on 5/14/24 at 1:52 p.m. revealed a main gate to exit the courtyard, a side gate to exit the courtyard, and yet another gate to exit the side yard. Each gate was equipped with a padlock that prevented the gates from opening. There was an illuminated exit sign above the door leading to the courtyard and the side yard and emergency exit route maps posted on the wall which directed people to exit through the courtyard and the side yard. B. Staff InterviewsCertified nurse aide (CNA) #7, who worked on the third floor, was interviewed on 5/14/24 at 2:03 p.m. She said she did not know the evacuation route in case of an emergency. She said usually she would get the residents who ambulate out first, probably down the stairs. She said if the stairway was blocked, she would go to the smoking patio but she did not know the protocol because that area was gated and locked. CNA #2 and CNA #3 were interviewed together on 5/14/24 at 2:06 p.m. They said in an emergency, they would secure each resident in their room. They both denied any knowledge of how to exit the building in the event of an emergency that required evacuation. Neither CNA knew how to open the gate in the courtyard or the C clamp and would have to ask the nurse how to exit in an emergency. RN #2, who worked on the third floor, was interviewed on 5/14/24 at 2:10 p.m. She said the evacuation process would depend on the emergency. She said if there was a fire, she would evacuate everyone out of the emergency doors, and avoid the elevator and gym. She said if there was a fire inside she would evacuate to the smoking patio; however, there were gates there that were currently locked. She said the only one who had a key was the environmental services director (ESD). RN #2 said if a resident was non-ambulatory and needed to evacuate down the stairs, she was not sure how this would occur. The environmental service director (ESD) was interviewed on 5/14/24 at 2:15 p.m. The ESD said he held the only key to all three padlocks and the C clamp required a socket wrench for removal. He said the C clamp was temporary to prevent second floor residents from exiting the facility while he waited for the gate to be repaired, but the locks on the gates were placed at the direction of the previous nursing home administrator (NHA) to keep outside people from getting in and keeping residents from leaving the community. The Maintenance assistant (MA) was interviewed on 5/14/24 at 2:20 p.m. He said he had worked in the facility for ten years, and in the maintenance department for four years. He said for an emergency, the alarm should be pulled and residents were to evacuate to the patio and through the gate and wait for help. The MA said when the fire alarm was pulled, the magnetic locks released, and for the padlock on the third floor gate, there was a key downstairs. The MA said he did not know the procedure for evacuating residents down the stairs. Licensed Practical Nurse (LPN) # 3 was interviewed on 5/14/24 at 2:20 p.m. She said she had worked for the facility for about 14 years and said staff received education regarding fire safety/drills. She said she was unsure if employees were provided training on the floor about evacuations. LPN #3 said staff escorted residents to their rooms and closed the door when the fire alarm was activated. She said if an evacuation was necessary, she would wait until instructed to evacuate residents. LPN #3 said residents were evacuated using their wheelchair or a sled. -LPN #3 demonstrated the fire escape door on the third floor opened after the alarm bar was depressed for 15 seconds. She had difficulty opening the door. She was unsure how long to depress the activation bar and it took 3 start-stop attempts to open the door. The alarm rang when she first depressed the bar and she was able to silence the alarm outside near the door frame with her key.-LPN #3 said she had never participated in an evacuation drill. She said they would work together and staff would carry residents down the stairs. She was unaware if the facility had evacuation supplies such as carry chairs or sleds. LPN #3 said she was unaware which employee would account for residents and staff during an evacuation and thought it would be the NHA. The NHA was interviewed on 5/14/24 at 2:30 p.m. The NHA said she was not aware of the C clamp on the second-floor courtyard gate or the padlocks on the three courtyard gates on the third floor. She was also unaware that the ESD reported he held the only key to the padlocks on the three gates in the third-floor courtyard. The NHA said in the event of an emergency that required evacuation of the building, she was confident staff would react appropriately and be able to determine how to safely evacuate residents from the building. Housekeeper (HK) #1, who worked on the third floor, was interviewed on 5/14/24 at 2:35 p.m. She said if there was a fire, do not use the elevator but take the stairs. She said she was not sure how to help the residents down the stairway; if they could not walk; it would be a problem. HK #1 said she was not sure how to evacuate from the smoking patio on the third floor. HK #2 was interviewed on 5/14/24 at 2:38 p.m. She said she had worked for the facility for two years. She said when the fire alarm was activated, her role was to help clear the common areas and hallways and see if residents were in a safe place. HK #2 said if an evacuation was necessary, they would use the buddy system. She said all the employees were strong and they would work as a team to carry residents down the fire exit stairs. The director of nursing (DON) and the ESD were interviewed together on 5/14/24 at 3:40 p.m. The DON said staff received basic fire safety education through computer-based training modules. The DON provided a copy of the new employee skills competency for the nursing department and fire safety was not listed. He said the competencies were all clinical in nature. -The ESD said that he was responsible for training staff in fire safety and held a fire drill one time a month. He said the computer tracking software system notified them where and when the monthly drill should be conducted. The ESD said after each drill he completed a fire drill evaluation form and the drill was reviewed during the next interdisciplinary meeting, usually the next day after the drill. -The ESD provided a copy of the fire drill assessment form and the form included an evaluation of staff response up to the point an evaluation would be necessary. The documentation did not indicate evacuations were practiced or discussed. -The DON said when a fire alarm was activated in the building, the fire panel displayed the location of the alarm in the building. He said the fire panels were located at each nursing station. He said if evacuation was necessary, the policy was to start with the room above the fire alarm as well as the room on either side. He said that if a larger evacuation was necessary, staff should assist residents behind the fire door where they would gain two to four hours of protection. The DON said the fire exit stairs were not the first choice for fire exits. The DON said the facility was constructed on a hill and each floor had a ground-level exit. The ground-level exit would accommodate those residents in wheelchairs or being moved in their beds. The DON said the door on the second floor that led to the courtyard was not a fire exit and said it was chained and locked. The DON said all the doors that have alarms attached open after depressing the activation bar. He said that staff would be available to open the door for those with lower cognition or physically unable to depress the activation bar. FALL PREVENTIONRecord review, observations, and interviews revealed the facility failed to ensure an environment free from the risk of accidents and hazardous situations for Resident #45. On 4/30/24, Resident #45 sustained a witnessed fall when she rocked herself out of her wheelchair. Resident #45 sustained a laceration to her face, was thought to have a broken nose, and was transported to the hospital. A care plan for the resident "putting herself on the floor" was added on 5/1/24. The only intervention added on 5/1/24 to this care plan was that Resident #45 would make her needs and wants known to staff. A full fall investigation was not carried out by the facility, as the director of nursing (DON) deemed the incident to be a behavior and not a fall. The facility failed to take sufficient steps to investigate Resident #45's fall with injury and failed to develop and implement appropriate and effective fall interventions given the resident's known cognitive and functional limitations and behavior. The facility failures contributed to a fall with injury. I. Facility policyThe Fall Management policy (no date of creation or revision) was received from the NHA on 5/21/24 at 12:09 p.m. It read in pertinent part:"If a resident experiences more than one fall, a collaborative discussion between the Wellness Director, ED (executive director), Connections Director, the family, and resident's physician will be held to review the resident's needs. Discussion may include changing current pharmacology, diet, increasing activities participation, or another alternate to enhance and promote the resident's quality of life. All interventions are documented in the resident's Service Plan and Health Plan."An incident report is completed and the incident report policy is followed. An incident/accident investigation will be completed and reviewed."II. Resident #45A. Resident statusResident #45, age 81, was admitted to the facility on 4/21/23, transported to the hospital on 4/30/24 after a fall, and returned to the facility on 5/1/24. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia, cognitive communication deficit, and altered mental status. The 5/2/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. The resident was dependent and required supervision and assistance with all activities of daily living. The 2/21/24 care plan revealed Resident #45 was at high risk for falls due to confusion and unawareness of safety needs. Pertinent interventions included anticipating and meeting Resident #45's needs, reviewing information on past falls and attempting to determine the cause of falls, recording possible root causes, and altering or removing potential causes if possible. B. Observations and resident interviewOn 5/15/24 at 10:20 a.m., Resident #45 sat in her wheelchair in the dining room. Resident #45 was wearing anti-slip socks. She did not have any anti-tip bars or anti-rollbacks in place on her wheelchair. On 5/16/24 at 9:46 a.m., Resident #45 said her hand and her face hurt. Resident #45 had bruising present on both her face and her hands. Resident #45's left hand was red and swollen, especially around her knuckles. Resident #45's right hand had a purple and yellow bruise approximately three inches by four inches in size. Resident #45 had crescent-shaped bruising on her cheekbones and an inch-sized round bruise on her forehead that was covered with thin medical bandages. On 5/21/24 at 12:17 p.m. Resident #45 was in her bed. The bed was in the lowest position, and the fall mat was in place. C. Record review 1. Fall 4/30/24A progress note dated 4/30/24 at 11:38 a.m. revealed Resident #45 was observed rocking herself forward and falling out of her wheelchair, resulting in a laceration to her forehead. A progress note dated 4/30/24 at 11:58 a.m. revealed Resident #45's representative was contacted by the facility staff regarding the resident's fall out of her wheelchair. A risk management report, dated 4/30/24 at 11:40 a.m., revealed Resident #45 fell forward out of her wheelchair and landed on her face on the floor. The note revealed Resident #45's fall resulted in a forehead laceration, bruising over her face, right hand, and left forearm, and a possible broken nose. The note revealed Resident #45 was frequently confused and not able to follow simple commands or make her needs known. Hospital notes, dated 4/30/24 at 12:03 p.m., revealed Resident #45 was transported to the hospital for evaluation after a fall. Diagnoses included a closed head injury and a laceration of the forehead. 2. Facility response to Resident 45's fall with injuryRecord review revealed the facility failed to comprehensively investigate the resident's fall to develop and implement resident-specific interventions based on her known cognitive, and functional impairments and known behaviors. The 4/30/24 24-hour report form revealed Resident #45 rocked herself out of her wheelchair, which was a behavior resulting from intentionally acting out. The report form revealed instructions to monitor Resident #45 for behaviors of rocking or propelling herself forward out of her wheelchair or bed when the resident returned from the hospital. A care plan dated 5/1/24 revealed Resident #45 "putting herself on the floor by rocking forward in her wheelchair and vaulting herself to the floor." The intervention included was to have Resident #45 make her needs and wants known to facility staff members. But see above; the 4/30/24 risk management report read the resident was not able to make her needs known. A review of the May 2024 CPO revealed an order indicating Resident #45 was a high fall risk. Interventions in place from this order included purposeful rounding, proper non-skid footwear, and having her bed in the lowest position. The 5/1/24 24-hour report form revealed instructions to continue monitoring Resident #45 for behaviors and to intervene if the resident was seen rocking to prevent a fall. A post-incident investigation for falls was started on 5/1/24 at 9:28 a.m. but was not completed. A note on the risk management report from 5/1/24 revealed the risk management report was struck out by the DON because the incident was considered an intentional act and not a fall. Multidisciplinary care conference notes dated 5/6/24 at 3:13 p.m. revealed Resident #45 rarely verbally communicated her needs and had increased behaviors over the previous quarter. Occupational therapy (OT) notes from 5/14/24 revealed Resident #45 had a recent fall with resulting forehead laceration and facial bruising and that the resident demonstrated weakness and decline in coordination and self-feeding skills. The OT notes revealed Resident #45 had mild pain generally in her head and body over the prior five days at the time of the note. The OT notes revealed Resident #45 had impaired safety awareness, and was sometimes understood when communicating with others. C. Staff interviewsStaff interviews confirmed the facility failed to comprehensively investigate the resident's fall to develop and implement resident-specific interventions based on her known cognitive and functional impairments and known behaviors. Registered nurse (RN) #1 was interviewed on 5/16/24 at 3:27 p.m. RN #1 said the standard procedures after a resident fell included starting neurological checks, doing a physical assessment, and initiating a risk management indicator on the resident's electronic medical record. RN #1 said physical and occupational therapy would then evaluate the resident to see if they had any changes in mobility that caused their fall. RN #1 said Resident #45 had a history of attention-seeking behaviors, but could not remember if the resident had any fall interventions. RN #2 was interviewed on 5/21/24 at 10:00 a.m. RN #2 said Resident #45 sometimes got agitated and called out, but could usually make her needs known. RN #2 said Resident #45 could call out for a nurse or CNA and ask for what she wanted. RN #2 said Resident #45 fell approximately three weeks ago. RN #2 said Resident #45 had leaned forward in her wheelchair and fell to the floor and she was sent out to the hospital. RN #2 said Resident #45's interventions included ensuring the resident did not transfer by herself, checking the resident frequently, using non-slip socks, and encouraging the resident to express what she wanted. CNA #1 was interviewed on 5/21/24 at 10:18 a.m. CNA #1 said Resident #45 preferred male staff members over females for care. CNA #1 said Resident #45 had difficulty focusing and needed cueing for eating. The CNA said it would sometimes take a while for her to process her needs and sometimes, Resident #45 would start screaming and would not be able to say what she needed, but eventually, the nurse could get an answer out of her. CNA #1 said Resident #45 flung herself out of her wheelchair a while ago. CNA #1 said the male CNA who usually worked with Resident #45 was out of town, so there were only female staff members working with Resident #45. The resident became overstimulated and threw herself out of her wheelchair. CNA #1 said Resident #45 had a tendency to fling herself out of her bed or wheelchair, so the interventions they used for her included having a low bed and keeping a fall mat in place. CNA #1 said information regarding care areas like fall interventions was communicated verbally during orientation for new staff members during their walkthrough, but that nothing was written down in an area that was accessible for CNAs. The DON was interviewed on 5/21/24 at 11:01 a.m. The DON said the facility staff determined Resident #45 was having a fit and asking for the one male CNA she usually worked with who was out on vacation, so the resident started rocking in her chair and threw herself on the floor. The DON said the facility staff determined Resident #45 had a history of rocking and throwing herself out of her chair when she did not get her way. The DON said the instance in question was not a typical fall but was instead a behavior, and as such, they did not continue a fall investigation. The DON said the facility staff brought attention and awareness to Resident #45's behavior and that therapy had been in with her frequently. The DON said Resident #45 had not been assessed by physical therapy yet due to issues with insurance authorization. The DON said many of the residents at the facility had wheelchair accommodations like anti-rollbacks and anti-tip bars, but that they may not work if the residents got around the facility by self-propelling backward. The DON said that when care plans were updated, the interventions were placed as an order in the resident's chart and were communicated to the CNAs by the restorative or nursing staff. These communications are both verbal and written in a physical 24-hour report book. The DON said care plans should match what was ordered by the physician. The DON said if a resident was ordered for a low bed or fall mat, it should be in their care plan. When looking at Resident #45's risk management report, the DON identified and highlighted a note that said he had determined it was not a fall because it was a behavior and confirmed that was the case. D. Additional informationAdditional information was provided by the NHA on 5/23/24 at 1:51 p.m. This information included an updated care plan for Resident #45. The care plan revealed additional interventions for the focus of Resident #45 putting herself on the ground, including having a fall mat provided, having a low bed, and educating staff on being aware of and attempting to redirect Resident #45's behaviors.

Based on record review and interviews, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two (#118 and #126) of seven residents out of 56 sample residents. Specifically, the facility failed to ensure trauma assessments were conducted to determine the residents' history of post-traumatic stress disorder (PTSD) and/or trauma, identify triggers and develop person centered interventions within the comprehensive care plan for Resident #118 and #126. Findings include:I. Resident #118A. Resident statusResident #118, age 73, was admitted on 8/17/23. According to the May 2024 computerized physicians orders (CPO), diagnoses included post traumatic stress disorder (PTSD), Alzheimer's disease and bipolar disorder. According to the 3/24/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He was independent with eating, toileting, bed mobility and transferring. He did not use any mobility devices. The assessment documented the resident had an active diagnosis of PTSD. B. Record reviewThe Level II preadmission screening and resident review (PASRR), with an evaluation date of 8/9/23, revealed Resident #118 had worsening symptoms of depression, paranoia, suicidal ideations and was experiencing anxiety related to "being locked up". The PASRR Level II revealed Resident #118 declined to discuss his psychiatric conditions or medications but there was a known diagnosis of PTSD without further information on origin. The PASRR Level II revealed Resident #118 was fearful about his safety and being placed in long term care as he was distrustful of others. The suicidal ideation care plan, initiated on 2/19/24, revealed Resident #118 had expressed not wanting to live and accomplishing this by not eating. It indicated Resident #118 would not express suicidal ideations through the next review date. Pertinent interventions included encouraging the resident to eat and participate in meal time and monitoring the resident's weights. The 3/15/24 progress note indicated Resident #118 had refused breakfast, lunch, medications and beverages and was behavioral and agitated. The 4/27/24 progress note indicated Resident #118 was observed by staff, standing on the patio, talking to himself about going to church and the number six, he was not wearing a jacket, shoes or socks. The progress note revealed when nursing staff attempted to escort Resident #118 back inside, Resident #118 grabbed and held onto the nurse's forearm for a minute's time while telling the nurse to go away from him. The progress note revealed Resident #118 was calling the nurse a liar and accusing the nurse of destroying his things and Resident #118 stated he wished to be dead. The progress note revealed the nurse asked Resident #118 to release his grasp from their forearm and the resident would not. The nurse had to ultimately pry Resident #118's hand from their forearm. The progress note revealed nursing staff was able to administer a scheduled dose of Seroquel (medication used for certain mental/mood disorders), however, Resident #118 was sent to the hospital after banging on the walls and windows of the unit. The 5/5/24 progress note indicated Resident #118 began yelling at staff and threatening to kill them and was having a conversation with a known relative that could be heard only by the resident. The progress note revealed Resident #118 worked better with male staff members when he became paranoid and angry.-The facility was unable to provide a screening assessment specific to trauma or care plan related to Resident #118's PTSD to include personalized triggers, person-centered individualized interventions or personalized signs and symptoms of retraumatization. C. Staff interviewsThe director of nursing (DON) was interviewed on 5/21/24 at 11:30 a.m. The DON said the facility was not currently conducting PTSD assessments or initiating care plans for residents with a known diagnosis of PTSD. The DON said doing so would be an effective way to identify and communicate person centered events of PTSD and reduce retraumatization. II. Resident #126A. Resident statusResident #126, over the age of 65, was admitted on 3/29/24. According to the May 2024 CPO, diagnoses included bipolar disorder, dementia, post-traumatic stress disorder (PTSD) and anxiety disorder. The 4/4/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. He required supervision and assistance with activities of daily living (ADLs). The assessment documented the resident had an active diagnosis of PTSD.B. Record review-Review of Resident #126's comprehensive care plan, initiated 4/3/24, revealed there was not a care plan focus related to Resident #126's PTSD to include person-centered individualized interventions, personalized triggers, or personalized signs and symptoms.-A trauma screen was not found in Resident #126's electronic medical record (EMR). The referral for secured unit placement from the Veterans Administration (VA) documented the resident had a diagnosis of PTSD. C. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 5/20/24 at 3:28 p.m. LPN #4 said he was the nurse for Resident #126 and it was his first day working at the facility. He was unable to locate a care plan for Resident #126 that directed care for his PTSD. The DON was interviewed on 5/21/24 at 11:06 a.m. The DON said a Trauma-informed Care assessment should have been completed on admission because the facility and its staff needed to know how to provide care for Resident #126. The DON said the residents' care plan should include goals and interventions for each resident with PTSD to provide care staff the ability to provide the best care possible. He said the assistant director of nursing (ADON) was primarily responsible for completing the care plans with assistance from the social services director (SSD).

Based on observations and staff interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift on a daily basis. Findings include:I. Failure to have staffing postedObservations in the facility on 5/14/24 at 5:24 p.m. revealed, on the first floor, staffing was posted and dated 4/21/24 and showed a census of 122. -The posting was not for the current day or the current census of 130. Observations in the facility on 5/15/24 at 10:20 a.m. revealed, on the first floor, staffing was posted and dated 5/15/24 and showed a census of 122. -The posting did not show the current census of 130. Observations in the facility on 5/19/24 at 5:00 p.m. revealed, on the first floor, staffing was posted and dated for the previous day 5/18/24. -The posting was not for the current day. II. Staff interviewsThe social services director (SSD) was interviewed on 5/20/24 at 3:21 p.m. The SSD said the health information specialist (HIM) was responsible for posting all of the required information. The SSD said residents in wheelchairs were not able to read the information on the postings because the postings were placed too high on the wall. The nursing home administrator (NHA) was interviewed on 5/23/24 at 9:40 a.m. The NHA said the staffing coordinator was responsible for posting the staffing information. She said the person in that position was new and just started the previous Monday (5/13/24). The NHA said another person that helped with the nurse staffing was posting the information prior to the new staffing coordinator starting. She said, on the weekends, the concierge was responsible for the postings. The NHA said the information should be updated and posted every day and the information for the posting was obtained from the daily staffing report which was produced by the scheduling department.

Based on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for one out of five medication carts in the facility. Specifically, the facility failed to ensure medication carts were locked when unattended and not within the line of sight of the nursing staff. Findings include:I. Facility policyThe Medication Storage policy, undated, was received from the director of nursing (DON) on 5/21/24 at 1:08 p.m. It read in pertinent part,"Purpose: To provide guidelines for proper storage of medications within the community."Procedure: Medications will be stored in a locked cart accessible to authorized personnel." II. Observations and interviews On 5/19/24 at 5:15 p.m. the medication cart on the east side of the second floor was unlocked and positioned in the dining room, next to the nurse's desk. Licensed practical nurse (LPN) #1 was seated at the nurse's desk, facing away from the medication cart. There were several residents walking around the nurse's desk and the medication cart. LPN #1 was interviewed at 5:18 p.m. at the unlocked medication cart. LPN #1 said the facility policy was to have the medication cart locked at all times to prevent unauthorized access to items in the medication cart. LPN #1 said the medication cart was in his line of sight when he sat at the nurse's desk. LPN #1 said when he looked at his computer screen he was unable to have a full line of sight of all the items in the medication cart. During a continuous observation on 5/21/24 beginning at 10:59 a.m. and ending at 11:03 a.m. the following was observed:At 10:59 a.m. the medication cart on the east side of the second floor was unlocked and unattended. There were several residents in the dining room and an unidentified certified nurse aide (CNA) was sitting on the west side of the nurse's desk looking at her cell phone. At 11:03 a.m. LPN#1 returned to the medication cart LPN #1 was interviewed immediately and said he should not have left the cart unlocked because the resident population was high risk and they could potentially open the medication cart. LPN #1 said he was away from the medication cart for just a few minutes because he was helping a resident in the shower room. III. DON interviewThe DON was interviewed on 5/20/24 at 8:20 a.m. The DON said the facility required all of the medication carts to be locked when not attended by the licensed nurse. He said there were several residents on the second floor that had behavioral health concerns and the medication cart should not be left unlocked and unattended. The DON said he would educate the nursing staff immediately to ensure they locked the medication carts when the carts were not within their line of sight. The DON was interviewed again on 5/21/24 at 11:06 a.m. The DON said he completed education with nursing staff working on 5/20/24 and reminded them the facility policy was to lock the medication carts when they were not attended. The DON said he had provided additional education to LPN #1 on 5/21/24 to lock the medication cart when it was unattended. He said he would follow- up with additional education for all nursing staff regarding locking medication carts.

