LOWRY HILLS CARE AND REHABILITATION

A complaint survey, prompted by #CO39690, #CO39756 and #CO39785 was conducted on 4/21/25 to 4/22/25. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to ensure:-A clean location was provided for wound care supplies; and,-Enhanced barrier precautions (EBP) and proper hand hygiene were followed for wound care activities. Findings include:I. 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 4/23/25 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 (multidrug resistant organism) 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, tracheotomy/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 4/23/25 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."II. Facility policy and proceduresThe Clean Dressing Change policy, revised 4/21/25, was provided by the nursing home administrator (NHA) on 4/21/25 at 5:05 p.m. It read in pertinent part, "Set up clean field on the overbed table with needed supplies for wound cleaning and dressing application. If the table is soiled, wipe clean. Place a disposable cloth or linen saver on the overbed table. Establish area for soiled products to be placed."Wash hands and put on clean gloves. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. Loosen the tape and remove the existing dressing. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. Wash hands and put on gloves. Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound. Pat dry with gauze. Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered. Secure dressing. Mark with initials and date. Discard disposable items and gloves into appropriate trash receptacle and wash hands."The Enhanced Barrier Precautions policy, undated, was provided by the NHA on 4/21/25 at 5:05 p.m. The policy read in pertinent part, "Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. High contact resident activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care."III. ObservationsDuring an observation of Resident #9's wound care on 4/21/25 at 10:45 a.m., the following was observed:Certified nurse aide (CNA) #2 and CNA #3 donned (put on) gloves and assisted licensed practical nurse (LPN) #2 with repositioning Resident #9 on his side to replace a wound dressing which had fallen off the sacrum (base of spine). -However, CNA #2 and CNA #3 failed to don a gown prior to high contact care for Resident #9. During the dressing change, CNA #2 left Resident #9's bedside, took the resident's roommate's water pitcher out of the room and filled it, assisted the roommate to drink water and then returned to Resident #9 during wound care.-However, CNA #2 did not change her gloves or use hand hygiene after she provided water to the roommate. LPN #2 cleaned Resident #9's wounds and applied a new wound dressing to the sacrum and left ischium (near hip joint), and the upper shin of the left leg. LPN #2 changed her gloves four times during wound care, after wounds were cleaned and prior to application of the new dressings. -However, LPN #2 did not use hand hygiene after she removed her gloves and before applying new gloves. During an observation of Resident #3's wound care on 4/21/25 at 12:55 p.m., the following was observed:LPN #3 placed dressing change supplies on Resident #3's bedside table.-However, LPN #3 did not clean the table and create an area on the table for the wound care supplies. The supplies were placed next to a peanut butter jar and cereal bowl on the table, amongst several other personal items of Resident #3. Resident #3's wound dressing had been removed prior to wound care, as it was soiled. LPN #3 donned a gown and gloves for Resident #3's left ischium wound care. She cleaned the wound and reapplied a dressing to the wound.-However, LPN #3 did not change her gloves or perform hand hygiene throughout Resident #3's wound care, specifically when she removed several soiled four by four inch gauzes which had been used to clean the wound. During an observation of Resident #8's wound care on 4/21/25 at 1:45 p.m., the following was observed:CNA #5 donned gloves and assisted the infection preventionist (IP) with repositioning Resident #8 onto her side.-However, CNA #5 failed to don a gown prior to high contact care for Resident #8. CNA #6 later entered the room to assist during the dressing change. CNA #6 donned gloves.-However, CNA #6 failed to don a gown prior to high contact care for Resident #8. IV. Staff interviewsLPN #2 was interviewed on 4/21/25 at 12:23 p.m. LPN #2 said she changed her gloves each time after cleaning wounds and prior to applying clean dressings. LPN #2 said she changed her gloves four times during Resident #9's wound care and should have used hand hygiene when she changed her gloves each time. She said there was no hand sanitizer in the room. She said there was a sink in the room, but sometimes there were no paper towels to dry her hands. She said those were not sufficient reasons to not perform hand hygiene. LPN #2 said the use of hand hygiene would help to prevent infection. The director of nursing (DON) and the clinical resource (CR) were interviewed together on 4/21/25 at 5:16 p.m. The DON said the CNAs should have donned gowns when they repositioned residents with wounds and during wound care. The DON said a clean area for wound care supplies should be provided and the nurse should not have placed Resident #3's dressing supplies on the soiled bedside table mixed in with Resident #3's personal food items. The DON and the CR both said the nurses should have changed gloves and used hand hygiene each time they transitioned between dirty and clean, such as after cleaning the wounds. The treatment nurse (TN) was interviewed on 4/22/25 at 4:58 p.m. The TN said a gown should be worn for all wound care. The TN said she had provided education to the CNA staff which included the need to wear gowns during wound care. The TN said gloves should be changed and hand hygiene performed after touching soiled dressings and after cleaning wounds.

A revisit survey was completed on 4/9/25 for all previous deficiencies cited on 3/13/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO39166, #CO39454, Incident #39447 and Incident #39449 was conducted on 3/12/25 to 3/13/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure one (#3) of three residents were free from abuse out of seven sample residents. Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #2. Findings include:I. Facility policy and procedureThe Abuse, Neglect, and Exploitation policy, revised 1/5/25, was provided by the director of nursing (DON) on 3/13/25. It read in pertinent part,"The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect."II. Facility investigationsA. Incident of physical abuse by Resident #2 towards Resident #3 on 2/8/25 The facility's investigation documented an incident occurred on 2/8/25 between Resident #2 and Resident #3. Another resident reported to the staff that Resident #2 had pulled Resident #3's hair in the lunchroom. It was not determined the reason Resident #2 pulled Resident #3's hair. Resident #3 denied feeling unsafe and Resident #2 denied recollection of the event. Resident #2 was put on one-on-one supervision. Through the facility's investigation, they were unable to find any witnesses, as the reporting resident later stated she was not sure what she had seen. The facility unsubstantiated the abuse due to no injuries occurring and no intent to harm. The facility was unable to determine the reason the abuse occurred due to Resident #2 stating she had no recollection of her behavior or the event. B. Incident of physical abuse by Resident #2 towards Resident #3 on 2/19/25The facility's investigation documented an incident occurred on 2/19/25 between Resident #2 and Resident #3. Resident #2 and Resident #3 were in the lunchroom in line to get coffee. Resident #3 reported to the staff that Resident #2 had cut in front of him in line and he asked her to move. Resident #2 then turned around and splashed her coffee in his direction and it hit him in the face. Resident #3 denied feeling unsafe and Resident #2 denied recollection of the event. Resident #2 was put on one-on-one supervision. Through the facility's investigation, they were unable to find any witnesses and Resident #2 could not recall the event. The facility unsubstantiated the abuse due to no injuries occurring and no intent to harm. The abuse occurred as a result of Resident #3 verbalizing displeasure to Resident #2's cutting in line and Resident #2's reaction to his verbalization of displeasure. III. Resident #3 (victim)A. Resident statusResident #3, age less than 65, was admitted on 11/10/23. According to the March 2025 computerized physician orders (CPO), diagnoses included anxiety, depression, traumatic brain injury and stroke. The 1/24/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. He required staff supervision with bathing, bed mobility, dressing, eating, toileting and transfers. The resident used a wheelchair for ambulation. B. Resident interviewResident #3 was interviewed on 3/13/25 at 2:45 p.m. Resident #3 said he did not remember the incidents with Resident #2. C. Record reviewResident #3's trauma care plan, initiated 2/24/25, revealed the resident had been involved in two resident-to-resident altercations with the same resident, where Resident #3 was the victim. Interventions included encouraging Resident #3 to either move away from that resident's (Resident #2) vicinity or to notify staff to redirect the resident away from the vicinity, providing the resident with validation when he was emotionally distressed, providing active listening and notifying social services and the resident's psychologist of emotional distress. The change of condition nursing note, dated 2/8/25, revealed Resident #3 was involved in a resident-to-resident incident. Neurological checks, skin checks and vital signs were all within normal range. The physician was notified of the incident. The change of condition nursing note, dated 2/19/25, revealed Resident #3 was involved in a resident-to-resident incident. Neurological checks, skin checks and vital signs were all within normal range. The physician was notified of the incident. The alert note, dated 2/19/25, revealed Resident #3 reported to staff there was no precepting reason for the incident. Resident #3 wanted to file a police report and denied injuries or feeling unsafe. IV. Resident #2 (assailant)A. Resident statusResident #2, age less than 65, was admitted on 8/4/23. According to the March 2025 CPO, diagnoses included neoplasm of cerebellum (brain tumor), unspecified psychosis and a delusional disorder. The 1/20/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of two out of 15. She was independent in her bathing, eating, toileting, dressing and transferring. The resident used a wheelchair for ambulation. The MDS assessment indicated she had delusions and had physical and verbal aggressive behaviors directed towards others. B. Resident interviewResident #2 was interviewed on 3/12/25 at 2:09 p.m. Resident #2 said there was a horrible man in a white shirt (Resident #3) that ran his wheelchair over her foot because she was taking too long to fix her coffee in the dining room. Resident #2 said because of this, she splashed her cold cup of coffee in his face. Resident #2 said on another occasion, she pulled Resident 3's hair because she believed he wanted to rape and murder her. C. Record reviewResident #2's behavior care plan, initiated 2/24/25, revealed the resident displayed fluctuations in cognition due to a mental illness and a brain tumor. She presented with episodes of delusional thinking and paranoia causing her to display verbal and physical aggression. She had been involved in multiple incidents. Interventions included one-on-one monitoring, providing psychological support, redirection and validating her feelings. Additional interventions included providing the resident space alone, music and conversations regarding her favorite topics (sports such as soccer) could be used as redirection. V. Staff interviewsThe regional clinical consultant (RCC) and the DON were interviewed together on 3/13/25 at 10:35 a.m. The DON said she had done one-on-one verbal training with the staff on person-centered approaches for Resident #2 but she did not document the training. The DON said Resident #2 had deteriorated due to her brain tumor and had refused to take medications or attend oncology appointments. The DON said during Resident #2's last hospital stay, a palliative assessment was recommended. The DON said she did not know the status of the palliative assessment. The DON said the current interventions for Resident #2 included a one-on-one staff member outside of her room and to explore options on how to implement a guardian for Resident #2 to assist with decision making. The DON said Resident #2 had behaviors of self-isolation, refusals of care and aggression. She said the resident had displayed physical and verbal aggression towards the nurses and the certified nurse aides (CNA), which included pushing, kicking, hitting and threats. The DON said Resident #2 suffered from delusions that consisted of the other residents wanting to rape and murder her. The DON said due to the inconsistency of Resident #2's cognition, creating an intervention to address the resident's behavior had been challenging. The DON said the facility implemented a one-on-one caregiver to sit outside of Resident #2's room from 2/8/25 to 2/11/25. She said after the second incident on 2/19/25, the one-on-one caregiver was restarted. The DON said Resident #2's behaviors of delusions and aggression should be monitored in the treatment administration record (TAR) or in the progress notes. She said the behavior monitoring should include non-pharmological interventions and effectiveness of interventions. The DON was unaware Resident #2 did not have an order for behavior monitoring. CNA #2 was interviewed on 3/13/25 at 12:01 p.m. CNA #2 said today (3/13/25) was her first shift as the one-on-one caregiver for Resident #2. She said she helped Resident #2 with her meals and monitored her behaviors when she left her room. CNA #2 said Resident #2 required a one-on-one caregiver because she had displayed physical aggression towards other residents. CNA #2 said she did not know if Resident #2 had altercations with staff. CNA #2 said the management did not tell her what the resident's triggers were. She said she knew she was supposed to de-escalate Resident #2, but she had not been trained on how to de-escalate Resident #2 specifically, only general training for all residents. CNA #1 was interviewed on 3/13/25 at 12:15 p.m. CNA #1 said she had only worked on Resident #2's hallway for four days and did not know her very well. She said she was given information on Resident #2's behaviors from the other CNAs, not from management. CNA #1 said she was was told by other CNAs that Resident #2 had behaviors of yelling out and wandering. CNA #1 said she did not know the resident's behavior triggers, diagnoses, or past incidents with staff and other residents. The social services assistant (SSA) and the social services director (SSD) were interviewed together on 3/13/25 at 1:15 p.m. The SSD said she worked at a sister facility and was working in the facility to assist the SSA until a permanent SSD was hired. The SSA said regarding Resident #2's behaviors, her role was to conduct investigations and provide psychosocial support to residents. Licensed practical nurse (LPN) #1 was interviewed on 3/13/25 at 2:30 p.m. LPN #1 said Resident #2 had behaviors of refusing care, refusing medications, and verbal and physical aggression towards staff and other residents. LPN #1 said the interventions the staff used with her were to leave her alone and give her space when she was agitated. LPN #1 said the nurses documented her behaviors on the TAR according to the behavior tracking order on the March 2025 CPO. LPN #1 said she was able to locate the behavior tracking order for Resident #2's verbally and physically aggressive behaviors and she initiated it on 3/12/25 (during the survey).

A complaint survey, prompted by #CO38560, #CO38807 and #CO38815 was conducted on 1/22/25. No deficiencies were cited.

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

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

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 revisit survey was completed on 7/9/24 for all previous deficiencies cited on 5/7/24. The facility is in compliance with all regulations surveyed.

A Comparative Federal Monitoring Survey was conducted on 6/26/24, following a State Agency Annual Survey on 5/22//24, in accordance with 42 Code of Federal Regulations, Part 483: Requirements for Long Term Care Facilities. During this Comparative Federal Monitoring Survey, the facility was found to be in compliance with the Requirements for Participation in Medicare and Medicaid.

A Comparative Federal Monitoring Survey was conducted on 6/26/24, following a State Agency Annual Survey on 5/22//24, in accordance with 42 Code of Federal Regulations, Part 483: Requirements for Long Term Care Facilities. During this Comparative Federal Monitoring Survey, the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. The findings that follow demonstrate noncompliance with Title 42, Code of Federal Regulations, 483.90 (a) et seq. (Life Safety from Fire).

Based on observation and interview, the facility failed to protect the hazardous area. The deficient practice affected 1 of 8 smoke compartments. The facility had a capacity for 108 beds with a census of 88 on the day of the survey. The findings include:During the facility inspection tour on 6/26/24, it was observed that ,when tested, dirty side laundry door to the hallway did not latch. An interview with the Maintenance Director on the day of survey revealed that the facility was not aware of this problem. The census of 88 was verified by the Administrator on 6/26/24. The findings were acknowledged by the Administrator and the Maintenance Director during the exit interview on 6/26/24.

Based on observation and interview, the facility failed to maintain smoke barriers. The deficient practice affected 2 of 8 smoke compartments. The facility had a capacity for 108 beds with a census of 88 on the day of the survey. The findings include:During the facility inspection tour on 6/26/24, it was observed that smoke barrier located at 100 hall was not smoke tight due to a large opening ranging from 14' x 1' to 14'x 1" above the ceiling tiles, between ADON office and resident room # 101. An interview with the Maintenance Director on the day of survey revealed that the facility was not aware of this problem. The census of 88 was verified by the Administrator on 6/26/24. The findings were acknowledged by the Administrator and the Maintenance Director during the exit interview on 6/26/24.

Based on observation and interview, the facility failed to maintain smoke barrier doors. The deficient practice affected 2 of 8 smoke compartments. The facility had a capacity for 108 beds with a census of 88 on the day of the survey. The findings include:During the facility inspection tour on 6/26/24, it was observed that smoke barrier doors/fire doors located at the 100 hall did not close and latch. An interview with the Maintenance Director on the day of survey revealed that the facility was not aware of this problem. The census of 88 was verified by the Administrator on 6/26/24. The findings were acknowledged by the Administrator and the Maintenance Director during the exit interview on 6/26/24.

Based on observation and interview, the facility failed to protect the oxygen transfilling location. The deficient practice affected 1 of 8 smoke compartments. The facility had a capacity for 108 beds with a census of 88 on the day of the survey. The findings include:During the facility inspection tour on 6/26/24, it was observed that 300 hall oxygen transfilling room was not separated from the rest of the facility by a fire barrier of 1 hour fire-resistive construction due to lack of fire dampers at the air duct registers in the transfer room. An interview with the Maintenance Director on the day of survey revealed that the facility was not aware of this requirement. The census of 88 was verified by the Administrator on 6/26/24. The findings were acknowledged by the Administrator and the Maintenance Director during the exit interview on 6/26/24. NFPA 99, 11.5.2.3.1 Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa(50 psi) shall include the following:(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.

The facility was found to be in compliance with Title 42, Code of Federal Regulations, 483.73 et seq. (Emergency Preparedness).

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (000), construction with a partial basement used for support services only. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinkled. The facility was constructed in 1965 and is licensed for 108 beds. This re-certification survey conducted on May 22, 2024, was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". Deficient items were discussed with the Administrator and during the exit conference.

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. Outside exit gates need UL-listed exit signs NFPA 101, 7.8.1.1. Illumination of Means of Egress. Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The maintenance director discussed deficient items at the exit conference.

Based on observation and staff interviews during the course of the survey, it was determined the facility failed to maintain hazard areas in accordance with NFPA 101 1. The nourishment room fire door has been removed 2. Fire door 300 not latching 3. Smoke doors to the dining need to be adjusted8.7.1.1* 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:Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3Protecting the area with automatic extinguishing systems in accordance with Section 9.7Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and Maintenance director discussed deficient items at the exit conference.

Based on observation, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96 (Chapter 12, Section 12.1.2.3.1) and the cooking appliance restraint as required by NFPA 54, 9.6.1.2. 1. Cooking appliances need noncombustible restraint 2. Dry chem electric needs to be repaired. does not shunt trip 3. The hood damper needs to be inspectedNFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer installation instructions. Standard for Dry Chemical Extinguishing Systems 9.3.1 Dry chemical fire extinguishing systems for commercial kitchen hood, duct, and cooking appliances shall comply with ANSI/UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Commercial Cooking Equipment, or equivalent listing standard. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and Maintenance director discussed deficient items at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 and NFPA 72. Duct detectors not tested2012 Life Safety Code 101 section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling CodeThis deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.

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. Fire sprinkler flow switches shall be tested. 2. Need a semi-annual fire sprinkler report. 3. Quick response fire sprinkler heads expired dated 1994. Only good for 25 years 4. Loading on fire sprinkler heads throughout the buildingNFPA 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 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. 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. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.