Based on observations, record review, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to ensure food items served during meals were consistent with the posted daily menu. Findings include:I. Resident group interviewThe resident group interview was conducted on 5/15/24 at 11:00 a.m. with seven residents (#76, #75, #115, #68, #7, #77 and #112) who were members of the resident council. The residents were identified as interviewable by the facility and assessments. The residents said the posted menu rarely matched what was served to residents during meals. The residents said they did not receive mashed potatoes and gravy very often. The residents said chicken was served a lot in the past but they complained about it, so now they were served a lot of pasta and rice dishes. II. Meal observationsThe 5/13/24 posted lunch menu revealed residents were to be served barbeque beef brisket, hot German potato salad, collard greens, vegetable soup and a dinner roll with butter. Dessert was listed as fruit gelatin with marshmallows and assorted beverages were to be served. During a continuous lunch observation of the third floor dining room on 5/13/24, beginning at 11:30 a.m. and ending at 1:30 p.m., the following was observed: -Butter was not provided for dinner rolls;-Soup was not offered or served; -The potatoes were mashed instead of a potato salad; and,-Dessert was an orange-colored fruit gelatin, however, there were no marshmallows in the dessert. Alternative selection for the main dish was pasta salad with protein (seafood)The 5/14/24 posted lunch menu revealed residents were to be served grilled chicken with onions, savory summer squash, cheesy potato casserole, poultry gravy, tomato florentine soup and a cornbread with butter. Dessert was listed as cheesecake with a cherry topping. During a continuous lunch observation of the third floor dining room on 5/14/24, beginning at 12:00 p.m. and ending at 2:00 p.m., the following was observed:-The chicken was baked instead of grilled and served without onions or gravy; -The potatoes were mashed instead of a cheesy potato casserole; -Butter was not served with the cornbread;-Soup was not offered or served; and,-Dessert was a squared piece of cake, brown in color, without frosting instead of cheesecake with a cherry topping. Alternative selection for the main dish was pasta salad with protein (seafood).-This was the second day in a row the alternative main dish option was pasta salad with seafood. The 5/15/24 lunch menu revealed residents were to be served rosemary pork loin with lemon dill sauce, rice pilaf, braised cabbage and carrots and a dinner roll with butter. Dessert was listed as coconut cream pie. Alternative selection for the main course was spaghetti with meat sauce on the second and third floor dining rooms. During a continuous lunch observation of the third floor dining room on 5/15/24, beginning at 12:00 p.m. and ending at 1:30 p.m., the following was observed:-The pork was served without the lemon dill sauce; -The rice was white rice instead of rice pilaf;-Butter was not served with the dinner roll; -Soup was not offered or served; and, -Dessert was pudding, off-white in color. Instead of coconut cream pie. III. Staff interviewThe dining services manager (DSM) was interviewed on 5/21/24 at 11:00 a.m. The DSM said the facilities corporate office created the menus and the DSM was responsible for implementing resident suggestions and/or requests. The DSM said there was a registered dietitian who reviewed the menus as well. The DSM said any changes made to the menu were authorized by her first. The DSM said the facility had a five week menu that had a main selection and alternative meal selections came from information received by the facilities food committee and resident requests. The DSM said she had not received any resident complaints regarding menu changes without prior notice. The DSM said menu changes only happened if a product was unavailable from a vendor.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to:-Ensure temperatures were taken prior to meal service;-Ensure food was served and held at appropriate temperatures;-Ensure all damaged tiles were repaired to ensure all surfaces in the kitchen were cleanable; -Ensure the can opener was clean; and,-Ensure cups and silverware were handled appropriately. Findings include:I. Food temperaturesA. Professional ReferenceThe Colorado Retail Food Regulations, (3/16/24), were retrieved on 6/1/24 from https://cdphe.colorado.gov/environment/food-regulations. The regulations read in pertinent part,"Except during preparation, cooking, or cooling, or when time is used as thepublic health control as specified time/temperature control for safety shall be maintained at 57°C (135°F) or above."B. ObservationsOn 5/14/24 at approximately 12:00 p.m., the hot holding food cart was brought to the second floor dining room. Dietary aide (DA) # 1 put the food onto the steam table. DA #1 did not take food temperatures prior to serving the first resident. At 5:13 p.m. the dining services manager (DSM) was serving dinner to the residents from the steam table in the first floor kitchen. The DSM took the temperature of the chicken and cheese enchiladas. The temperature of the enchiladas ranged from 128 to 130 degrees Fahrenheit (F). The DSM served the enchilada to a resident in the main dining room.-The DSM did not reheat the chicken enchilada prior to serving it to the resident. At 6:00 p.m., after the last resident was served on the second floor, cook (CK) #1 took the temperatures of the remaining food: -The roasted chicken thighs were 98 degrees F;-The garlic roasted potato wedges were 82 degrees F;-The chicken and cheese enchiladas were 80 degrees F;-The pureed chicken was 110 degrees F; and,-The pureed potatoes were 114 degrees F.-The roasted chicken thighs, garlic roasted potato wedges, chicken and cheese enchiladas, pureed chicken and the pureed potatoes were not maintained at the correct hot holding temperature during meal service. C. Staff interviewsThe DSM was interviewed on 5/14/24 at 5:15 p.m. The DSM said food should be at least 140 degrees F or higher when served to the residents. CK #1 was interviewed on 5/14/24 at 6:00 p.m. CK #1 said the temperature on the tray line needed to be at 140 degrees F or above for the entire food service. The DSM was interviewed again on 5/21/24 at 11:00 a.m. The DSM said the temperature of the food should be taken after cooking the food, before serving the food and at the end of every food service. The DSM said food should be held at 140 degrees F or higher for hot foods and 40 degrees F or lower for cold foods. II. Ensure all damaged tiles were repaired to ensure all surfaces in the kitchen were cleanable. A. Professional referenceThe Colorado Retail Food Regulations, (3/16/24), were retrieved on 6/1/24 from https://cdphe.colorado.gov/environment/food-regulations. It read in pertinent part, "Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable."B. ObservationsOn 5/14/24 at 5:15 p.m. the floor of the kitchen, which included the dry storage room, was observed. Approximately 10 tiles were observed to be missing near the steam table. There were other broken tiles scattered around the kitchen. The dry storage floor was visibly dirty with a dark substance on the floor on approximately 15 tiles. The floor to the walk-in refrigerator was blackened and visibly dirty, it was coated in a dark substance beginning at the entrance and extending to all corners. Upon entering the refrigerator and to the right, the floor was worn and deteriorating. C. Staff interviewsThe DSM was interviewed on 5/21/24 at 11:00 a.m. The DSM said the kitchen was cleaned daily and each staff member was assigned specific cleaning tasks. The DSM said the kitchen was deep cleaned by the facility housekeepers once a month. The DSM said any surfaces that were deemed uncleanable in the kitchen needed to be replaced. IV. Can openerA. ObservationsOn 5/15/24 at 11:00 a.m. the can opener had dried red food on the blade of the can opener. The can opener attachment, which was screwed to the table, had a dark substance around it. B. Staff interviewsCK #2 was interviewed on 5/15/24 at 11:00 a.m. CK #2 said the can opener needed to be washed in the dish machine once a day. She said there was dried food on the blade of the opener. CK #2 took the can opener to the dishwasher and washed it. The DSM was interviewed on 5/21/24 at 11:00 a.m. The DSM said the can opener should be cleaned daily and as needed. The DSM said this was to ensure food safety and to avoid cross contamination. V. Ensure cups and silverware were handled appropriatelyA. Professional referenceThe Colorado Retail Food Regulations, (3/16/24), were retrieved on 6/1/24 from https://cdphe.colorado.gov/environment/food-regulations. The regulations read in pertinent part, "Single-service and single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food- and lip-contact surfaces is prevented."The Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings guidance, (1/30/2020), retrieved on 6/1/24 from https://www.cdc.gov/handhygiene/providers/guideline.html., read in pertinent part, "Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (for example, placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal."B. ObservationsDuring a continuous observation of the second floors lunch service on 5/14/24, beginning at 11:30 a.m. and ending at 12:30 p.m., the following was observed:At 11:54 a.m., an unidentified certified nurse aide (CNA) was observed to touch the drinking surface of the glasses when they were served to the residents. On 5/15/24 at 2:04 p.m., DA #1 was observed sorting the clean eating utensils by touching the eating surface of the utensils. On 5/15/24 at 5:00 p.m., the CNAs were passing drinks to the residents. The CNAs were observed touching the drinking surface of the glasses when passing the drinks to the residents. C. Staff interviewsThe DSM was interviewed on 5/21/24 at 11:21 a.m. The DSM said cups should be handled from the bottom of the cup. The DSM said silverware should be handled by the handle. The DSM said staff should never touch their hands to the drinking or eating surfaces of any cup or eating utensil that comes into contact with someone's mouth.

Based on observations, record review and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects in one of one dumpster area. Specifically, the facility failed to ensure the dumpster lids were closed and the surrounding environment was maintained in a cleanly manner. Findings include:I. Professional referenceThe Colorado Retail Food Regulations, (3/16/24), were retrieved on 6/1/24 from https://cdphe.colorado.gov/environment/food-regulations. It read in pertinent part,"Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors or covers."Cardboard or other packaging material that does not contain food residues and that is awaiting regularly scheduled delivery to a recycling or disposal site may be stored outside without being in a covered receptacle if it is stored so that it does not create a rodent harborage problem."Storage areas, enclosures, and receptacles for refuse, recyclables and returnables shall be maintained in good repair."Refuse, recyclables, and returnables shall be removed from the premises at a frequency that will minimize the development of objectionable odors and other conditions that attract or harbor insects and rodents."II. ObservationsOn 5/15/24 at 1:00 p.m. there were bags of trash on the side of and behind the dumpster. The dumpster was located in the west facing alley that was accessible to staff by exiting a door past the main kitchen. On 5/16/24 at 11:31 a.m. a trash disposal truck was observed emptying the dumpster in the west facing alley. The disposal truck emptied the dumpster, however there were bags of trash on the ground that the disposal truck did not remove. On 5/16/24 at 1:28 p.m. the lid to the dumpster was not closed and the side panel was open. The trash bags that had not been picked up by the trash disposal truck continued to lay on the ground to the right of the dumpster. The recyclable dumpster lid was open. On 5/18/24 at 7:32 p.m. the lid to the dumpster was not closed and the side panel was open. There were trash bags that continued to lay on the ground to the right of the dumpster. The recyclable dumpster lid was open. On 5/19/24 at 5:30 p.m. the lid to the dumpster was not closed and the side panel was open. The recyclable dumpster lid was open. III. Record reviewOn 5/20/24 at 11:25 a.m. the environmental services director (ESD) provided pest control invoices. An invoice dated 1/8/24 documented there was minor cockroach activity noticed near the kitchen areas. The invoice documented 25 percent (%) to 50% of the rodent bait was eaten. An invoice dated 1/22/24 documented there was moderate cockroach and mouse activity throughout the building. There was a higher concentration on the lower levels of the building. 75% to 100% of the rodent bait was eaten. There were dead mice observed in the facility. An invoice dated 2/19/24 documented that near the kitchen area was treated again for cockroaches and there were three living cockroaches in a trap. Old rodent droppings were observed. An invoice dated 3/30/24 documented 25% to 50% of the rodent bait was eaten at three separate trap stations. 50% to 75% of the rodent bait was eaten at one other trap station. An invoice dated 4/26/24 documented dead mice were observed in the facility. IV. InterviewThe dining services manager (DSM) was interviewed on 5/21/24 at 11:20 a.m. The DSM said various departments disposed of trash in the dumpsters and recycling bin that were located in the west facing alley that was accessible to staff by exiting a door past the main kitchen. The DSM said it was the responsibility of all departments to keep the area clean. The DSM said she was not aware it was the responsibility of the kitchen staff to ensure lids remained closed and surroundingareas free of trash. The DSM said she was unsure of when staff was last trained on the importance of closing trash lids and keeping surrounding areas free of trash. The DSM said she would educate the dietary staff on the importance of keeping the dumpster lids closed and the surrounding area clean. The DSM said keeping lids closed and keeping surrounding areas free of trash was important to deter rodents and pests from entering the building. V. Facility followup On 5/21/24 (during the survey), the DSM began providing education to the dietary staff. The education read in pertinent part, "All dumpster doors must be closed after disposing trash into the dumpster."

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to:-Quality of life in which the facility failed to provide an environment which supported and enhanced each resident's quality of life which was the result of the cumulative effect of noncompliance and rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely; and,-Accident/hazards in which the facility failed to have a system in place to ensure the staff followed the facility emergency plan regarding evacuation procedures and physical barriers (locks) in place that prevented staff and residents from evacuating the premises which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include:I. Facility policyThe Quality Assurance and Performance Improvement (QAPI) Program policy and procedure, revised February 2020, was provided by the nursing home administrator (NHA) on 5/21/24 at 10:40 a.m. It read in pertinent part, "The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents."The objectives of the QAPI program are to: -Provide a means to measure current and potential indicators for outcomes of care and quality of life; -Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; -Reinforce and build upon effective systems and processes related to the delivery of quality care and services; and, -Establish systems through which to monitor and evaluate corrective actions."Implementation: The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. "The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: -Tracking and measuring performance;-Establishing goals and thresholds for performance measurement;-Identifying and prioritizing quality deficiencies; -Systematically analyzing underlying causes of systemic quality deficiencies;-Developing and implementing corrective action or performance improvement activities; and, -Monitoring or evaluating the effectiveness of corrective and action/performance improvement activities, and revising as needed."The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan."II. Cross-reference citationsCross-reference F675: The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Quality of life was a fundamental principle which applied to all care and services provided to residents. The facility's failure to allow residents personal control over choices, and the facility's failure to honor and support each resident's preferences, choices, and values put residents in a situation where a serious outcome was likely to occur and created an immediate jeopardy situation. Cross-reference F689: The facility failed to ensure all staff were trained in procedures to emergently evacuate residents from the facility, affecting the safety of all facility residents. The facility's failure to have physical barriers (locks) were in place that prevented staff and residents from evacuating the premises put residents and staff in a situation where a serious outcome was likely to occur and created an immediate jeopardy situation. III. Staff interviewsThe medical director (MD) was interviewed on 5/21/24 at 12:56 p.m. The MD said she was in the facility at least once per month, attended QAPI meetings monthly and was last at the facility on the prior Tuesday (5/14/24). The MD said some roles she provided were to participate in QAPI meetings, psychopharmacological meetings, medication management, education, medical review, and laboratory results review. The MD said she provided education to the administrative team but so far had not been asked to provide education at the all staff meetings. The MD said the types of reports that she received and reviewed included medications, laboratory results, QAPI data, statistics, reportable occurrences, census information, performance improvement plans (PIP), rehospitalizations and she had full access to the electronic medical records for all residents' reviews. The MD said she provided oversight and follow up and gave suggestions to the administrative team, and the team would also reach out if there was a need for a chart review. The MD said she would review policies and make changes to policies if there was a requirement during a PIP. She said she would update policies as needed. The MD said she had been the MD at the facility for six or seven years. The MD said the facility had informed her of the immediate jeopardy situations and she had provided suggestions to the facility on next steps they needed to take to address the situations, including better education with the staff in regards to the evacuation plan. The NHA was interviewed on 5/21/24 at 6:11 p.m. The NHA said the QAPI committee met monthly on the second Tuesday of each month. The NHA said QAPI meetings included a full review of the previous month's activities. The NHA said the committee reviewed the reported data for the entire month such as risk management, resident council and grievances. The NHA said standard items were reviewed such as admissions, discharges, dietary, weight loss, therapy, restorative programs, falls (including where/why with root cause analysis), medical appointments and transportation, census, hospitalizations, infection control, recruitment and hiring and relias training (online continuing education), the on-boarding process and the employee survey. The NHA said the committee would review each department such as environmental services and review work orders, resident council, volunteers, outings, social services and ancillary. The NHA said the committee created at least one PIP annually. The NHA provided the QAPI sign in sheet and more than the minimum required members were included with the last QAPI meeting on 5/14/24. The NHA said the QAPI committee had not previously identified concerns related to quality of life or accidents/hazards and this would be a new addition to QAPI meetings moving forward.

A licensure survey was completed on 5/13/24 to 5/23/24. Two deficiencies were cited.