Based on observation and staff interviews 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 19.3.6.3310 door seal gap is too largeNFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors and gaps in the door smoke seal. Deficient items were discussed with the maintenance director during the survey and the Maintenance Director and Administrator 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 105Records were unavailable during the survey to document the inspection and testing operation of the fire dampers installed in the facility as required one year after the initial inspection. 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 that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. This deficiency can potentially affect occupants, including 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 timesNFPA 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 can potentially affect occupants, including 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 Combustible Decorations requirements in accordance with NFPA 101, 19.7.5.6. This was evidenced by:Decoration Hall 300 needs fireproof criteria. Life Safety Code Section 19.7.5.6 Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:(1)They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.(2)The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.(3)The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20 kW ignition source.(4)*The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:(a)Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 19.7.5.6(b), (c), or (d).(b)Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.(c)Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system in accordance with Section 9.7.(d)Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms, having a capacity not exceeding four persons, in a smoke compartment that is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.(5)*They are decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present. Life Safety Code Section 19.7.5.1 Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1(see 19.3.5.11), and the following also shall apply: (1) Such curtains shall include cubicle curtains. (2) Such curtains shall not include curtains at showers and baths. (3) Such draperies and curtains shall not include draperies and curtains at windows in patient sleeping rooms in smoke compartments sprinklered in accordance with 19.3.5. (4) Such draperies and curtains shall not include draperies and curtains in other rooms or areas where the draperies and curtains comply with all of the following: (a) Individual drapery or curtain panel area does not exceed 48 ft2 (4.5 m2). (b) Total area of drapery and curtain panels per room or area does not exceed 20 percent of the aggregate area of the wall on which they are located. © Smoke compartment in which draperies or curtains are located is sprinklered in accordance with 19.3.5. This deficiency can potentially affect occupants, including residents, staff, and visitors within 1 smoke compartment. The maintenance director and administrator discussed deficient items during the survey and 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. Fridges plugged into surge protectors throughout the building 2. Power strips throughout the building (flexible cords and cables shall not be used as a substitute for the fixed wiring of a structure.)Flexible cords and cables in accordance with Chapter 4 of NFPA 70, Section 400.8(1), in part, flexible cords and cables shall not be used as a substitute for the fixed wiring of a structure. Furthermore, Health Care Facilities Code section 10.2.3.6 (2), "The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets."This deficiency can affect the occupants, including 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 survey, it was determined that the facility failed to maintain a hazardous area per NFPA 99. This was evidenced by the following:1. Oxygen Transfill rooms need a vent 12" off the floor 2. Oxygen shall not be stored in the patient room. One bottle or condenser per patient in rooms. 3. Oxygen storage needs empty full signs on the wallsNFPA 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. 11.7.4.1 The maximum total quantity of liquid oxygen permitted in storage and in use in a patient bed location or patient care room shall be 120 L (31.6 gal), provided that the patient bed location or patient care room, or both, are separated from the remainder of the facility by fire barriers and horizontal assemblies having a minimum fire resistance rating of 1 hour in accordance with the adopted building code. 11.7.4.2 One liquid oxygen portable container [limited to 1.5 L (0.396 gal) capacity] per patient is permitted to be stored or used in a patient bed location or patient care room without having to meet the fire separation requirements of 11.7.4.1. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and Maintenance director discussed deficient items at the exit conference.

A recertification survey with complaint #CO35969 was completed on 5/1/24 to 5/7/24. Twelve deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/1/24 to 5/7/24. No deficiencies were cited.

Based on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for three (#46, #25 and #47) of five residents reviewed for unnecessary medications out of 34 sample residents. Specifically, the facility failed to ensure informed consents, which included the risks associated with taking a psychotropic medication, were obtained for Resident #46, Resident #25 and Resident #47. Findings include:I. Facility policy and procedureThe Use of Psychotropic Medications policy and procedure, revised 4/12/24 was provided by the nursing home administrator (NHA) on 5/7/24 at 12:47 p.m. It read in pertinent part, "Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the residents response to medications."Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatment/non-pharmacological interventions."II. Resident #46A. Resident statusResident #46, age greater than 65, admitted on 5/23/23. According to the May 2024 computerized physician orders (CPO), diagnoses included atrophy of the kidney (decrease in size and functional ability of the kidney), cerebral infarction (disrupted blood flow to the brain), osteomyelitis of lumbar vertebra (infection of the spine), dementia with psychotic disturbances, and hypertension (high blood pressure). The 2/8/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview of mental status (BIMS) score of nine out of 15. Resident #46 received antipsychotic medications. B. Record reviewThe May 2024 CPO revealed the following physician's orders: Zyprexa (antipsychotic) 5 milligram (mg) at bedtime related to unspecified dementia, moderate with psychotic disturbances. Ordered on 8/23/23. Resident #46's care plan, dated 2/14/24 revealed Resident #46 used psychotropic medications related to behaviors associated with the progression of dementia with psychosis. Interventions were to discuss with the medical doctor and family regarding the ongoing need for use of the medication (initiated on 10/9/23). A review of Resident #46's electronic medical record (EMR) failed to reveal an informed consent, which included the risks associated with taking the medication, had been obtained from the resident or the resident's representative for the administration of the Zyprexa. A 5/8/23 progress note written by the admitting physician revealed the resident was noted to be lacking decision making capabilities. Guardianship was completed on 5/5/23. On 5/6/24 at 9:01 a.m. the NHA provided a document of informed consent for Resident #46's Zyprexa.-The informed consent was signed by the resident but failed to have a date of when it was signed. -Additionally, the resident had a court ordered guardianship in place as he was unable to make decisions.-Review of the EMR failed to reveal the resident's guardian had signed an informed consent for Resident #46's Zyprexa medication. C. Staff interviewsRegistered nurse (RN) #3 was interviewed on 5/7/24 at 9:38 a.m. RN #3 said an informed consent must be obtained when a psychotropic medication was ordered. RN #3 said a consent must be signed prior to the initial medication administration so the resident or resident's representative was aware of the side effects of the medication. RN #3 said if a resident could sign for themselves, they could give consent, even if the resident had a guardian in place. Licensed practical nurse (LPN) #1 was interviewed on 5/7/24 at 9:47 a.m. LPN #1 said the family could sign an informed consent if the family member was the resident's legal representative, or the resident could sign as long as the resident was able to make their own decisions. LPN #1 said informed consentfor psychotropic medications should be obtained prior to the first administration of the medication. LPN #1 said if a resident had a guardian in place, the guardian must be contacted for consent. LPN #1 said Resident #46 was unable to sign an informed consent because he was confused due to his medical diagnoses. The director of nursing (DON) was interviewed on 5/7/24 at 9:55 a.m. The DON said informed consent for psychotropic medications should be obtained before the first dose of the medication was administered. The DON said the resident had the right to know about side effects of the medication. The DON said if a resident was cognitive with a BIMs score of eight or higher and could make their needs known, they were able to sign an informed consent. The DON said if there was a guardian or legal representative set up for a resident the consent needed to come from the guardian/legal representative. -The DON was unable to determine the date when Resident #46 signed his consent for the Zyprexa (See record review above). The social service director (SSD) was interviewed on 5/07/24 at 11:18 a.m. The SSD said she started at the facility on 4/1/24. The SSD said she touched base with nursing because they were responsible for getting the informed consents. The SSD said informed consents should be signed before a medication was administered. The SSD said the facility had a psychotropic/pharmacological meeting monthly and would start discussing new medications started or changes made to medications. The SSD said the facility would make sure informed consents were in place for residents prior to them starting a psychotropic medication. The SSD said it was important for the resident to know the side effects of medications and what medications they were prescribed. The SSD said if a resident had a guardian, the guardian must sign the informed consent. III. Resident #25A. Resident statusResident #25, age 84, was admitted on 1/20/23. According to the May 2024 CPO, diagnoses included type II diabetes mellitus, heart disease, depression, and mood disorders. The 4/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He was independent with hygiene, eating, toileting, and dressing and needed supervision with bathing and transfers. The MDS assessment documented Resident #25 was taking an antipsychotic medication and antidepressant medication. B. Record reviewResident #25's 8/22/23 physician's order note documented an olanzapine (antipsychotic medication)oral tablet 2.5 mg was to be administered to Resident #25 by mouth at bedtime for his diagnosis of persistent mood disorders. The progress note further documented possible interactions with other medications Resident #25 was taking, including an interaction with mirtazapine (the resident's antidepressant medication) which could enhance adverse effects of the olanzapine medication resulting in a serious drug reaction.-There was no documentation in the resident's EMR to indicate Resident #25 was informed of the possible interactions of olanzapine with his other medications. Resident #25's psychotropic medication care plan, initiated 10/4/23, revealed the resident received psychotropic medication for behavior management. Pertinent interventions included to administer psychotropic medications according to the physician's order and monitor for side effects and effectiveness every shift. The 4/11/24 medication regimen review documented Resident #25 had been taking the antipsychotic medication olanzapine 2.5 mg since 8/2/23.-There was no documentation in the resident's EMR to indicate Resident #25 was informed of the possible interactions of olanzapine with his other medications. The medication review was completed with Resident #25 on 5/3/24 (during the survey). The medication review documented Resident #25's psychotropic medications were reviewed, both current and a historical data review. The resident was his own decision maker. The resident reported being aware of receiving psychotropic medications while at the facility. Resident #25 reported being in agreement with the psychotropic medications he received while a resident at the facility. The medication review was signed by the interviewer and the resident on 5/3/24 (during the survey).-The medication review did not document Resident #25 was specifically informed of the risks of taking the olanzapine medication. -The facility was unable to provide documentation of an informed consent to indicate Resident #25 was informed of the risks versus benefits of his psychotropic medications prior to the medication being administered. C. Staff interviewsThe DON was interviewed on 5/7/24 10:02 a.m. The DON said nursing staff should obtain informed consents for psychotropic medication use upon the resident's arrival at the facility. The DON said the floor nurses should obtain the resident's consent for the antipsychotic medication if a new medication order was placed after the resident's admission to the facility. The DON said, going forward, antipsychotic medication informed consent forms should be at the nurses station. IV. Resident #47A. Resident statusResident #47, age younger than 65, was admitted on 7/25/22. According to the May 2024 CPO, diagnoses included generalized anxiety disorder and bipolar depression. The 3/28/24 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. She had no behaviors and did not reject care. She had impairment to both lower extremities. The MDS assessment documented the resident received antipsychotic and antidepressant medications daily. B. Record reviewThe May 2024 CPO documented the following physician's orders:Seroquel (antipsychotic) oral tablet 100 mg. Give 150 mg by mouth one time a day for bipolar. Start date 11/22/23. Seroquel oral tablet give 300 mg by mouth at bedtime for bipolar disorder. Start date 11/21/23. Zoloft (antidepressant) oral tablet 50 mg give three tablets by mouth one time a day for depression. Start date 3/13/24. The psychotropic medication care plan, revised 4/22/24, revealed Resident #47 used psychotropic medications related to bipolar disorder. Interventions included education of the resident about the risks, benefits and the side effects and/or toxic symptoms. The antidepressant medication care plan, revised 4/5/24, revealed Resident #47 used an antidepressant medication related to depression. The interventions included educating the resident/family/caregivers about the risks, benefits, and the side effects and/or toxic symptoms of the drugs being given. -Review of Resident #47's EMR revealed an informed consent for Seroquel and Zoloft were both signed on 5/3/24 (during the survey). Staff interviewsLPN #2 was interviewed on 5/7/24 at 9:38 a.m. LPN #2 said informed consents should be signed by the resident or the resident's representative prior to the administration of a psychotropic medication. She said it was important to educate the resident/family on the possible side effects and what medications the resident was prescribed. The DON was interviewed on 5/7/24 at 9:54 a.m. The DON said informed consents should be signed prior to the administration of a psychotropic medication. She said discussing the medication and signing the consent helped to ensure everyone understood the risks of the medication. The DON said the informed consent included black box warnings (a label that alerts individuals to serious medication safety risks), side effects and the medication prescribed. She said nursing was responsible for getting the informed consents signed.

Based on record review and interviews, the facility failed to ensure a Level II preadmission and resident review (PASRR) was completed for one (#33) of three residents out of 34 sample residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being. Specifically, the facility failed to ensure a Level II PASRR was in place for Resident #33. Findings include:I. Facility policy and procedureThe Behavioral Health policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:13 p.m. It read in pertinent part, "It is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching their highest level of mental and psychosocial functioning. II. Resident statusResident #33, age younger than 65, was admitted on 2/22/24. According to the May 2024 computerized physician orders (CPO), diagnoses included mild neurocognitive disorder due to unknown physiological condition with behavioral disturbance, nonpsychotic mental disorder and major depressive disorder. The 2/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. He had no behaviors and did not reject care. He required setup assistance with eating and showering. He was independent with all other activities of daily living (ADL). III. Record reviewReview of Resident #33's Level I PASRR revealed the resident was recommended to be evaluated for a Level II PASRR. -Record review revealed no evidence a Level II PASRR had been completed. The behavior care plan, revised 4/8/24, documented the resident was resistive to care related to major depression. The interventions included to allow the resident to make decisions about his treatment regimen to provide control and to praise the resident when behavior was appropriate. IV. Staff interviewsThe social services director (SSD) was interviewed on 5/2/24 at 11:45 a.m. The SSD said a Level II PASRR was recommended for Resident #33. However, she said it was not completed. She said she would immediately submit a request for a Level II assessment for Resident #33. The director of nursing (DON) was interviewed on 5/7/24 at 10:11 a.m. The DON said a Level I PASRR should be completed on admission and if the Level I recommended a Level II assessment, the Level II assessment should be completed. She said it was important to complete a Level II assessment to ensure any triggers for behaviors were documented and to determine the level of care the resident needed. The SSD was interviewed a second time on 5/7/24 at 11:18 a.m. The SSD said she completed an audit on all Level I PASRRs to ensure a Level II assessment was completed if recommended. She said she would continue to work with the PASRR agency to ensure all Level II PASRR assessments were in place for residents who triggered for an assessment.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#69 and #35) of three residents reviewed out of 34 sample residents. Specifically, the facility failed to ensure Resident #69 and Resident #35, who were dependent on staff for bathing, received their scheduled showers. Findings include:I. Facility policy and procedureThe Resident Shower policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/9/24 at 10:48 a.m. It read in pertinent part, "It is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues." The Activity of Daily Living policy, revised 4/12/24, was provided by the NHA on 5/6/24 at 3:13 p.m. It read in pertinent part, "The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. "Care and services will be provided for the following activities:-Bathing, dressing, grooming and oral care;-Transfer and ambulation;-Toileting;Eating to include meals and snacks; and -Using speech, language or other functional communication systems. "A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral care."II. Resident #69A. Resident statusResident #69, age younger than 65, was admitted on 10/11/23. According to the May 2024 CPO, diagnoses included chronic kidney disease, congestive heart failure, traumatic brain injury (TBI), transient ischemic attack, acquired absence of left toe, anxiety disorder and depressive episode. The 1/24/24 MDS revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He used a wheelchair and was dependent on staff for bathing. He was occasionally incontinent of urine and always continent of bowel. B. Resident interviewResident #69 was interviewed on 5/2/24 at 3:51 p.m. during the group interview. Resident #69 said his last shower on 5/6/24 was the first shower he had in three weeks. He said he was scheduled to receive two showers a week on Wednesdays and Saturday. C. Record reviewThe ADL care plan, revised on 10/12/23, revealed Resident #69 had an ADL self-care performance deficit related to weakness and cognitive deficits resulting from a TBI. Interventions included supervision/touching assistance of one staff member with showering/bathing. Review of the February 2024 through May 2024 shower logs revealed Resident #69 had not received two showers in February 2024, four showers in March 2024, four showers in April 2024 and one shower in May 2024. III. Resident #35A. Resident statusResident #35, age 65, was admitted on 7/8/23. According to the May 2024 computerized physician orders (CPO), diagnoses included Guillain-Barre syndrome (the immune system attacks the nerves), contracture (shortening of the muscle causing a deformity), difficulty in walking, muscle weakness, morbid obesity and bilateral primary osteoarthritis of the knees. The 4/8/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He had impairment to both of his lower extremities. He used a wheelchair and was dependent on staff for bathing. He was occasionally incontinent of urine and frequently incontinent of bowel. B. Resident interviewResident #35 was interviewed on 5/1/24 at 1:08 p.m. Resident #35 said he did not receive his bed baths as scheduled. He said he was scheduled to have two showers a week on Tuesdays and Fridays. C. Record reviewReview of the February 2024 through April 2024 shower logs revealed Resident #35 had not received two bed baths in February 2024 and one bed bath in April 2024. The ADL care plan, revised on 1/25/24, revealed Resident #35 had an ADL self-care performance deficit related to Guillain Barre syndrome, transient ischemic attack (TIA) (a mini stroke), contracture and muscle weakness. Interventions included providing a sponge bath when a full bath or shower could not be tolerated and the resident preferred them on Mondays and Fridays. The resident required assistance twice weekly and as necessary. The resident was bed fast most of the time. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 5/7/24 at 9:33 a.m. CNA #1 said residents were given at least two showers a week and they were documented in the electronic medical record (EMR). She said it was important for the residents to receive their scheduled showers for hygiene, nail care and odors. She said if a shower was refused, the CNAs would make three attempts to reoffer the shower on the scheduled day. She said if the three attempts did not work, the CNA would offer a shower the following day. Licensed practical nurse (LPN) #2 was interviewed on 5/7/24 at 9:38 a.m. LPN #2 said the CNAs were responsible for giving the residents a shower on their scheduled day. She said if a shower was refused, the CNAs would report it to the nurse and a shower sheet, as well as a progress note, would be completed. She said it was important for the residents to receive their showers for hygiene and skin integrity. She said each resident should receive two showers weekly. The director of nursing (DON) was interviewed on 5/7/24 at 9:51 a.m. The DON said Resident #69 and Resident #35 were scheduled to receive their showers on Mondays and Fridays. She said it was important for the residents to receive their scheduled showers twice a week for hygiene, skin integrity and wounds. She said she was not sure why the showers were missed and would complete a full house audit.

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#60 and #58) of six residents out of 34 sample residents reviewed for nutrition status. Specifically, the facility failed to obtain weekly weights per the physician's orders for Resident #60 and Resident #58. Findings include:I. Facility policy and procedureThe Weight Monitoring policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/7/24 at 4:00 p.m. The policy read in pertinent part, "Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended weight loss over a period of time) may indicate a nutritional problem. A weight monitoring schedule will be developed upon admission for all residents: Weights should be recorded at the time obtained. Newly admitted residents and residents with weight loss will have weight monitored weekly for four weeks. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate."II. Resident #60A. Resident statusResident #60, age less than 65, was admitted on 2/3/24. According to the May 2024 computerized physician orders (CPO), diagnoses included bacterial infection, sickle cell anemia (disorder that causes red blood cells to be misshapen), weakness, heart failure, and severe protein-calorie malnutrition. The 2/10//24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He needed supervision while bathing and was independent with all other activities of daily living. The MDS assessment documented Resident #60 had not refused care. B. Resident interviewResident #60 was interviewed on 5/1/24 at 2:19 p.m. and said he was concerned about his recent weight. C. Record review The 2/19/24 nutrition evaluation documented in the recommendation/plan section to monitor routine weights and weekly weights were needed to closely monitor Resident #60 as his body mass index (BMI) was 15.3 (underweight status). Resident #60 had a physician's order for weekly weights for four weeks and then to reevaluate, ordered on 2/26/24. A review of Resident #60's electronic medical record (EMR) documented he weighed 97.7 pounds (lbs) on 2/3/24. -Resident #60 was not weighed until 4/1/24 where he weighed 93.4 lbs. -The facility failed to monitor and record any weights for Resident #60 between 2/3/24 and 4/1/24 per the physician's order. -Between 2/3/24 and 4/1/24, Resident #60 lost 4.3 lbs, or 4.4% of his body weight, which was not significant. III. Resident #58A. Resident status Resident #58, age greater than 65, was admitted on 4/3/24. According to the May 2024 CPO, diagnoses included dementia, heart disease, anxiety, type II diabetes mellitus, high blood pressure, mild-protein calorie malnutrition and adult failure to thrive. The 4/11/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. She needed moderate assistance with bathing and personal and toileting hygiene, and supervision with lower body dressing and footwear, transfers and walking throughout the unit. She needed set up assistance with eating, oral hygiene and upper body dressing. The MDS assessment documented Resident #58 occasionally rejected care. B. Record reviewA review of Resident #58's EMR documented her weight upon admission on 4/3/24 was 125.4 lbs. A physician's order for weekly weights for four weeks and then to reevaluate was ordered on 4/17/24. -A review of Resident #58's EMR revealed the resident's weight was not obtained after her initial admission weight was acquired on 4/3/24. The following responses were recorded in the resident's EMR when her weight was to be obtained:-4/15/24: Not applicable;-4/22/24: Resident not available; and,-4/29/24: Not applicable.-Resident #58's physician's order was updated on 5/6/24 (during the survey) to weigh Resident #58 every Tuesday for four weeks. C. Facility follow upThe facility provided additional information on 5/8/24 that, per Resident #58's shower sheet, she refused to be weighed on 4/25/24. -However, Resident #58 was admitted on 4/3/24 and weekly weights were not obtained or documented as refused by Resident #58 on any additional days after her admission to the facility. IV. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 5/7/24 at 10:00 a.m. CNA #2 said residents were weighed the first day they were admitted to the facility if possible. She said residents were weighed every two weeks and then once a month following their admission. CNA #2 said residents could be weighed more frequently than once a month if requested. CNA #2 said staff documented residents' refusal of weights in the residents' EMR, and staff attempted to obtain a resident's weight three times before marking it as refused. CNA #2 said after the third attempt to obtain a resident's weight she notified a nurse and the nurse would follow-up with the resident. Licensed practical nurse (LPN) #1 was interviewed on 5/7/24 at 10:30 a.m. LPN #1 said the CNAs obtained the residents' weights. LPN #1 said if a resident refused to be weighed a CNA should let a nurse know and the nurse would try to offer to weigh the resident. LPN #1 said if the resident refused to be weighed, the resident's refusal was documented in the EMR.The director of nursing (DON) was interviewed on 5/7/24 at 1:20 p.m. The DON said staff should obtain residents' weights per the facility policy. The DON said CNAs should notify the nurse if a resident refused to be weighed or staff should reattempt to obtain the resident's weight and document the additional attempts and refusals.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five (#1, #4, #5, #6 and #7) of five certified nurse aides. Specifically, the facility had not completed annual performance reviews for certified nurse aide (CNA) #1, #4, #5, #6 and #7 in order to determine potential training needs. Findings include:I. Facility policy and procedureThe Evaluation Process policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:13 p.m. It read in pertinent part, "It is the policy of our facility to review the work performance of employees with a formal written evaluation. Factors that will be considered in making decisions include job performance, achieving goals, attendance record and adherence to workplace policies."II. Record reviewAnnual performance reviews were requested on 5/6/24 at 1:59 p.m for CNAs #1, #4, #5, #6 and #7. The facility was unable to provide annual performance evaluations for 2023 for all five CNAs. -The director of nursing (DON) said CNAs #1, #4, #5, #6 and #7 did not have annual performance reviews and had not completed annual in-service education based on the outcome of their reviews. Cross-reference F947 for failure to ensure CNAs received annual training as required. III. Staff interviewsThe director of nursing (DON) was interviewed on 5/7/24 at 10:51 a.m. The DON said the annual performance reviews were to be completed by the DON/nurse management. She said she had only been employed at the facility the week of the survey (5/1/24 to 5/7/24). She said she did not know which employees a performance review had been completed for by the previous DON and would complete a full audit to determine which employees needed their performance evaluation completed.

Based on observations, record review and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (#46) of five residents reviewed for unnecessary medications out of 34 sampled residents. Specifically the facility failed to ensure:-Acetaminophen (pain medication) administered to Resident #46 did not exceed the recommended 3 grams (gm) in a 24-hour period; and,-As needed (PRN) medication was administered per physician's orders. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.sevier, St. Louis Missouri, pp. 606-607, "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. "Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication."II. Facility policy and procedureThe Medication Administration policy and procedure, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/7/24 at 12:47 p.m. It revealed in pertinent part, "Obtain and record vital signs, when applicable or per physician order."Example guidelines for medication administration (unless otherwise ordered by physician), this list is not all-inclusive:-Medications requiring vital signs prior to administration of antihypertensives."III. Resident statusResident #46, age greater than 65, was admitted on 5/23/23. According to the May 2024 computerized physician orders (CPO), diagnoses included atrophy of the kidney, cerebral infarction (stroke), osteomyelitis of lumbar vertebra (infection of the spine), dementia with psychotic disturbances (abnormal thought process), and hypertension (high blood pressure). The 2/8/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. He was dependent on staff for transfers, dressing, and toileting. He needed substantial assistance with personal hygiene and set up with eating. The assessment revealed the resident received scheduled pain medications. IV. Record review 1. AcetaminophenResident #46's May 2024 CPO revealed the following physician's orders:Acetaminophen (pain and fever reducer) 500 milligrams (mg) two tablets three times a day for pain, ordered on 4/11/24.-The routine physician's order total dosage equaled the recommended maximum dose of 3 gm of acetaminophen in 24 hours. Acetaminophen 325 mg two tablets every six hours as needed for pain (PRN) level of 1 to 4 on a pain scale of 1-10. Not to exceed 3 grams (gm) of acetaminophen in 24 hours,ordered on 2/22/24. -Administering the PRN acetaminophen dose would result in Resident #46 receiving 650 mg over the recommended maximum dose of 3 gm of acetaminophen each time the PRN medication was administered. The April 2024 medication administration record (MAR) revealed the following:On 4/13/24, Resident #46 received one dose of PRN acetaminophen.-Resident #46 received 650 mg of acetaminophen over the maximum recommended dose of 3 gm of acetaminophen in 24 hours. On 4/17/24, Resident #46 received one dose of PRN acetaminophen.-Resident #46 received 650 mg of acetaminophen over the maximum recommended dose of 3 gm of acetaminophen in 24 hours.-Resident #46's progress notes failed to document that a physician was notified on 4/13/24 and 4/17/24 for acetaminophen exceeding the recommended maximum dose of 3 grams of acetaminophen in 24 hours. 2. HydralazineResident #46's April 2024 CPO revealed the following physician's orders:Hydralazine (anti hypertensive medication) 25 mg give one tablet every six hours as needed for systolic blood pressure over 160 millimeters of mercury (mmHg), ordered on 5/13/23. The April 2024 MAR revealed the following:On 4/3/24, during the day shift, Resident #46's blood pressure was 164/87 mmHg.-The resident was not administered Hydralazine for a systolic blood pressure over 160 mmHg per the physician's order. On 4/13/24, during the day shift, Resident #46's blood pressure was 162/80 mmHg.-The resident was not administered Hydralazine for a systolic blood pressure over 160 mmHg per the physician's order..-Resident #46's progress notes for 4/3/24 and 4/13/24 failed to document that the physician was notified that Hydralazine was not administered. V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 5/6/24 at 2:41 p.m. LPN #1 said she was unaware Resident #46 had an as needed order for Hydralazine since she had never had to administer Resident #46's Hydralazine. LPN #1 said if a resident did not get an antihypertensive medication it could lead to risk of stroke because the resident's blood pressure could get too high. LPN #1 said Resident #46 had scheduled acetaminophen and as needed pain acetaminophen. LPN #1 said if a resident was administered more acetaminophen than a recommended dose it could lead to liver issues. Resident #46's primary care physician (PCP) was interviewed on 4/7/24 at 8:56 a.m. The PCP said if a resident did not get an antihypertensive medication administered as physician ordered, it could lead to stroke due to the resident's blood pressure not being controlled. The PCP said too much acetaminophen could lead to liver complications. The director of nursing (DON) was interviewed on 5/7/24 at 10:18 a.m. The DON said nurses should check blood pressure prior to administering any antihypertensive medications. The DON said, based on Resident #46's physician's orders, if the blood pressure reading was above 160 mmHg systolic, nurses were to administer a dose of Hydralazine. The DON said not administering an antihypertensive medication placed the resident at risk of a hypertensive crisis (medical emergency when blood pressure is too high). The DON said if a resident was administered acetaminophen over the recommended 3 grams of acetaminophen in 24 hours it could place strain on the resident's liver. The DON said the nurse should contact the resident's physician to inform the physician of the excessive dose and ask if there would be any special monitoring needed. The DON said the nurse should write a progress note to indicate the physician was notified.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in one of three medication carts and one of two medication storage rooms. Specifically the facility failed to:-Ensure expired medications and vaccines were disposed of timely;-Ensure insulin pens (medication used for glucose control) were labeled with open dates; and,-Ensure Tubersol (used to test for tuberculosis) vials were labeled with open dates. Findings include:I. Professional referencesAccording to the Lantus glargine insulin package insert, retrieved on 4/29/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, "When not in use store in refrigerated temperatures of 36 to 46 degrees fahrenheit (F). When in use, can be kept at room temperature for up to 28 days."According to the Novolog insulin package insert, retrieved on 5/8/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/020986s082lbl.pdf "After initial use a vial may be kept at temperatures below 30 degrees celsius (C) (86 degrees F) for up to 28 days, but should not be exposed to excessive heat or light."According to the Tubersol package insert, retrieved on 5/8/24 from https://www.fda.gov/media/74866/download, "A vial of Tubersol which has been entered and in use for 30 days should be discarded."According to the Latanoprost package insert, retrieved on 5/8/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020597s044lbl.pdf, "Store unopened bottle(s) under refrigeration at two to eight degrees C (36 to 46 degrees F). Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees C (77 degrees F) for six weeks."II. Facility policy and procedureThe Medication Storage policy and procedure, revised on 4/12/24, was provided by the nursing home administrator (NHA) on 5/7/24 at 12:47 p.m. It revealed in pertinent part, "Policy of this facility is to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitization, temperature, light, ventilation, moisture control, segregation and security. "Unused medications: the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications."III. Observations and staff interviewsOn 5/2/24 at 2:25 p.m. the main nurses medication room was observed with registered nurse (RN) #2. The following items were found:One Lantus insulin pen that had a manufacturer's expiration date of February 2024.-The medication was over one month past the manufacturer's expiration date. One opened Lantus insulin pen with no open date. One opened vial of Tubersol with no open date. One opened vial of Tubersol with an open date of 3/5/24.-The medication was 27 days past the recommended date of open use (see manufacturer's recommendation above). One Spivax Covid-19 vaccine that expired on 4/24/24.-The medication was six days past the expiration date. One opened Novolog insulin vial with an open date of 9/29/23.-The medication was six months past the recommended use by date after opening (see manufacturer's recommendation above). Two intravenous (IV) bags of Daptomycin (antibiotic) 600 milligrams (mg) in 50 milliliters (ml) that expired on 4/3/24.-The medication was 30 days past the expiration date. RN #2 said the expired medications should have been removed from the refrigerator to help prevent a nurse from administering the medications or vaccines to a resident. RN #2 said if a resident were to receive a medication that was expired or used past the recommended use by date, the resident might not get the expected response from the medications. RN #2 took the expired medications to the director of nursing's (DON) office for destruction at 2:39 p.m. On 5/2/24 at 2:51 p.m. the 400 hall medication cart was observed with RN #1. The following items were found:One bottle of Latanoprost 0.005% eye drops that was opened on 1/25/24.-The Latanoprost eye drops were 10 weeks past the recommended use by open date (see manufacturer recommendation above). One bottle of Latanoprost 0.005% eye drops that was opened on 2/2/24.-The Latanoprost eye drops were eight weeks past the recommended use by open date (see manufacturer recommendation e above).-One vial of Lantus insulin with no open date was stored in a box of Timolol (prescription eye drops) in the top drawer of the medication cart. RN #1 said it was the responsibility of the nurses to remove expired medications from the medication carts or refrigerators. RN #1 said expired medications increased the risk of the medications being less effective. RN #1 said eye drop bottles could grow bacteria and lead to infection if used past the recommended dates. RN #1 said bottles of Latanoprost eye drops were good for four weeks after opening the bottle, then the bottle should be discarded and a new bottle should be used. IV. Additional staff interviewsThe DON was interviewed on 5/7/24 at 10:03 a.m. The DON said insulin medications were only good for 30 days once they were opened. The DON said labeling the medications with open dates was important so staff know when the medications expired. The DON said Latanoprost eye drops were good for 30 days once opened.-However, according to the manufacturer's guidelines, Novolog and Lantus were only good for 28 days once they were opened (see professional references above).-However, the manufacturer guidelines revealed Latanoprost eye drops were good for six weeks after opening (see professional references above). The DON said it was the responsibility of the nurses to ensure expired and discontinued medications were removed from the medication carts and medication refrigerators. The DON said if an expired medication was given it would not be as effective for the resident.