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

Based on observations, interviews, and record review, the facility failed to have a plan to ensure staff were trained and had the necessary equipment to emergently evacuate residents from the facility, affecting the safety of all 130 facility residents. Review of the facility floor plans, observations, and interviews revealed three facility emergency exits that led to two outdoor courtyards. Each exit had an EXIT sign that pointed to the courtyard doors. Observation of the outdoor courtyards revealed one of the courtyards had three exits through gates secured with padlocks that required a key to unlock. Staff reported they did not know where to locate a key to release the padlocks on the gates. The second outdoor courtyard revealed one exit through a gate. This gate was secured with a C clamp (device to hold objects together), that required a tool to remove it. Staff reported they did not know how to remove the C clamp on the gate. The facility's failure to have a plan to ensure staff were trained and had the necessary equipment to evacuate residents from the facility emergently created a situation with widespread potential for serious harm if the failure was not immediately corrected. Further review, observation, and interviews revealed the facility failed to take sufficient steps to prevent Resident #45's fall with injury and failed to develop and implement appropriate and effective fall interventions given the resident's known cognitive and functional limitations and behaviors. Findings include:I. Facility failure to have a safe evacuation plan for residents Staff interviews revealed the facility failed to have a plan that ensured the safe evacuation of residents from the facility in an emergency. Observations revealed the facility had three floors. Forty-six residents resided on the second floor and 84 residents resided on the third floor. Evacuation floor plans were posted on the wall on each floor. Directional arrows showed the path to follow in the event of evacuation. Review of the facility evacuation plans, observations, and interviews revealed the second floor plan had two stairwell exits and two ramp exits with egress doors that led to a courtyard with an egress gate. The gate was equipped with a broken magnetic lock and secured with a C clamp that required a socket wrench for removal so that staff and residents could evacuate from the second floor. Review of the facility evacuation plans, observations, and interviews revealed the third floor plan had an emergency exit through the recreation area (patio) that opened into a gated courtyard. The main exit from the courtyard had a padlock on the gate. The secondary path to exit the courtyard had a padlock on the gate, which led to another small fenced-in area with a padlock on the gate. Another path showed direction out another door, which led to the gated patio. The staff interviewed were unaware of any process to evacuate residents and reported they did not have access to keys to unlock the padlocks on the gates or knew how to remove the C clamp. The environmental services director (ESD) said he held the only key to all three padlocks and the C clamp required a socket wrench for removal. He said the C clamp was temporary but the padlocks on the gates were placed at the direction of the previous nursing home administrator (NHA) to keep outside people from getting in and keeping residents from leaving the community. Staff demonstrated a lack of understanding and training with the plan for evacuation and observations revealed the presence of physical barriers (padlocks and C clamp) that prevented staff and residents from evacuating the premises. The facility's failure to have a plan that ensured the safe evacuation of residents created a hazardous environment with the potential for serious harm, affecting 130 facility residents. On 5/15/24 at 2:18 p.m., NHA provided a plan which read:Plan of Correction:-All padlocks have been removed on 5/14/24 at 2:00 p.m. C clamp was removed on 5/14/24 at 3:30 p.m. The consultants provided interdisciplinary team (IDT) members training and education on never placing padlocks on emergency egress gates.-The ESD and consultants completed a walkthrough of the community on 5/15/24. Verified all locks were removed. Recommendations were made to change the layout of primary exit doors on 5/15/24. The ESD updated the emergency exit floor plan to reflect the necessary changes to the emergency exits on 5/15/24. Additionally, the ESD updated the emergency exit signage and removed emergency exit signs that will no longer be emergency exits on 5/15/24. All staff were re-educated on looking for emergency exit signs and new emergency exits on 5/15/24.-The community is purchasing a new emergency preparedness (EP) manual. This manual will arrive 5/16/24. The consultants will provide education and training with the NHA/ESD on the content of the EP manual 5/15/24.-All community staff (IDT members, licensed nursing, nursing assistants, dietary, housekeeping/maintenance) have been educated on the procedure to evacuate a resident in case of an emergency on 5/14/24 and 5/15/24 between 6:00 a.m. and 2:00 p.m. for first shift, second shift between 2:00 p.m. to 10:00 p.m. and between 10:00 p.m. to 6:00 a.m. for third shift. Specifically, staff received additional training and education on 5/15/24 on the following:Evacuation Procedure -1. Staff members have been trained to pull fire alarm in the event of an emergency that would require potential evacuation / call 911.2. Designate staff member to complete and maintain resident tracking 3. Evacuation exit doors /community evacuation floor plan 4. Phases of evacuation includingPhase 1 ambulatoryPhase 2 wheelchair dependentPhase 3 bed bound.-The community ordered five evacuation sleds for emergency exits with stairs. The emergency sled will be stored in the stairwell. When the sleds arrive the ESD will provide education and training with staff on how to use the emergency sleds. In the meantime, the ESD trained community staff on the use of a mattress to transport wheelchair or bed bound residents.-All community staff (IDT members, licensed nursing, nursing assistants, dietary, housekeeping/maintenance) have been educated on the location of the disaster preparedness binders and where to find them on 5/14/24 and 5/15/24 between 6:00 a.m. and 2:00 p.m. for first shift, second shift between 2:00 p.m. to 10:00 p.m. and between 10:00 p.m. to 6:00 a.m. for third shift. All departments have been provided the education with signatures. -When the new emergency manual arrives the community will remove old manuals.-The ESD /NHA confirms no other doors or exits have physical barriers. All secured /locked evacuation routes can be quickly opened to safely evacuate residents.-Emergency doors will be checked daily by the ESD or designee for one week for functioning and accessibility. The ESD or designee will check the emergency door weekly for a month and report to the QAPI committee for review and recommendations. Recommendations made by the QAPI committee will be executed by the ESD or designee.-Facility staff will continue to be trained on evacuation routes and procedures monthly during scheduled drills.-The IDT team will complete visual door checks on emergency exits to ensure there are no barriers present daily. The checks will be documented on an audit sheet. These visual checks will be conducted daily for 30 days. Findings of the audits will be reported to the QAPI committee for review and recommendations. The Administrator will beresponsible to execute findings of the QAPI committee related to ongoing audits and frequency of the audits.-Emergency Preparedness will be reviewed monthly in QAPI and Safety Committee monthly for three months and quarterly thereafter. The above plan was accepted on 5/16/23 at 5:07 p.m. II. Facility PolicyThe facility's evacuation plan was received from the NHA on 5/14/24 at 1:30 p.m. It read in pertinent part:"-A Community specific Evacuation plan is developed and posted.-Residents and staff are trained on evacuation routes and procedures on a monthly basis during scheduled drills.-Routes for evacuation may change due to the location, therefore use the nearest exits, avoiding the fire, as directed by the individual in command. Evacuation is made to a fire safe area. The fire safe areas for the community are the parking lot across from the church which is located on the northeast corner of 30th and Vallejo. -The procedure for building evacuation is as follows.a. Residents in immediate danger shall be evacuated first.b. Residents closest to danger will be evacuated next (adjacent, across and above fire).c. Ambulatory residents shall then be assistedd. Residents who are unable to evacuate independently (due to cognitive, psychological, or physical reasons) shall be assisted next.-Evacuation, if necessary, is conducted under the direction of the Executive Director prior to the arrival of the Fire Department."III. Observations, interviews, and record review revealed the facility failed to have a plan to ensure staff were trained and had the necessary equipment to evacuate residents from the facility emergently. A. ObservationsObservations revealed the facility had three floors. Forty-six residents resided on the second floor and 84 residents resided on the third floor. Evacuation floor plans were posted on the wall on each floor. Directional arrows showed the path to follow in the event of evacuation. Three facility emergency exits led to two outdoor courtyards. Observation of the second floor courtyard emergency exit on 5/14/24 at 1:45 p.m. revealed the gate which allowed exit from the courtyard in the event of an emergency was secured with a C clamp and two screws. There was an illuminated exit sign above the door leading to the courtyard and an emergency exit route map posted on the wall that directed people to exit through the courtyard. Observation of the third floor courtyard emergency exit on 5/14/24 at 1:52 p.m. revealed a main gate to exit the courtyard, a side gate to exit the courtyard, and yet another gate to exit the side yard. Each gate was equipped with a padlock that prevented the gates from opening. There was an illuminated exit sign above the door leading to the courtyard and the side yard and emergency exit route maps posted on the wall which directed people to exit through the courtyard and the side yard. B. Staff InterviewsCertified nurse aide (CNA) #7, who worked on the third floor, was interviewed on 5/14/24 at 2:03 p.m. She said she did not know the evacuation route in case of an emergency. She said usually she would get the residents who ambulate out first, probably down the stairs. She said if the stairway was blocked, she would go to the smoking patio but she did not know the protocol because that area was gated and locked. CNA #2 and CNA #3 were interviewed together on 5/14/24 at 2:06 p.m. They said in an emergency, they would secure each resident in their room. They both denied any knowledge of how to exit the building in the event of an emergency that required evacuation. Neither CNA knew how to open the gate in the courtyard or the C clamp and would have to ask the nurse how to exit in an emergency. RN #2, who worked on the third floor, was interviewed on 5/14/24 at 2:10 p.m. She said the evacuation process would depend on the emergency. She said if there was a fire, she would evacuate everyone out of the emergency doors, and avoid the elevator and gym. She said if there was a fire inside she would evacuate to the smoking patio; however, there were gates there that were currently locked. She said the only one who had a key was the environmental services director (ESD). RN #2 said if a resident was non-ambulatory and needed to evacuate down the stairs, she was not sure how this would occur. The environmental service director (ESD) was interviewed on 5/14/24 at 2:15 p.m. The ESD said he held the only key to all three padlocks and the C clamp required a socket wrench for removal. He said the C clamp was temporary to prevent second floor residents from exiting the facility while he waited for the gate to be repaired, but the locks on the gates were placed at the direction of the previous nursing home administrator (NHA) to keep outside people from getting in and keeping residents from leaving the community. The Maintenance assistant (MA) was interviewed on 5/14/24 at 2:20 p.m. He said he had worked in the facility for ten years, and in the maintenance department for four years. He said for an emergency, the alarm should be pulled and residents were to evacuate to the patio and through the gate and wait for help. The MA said when the fire alarm was pulled, the magnetic locks released, and for the padlock on the third floor gate, there was a key downstairs. The MA said he did not know the procedure for evacuating residents down the stairs. Licensed Practical Nurse (LPN) # 3 was interviewed on 5/14/24 at 2:20 p.m. She said she had worked for the facility for about 14 years and said staff received education regarding fire safety/drills. She said she was unsure if employees were provided training on the floor about evacuations. LPN # 3 said staff escorted residents to their rooms and closed the door when the fire alarm was activated. She said if an evacuation was necessary, she would wait until instructed to evacuate residents. The LPN said residents were evacuated using their wheelchair or a sled. -LPN #3demonstrated the fire escape door on the third floor opened after the alarm bar was depressed for 15 seconds. She had difficulty opening the door. She was unsure how long to depress the activation bar and it took 3 start-stop attempts to open the door. The alarm rang when she first depressed the bar and she was able to silence the alarm outside near the door frame with her key.-LPN #3 said she had never participated in an evacuation drill. She said they would work together and staff would carry residents down the stairs. She was unaware if the facility had evacuation supplies such as carry chairs or sleds. LPN said she was unaware which employee would account for residents and staff during an evacuation and thought it would be the NHA. The NHA was interviewed on 5/14/24 at 2:30 p.m. The NHA said she was not aware of the C clamp on the second-floor courtyard gate or the padlocks on the three courtyard gates on the third floor. She was also unaware that the ESD reported he held the only key to the padlocks on the three gates in the third-floor courtyard. The NHA said in the event of an emergency that required evacuation of the building, she was confident staff would react appropriately and be able to determine how to safely evacuate residents from the building. Housekeeper (HK) #1, who worked on the third floor, was interviewed on 5/14/24 at 2:35 p.m. She said if there was a fire, do not use the elevator but take the stairs. She said she was not sure how to help the residents down the stairway; if they could not walk; it would be a problem. HK #1 said she was not sure how to evacuate from the smoking patio on the third floor. HK #2 was interviewed on 5/14/24 at 2:38 p.m. She said she had worked for the facility for two years. She said when the fire alarm was activated, her role was to help clear the common areas and hallways and see if residents were in a safe place. HK #2 said if an evacuation was necessary, they would use the buddy system. She said all the employees were strong and they would work as a team to carry residents down the fire exit stairs. The director of nursing (DON) and the ESD were interviewed together on 5/14/24 at 3:40 p.m. The DON said staff received basic fire safety education through computer-based training modules. The DON provided a copy of the new employee skills competency for the nursing department and fire safety was not listed. He said the competencies were all clinical in nature. -The ESD said that he was responsible for training staff in fire safety and held a fire drill one time a month. He said the computer tracking software system notified them where and when the monthly drill should be conducted. The ESD said after each drill he completed a fire drill evaluation form and the drill was reviewed during the next interdisciplinary meeting, usually the next day after the drill. -The ESD provided a copy of the fire drill assessment form and the form included an evaluation of staff response up to the point an evaluation would be necessary. The documentation did not indicate evacuations were practiced or discussed. -The DON said when a fire alarm was activated in the building, the fire panel displayed the location of the alarm in the building. He said the fire panels were located at each nursing station. He said if evacuation was necessary, the policy was to start with the room above the fire alarm as well as the room on either side. He said that if a larger evacuation was necessary, staff should assist residents behind the fire door where they would gain two to four hours of protection. The DON said the fire exit stairs were not the first choice for fire exits. The DON said the facility was constructed on a hill and each floor had a ground-level exit. The ground-level exit would accommodate those residents in wheelchairs or being moved in their beds. The DON said the door on the second floor that led to the courtyard was not a fire exit and said it was chained and locked. The DON said all the doors that have alarms attached open after depressing the activation bar. He said that staff would be available to open the door for those with lower cognition or physically unable to depress the activation bar. FALL PREVENTIONRecord review, observations, and interviews revealed the facility failed to ensure an environment free from the risk of accidents and hazardous situations for Resident #45. On 4/30/24, Resident #45 sustained a witnessed fall when she rocked herself out of her wheelchair. Resident #45 sustained a laceration to her face, was thought to have a broken nose, and was transported to the hospital. A care plan for the resident "putting herself on the floor" was added on 5/1/24. The only intervention added on 5/1/24 to this care plan was that Resident #45 would make her needs and wants known to staff. A full fall investigation was not carried out by the facility, as the director of nursing (DON) deemed the incident to be a behavior and not a fall. The facility failed to take sufficient steps to investigate Resident #45's fall with injury and failed to develop and implement appropriate and effective fall interventions given the resident's known cognitive and functional limitations and behavior. The facility failures contributed to a fall with injury. I. Facility policyThe Fall Management policy (no date of creation or revision) was received from the NHA on 5/21/24 at 12:09 p.m. It read in pertinent part:"If a resident experiences more than one fall, a collaborative discussion between the Wellness Director, ED (executive director), Connections Director, the family, and resident's physician will be held to review the resident's needs. Discussion may include changing current pharmacology, diet, increasing activities participation, or another alternate to enhance and promote the resident's quality of life. All interventions are documented in the resident's Service Plan and Health Plan."An incident report is completed and the incident report policy is followed. An incident/accident investigation will be completed and reviewed."II. Resident #45A. Resident statusResident #45, age 81, was admitted to the facility on 4/21/23, transported to the hospital on 4/30/24 after a fall, and returned to the facility on 5/1/24. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia, cognitive communication deficit, and altered mental status. The 5/2/24 facility assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. The resident was dependent and required supervision and assistance with all activities of daily living. The 2/21/24 care plan revealed Resident #45 was at high risk for falls due to confusion and unawareness of safety needs. Pertinent interventions included anticipating and meeting Resident #45's needs, reviewing information on past falls and attempting to determine the cause of falls, recording possible root causes, and altering or removing potential causes if possible. B. Observations and resident interviewOn 5/15/24 at 10:20 a.m., Resident #45 sat in her wheelchair in the dining room. Resident #45 was wearing anti-slip socks. She did not have any anti-tip bars or anti-rollbacks in place on her wheelchair. On 5/16/24 at 9:46 a.m., Resident #45 said her hand and her face hurt. Resident #45 had bruising present on both her face and her hands. Resident #45's left hand was red and swollen, especially around her knuckles. Resident #45's right hand had a purple and yellow bruise approximately three inches by four inches in size. Resident #45 had crescent-shaped bruising on her cheekbones and an inch-sized round bruise on her forehead that was covered with thin medical bandages. On 5/21/24 at 12:17 p.m. Resident #45 was in her bed. The bed was in the lowest position, and the fall mat was in place. C. Record review 1. Fall 4/30/24A progress note dated 4/30/24 at 11:38 a.m. revealed Resident #45 was observed rocking herself forward and falling out of her wheelchair, resulting in a laceration to her forehead. A progress note dated 4/30/24 at 11:58 a.m. revealed Resident #45's representative was contacted by the facility staff regarding the resident's fall out of her wheelchair. A risk management report, dated 4/30/24 at 11:40 a.m., revealed Resident #45 fell forward out of her wheelchair and landed on her face on the floor. The note revealed Resident #45's fall resulted in a forehead laceration, bruising over her face, right hand, and left forearm, and a possible broken nose. The note revealed Resident #45 was frequently confused and not able to follow simple commands or make her needs known. Hospital notes, dated 4/30/24 at 12:03 p.m., revealed Resident #45 was transported to the hospital for evaluation after a fall. Diagnoses included a closed head injury and a laceration of the forehead. 2. Facility response to Resident 45's fall with injuryRecord review revealed the facility failed to comprehensively investigate the resident's fall to develop and implement resident-specific interventions based on her known cognitive, and functional impairments and known behaviors. The 4/30/24 24-hour report form revealed Resident #45 rocked herself out of her wheelchair, which was a behavior resulting from intentionally acting out. The report form revealed instructions to monitor Resident #45 for behaviors of rocking or propelling herself forward out of her wheelchair or bed when the resident returned from the hospital. A care plan dated 5/1/24 revealed Resident #45 "putting herself on the floor by rocking forward in her wheelchair and vaulting herself to the floor." The intervention included was to have Resident #45 make her needs and wants known to facility staff members. But see above; the 4/30/24 risk management report read the resident was not able to make her needs known. A review of the May 2024 CPO revealed an order indicating Resident #45 was a high fall risk. Interventions in place from this order included purposeful rounding, proper non-skid footwear, and having her bed in the lowest position. The 5/1/24 24-hour report form revealed instructions to continue monitoring Resident #45 for behaviors and to intervene if the resident was seen rocking to prevent a fall. A post-incident investigation for falls was started on 5/1/24 at 9:28 a.m. but was not completed. A note on the risk management report from 5/1/24 revealed the risk management report was struck out by the DON because the incident was considered an intentional act and not a fall. Multidisciplinary care conference notes dated 5/6/24 at 3:13 p.m. revealed Resident #45 rarely verbally communicated her needs and had increased behaviors over the previous quarter. Occupational therapy (OT) notes from 5/14/24 revealed Resident #45 had a recent fall with resulting forehead laceration and facial bruising and that the resident demonstrated weakness and decline in coordination and self-feeding skills. The OT notes revealed Resident #45 had mild pain generally in her head and body over the prior five days at the time of the note. The OT notes revealed Resident #45 had impaired safety awareness, and was sometimes understood when communicating with others. C. Staff interviewsStaff interviews confirmed the facility failed to comprehensively investigate the resident's fall to develop and implement resident-specific interventions based on her known cognitive and functional impairments and known behaviors. Registered nurse (RN) #1 was interviewed on 5/16/24 at 3:27 p.m. RN #1 said the standard procedures after a resident fell included starting neurological checks, doing a physical assessment, and initiating a risk management indicator on the resident's electronic medical record. RN #1 said physical and occupational therapy would then evaluate the resident to see if they had any changes in mobility that caused their fall. RN #1 said Resident #45 had a history of attention-seeking behaviors, but could not remember if the resident had any fall interventions. RN #2 was interviewed on 5/21/24 at 10:00 a.m. RN #2 said Resident #45 sometimes got agitated and called out, but could usually make her needs known. RN #2 said Resident #45 could call out for a nurse or CNA and ask for what she wanted. RN #2 said Resident #45 fell approximately three weeks ago. RN #2 said Resident #45 had leaned forward in her wheelchair and fell to the floor and she was sent out to the hospital. RN #2 said Resident #45's interventions included ensuring the resident did not transfer by herself, checking the resident frequently, using non-slip socks, and encouraging the resident to express what she wanted. CNA #1 was interviewed on 5/21/24 at 10:18 a.m. CNA #1 said Resident #45 preferred male staff members over females for care. CNA #1 said Resident #45 had difficulty focusing and needed cueing for eating. The CNA said it would sometimes take a while for her to process her needs and sometimes, Resident #45 would start screaming and would not be able to say what she needed, but eventually, the nurse could get an answer out of her. CNA #1 said Resident #45 flung herself out of her wheelchair a while ago. CNA #1 said the male CNA who usually worked with Resident #45 was out of town, so there were only female staff members working with Resident #45. The resident became overstimulated and threw herself out of her wheelchair. CNA #1 said Resident #45 had a tendency to fling herself out of her bed or wheelchair, so the interventions they used for her included having a low bed and keeping a fall mat in place. CNA #1 said information regarding care areas like fall interventions was communicated verbally during orientation for new staff members during their walkthrough, but that nothing was written down in an area that was accessible for CNAs. The DON was interviewed on 5/21/24 at 11:01 a.m. The DON said the facility staff determined Resident #45 was having a fit and asking for the one male CNA she usually worked with who was out on vacation, so the resident started rocking in her chair and threw herself on the floor. The DON said the facility staff determined Resident #45 had a history of rocking and throwing herself out of her chair when she did not get her way. The DON said the instance in question was not a typical fall but was instead a behavior, and as such, they did not continue a fall investigation. The DON said the facility staff brought attention and awareness to Resident #45's behavior and that therapy had been in with her frequently. The DON said Resident #45 had not been assessed by physical therapy yet due to issues with insurance authorization. The DON said many of the residents at the facility had wheelchair accommodations like anti-rollbacks and anti-tip bars, but that they may not work if the residents got around the facility by self-propelling backward. The DON said that when care plans were updated, the interventions were placed as an order in the resident's chart and were communicated to the CNAs by the restorative or nursing staff. These communications are both verbal and written in a physical 24-hour report book. The DON said care plans should match what was ordered by the physician. The DON said if a resident was ordered for a low bed or fall mat, it should be in their care plan. When looking at Resident #45's risk management report, the DON identified and highlighted a note that said he had determined it was not a fall because it was a behavior and confirmed that was the case. D. Additional informationAdditional information was provided by the NHA on 5/23/24 at 1:51 p.m. This information included an updated care plan for Resident #45. The care plan revealed additional interventions for the focus of Resident #45 putting herself on the ground, including having a fall mat provided, having a low bed, and educating staff on being aware of and attempting to redirect Resident #45's behaviors.

A revisit to the 12/19/2023 survey was completed on 2/14/2024. The facility was in compliance with the regulation surveyed.

A revisit to the 12/19/2023 survey was completed on 2/14/2024. The facility was in compliance with the regulation surveyed.

A complaint survey, prompted by #CO31230, #CO32360, #CO34456, #CO34459 and #CO34505 was conducted on 12/18/23-12/19/23. One deficiency was cited.

Based on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one (#3) of five residents reviewed for catheter care management out of 11 sample residents. Resident #3 was admitted to the facility on 6/16/23 for long term care. He had a diagnosis of dementia with behaviors, Parkinson's disease and kidney disease. On 9/10/23 the resident developed signs of a urinary tract infection (UTI). He was sent to the emergency room (ER) for the evaluation and returned to the facility the next day (9/11/23) with an indwelling urinary catheter. Upon the resident's readmission from the ER, the facility failed to assess the resident for the need of the urinary catheter and did not document its presence and care. Subsequently, the resident developed an acute UTI with sepsis (a serious condition in which the body responds improperly to an infection) that resulted in two separate hospitalizations on 9/18/23 and 11/12/23. During the last hospitalization, the catheter was removed in the hospital due to the resident being able to void. In addition, the facility failed to schedule a urology follow up that was recommended by primary care physician (PCP) #1. Findings include:I. Facility policy and proceduresThe Resident with Indwelling Catheter policy, with no revision date, was provided by the nursing home administrator (NHA) on 12/22/23. It read in pertinent part: "The purpose of this policy is to ensure that a resident who enters the community without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. The community is responsible for the assessment of the resident at risk for urinary catheterization and/or ongoing assessment of the resident who currently has a catheter. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. "The clinician's decision to use an indwelling catheter in the elderly should be based on valid clinical indicators."II. Resident statusResident #3, age 78, was admitted on 6/16/23 and discharged on 11/17/23. According to the November 2023 computerized physician orders (CPO), diagnoses included dementia with behaviors, Parkinson's disease, kidney disease stage one, history of urinary tract infection and sepsis was added on 9/25/23. The 9/18/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired and a brief interview for mental status (BIMS) score was not conducted. He required substantial/maximal assistance with activities of daily living. He had an indwelling urinary catheter in place and was marked as frequently incontinent of bowel and bladder. III. Record reviewThe initial nursing assessment on 6/16/23 documented that Resident #3 was admitted to the facility for long term care. He was independent with all daily activities and was oriented to person, place and time. The resident was continent of bowel and bladder and did not have an indwelling urinary catheter on admission. 1. Hospitalization on 9/10/23On 9/10/23 a nurse progress note documented the resident had blood in the urine and after the laboratory results were reviewed by the PCP #1, the decision was made to send the resident to the ER for the evaluation. Review of the progress notes between 9/10/23 and 9/18/23 revealed that the resident returned to the facility from the ER on 9/11/23 with an indwelling urinary catheter. He continued to have blood in the urine and was treated with antibiotics for UTI. -PCP #1's evaluation was not located in the resident's electronic records and was not provided by the facility upon request by exit 12/19/23. It was unclear if the resident was evaluated by PCP #1 after his return from the hospital. -There was no supporting note clarifying the use of indwelling urinary catheter after resident was readmitted to the facility. The care plan for the indwelling urinary catheter, initiated on 9/26/23 (15 days after the catheter was inserted in the ER) and revised on 12/19/23 (a month after the resident was discharged from the facility), revealed the resident had a catheter. Interventions included to check the catheter tubing for knicks each shift and monitor for signs and symptoms of discomfort on urination and frequency.-The care plan did not specify the type of catheter the resident was using. -Resident #3's care plan did not mention the resident's predisposition for urinary tract infections and recent hospitalizations related to the catheter. -The medical administration record (MAR) and treatment administration record (TAR) for September 2023, October 2023 and November 2023 revealed no orders for the indwelling urinary catheter or care that was provided to the resident. -The review of medical diagnosis in the electronic medical record revealed no documentation of chronic use of indwelling urinary catheter or supporting diagnosis for its use. On 9/18/23, eight days after being readmitted to the facility from the previous hospitalization, Resident #3 was hospitalized again. 2. Hospitalization on 9/18/23Hospital admission note dated 9/18/23 revealed the resident was admitted 9/18/23 with altered mental status, he was tested positive for UTI. Admitting diagnosis was catheter associated UTI with sepsis. The admission note read: "Patient presented with encephalopathy, most consistent with toxic metabolic etiology in the setting of likely UTI. Evidence of catheter associated UTI after replacement of Foley catheter and testing of urine."The hospital discharge summary on 9/25/23 documented the resident was treated with several antibiotics and required a one-on-one sitter due to "consistently pulling on his catheter."-There were no documented progress notes in the facility's electronic medical records between 9/15/23 and 9/18/23, prior to Resident #3's hospitalization. On 9/25/23 a nurse progress note documented that Resident #3 returned to the facility from the hospital. PCP #1's note on 9/28/23 documented the resident was hospitalized and diagnosed with UTI and clostridium difficile (C-diff) colitis. He received a course of antibiotics in the hospital. PCP #1 recommended to schedule a urology consultation as soon as possible. -There were no additional notes regarding catheter care or follow up with urology in the electronic medical record. On 10/31/23 a nurse progress note documented: "This morning on early rounds resident was found to have pulled foley catheter out. No bleeding noted bed was soaked."-There were no additional progress notes regarding what was done for the resident after he pulled his catheter. There was no evidence that it was communicated to PCP #1. 3. Hospitalization on 11/12/23The hospital admission note on 11/12/23 documented that Resident #3 was sent to the emergency room for evaluation after he developed "lethargy, hypotension and positive UTI with concerns for sepsis. "Patient required an indwelling urinary catheter at last admission to the hospital and needed intermittently, but did not arrive at the emergency department with the catheter."Admitting diagnoses included sepsis with urinary source, hypotension, acute kidney injury and toxic encephalopathy. The resident was started on antibiotics. After intravenous fluids and antibiotics, the resident's mental status returned to his baseline, he was able to recognize family members and made telephone calls. The indwelling urinary catheter was discontinued in the hospital. On 11/15/23, the resident was discharged back to the nursing facility. The admission note to the nursing facility on 11/15/23 read that the resident was alert and oriented to time and place, he was able to ambulate to bed. Resident #3 communicated the need to use a urinal and he was able to void about 200 milliliters of clear urine into the urinal. IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 12/19/23 at 11:15 a.m. She said she did not recall working with Resident #3. She said currently she had two residents who had indwelling urinary catheters. She said it was the nursing staff's responsibility to assess the catheter site for signs of infection every shift. She said catheter care was provided by certified nurse aides (CNAs) during incontinence care. She demonstrated the MAR for current residents which included catheter care every shift and supporting diagnosis for the catheter. CNA #4 was interviewed on 12/19/23 at 11:30 a.m. She said she had two residents on her unit who had indwelling urinary catheters. She said care was provided at least once during the shift and after every incontinence episode. She said the catheter bag was checked at the beginning and end of the shift and output was documented under tasks. She said if urine looked cloudy or bloody she would report it to the nurse. The director of nursing (DON) was interviewed on 12/19/23 at 1:45 p.m. He said Resident #3 was admitted to the facility for long term care. He said the resident was admitted without an indwelling urinary catheter, however, after he developed blood in his urine on 9/10/23, he was sent to the hospital where the catheter was placed. He said he was not sure about the actual diagnosis for the catheter as it was not listed on the resident's diagnosis list. He said since the resident spent only one night in the emergency room, from 9/10/23 to 9/11/23, a complete nursing assessment was not completed upon his arrival to the facility and catheter care was not added to the resident's MAR and TAR. He said the catheter care was still provided to the resident as it was documented in some progress notes. He said the catheter care was not consistently documented. Regarding the note on 10/31/23, when it was documented the resident pulled the catheter, he said he personally contacted PCP #1 and discussed it with her. He said the decision was made to use a condom catheter instead of an indwelling catheter since the resident was consistently pulling it out. He said the condom catheter was placed and monitored. He said he recognized the poor and inconsistent documentation regarding catheter care and he was not sure how that happened. PCP #1 was interviewed over the phone on 12/19/23 at approximately 3:00 p.m. She said the resident had chronic UTIs and she recommended follow up with urology back on 9/28/23. She said she had not heard back from the DON or other facility staff about the follow up and did not know if it was scheduled. She said she recalled multiple conversations with the DON regarding the treatment for Resident #3, the care for the indwelling catheter and ongoing infections. She said she did not recall the conversation about Resident #3 pulling the catheter. She said the proper follow up would be to do a bladder scan to check for residuals and evaluate the need for the catheter in light of the resident's mental and physical condition. She said she believed the resident had a urinary retention due to enlargement of the prostate and that was the reason for using the catheter. She said it was not documented among the listed diagnoses on the resident's electronic medical records, however the hospital records mentioned it. She said she did not believe Resident #3's hospitalizations were related to the care the resident received in the facility. She believed the appropriate care was provided based on the numerous discussions that she had with the facility staff. She said lack of documentation of the discussions of care was concerning, however not an indication for the lack of proper care. The NHA was interviewed on 12/19/23 at 4:30 p.m. She said the DON was not immediately available but would provide his comment regarding urology follow up by email. V. Facility follow-upOn 12/21/23, the NHA submitted an email with the following comment regarding urology follow up. "Transportation was attempting to get an appointment at the VA (Veterans Administration) for urology. I was notified that for new specialty referrals the request must be made through our SS (social services) contact. On 11/17 an email was sent to our SS contact to get his urology appointment request approved."-The note did not include why urology follow up was delayed by almost two months and was not scheduled in a more timely manner.

A survey prompted by complaint #CO34568 was completed 12/18/23 to 12/19/23. One deficiency was cited.

Based on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one (#3) of five residents reviewed for catheter care management out of 11 sample residents. Resident #3 was admitted to the facility on 6/16/23 for long term care. He had a diagnosis of dementia with behaviors, Parkinson's disease, and kidney disease. On 9/10/23 the resident developed signs of a urinary tract infection (UTI). He was sent to the emergency room (ER) for the evaluation and returned to the facility the next day (9/11/23) with an indwelling urinary catheter. Upon the resident's readmission from the ER, the facility failed to assess the resident for the need of the urinary catheter and did not document its presence and care. Subsequently, the resident developed an acute UTI with sepsis (a serious condition in which the body responds improperly to an infection) that resulted in two separate hospitalizations on 9/18/23 and 11/12/23. During the last hospitalization, the catheter was removed in the hospital due to the resident being able to void. In addition, the facility failed to schedule a urology follow up that was recommended by primary care physician (PCP) #1. Findings include:I. Facility policy and proceduresThe Resident with Indwelling Catheter policy, with no revision date, was provided by the nursing home administrator (NHA) on 12/22/23. It read in pertinent part: "The purpose of this policy is to ensure that a resident who enters the community without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. The community is responsible for the assessment of the resident at risk for urinary catheterization and/or ongoing assessment of the resident who currently has a catheter. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. "The clinician's decision to use an indwelling catheter in the elderly should be based on valid clinical indicators."II. Resident statusResident #3, age 78, was admitted on 6/16/23 and discharged on 11/17/23. According to the November 2023 computerized physician orders (CPO), diagnoses included dementia with behaviors, Parkinson's disease, kidney disease stage one, history of urinary tract infection and sepsis was added on 9/25/23. The 9/18/23 facility assessment revealed the resident was cognitively impaired and a brief interview for mental status (BIMS) score was not conducted. He required substantial/maximal assistance with activities of daily living. He had an indwelling urinary catheter in place and was marked as frequently incontinent of bowel and bladder. III. Record reviewThe initial nursing assessment on 6/16/23 documented that Resident #3 was admitted to the facility for long term care. He was independent with all daily activities and was oriented to person, place and time. The resident was continent of bowel and bladder and did not have an indwelling urinary catheter on admission. 1. Hospitalization on 9/10/23On 9/10/23 a nurse progress note documented the resident had blood in the urine and after the laboratory results were reviewed by the PCP #1, the decision was made to send the resident to the ER for the evaluation. Review of the progress notes between 9/10/23 and 9/18/23 revealed that the resident returned to the facility from the ER on 9/11/23 with an indwelling urinary catheter. He continued to have blood in the urine and was treated with antibiotics for UTI. -PCP #1's evaluation was not located in the resident's electronic records and was not provided by the facility upon request by exit 12/19/23. It was unclear if the resident was evaluated by PCP #1 after his return from the hospital. -There was no supporting note clarifying the use of indwelling urinary catheter after resident was readmitted to the facility. The care plan for the indwelling urinary catheter,initiated on 9/26/23 (15 days after the catheter was inserted in the ER) and revised on 12/19/23 (a month after the resident was discharged from the facility), revealed the resident had a catheter. Interventions included to check the catheter tubing for knicks each shift and monitor for signs and symptoms of discomfort on urination and frequency.-The care plan did not specify the type of catheter the resident was using. -Resident #3's care plan did not mention the resident's predisposition for urinary tract infections and recent hospitalizations related to the catheter. -The medical administration record (MAR) and treatment administration record (TAR) for September 2023, October 2023 and November 2023 revealed no orders for the indwelling urinary catheter or care that was provided to the resident. -The review of medical diagnosis in the electronic medical record revealed no documentation of chronic use of indwelling urinary catheter or supporting diagnosis for its use. On 9/18/23, eight days after being readmitted to the facility from the previous hospitalization, Resident #3 was hospitalized again. 2. Hospitalization on 9/18/23Hospital admission note dated 9/18/23 revealed the resident was admitted 9/18/23 with altered mental status, he was tested positive for UTI. Admitting diagnosis was catheter associated UTI with sepsis. The admission note read: "Patient presented with encephalopathy, most consistent with toxic metabolic etiology in the setting of likely UTI. Evidence of catheter associated UTI after replacement of Foley catheter and testing of urine."The hospital discharge summary on 9/25/23 documented the resident was treated with several antibiotics and required a one-on-one sitter due to "consistently pulling on his catheter."-There were no documented progress notes in the facility's electronic medical records between 9/15/23 and 9/18/23, prior to Resident #3's hospitalization. On 9/25/23 a nurse progress note documented that Resident #3 returned to the facility from the hospital. PCP #1's note on 9/28/23 documented the resident was hospitalized and diagnosed with UTI and clostridium difficile (C-diff) colitis. He received a course of antibiotics in the hospital. PCP #1 recommended to schedule a urology consultation as soon as possible. -There were no additional notes regarding catheter care or follow up with urology in the electronic medical record. On 10/31/23 a nurse progress note documented: "This morning on early rounds resident was found to have pulled foley catheter out. No bleeding noted bed was soaked."-There were no additional progress notes regarding what was done for the resident after he pulled his catheter. There was no evidence that it was communicated to PCP #1. 3. Hospitalization on 11/12/23The hospital admission note on 11/12/23 documented that Resident #3 was sent to the emergency room for evaluation after he developed "lethargy, hypotension and positive UTI with concerns for sepsis. "Patient required an indwelling urinary catheter at last admission to the hospital and needed intermittently, but did not arrive at the emergency department with the catheter."Admitting diagnoses included sepsis with urinary source, hypotension, acute kidney injury and toxic encephalopathy. The resident was started on antibiotics. After intravenous fluids and antibiotics, the resident's mental status returned to his baseline, he was able to recognize family members and made telephone calls. The indwelling urinary catheter was discontinued in the hospital. On 11/15/23, the resident was discharged back to the nursing facility. The admission note to the nursing facility on 11/15/23 read that the resident was alert and oriented to time and place, he was able to ambulate to bed. Resident #3 communicated the need to use a urinal and he was able to void about 200 milliliters of clear urine into the urinal. IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 12/19/23 at 11:15 a.m. She said she did not recall working with Resident #3. She said currently she had two residents who had indwelling urinary catheters. She said it was the nursing staff's responsibility to assess the catheter site for signs of infection every shift. She said catheter care was provided by certified nurse aides (CNAs) during incontinence care. She demonstrated the MAR for current residents which included catheter care every shift and supporting diagnosis for the catheter. CNA #4 was interviewed on 12/19/23 at 11:30 a.m. She said she had two residents on her unit who had indwelling urinary catheters. She said care was provided at least once during the shift and after every incontinence episode. She said the catheter bag was checked at the beginning and end of the shift and output was documented under tasks. She said if urine looked cloudy or bloody she would report it to the nurse. The director of nursing (DON) was interviewed on 12/19/23 at 1:45 p.m. He said Resident #3 was admitted to the facility for long term care. He said the resident was admitted without an indwelling urinary catheter, however, after he developed blood in his urine on 9/10/23, he was sent to the hospital where the catheter was placed. He said he was not sure about the actual diagnosis for the catheter as it was not listed on the resident's diagnosis list. He said since the resident spent only one night in the emergency room, from 9/10/23 to 9/11/23, a complete nursing assessment was not completed upon his arrival to the facility and catheter care was not added to the resident's MAR and TAR. He said the catheter care was still provided to the resident as it was documented in some progress notes. He said the catheter care was not consistently documented. Regarding the note on 10/31/23, when it was documented the resident pulled the catheter, he said he personally contacted PCP #1 and discussed it with her. He said the decision was made to use a condom catheter instead of an indwelling catheter since the resident was consistently pulling it out. He said the condom catheter was placed and monitored. He said he recognized the poor and inconsistent documentation regarding catheter care and he was not sure how that happened. PCP #1 was interviewed over the phone on 12/19/23 at approximately 3:00 p.m. She said the resident had chronic UTIs and she recommended follow up with urology back on 9/28/23. She said she had not heard back from the DON or other facility staff about the follow up and did not know if it was scheduled. She said she recalled multiple conversations with the DON regarding the treatment for Resident #3, the care for the indwelling catheter and ongoing infections. She said she did not recall the conversation about Resident #3 pulling the catheter. She said the proper follow up would be to do a bladder scan to check for residuals and evaluate the need for the catheter in light of the resident's mental and physical condition. She said she believed the resident had a urinary retention due to enlargement of the prostate and that was the reason for using the catheter. She said it was not documented among the listed diagnoses on the resident's electronic medical records, however the hospital records mentioned it. She said she did not believe Resident #3's hospitalizations were related to the care the resident received in the facility. She believed the appropriate care was provided based on the numerous discussions that she had with the facility staff. She said lack of documentation of the discussions of care was concerning, however not an indication for the lack of proper care. The NHA was interviewed on 12/19/23 at 4:30 p.m. She said the DON was not immediately available but would provide his comment regarding urology follow up by email. V. Facility follow-upOn 12/21/23, the NHA submitted an email with the following comment regarding urology follow up. "Transportation was attempting to get an appointment at the VA (Veterans Administration) for urology. I was notified that for new specialty referrals the request must be made through our SS (social services) contact. On 11/17 an email was sent to our SS contact to get his urology appointment request approved."-The note did not include why urology follow up was delayed by almost two months and was not scheduled in a more timely manner.

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 08/21/2023 and 08/27/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/14/2023 and 08/20/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit survey was completed on 8/15/23 for all previous deficiencies cited on 5/24/23. The facility is in compliance with all regulations surveyed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/07/2023 and 08/13/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/31/2023 and 08/06/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A complaint survey, prompted by #CO32200 and #CO32234 was conducted on 5/23/23 to 5/24/23. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure residents retained the rights to their personal belongings for three (#7, #29 and #16) of three residents out of nine sample residents. Specifically, the facility failed to ensure the resident representatives for Residents #7, #29 and #16 were given the opportunity to retrieve the resident's personal belongings after the residents passed away. Findings include:I. Facility policy and procedureThe Disposition of Personal Property policy, which was undated, was provided by the nursing home administrator (NHA) via email on 5/25/23 at 11:58 a.m. It read in pertinent part, "Upon the resident's death, the facility may contact the resident's authorized representative within 72 hours to arrange for an inventory of the resident's personal property. The facility is authorized to transfer the resident's personal property to a duly authorized representative of the resident's estate or to such parties or persons entitled to the property under current law. The duly authorized representative of the resident's estate or other persons entitled to property under current law must acknowledge, in writing, the receipt of the personal property transferred to his or her custody by the facility. After the resident's death, the facility may keep the resident's personal property in the resident's personal care room for a period of time up to 30 days or until the property is claimed by an authorized representative of the resident's estate or any parties or persons entitled to the property under current law, whichever is sooner. If property is not claimed within 30 days, the facility shall send a notice to the authorized representative via certified mail that if items are not removed within 14 days, the facility may dispose of the resident's property."II. Resident #7A. Resident statusResident #7, age 80, was admitted on 12/29/22 and passed away at the facility on 2/18/23. According to the February 2023 computerized physician orders (CPO), diagnoses included dementia, heart failure and atrial fibrillation. B. Record reviewReview of Resident #7's electronic medical record (EMR) revealed the following progress notes documented in pertinent part:2/18/23 at 5:38 a.m: "Resident found in bed not responding. Unable to obtain palpable radial,carotid and femoral pulses. No blood pressure obtainable. All respirations ceased. Pupils dilated and not responding to light. Hospice notified and spoke with the triage nurse. Expecting her in the facility at this time. Facility on-call notified."2/18/23 at 11:34 a.m: "Hospice nurse in house to complete final arrangements, contact wife of resident and notify physician, coroner, and arrange for pick up by mortuary. Mortuary in house at 10:05 a.m. to pick up the resident's body. No personal belongings were sent with the resident besides clothes that he was wearing. In house body release form signed by mortician tech."-There were no progress notes which indicated the resident's power of attorney (POA) had been notified that they had 30 days to pick up Resident #7's personal belongings or the facility would dispose of them. Review of an inventory list for Resident #7's belongings, which was dated 2/18/23, documented the resident had several items of clothing, glasses, dentures and cochlear implants (electronic devices that reduce hearing loss). The form was signed by the social services representative.-The form was not signed by Resident #7's POA, nor was there documentation on the form to indicate the social services representative had gone over the resident's inventory with the POA.Review of the social services section on Resident #7's Interdisciplinary Discharge Summary form, which was dated 2/18/23 and signed by the social services representative, documented the following in pertinent part: "Cochlear hearing aids mailed to family. All other belongings donated."The form was signed by the social services representative.-The form was not signed by Resident #7's POA, nor was there documentation on the form to indicate the social services representative had communicated with the POA regarding the resident's belongings. III. Resident #29A. Resident statusResident #29, age younger than 70, was admitted on 3/4/2020 and passed away at the facility on 4/10/23. According to the April 2023 CPO, diagnoses included alcohol dependence, adult failure to thrive and history of traumatic brain injury. B. Record reviewReview of Resident #29's EMR revealed the following progress notes documented in pertinent part:4/10/23 at 11:36 a.m: "Hospice certified nurse aide (CNA) reported to this writer that while giving Resident #29 a bed bath, she noticed the resident with no respirations. This writer went in to assess the resident, and the resident had no vital signs. Call placed to the hospice nurse. Notified leadership team."4/10/23 at 1:49 p.m: "Hospice nurse in, physician notified, resident pronounced death at 11:30 a.m. by the physician. Resident was transferred from the facility by the mortuary."-There were no progress notes which indicated the resident's POA had been notified that they had 30 days to pick up Resident #29's personal belongings or the facility would dispose of them. Review of an inventory list for Resident #29's belongings, which was dated 4/10/23, documented the resident had several items of clothing, a talisman pouch and an album. The form documented all clothing was donated by the family, the talisman pouch was sent with the body to the mortuary and the album was returned to the family at the time of Resident #29's death. The form was signed by the social services representative.-The form was not signed by Resident #29's POA, nor was there documentation on the form to indicate the social services representative had gone over the resident's inventory with the POA.Review of the social services section on Resident #29's Interdisciplinary Discharge Summary form, which was dated 4/10/23 and signed by the social services representative, documented the following in pertinent part: "Talisman sent with resident, photo albums with family, and other belongings were donated."The form was signed by the social services representative.-The form was not signed by Resident #29's POA, nor was there documentation on the form to indicate the social services representative had communicated with the POA regarding the resident's belongings. IV. Resident #16A. Resident statusResident #16, age 83, was admitted on 11/4/22 and passed away at the facility on 1/18/23. According to the January 2023 CPO, diagnoses included dementia, chronic kidney disease and heart failure. B. Record reviewReview of Resident #16's EMR revealed the following progress notes documented in pertinent part:1/18/23 at 7:22 a.m: "(Deceased) Resident #16 was found in his room unresponsive. Director of nursing (DON) notified, and handled the situation."1/18/23 at 9:10 a.m: "Body was released to the mortuary at approximately 9:00 a.m. Wife notified of resident's departure from the facility."-There were no progress notes which indicated the resident's POA had been notified that they had 30 days to pick up Resident #16's personal belongings or the facility would dispose of them. Review of an inventory list for Resident #16's belongings, which was dated 11/4/22, documented the resident had several items of clothing, glasses, hangers, a suitcase and a backpack. The form was signed by the resident's POA.-The form was not signed by the social services representative.-The facility did not provide an inventory form dated for 1/18/23, the date of Resident #16's death, to indicate what belongings he had at the facility.-There was no documentation to indicate the social services representative had gone over the Resident #16's inventory with the POA at the time of his death. Review of the social services section on Resident #16's Interdisciplinary Discharge Summary form, which was dated 1/18/23 and signed by the social services representative, documented the following in pertinent part: "Watch, ring, glasses, and military cap sent with the family, and other belongings were donated."The form was signed by the social services representative.-The form was not signed by Resident #16's POA, nor was there documentation on the form to indicate the social services representative had communicated with the POA regarding the resident's belongings. V. Staff interviewsThe director of nursing (DON) was interviewed on 5/23/23 at 2:25 p.m. The DON said when residents passed away either nursing staff or the social services director would contact the family and inform them they had 30 days to come collect the resident's belongings. He said after 30 days, if the belongings had not been picked up they were disposed of or donated to other residents. The DON said there was not a form that the facility filled out regarding where the resident's belongings were released to or what was done with them. He said that there should be a progress note in the resident's EMR which documented that the family was informed that they should pick up the resident's belongings within 30 days. He said there should be documentation on whether or not the family ever came to pick up the belongings. The DON said the documentation did not always occur and he had been working on that process. He said he had spoken with Resident #16's wife at the time of his death and he said she donated his belongings. He said he did not document the conversation. The interim social services director (ISSD) was interviewed on 5/24/23 at 1:43 p.m. The ISSD said if a family member was present at the time of a resident's death, she might have a conversation with them regarding the resident's belongings at that time. She said if they were too distraught then she would wait a week or two to contact them regarding what to do with their belongings. The ISSD said she would document on the inventory sheet what a family member took with them and what was donated. She said the resident's POA did not sign the form and she did not document the conversation in the resident's progress notes. The ISSD said she spoke with Resident #7's POA about his belongings several times after his death. She said the POA only wanted the resident's cochlear implants and she donated the rest of his belongings. She said she mailed the cochlear implants to Resident #7's POA. The ISSD said she did not document any of the conversations in the resident's progress notes. She said the POA did not sign the inventory form because she lived out of town. The ISSD said Resident #29's family was present at the time of his death. She said they took an album with them and wanted his talisman pouch sent to the mortuary with the resident. She said they donated the rest of the resident's belongings about a week after his death when she spoke to them regarding what to do with the rest of his personal things. The ISSD said she did not document any of the conversations in the resident's progress notes and the family did not sign the inventory form at the time of the resident's death. The ISSD said the facility should have documented in a progress note who was spoken to regarding all three resident's belongings and what that person wanted done with each resident's belongings. She said the dates of the conversations should be documented.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/01/2023 and 05/07/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

A revisit survey was completed on 3/30/23 for all previous deficiencies cited on 1/30/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 3/30/23 for all previous deficiencies cited on 1/30/23. The facility is in compliance with all regulations surveyed.

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility's general characteristics. The facility consists of two structures separated by a common wall with a two-hour fire rating. The original structure, constructed in 1963, is a two-story, type II (222) structure and has been designated as building A-1 on past surveys. In 1973, the facility constructed a three-story addition to the original structure. The three-story addition is a type II (111) structure and has been designated as building A-2 on past surveys. Due to the fact that both structures are classified as fully protected with a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, it has been decided to no longer survey the buildings as two separate structures, but combine them, with no negative outcome to the facility, to create one building (A-3), classified as a type II(111) structure, based on the lesser of the two construction types. The two-hour fire rate separation is considered to be an acceptable horizontal exit, serving either side.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times in accordance with Life Safety Code 101 Section 19.2.2.2.4, 7.2.1.5.3. This deficient practice could affect all residents, staff and visitors within the facility if the Means of Egress is not maintained throughout the facility. This was evidenced by the following:Both kitchen doors were equipped with locking/latching devices were two releasing operation were required to operate the door. Life Safety Code 101 Section 7.2.1.5.3. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. The Director of Maintenance acknowledged the condition of the door during the time of the tour.

STANDARD is not met as evidenced by: Based on observation and staff interviews of the emergency lighting, the facility failed to maintain the battery-powered emergency lights accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:Boiler room and elevator equipment room battery back-up lights are non-functional. The Maintenance Director acknowledge the required testing of the emergency lighting during the tour of the facility. 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

STANDARD is not met as evidenced by: Through observation and discussion during the tour of the facility, it was determined the facility failed to install and maintain fire rated doors per NFPA 101 2012 Edition Chapter 9 Section 9.5 and 19.5.4. Failure to maintain fire rated door and assemblies in hazardous areas has the potential to harm all occupants, staff and visitor in the building if the fire rated doors failed to operate if a fire was to occur. This was evidence by the following. The existing laundry chute door self-closing device is disconnected not allowing the door to close creating a 1-hour fire protection rating. The Director of Maintenance acknowledged the hazardous area enclosures and door condition during a tour of the facility. 19.5.4.1Existing rubbish chutes or linen chutes, including pneumatic rubbish and linen systems, that open directly onto any corridor shall be sealed by fire-resistive construction to prevent further use or shall be provided with a fire door assembly having a minimum 1-hour fire protection rating. All new chutes shall comply with Section 9.5.

STANDARD is not met as evidenced by: Based review of the records and discussion during the survey, it was determined the facility failed to inspect and test the fire alarm system per NFPA 101, Chapter 9 (Section 9.6 Paragraph 9.6.1.4) and NFPA 72, (Chapter 7, Paragraph 7-1.2.2). Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff and visitor in the build if the fire alarm system failed to operate if a fire was to occur. During the review of the records, with the Administrator, documentation was not available to verify the sensitivity testing of the smoke detectors per NFPA 101 2012 Edition 19.3.4.1, 9.6.1.3, NFPA 72 7-3 and 7-3.2.1. The Administrator and Maintenance Director acknowledged the condition of testing the fire alarm system during the record review. 7-3.2.1*Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following. Pendent sprinkler heads located in the walk-in cooler and freeze observed to be older than 5 years old and shall be replaced. The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility. NFPA 25, 2010 section 5.3.1.1.2* Where sprinklers are subjected to harsh environments, including corrosive atmospheres and corrosive water supplies, on a 5-year basis, either sprinklers shall be replaced or representative sprinkler samples shall be tested.

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors. This was evidenced by the following: Corridor doors were not maintained to close and positively latch, as required. Door to resident's rooms 114, 217, 219, 220 and 344 would not close and latch into the door frame to resist the passage of smoke. The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latching into the door frame. Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinklered protected smoke compartments be constructed to resist the passage of smoke. The Director of Maintenance acknowledge the corridor door condition during the facility tour.

STANDARD is not met as evidenced by: During observation of the kitchen gas fired cooking equipment it did not meet the requirements of the 2012 Edition of NFPA 54 Fuel and Gas Code 9.6.1.2. This deficient practice could affect all residents, and staff should a fire occur due to failure to operate safely due to non-code compliant. This was evidence by the following. Gas fired cooking equipment with casters where not limited by a restraining device. The Maintenance Director acknowledge lack of a restraining on the gas fired cooking appliances. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliance with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufactures installation instructions.

This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to provide an adequate source of input ratings of appliances operating at levels above 2000 feet in accordance with National Fire Protection Association (NFPA) Life Safety Code and NFPA 54 Natural Fuel Gas Code. This deficient practice could affect all residents and staff in the core smoke compartment should the natural gas fueled heating equipment malfunction due to improper settings. This was evidenced by the following:Orifice for cloth dryers not sized correctly currently set for 0-2000 feet according to dryer data plate at the rate of 4 percent for each 1000 ft (300 m) above sea level. 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction(3) In accordance with the manufacturer's installation instructionsThe dryer deficiencies were discussed with the Maintenance Director during the survey and again during the exit conference with the Administrator.

STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to Inspect and Test at frequencies specified by Appendix N of ASMEnA17.1/CSA B44, Safety Code for Elevators and Escalators. This deficient practice could affect all residents if the Firefighter' Emergency Operations if a fire emergency occurred on the upper floors. The facility failed to certify the elevators monthly operation with written reports of the Firefighter Service. The elevator deficiency item was discussed with the Maintenance Director and Administrator during the exit conference. 9.4.2.3 Elevators in accordance withASMEA17.7/CSA B44.7, Performance-Based Safety Code for Elevators and Escalators, shall be deemed to comply with ASME A17.1/CSA B44, Safety Code for Elevators and Escalators, or ASME A17.3, Safety Code for Existing Elevators and Escalators.

STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following: Fire drills are required to be conducted on each shift quarterly, the facility failed to conduct a fire drill on the:2nd. Shift, Fourth quarter. 3rd. Shift, Second quarter. The Director of Maintenance acknowledge the conditions of fire drills deficiency during record review of the facility. Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was evidenced by the following. The facility failed to provide proper documentation at the time of the survey to reflect that the emergency generator was inspected weekly. The emergency power supply system deficiency item was discussed with the Maintenance Director during the survey and again during the exit conference with the Administrator. NFPA 110-8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

A complaint survey, prompted by #CO30045, #CO30573 and #CO30601 was conducted on 1/23/23 to 1/30/23. Twelve deficiencies were cited.

An Emergency Preparedness survey was conducted from 1/23/23 to 1/30/23. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure five (#89, #105, #44, #31, #53) of seven Medicaid funded residents reviewed, out of 41 sample residents, deposited the residents' personal funds in excess of $50.00 in an interest bearing account and credited all interest earned on the resident's funds to the resident's account. Specifically, the facility failed to allocate interest accrued to medicaid funded Resident #89, #105, #44, #31, and #53, who had accounts with funds over $50.00 for December 2022 and January 2023. Findings include: I. Record reviewA. Personal funds accountsThe last two quarterly statements with interest were requested for the following residents' trust accounts. A transaction history with an opening balance and closing balance from 12/1/22 to 1/26/23 were provided for each resident.-Resident #89 was admitted on 9/30/22. The resident had a beginning balance of $2216.89 and an ending balance of $2163.89 from 12/1/22 to 1/26/23. There was no interest credited to the account.-Resident #105 was admitted on 7/24/2020. The resident had a beginning balance of $2275.12 and an ending balance of $2359.25. There was no interest credited to the account.-Resident #44, was admitted on 4/2/16. The resident had a beginning balance of $1951.02 and an ending balance of $1985.40. There was no interest credited to the account.-Resident #31 was admitted on 6/20/11. The resident had a beginning balance of $2135.24 and an ending balance of $2287.38. There was no interest credited to the account.-Resident #53 was admitted on 2/4/16. The resident had a beginning balance of $2734.92 and an ending balance of $1828.56. There was no interest credited to the account. II. InterviewsThe business office manager (BOM) was interviewed on 1/30/23 at 4:45 p.m. She stated money was pooled into an interest bearing account, and the corporate office controlled the interest bearing on the accounts and she was unsure how it was accrued and credited to the resident's account. III. Facility follow-upThe BOM emailed a batch-trust transaction list on 1/31/23 at 12:41 p.m. The account was titled resident trust bank and listed interest earned by each resident from January 2022 to December 2022 but did not include information on interest credited back to the residents' trust account.

Based on record review and staff interviews, the facility failed to ensure money from personal funds accounts was conveyed to the appropriate individuals within 30 days after discharge or death for 14 discharged residents. Specifically, the facility failed to convey personal funds to the appropriate individual within 30 days following resident death or discharge at the facility. Findings include:I. Record reviewReview of resident personal trust accounts revealed 14 residents discharged from the facility had remaining account balances as of 1/26/23. The 14 residents included all had discharge dates from 2016 to 2022. Three of the highest balances included $2022.56, $2384.34 and $4951.91II. InterviewsThe business office manager (BOM) was interviewed on 1/30/23 at 4:45 p.m. She stated the NHA was working with discharged resident accounts that showed a balance in their personal fund account. The nursing home administrator (NHA) was interviewed on 1/30/23 at 4:48 p.m. She stated she had tried to reach out to return the remaining balances and was working with the state. She used the same process for all the discharged/deceased resident account balances. She was starting with the highest balances and attempting to return those funds first.-Correspondence from the NHA was requested to show the facility was working on the balances, however this was not provided by the exit of the survey on 1/30/23.