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanical soft diets had food prepared according to their diet orders of mechanical soft as indicated on their meal tray cards. Findings include:I. Facility policy and procedureThe Therapeutic Diet Orders policy and procedure, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:00 p.m. The policy read in pertinent part, "The facility provides all residents with foods in the appropriate form and/or the the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat and thickened liquids. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed."II. Record reviewThe mechanical soft diet description from the facility diet manual was provided by the NHA on 5/6/24 at 9:30 a.m. The diet manual documented the following modifications for the mechanically altered food items served during lunch meal service on 5/2/24:Bread was to be served slurried using a commercial thickener combined with liquid and bread or commercially prepared pureed bread products. Whole corn was restricted. Instead the cooks were to utilize commercially prepared pureed corn and pea products that were smooth and did not present a choking hazard to the resident. Casseroles that contained restricted items such as whole rice grains were to be served pureed. The diet menu for the mechanical soft diets was provided by the NHA on 5/6/24 at 4:30 p.m. The mechanical soft diet menu documented the following mechanical soft modifications for menu items served during the lunch meal on 5/2/24:-The stuffed pepper was to be served as a pureed stuffed pepper;-The corn was to be served pureed;-The wheat roll needed to be slurried; and,-The mocha fudge marble cake needed to be served as a slurried mocha fudge marble cake.-The facility failed to ensure the resident's who were prescribed a mechanical soft diet received foods that were altered to the correct texture for the lunch meal on 5/2/24. II. Meal service observation and staff interviewsDuring a continuous observation of the lunch meal service on 5/2/24, beginning at 11:15 a.m. and ending at 12:25 p.m., the following was observed:-The posted menu in the dining room documented the lunch meal consisted of stuffed bell peppers, wheat roll, buttered corn, and mocha fudge marble cake. -At 11:15 a.m. the mechanically altered items were in the hot food holding steam table. The mechanically altered menu items held in the hot food holding table were reviewed with cook (CK) #1. CK #1 said the following foods in the steam table were mechanical soft foods: a pan of creamed corn (with visible chunks of corn) and a pan of ground beef mixed with individually cooked whole grains of rice. -According to the dietary manual (see above), the mechanical soft diet restricted whole kernels of corn. The dietary manual indicated a commercially prepared pureed (smooth with no lumps) corn product was to be served instead. The commercially prepared puree corn products were smooth and did not present a choking hazard to the residents. Casseroles with restricted food items, such as rice, were to be pureed for the residents on mechanical soft diets. At 11:30 a.m. service for the lunch meal began. Between 11:30 a.m. and 12:15 p.m., five lunch meal plates, for residents who were prescribed a mechanical soft diet per their dietary meal tickets, were assembled and placed in the meal delivery carts for delivery to the resident's rooms. -The five meal plates included the ground beef and rice CK #1 had identified as the mechanical soft entree (see CK #1's interview and observation above) and a regular dinner roll, which was not modified with a slurry. -Three of the five plates included the creamed corn (not the commercially prepared pureed corn that was indicated should be served per the dietary manual).-The facility failed to puree the rice item served as part of the mechanically altered stuffed pepper, failed to serve a slurried roll and failed to serve a puree corn or mechanically appropriate vegetable for residents on the mechanical soft diets and according to the recommendations in the dietary manual and mechanically altered menus.-At 12:15 p.m., during lunch service, CK #2 was interviewed. CK #2 said she was the evening cook. CK #2 said mechanically altered menus for the meals were not available for guidance in the kitchen when the cooks were preparing and serving the meals, but the dietary manager (DM) might have the mechanically altered diet menus. IV. Additional staff interviewsThe DM was interviewed on 5/2/24 at 12:20 p.m.. The DM said she used the dietary manual as a guideline for preparing and serving mechanically altered diets at the facility instead of utilizing the mechanically altered menus. On 5/2/24 at 12:25 p.m. the mechanically altered menus were requested from the NHA. The NHA said he would print and provide the mechanically altered menus. The NHA said he was not sure if the DM knew how to print the mechanically altered menus and the facility used the level two national dysphagia diet for mechanical soft meal modifications. The NHA said the dietary manager was new to the facility and the facility's menu program so a staff member who was trained to use the menu program would train the DM on the program. Certified nurse aide (CNA) #2 was interviewed on 5/7/24 at 10:00 a.m. CNA #2 said she had not received training on mechanically altered diets or how to recognize if a modified texture diet was prepared incorrectly in order to identify an error prior to the resident being served a meal tray. CNA #2 said if a resident ordered a menu item she thought was not part of the resident's prescribed diet, she would notify the DM. She said the DM could talk to and educate the resident about the resident's diet. The DM and NHA were interviewed together on 5/7/24 at 11:30 a.m. The DM said she was not aware the stuffed peppers served during the 5/2/24 lunch meal were to be served pureed for residents on a mechanical soft diet. The DM said she did not slurry the wheat rolls and mocha fudge cakes prior to the lunch meal being served to residents on the mechanical soft diets. The DM said she knew the items needed to be soft to decrease the risk of the resident choking. The NHA said if a resident requested an item not recommended on their prescribed diet, the facility would provide education to the resident, contact the physician and the facility could consider a speech evaluation to upgrade a resident's diet texture if it was appropriate. The NHA said the dietary staff used the mechanical soft diet menus for meals after the lunch meal service on 5/2/24. The NHA said the facility planned to transition to the International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) (a tool to standardize mechanically altered diets and liquids) and speech therapists at the facility would assist with training facility staff during the transition. The NHA said CNAs were all previously trained on recognizing appropriate items for modified textures during meal time. The NHA said the CNAs were scheduled to have additional training on mechanically altered diets during their upcoming skills fair.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to:-Ensure staff performed hand hygiene appropriately while washing dishes and handling clean dishes; and,-Ensure food was labeled, dated and disposed of timely in the nourishment refrigerator. Findings include:I. Ensure staff performed hand hygiene appropriately while washing dishes and handling clean and sanitized dishesA. Professional referenceThe Colorado Retail Food Regulations, (3/16/24), retrieved on 5/9/24 from https://cdphe.colorado.gov/environment/food-regulations, The regulations read in pertinent part, "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."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; when switching between working with raw food and working with ready-to-eat food; before donning 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 Food Safety Requirements policy, revised 4/12/14, was provided by the nursing home administrator (NHA) on 5/6/24 at 10:00 a.m. The policy read in pertinent part, "All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. Clean dishes shall be kept separate from dirty dishes. Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils."Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Staff shall wash hands according to facility procedures. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas. Gloves will be worn when directly touching ready-to-eat foods and when serving residents who are on transmission-based precautions. However, staff do not need to wear gloves when distributing foods to residents at the dining table(s) or when assisting residents to dine unless touching ready-to-eat food."C. ObservationsDuring a continuous observation during the lunch meal service on 5/2/24, beginning at 11:15 a.m. and ending at 12:25 p.m., the following was observed:-At 11:36 a.m. dietary aide (DA) #1 lifted the dish machine door on the soiled side of the machine where soiled dishes were placed, pushed a rack of dishes into the dish machine and closed the dish machine door which automatically started the dishwashing cycle. DA #1 moved to the clean side of the dish machine and removed a pair of tongs from the clean and sanitized dish rack, carried the tongs to the three compartment sink, turned on the faucet with one hand, rinsed off the tongs in her other hand, turned off the faucet, shook the tongs and placed the tongs with the clean and sanitized dishes. DA #1 failed to perform hand hygiene before handling clean and sanitized dishes and placing them back with clean dishes used for food production.-At 11:38 a.m. DA #1 placed three full size baking sheets on the soiled side of the dish machine. DA #1 then placed a soiled pot and serving utensil on a dish rack. DA #1 walked to the clean side of the dish machine, used her hand to open the dish machine door and pulled the dish rack that contained clean out of the machine. DA #1 pushed another dish rack with soiled dishes into the dish machine, closed the dish machine door to start an automatic dishwashing cycle. Without performing hand hygiene, DA #1 then picked up a clean and sanitized six inch deep full size food steam table pan and placed the pan on a shelf with other clean and sanitized pans used for food production. DA #1 opened the dish machine door on the clean side of the dish machine and pulled the clean and sanitized dish rack onto the dish table.-At 11:40 a.m. DA #1 lifted two buckets on the shelf above the three compartment sink. She also turned on the water faucet in the three compartment sink. Without performing hand hygiene, DA #1 walked to the clean side of the dish area and began putting away clean dishes. -At 11:42 a.m. DA #1 opened the dish machine door on the soiled side and pushed a rack into the dish machine to be washed and closed the door to the dish machine. DA #1 walked to the three compartment sink, picked up an orange towel and wiped the table and sinks that were on the soiled and clean side of the dish machine. Without performing hand hygiene, DA #1 picked up clean dishes and put them away. DA #1 walked back to the three compartment sink, turned off the faucet with her hands, lifted a dirty item from inside the sink, walked over to a trash bin, lifted the trash can lid with her left hand and placed the item in the trash bin with her right hand. DA #1 walked back to the three compartment sink a second time, lifted a dirty item from inside the sink, walked back to the trash can, lifted the trash can lid with her left hand and placed something in the trash bin with her right hand.-At 11:44 a.m. without performing hand hygiene, DA #1 picked up a clean sauce pot and put it away with the clean dishes.-At 11:49 a.m. DA #1 put on single use disposable gloves. DA #1 began scraping food off dirty plates and bowls into the trash bin while wearing the single use gloves. A staff member approached DA #1 and asked for a coffee cup. While still wearing the same gloves, DA #1 picked up a clean coffee cup and gave the cup to a staff member. The staff member then filled the cup with coffee, walked into the dining room and handed the cup of coffee to a resident. D. InterviewsThe director of housekeeping (DOH), the dietary manager (DM) and the NHA were interviewed together on 5/7/24 at 11:30 a.m. The DOH said the previous infection preventionist (IP) had provided hand hygiene in-services to the kitchen staff which included education on performing hand hygiene after handling dirty dishes and before handling clean dishes. The NHA said handwashing education was provided to the kitchen staff during the survey. He said the education covered proper hand hygiene while washing dishes. He said he would include the information in the upcoming staff skills fair. The DM said DA #1 had been provided hand hygiene education prior to the survey. DA #1 was interviewed on 5/7/24 at 1:00 p.m. DA #1 said she typically washed and put away dishes as needed. DA #1 said if she wore disposable gloves to wash dishes, she needed to remove her gloves and clean her hands before handling clean dishes. DA #1 said she knew to wash her hands for 15 seconds during the hand washing process. She said she knew her hands needed to be washed after touching an unclean item and prior to touching a clean item. DA #1 said she had not been provided handwashing education until 5/2/24 (during the survey). DA #1 said she believed she received handwashing training upon hire two years ago. The IP was interviewed on 5/7/24 at 4:00 p.m. The IP said she provided hand hygiene education to the dietary staff on 5/2/24 (during the survey). She said the education included teaching staff hand hygiene needed to be performed after handling soiled dishes and before touching clean dishes. The IP said she tracked staff education with a spreadsheet and all staff signed off verifying the education was provided. The IP said she provided hand hygiene education to the facility staff at an all staff meeting prior to the survey. The director of nursing (DON) was interviewed on 5/7/24 at 4:00 p.m. The DON said hand hygiene audits would be in place for all departments including staff who worked in the kitchen. II. Ensure food was labeled and dated and disposed of timely in the main kitchen and nourishment refrigeratorA. Professional referenceThe Colorado Retail Food Regulations, (3/16/24), retrieved on 5/9/24 from https://cdphe.colorado.gov/environment/food-regulations. The regulation read in pertinent part,"A date marking system may include 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; 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; and using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the regulatory authority upon request."B. Facility policy and procedureThe Food Safety Requirements policy, revised 4/12/14, was provided by the nursing home administrator (NHA) on 5/6/24 at 10:00 a.m. The policy read in pertinent part, "Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. Practices to maintain safe refrigerated storage include: Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation; labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and keeping foods covered or in tight containers." C. Observations On 5/2/24 at 2:00 p.m. the following items were observed in the nourishment room refrigerator:-A stack of three plastic food containers. The top container had a resident's name and the date 2/28/24 was written on a label on the container. The middle had a name written on the label but did not have a date written on the container. The bottom container had no label or date.-A local fast food restaurant sandwich bag with the date 4/23/24 written on the bag.-A sandwich on the bottom shelf of the refrigerator in a clear sandwich bag with 'PBJ' and 4/19/24 written on the clear sandwich bag. -One 32 ounce (oz) container of carrot juice. The container was half full with a name written on the bottle. An open date was not written on the bottle. -An open four oz container of yogurt. The yogurt container was half full and did not have a name or open date and was not rewrapped to seal the yogurt.-There were two individual portion cups that did not have a name, date or label to indicate what was in the cups.-A paper bag containing food items was in the freezer. The bag was not labeled with a name and the date 4/14/24 was on the bag. The nourishment refrigerator was observed again on 5/6/24 at 10:30 a.m. The following items were observed in the nourishment room refrigerator:-The stack of three plastic food containers remained in the refrigerator. The top container had a resident's name and the date 2/28/24 was written on a label on the container. The middle had a name written on the label but did not have a date written on the container. The bottom container had no label or date. -The fast food restaurant sandwich bag with the date 4/23/24 written on the bag was still in the refrigerator.-The sandwich on the bottom shelf of the refrigerator in a clear sandwich bag with 'PBJ' and 4/19/24 written on the clear sandwich bag was still in the refrigerator. -Two individual portion cups that did not have a name, date or label to indicate what was in the cups remained in the refrigerator.-A reusable ceramic drink cup with a lid that did not have a name or date on the cup. D. Staff interviewsThe NHA was interviewed on 5/6/24 at 10:45 a.m. The NHA said the DM was responsible for monitoring the contents of the refrigerator and removing expired items. Certified nurse aide (CNA) #4 was interviewed on 5/7/24 at 10:00 a.m. CNA #4 said the dietary staff removed expired food from the nourishment refrigerator but the other staff could also throw away expired food. CNA #4 said she was trained to write a resident's name on the food items brought by the family or resident and put the resident's room number on the item. CNA #4 said she was unsure of an appropriate expiration date for the food items brought by residents or their family. The DM was interviewed with the NHA on 5/7/24 at 11:30 a.m. The DM said a dietary aide checked the nourishment refrigerator daily and she would check the refrigerator also. The DM said dietary staff should clean out the expired food products. The DM said families brought in food for the residents. The DM said food made at the facility and placed in the nourishment refrigerator should be used within three days or discarded. The DM said sandwiches made at the facility were usually placed in a different smaller refrigerator instead of the larger refrigerator the expired food was found in. The NHA said the sandwiches might have been placed in the wrong refrigerator and should have been placed in the smaller refrigerator. The NHA said the large refrigerator was labeled as a resident refrigerator only and staff should not put their drinks in the larger refrigerator.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of six units. Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touched areas (call lights, door handles and handrails);-Ensure housekeeping staff were trained appropriately on housekeeping procedures;-Ensure housekeeping staff used the correct surface disinfectant products; and,-Ensure surface disinfectant times were adhered to. Finding include: I. Professional referenceAssadian 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, was retrieved on 5/9/24. It revealed in pertinent part, "High-touch surfaces, on the other hand, 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) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. 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." The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 5/9/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, "High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs."Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."II. Facility policy and procedureThe Housekeeping Services policy and procedure, revised on 4/12/24, was provided by the director of nursing (DON) on 5/7/24 at 3:17 p.m. It read in pertinent part, "It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in resident rooms and common areas. Cleaning considerations include, but are not limited to, the following: clean from top to bottom (bring dirt from high levels down to floor levels) and clean from back to front areas."Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: toilet flush handles, bed rails,tray tables, call buttons, television remote, telephones, toilet seats, monitor control panels, touch screens and cables, resident chairs, IV (intravenous) poles, blood pressure cuffs, sinks and faucets, light switches and door knobs and levers."The disinfectant solution will be prepared fresh daily and changed frequently in order to ensure effectiveness. Housekeeping staff should follow manufacturer recommendations for dilution and frequency of changing of disinfectant solution. Housekeeping staff should follow manufacturer recommendations regarding appropriate contact times to ensure adequate disinfection."The director of housekeeping (DOH) provided the surface cleaner instructions on 5/2/24 at 3:45 p.m. it read "The surface cleaner used in the facility is Spray Kleen Multi-Surface Neutral Cleaner. The guidelines read: "Spray Kleen Multi-Surface Neutral Cleaner is a superior multi-purpose cleaner specifically designed to safely clean most kitchen surfaces. Spray Kleen multi-surface neutral cleaner is perfect for kitchen floors and is economical to use. The product picks up grease, cleans out grout and leaves surfaces clean and film free. The product is ideal for cleaning floors, walls, terrazzo and quarry tile."III. ObservationsDuring a continuous observation on 5/6/24, beginning at 12:30 p.m. and ending at 12:59 p.m., housekeeper (HSKP) #1 was observed cleaning room #203 and #204 -HSKP #1 used a surface cleaner (see above) not a disinfectant to clean the surfaces in the room. HSKP #1 used a cleaner agent soaked cloth and wiped the horizontal surfaces in the rooms (night stands and tray tables). HSKP #1 wiped the surfaces in the rooms with the cleaning agent soaked cloth for four seconds per surface. HSKP #1 used the same cleaning agent soaked cloth to clean the nightstands and tray tables for all three residents in room #203 and used a different cleaning agent soaked cloth to clean the nightstands and tray tables for all three residents in room #204. -HSKP #1 did not use a separate rag for each resident's nightstand and tray table in the two rooms.-HSKP #1 did not sanitize or clean the high frequency touch areas (call lights, door knobs, light switches, closet handles, bathroom grab bars and bed remote) in room #203 or room #204. The bathroom in each room had a safety rail which was shared by the three residents who resided in the room. -HSKP #1 did not disinfect the bathroom safety rails in room #203 or room #204.. During a continuous observation on 5/6/24, beginning at 1:15 p.m. and ending at 1:30 p.m., HSKP #2 was observed cleaning room #304. -HSKP #2 used a surface cleaner (see above) not a disinfectant to clean the surfaces in the room. HSKP #2 used a cleaning agent soaked cloth and wiped horizontal surfaces in the room (night stands and tray tables). HSKP #2 wiped the surfaces in the room for four seconds per surface and the surface. HSKP #2 sprayed the cleaning agent inside the toilet bowl and used a brush to clean the inside of the toilet. HSKP #2 used the same toilet brush to clean the outside of the toilet bowl and the flushing handle. -HSKP #2 did not sanitize or clean the high frequency touch areas (call lights, door knobs, light switches, closet handles, bathroom grab bars and bed remote). IV. Staff interviewsHSKP #1 was interviewed on 5/6/24 at 1:07 p.m. HSKP #1 said she used the Spray Kleen Multi-Surface Cleaner to clean the residents' rooms. She said she did not disinfect the room with an approved disinfectant product. She said she did not clean all of the high frequency touch areas in rooms #203 and #204. HSKP #2 was interviewed on 5/6/24 at 1:31 p.m. HSKP #2 said she used the Spray Kleen Multi-Surface Cleaner to clean the residents' rooms. She said she did not disinfect the room with an approved disinfectant product. HSKP #2 said she was not trained in housekeeping properly and she was recently hired. She said she did not know what high frequency touch areas were. The DOH was interviewed on 5/7/24 at 2:15 p.m. The DOH said there were areas of opportunity to improve on related to housekeeping and routine room cleaning procedures. The DOH said housekeeping staff did not clean the residents' rooms according to the facility's procedure. The DOH said the facility disinfectant needed to be used when cleaning the resident rooms. He said the high frequency touch areas needed to be disinfected as well. He said the rooms should never be cleaned with only a cleaning agent. The DOH said he needed to provide training to all housekeeping staff. He said he needed to revise the current training program to cover using the correct surface disinfectant, not mixing chemicals, proper hand hygiene, surface disinfectant dwell times, room cleaning procedures and high frequency touch areas and he would have to audit housekeeping staff when they were cleaning residents' rooms to determine if they needed additional training. The director of nursing (DON) and infection preventionist (IP) were interviewed together on 5/7/24 at 2:23 p.m. The DON and the IP said surface disinfectant times should be adhered to in order to ensure surfaces were properly disinfected and all pathogens were destroyed. The DON and the IP said high frequency touch areas should be disinfected and only approved facility disinfectant products should be used. The DON and the IP said housekeeping staff should change cleaning cloths and gloves and complete hand hygiene appropriately between different areas of cleaning the resident rooms, between the A, B and C side of the rooms and between the bathroom and room. The DON and the IP said a toilet brush should never be used to clean the outside of the toilet bowl after cleaning the inside of the toilet bowl.

Based on observations and interviews, the facility failed to maintain an environment for residents, staff and the public that is safe, functional, sanitary and comfortable for one of two shower rooms at the facility. Specifically, the facility failed to ensure the shower room was sanitary and safe for residents to use. Finding include: I. Facility policy and procedureThe Housekeeping Services policy and procedure, revised on 4/12/24, was provided by the director of nursing (DON) on 5/7/24 at 3:17 p.m. It read in pertinent part, "It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible." II. ObservationsOn 5/7/24 at 2:30 p.m. the shower room between unit 100 and 200 was observed. The following was observed:The shower room had two wooden fabric woven chairs used for residents besides the shower. Both chairs were damp to touch and had visible brown stains on them. The shower curtain divider that hung between both sides of the shower had brown and black stains on it. Approximately 12 inches of the curtain was touching the ground. The corner wall by the shower entrance had a hole in the wall with jagged tile edges that was approximately six inches from the ground. There was another hole in the wall on the west wall near the entry from the 200 hall. The hole in the wall was approximately two inches in diameter and was approximately 12 inches from the ground. The grout in the shower room around the corners and in the shower had white, brown and black hardened debris that protruded approximately half an inch. There were five missing floor tiles by the shower entrance. The floor of the shower room by the shower entrance had a bottle of shampoo and body lotion stored on the ground next to a soiled adult brief. There was a razor that was on the floor next to used paper towels. The sharps container (a container used to dispose of needles and other sharp medical waste) was full. There was a bottle of glass cleaner by the shower room entrance on the floor, however, there were no other disinfectant products visible in the shower room for the certified nurse aides (CNA) to disinfect surfaces between residents. III. Staff interviewsHousekeeper (HSKP) #1 was interviewed on 5/7/24 at 2:45 p.m. HSKP #1 said she did not know she needed to clean the shower room between unit 100 and 200. The director of housekeeping (DOH) was interviewed on 5/7/24 at 2:50 p.m. The DOH said there were areas of opportunity related to housekeeping and shower room cleaning procedures they could improve on. The DOH said housekeeping staff were not cleaning the shower room according to the facility's procedure. The DOH said the approved facility disinfectant should be used when cleaning the shower rooms and housekeeping staff should clean the shower room at least once daily. The DOH said the shower room needed to be deep cleaned to ensure the grout was clean without any accumulation of debris. He said the missing tiles and holes in the wall needed to be repaired before staff or residents used the room for safety purposes. The DOH said he needed to replace the shower divider with the appropriate length one. He said he needed to ensure it was cleaned and did not hang on the floor for infection control purposes. The DOH said personal hygiene items, trash and razors should not be stored on the ground as it was unsanitary and posed a potential safety risk. The DOH said the chairs used in the shower room were not appropriate to be used as shower chairs since the surfaces were not cleanable. He said water and other materials would soak into the fabric and the wood would rot over time since it was damp and wet in the shower room. The DOH said he needed to provide training and education to all housekeeping staff related to their responsibilities, cleaning procedures and he needed to audit the shower room weekly to ensure the room was safe, sanitized, cleaned and free of damage. The director of nursing (DON) and infection preventionist (IP) were interviewed together on 5/7/24 at 3:05 p.m. The DON and the IP said the shower chairs were not cleanable and should have never been used as they collected bacteria due to the porous surface of the fabric chair. They said the wood would rot and the chairs might not be able to withstand a person's weight. The DON and the IP said all items should be picked up off the floor including the shower divider and no trash should be left on the floor. The DON and the IP said all sharps should be disposed of in the appropriate sharps receptacle and all surfaces should be cleanable. The DON and the IP said loose and/or broken tiles and holes in the wall should be repaired to prevent pathogens from developing and to ensure black mold would not develop from the lack of cleaning in addition to the moist environment. The DON and the IP said they needed to work closely with housekeeping and all nursing care staff to provide education and training related to infection control practices related to the observed areas of opportunity in the shower room.

Based on record review and interviews, the facility failed to ensure five (#1, #4, #5, #6 and #7) of five certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, the facility failed to ensure CNA #1, #4, #5, #6 and #7 received 12 hours of training annually. Findings include:I. Facility policy and procedureThe Nurse Aide Training Program policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:13 p.m. It read in pertinent part, "The facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides. "The staff development coordinator (SDC), with oversight from the director of nursing (DON), shall be responsible for the coordination and/or provision of nurse aide education. "Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year."II. Training reviewA review of all five CNAs annual training was reviewed on 5/6/24 at 1:59 p.m. It revealed that documentation of annual training was not maintained. -The SDC was unable to provide documentation of the required 12 hour continued education units (CEU). III. Staff interviewsThe SDC was interviewed on 5/7/24 at 10:37 a.m. The SDC said the facility did not have a process to track the required 12 hour annual CEUs for the CNAs. She said she had put binders together in March 2024 and was currently working on a tracking form to document the CNAs completed in-service training. She said the facility had a planned skills fair for June 2024. She said she was putting a new employee packet together for training and competencies.

A complaint survey, prompted by #CO35415, #CO35450 and Incident #CO34415 was conducted on 4/1/24 to 4/2/24. No deficiencies were cited.

A complaint survey, prompted by #CO34566 and Incident #34492 was conducted on 1/9/24. No deficiencies were cited.

A revisit survey was completed on 1/8/24 for all previous deficiencies cited on 12/6/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/8/24 for all previous deficiencies cited on 12/6/23. The facility is in compliance with all regulations surveyed.

A complaint survey prompted by #CO33744, #CO34222, #CO34234, #CO34288, #CO34370 and Incident #31733 was conducted on 12/5/23 to 12/6/23. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure interventions were carried out or offered to prevent pressure injury from occurring for two (#8 and #9) of five residents reviewed for pressure injuries out of 15 sample residents. Resident #8, was admitted on 9/5/23 for long term care. The resident was admitted without a pressure injury to the right heel. The resident was at risk for developing pressure injuries. The facility failed to proactively implement treatment interventions to prevent the resident from developing a deep tissue pressure injury to her right heel on 11/1/23 that was staged as stage 3 on 11/28/23. No treatment orders or physician orders were in place to promote prevention and active healing of the pressure injury. The care plan was not updated with a focus, goals and interventions to specifically address the facility acquired pressure injury. Observations revealed the resident was not offered pressure relieving boot to her right heel. Additionally, Resident #9 was at high risk for pressure injuries when admitted to the facility on 3/20/23. The facility failed to implement preventative measures despite the resident's known risk. The resident developed a facility acquired unstageable wound on 4/4/23, 15 days after her admission. The wound progressed to a stage 3 pressure injury on 6/16/23. Findings include:I. Professional referenceThe National Pressure Injury Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 12/8/23 read in pertinent part:"Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury:Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed."Steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time."The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing:-Positioning that places pressure on the pressure ulcer should be avoided.-The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented.-The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications.-Signs of deterioration in the wound should be addressed immediately.-The assessment should include: location, category/stage, size, tissue type, color, periwound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order."II. Facility policy and procedureThe Pressure Injury Prevention and Management policy, not dated, was provided by the nursing home administrator (NHA) on 12/6/23. It read in pertinent part: "This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. "After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). "Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to:Redistribute pressure (such as repositioning, protecting and/or offloading heels);Minimize exposure to moisture and keep skin clean, especially of fecal contamination;Provide appropriate, pressure-redistributing, support surfaces;Provide non-irritating surfaces; and- Maintain or improve nutrition and hydration status, where feasible. Any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner."Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include:Changes in resident's degree of risk for developing a pressure injury. New onset or recurrent pressure injury development. Lack of progression towards healing. Resident non-compliance. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights."III. Resident #8A. Resident statusResident #8, above the age of 65, was admitted on 9/5/23. According to the December 2023 computerized physician orders (CPO), diagnoses included malignant neoplasm (cancer) of an unspecified part of an unspecified bronchus or lung, chronic respiratory failure, unspecified whether with hypoxia (inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood ) or hypercapnia (too much CO2 in the blood), secondary malignant neoplasm of retroperitoneum (an anatomical space located behind the abdominal or peritoneal cavity) and peritoneum (continuous transparent membrane which lines the abdominal cavity and covers the abdominal organs), extended spectrum beta lactamase resistance ( enzymes that confer resistance to most beta-lactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam. Infections with ESBL-producing organisms have been associated with poor outcomes.), repeated falls, polyneuropathy (multiple peripheral nerves become damaged), unspecified protein calorie malnutrition, type II diabetes mellitus with hyperglycemia and essential primary hypertension. The 9/18/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required extensive assistance with bed mobility, dressing and personal hygiene and limited assistance with toilet use. The resident did not have any pressure injuries or skin conditions coded on the assessment. B. ObservationsOn 12/5/23 Resident #8 was observed continuously from 11:59 a.m. until 12:23 p.m. Resident #8 was sitting in her wheelchair without her heel pressure relief boot on. The pressure relief boot was on the resident's table covered with clothes. A dressing was on the resident's right heel. The resident's heel was resting directly on the wheelchair's foot pedal. A certified nurse aide (CNA) entered the resident's room, however, the heel pressure relief boot was not offered and foot elevation was not offered. The resident's mattress was a standard mattress and not an air mattress. On 12/6/23 Resident #8 was observed continuously from 10:35 a.m. until 11:15 a.m. Resident #8 was seated upright in her wheelchair without her heel pressure relief boot on. The pressure relief boot was on the resident's table covered with clothes in the same position as it was observed on 12/5/23. A dressing was observed on the resident's right heel. The resident's heel was resting directly on the wheelchair's foot pedal. A CNA and a registered nurse (RN) entered the resident's room, however, the heel pressure relief boot was not offered and foot elevation was not offered. The resident's mattress was a standard mattress and not an air mattress. C. Record review The 9/5/23 initial skin assessment documented the resident had no pressure injuries. The Braden scale completed on 9/5/23 documented the resident was at moderate risk for developing pressure ulcers. The wound to the right heel was identified on 11/1/23 on the weekly skin assessment. The comments revealed "will monitor and float heel, wound Medical Doctor (MD) to evaluate."-There was no wound stage identified on the assessment. -However, the wound doctor did not assess the wound until a week later and those notes were not available. The first wound doctor note was on 11/16/23 (see below). The progress note dated 11/8/23 revealed interventions listed were to encourage offloading boots.-No orders were in place for offloading boots on the CPO.The weekly pressure ulcer report dated 11/14/23 was reviewed. It revealed the resident's deep tissue injury had dimensions of 5 centimeters (cm) by 4 cm by 0 cm. The treatment/evaluation of effectiveness listed was to continue to stress the importance of floating heel. The wound physician assessed Resident #8 on 11/16/23. The wound note dated 11/16/23 was reviewed, it revealed the resident developed a deep tissue pressure injury with dimensions of 5 cm by 4 cm by 0 cm. The treatment order was to paint with betadine daily and leave open to air. The progress note dated 11/17/23 revealed the intervention was to continue to float heels. The weekly pressure ulcer report dated 11/17/23 was reviewed. It revealed the resident's right heel deep tissue injury had dimensions of 5 cm by 4 cm by 0 cm.-The treatment/evaluation of effectiveness was not completed. The wound note dated 11/21/23 revealed the resident's deep tissue pressure injury dimensions were 3 cm by 3 cm by 0 cm. The treatment order was to use skin prep, xeroform and dry dressing change three times weekly. The weekly pressure ulcer report dated 11/21/23 revealed the resident's deep tissue pressure injury had dimensions of 3 cm by 3 cm by 0 cm.-The treatment/evaluation of effectiveness was not completed. The progress note dated 11/22/23 revealed the interventions were to continue treatment orders. The weekly pressure ulcer report dated 11/28/23 revealed the resident's deep tissue pressure injury to the right heel was classified as a stage 3 pressure injury with dimensions of 2.5 cm by 2.5 cm by 0.3 cm.-The treatment/evaluation of effectiveness was not completed. The progress note dated 12/1/23 revealed the intervention was to continue to float heels. A physician's order was initiated on 11/2/23 and discontinued on 11/28/23. The order read "right heel wound orders: paint with betadine daily."A physician's order was identified for wound care to the right heel. The order was initiated on 11/29/23. The order read: "Wound care orders for right heel: skin prep, silver alginate, foam and change three times per week one time a day for wound care."-No other physician orders were in place for the resident to be offloaded or to utilize the pressure relief boot. The care plan,revised on 11/17/23, identified the resident was at high risk for potential and or actual impairment to skin integrity related to fragile skin. Pertinent interventions included: pressure relieving device and positioning.-The care plan did not identify the specific pressure area and specific interventions to promote wound healing through wound care. D. Staff interviews CNA #1 was interviewed on 12/6/23 at 11:05 a.m. The CNA said she was aware of the resident's stage 3 pressure injury to the right heel. She said there was not anything certain to do for the resident's pressure injury that she would be involved in. She said the care plan only addressed repositioning in bed and to use a pressure relief device but she was not certain the resident had one to be used. She said the resident would benefit from offloading, an air mattress and pressure relief boots and said she did not offer to offload the resident and or offer any pressure relief devices. Licensed practical nurse (LPN) #1 was interviewed on 12/6/23 at 11:17 a.m. The LPN said the resident developed the pressure ulcer from not being mobile and from being in bed or the wheelchair most of the day as the resident required total assistance from staff. LPN #1 said in order to treat the pressure injury, the resident should be provided with an air mattress, repositioning every two hours, pressure relief boots when in bed or the wheelchair, offloading/elevation with a pillow andProstat (a protein supplement to promote wound healing). LPN #1 said any care staff member could offer the resident the pressure relief boots and they should be offered every time the resident was in bed or in her wheelchair. LPN #1 said she would review the physician's orders to determine what treatment to carry out. LPN #1 said there were no additional orders aside from wound care. LPN #1 said the resident was not offered the pressure relief boots because the resident did not have boots ordered and may not have a pressure relief boot in the room. LPN #1 identified the boot after prompting and she said the boot would be hard to find under a pile of clothes. LPN #1 said the resident was not offered repositioning by her or the staff present on 12/6/23 during continuous observation. LPN #1 said the resident did not have an air mattress. The assistant director of nursing (ADON) was interviewed on 12/6/23 at 12:40 p.m. She said Resident #8 acquired a stage 3 pressure injury at the facility. No treatment orders were obtained and or updated by the physician aside from the bandage to the heel. She said orders should be in place for boots and offloading. The ADON said the resident would benefit from an air mattress and Prostat for wound healing and said there were no orders currently in place. The ADON said the resident should be wearing the boot while in the wheelchair and in bed. The ADON said the resident's heels were not offloaded on 12/6/23 and the resident did not have an air mattress. The ADON said if appropriate interventions were in place the facility could have prevented the wound from developing. The ADON said the facility would obtain orders for the pressure relief boots, offloading, Prostat after consulting with the registered dietitian, obtain an air mattress and update the resident's care plan. IV. Resident #9A. Resident statusResident #9, age 85, was admitted on 3/20/23. According to the December 2023 CPO, diagnoses included Alzheimer's (disease affecting memory), dementia (disease affecting memory), chronic obstructive pulmonary disease (COPD) abnormal oxygen exchange), chronic respiratory failure (abnormal oxygen exchange) and major depressive disorder. The 11/8/23 MDS assessment revealed the resident was cognitively impaired with short and long term memory loss. She required maximal assistance with eating, dressing, toileting, transfers and toileting. It documented a stage 3 pressure injury over a bony prominence. B. Record reviewReview of the 3/22/23 comprehensive care plan, initiated on 9/26/23, revealed Resident #9 had potential/actual impairment to skin integrity related to limited mobility. The care plan documented the following interventions: floating heels while in bed, measure and document on wound progression weekly, physician notification if wound worsening, supplements per physician order, weekly skin checks per facility protocol and wound treatment orders to right heel per physician order.-The care plan interventions were all initiated five months after the right heel pressure injury was identified (see below). The discharge paperwork from the facility where Resident #9 previously resided prior to coming to the current facility documented the resident's skin was intact on 2/26/23. According to the admission assessment completed on 3/20/23, Resident #9's skin was observed to be intact on admission. A weekly skin assessment completed on 3/29/23 identified Resident #9's skin was intact.-Fifteen days post admission, a pressure injury was identified to the right heel during the weekly skin assessment (see below). The admission Braden scale (assessment tool to determine risk factors for pressure injury development) documented Resident #9 was at moderate risk for pressure injury development. The 3/27/23 admission MDS assessment indicated Resident #9 did not have any pressure injuries on admission but the resident was identified at risk for developing pressure injuries. The March 2023 CPO documented no orders for wound care to the right heel. The weekly skin assessment on 4/4/23 identified a pressure injury to the right heel. The April 2023 CPO revealed an order to start on 4/5/23 for wound care right heel apply betadine daily, leave open to air and off load heel. Review of the wound physician progress note dated 4/4/23 revealed the wound physician first evaluated Resident #9 who presented with a new unstageable wound to her right heel. An interdisciplinary team note dated 6/16/23 identified the wound progressed from unstageable to a stage 3 pressure injury. An evaluation summary progress note on 8/29/23 documented the right heel was a stage 4 pressure injury. An evaluation summary progress note on 9/19/23 documented the right heel wound as a stage 3 pressure injury. An evaluation summary progress note on 11/28/23 documented the right heel wound as a stage 3pressure injury. C. Staff interviewsThe ADON was interviewed on 12/6/23 at 12:45 p.m. She said it was the responsibility of the nurse admitting the resident to complete a skin assessment. The ADON said if the admitting nurse was a LPNthey were to seek assistance from a registered nurse (RN) for staging a pressure wound. The ADON said skin assessments were to be completed on admission and then weekly by a licensed nurse. The ADON said if there was a skin issue identified, such asa pressure injury, the resident would see the wound physician at their next visit to the facility and the facility's wound physician made rounds weekly on Tuesdays. The ADON said the attending physician would then give wound care orders until the wound physician was able to see the resident. The ADON reviewed the following documents (identified above in record review) and said it was a facility acquired wound. The ADON said nursing completed weekly wound rounds with the wound physician. The NHAwas interviewed on 12/6/23 at 12:45 p.m. She said the MDS nurse was working remotely and did not see the resident personally when completing the MDS assessment and she would needed to do more research into Resident #9's wound situation to determine if the wound was facility acquired or if Resident #9 was admitted with the pressure injury.-However, the resident's skin assessments prior to developing the wound, 15 days after admission, indicated her skin was intact. V. Additional informationThe NHA provided a progress note on 12/6/23 at 1:45 p.m. The progress note, dated 8/15/23, documented the initial observation of the right heel wound was 3/20/23.-This progress note was dated five months after admission. The NHA provided a plan of correction dated 9/25/23 for accuracy of assessments identifying the director of nursing audited charts and corrected charts to ensure accuracy. The director of nursing (DON) was also responsible for educating staff on how to accurately complete assessments and ensure all data was correct. Documentation of staff that attended the education on 10/19/23 were six licensed nursing staff members including the DON. A seventh staff member completed the education on 10/23/23.-The staff education was not completed with all licensed nursing staff employed by the facility.