Based on observations, record review and interviews, the facility failed to provide a safe, clean, sanitary, and homelike environment for residents in one of four facility spas. Specifically, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in the facility spa. Findings include:I. Facility policyThe Infection Control Program Overview, revised 1/1/22, was provided by the assistant nursing home administrator (ANHA) on 1/24/23 at 2:09 p.m. It read in pertinent part, "Infection Control Program designed to provide a sanitary and comfortable environment and to assist in preventing the development and transmission of disease and infection. Reducing and/or preventing infections through indirect contact required the decontamination (such as cleaning, sanitizing, or disinfecting of an object to render it safe for handling) of resident equipment, medical devices and the environment."II. Observations and resident interviewThe shower (spa) room was observed on 1/23/23 at 2:22 p.m. on unit 300. The room had an odor of feces. There were two shower chairs in the shower room and a shower hand sprayer hanging on the side rail. An unidentified housekeeping associate passed the shower room at 1/23/23 at 2:24 p.m., looked inside and went by organizing the furniture in the hallway. She cleaned the chairs and tables in the hallway. The spa room was observed on 1/24/23 at 3:45 p.m. on unit 300. The room had a urine odor. The light was on and the ceiling ventilation was not heard to be working. There was no switch to turn on a vent. The toilet seat was on the floor to the left of the toilet. An unlabeled portable urinal containing urine was on the toilet tank. The urine odor could be smelled up to six feet outside the spa. An unlabeled and uncovered six ounce plastic cup half filled with liquid soap was on a shower bench. The spa room was observed on 1/25/23 at 12:38 p.m. on unit 300. The room had a urine odor and the toilet seat was on the floor to the left of the toilet. At 12:47 p.m. a resident used the spa on unit 300. A urine order could be smelled when the door to the spa opened. At 2:00 p.m the environmental services director checked the exhaust fan in the 300 unit spa and it did not put out or suck in any airAt 4:00 p.m. an unidentified resident asked if the spa could be fixed because the smell was so terrible. III. Staff interviewsHousekeeping associate (HA) #1 was interviewed on 1/20/23 at 10:30 a.m. She stated the smell in the 300 unit spa was coming from the drain. She said the residents go to the bathroom into the drain. She had made a few reports to the maintenance department but could not remember if they were written or verbal, but thought she made two verbal reports. She said the facility did have papers to fill out for maintenance requests. She said the spa was cleaned two times a day and she usually did it twice a day when she worked, but she could not get into the drain. The environmental services director (ESD) was interviewed on 1/25/23 at 2:00 p.m. He stated he was not aware of a regulation that stated a bathroom had to have a working exhaust fan. He stated that the odor in the bathroom was from the body odor of residents after they bathe. He stated that a Life Safety Inspector told him the exhaust fans in the bathrooms were not required and were for aesthetic purposes only. The ESD said he did not know why some fans were working and some were aesthetic. He stated he cleaned the spa on unit 300 that morning with drain cleaner and that it smelled better than the day before. He stated it was cleaned by the housekeeping department and not the certified nursing assistants (CNAs) after a shower would be used by a resident. He stated he or department staff did audits on the bathrooms and the light was automatic based on motion. He was unsure if the exhaust fan would also turn on automatically with the automatic light. IV. Record reviewCleaning checklists for the spa on unit 300 were provided by the (ANHA) on 1/31/2023 at 3:57 p.m. for November and December of 2022 and January of 2023. The November 2022 cleaning checklists provided marked the spa on unit 300 as being cleaned 12 times in November on the following dates: 11/2/22, 11/3/22, 11/4/22, 11/5/22, 11/6/22, 11/9/22, 11/10/22, 11/12/22, 11/13/22, 11/17/22, 11/18/22 and 11/24/22. The December 2022 cleaning checklists provided marked the spa on unit 300 as being cleaned nine times in December on the following dates: 12/8/22, 12/9/22, 12/10/22, 12/11/22, 12/12/22, 12/20/22, 12/21/22, 12/22/22 and 12/31/22. The January 2023 cleaning checklists provided marked the spa on unit 300 as being cleaned 12 times in January on the following dates: 1/4/23, 1/5/23, 1/6/23, 1/7/23, 1/8/23, 1/9/23, 1/12/23, 1/13/23, 1/14/23, 1/15/23, and 1/24/23. -The spa had not been cleaned for nine days from 1/15/23 to 1/24/23. After the spa had been cleaned on 1/24/22, urine odors could be smelled from the shower room.

Based on interviews and record review, the facility failed to take steps to protect one (#182) of four residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to ensure Resident #182 was free from physical abuse from a staff member. Findings include:I. Facility policy and procedureThe Abuse policy, revised 2/3/17, was provided by the assistant nursing home administrator (ANHA) on 1/25/23 at 11:30 a.m. It revealed, in pertinent part, "Purpose: to provide the appropriate State Licensing Agent both verbal and written notification of reportable occurrences."Abuse is defined as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish."II. Incident of physical abuse of Resident #182 by a staff member on 9/16/22 The 9/16/22 wellness note documented Resident #182 had an altercation with a staff member around 3:00 p.m. Resident #182 had a laceration and hematoma (clotted blood) on his left forehead and temporal area. He had a laceration on his left knee. The resident was assessed and neurological checks were stable. The injuries were cleaned and bandages were applied. Resident #182 was given tylenol for pain and was also given medication for agitation. Resident #182 declined going to the hospital. The progress note documented upper management and social services were involved. The police were contacted by the social worker. The physician was notified and a voicemail was left for the family. The 9/16/22 skin integrity evaluation documented Resident #182 had a 1 centimeter (cm) by 0.2 cm laceration to his left forehead. The laceration was cleaned and a bandage was applied. The 9/16/22 abuse investigation documented that on 9/16/22 Resident #182 followed a male staff member onto the outdoor patio. Resident #182 struck the staff member. The staff member then assaulted the resident. The investigation documented the staff member was immediately suspended. Other residents were kept safe by keeping residents under constant supervision. The police were contacted and medication was administered to Resident #182. The mental health case manager was contacted. Resident #182 remained under staff supervision and medication was evaluated. The investigation documented the resident sustained a hematoma above his left eye and a skin tear to the left side of his face. The resident was given an ice pack and bandages were placed to the open areas. The investigation documented the alleged assailant provided a statement explaining Resident #182 approached him and hit him in the face. The assailant said he pushed the resident several times when the resident was attempting to get up. The assessment documented the assailant pushed the resident since he kept trying to get up. The assailant was terminated on 9/19/22. III. Resident #182 A. Resident statusResident #182, under the age of 65, was admitted on 7/29/2020, readmitted on 10/18/22 and he was discharged on 10/31/22. According to the October 2022 computerized physician orders (CPO), the diagnosis included anoxic brain damage (complete lack of oxygen to the brain), personal history of sudden cardiac arrest, epilepsy (seizure disorder), psychotic disorder with delusions, restlessness and agitation, insomnia (difficulty sleeping) and unspecified dementia, unspecified severity with other behavioral disturbanceThe 10/31/22 minimum data set (MDS) assessment revealed the resident had a short-term memory impairment. The resident was moderately impaired making decisions regarding tasks of daily life. He required supervision for bed mobility, walking in his room, walking in the corridor, locomotion on and off the unit, dressing, eating and personal hygiene. He required limited assistance with toileting and transfers. The MDS assessment documented the resident had physical and verbal behaviors directed towards others and behaviors not directed at others one to three days in the review period. The MDSassessment documented the resident did not reject care and displayed wandering behaviors one to three days in the review period. B. Record reviewThe cognitive care plan, initiated on 7/30/2020 and revised on 11/3/22, revealed the resident had impaired cognitive functioning or impaired thought process related to anoxic (lack of oxygen) brain injury. The interventions included: administering medications as ordered, communicating with family and resident regarding Resident #182's capabilities and needs, identifying oneself during interactions with the resident, keeping Resident #182's routine consistent, monitoring and documenting changes and reporting to the physician as needed, providing supervision and assistance with all decision making, providing a homelike environment and using segmented tasks to support short term memory deficits. The behavior care plan, initiated on 8/6/22 and revised on 11/3/22, revealed Resident #182 had a behavior problem related to anger and control of lashing out. Resident #182 received medications for aggressive behaviors related to his anoxic brain injury. The interventions included: administering medications as ordered, completing abnormal involuntary movement scale assessments upon admission and quarterly, monitoring for side effects of medications, mental health services, providing two staff during cares, reviewing behavior and medication quarterly and as needed and requesting a risk vs benefit statement from the physician if polypharmacy or dose reductions have failed. The acute care plan, initiated on 10/9/22 and revised on 11/3/22, revealed Resident #182 had an altercation with a staff member. Resident #182 sustained a laceration and hematoma on his left forehead and temporal area and a laceration on his left knee. The interventions included: assessing the resident, neurological checks, cleaning the injury and applying a bandage, administering tylenol as needed for pain, administering medication for agitation, notifying police, notifying the physician and leaving a message with the resident's family. IV. Staff interviewsThe ANHA was interviewed on 1/30/23 at 5:18 p.m. She said she reviewed the surveillance cameras after the incident on 9/16/22. She said the male staff member went outside to the patio. She said Resident #182 followed the staff member outside and punched the staff member. She said the staff member pushed Resident #182 to the ground and when Resident #182 attempted to get up, he held the resident down. The ANHA said Resident #182 sustained a laceration and a hematoma on his face. The ANHA said the staff member was immediately suspended and terminated after the investigation was completed. She said the staff member's license was reported to the department of regulatory agencies (DORA).

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the proper authority, including the policy and state oversight agency in accordance with state law for eight alleged violations; involving three (#182, #11 and #76) of four residents reviewed for allegations of abuse out of 41 sample residents. Specifically, the facility failed to report to the State Agency timely:-Four allegations of resident abuse by Resident #182; and; -One allegation of abuse between Resident #76 and Resident #11. Findings include:I. Facility policy and procedureThe Abuse policy, revised 2/3/17, was provided by the assistance nursing home administrator (ANHA) on 1/25/23 at 11:30 a.m. It revealed, in pertinent part, "Purpose: to provide the appropriate State Licensing Agent both verbal and written notification of reportable occurrences."Abuse is defined as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish.'"Alleged and substantial incidents, complete investigation reports, and if necessary, corrective actions taken, will be reported to the Resident's responsible party, physician, ombudsman, state licensing authority and police department as appropriate."II. Resident #182A. Resident statusResident #182, under the age of 65, was admitted on 7/29/2020, readmitted on 10/18/22 and he was discharged on 10/31/22. According to the October 2022 computerized physician orders (CPO), the diagnoses included anoxic brain damage (complete lack of oxygen to the brain), personal history of sudden cardiac arrest, epilepsy (seizure disorder), psychotic disorder with delusions, restlessness and agitation, insomnia (difficulty sleeping) and unspecified dementia, unspecified severity with other behavioral disturbanceThe 10/31/22 minimum data set (MDS) assessment revealed the resident had a short-term memory impairment. The resident was moderately impaired making decisions regarding tasks of daily life. He required supervision for bed mobility, walking in his room, walking in the corridor, locomotion on and off the unit, dressing, eating and personal hygiene. He required limited assistance with toileting and transfers. The MDS assessment documented the resident had physical and verbal behaviors directed towards others and behaviors not directed at others one to three days in the review period. The MDS assessment documented the resident did not reject care and displayed wandering behaviors one to three days in the review period. B. Record reviewThe cognitive care plan, initiated on 7/30/2020 and revised on 11/3/22, revealed the resident had impaired cognitive functioning or impaired thought process related to anoxic (lack of oxygen) brain injury. The interventions included: administering medications as ordered, communicating with family and resident regarding Resident #182's capabilities and needs, identifying oneself during interactions with the resident, keeping Resident #182's routine consistent, monitoring and documenting changes and reporting to the physician as needed, providing supervision and assistance with all decision making, providing a homelike environment and using segmented tasks to support short term memory deficits. The behavior care plan, initiated on 8/6/22 and revised on 11/3/22, revealed Resident #182 had a behavior problem related to anger and control of lashing out. Resident #182 received medications for aggressive behaviors related to his anoxic brain injury. The interventions included: administering medications as ordered, completing abnormal involuntary movement scale assessments upon admission and quarterly, monitoring for side effects of medications, mental health services, providing two staff during cares, reviewing behavior and medication quarterly and as needed and requesting a risk vs (versus) benefit statement from the physician if polypharmacy or dose reductions have failed. The acute care plan, initiated on 10/27/22 and canceled on 11/3/22, revealed Resident #182 was showing extreme aggression to other residents. He made physical contact with two residents in their faces a couple of times before Resident #182 was separated and assisted to his room. The interventions included: drawing labs, changing medications, remaining on 15 minute safety checks, training staff on physical holds and calling codes and mental health services to continue following the resident. 1. Incident on 10/7/23The 10/7/22 behavior note documented Resident #182 asked another resident to have sex with him. The other resident said no. It documented the other resident was perseverating on the situation, but did feel safe. The 10/7/22 abuse investigation report documented the other resident felt safe and was not worried about Resident #182. It documented the other resident said Resident #182 was their friend and he was having a bad day. There were no reports of physical touch or aggression. It documented there was not a recurrence. 2. Incident on 10/17/23 The 10/17/22 wellness note documented at 2:07 p.m., read, in pertinent part, Resident #182's sexual and aggressive behavior was increasing. On this shift the nursing had to redirect Resident #182 to go back to his room due to being sexually inappropriate with another resident by touching her leg and standing over her. It was documented at approximately 12:15 a.m. Resident #182 went into the other residents room and shut the door. Resident #182 blocked the door and would not open it for approximately 30 seconds. It documented once Resident #182 opened the door, he was easily redirected back to his room. The 10/17/22 wellness note documented at 10:31 a.m. read, in pertinent part, Resident #182 was being sexually inappropriate with female staff and residents. The 10/21/22 sexual abuse investigation documented that the incident of sexual inappropriateness as documented in the 10/17/22 wellness note had really occurred on 10/20/22 (however the incident note was entered into the resident electronic record on 10/17/22 and electronically time date stamped with the date of 10/17/22. The investigation report documented an investigation was conducted and the resident was being monitored for medication changes. The resident was being evaluated by mental health services for alternative placement. -The facility did not investigate what occurred when Resident #182 held the door closed for 30 seconds. -The facility failed to report this incident of sexual abuse to the State Agency. 4. Incident on 10/21/23The 10/21/22 behavior note documented, in pertinent part, Resident #182 made numerous attempts to hit or punch other residents including staff members. The 10/22/22 physical abuse investigation report of the events on 10/21/22 documented an investigation was conducted and verified on video surveillance that the resident was able to be redirected. The report documented there was no physical contact made. The investigation documented the intervention was to a request for a full electronic health record review (the investigation report did not document the result or why this was requested). The investigation documented an as needed was administered (the report did not document what the "as needed" was or if it was effective).-The facility failed to report this incident of physical abuse using gestural threats towards other residents to the State Agency. 5. Incident on 10/23/23 The 10/23/22 behavior note documented at 4:41 p.m., revealed Resident #182 kept charging at both residents and staff, asking staff to have sex with him. Resident #182 exposed his genital organs to staff and was not easily redirected; so staff placed the resident on one-to-one monitoring. The investigation documented an investigation was conducted, Resident #182 was noted to be approaching staff asking for sexual favors. It was misreported that residents were approached for sexual favors. -The facility failed to report this incident of physical abuse with gestural threats towards other residents to the State Agency. 6. Incident on 10/31/23The 10/31/22 immediate notice of discharge for Resident #182 documented on 10/30/22 and 10/31/22 Resident #182 was repeatedly menacing other residents with a closed fist. It documented he was walking around the unit with no clothing requesting inappropriate favors from staff and residents. The discharge notice documented residents on the unit were expressing fear for their safety as Resident #182's maladaptive behaviors continued to escalate. -The facility failed to report this incident of physical abuse with gestural threats and sexual abuse to the State Agency. C. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 1/25/23 at 1:40 p.m. She said she reported any abuse allegations to the assistant director of wellness (ADOW) immediately. CNA #6 was interviewed on 1/25/23 at 1:43 p.m. She said the nursing home administrator (NHA) was the abuse coordinator. She said abuse allegations were reported to the abuse coordinator immediately. Registered nurse (RN) #4 was interviewed on 1/25/23 at 1:51 p.m. She said the NHA was the abuse coordinator. She said all abuse allegations were reported to the NHA immediately. The ANHA and the nursing home administrator (NHA) were interviewed on 1/30/23 at 3:17 p.m. The NHA said she was the abuse coordinator. She said all abuse allegations were directly and immediately reported to her. The NHA said all abuse allegations were handled on a case by case basis. She said when an allegation of abuse was given to her she immediately started an investigation. The NHA said the investigation included interviewing all parties involved, keeping the residents safe and providing any necessary medical attention. She said she involved the police if necessary. The NHA said she would report abuse allegations to the State Agency if they met the correct criteria. The ANHA said Resident #182 had sexual behaviors towards the staff. She said the sexual abuse incidents were not substantiated. The ANHA said Resident #182 had increased behaviors and was discharged to the hospital. III. Incident allegation of physical abuse between Resident #11 and Resident #76 on 1/16/23A, Resident #111. Resident statusResident #11, age 69, was admitted on 5/27/13 and readmitted on 9/8/16. According to the January 2023 CPO, the diagnoses included unspecified dementia, unspecified severity with other behavior disturbance, other specified depressive episodes, history of traumatic brain injury and dysphagia (swallowing difficulty). The 12/8/22 MDS assessment revealed the resident had short-term and long-term memory impairment. The resident was moderately impaired making decisions regarding tasks of daily life. She required limited assistance of one person for bed mobility, transfers, locomotion on the unit, dressing and eating. She required extensive assistance of one person for locomotion off the unit, toileting and personal hygiene. 2. Record reviewResident #11's comprehensive care plan, initiated on 7/28/13 and revised on 10/14/14, documented Resident #11 had the potential for altercations by taking others personal property away from them. The interventions included: providing close observation and documentation for 72 hours for increase behaviors and safety, encouraging distance between the resident and other residents, encouraging her to become involved in activities that retain her concentration, providing acute in patient hospital treatment as needed to reach psychosocial stability of exacerbated behaviors, providing close observation of resident and redirect as needed to prevent verbal and physical altercation with others, providing medications as ordered, notifying physician if medications are not effective, observing and documenting sleep patterns as needed, providing 15 minutes checks for close observation and safety during acute episodes, redirecting and assuming that the resident and others remain safe and free from harm during episodes of increased anger and aggression toward self and others and providing redirection as needed. The communication care plan, initiated on 8/11/13 and revised on 10/15/14, documented Resident #11 was at risk for a communication deficit related to she was not always able to verbalize or gesture her needs. The interventions included: allowing Resident #11 time to express herself through words or gestures as needed and reapproach her if she is unable to communicate with staff or becomes anxious. B. Resident #761. Resident statusResident #76, under the age of 65, was admitted on 6/10/21. According to the January 2023 CPO the diagnoses included bipolar disorder, cerebral infarction (stroke), seizures, gastro-esophageal reflux disease (GERD), anxiety disorders, depression and tremors. The 12/14/22 MDS revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. He required supervision of one person for bed mobility, transferred, toileting and personal hygiene. He was independent, but required set-up for locomotion on the unit and eating. He required supervision with set-up for locomotion off the unit and limited assistance of one person for dressing. The MDS assessment documented the resident had rejected care one to three days within the review period and did not have any physical or verbal behaviors directed at others. 2. Record reviewThe acute care plan, initiated on 8/25/22, revealed Resident #76 was observed hitting another resident in the face. Resident #76 said the other resident was in his way, so he hit him. The interventions included: notifying the physician and sending to the emergency room for evaluation, notifying mental health services, contacting the police and escorting the resident away from the situation. C. Physical abuse incidentThe 1/15/23 wellness note documented into Resident #11's medical record at 1:03 p.m., documented Resident #11 got into an argument with Resident #76, before staff could intervene Resident #76 punched Resident #11 in the nose causing a mild nosebleed. The progress note documented the residents were separated immediately. Resident #11's nose was red and had no bruising or swelling. Resident #11 refused an assessment. Vitals signs and neurological checks were initiated for Resident #11. The progress note documented all parties were notified. The 1/15/23 wellness note documented in Resident #11's medical record at 4:08 p.m., documented slight swelling was noted to her nose. Tylenol was offered multiple times for pain, but the resident refused. Resident #11 was refusing assessment and vital signs. The 1/16/23 physical abuse investigation documented Resident #11 was punched by Resident #76. The investigation documented this report of abuse was documented in the electronic medical record. After investigation the investigator determined the information about the allegation was to not factual. Resident #11 and Resident #76 were not in an altercation. The employees were given a verbal warning on reporting and a clarification note was documented by the director of wellness (DOW).-Despite the investigator un-substantiating this allegation of physical abuse the facility failed to report an allegation of physical abuse that led to an injury of bodily harm within the required two hour notification time period. The 1/24/23 wellness note documented in Resident #11's medical record by the DOW, documented the interdisciplinary team met on 1/19/23. The note documented upon further investigation it was determined that the injury was sustained during a self initiated interaction with another resident. Resident #11 was reaching into the space of Resident #76. Resident #76 attempted to ward off Resident #11's reach. During this interaction Resident #11 sustained a minor injury. The note documented there were no signs of abuse or neglect. B. Staff interviewsThe ANHA and the nursing home administrator (NHA) were interviewed on 1/30/23 at 3:17p.m. The ANHA said Resident #11 sustained the nosebleed from picking at her nose. She said the incident of physical abuse between Resident #11 and Resident #76 on 1/16/23 did not meet the criteria to report to the State Agency. The ANHA said staff did not appropriately document the situation in the electronic medical record and assumptions were made by staff when reporting the abuse allegation. -However, all abuse allegations need to be reported to the State Agency even if the investigation was not substantiated.

Based on record review and interviews, the facility failed to refer four (#95, #125, #77 and #111) of seven residents reviewed for preadmission screening and resident review (PASRR) out of 41 sample residents to the appropriate state-designated authority for level I and level II PASRR evaluation and determination for services. Specifically, the facility failed to ensure that residents had a PASRR level I screen completed in order to ensure Resident #95, #125, #77 and #111 received services to maintain their highest practicable medical, emotional and psychosocial well-being. Findings include:I. Facility policy and procedureThe PASRR policy, revised 4/30/15, was provided by the social services director (SSD) on 1/30/23 at 6:43 p.m. It revealed, in pertinent part, "Level 1 PASRR's are required for every move-in to any Medicaid participating wellness community."If a move-in is approved as a convalescent care they will end up staying past the approved 60 days, the community must notify the OBRA (office of specialized nursing homes) evaluator prior to the end date in order for the level II to be timely."Keep all PASRR documents in the medical record (this includes Level II determination letters, depression diversion, status changes, and old level I's)."Care plans should include issues identified in the level II."II. Resident #95A. Resident statusResident #95, under the age of 65, was admitted on 11/17/22 and readmitted on 12/24/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included heart failure, chronic obstructive pulmonary disease (COPD), schizoaffective disorder bipolar type, epilepsy (seizure disorder), insomnia (sleep difficulty), fluid overload and gastro-esophagueal reflux disease (GERD). The 1/9/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) with a score of 12 out of 15. He required supervision of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toileting and personal hygiene. He required supervision with set up assistance for walking in his room and eating. He required supervision for walking in the corridor. The MDS assessment documented the resident had not been evaluated by level II PASRR.B. Record review A request was made for documentation indicating a level I PASRR had been submitted for Resident #95 on 1/25/23 at 1:02 p.m. The facility did not have any documentation to show an level I PASRR had been submitted for Resident #95. The SSD said she was unable to provide documentation revealing the PASRR had been submitted. III. Resident #125A. Resident statusResident #125, under the age of 65, was admitted on 11/9/22. According to the January 2023 CPO, the diagnoses included schizoaffective disorder, anxiety disorder and gastro-esophageal reflux disease (GERD). The 11/16/22 MDS assessment revealed the resident was cognitively intact with a BIMS with a score of 15 out of 15. She required limited assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. She required supervision of one person for walking in her room and corridor, locomotion on and off the unit and eating. The MDS assessment documented the resident had not been evaluated by level II PASRR.B. Record reviewA request was made for documentation indicating a level I PASRR had been submitted for Resident #125 on 1/25/23 at 1:02 p.m. The facility did not have any documentation to show an level I PASRR had been submitted for Resident #125. The SSD said she was unable to provide documentation revealing the PASRR had been submitted. IV. Resident #77A.Resident statusResident #77, under the age of 65, was admitted on 5/18/22. According to the January 2023 CPO, the diagnoses included schizoaffective disorder bipolar type, type two diabetes mellitus and glaucoma. The 11/22/22 MDS assessment revealed the resident was cognitively intact with a BIMS with a score of 14 out of 15. She required supervision for all activities of daily living (ADLs). The MDS documented the resident did not have diabetes mellitus. The MDS assessment was not filled out to determine if the resident had been evaluated by level II PASRR.B. Record reviewA request was made for documentation indicating a level I PASRR had been submitted for Resident #77 on 1/25/23 at 1:02 p.m. The facility did not have any documentation to show an level I PASRR had been submitted for Resident #77. The SSD said she was unable to provide documentation revealing the PASRR had been submitted. V. Resident #111A. Resident statusResident #111, younger than age 65, was admitted on 12/2/22. According to the January 2023 computerized CPO, diagnoses included Schizoaffective disorder, post traumatic stress disorder (PTSD), bipolar disorder, diabetes and visual impairment. The 12/8/2022 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. The resident required minimal assistance with transferring, bathing, extensive assistance with dressing and supervision with eating. B. Record reviewThe care plan, initiated on 12/2/22 and revised on 1/6/23 identified the resident had been diagnosed with Schizoaffective disorder and PTSD. The care plan did not include a level I and level II preadmission screening and resident review (PASRR) evaluation. The level I and Level II evaluations were not located in any other part of the resident's records. C. InterviewLicensed practical nurse (LPN) #1 was interviewed on 1/24/23 at 4:00 p.m. She said there were no specific folders at the nurses station that contained PASRR evaluations. She suggested looking in the resident's medical records. She said she did not know if Resident #111 had PASRR evaluations completed. VI. Administrative interviewsThe SSD and social services assistant (SSA) #1 were interviewed on 1/25/23 at 1:02 p.m. The SSD said PASRR level I's were submitted within the first 30 days a resident was admitted to the facility. She said it was taking three to four months to receive a response regarding a level I PASRR and was taking even longer for the level IIs. The SSD said the PASRR level I and level II should be in the resident's medical record. She said the recommendations made for the PASRR level II should be included on the resident's care plan. She said did not received PASSRs for Resident #95, #125, #77 or #111. The state PASRR coordinator was interviewed on 1/26/23 at 11:49 a.m. She said the facility had not submitted PASRRs for Resident #95, #125, #77 or #111 since they had been admitted to the facility. She said the PASRR website was currently working. The SSD and SSA #1 were interviewed again on 1/30/23 at 1:15 p.m. The SSD said she was unable to provide documentation that a PASRR for Resident #95, #125, #77 or #111 were submitted. The assistant nursing home administrator (ANHA) and the admissions coordinator (AC) were interviewed on 1/30/23 at 6:00 p.m. The ANHA said PASSRs were being submitted on the website, but the website had been down recently.