A survey prompted by complaint #CO34424 was completed 12/5/23 to 12/6/23. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure interventions were carried out or offered to prevent pressure injury from occurring for two (#8 and #9) of five residents reviewed for pressure injuries out of 15 sample residents. Resident #8, was admitted on 9/5/23 for long term care. The resident was admitted without a pressure injury to the right heel. The resident was at risk for developing pressure injuries. The facility failed to proactively implement treatment interventions to prevent the resident from developing a deep tissue pressure injury to her right heel on 11/1/23 that was staged as stage 3 on 11/28/23. No treatment orders or physician orders were in place to promote prevention and active healing of the pressure injury. The care plan was not updated with a focus, goals and interventions to specifically address the facility acquired pressure injury. Observations revealed the resident was not offered pressure relieving boot to her right heel. Additionally, Resident #9 was at high risk for pressure injuries when admitted to the facility on 3/20/23. The facility failed to implement preventative measures despite the resident's known risk. The resident developed a facility acquired unstageable wound on 4/4/23, 15 days after her admission. The wound progressed to a stage 3 pressure injury on 6/16/23. Findings include:I. Professional referenceThe National Pressure Injury Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 12/8/23 read in pertinent part:"Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury:Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed."Steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time."The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing:-Positioning that places pressure on the pressure ulcer should be avoided.-The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented.-The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications.-Signs of deterioration in the wound should be addressed immediately.-The assessment should include: location, category/stage, size, tissue type, color, periwound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order."II. Facility policy and procedureThe Pressure Injury Prevention and Management policy, not dated, was provided by the nursing home administrator (NHA) on 12/6/23. It read in pertinent part: "This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. "After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). "Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to:Redistribute pressure (such as repositioning, protecting and/or offloading heels);Minimize exposure to moisture and keep skin clean, especially of fecal contamination;Provide appropriate, pressure-redistributing, support surfaces;Provide non-irritating surfaces; and- Maintain or improve nutrition and hydration status, where feasible. Any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner."Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include:Changes in resident's degree of risk for developing a pressure injury. New onset or recurrent pressure injury development. Lack of progression towards healing. Resident non-compliance. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights."III. Resident #8A. Resident statusResident #8, above the age of 65, was admitted on 9/5/23. According to the December 2023 computerized physician orders (CPO), diagnoses included malignant neoplasm (cancer) of an unspecified part of an unspecified bronchus or lung, chronic respiratory failure, unspecified whether with hypoxia (inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood ) or hypercapnia (too much CO2 in the blood), secondary malignant neoplasm of retroperitoneum (an anatomical space located behind the abdominal or peritoneal cavity) and peritoneum (continuous transparent membrane which lines the abdominal cavity and covers the abdominal organs), extended spectrum beta lactamase resistance ( enzymes that confer resistance to most beta-lactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam. Infections with ESBL-producing organisms have been associated with poor outcomes.), repeated falls, polyneuropathy (multiple peripheral nerves become damaged), unspecified protein calorie malnutrition, type II diabetes mellitus with hyperglycemia and essential primary hypertension. The 9/18/23 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required extensive assistance with bed mobility, dressing and personal hygiene and limited assistance with toilet use. The resident did not have any pressure injuries or skin conditions coded on the assessment. B. ObservationsOn 12/5/23 Resident #8 was observed continuously from 11:59 a.m. until 12:23 p.m. Resident #8 was sitting in her wheelchair without her heel pressure relief boot on. The pressure relief boot was on the resident's table covered with clothes. A dressing was on the resident's right heel. The resident's heel was resting directly on the wheelchair's foot pedal. A certified nurse aide (CNA) entered the resident's room, however, the heel pressure relief boot was not offered and foot elevation was not offered. The resident's mattress was a standard mattress and not an air mattress. On 12/6/23 Resident #8 was observed continuously from 10:35 a.m. until 11:15 a.m. Resident #8 was seated upright in her wheelchair without her heel pressure relief boot on. The pressure relief boot was on the resident's table covered with clothes in the same position as it was observed on 12/5/23. A dressing was observed on the resident's right heel. The resident's heel was resting directly on the wheelchair's foot pedal. A CNA and a registered nurse (RN) entered the resident's room, however, the heel pressure relief boot was not offered and foot elevation was not offered. The resident's mattress was a standard mattress and not an air mattress. C. Record review The 9/5/23 initial skin assessment documented the resident had no pressure injuries. The Braden scale completed on 9/5/23 documented the resident was at moderate risk for developing pressure ulcers. The wound to the right heel was identified on 11/1/23 on the weekly skin assessment. The comments revealed "will monitor and float heel, wound Medical Doctor (MD) to evaluate."-There was no wound stage identified on the assessment. -However, the wound doctor did not assess the wound until a week later and those notes were not available. The first wound doctor note was on 11/16/23 (see below). The progress note dated 11/8/23 revealed interventions listed were to encourage offloading boots.-No orders were in place for offloading boots on the CPO.The weekly pressure ulcer report dated 11/14/23 was reviewed. It revealed the resident's deep tissue injury had dimensions of 5 centimeters (cm) by 4 cm by 0 cm. The treatment/evaluation of effectiveness listed was to continue to stress the importance of floating heel. The wound physician assessed Resident #8 on 11/16/23. The wound note dated 11/16/23 was reviewed, it revealed the resident developed a deep tissue pressure injury with dimensions of 5 cm by 4 cm by 0 cm. The treatment order was to paint with betadine daily and leave open to air. The progress note dated 11/17/23 revealed the intervention was to continue to float heels. The weekly pressure ulcer report dated 11/17/23 was reviewed. It revealed the resident's right heel deep tissue injury had dimensions of 5 cm by 4 cm by 0 cm.-The treatment/evaluation of effectiveness was not completed. The wound note dated 11/21/23 revealed the resident's deep tissue pressure injury dimensions were 3 cm by 3 cm by 0 cm. The treatment order was to use skin prep, xeroform and dry dressing change three times weekly. The weekly pressure ulcer report dated 11/21/23 revealed the resident's deep tissue pressure injury had dimensions of 3 cm by 3 cm by 0 cm.-The treatment/evaluation of effectiveness was not completed. The progress note dated 11/22/23 revealed the interventions were to continue treatment orders. The weekly pressure ulcer report dated 11/28/23 revealed the resident's deep tissue pressure injury to the right heel was classified as a stage 3 pressure injury with dimensions of 2.5 cm by 2.5 cm by 0.3 cm.-The treatment/evaluation of effectiveness was not completed. The progress note dated 12/1/23 revealed the intervention was to continue to float heels. A physician's order was initiated on 11/2/23 and discontinued on 11/28/23. The order read "right heel wound orders: paint with betadine daily."A physician's order was identified for wound care to the right heel. The order was initiated on 11/29/23. The order read: "Wound care orders for right heel: skin prep, silver alginate, foam and change three times per week one time a day for wound care."-No other physician orders were in place for the resident to be offloaded or to utilize the pressure relief boot. The care plan, revised on 11/17/23, identified the resident was at high risk for potential and or actual impairment to skin integrity related to fragile skin. Pertinent interventions included: pressure relieving device and positioning.-The care plan did not identify the specific pressure area and specific interventions to promote wound healing through wound care. D. Staff interviews CNA #1 was interviewed on 12/6/23 at 11:05 a.m. The CNA said she was aware of the resident's stage 3 pressure injury to the right heel. She said there was not anything certain to do for the resident's pressure injury that she would be involved in. She said the care plan only addressed repositioning in bed and to use a pressure relief device but she was not certain the resident had one to be used. She said the resident would benefit from offloading, an air mattress and pressure relief boots and said she did not offer to offload the resident and or offer any pressure relief devices. Licensed practical nurse (LPN) #1 was interviewed on 12/6/23 at 11:17 a.m. The LPN said the resident developed the pressure ulcer from not being mobile and from being in bed or the wheelchair most of the day as the resident required total assistance from staff. LPN #1 said in order to treat the pressure injury, the resident should be provided with an air mattress, repositioning every two hours, pressure relief boots when in bed or the wheelchair, offloading/elevation with a pillow andProstat (a protein supplement to promote wound healing). LPN #1 said any care staff member could offer the resident the pressure relief boots and they should be offered every time the resident was in bed or in her wheelchair. LPN #1 said she would review the physician's orders to determine what treatment to carry out. LPN #1 said there were no additional orders aside from wound care. LPN #1 said the resident was not offered the pressure relief boots because the resident did not have boots ordered and may not have a pressure relief boot in the room. LPN #1 identified the boot after prompting and she said the boot would be hard to find under a pile of clothes. LPN #1 said the resident was not offered repositioning by her or the staff present on 12/6/23 during continuous observation. LPN #1 said the resident did not have an air mattress. The assistant director of nursing (ADON) was interviewed on 12/6/23 at 12:40 p.m. She said Resident #8 acquired a stage 3 pressure injury at the facility. No treatment orders were obtained and or updated by the physician aside from the bandage to the heel. She said orders should be in place for boots and offloading. The ADON said the resident would benefit from an air mattress and Prostat for wound healing and said there were no orders currently in place. The ADON said the resident should be wearing the boot while in the wheelchair and in bed. The ADON said the resident's heels were not offloaded on 12/6/23 and the resident did not have an air mattress. The ADON said if appropriate interventions were in place the facility could have prevented the wound from developing. The ADON said the facility would obtain orders for the pressure relief boots, offloading, Prostat after consulting with the registered dietitian, obtain an air mattress and update the resident's care plan. IV. Resident #9A. Resident statusResident #9, age 85, was admitted on 3/20/23. According to the December 2023 CPO, diagnoses included Alzheimer's (disease affecting memory), dementia (disease affecting memory), chronic obstructive pulmonary disease (COPD) abnormal oxygen exchange), chronic respiratory failure (abnormal oxygen exchange) and major depressive disorder. The 11/8/23 facility assessment revealed the resident was cognitively impaired with short and long term memory loss. She required maximal assistance with eating, dressing, toileting, transfers and toileting. It documented a stage 3 pressure injury over a bony prominence. B. Record reviewReview of the 3/22/23 comprehensive care plan, initiated on 9/26/23, revealed Resident #9 had potential/actual impairment to skin integrity related to limited mobility. The care plan documented the following interventions: floating heels while in bed, measure and document on wound progression weekly, physician notification if wound worsening, supplements per physician order, weekly skin checks per facility protocol and wound treatment orders to right heel per physician order.-The care plan interventions were all initiated five months after the right heel pressure injury was identified (see below). The discharge paperwork from the facility where Resident #9 previously resided prior to coming to the current facility documented the resident's skin was intact on 2/26/23. According to the admission assessment completed on 3/20/23, Resident #9's skin was observed to be intact on admission. A weekly skin assessment completed on 3/29/23 identified Resident #9's skin was intact.-Fifteen days post admission, a pressure injury was identified to the right heel during the weekly skin assessment (see below). The admission Braden scale (assessment tool to determine risk factors for pressure injury development) documented Resident #9 was at moderate risk for pressure injury development. The 3/27/23 admission facility assessment indicated Resident #9 did not have any pressure injuries on admission but the resident was identified at risk for developing pressure injuries. The March 2023 CPO documented no orders for wound care to the right heel. The weekly skin assessment on 4/4/23 identified a pressure injury to the right heel. The April 2023 CPO revealed an order to start on 4/5/23 for wound care right heel apply betadine daily, leave open to air and off load heel. Review of the wound physician progress note dated 4/4/23 revealed the wound physician first evaluated Resident #9 who presented with a new unstageable wound to her right heel. An interdisciplinary team note dated 6/16/23 identified the wound progressed from unstageable to a stage 3 pressure injury. An evaluation summary progress note on 8/29/23 documented the right heel was a stage 4 pressure injury. An evaluation summary progress note on 9/19/23 documented the right heel wound as a stage 3 pressure injury. An evaluation summary progress note on 11/28/23 documented the right heel wound as a stage 3 pressure injury. C. Staff interviewsThe ADON was interviewed on 12/6/23 at 12:45 p.m. She said it was the responsibility of the nurse admitting the resident to complete a skin assessment. The ADON said if the admitting nurse was a LPNthey were to seek assistance from a registered nurse (RN) for staging a pressure wound. The ADON said skin assessments were to be completed on admission and then weekly by a licensed nurse. The ADON said if there was a skin issue identified, such asa pressure injury, the resident would see the wound physician at their next visit to the facility and the facility's wound physician made rounds weekly on Tuesdays. The ADON said the attending physician would then give wound care orders until the wound physician was able to see the resident. The ADON reviewed the following documents (identified above in record review) and said it was a facility acquired wound. The ADON said nursing completed weekly wound rounds with the wound physician. The NHA was interviewed on 12/6/23 at 12:45 p.m. She said the facility assessment nurse was working remotely and did not see the resident personally when completing the facility assessment and she would needed to do more research into Resident #9's wound situation to determine if the wound was facility acquired or if Resident #9 was admitted with the pressure injury.-However, the resident's skin assessments prior to developing the wound, 15 days after admission, indicated her skin was intact. V. Additional informationThe NHA provided a progress note on 12/6/23 at 1:45 p.m. The progress note, dated 8/15/23, documented the initial observation of the right heel wound was 3/20/23.-This progress note was dated five months after admission. The NHA provided a plan of correction dated 9/25/23 for accuracy of assessments identifying the director of nursing audited charts and corrected charts to ensure accuracy. The director of nursing (DON) was also responsible for educating staff on how to accurately complete assessments and ensure all data was correct. Documentation of staff that attended the education on 10/19/23 were six licensed nursing staff members including the DON. A seventh staff member completed the education on 10/23/23.-The staff education was not completed with all licensed nursing staff employed by the facility.

A revisit to the 4/18/2023 survey was completed on 6/13/2023. The facility was in compliance with the regulation surveyed.

A revisit to the 4/18/2023 survey was completed on 6/13/2023. The facility was in compliance with the regulation surveyed.

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

A survey prompted by complaint #CO31857 was completed 4/18/23. One deficiency was cited.

Based on interviews and record review the facility failed to ensure one (#1) of three sample residents were free from sexual abuse. The facility failed to protect Resident #1 who no longer wanted her prior consensual intimate relationship with Resident #2. On 3/22/23 (one day after Resident #1 returned from the hospital) Resident #2 came into Resident #1's room while she was sleeping and without her consent did a sexual act on her. Resident #1 said she was sleeping on 3/22/23 and the sexual act was non-consensual. After the 3/22/23 abuse, Resident #1 was moved to a different hallway in the facility to keep her away from Resident #2. On 4/6/23 Resident #2 came into her new room while she was sleeping and did a sexual act to her which again, which Resident #1 said also was non-consensual. The facility failed on both dates to protect Resident #1 from abuse by Resident #2. Resident #1 expressed she did not feel safe even after changing rooms until Resident #2 discharged from the facility on 4/13/23. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy 1/1/22, and revised 6/1/22 was provided by the nursing home administrator (NHA) on 4/18/23 at 3:08 p.m. It revealed in pertinent part,"It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. "'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse."'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm."'Sexual Abuse' is non-consensual sexual contact of any type with a resident."Prevention of Abuse, Neglect and Exploitation"The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:"Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship;"The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect;"Protection of Resident"The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:"Responding immediately to protect the alleged victim and integrity of the investigation;"Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;"Increased supervision of the alleged victim and residents;"Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;"Protection from retaliation;"Providing emotional support and counseling to the resident during and after the investigation, as needed."II. Resident statusA. Resident #1 (victim)Resident #1, age 73, was admitted on 3/15/22 and readmitted on 3/21/23. According to the April 2023 computerized physician orders (CPO), the diagnoses included emphysema (damage of lung tissue), chronic obstructive pulmonary disease (COPD), stage three chronic kidney disease, Parkinson's Disease, hypertension (high blood pressure), unspecified dementia, difficulty walking, and dysphagia (difficulty swallowing). The 3/23/23 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required extensive assistance with dressing, toilet use, and personal hygiene. She did not walk in her room or the corridors. She had adequate vision. B. Resident interviewResident #1 was interviewed on 4/18/23 at 4:05 p.m. She said she had been in a consensual romantic relationship with Resident #2. She said after her hospital stay in March 2023 she no longer wanted to be anything but friends with him. She said she certainly would never allow him to come into her room while she was sleeping and have sexual acts with her without her permission. She said she was sleeping on both occasions when Resident #2 came into her room and performed sexual acts on her. She said she had good vision but had a hard time keeping her eyes open. She said after the first time he took advantage of her the facility moved her onto another wing to live to keep her safe from Resident #2. She said she still talked to him in the hallways and dining room because they were once friends. She said in her new room he came in and did the same thing to her again. She said, "I heard he doesn't live here anymore and that makes me feel safe. I didn't feel safe from him until he moved." C. Record reviewThe sexual expression care plan was signed by Resident #1 on 2/1/23. Resident #1 signed a consent which read she wanted the facility to honor her wishes to have sexual relations. The target date on the facility form was only documented as ongoing.-This agreement was never re-evaluated or discussed with her again, including after both sexual abuse incidents on 3/22/23 and 4/6/23 (see social service director interview below). The form did not document any other review dates for her sexual expression. The progress note on 3/21/23 revealed, Resident #1 was readmitted to the facility from the hospital. The nursing progress note 3/22/23 at 2:39 p.m. revealed, the resident was unable to consent to sexual interactions. Her roommate went to a nurse to get help for Resident #1. The nurse witnessed Resident #2's pants down and (his) private areas were in Resident #1's mouth. Resident #2 was informed to put his pants up and leave the room. Resident #2 was told no sexual interaction could occur when the other person could not consent. Both residents remained separated. The comprehensive care plan updated 3/23/23 revealed in pertinent part,Focus: Psychosocial well-being: Resident #1 was at risk for emotional distress with a history of a sexual relationship with a resident of the opposite gender. She received unwanted sexual contact from another resident while she was sleeping and (was) unable to give consent. Resident #1 was previously agreeable to this sexual relationship but indicated she does not want it to continue. Resident #1 was able to discuss her feelings and concerns. Goal: Resident #1 will remain free from emotional distress with resident to resident altercation through the review date of 6/14/23. Interventions: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears as needed. Anticipate and meet the resident's needs. Ensure (the) resident feels safe in the facility. Frequent checks as needed when incidents occur. The social service progress note 3/24/23 revealed Resident #1 said she wanted to only meet with Resident #2 in the common areas such as the lobby and not in her room. Follow-up visits to be continued to ensure resident's safety. The social service progress note 3/27/23 revealed a BIMS test was conducted on Resident #1 and she scored a 14 out of 15, she was cognitively intact. The nursing progress note 4/6/23 at 2:39 a.m. revealed Resident #1 was unable to consent to sexual interactions. The nurse and a certified nurse aide (CNA) witnessed Resident #2 with his pants down and his private parts were in Resident #1's mouth while the resident was in her bed trying to sleep. Resident #2 was asked to leave the room and told sexual encounters cannot take place without consent. The social service progress note 4/6/23 at 2:09 p.m. revealed Resident #1 said, Resident #2's behavior was not acceptable and she did not want to see Resident #2 in her room again or in the common areas. III. Resident statusA. Resident #2 (perpetrator)Resident #2, age under 65, was admitted on 5/6/21 and was discharged on 4/13/23. According to the April 2023 CPO, the diagnoses included cerebral infarction (stroke), hypertension (high blood pressure), altered mental status, alcohol abuse, alcohol hepatitis (inflammation of liver) and homelessness. The 2/25/23 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He required extensive assistance with dressing, and personal hygiene. He required limited assistance with bed mobility. He was independent in his room, and walking in his room and in the corridors. B. Record reviewThe nursing progress note 3/22/23 at 2:30 p.m. revealed Resident #2 was found in the room of Resident #1 with his pants down and his private parts in her mouth. Resident #2 was reminded he was unable to have sexual interactions with an individual without their consent. The comprehensive care plan 3/23/23 revealed,Focus: Resident #2 has a potential behavior problem with sexually inappropriate activity. He has a history of exploring sexually consensual relationships with residents of the opposite gender, but he may attempt to engage in sexual activity when they are not able to give consent (when they are sleeping). He needs to have his care needs met daily without causing harm to himself or others. Goal: Resident #2 will have no evidence of behavior problems by review date. Interventions: Frequent checks as needed when incidents occur. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Divert attention, remove from(the) situation, and take to (an) alternate location as needed. Document behavior and potential causes. The comprehensive care plan was updated on 4/11/23 and revealed as an intervention, one-to-one as needed when incident(s) arise. The nursing progress note 4/6/23 at 2:21 a.m revealed Resident #2 was found in the room that Resident #1 had recently been moved into (see nursing home administrator below that Resident #1 was moved to another room to keep her safe from Resident #2). A nurse and a CNA witnessed Resident #2 with his pants down, and he extended his penis in Resident #1's mouth while she was sleeping. Resident #2 (was) reminded he was not allowed to have sexual encounters with others without their consent. -Resident #2 was placed on one-to-one care with a CNA until a discharge plan could be achieved. The social service progress note 4/6/23 revealed Resident #2 was told not to come into the resident's room, or near Resident #1 or the police would be called. The nursing progress note 4/10/23 revealed Resident #2 was found sitting in his wheelchair in a female's room. The note did not document who the female resident was. Fifteen minute checks were to go on for both residents. IV. Facility investigationThe investigation summary of the 3/22/23 incident was provided by the NHA on 4/18/23 at 1:45 p.m. The summary revealed in pertinent part,"On 3/22/23 it was reported to the administration that an alleged sexual abuse occurred where one of the other residents with whom resident has a history of sexual relationship on a consensual basis. On this day the alleged perpetrator was observed attempting to make sexual contact (with Resident #1)."Resident #1 said, "She was unaware of the alleged sexual abuse. Resident #1 stated she is not okay with that kind of behavior and does not want the alleged perpetrator in her room."Resident #2 said, "Whosoever is saying that is lying." When Resident #2 was told that Resident #1 did not want him in her room he responded, "Whatever."The investigation summary of the second incident on 4/6/23 was provided by the NHA on 4/18/23 at 3:35 p.m. (After it was revealed in a progress note that a second sexual abuse incident had occurred) It revealed in pertinent part, "On this day the alleged perpetrator (Resident #2) was observed penetrating Resident #1's mouth while she was sleeping and hence, it was without her consent."V. Staff interviewsThe NHA was interviewed on 4/18/23 at 2:10 p.m. She said the CNAs were to do 15-20 minute checks on Resident #2 after the 3/22/23 incident. She said the facility CNAs did not observe him closely enough. She said Resident #1 was moved to a different hallway to protect her from Resident #2. The assistant director of nursing (ADON) was interviewed on 4/18/23 at 2:47 p.m. She said on 3/22/23 Resident #1's roommate came to alert her that Resident #2 was in the room and something sexual was going on. She said when she entered she could see Resident #2's private parts were on Resident #1's face. She said she told him to remove himself from the room. She said the facility moved Resident #1 to another room on a different hallway to keep her safe from Resident #2. She said Resident #2 was supposed to be watched by the CNAs but apparently he was not watched closely enough and on 4/6/23 he went into Resident #1's new room and did the same non-consensual sex act again. The social service director (SSD) was interviewed on 4/18/23 at 3:10 p.m. She said Resident #1 and Resident #2 had signed a sexual consent document back in February 2023. She said the facility had both Resident #1 and Resident #2 sign the paperwork called a consensual sexual expression care plan. She said as far as she knew Resident #2 was the only person Resident #1 had relations with. She said Resident #1 went to the hospital for pneumonia and respiratory failure in March 2023. She said when Resident #1 returned to the facility she noticed changes in her and did some cognitive tests. She said she never re-evaluated Resident #1 about her sexual consent paperwork. She said after both incidents, 3/22/23 and 4/6/23, she did not re-evaluate the sexual consent assessment with either Resident #1 or Resident #2. She said she interviewed Resident #1 after both incidents. She said Resident #1 told her she did not consent to either sexual incidents. She said Resident #1 was asleep both times Resident #2 was found in her room doing sexual acts. She said after the first incident Resident #2 said he did not care about what had happened. She said after she spoke to him after the second sexual incident he refused to speak or respond to her when she attempted to speak to him. She said he just shrugged his shoulders in front of her. The NHA was interviewed again on 4/18/23 at 3:40 p.m. She said there was no behavioral tracking done for either resident after the 3/22/23 or 4/6/23 incidents. She said after the first incident she put in a request for counseling for Resident #1 but had not heard back from the company yet and she would call the counseling company soon to see what had happened with her request. She said Resident #1 was moved to another hallway to keep her safe from Resident #2. She said after the 4/6/23 incident the CNAs were to do one-to-one observations 24 hours, seven days a week with Resident #2 until he could be discharged from the facility. She said on 4/6/23 he was found in Resident #1's new room and again had non-consensual sexual relations with her. She said apparently the 15-20 minute checks were not enough to stop him from doing this act again. She said the CNA was not watching him on 4/6/23 closely enough. She said Resident #2 was very quick when he walked. She said she did not know how Resident #2 got to Resident #1's room without being noticed on 4/6/23 except that he was not being watched closely enough. She did not know how Resident #2 knew where Resident #1's new room was except maybe Resident #1 talked to him in the halls and dining room area prior to 4/6/23 and told him. She said maybe Resident #2 noticed her coming out of the beauty salon which was close to her room and watched her go to her room. VI. Facility follow-upOn 4/19/23 at 12:29 p.m. the NHA emailed follow-up staff interviews the facility had done after the 4/18/23 survey. During the recent interviews of the incidents almost a month later, the staff had variances in their story of where exactly Resident #2's private parts were during the incidents. During the follow-up interviews the facility staff verified Resident #2's pants were down and his private parts were exposed. On 4/19/23 at 12:29 p.m. the NHA also provided interdisciplinary care team (IDT) notes after the incidents which revealed in pertinent part, -On 3/23/23 Resident #1 only wanted to see Resident #2 in the hallways. Resident #1 was moved to another room to give her some space from Resident #2. Resident #2 was started on frequent safety checks.-On 4/6/23 after the incident occurred staff were educated on one-to-one supervision for Resident #2. Resident #2 remained with one-to-one care 24 hours, seven days a week until he was discharged to another facility.

A survey for Incident #31441 was conducted on 4/18/23. One deficiency was cited.

Based on interviews and record review the facility failed to ensure one (#1) of three sample residents were free from sexual abuse. The facility failed to protect Resident #1 who no longer wanted her prior consensual intimate relationship with Resident #2. On 3/22/23 (one day after Resident #1 returned from the hospital) Resident #2 came into Resident #1's room while she was sleeping and without her consent did a sexual act on her. Resident #1 said she was sleeping on 3/22/23 and the sexual act was non-consensual. After the 3/22/23 abuse, Resident #1 was moved to a different hallway in the facility to keep her away from Resident #2. On 4/6/23 Resident #2 came into her new room while she was sleeping and did a sexual act to her which again, which Resident #1 said also was non-consensual. The facility failed on both dates to protect Resident #1 from abuse by Resident #2. Resident #1 expressed she did not feel safe even after changing rooms until Resident #2 discharged from the facility on 4/13/23. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy 1/1/22, and revised 6/1/22 was provided by the nursing home administrator (NHA) on 4/18/23 at 3:08 p.m. It revealed in pertinent part,"It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. "'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse."'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm."'Sexual Abuse' is non-consensual sexual contact of any type with a resident."Prevention of Abuse, Neglect and Exploitation"The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:"Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship;"The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect;"Protection of Resident"The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:"Responding immediately to protect the alleged victim and integrity of the investigation;"Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;"Increased supervision of the alleged victim and residents;"Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;"Protection from retaliation;"Providing emotional support and counseling to the resident during and after the investigation, as needed."II. Resident statusA. Resident #1 (victim)Resident #1, age 73, was admitted on 3/15/22 and readmitted on 3/21/23. According to the April 2023 computerized physician orders (CPO), the diagnoses included emphysema (damage of lung tissue), chronic obstructive pulmonary disease (COPD), stage three chronic kidney disease, Parkinson's Disease, hypertension (high blood pressure), unspecified dementia, difficulty walking, and dysphagia (difficulty swallowing). The 3/23/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required extensive assistance with dressing, toilet use, and personal hygiene. She did not walk in her room or the corridors. She had adequate vision. B. Resident interviewResident #1 was interviewed on 4/18/23 at 4:05 p.m. She said she had been in a consensual romantic relationship with Resident #2. She said after her hospital stay in March 2023 she no longer wanted to be anything but friends with him. She said she certainly would never allow him to come into her room while she was sleeping and have sexual acts with her without her permission. She said she was sleeping on both occasions when Resident #2 came into her room and performed sexual acts on her. She said she had good vision but had a hard time keeping her eyes open. She said after the first time he took advantage of her the facility moved her onto another wing to live to keep her safe from Resident #2. She said she still talked to him in the hallways and dining room because they were once friends. She said in her new room he came in and did the same thing to her again. She said, "I heard he doesn't live here anymore and that makes me feel safe. I didn't feel safe from him until he moved." C. Record reviewThe sexual expression care plan was signed by Resident #1 on 2/1/23. Resident #1 signed a consent which read she wanted the facility to honor her wishes to have sexual relations. The target date on the facility form was only documented as ongoing.-This agreement was never re-evaluated or discussed with her again, including after both sexual abuse incidents on 3/22/23 and 4/6/23 (see social service director interview below). The form did not document any other review dates for her sexual expression. The progress note on 3/21/23 revealed, Resident #1 was readmitted to the facility from the hospital. The nursing progress note 3/22/23 at 2:39 p.m. revealed, the resident was unable to consent to sexual interactions. Her roommate went to a nurse to get help for Resident #1. The nurse witnessed Resident #2's pants down and (his) private areas were in Resident #1's mouth. Resident #2 was informed to put his pants up and leave the room. Resident #2 was told no sexual interaction could occur when the other person could not consent. Both residents remained separated. The comprehensive care plan updated 3/23/23 revealed in pertinent part,Focus: Psychosocial well-being: Resident #1 was at risk for emotional distress with a history of a sexual relationship with a resident of the opposite gender. She received unwanted sexual contact from another resident while she was sleeping and (was) unable to give consent. Resident #1 was previously agreeable to this sexual relationship but indicated she does not want it to continue. Resident #1 was able to discuss her feelings and concerns. Goal: Resident #1 will remain free from emotional distress with resident to resident altercation through the review date of 6/14/23. Interventions: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears as needed. Anticipate and meet the resident's needs. Ensure (the) resident feels safe in the facility. Frequent checks as needed when incidents occur. The social service progress note 3/24/23 revealed Resident #1 said she wanted to only meet with Resident #2 in the common areas such as the lobby and not in her room. Follow-up visits to be continued to ensure resident's safety. The social service progress note 3/27/23 revealed a BIMS test was conducted on Resident #1 and she scored a 14 out of 15, she was cognitively intact. The nursing progress note 4/6/23 at 2:39 a.m. revealed Resident #1 was unable to consent to sexual interactions. The nurse and a certified nurse aide (CNA) witnessed Resident #2 with his pants down and his private parts were in Resident #1's mouth while the resident was in her bed trying to sleep. Resident #2 was asked to leave the room and told sexual encounters cannot take place without consent. The social service progress note 4/6/23 at 2:09 p.m. revealed Resident #1 said, Resident #2's behavior was not acceptable and she did not want to see Resident #2 in her room again or in the common areas. III. Resident statusA. Resident #2 (perpetrator)Resident #2, age under 65, was admitted on 5/6/21 and was discharged on 4/13/23. According to the April 2023 CPO, the diagnoses included cerebral infarction (stroke), hypertension (high blood pressure), altered mental status, alcohol abuse, alcohol hepatitis (inflammation of liver) and homelessness. The 2/25/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He required extensive assistance with dressing, and personal hygiene. He required limited assistance with bed mobility. He was independent in his room, and walking in his room and in the corridors. B. Record reviewThe nursing progress note 3/22/23 at 2:30 p.m. revealed Resident #2 was found in the room of Resident #1 with his pants down and his private parts in her mouth. Resident #2 was reminded he was unable to have sexual interactions with an individual without their consent. The comprehensive care plan 3/23/23 revealed,Focus: Resident #2 has a potential behavior problem with sexually inappropriate activity. He has a history of exploring sexually consensual relationships with residents of the opposite gender, but he may attempt to engage in sexual activity when they are not able to give consent (when they are sleeping). He needs to have his care needs met daily without causing harm to himself or others. Goal: Resident #2 will have no evidence of behavior problems by review date. Interventions: Frequent checks as needed when incidents occur. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Divert attention, remove from(the) situation, and take to (an) alternate location as needed. Document behavior and potential causes. The comprehensive care plan was updated on 4/11/23 and revealed as an intervention, one-to-one as needed when incident(s) arise. The nursing progress note 4/6/23 at 2:21 a.m revealed Resident #2 was found in the room that Resident #1 had recently been moved into (see nursing home administrator below that Resident #1 was moved to another room to keep her safe from Resident #2). A nurse and a CNA witnessed Resident #2 with his pants down, and he extended his penis in Resident #1's mouth while she was sleeping. Resident #2 (was) reminded he was not allowed to have sexual encounters with others without their consent. -Resident #2 was placed on one-to-one care with a CNA until a discharge plan could be achieved. The social service progress note 4/6/23 revealed Resident #2 was told not to come into the resident's room, or near Resident #1 or the police would be called. The nursing progress note 4/10/23 revealed Resident #2 was found sitting in his wheelchair in a female's room. The note did not document who the female resident was. Fifteen minute checks were to go on for both residents. IV. Facility investigationThe investigation summary of the 3/22/23 incident was provided by the NHA on 4/18/23 at 1:45 p.m. The summary revealed in pertinent part,"On 3/22/23 it was reported to the administration that an alleged sexual abuse occurred where one of the other residents with whom resident has a history of sexual relationship on a consensual basis. On this day the alleged perpetrator was observed attempting to make sexual contact (with Resident #1)."Resident #1 said, "She was unaware of the alleged sexual abuse. Resident #1 stated she is not okay with that kind of behavior and does not want the alleged perpetrator in her room."Resident #2 said, "Whosoever is saying that is lying." When Resident #2 was told that Resident #1 did not want him in her room he responded, "Whatever."The investigation summary of the second incident on 4/6/23 was provided by the NHA on 4/18/23 at 3:35 p.m. (After it was revealed in a progress note that a second sexual abuse incident had occurred) It revealed in pertinent part, "On this day the alleged perpetrator (Resident #2) was observed penetrating Resident #1's mouth while she was sleeping and hence, it was without her consent."V. Staff interviewsThe NHA was interviewed on 4/18/23 at 2:10 p.m. She said the CNAs were to do 15-20 minute checks on Resident #2 after the 3/22/23 incident. She said the facility CNAs did not observe him closely enough. She said Resident #1 was moved to a different hallway to protect her from Resident #2. The assistant director of nursing (ADON) was interviewed on 4/18/23 at 2:47 p.m. She said on 3/22/23 Resident #1's roommate came to alert her that Resident #2 was in the room and something sexual was going on. She said when she entered she could see Resident #2's private parts were on Resident #1's face. She said she told him to remove himself from the room. She said the facility moved Resident #1 to another room on a different hallway to keep her safe from Resident #2. She said Resident #2 was supposed to be watched by the CNAs but apparently he was not watched closely enough and on 4/6/23 he went into Resident #1's new room and did the same non-consensual sex act again. The social service director (SSD) was interviewed on 4/18/23 at 3:10 p.m. She said Resident #1 and Resident #2 had signed a sexual consent document back in February 2023. She said the facility had both Resident #1 and Resident #2 sign the paperwork called a consensual sexual expression care plan. She said as far as she knew Resident #2 was the only person Resident #1 had relations with. She said Resident #1 went to the hospital for pneumonia and respiratory failure in March 2023. She said when Resident #1 returned to the facility she noticed changes in her and did some cognitive tests. She said she never re-evaluated Resident #1 about her sexual consent paperwork. She said after both incidents, 3/22/23 and 4/6/23, she did not re-evaluate the sexual consent assessment with either Resident #1 or Resident #2. She said she interviewed Resident #1 after both incidents. She said Resident #1 told her she did not consent to either sexual incidents. She said Resident #1 was asleep both times Resident #2 was found in her room doing sexual acts. She said after the first incident Resident #2 said he did not care about what had happened. She said after she spoke to him after the second sexual incident he refused to speak or respond to her when she attempted to speak to him. She said he just shrugged his shoulders in front of her. The NHA was interviewed again on 4/18/23 at 3:40 p.m. She said there was no behavioral tracking done for either resident after the 3/22/23 or 4/6/23 incidents. She said after the first incident she put in a request for counseling for Resident #1 but had not heard back from the company yet and she would call the counseling company soon to see what had happened with her request. She said Resident #1 was moved to another hallway to keep her safe from Resident #2. She said after the 4/6/23 incident the CNAs were to do one-to-one observations 24 hours, seven days a week with Resident #2 until he could be discharged from the facility. She said on 4/6/23 he was found in Resident #1's new room and again had non-consensual sexual relations with her. She said apparently the 15-20 minute checks were not enough to stop him from doing this act again. She said the CNA was not watching him on 4/6/23 closely enough. She said Resident #2 was very quick when he walked. She said she did not know how Resident #2 got to Resident #1's room without being noticed on 4/6/23 except that he was not being watched closely enough. She did not know how Resident #2 knew where Resident #1's new room was except maybe Resident #1 talked to him in the halls and dining room area prior to 4/6/23 and told him. She said maybe Resident #2 noticed her coming out of the beauty salon which was close to her room and watched her go to her room. VI. Facility follow-upOn 4/19/23 at 12:29 p.m. the NHA emailed follow-up staff interviews the facility had done after the 4/18/23 survey. During the recent interviews of the incidents almost a month later, the staff had variances in their story of where exactly Resident #2's private parts were during the incidents. During the follow-up interviews the facility staff verified Resident #2's pants were down and his private parts were exposed. On 4/19/23 at 12:29 p.m. the NHA also provided interdisciplinary care team (IDT) notes after the incidents which revealed in pertinent part, -On 3/23/23 Resident #1 only wanted to see Resident #2 in the hallways. Resident #1 was moved to another room to give her some space from Resident #2. Resident #2 was started on frequent safety checks.-On 4/6/23 after the incident occurred staff were educated on one-to-one supervision for Resident #2. Resident #2 remained with one-to-one care 24 hours, seven days a week until he was discharged to another facility.

A revisit to the 1/26/2023 survey was completed on 3/22/2023. The facility was in compliance with the regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (000), construction with a partial basement used for support services only. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1965 and is license for 108 beds. This re-certification survey conducted on February 21, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". Deficient items were discussed with the Administrator and during the exit conference.

Based on observation during the course of the survey, it was determined the facility failed to maintain the means of egress doors in accordance with NFPA 101, 19.2.2 and 7.2.1.4.2 The following evidenced this: 1. Egress door in 400 courtyard swings inward 2. Egress door in kitchen hallway malfunctioning NFPA 101 7.2.1.4.2 Door leaves required to be of the side-hinged or pivoted-swinging type shall swing in the direction of egress travel under any of the following conditions:(1)Where serving a room or area with an occupant load of 50 or more, except under any of the following conditions:(a)Door leaves in horizontal exits shall not be required to swing in the direction of egress travel where permitted by 7.2.4.3.8.1 or 7.2.4.3.8.2. (b)Door leaves in smoke barriers shall not be required to swing in the direction of egress travel in existing health care occupancies, as provided in Chapter 19.(2)Where the door assembly is used in an exit enclosure, unless the door opening serves an individual living unit that opens directly into an exit enclosure(3)Where the door opening serves a high hazard contents areaThe deficiency has the potential to affect all occupants, including staff, residents, and visitors within the facility. This item was discussed during the survey and again during the exit conference.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25,5.2.1.1.1. This was evidence by the following. 1. Rm 106 escutcheon in bathroom, store room, 308 404, 4062. Kitchen refrigerator sprinkler head has glue on it 3. No record of 5 year internal pipe inspectionNFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12, and NFPA 25, 5.2.1 NFPA 25, 4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. NFPA 25, 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 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. The deficiencies were discussed during the exit conference.