Based on observations, record review and interviews the facility failed to prevent multiple falls with injury for two (#17 and #57) of two residents reviewed out of 41 sample residents. Resident #17 had a diagnosis of dementia, repeated falls, unsteadiness on feet, unspecified fracture of left arm. The facility failed to develop a person centered plan of care to promote safety and prevent repeated falls. Resident #17 had falls on 8/18/22, on 9/9/22 (had a 0.5 centimeter by 1 centimeter laceration was noted on the lower left leg), on 9/26/22; and on 11/11/22. Resident #17 had a laceration after she fell on 11/11/22 to her left front forearm, emergency medical services (EMS) were called and the resident was taken to the hospital. Hospital documentation revealed Resident #17 suffered a displaced fracture of the humerus (arm bone, see record review below). A person centered approach was not implemented until Resident #17 suffered a fracture on 11/11/22 (see record review below). A fall occurred on 11/21/22, a large bruise was noted to Resident #17's sacrum. A fall occurred on 11/22/22 and an abrasion was noted to Resident #17's sacrum. In addition, the facility failed to complete neurological checks for unwitnessed falls for Resident #17. Resident #57 was at high risk for falling related to confusion, deconditioning, poor communication and comprehension, and was unaware of safety needs. On 12/22/22 the resident was found on the floor. Subsequent to the fall, the resident was sent to the hospital on 12/23/22 and treated for a fractured hip and required surgery. The facility failed to implement effective interventions with his known fall risk and after the fall with injury on 12/22/22. Findings include:I. Facility policyThe Fall policy, revised 11/12/10, was received from medical records (MR) on 1/30/23 at 5:00 p.m It read in pertinent part:"Community residents will have a fall evaluation and prevention plan. Based on previous evaluations and current data along with the attending physician, therapy staff and others, the facility will seek to identify resident risk factors for falls and will document those risk factors in the residents medical record."Fall risk evaluations and a plan of care are completed upon admission. Approaches related to fall management are documented in the care plan and progress notes. Community staff are trained regarding fall prevention techniques. "Education is provided to the resident, family, and staff regarding the fall risk and the fall care plan. When a resident falls complete the following documentation:-Incident report;-Wellness notes;-Post accident investigation; -Intervention; and,-24 hour report."II. Resident #17A. Resident statusResident #17, age 62, was admitted on 9/8/07 and re-admitted on 11/14/22. According to the January 2023 computerized physicians orders (CPO), diagnoses included non traumatic subdural hemorrhage (head trauma), alcohol abuse, lack of coordination, repeated falls, and fracture of left arm. The 11/14/2022 minimum data set (MDS) assessment was reviewed and revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision with bed mobility and transfers. She required supervision with toilet use, walking and was able to stabilize with human assistance and the use of her walker. B. ObservationsResident #17 was observed on 1/24/23 at 3:15 p.m. She was walking around the unit with her walker and was unsteady on her feet. The tennis shoes she was wearing were flopping up and down as she walked as if they were too big for her feet. The resident was thin and frail and took small steps as she walked. She wore a protective helmet while walking outside of her room. C. Resident interviewResident #17 was interviewed on 1/24/23 at 10:00 a.m. The resident said she had fallen quite a few times since being admitted to the facility. She said the worst fall was when she fractured her left arm on 11/11/22. She said that was a very painful experience for her. Resident #17 said she should use her walker to help her stay safe, but she just could not remember to always use it. She said on 11/11/22 she got up from the bed and walked to the bathroom. She said she was walking barefoot in her room, she slipped on something in her room and fell to the floor. She said she complained of pain to her left arm when she tried to get up from the floor with assistance from the staff. She was assisted to a chair while staff called emergency services and was taken to the emergency room. She said she had surgery to repair the fracture to her left arm. D. Record reviewThe resident had fallen on 8/18/22, 9/9/22, 9/26/22, 11/11/22, 11/21/22 and 11/22/22. The falls were not listed in the care plan. The care plan included the following interventions: call light within reach at all times (1/30/14) and staff to assist with transfers and mobility and frequent checks. The care plan, initiated 11/11/19 and revised on 10/11/22 revealed the resident was at a moderate risk for falls with gait and balance problems. Interventions listed for falls: -Follow facility fall protocol, date initiated 10/11/22; and,-Physical therapy to evaluate and treat as ordered, date initiated 11/11/22. IncidentsThe 8/18/22 incident report revealed the following:The certified nurse aide (CNA) notified the nurse that the resident fell on her side at 8:10 a.m. when she went to pick up a pen that had fallen on the floor of the smoking area. The resident's vital signs were normal, she did not have any wounds, and the resident denied any pain. The resident was advised to continue using her walker.-There were no post injury assessments for this fall or an interdisciplinary team (IDT) assessment/review. The 9/9/22 incident report revealed the following:The resident was found in the sitting position on the floor of her room at 9:50 a.m. The resident had a 0.5 centimeter by 1 centimeter laceration on her left leg. She said she was making her way to the restroom and lost her balance and fell. The resident did not use her walker. Resident #17 denied any pain. -There were no post injury interventions for this fall or an IDT assessment/review. The 9/26/22 incident report at 8:54 a.m. revealed the following:Licensed practical nurse (LPN) #1 said she saw the resident tip to the right in a chair and landed on her right side in the dining room. The resident said she tried to sit on the arm of the chair and it tipped over. No injuries were noted. The resident did not use her walker. The resident experienced three or more falls in the last three months. The resident had a balance problem with walking or standing. She experienced decreased muscle coordination. The post fall assessment for this fall 9/26/22 included: The resident was disoriented times three, had three or more falls in the past 30 days, balance problems with standing or walking, and was not incontinent.-There were no post injury interventions for this fall or an IDT assessment/review. The incident report on 11/11/22 at 9:50 a.m. revealed the following:A resident went to the front desk and told the nurse Resident #17 had fallen. Resident #17 was found in her room on the floor by her dresser. When attempting to stand the patient up her left arm was noted to be deformed and the resident was complaining of severe pain. The resident said she slipped and fell in her room. The resident refused to stand all the way up while complaining of pain in her left arm. The emergency medical services (EMS) were called and the resident was taken to the emergency room. Resident #17 experienced decreased safety awareness and did not use a walker as instructed. Hospital notes dated 11/11/22 indicated:Resident #17 was admitted to the emergency room on 11/11/22 at 6:00 p.m. The diagnosis was a displaced fracture of the left humerus (forearm) along with recommendation for surgery. No discharge instructions for the resident were given. The resident was recommended for physical and occupational therapy. Occupational therapy notes, dated 11/14/22 indicated the goals for the resident were bed mobility goals for modified independence, time frame one to three weeks. Toilet transfer goal given the time frame of two to three weeks. Physical therapy goal for the resident for modified independence in the time frame of two to three weeks. Upper and lower body dressing goal (modified) one to three weeks. The resident was discharged back to the facility on 11/14/22. Progress notes 1/22/22 at 12:03 p.m. Resident #17 was moved to another room next to the nurse's station. Incident note: 1/22/22 at 2:30 p.m. Resident #17 self reported a fall. She said she was attempting to use the bathroom when she slid off the toilet and landed on her coccyx (sacrum). She said she scooted across the floor on her bare bottom to get to a call light to call for help. This fall occurred after the resident was moved next to the nurses station for her safety. Post fall assessment for 1/23/22:The fall was not witnessed. The resident was observed on the floor. The resident was not incontinent and the floor was not wet. The call light was not on and within reach. The resident hit her head when she fell. The neuro checks were not completed. The resident had four falls in the last 30 days. Interventions added were increased safety checks, and assigned to fall prevention programs. These interventions were not added to the resident's care plan. The neurological checks for Resident #17 were requested from the assistant director of nursing (ADON) on 1/26/23 at 2:00 p.m. they were not provided by the end of the survey on 1/30/23. E. Interviews The ADON was interviewed on 1/24/23 at 2:00 p.m. She said Resident #17 had multiple falls since admission. She said the following interventions were in the care plan: the call light was within reach, the resident should be using her walker when out of bed and wear the proper type of shoes that fit properly, with anti-skid protection on the bottom. She said any fall intervention should always be listed in the resident's care plan. The only intervention found from the list in the care plan was the call light within reach. LPN #1 was interviewed on 1/25/23 at 4:55 p.m. She said Resident #17 wore a helmet to protect her head if she had a seizure while she was walking. She said the resident was often unsafe when she walked and unsteady on her feet. CNA #3 was interviewed on 1/30/23 at 10:00 a.m. She said Resident #17 did not fall in the day time, but usually at night time. She said she thought there was not enough staff to care for the residents on the evening shifts so therefore the residents were not watched close enough to prevent accidents. She said one intervention put into place was to move the resident closer to the nurse station. She said one intervention was to have the call light within reach (2014). CNA #3 said although the call light was within reach (2014), the resident would hardly ever use it until after a fall had taken place. CNA #2 was interviewed on 1/30/23 at 10:30 a.m. She said she was not working the day that Resident #17 fell and broke her arm, but there were many times when the resident would not use her walker, especially in her room and that had caused accidents to happen. Resident #17 visited her husband on the first floor for lunch every day. She said the resident was escorted by the staff to the first floor because she was too weak and frail to walk by herself. LPN #4 was interviewed on 1/30/23 at 4:30 p.m. She said Resident #17 had multiple falls since she was admitted to the facility. She said the resident would not listen to any education that staff provided to her about safety when ambulating. She said most of her falls occurred in her room because she did not use her walker. She said the resident believed she could walk without the walker. LPN #4 said the resident was moved closer to the nurses station for safety, but she still kept falling. The IDT notes for these specific falls were asked for but not provided. III. Resident #57A. Resident statusResident #57, age 72, was admitted on 10/19/22. According to the January 2023 computerized physician orders (CPO) the diagnoses included schizophrenia, diabetes mellitus type two, arthritis, high blood pressure and dementia. The 1/23/23 minimum data set (MDS) revealed the resident was unable to complete the brief interview for mental status (BIMS). He required assistance of one person for activities of daily living (ADLs) as well as locomotion on the unit, and was a two person assist for transfers. The MDS indicated walking in the resident's room or on the unit did not occur. B. ObservationsOn 1/23/23 at 4:04 p.m. Resident #57 was observed lying in bed. His bed was not in a low position and there was no fall mat by his bed. The fall mat was folded in a small closet area in the resident's room. On 1/24/23 at 2:00 p.m. Resident #57 was observed lying in bed. His bed was not in a low position and there was no fall mat by his bed. The fall mat was folded in a small closet area in the resident's room. On 1/30/23 at 9:38 a.m. Resident #57 was observed lying in bed. His bed was not in a low position and there was no fall mat by his bed. The fall mat was folded in a small closet area in the resident's room. C. Record reviewThe care plan focus initiated 10/31/22 revealed Resident #57 was at high risk for falls related to confusion, deconditioning, poor communication and comprehension, and was unaware of safety needs. The goal was for Resident #57 to be free of injury through the review date of 4/11/23. Interventions included family/caregivers about safety reminders and what to do if a fall occurs, and staff will anticipate and meet Resident #57's needs. The progress note dated 12/22/22 at 11:13 p.m. revealed Resident #57 was found on the floor unable to relate the events of his fall. No visible injury was observed at that time. The progress note dated 12/23/22 at 10:10 a.m. revealed the resident's right thigh appeared swollen and and the resident appeared to be in pain when right thigh was touched. The progress note dated 12/23/22 at 1:40 p.m. revealed the resident was sent to the hospital at 1:25 p.m. for further evaluation of his right hip. -The resident returned to the facility on 12/27/22 due to right hip fracture and surgery (see notes below). The post incident/accident investigation dated 12/24/22 revealed Resident #57 was found on the floor at his bedside. The resident was unable to relate events leading to the fall. No visible injury was observed. Vital signs and neurological assessment were within normal limits. No injuries were observed at the time of the incident. The corrective actions listed were an increase in safety checks, assigned to a fall prevention program and a physician consultation. The post incident and accident investigation also revealed the care plan was reviewed and updated and a significant change in the MDS assessment was required. The progress notes reviewed for Resident #57's post fall interventions revealed the following:12/27/22 at 6:29 p.m. revealed Resident #57 was transported back to the facility at 4:45 p.m. on post right hip fracture and surgery. 12/29/22 at 11:44 a.m. risk management noted a fall mat should be placed at Resident #57's bedside and his bed in the lowest position; the resident should be on frequent rounding. 1/11/23 5:33 a.m. Resident #57 was trying to transfer out of bed unsafely and staff had to redirect the resident back to bed. -The fall mat and the bed in low position were not noted to be in place. 1/14/23 4:46 a.m. Resident #57 tried to get up from bed; the call light was in reach. The fall mat and bed in low position were not noted to be in place. 1/22/23 5:45 a.m. the bed was in a low position. -The fall mat was not noted to be in place.-The care plan focus for falls was not updated to include the recommended interventions written in the 12/29/22 risk management progress note. D. InterviewsThe assistant director of wellness (ADOW) #2 was interviewed on 1/30/23 at 9:40.a.m. She stated that Resident #57 should have a fall mat but only at night. She stated the resident was starting to ambulate more and walk without supervision as his strength increased and having a mat on the floor during the day was a trip hazard for him.

Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and three out of three nourishment rooms. Specifically, the facility failed to:-Ensure food was labeled and dated in the walk-in refrigerator in the main kitchen;-Ensure three unit nourishment rooms were clean and sanitary;-Ensure garbage was covered and disposed of in the main kitchen, and,-Ensure appropriate use of gloves when handling ready-to-eat foods. Findings include:I. Ensure food was labeled and dated in the main kitchenA. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdfIt revealed in pertinent part, "A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request." (Retrieved 2/1/23)B. Facility policy and procedureThe Labeling and Dating of Food policy, revised 11/1/16, was provided by the director of dining (DOD) on 1/30/23 at 5:00 p.m. It revealed, in pertinent part, "Policy: to provide foods that are safe to serve to residents."Procedure: all food removed from original package must have product name, receive date and use by date. Any food that is made in house must not exceed usage of more than five days including the date on which it was prepared, any food containing mayonnaise may not exceed longer than three days including the date on which it was made. Any product that is made to be hearted at another date and time. Needs to show HACCP (hazard analysis and critical control points) cooling and reheating schedule."C. ObservationsOn 1/23/23 at 9:32 a.m. the initial kitchen tour was conducted and the following was observed:-In the main kitchen, a container of Rice Krispies, a container of Fruit Loops, a container of Raisin Bran and a container of Frosted Flakes did not have a label or date.-In the reach in freezer, an opened bag of frozen berries did not have a label or date on them. -In the main walk-in refrigerator, a container of sliced oranges did not have a label or a date. A container of nectar thick apple juice, a container of nectar thick cranberry juice, a container of nectar thick orange juice and two containers of nectar thick water were opened and did not have an open date (according to the label, should be discarded after 10 days once opened). A bag of canadian bacon had an expiration date of 1/11/23 and a bag of bologna was opened and not labeled. On 1/26/23 at 4:33 p.m. the following was observed in the main kitchen:-In the main kitchen, the container of Rice Krispies, the container of Fruit Loops, the container of Raisin Bran and the container of Frosted Flakes remained unlabeled and undated.-In the main walk-in refrigerator, the canadian bacon labeled 1/11/23 was still present. An opened container of nectar thick cranberry juice was opened and did not have a useby date. -In the reach in freezer, there was an opened bag of frozen fruit. The DOD took it out and placed a label on it. D. Staff interviews The DOD was interviewed on 1/26/23 at 4:33 p.m. She said food should be labeled and dated when stored in the kitchen. II. Ensure three unit nourishment rooms were clean and sanitaryA. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations,https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part;-"Time/temperature control for safety of food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41º (degrees) F (Farenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.-"In a mechanically refrigerated storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit." (Retrieved 12/1/23). B. Facility policy and procedureThe outside food and reheating policy, undated, was provided by the DOD on 1/30/23 at 5:00 p.m. It revealed, in pertinent part, "Social workers and unit staff will be responsible for labeling and dating the outside resident food. "All food brought in the facility and in the unit refrigerator will be discarded in three days."C. ObservationsOn 1/26/23 at 3:57 p.m. the following was observed in the Pinion unit nourishment room:-In the freezer a Hot Pocket was unlabeled. The DOD said she was unable to find an expiration date on the item. -A tin of Christmas cookies was unlabeled in the refrigerator. The DOD said she was unsure when the cookies were placed in the refrigerator and said they should be discarded.-A carton of tomato juice, gallon of milk and nectar thick water were all opened and did not have an opened date. -A hamburger brought in by a resident was not labeled. The DOD said the hamburger did not have a use-by date on it.-Two plastic bags were in the bottom of the refrigerator that had a yellow substance in them. The DOD said she was unsure what the bags were for, but said they should have been thrown out. The DOD discarded them. On 1/26/23 at 4:10 p.m. the following was observed in the Juniper unit nourishment room:-In the freezer, a frozen microwave meal had expired on 12/30/2 and a container of ice cream was opened and did not have an opened date. The DOD said the expired food needed to be thrown away.-In the refrigerator, a bottle of half and half was opened and did not have an opened date, a container of Irish cream coffee creamer was opened and did not have an opened date on it and a leftover slice of pizza was wrapped in foil and did not have a label or date on it. The DOD said the expired food needed to be thrown away. -The refrigerator and freezer had food debris spilt. The DOD said the refrigerator was dirty and needed to be cleaned. On 1/26/23 at 4:20 p.m. the following was observed in the Spruce unit nourishment room:-In the freezer, an opened bag of frozen chicken wings that did not have a use-by date, six small plastic cups with frozen soda that was not covered or labeled and 14 Mighty Shakes (nutritional supplement) that expired in December 2022. The DOD said the expired food needed to be thrown away.-In the refrigerator there was an opened container of bologna labeled 9/5/22, a cake that did not have a date, an opened jar of peaches that did not have a use-by date, a container of soup that expired on 1/17/23, a container of kombucha labeled 1/17/23, five wrinkled apples, a package of tortillas that expiredon 5/8/22, two string cheeses that expired on 9/22/22, an opened container of prune-juice that was not dated with an open date, an opened jar of kimchi that did not have a date on it, a container of watermelon juice that did not have an open date on it, a jar of pickles that expired on 3/12/22, an opened jar of salsa that did not have an open date on it, a container of prune juice that expired on 1/25/22, a container of tomato juice that expired on 11/17/22, a jar of raspberry jam that did not have an open date, a muffin that expired on 1/11/23, three buns that were expired, two rolls were in a plastic bag that did not have a use-by date, an opened container of whipped topping that did not have a use-by date and an opened container of nectar thick orange juice did not have an opened date. and a container of creamy French dressing that expired on 2/18/2020. The DOD said the expired foods and food without open dates needed to be thrown out. D. Staff interviews The DOD was interviewed on 1/26/23 at 4:33 p.m. She said the social services department was responsible for putting resident ' s food into the nourishment room refrigerators. She said she needed to provide an in-service on labeling and dating food properly. The DOD said foods should have an open date. She said thickened liquids should be discarded three days after they were opened. She said the food should also be labeled with the residents name. The DOD said there was a lot of food in the nourishment room refrigerators that needed to be discarded. She said she would have a dining staff member clean the refrigerators to remove leftover food debris and place it on the cleaning task sheet to be cleaned regularly. Certified nurse aide (CNA #4 was interviewed on 1/30/23 at 9:47 a.m. She said she was not responsible for putting resident food into the nourishment room refrigerators. The social services director (SSD) and social services assistant (SSA) #1 were interviewed on 1/30/23 at 1:15 p.m. The SSD said the social services department was not responsible for placing resident ' s food into the nourishment room refrigerators. III. Ensure garbage was covered and disposed of in one of the nourishment kitchensA. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations,https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, -"Receptacles and waste handling units for refuse, recyclables, and returnables and for use with materials containing food residue shall be durable, cleanable, insect- and rodent-resistant, leak-proof, and nonabsorbent.-"Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: Inside the food establishment if the receptacles and units contain food residue and after they are filled." (Retrieved 2/1/23)B. ObservationsOn 1/26/23 at 3:57 p.m. the following was observed in the pinion unit nourishment room:-Two trash receptacles were open and did not have lids. C. Staff interviews The DOD and the maintenance director (MTD) were interviewed on 1/26/23 at 3:57 p.m. The MTD said the two trash cans inside the nourishment room did not have lids on them. The DOD said meals were served out of the steam table that was inside the Pinion unit nourishment room. She acknowledged since food was served out of the nourishment room that the trash cans needed to be covered. IV. Ensure appropriate use of gloves when handling ready-to-eat foodsA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations (CRFERR) revised January 2019, read in pertinent part, "Employees prevent bare hand contact with ready-to-eat food by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task, such as working with ready-to-eat food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and before handling or putin gon single-use gloves for working with food, and between removing soiled gloves and putting on clean gloves." (Retrieved 2/2/23)The Food and Drug Administration (FDA) Food Code (2019) page. 47-48, detailed the following instances when foodservice staff should wash their hands:-"Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service articles and single-use articles; -"After touching bare human body parts other than clean hands and clean, exposed portions of arms;-"After handling soiled equipment or utensils;-"During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; -"Before donning (putting on) gloves to initiate a task that involves working with food; and, -After engaging in other activities that contaminate the hands."B. Facility policy and procedureThe Handwashing and HandHygiene policy, revised 1/1/22, was provided by the ANHA on 1/30/23 at 1:11 p.m. It revealed, in pertinent part, "Associated will was their hands: before and after contact with a resident, after cleaning a room, after handling waste or linen, after using the bathroom, before and after serving in the dining room, before and after eating, after sneezing or coughing, any time hands have possibly become contaminate, before and after performing invasive procedures, before and after performing treatments, before and after applying gloves, when moving from a contaminated body site to a clean body site and after contact with furnishings or medical equipment in immediate vicinity of resident."C. ObservationsDuring the dinner meal on 1/25/23 at 4:57 p.m. the following was observed in the Pinion unit dining room:-Dietary aide (DA) #1 had a glove on his right hand. He used the glove hand to pick up a tortilla. He placed the tortilla on the plate. He then used the same gloved hand to scoop meat and rice onto the plate. He completed this procedure for two more plates. He did not perform hand hygiene or change his glove after touching the serving scoops and before touching the ready-to-eat tortilla. During a continuous observation during the dinner meal in the Juniper unit dining room on 1/25/23 beginning at 4:55 p.m. and ending at 5:12 p.m. the following was observed:-DA #2 had gloves on both hands. He moved the steam table and plugged the steam table into the wall. DA #2 then grabbed a tortilla with the same gloved hands. He did not change his gloves or perform hand hygiene prior to touching the ready-to-eat tortilla or sprinkling the shredded cheese on top of the taco. -At 5:12 p.m. he moved the steam table again and touched his mask. He did not change his gloves or perform hand hygiene. He then prepared another taco by touching a ready-to-eat tortilla with the same gloved hands. D. Staff interviewsThe DOD was interviewed on 1/26/23 at 4:33 p.m. She said clean gloved hands should be used to handle ready-to-eat foods. The DOD said if a dining staff member had gloves on then touched the steam table, they should perform hand hygiene and a glove change prior to touching ready-to-eat foods. The DOD said hand hygiene should be performed before and after glove usage. The DOD said she regularly conducted in-services on hand hygiene. VI. Facility follow upThe ANHA provided a copy of the hand hygiene in-service that was provided to the dietary department on 1/30/23 (during the survey process) on 1/31/23 at 3:57 p.m. She also provided a copy of the unit refrigerators in-service that was provided on 1/26/23 (during the survey process) that read, "all personal resident food items and drinks must have a name, received date and open date. All new juice and milk must have an opened date written directly on the bottle. All food and drinks on the unit that are opened three days passed the opened date must be discarded. (even if the item has manufacturer expiration date.) Any food that is not labeled at all will be discarded immediately. Pre-poured drinks without covers or dates will be discarded immediately. Any foul odor foods will be discarded."

Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for two (#98 and #103) of two residents reviewed for hospice services out of 41 sample residents. Specifically, the facility:-Develop a system to effectively ensure hospice visit notes were integrated to ensure residents had a complete medical chart for Resident #98 and #103 and care was provided accordingly; and, -Maintain an effective plan of communication for the coordinated plan of care for Resident #98 and #103. Findings include:I. Facility policyThe Hospice policy, revised 7/1/15, was provided by the assistant nursing home administrator (ANHA) on 1/26/22 at 3:49 p.m. It read in pertinent part, "The community/wellness department will work closely with their partner in caring hospice provider to provide programs to meet the specialized needs of individuals who are at their end of life. When a resident participates in the hospice program, a coordinated plan of care between the community, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status."II. Resident #98A. Resident statusResident #98, age 78, was admitted to the facility on 10/12/2020. According to the January 2023 computerized physician orders (CPO), diagnoses included Alzheimer's, anxiety, and high blood pressure. The 1/24/23 minimum data set (MDS) revealed the resident was unable to complete the brief interview for mental status (BIMS) interview. The resident was coded as having short and long term memory impairments and severely impaired decision making skills. The MDS assessment revealed that the resident required two person assistance for toileting and dressing; one person assist for transfers, eating and hygiene and supervision for ambulating on the unit. The MDS assessment was not marked to indicate that the resident was receiving hospice care. B. Record reviewThe CPO revealed an order on 6/28/22 for a hospice agency to evaluate and treat. The comprehensive care plan last revised on 6/28/22 identified the resident was receiving hospice services for nutrition at risk focus area. Pertinent interventions included to encourage extra snacks for calories. There were no additional hospice interventions listed. A review of hospice notes in the facility electronic charting system revealed the last hospice notes uploaded into the facility electronic charting system were dated 10/5/22. The hospice notes dated 10/5/22 revealed the following visit frequencies from the hospice provider:-Certified nurse aide (CNA) twice a week for 13 weeks from 9/26/22 to 12/24/22.-Registered nurse (RN) or licensed vocational nurse twice a week for 13 weeks starting 9/26/22 to 12/24/22.-Social worker twice a month for three months starting 10/4/22 and ending 12/24/22. III. Resident #103A. Resident statusResident #103, age 80, was admitted to the facility on 7/12/21. According to the January 2023 CPO, diagnoses included diabetes type two, schizophrenia, osteoarthritis, weakness, scoliosis, heart disease and high blood pressure. The 11/16/22 MDS revealed the resident was unable to complete the brief interview for mental status (BIMS). The MDS assessment revealed the resident was a one person physical assist with bed mobility, transfers, ambulating on the unit, toileting and transfers. The resident required set up help only with eating. B. Record reviewThe January 2023 CPO revealed a hospice order 11/21/22. The 12/1/22 progress note revealed the resident was admitted to hospice. A review of Resident #103's hospice binder on 1/26/23 revealed hospice visit notes were not present in the binder. A review of Resident #103's comprehensive care plan revealed a hospice care plan was not initiated by the facility. IV. InterviewsThe socialservices assistant (SSA) was interviewed on 1/26/23 at 1:50 p.m. She stated Resident #98's hospice notes were in the facility's electronic charting system. RN #1 and CNA #5 was interviewed on 1/26/23 at 1:55 p.m. RN #1 said hospice staff would usually give an update before they left the building, which was usually one of the nurse managers. RN #1 and CNA#5 stated they never signed anything from a hospice staff member after a visit (as indicated by the assistant director of wellness, see below). Assistant director of wellness (ADOW) #2 was interviewed on 1/26/23 at 4:30 p.m. She stated the hospice company for Resident #98 faxed their visit notes to the facility and they were scanned into the facility's electronic charting system through medical records. She stated medical records tracked hospice notes that have been sent for Resident #98. The ADOW#2 stated she was unsure if Resident #98's notes were in the facility's electronic charting system but that they could be faxed over immediately. ADOW #2 stated she had a link to access Resident #103's hospice notes electronically. ADOW #2 said hospice staff checked in with her as well as a floor nurse or a CNA. She said the hospice staff had a hand held device the facility staff signed after hospice staff completed a visit. The ADOW acknowledged having the hospice information for the residents was important to ensure collaboration in care. V. Facility follow-upPrinted hospice notes for Resident #103 were provided by ADOW #2 on 1/26/23 at 3:00 p.m. which was during the survey. The notes were for visits dated 1/16/23, 1/17/23, 1/19/23 and 1/23/23. Resident #98's printed hospice notes were provided by ADOW #2 on 1/30/23 for visits from 10/5/22 to 12/21/22. The notes were faxed to the facility on 1/30/23 at 9:36 a.m.which was during the survey.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life, freedom from abuse, quality of care and infection control. Findings include:I. Facility policyThe Quality Assurance and Performance Improvement (QAPI) Plan, last revised on 7/1/14, was received from the assistant nursing home administrator (ANHA) on 1/30/23 at 5:00 p.m. The policy read in pertinent part, "The facility utilizes a standardized agenda that includes services provided by all departments. The team reviews data ongoing and identifies opportunities for improvement. The team meets monthly and team members include, Administrator, Director of Nursing, Medical Director and representation from each department, as well as regional consultants who participate as active members of the this team."II. Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies and initiate a plan to correctF600 Free from abuseDuring an abbreviated survey on 3/29/21 F600 (Free from abuse) was cited at a "G" harm level. During the recertification survey on 9/30/21 F600 (Free from abuse) was cited at a "D" level. During the recertification survey on 1/30/23, the facility was cited at a "D" level. F880 Infection ControlDuring an infection control survey on 7/14/2020 F880 (infection control) was cited at a "F" level. During the recertification survey on 1/30/23, the facility was cited at an increase of scope and severity for abuse at a "K" (immediate jeopardy) level. III. Cross-referenced citationsCross-reference F689 accident hazard: The facility failed to ensure residents were safe from falls. IV. InterviewThe assistant nursing home administrator (ANHA) was interviewed on 1/30/23 at 5:50 p.m. The ANHA said the QAPI committee met monthly with the interdisciplinary team (IDT) and the medical director in attendance. The ANHA said the meeting had an agenda. She said the agenda changed monthly. The ANHA said the IDT met daily to discuss any issues from the previous night, and answer the "five whys" in order to determine a root cause (an iterative interrogative technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question "Why?" five times). The QAPI looked for trends and then root causes and then put a performance improvement plan in place. The ANHA said infection control was discussed monthly. She said that handwashing had been discussed, but she was not sure where the system had broken with continued issues of hands not being washed properly. The AHNA said abuse allegations were discussed in QAPI and information about the investigation. She said they provide a lot of education, however, the facility had resident to resident altercations. She said she did not have a root cause for the abuse between residents and staff. The falls were discussed in a fall committee and also daily when falls occur. She said the two residents identified during the survey had a history of poor bone health. She said interventions were put into place when a resident fell. The AHNA said overall she believed the facility had a good QAPI program, however, she did recognize communication between all staff was an area needed for improvement.

Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations and interviews revealed the nursing staff lacked knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs. The facility's failure to monitor the blood glucose meters (glucometer) according to standard practice, coupled with the staff's lack of knowledge to ensure blood glucose meters were cleaned, sanitized, and stored properly in between each residents' use created the situation for serious harm likely to occur at a level of immediate jeopardy if the blood glucose meters continued to be shared among residents due to potential transmission of blood-borne pathogens. One resident who shared the glucometer with another had a diagnosis of chronic viral hepatitis C. In addition, the staff failed to perform hand hygiene when cleaning resident rooms. Findings include: I. Immediate JeopardyA. Findings of Immediate Jeopardy Blood glucose metersThe facility had two blood glucose meters, which were shared among three residents who required routine blood sugar checks. This included one resident who had a diagnosis of chronic viral hepatitis C. The Infection Control Program overview last updated 1/1/22 facility's policy and procedure documented to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current standards of practice. ObservationDuring an observation on 1/24/23 beginning at 3:50 p.m. and ending at 4:03 p.m. the following was observed:-At 3:50 p.m. registered nurse (RN) #1 took gloves out of her pocket and entered room 305 with the glucometer. -At 3:51 p.m. RN #1 left room 305 with the glucometer. She took more gloves out of her pocket and placed a pile of them on the medication cart. She put gloves on both hands without performing hand hygiene. She opened the container of test strips. She took the glove off her left hand and reached into her pocket to obtain her keys with her left hand. She then opened the medication cart. She then put on another glove that was sitting on top of the medication cart back on her left hand. She put her keys back in her pocket. She opened the cart and closed the cart again. She picked up the glucometer. She knocked on room 305's door and entered the room. She did not perform hand hygiene or take the gloves off prior to entering the room. -At 3:54 p.m. RN #1 came out of room 305 with gloves on and the glucometer in hand. She took her gloves off and disposed of them in the trash can. She did not perform hand hygiene. She opened her computer. -At 3:55 p.m. RN #1 crossed her arms across her body. -At 3:56 p.m. RN #1 reopened the cart and began looking in the cart. She put another pair of gloves on without performing hand hygiene. She obtained a bottle of insulin solution and a syringe put the needle into a bottle of insulin and filled it. She closed the cart and went into room 305. -At 3:58 p.m. RN #1 exited room 305 and disposed of the used insulin syringe. She picked up the pile of gloves that remained on the medication cart and disposed of them in the trash can. She did not perform hand hygiene. She placed the glucometer in a black pouch without sanitizing it and entered room 304. She exited room 304.-At 4:00 p.m. RN #1 opened the cart and put the keys in her pocket. She obtained more glucometer test strips.-At 4:01 p.m. RN #1 put the test strip in the glucometer.-At 4:02 p.m. RN #1 assisted a resident move by touching their wheelchair. She then entered room 305. InterviewsRegistered nurse (RN) #1 was interviewed on 1/24/23 at approximately 4:15 p.m. RN #1 who was working on the East cart said she had three residents who had to have their blood sugars checked. She said she only had two glucometers. She confirmed that she had tested two residents with one meter. She said she cleaned the meter with an alcohol swab after the first resident. She said she then cleaned it again with alcohol after the second blood check. The two glucometers were stored in their own bag, with a name on them. -However, observations of the blood glucose meters revealed they were not labeled. The assistant director of wellness (ADOW) was interviewed on 1/24/23 at approximately 4:15 p.m. The ADOW said the glucometers were not to be shared. She said the meters were meant to be individual and labeled with each resident name. She said when the meters were used they were to be cleaned with a purple top sani-wipe. She said then the glucometer needed to stay wet for two minutes since that was the surface disinfectant time. RN #2 was interviewed on 1/24/23 at 4:21 p.m. She stated there were three glucometers on the Pinion unit for three residents and she used alcohol wipes to clean the glucometers. She stated there was one glucometer that was specifically used for one resident but it was not labeled. All glucometers were observed stored together in the medication cart. They were not in individual bags or labeled with a resident's name and were touching each other in the cart. LPN #1 was interviewed on 1/24/23 at 4:28 p.m. She worked on unit 200. She stated she had two glucometers on her cart for two residents. She stated she was unsure what kind of cleaning wipes were used for the glucometers as she had used the last of the wipes and went to central supply for more. She returned with super sani cloth disinfecting wipes. LPN #5 was interviewed on 1/24/23 at approximately 4:30 p.m. She worked on the Juniper West cart. She said she had three residents who required blood sugar checks, but only had two meters. The meters were stored without individual bags, and were not labeled. The LPN said she used an alcohol pad to clean the meters in between residents. RN #1 was interviewed a second time on 1/24/23 at approximately 5:00 p.m. RN #1 said that when she took the resident's blood sugar with the glucometer, she did not pick and choose which one to use. She said that she just picked one of the glucometers. Facility policy and procedure The Infection Control Program Overview, revised on 1/1/22, was received on 1/24/23 from the assistant nursing home administrator. The policy read in pertinent part, "Indirect transmission the transfer of an infectious agent through a contaminated inanimate object. The following are examples of opportunities for indirect contact. -Resident care devices (electronic thermometers or glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared without cleaning and disinfecting between uses for different residents. Reducing and/or preventing infections through indirect contact requires the decontamination (cleaning, sanitizing, or disinfecting of an object to render it safe for handling) of resident equipment, medical devices, and the environment."B. Facility notice of immediate jeopardy On 1/25/23 at 12:15 p.m. the nursing home administrator (NHA) was notified of the immediate jeopardy. C. Facility plan to remove immediate jeopardy On 1/25/23 at 2:00 p.m., the NHA provided a plan to remove the immediate jeopardy. The plan read:"Every resident requiring a glucometer has their own rather than sharing. This is a standard of practice to prevent exposure to bloodborne pathogens. No sharing of glucometers is permitted. After use of a glucometer, the device will be cleaned and disinfected after every use per manufacturer's instructions for cleaning and disinfecting are as follows:Glucometer Cleaning instructions Cleaning/Disinfecting equipment:-Perform hand hygiene before handling the meter, then don gloves.-Use Super Sani-Cloth Germicidal Disposable Wipes to wipe down Glucometer, then allow 2-minute wet (dwell) time (to allow for proper disinfection). -Make sure the meter is off and a test strip is not inserted. Wipe the outside of the meter thoroughly with a fresh Super Sani-Cloth wipe. Discard wipe. Using a new Super (sic) Sani-Cloth wipe, rub the entire outside of the meter using 3 circular wiping motions with (sic) moderate pressure on the front, back , left side, right side, top and bottom of the meter. Repeat as needed until all surfaces are visibly clean. Discard used wipes. Ensure that the outside of the meter stays wet for 2-minutes. NEVER put the meter in liquids or allow any liquids to enter the test port. Let meter air dry thoroughly before using it to test. Properly dispose of gloves and wipes after cleaning. Wash hands thoroughly after removing gloves. -This will be performed after each use of a glucometer.-Disinfection will also be performed and documented each night on the third shift along with the Quality Control check. (The two residents) will be tested on 1/25/23 for exposure to bloodborne pathogens, specifically Hepatitis C.A par level of ten (10) extra glucometers will be always maintained by central supply staff or designee in addition to the individual glucometers assigned to those residents with current physician orders. Every glucometer will be labeled with the resident's name clearly identified. Each glucometer will be placed in its own bag, also clearly identified with the resident's name. All nurses have been in service with repeat demonstration technique on 1/25/23 on proper cleaning and disinfecting procedures for glucometers. Agency nurses, new and/ or rehired nurses and vacation/absent nurses will be in service with repeat demonstration technique prior to working their shift. An extra glucometer will be retained in each nurse's cart in the event a resident's glucometer malfunctions. The nurse will notify central supply and/or designee for a replacement of the extra. Upon death and/or discharge, the resident's glucometer will be disposed of and not reassigned. The ADOW's assignee to (sic) the specific units will verify in writing every seven (7) days to ensure that every resident requiring a glucometer has their own. ADOW's will complete random visual performance checks on staff to ensure proper cleaning and disinfection of the glucometers. These checks will be documented on the glucometer cleaning form. These visual checks will be conducted daily for 30 calendar days then monthly thereafter. All findings of identification of concerns of witnessed cleaning procedure will be corrected and reported to the Quality Assurance Committee Meeting monthly for three (3) months then quarterly thereafter." D. Removal of immediate jeopardyThe facility's plan to remove immediate jeopardy was accepted on 1/25/23 at 5:00 p.m. Record review and observations revealed the facility had not implemented their policy and procedure for blood glucose meter cleaning. They provided new blood glucose meters for each resident. The ADOW said they had to replace five meters. However, deficient practice remained at an E scope and severity, a pattern with the potential for more than minimal harm. II. Failure to ensure blood glucose meters were cleaned, stored, and sanitized in a manner consistent with standards of practice. A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Injection Safety, InfectionPrevention during Blood Glucose Monitoring and Insulin Administration, retrieved fromhttps://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (2/5/23): "The CDC has become increasingly concerned about the risks for transmitting hepatitis B virus(HBV) and other infectious diseases during assisted blood glucose monitoring and insulinadministration. CDC is alerting all persons who assist others with blood glucose monitoringand/or insulin administration of the following infection control requirements: Finger stick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Meters requiring preloading of the test strip may come in direct or close contact with the resident's finger stick wound. Subsequent residents can be exposed when the meter is used on them. Staff hands can become contaminated with blood that is transferred to the meter when they obtain the reading. Blood remaining on the meter can be transferred to subsequent residents through staff hands when they perform the next procedure."According to the CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, obtained from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#anchor_1556215485 on 1/25/23, "Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over of blood and infectious agents."B. Manufacturer instructionsThe McKesson True Metrix blood glucose meter manufacturer cleaning recommendations were retrieved from:https://imgcdn.mckesson.com/CumulusWeb/Click_and_learn/TMX-Pro-CleaningGuide-v6.pdf on 1/25/23, read in pertinent part, "Always wash hands and wear gloves when performing blood glucose testing, and when cleaning and disinfecting the meter; contact with blood presents a potential infection riskTo Clean: Make sure the meter is off and a test strip is not inserted. Wipe the outside of the meter thoroughly with a fresh Super Sani-Cloth Wipe. Discard wipe. Using a new Super Sani-Cloth wipe, rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter. Repeat as needed until all surfaces are visibly clean. Discard used wipes. To Disinfect: Using fresh wipes, ensure that the outside surfaces of the meter stays wet for 2 minutes. NEVER put meter in liquids or allow any liquids to enter the test portLet the meter thoroughly air dry before using it to test. Properly dispose of gloves and wipes after cleaning. Wash hands after removing gloves."B. Facility cleaning product after immediate jeopardy The facility used a product by PDI manufacturer, Super Sani-Cloth germicidal disposable wipes, to clean all blood glucose meter devices after the immediate jeopardy. The wipe required a two minute surface disinfectant time and was documented to be effective against non-enveloped viruses, bacteria, tuberculosis, fungi, multidrug resistant organisms and blood borne pathogens. The ADOW was interviewed on 1/24/23 at approximately 2:00 p.m The ADOW said new glucometers were replaced for five residents who required blood sugar monitoring. The glucometer would then be disposed of upon discharge. III. Additional interviewsThe medical director (MD) was interviewed on 1/25/23 at approximately 2:00 p.m. The MD said she was notified the facility received an immediate jeopardy for not cleaning the glucometers correctly. She said although the facility did not clean the glucometer correctly, she did not agree that it was an immediate jeopardy situation. She said the blood borne infection could not be transmitted through the glucometer unless there was a significant amount of blood. She said it could be transferred through the lancet. She said that alcohol was acceptable to clean the glucometer meter. She said hepatitis C was not an airborne disease. The MD said the building had issues acquiring the correct disinfecting wipes due to personal protective equipment shortagesThe nursing home administrator (NHA) was interviewed on 1/25/23 at 4:00 p.m The NHA said the building had no issues with any PPE shortages in the previous 90 days. IV. Hand hygiene failures while cleaning resident roomsA. Professional referenceThe Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last reviewed 1/30/2020, retrieved on 2/2/23 from https://www.cdc.gov/handhygiene/providers/guideline.html included the following recommendations, in pertinent part for hand hygiene, "Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal."B. Facility policy and procedure The Infection Control Program Overview policy dated 1/1/22 was provided by the assistant nursing home administrator (ANHA) on 1/24/23 at 2:09 p.m. and read in pertinent parts, "Associates will wash their hands before and after contact with a resident; after cleaning a room, after handling waste or linen, after using the bathroom, before and after serving in the dining room, any time hands have possibly become contaminated, before and after applying gloves. Waterless hand cleanser, ABHR, will be provided to associates when handwashing facilities are not readily available. The cleanser may not be used more than three times in a row without washing hands. C. ObservationOn 1/30/23 beginning at 10:02 a.m. a continuous observation of housekeeping services was made outside rooms #312 and #314. -At 9:53 a.m. in room #312, housekeeping associate (HA) #1 finished cleaning the resident room. She did remove her gloves and performed hand hygiene with ABHR, however it was for only six seconds, and put on new gloves.-At 10:05 a.m. HA#1 knocked on the room #314's door. HA#1 entered the room and picked up oxygen tubing off the floor and placed it on the resident's bed.-At 10:07 a.m. HA#1 wiped down the entire toilet in the bathroom, including the tank, seat and base. She did not perform hand hygiene and then changed the hand towels and soap over the hand sink. -At 10:09 a.m. HA#1 removed her gloves and performed hand hygiene with ABHR, however it was only for seven seconds, and then donned a new pair of gloves. D. Staff interviewsHA #1 was interviewed on 1/30/23 at 10:35 a.m. She said she should change her gloves when they were contaminated. The NHA was interviewed on 1/30/23 at 4:00 p.m. The NHA said ABHR should be utilized after every resident interaction and when gloves were contaminated. The process was to use ABHR to cover their hands and wrists until it was dry, and the ABHR took 20 to 30 seconds to dry. She said she did hand hygiene audits to monitor if staff performed hand hygiene correctly.

Based on record review and staff interviews, the facility failed document the resident either received the pneumococcal immunization or did not receive pneumococcal immunization due to medical contraindication or refusal for four (#74, #6, #81 and #57) of five residents reviewed for immunizations out of 41 sample residents. Specifically, the facility failed to offer and provide the Pneumococcal Conjugate Vaccine (PCV15 or PCV20) to Residents #74, #6, #81 and #57. Findings Include:I. Professional StandardThe Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2022, retrieved on 2/2/23 from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf on 2/1/23, read in pertinent part, "Age 19-64 with certain underlying medical conditions or risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition. Age 65 years or older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition. Underlying medical conditions or other risk factors include chronic lung/liver/heart disease."II. Facility policyThe pneumococcal vaccine policy was requested upon for the recertification survey and resident vaccination and refusal policy was requested on 1/25/23. III. Resident census and conditionsThe resident census and condition document dated 1/23/23 showed a resident census of 124. Thirty-nine residents received the pneumococcal out of the 124 residents. IV. Resident #74A. Resident statusResient #74, age under 65 years old, was admitted on 8/30/22. According to the January 2023 computerized physician orders (CPO), diagnoses include bipolar disorder, multiple sclerosis, chronic obstructive pulmonary disease (COPD), anxiety, high blood pressure, asthma and depression. The minimum data set (MDS) dated 12/6/22 showed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required one person assistance for eating and ambulating on the unit, and two person assistance for dressing, hygiene and bathing. The MDS assessment revealed the resident's pneumococcal vaccine was not up to date and the resident was not eligible-medical contraindication. B. Record reviewThe immunization report did not include documentation that the resident received or did not receive the pneumococcal vaccine. The resident service agreement pneumococcal immunization informed consent was signed by Resident #74 on 8/29/22 and was marked indicating the resident wanted the pneumococcal immunization. V. Resident #6A. Resident statusResient #6, age 76, was admitted on 7/24/2020. According to the January 2023 CPO, diagnoses include diabetes, schizophrenia and weakness. The MDS dated 1/24/23 revealed Resident #6 had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required set up help only for bed mobility, transfers, walking and eating and she was a two person transfer for toileting. The MDS assessment revealed the resident's pneumococcal vaccine was not up to date and it was not offered to the resident. B. Record reviewThe immunization report did not include documentation that the resident received or did not receive the pneumococcal vaccine. The resident service agreement pneumococcal immunization informed consent revealed a "verbal consent from guardian" was written in place of the resident's name on 7/23/2020. The guardian's name or residents name was not written on the consent form. The consent form was marked indicating the resident wanted the pneumococcal immunization. VI. Resident #81A. Resident statusResient #81, age 65, was admitted on 5/21/21. According to the January 2023 CPO, diagnoses include schizophrenia, traumatic brain injury, high blood pressure and cellulitis (skin infection). The MDS dated 12/16/22 revealed Resident #81 had moderate cognitive impairment with a BIMS score of 12 out of 15. He needed set up assistance only at meals and was otherwise independent. The MDS assessment revealed the resident's pneumococcal vaccine was not up to date and the resident declined the vaccine. B. Record reviewThe immunization report did not include documentation that the resident received or refused the pneumococcal vaccine. The resident service agreement pneumococcal immunization informed consent signed by Resident #81 revealed he consented to receiving the pneumococcal vaccine on 11/27/18. VII. Resident #57A. Resident statusResient #57, age 73, was admitted on 10/19/22. According to the January 2023 CPO, included schizophrenia, diabetes mellitus type two, arthritis, high blood pressure and dementia. The MDS dated 1/23/23 revealed the resident was unable to complete the brief interview for mental status (BIMS). He required assistance of one person for activities of daily living (ADLs) as well as locomotion on the unit, and was a two person assist for transfers. The MDS assessment indicated walking in the resident's room or on the unit did not occur. The MDS assessment revealed the resident's pneumococcal vaccine was not up to date and was not offered to the resident. B. Record reviewThe immunization report did not include documentation that the resident received or did not receive the pneumococcal vaccine. The resident service agreement pneumococcal immunization informed consent signed by Resident #57 revealed he consented to receiving the pneumococcal vaccine on 8/29/22. VIII. InterviewsThe nursing home administrator (NHA) was interviewed on 1/30/23 at 4:00 p.m. She stated the residents' pneumococcal vaccine consent and refusal was in the resident agreement and should be signed at the time of admission. The assistant director of wellness (ADOW) was interviewed on 1/30/23 at 4:17 p.m. She stated the pneumococcal vaccine would be requested from a pharmacy and was handled by the director of wellness (DOW). There was not a time frame for a resident to receive the vaccine that she was aware of and the staff at the building had been more focused on COVID-19. The assistant director of wellness (ADOW) #1 was interviewed on 1/30/23 at 4:27 p.m. She stated the pneumococcal immunization was recommended for people over a certain age but there was not a time frame for receiving the immunization.

A licensure survey was completed on 1/23/23 to 1/30/23. Two deficiencies were cited.

Based on observations, record review and interviews the facility failed to prevent multiple falls with injury for two (#17 and #57) of two residents reviewed out of 41 sample residents. Resident #17 had a diagnosis of dementia, repeated falls, unsteadiness on feet, unspecified fracture of left arm. The facility failed to develop a person centered plan of care to promote safety and prevent repeated falls. Resident #17 had falls on 8/18/22, on 9/9/22 (had a 0.5 centimeter by 1 centimeter laceration was noted on the lower left leg), on 9/26/22; and on 11/11/22. Resident #17 had a laceration after she fell on 11/11/22 to her left front forearm, emergency medical services (EMS) were called and the resident was taken to the hospital. Hospital documentation revealed Resident #17 suffered a displaced fracture of the humerus (arm bone, see record review below). A person centered approach was not implemented until Resident #17 suffered a fracture on 11/11/22 (see record review below). A fall occurred on 11/21/22, a large bruise was noted to Resident #17's sacrum. A fall occurred on 11/22/22 and an abrasion was noted to Resident #17's sacrum. In addition, the facility failed to complete neurological checks for unwitnessed falls for Resident #17. Resident #57 was at high risk for falling related to confusion, deconditioning, poor communication and comprehension, and was unaware of safety needs. On 12/22/22 the resident was found on the floor. Subsequent to the fall, the resident was sent to the hospital on 12/23/22 and treated for a fractured hip and required surgery. The facility failed to implement effective interventions with his known fall risk and after the fall with injury on 12/22/22. Findings include:I. Facility policyThe Fall policy, revised 11/12/10, was received from medical records (MR) on 1/30/23 at 5:00 p.m It read in pertinent part:"Community residents will have a fall evaluation and prevention plan. Based on previous evaluations and current data along with the attending physician, therapy staff and others, the facility will seek to identify resident risk factors for falls and will document those risk factors in the residents medical record."Fall risk evaluations and a plan of care are completed upon admission. Approaches related to fall management are documented in the care plan and progress notes. Community staff are trained regarding fall prevention techniques. "Education is provided to the resident, family, and staff regarding the fall risk and the fall care plan. When a resident falls complete the following documentation:-Incident report;-Wellness notes;-Post accident investigation; -Intervention; and,-24 hour report."II. Resident #17A. Resident statusResident #17, age 62, was admitted on 9/8/07 and re-admitted on 11/14/22. According to the January 2023 computerized physicians orders (CPO), diagnoses included non traumatic subdural hemorrhage (head trauma), alcohol abuse, lack of coordination, repeated falls, and fracture of left arm. The 11/14/2022 facility assessment was reviewed and revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision with bed mobility and transfers. She required supervision with toilet use, walking and was able to stabilize with human assistance and the use of her walker. B. ObservationsResident #17 was observed on 1/24/23 at 3:15 p.m. She was walking around the unit with her walker and was unsteady on her feet. The tennis shoes she was wearing were flopping up and down as she walked as if they were too big for her feet. The resident was thin and frail and took small steps as she walked. She wore a protective helmet while walking outside of her room. C. Resident interviewResident #17 was interviewed on 1/24/23 at 10:00 a.m. The resident said she had fallen quite a few times since being admitted to the facility. She said the worst fall was when she fractured her left arm on 11/11/22. She said that was a very painful experience for her. Resident #17 said she should use her walker to help her stay safe, but she just could not remember to always use it. She said on 11/11/22 she got up from the bed and walked to the bathroom. She said she was walking barefoot in her room, she slipped on something in her room and fell to the floor. She said she complained of pain to her left arm when she tried to get up from the floor with assistance from the staff. She was assisted to a chair while staff called emergency services and was taken to the emergency room. She said she had surgery to repair the fracture to her left arm. D. Record reviewThe resident had fallen on 8/18/22, 9/9/22, 9/26/22, 11/11/22, 11/21/22 and 11/22/22. The falls were not listed in the care plan. The care plan included the following interventions: call light within reach at all times (1/30/14) and staff to assist with transfers and mobility and frequent checks. The care plan, initiated 11/11/19 and revised on 10/11/22 revealed the resident was at a moderate risk for falls with gait and balance problems. Interventions listed for falls: -Follow facility fall protocol, date initiated 10/11/22; and,-Physical therapy to evaluate and treat as ordered, date initiated 11/11/22. IncidentsThe 8/18/22 incident report revealed the following:The certified nurse aide (CNA) notified the nurse that the resident fell on her side at 8:10 a.m. when she went to pick up a pen that had fallen on the floor of the smoking area. The resident's vital signs were normal, she did not have any wounds, and the resident denied any pain. The resident was advised to continue using her walker.-There were no post injury assessments for this fall or an interdisciplinary team (IDT) assessment/review. The 9/9/22 incident report revealed the following:The resident was found in the sitting position on the floor of her room at 9:50 a.m. The resident had a 0.5 centimeter by 1 centimeter laceration on her left leg. She said she was making her way to the restroom and lost her balance and fell. The resident did not use her walker. Resident #17 denied any pain. -There were no post injury interventions for this fall or an IDT assessment/review. The 9/26/22 incident report at 8:54 a.m. revealed the following:Licensed practical nurse (LPN) #1 said she saw the resident tip to the right in a chair and landed on her right side in the dining room. The resident said she tried to sit on the arm of the chair and it tipped over. No injuries were noted. The resident did not use her walker. The resident experienced three or more falls in the last three months. The resident had a balance problem with walking or standing. She experienced decreased muscle coordination. The post fall assessment for this fall 9/26/22 included: The resident was disoriented times three, had three or more falls in the past 30 days, balance problems with standing or walking, and was not incontinent.-There were no post injury interventions for this fall or an IDT assessment/review. The incident report on 11/11/22 at 9:50 a.m. revealed the following:A resident went to the front desk and told the nurse Resident #17 had fallen. Resident #17 was found in her room on the floor by her dresser. When attempting to stand the patient up her left arm was noted to be deformed and the resident was complaining of severe pain. The resident said she slipped and fell in her room. The resident refused to stand all the way up while complaining of pain in her left arm. The emergency medical services (EMS) were called and the resident was taken to the emergency room. Resident #17 experienced decreased safety awareness and did not use a walker as instructed. Hospital notes dated 11/11/22 indicated:Resident #17 was admitted to the emergency room on 11/11/22 at 6:00 p.m. The diagnosis was a displaced fracture of the left humerus (forearm) along with recommendation for surgery. No discharge instructions for the resident were given. The resident was recommended for physical and occupational therapy. Occupational therapy notes, dated 11/14/22 indicated the goals for the resident were bed mobility goals for modified independence, time frame one to three weeks. Toilet transfer goal given the time frame of two to three weeks. Physical therapy goal for the resident for modified independence in the time frame of two to three weeks. Upper and lower body dressing goal (modified) one to three weeks. The resident was discharged back to the facility on 11/14/22. Progress notes 1/22/22 at 12:03 p.m. Resident #17 was moved to another room next to the nurse's station. Incident note: 1/22/22 at 2:30 p.m. Resident #17 self reported a fall. She said she was attempting to use the bathroom when she slid off the toilet and landed on her coccyx (sacrum). She said she scooted across the floor on her bare bottom to get to a call light to call for help. This fall occurred after the resident was moved next to the nurses station for her safety. Post fall assessment for 1/23/22:The fall was not witnessed. The resident was observed on the floor. The resident was not incontinent and the floor was not wet. The call light was not on and within reach. The resident hit her head when she fell. The neuro checks were not completed. The resident had four falls in the last 30 days. Interventions added were increased safety checks, and assigned to fall prevention programs. These interventions were not added to the resident's care plan. The neurological checks for Resident #17 were requested from the assistant director of nursing (ADON) on 1/26/23 at 2:00 p.m. they were not provided by the end of the survey on 1/30/23. E. Interviews The ADON was interviewed on 1/24/23 at 2:00 p.m. She said Resident #17 had multiple falls since admission. She said the following interventions were in the care plan: the call light was within reach, the resident should be using her walker when out of bed and wear the proper type of shoes that fit properly, with anti-skid protection on the bottom. She said any fall intervention should always be listed in the resident's care plan. The only intervention found from the list in the care plan was the call light within reach. LPN #1 was interviewed on 1/25/23 at 4:55 p.m. She said Resident #17 wore a helmet to protect her head if she had a seizure while she was walking. She said the resident was often unsafe when she walked and unsteady on her feet. CNA #3 was interviewed on 1/30/23 at 10:00 a.m. She said Resident #17 did not fall in the day time, but usually at night time. She said she thought there was not enough staff to care for the residents on the evening shifts so therefore the residents were not watched close enough to prevent accidents. She said one intervention put into place was to move the resident closer to the nurse station. She said one intervention was to have the call light within reach (2014). CNA #3 said although the call light was within reach (2014), the resident would hardly ever use it until after a fall had taken place. CNA #2 was interviewed on 1/30/23 at 10:30 a.m. She said she was not working the day that Resident #17 fell and broke her arm, but there were many times when the resident would not use her walker, especially in her room and that had caused accidents to happen. Resident #17 visited her husband on the first floor for lunch every day. She said the resident was escorted by the staff to the first floor because she was too weak and frail to walk by herself. LPN #4 was interviewed on 1/30/23 at 4:30 p.m. She said Resident #17 had multiple falls since she was admitted to the facility. She said the resident would not listen to any education that staff provided to her about safety when ambulating. She said most of her falls occurred in her room because she did not use her walker. She said the resident believed she could walk without the walker. LPN #4 said the resident was moved closer to the nurses station for safety, but she still kept falling. The IDT notes for these specific falls were asked for but not provided. III. Resident #57A. Resident statusResident #57, age 72, was admitted on 10/19/22. According to the January 2023 computerized physician orders (CPO) the diagnoses included schizophrenia, diabetes mellitus type two, arthritis, high blood pressure and dementia. The 1/23/23 facility assessment revealed the resident was unable to complete the brief interview for mental status (BIMS). He required assistance of one person for activities of daily living (ADLs) as well as locomotion on the unit, and was a two person assist for transfers. The facility assessment indicated walking in the resident's room or on the unit did not occur. B. ObservationsOn 1/23/23 at 4:04 p.m. Resident #57 was observed lying in bed. His bed was not in a low position and there was no fall mat by his bed. The fall mat was folded in a small closet area in the resident's room. On 1/24/23 at 2:00 p.m. Resident #57 was observed lying in bed. His bed was not in a low position and there was no fall mat by his bed. The fall mat was folded in a small closet area in the resident's room. On 1/30/23 at 9:38 a.m. Resident #57 was observed lying in bed. His bed was not in a low position and there was no fall mat by his bed. The fall mat was folded in a small closet area in the resident's room. C. Record reviewThe care plan focus initiated 10/31/22 revealed Resident #57 was at high risk for falls related to confusion, deconditioning, poor communication and comprehension, and was unaware of safety needs. The goal was for Resident #57 to be free of injury through the review date of 4/11/23. Interventions included family/caregivers about safety reminders and what to do if a fall occurs, and staff will anticipate and meet Resident #57's needs. The progress note dated 12/22/22 at 11:13 p.m. revealed Resident #57 was found on the floor unable to relate the events of his fall. No visible injury was observed at that time. The progress note dated 12/23/22 at 10:10 a.m. revealed the resident's right thigh appeared swollen and and the resident appeared to be in pain when right thigh was touched. The progress note dated 12/23/22 at 1:40 p.m. revealed the resident was sent to the hospital at 1:25 p.m. for further evaluation of his right hip. -The resident returned to the facility on 12/27/22 due to right hip fracture and surgery (see notes below). The post incident/accident investigation dated 12/24/22 revealed Resident #57 was found on the floor at his bedside. The resident was unable to relate events leading to the fall. No visible injury was observed. Vital signs and neurological assessment were within normal limits. No injuries were observed at the time of the incident. The corrective actions listed were an increase in safety checks, assigned to a fall prevention program and a physician consultation. The post incident and accident investigation also revealed the care plan was reviewed and updated and a significant change in the facility assessment was required. The progress notes reviewed for Resident #57's post fall interventions revealed the following:12/27/22 at 6:29 p.m. revealed Resident #57 was transported back to the facility at 4:45 p.m. on post right hip fracture and surgery. 12/29/22 at 11:44 a.m. risk management noted a fall mat should be placed at Resident #57's bedside and his bed in the lowest position; the resident should be on frequent rounding. 1/11/23 5:33 a.m. Resident #57 was trying to transfer out of bed unsafely and staff had to redirect the resident back to bed. -The fall mat and the bed in low position were not noted to be in place. 1/14/23 4:46 a.m. Resident #57 tried to get up from bed; the call light was in reach. The fall mat and bed in low position were not noted to be in place. 1/22/23 5:45 a.m. the bed was in a low position. -The fall mat was not noted to be in place.-The care plan focus for falls was not updated to include the recommended interventions written in the 12/29/22 risk management progress note. D. InterviewsThe assistant director of wellness(ADOW) #2 was interviewed on 1/30/23 at 9:40.a.m. She stated that Resident #57 should have a fall mat but only at night. She stated the resident was starting to ambulate more and walk without supervision as his strength increased and having a mat on the floor during the day was a trip hazard for him.

Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations and interviews revealed the nursing staff lacked knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs. The facility's failure to monitor the blood glucose meters (glucometer) according to standard practice, coupled with the staff's lack of knowledge to ensure blood glucose meters were cleaned, sanitized, and stored properly in between each residents' use created the situation for serious harm likely to occur if the blood glucose meters continued to be shared among residents due to potential transmission of blood-borne pathogens. One resident who shared the glucometer with another had a diagnosis of chronic viral hepatitis C. In addition, the staff failed to perform hand hygiene when cleaning resident rooms. Findings include: I. Failures with resident blood glucose meters Blood glucose metersThe facility had two blood glucose meters, which were shared among three residents who required routine blood sugar checks. This included one resident who had a diagnosis of chronic viral hepatitis C. The Infection Control Program overview last updated 1/1/22 facility's policy and procedure documented to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current standards of practice. ObservationDuring an observation on 1/24/23 beginning at 3:50 p.m. and ending at 4:03 p.m. the following was observed:-At 3:50 p.m. registered nurse (RN) #1 took gloves out of her pocket and entered room 305 with the glucometer. -At 3:51 p.m. RN #1 left room 305 with the glucometer. She took more gloves out of her pocket and placed a pile of them on the medication cart. She put gloves on both hands without performing hand hygiene. She opened the container of test strips. She took the glove off her left hand and reached into her pocket to obtain her keys with her left hand. She then opened the medication cart. She then put on another glove that was sitting on top of the medication cart back on her left hand. She put her keys back in her pocket. She opened the cart and closed the cart again. She picked up the glucometer. She knocked on room 305's door and entered the room. She did not perform hand hygiene or take the gloves off prior to entering the room. -At 3:54 p.m. RN #1 came out of room 305 with gloves on and the glucometer in hand. She took her gloves off and disposed of them in the trash can. She did not perform hand hygiene. She opened her computer. -At 3:55 p.m. RN #1 crossed her arms across her body. -At 3:56 p.m. RN #1 reopened the cart and began looking in the cart. She put another pair of gloves on without performing hand hygiene. She obtained a bottle of insulin solution and a syringe put the needle into a bottle of insulin and filled it. She closed the cart and went into room 305. -At 3:58 p.m. RN #1 exited room 305 and disposed of the used insulin syringe. She picked up the pile of gloves that remained on the medication cart and disposed of them in the trash can. She did not perform hand hygiene. She placed the glucometer in a black pouch without sanitizing it and entered room 304. She exited room 304.-At 4:00 p.m. RN #1 opened the cart and put the keys in her pocket. She obtained more glucometer test strips.-At 4:01 p.m. RN #1 put the test strip in the glucometer.-At 4:02 p.m. RN #1 assisted a resident move by touching their wheelchair. She then entered room 305. InterviewsRegistered nurse (RN) #1 was interviewed on 1/24/23 at approximately 4:15 p.m. RN #1 who was working on the East cart said she had three residents who had to have their blood sugars checked. She said she only had two glucometers. She confirmed that she had tested two residents with one meter. She said she cleaned the meter with an alcohol swab after the first resident. She said she then cleaned it again with alcohol after the second blood check. The two glucometers were stored in their own bag, with a name on them. -However, observations of the blood glucose meters revealed they were not labeled. The assistant director of wellness (ADOW) was interviewed on 1/24/23 at approximately 4:15 p.m. The ADOW said the glucometers were not to be shared. She said the meters were meant to be individual and labeled with each resident name. She said when the meters were used they were to be cleaned with a purple top sani-wipe. She said then the glucometer needed to stay wet for two minutes since that was the surface disinfectant time. RN #2 was interviewed on 1/24/23 at 4:21 p.m. She stated there were three glucometers on the Pinion unit for three residents and she used alcohol wipes to clean the glucometers. She stated there was one glucometer that was specifically used for one resident but it was not labeled. All glucometers were observed stored together in the medication cart. They were not in individual bags or labeled with a resident's name and were touching each other in the cart. LPN #1 was interviewed on 1/24/23 at 4:28 p.m. She worked on unit 200. She stated she had two glucometers on her cart for two residents. She stated she was unsure what kind of cleaning wipes were used for the glucometers as she had used the last of the wipes and went to central supply for more. She returned with super sani cloth disinfecting wipes. LPN #5 was interviewed on 1/24/23 at approximately 4:30 p.m. She worked on the Juniper West cart. She said she had three residents who required blood sugar checks, but only had two meters. The meters were stored without individual bags, and were not labeled. The LPN said she used an alcohol pad to clean the meters in between residents. RN #1 was interviewed a second time on 1/24/23 at approximately 5:00 p.m. RN #1 said that when she took the resident's blood sugar with the glucometer, she did not pick and choose which one to use. She said that she just picked one of the glucometers. Facility policy and procedure The Infection Control Program Overview, revised on 1/1/22, was received on 1/24/23 from the assistant nursing home administrator. The policy read in pertinent part, "Indirect transmission the transfer of an infectious agent through a contaminated inanimate object. The following are examples of opportunities for indirect contact. -Resident care devices (electronic thermometers or glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared without cleaning and disinfecting between uses for different residents. Reducing and/or preventing infections through indirect contact requires the decontamination (cleaning, sanitizing, or disinfecting of an object to render it safe for handling) of resident equipment, medical devices, and the environment."B. Facility notice of failures On 1/24/23 at 12:15 p.m. the nursing home administrator (NHA) was notified of failures with the resident blood glucose meters. C. Facility plan to address failures On 1/24/23 at 2:00 p.m., the NHA provided a plan to address the facility failures: The plan read:"Every resident requiring a glucometer has their own rather than sharing. This is a standard of practice to prevent exposure to bloodborne pathogens. No sharing of glucometers is permitted. After use of a glucometer, the device will be cleaned and disinfected after every use per manufacturer's instructions for cleaning and disinfecting are as follows:Glucometer Cleaning instructions Cleaning/Disinfecting equipment:-Perform hand hygiene before handling the meter, then don gloves.-Use Super Sani-Cloth Germicidal Disposable Wipes to wipe down Glucometer, then allow 2-minute wet (dwell) time (to allow for proper disinfection). -Make sure the meter is off and a test strip is not inserted. Wipe the outside of the meter thoroughly with a fresh Super Sani-Cloth wipe. Discard wipe. Using a new Super (sic) Sani-Cloth wipe, rub the entire outside of the meter using 3 circular wiping motions with (sic) moderate pressure on the front, back , left side, right side, top and bottom of the meter. Repeat as needed until all surfaces are visibly clean. Discard used wipes. Ensure that the outside of the meter stays wet for 2-minutes. NEVER put the meter in liquids or allow any liquids to enter the test port. Let meter air dry thoroughly before using it to test. Properly dispose of gloves and wipes after cleaning. Wash hands thoroughly after removing gloves. -This will be performed after each use of a glucometer.-Disinfection will also be performed and documented each night on the third shift along with the Quality Control check. (The two residents) will be tested on 1/25/23 for exposure to bloodborne pathogens, specifically Hepatitis C.A par level of ten (10) extra glucometers will be always maintained by central supply staff or designee in addition to the individual glucometers assigned to those residents with current physician orders. Every glucometer will be labeled with the resident's name clearly identified. Each glucometer will be placed in its own bag, also clearly identified with the resident's name. All nurses have been in service with repeat demonstration technique on 1/25/23 on proper cleaning and disinfecting procedures for glucometers. Agency nurses, new and/ or rehired nurses and vacation/absent nurses will be in service with repeat demonstration technique prior to working their shift. An extra glucometer will be retained in each nurse's cart in the event a resident's glucometer malfunctions. The nurse will notify central supply and/or designee for a replacement of the extra. Upon death and/or discharge, the resident's glucometer will be disposed of and not reassigned. The ADOW's assignee to (sic) the specific units will verify in writing every seven (7) days to ensure that every resident requiring a glucometer has their own. ADOW's will complete random visual performance checks on staff to ensure proper cleaning and disinfection of the glucometers. These checks will be documented on the glucometer cleaning form. These visual checks will be conducted daily for 30 calendar days then monthly thereafter. All findings of identification of concerns of witnessed cleaning procedure will be corrected and reported to the Quality Assurance Committee Meeting monthly for three (3) months then quarterly thereafter." The facility's plan was accepted on 1/25/23 at 5:00 p.m. Record review and observations revealed the facility had not implemented their policy and procedure for blood glucose meter cleaning. They provided new blood glucose meters for each resident. The ADOW said they had to replace five meters. II. Failure to ensure blood glucose meters were cleaned, stored, and sanitized in a manner consistent with standards of practice. A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Injection Safety, InfectionPrevention during Blood Glucose Monitoring and Insulin Administration, retrieved fromhttps://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (2/5/23): "The CDC has become increasingly concerned about the risks for transmitting hepatitis B virus(HBV) and other infectious diseases during assisted blood glucose monitoring and insulinadministration. CDC is alerting all persons who assist others with blood glucose monitoringand/or insulin administration of the following infection control requirements: Finger stick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Meters requiring preloading of the test strip may come in direct or close contact with the resident's finger stick wound. Subsequent residents can be exposed when the meter is used on them. Staff hands can become contaminated with blood that is transferred to the meter when they obtain the reading. Blood remaining on the meter can be transferred to subsequent residents through staff hands when they perform the next procedure."According to the CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, obtained from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#anchor_1556215485 on 1/25/23, "Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over of blood and infectious agents."B. Manufacturer instructionsThe McKesson True Metrix blood glucose meter manufacturer cleaning recommendations were retrieved from:https://imgcdn.mckesson.com/CumulusWeb/Click_and_learn/TMX-Pro-CleaningGuide-v6.pdf on 1/25/23, read in pertinent part, "Always wash hands and wear gloves when performing blood glucose testing, and when cleaning and disinfecting the meter; contact with blood presents a potential infection riskTo Clean: Make sure the meter is off and a test strip is not inserted. Wipe the outside of the meter thoroughly with a fresh Super Sani-Cloth Wipe. Discard wipe. Using a new Super Sani-Cloth wipe, rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter. Repeat as needed until all surfaces are visibly clean. Discard used wipes. To Disinfect: Using fresh wipes, ensure that the outside surfaces of the meter stays wet for 2 minutes. NEVER put meter in liquids or allow any liquids to enter the test portLet the meter thoroughly air dry before using it to test. Properly dispose of gloves and wipes after cleaning. Wash hands after removing gloves."B. Facility cleaning product The facility used a product by PDI manufacturer, Super Sani-Cloth germicidal disposable wipes, to clean all blood glucose meter devices. The wipe required a two minute surface disinfectant time and was documented to be effective against non-enveloped viruses, bacteria, tuberculosis, fungi, multidrug resistant organisms and blood borne pathogens. The ADOW was interviewed on 1/24/23 at approximately 2:00 p.m The ADOW said new glucometers were replaced for five residents who required blood sugar monitoring. The glucometer would then be disposed of upon discharge. III. Additional interviewsThe medical director (MD) was interviewed on 1/24/23 at approximately 2:00 p.m. The MD said she was notified the facility was not cleaning the glucometers correctly. She said although the facility did not clean the glucometer correctly, she did not agree with the situation. She said the blood borne infection could not be transmitted through the glucometer unless there was a significant amount of blood. She said it could be transferred through the lancet. She said that alcohol was acceptable to clean the glucometer meter. She said hepatitis C was not an airborne disease. The MD said the building had issues acquiring the correct disinfecting wipes due to personal protective equipment shortagesThe nursing home administrator (NHA) was interviewed on 1/24/23 at 4:00 p.m The NHA said the building had no issues with any PPE shortages in the previous 90 days. IV. Hand hygiene failures while cleaning resident roomsA. Professional referenceThe Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last reviewed 1/30/2020, retrieved on 2/2/23 from https://www.cdc.gov/handhygiene/providers/guideline.html included the following recommendations, in pertinent part for hand hygiene, "Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal."B. Facility policy and procedure The Infection Control Program Overview policy dated 1/1/22 was provided by the assistant nursing home administrator (ANHA) on 1/24/23 at 2:09 p.m. and read in pertinent parts, "Associates will wash their hands before and after contact with a resident; after cleaning a room, after handling waste or linen, after using the bathroom, before and after serving in the dining room, any time hands have possibly become contaminated, before and after applying gloves. Waterless hand cleanser, ABHR, will be provided to associates when handwashing facilities are not readily available. The cleanser may not be used more than three times in a row without washing hands. C. ObservationOn 1/30/23 beginning at 10:02 a.m. a continuous observation of housekeeping services was made outside rooms #312 and #314. -At 9:53 a.m. in room #312, housekeeping associate (HA) #1 finished cleaning the resident room. She did remove her gloves and performed hand hygiene with ABHR, however it was for only six seconds, and put on new gloves.-At 10:05 a.m. HA#1 knocked on the room #314's door. HA#1 entered the room and picked up oxygen tubing off the floor and placed it on the resident's bed.-At 10:07 a.m. HA#1 wiped down the entire toilet in the bathroom, including the tank, seat and base. She did not perform hand hygiene and then changed the hand towels and soap over the hand sink. -At 10:09 a.m. HA#1 removed her gloves and performed hand hygiene with ABHR, however it was only for seven seconds, and then donned a new pair of gloves. D. Staff interviewsHA #1 was interviewed on 1/30/23 at 10:35 a.m. She said she should change her gloves when they were contaminated. The NHA was interviewed on 1/30/23 at 4:00 p.m. The NHA said ABHR should be utilized after every resident interaction and when gloves were contaminated. The process was to use ABHR to cover their hands and wrists until it was dry, and the ABHR took 20 to 30 seconds to dry. She said she did hand hygiene audits to monitor if staff performed hand hygiene correctly.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/26/2022 and 01/01/2023, 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.