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 and per NFPA 80-2010-Standard for Fire Doors and other Openings Protectives. This was evidenced by the following: 1. Resident room 100 wing fire doors doesn't latch 300 wing difficult to latch closed and will not resist the passage of smoke. 2. Rm 611 door knob doesn't work 3. No records for inspection of fire doorsNFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors and gaps in the door smoke seal. This was discussed during 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. Rm 106 ceiling tile brokenNFPA 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. The smoke barrier deficiency has the potential to affect all residents, visitors, and staff within those smoke compartments. The deficiencies were discussed during the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1and NFPA 54, 7.9.2.1. This was evidenced by the following:1. Gas orifice on dryer rated for 0-2000 feet in elevation in laundry room. 2. Sheet metal screws used to connect dryer vent pipe in laundry room. NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction.(3) In accordance with the manufacturer's installation instructions. This deficiency was discussed during the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1. No records or documentation of generator fuel testing. NFPA 110, 8.3.7 A fuel quality test shall be performed at least annually using applicable ASTM standards or the manufacturer's recommendations. This deficiency has the potential to affect all occupants, which might include staff, residents, and visitors should the generator fail to start during an emergency. This was discussed during the record review and again during the exit conference.

A recertification survey with complaints #CO30598 and #CO30599 was completed from 1/23/23 to 1/26/23. Eleven deficiencies were cited.

An Emergency Preparedness survey was conducted from 1/23/23 to 1/26/23. Two deficiencies were cited.

Based on record review and interviews, the facility failed to have an annual review of the complete emergency preparedness plan (EPP). Specifically, the facility failed to have an annual review of the EPP. Findings include: I. Record review The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) on 1/25/23 at 3:10 p.m. Review of the EPP revealed the facility did not have an annual review of the EPP. The EPP manual documented the last date of review was 3/26/2020. II. Staff interview The EPP was reviewed with the NHA and the maintenance director (MTD) on 1/26/23 at 6:12 p.m. The MTD acknowledged the plan had not been reviewed by the performance review committee who was composed of the NHA, MTD, director of nursing (DON), and other key management staff in the last 12 months. The MTD said he had been updating the EPP Manual but was still working on getting the book ready for annual review. -The MTD did not have a record of the updates made to the EPP. The MTD acknowledged the importance of making sure the EPP Manual was up to date and said he would get it ready for an annual review and make sure all policies and procedures were current and up to date within the week.

Based on record review and interviews, the facility failed to have a complete emergency preparedness communication plan. Specifically, the facility failed to have a complete communication plan that included an updated emergency use contact list to include the names and contact information for individuals and entities who will provide services to residents in the event of a variety of potential emergencies the facility and resident may experience. Findings include: I. Facility plan The Emergency Preparedness Plan (EPP), dated 3/26/22, last updated 3/26/2020 was provided by the nursing home administrator (NHA). -Review of the EPP revealed the communication plan did not include an updated contact list to include the name and phone numbers or other contact information for all facility staff who would provide emergency type services in the event of an emergency/disaster; all physician provides providing care and services for each resident of the facility; and potential voluntary service personal. The list contained in the emergency preparedness communication plan was last updated 3/25/2020 and did not document an updated contact list was not completed with all required contact information. II. Staff interviews The EPP was reviewed with the NHA and the maintenance director (MTD) on 1/26/23 at 6:12 p.m. The MTD acknowledged the contact list was not up to date with current staff. The NHA said the contact list would be updated immediately with all current staff and physician ' s information.

Based on interviews and record review the facility failed to ensure two residents (#60 and #67) of two residents reviewed out of 39 sample residents, had the right to participate in the development and implementation of his or her person centered plan of care. Specifically the facility failed to conduct consistent care planning meetings and invite Resident #60 and #67 to attend a care plan meeting to discuss and develop a person centered plan of care and services that the facility would provide to them. Findings includeI. Facility policy and procedureThe Care Planning-Resident Participation policy, undated, received from the chief clinical officer (CCO) on 1/27/23 at 6:29 p.m., revealed in pertinent part, "The facility supports the resident's rights to be informed of, and participate in, his or her care planning and treatment. The facility will inform the resident in advance of changes to the plan of care. The plan of care will be discussed at regular scheduled care plan conferences."The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes."II. Resident #60A. Resident statusResident #60, younger than 65 years old, admitted on 6/25/22. According to the January 2023 computerized physician orders (CPO) the diagnosis included metabolic encephalopathy (neurological disorder), bipolar (mental health disorder causing mood swings), congestive heart failure (heart pumping mechanism compromised), and chronic kidney disease (loss of kidney function). The 1/1/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a Brief interview of mental status score of 14 out of 15. The resident required extensive two person assistance with bed mobility, dressing, personal hygiene and toileting. The residents required a setup for eating. B. Resident interviewResident #60 was interviewed on 1/23/23 at 1:30 p.m. Resident #60 said she did not know what a care planning meeting was or if she ever had one. Resident #60 said she was never invited to attend a care planning meeting. -Resident #60 had been living in the facility for almost seven months without participating in a care plan meeting. Resident #60 was interviewed on 1/25/23 at 11:23 a.m. Resident #60 said she spoke to her daughter after the interview on 1/23/23 (see above); and her daughter was invited to participate in a care planning meeting about her care. The meeting was scheduled for 1/18/23 but did not occur because her daughter canceled due to a family conflict. Resident #60 said the facility did not inform her they were planning to have a care plan meeting about her care; she was not asked if the meeting time worked for her; and she was not formally invited to attend. Resident #60 said she would like to participate in all care planning conferences since it concerned her care. C. Record reviewReview of resident #60 medical record revealed the following:-Social service note dated 1/5/23 documented that a care conference was scheduled with the resident's daughter for 1/18/23 at 2:00 p.m.-The person centered baseline care plan dated 6/25/22 completed within 48 hours of the resident's admission date of 6/25/22, failed to reveal who was invited and who attended the care planning meeting. D. Staff interviewsThe director of nursing (DON) was interviewed on 1/26/23 at 8:51 a.m. The DON said resident care conferences were scheduled by social workers; the care plan conferences were to be done within 48 hours of admission for a baseline care plan and then quarterly thereafter. The conferences could occur more frequently if there were concerns or if the resident experienced a significant change of condition. The DON was interviewed again on 1/26/23 at 10:15 a.m. after she provided copies of the baseline care plan and the social service note documenting the 1/18/23 scheduled care conference (see above in record review). The DON said the social services department just rescheduled the care conference with the resident's daughter for 1/31/23 at 1:00 p.m. The DON acknowledged there was no documentation in Resident #60's medical record of any other care planning conferences occuring III. Resident #67A. Resident statusResident #67, age 72, was admitted to the facility on 2/25/22. According to the January 2023 computerized physician orders (CPO) the diagnoses include difficulty in walking, muscle weakness, cellulitis (infection of the skin) of left lower limb, and pressure ulcer of the left hip. The 11/24/22 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) of 15 out of 15. The resident required two person assistance with activities of daily living. B. Resident interviewResident #67 was interviewed on 1/26/23 at 3:20 p.m. The resident said that there had been a care conference a few months ago, on 11/23/22, but was never told how often there would be one. The resident said there had never been one before or after that one care conference. The resident said there were a number of things he needed help with including obtaining a new ID card so he could get new glasses and a care conference would be helpful to make plans to address his living concerns and needs. C. Record reviewReview of the resident record revealed the facility held only one care conference to discuss the resident's goals and care plan of services. This meeting was held on 11/23/22, nine months after the resident admission. There had been no other care conference held since. Social services note dated 11/23/22 at 2:09 p.m. documented the resident's care conference was held 11/23/22, and the resident was able to make his needs known. -The care conference was held nine months after the resident's admission on 2/25/22. There was no documentation of any other care conference being held. D. Staff interviewThe director of nursing (DON) was interviewed on 1/25/23 at 12:51 p.m. The DON said that she was not aware of any problems Resident #67 was having with his glasses or ID card. The DON said that she would work on getting resident #67 a new ID card replacement and an optometrist appointment. -The DON did not comment on an expectation for holding routine care conferences or a reason that Resident #67 had only had one care conference since admission. The NHA was interviewed on 1/25/22 at 12:57 p.m. The NHA said that she had not heard anything about a problem with Resident #67.

Based on interviews and record review the facility failed to honor resident choices for one (#19) of two reviewed for self-determination, out of 39 sample residents. Specifically, the facility failed to ensure dependent Resident #19, received showers consistently according to the resident's preference. Findings include:I. Facility policy and procedureAn undated Resident Shower policy was provided by the nursing home administrator (NHA) on 1/26/23 at 2:08 p.m. It read, in pertinent part "It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice."Residents will be provided showers as per request or as per facility schedules protocols andbased on resident safety."II. Resident #19A. Resident statusResident #19, under age 65, was admitted on 3/23/21 and readmitted on 1/10/23. According to the January 2023 computerized physician orders (CPO), diagnoses included bipolar disorder, mild depression, neuromuscular dysfunction of the bladder, mild intellectual disabilities, autistic disorder, and generalized anxiety disorder. The 12/16/22 minimum data set (MDS) assessment revealed Resident #19 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required assistance from two staff to complete activities of daily living including showering. The MDS assessment revealed the resident had no behaviors or rejection of care. B. Resident interviewResident #19 was interviewed on 1/25/23 at 2:03 p.m. Resident #19 said he was not getting showers regularly. The resident said he told staff he wanted to take showers twice a week and staff often told him they were too busy to give him two showers a week. Resident #19 said he kept it quiet and was not complaining because he was expecting to leave the facility, but he was frustrated and could not take it any longer. Resident #19 said his showers were important to him because he had impaired skin and a superpubic catheter; he was susceptible to developing wounds, skin infections, and catheter-associated urinary tract infections. Resident #19 said facility staff claimed he refused showers, but he was specific in saying that he was not refusing any showers and just wanted staff to give him the showers he was requesting. Resident #19 said the staff never asked him if he wanted to take a shower on his shower days; he had to ask staff for a shower; they always said they were too busy; sometimes his mother had to come to the facility to ask the staff to give him a shower. C. Record reviewThe resident's comprehensive care plan, dated 12/28/22, revealed the resident had a care focus for ADLs. The care plan documented in pertinent part "Bathing/showering: The resident requires total assistance twice weekly and as necessary, with two-person physical assistance. Verify resident has received showers on Wednesday- day shift and a bed bath on Saturday- day shift. Ensure nail care and or shaving as requested has been completed" revised 1/17/23. The care plan also documented "Bathing/showering: The resident prefers Monday/Thursday" showers; date initiated:11/27/21. The resident task record (point of care entry database where the certified nurse aids (CNA) record resident care assistance provided) for showers was reviewed for the look-back period from 12/26/22 to 1/26/23. The shower task record documented "Bathing: shower days are Wednesday and Saturday.'' The resident's record revealed Resident #19 received only one bed bath on Saturday 1/21/23. The record did not document that the resident refused any of the care planned/ scheduled shower days. The resident also had an as needed (PRN) bathing record (a bathing record in addition to the resident regular scheduled bathing/showering days). The PRN bathing record documented the resident received a shower on Wednesday 1/14/23 and a bed bath on Saturday 1/11/23. The resident was not in the facility on 1/5/23 for his bed bath.-According to the shower record Resident #19 had one shower and two bed baths and no documented refusals for either type of bathing assistance. The resident missed four out of seven opportunities to receive baths as care planned in the 30-day look-back period.-A review of the resident's medical record failed to provide documentation to explain why the resident was not receiving showers as planned. III. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 1/26/23 at 5:10 p.m. CNA #5 said the facility has stopped utilizing bath aides to perform showers. The CNAs on the shift were responsible for ensuring the residents were showered consistently based on the plan of care. CNA #5 said the CNAs used to complete shower sheets (paper documentation) and kept the papers in a binder at the nurse's station, but they no longer used the shower sheet to document resident showers. All resident care was now documented in the point of care (POC) database. CNA #5 said if a resident refused a shower the refusal was to be reported to the s charge nurse. Licensed practical nurse (LPN) #3 was interviewed on 1/26/23 at 5:15 p.m. LPN # 3 said the residents have their preferred days for taking showers which were to be followed. The CNAs were to report any refusals to the nurse and the nurse was to take that opportunity to talk to the residents about the importance of taking showers. The LPN said the standard facility protocol for shower refusals was to talk to the resident and offer them the opportunity to accept the shower, making three attempts, during the shift. If the resident refused to accept showering assistance the CNA would document the refusal on the POC task record. The nurse would also document the refusal and inform the director of nursing (DON). The DON was interviewed on 1/26/23 at 6:00 p.m. The DON said Resident #19 knows what he wants and was able to express his feelings about his care. The DON said the resident came to her about a month ago complaining about not getting his showers regularly. She said the resident chose Wednesdays for his showers and Saturdays for a bed bath and the resident's shower schedule was modified to meet his choice. The DON said the nurses were supposed to enter progress notes on shower refusals and inform her about any refusals after they offer the resident a shower three times, at different times during the shift. IV. Facility follow-upThe NHA provided additional information on 1/27/23 regarding the resident's bathing assistance. Instead of providing actual showering records for the resident medical record task record documentation the facility provided a one page word document with dates nursing staff was claiming the resident had a shower. The resident's medical record did not match this report. The document revealed the resident received showers on 1/1/23, 1/4/23, 1/11/23, and 1/14/23 and did not refuse any showers. The resident was in the hospital on 1/5/23 and therefore not present to receive or refuse a shower. The shower dates for 1/1/23 and 1/4/23 were not documented in the resident's record and the facility did not provide an explanation of why those dates were not documented. -In addition, the resident reported his bathing schedule was still an issue (see resident interview) and the director of nursing was aware of the resident complaining about it previously.

Based on observations and interviews the facility failed to provide a clean, safe homelike environment for the residents on six of six hallways and common areas. Specifically, the facility failed to:-Provide clean shared spaces throughout the facility;-Ensure the walls were repaired throughout the facility;-Ensure the walls were painted throughout the facility;-Ensure the resident doors were in good repair;-Ensure the floor tiles were in good condition;-Ensure the hallways were free of odors; and,-Ensure common areas maintain a comfortable temperature. I. Facility policy and proceduresThe Safe and Homelike environment policy and procedure, undated, was received from the nursing home administrator (NHA) on 1/27/23 at 6:29 p.m. It revealed in pertinent part,"In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment. "Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. "Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. "Housekeeping and maintenance services will be provided as necessary to maintain sanitary, orderly, and comfortable environment. "The facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees fahrenheit. "Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to housekeeping department." II. ObservationsOver several days from 1/23/23 through 1/26/23, the resident environment throughout the facility was observed for homelike, safe, and sanitary conditions. Observations included:A. Resident roomsThe doors in multiple resident rooms and door jams throughout the facility had chipped and peeling paint in many areas exposing bare wood where the paint had chipped off. Many rooms had areas where holes had been patched; had not been repainted. Many resident bathrooms had stain and/or cracked tiles in front of the toilet stool. -Room 409 had trash on the floor that had not been cleaned by housekeeping.-Room 506 had patch holes in the wall plastered but not repainted. -Room 508 the walls over the windows had been plastered but holes were not repainted.-Room 103 had patched holes in the wall that were not repainted.-Room 603 had paint scraped off over the resident's bed that had not been repaired or painted and the wall between windows stained with a dark colored substance.-Room 608 had holes in the wall above the bed that had not been patched or painted. -Room 609 had wallpaper peeling off the wall in places. B. Resident bathrooms-Room 204 has dark blackish stains on the floor around the toilet, on the floor.-Room 307 has dark blackish stains on the floor around the toilet, on the floor. -Room 501 has rust colored stains behind the toilet stool and cracked tiles on the floor in front of the toilet stool.-Room 504 has dark colored stains in front of the toilet stool base, and the resident's toothbrush and case was on the floor behind the toilet stool. -Room 404 had brown stains around the toilet stool and a urinal was hanging from the towel rack.-Room 401 had dark stains around the toilet stool, the toilet seat was loose, and both hand towel rings were held together and on the wall with masking tape. It was uncertain if they could hold a towel. C. Resident hallwaysThe 100 hallway had walls and doors that were scuffed and scraped down to the wood and plaster in some places. There were long scuff/scrape marks in the hallway on the wall near room 107. The common area, on 300 hallway, had spots on the floor that were soiled with a brown substance. The walls on the 300 hall had scuff marks. The 400 hallway near the shower room, on the wall outside the door, was scratched down to the plaster and wood; and the power conduit outlet was broken away from the wall. The 400 hallway floor was soiled with dirt tracks from outside. There were dark colored fluid drops melted snow, mud, and ice on the floor that had been tracked in. The 400 hallway had a strong odor of urine, body odor and of smoke and cigarettes throughout the hall, on every day of observation. The 500 hallway walls were badly scraped and scratched, down to the wood in many places. The 500 hallway handrails were badly scuffed and the paint was down to the wood in many places. The floor was soiled with dirt tracks and fluid drops throughout the hallway. The counter in front of the nurses station facing 500 and 600 hallways was scuffed and scratched down to the wood, and the floors were soiled. The metal doors leading into the 600 hallway were scuffed and scraped down to metal. There were many areas in the main hallway that were scraped and scratched where paint was also lacking. D. Dining areaOn 1/25/23 at 10:00 a.m. during the resident group meeting, the dining room was 67 degrees fahrenheit and there was cold air drafting in from the hall leading from the open back door. Residents complained of being cold and not liking to eat meals in the dining room because it was so cold. Several residents in the dining room had on outside coats or jackets and a couple wore gloves or a winter hat. One resident said this was a common occurrence. On 1/26/23 at 12:45 p.m. the dining room was feeling cold and drafty at 69 degrees fahrenheit. III. Staff interviewsHousekeeper (HSKP) #1 was interviewed on 1/25/23 at 2:36 p.m. HSKP #1 said the bathrooms smell so the facility used air freshener to take care of the odors. The HSKP said that the air freshener did not work on the smoke odor in the hallway (400), and was not strong enough to remove the odor in all areas of the facility. The HSKP said the floors were a problem, and were hard to keep clean. The big mop (mopping machine) did not do enough and the housekeeping staff had to clean in addition to the machine mop in order to get it clean, and sometimes when the weather was bad it was even worse. The HSKP said that sometimes the residents did not allow the staff to clean the rooms and they stayed dirty until the housekeeping supervisor (HSKS) talked to the resident about the need to clean the room and then the staff could clean. The NHA was interviewed on 1/26/23 at 3:30 p.m. The NHA said they had tried a lot of things to reduce the odor on the 400 hallway, but just could not get rid of the smell. The NHA acknowledged they had a number of residents who were less hygienic and resistant to bathing and the smell in that hall was overwhelming at times. The NHA said she would speak with environmental services to see what environmental options were available to reduce the odors on the 400 hallway.

Based on record review, observation,and interviews the facility failed to provide prompt responses and resolutions to grievances from residents. Specifically, the facility failed to respond to resident grievances regarding missing laundry and implement an acceptable resolution for the resident right to keep and use personal belongings and have the facility protect the resident property from theft and or loss. Findings include: I. Facility policy and procedure A Grievance/Complaint policy and procedure was requested on 1/26/23 and was not received from the facility. II. Record Review A. Resident laundry grievances On 8/24/22 Resident #38 reported that a fleece jacket had gone missing. According to the grievance document it was not found in the residents room or laundry. On 8/28/22 Resident #8 reported that three shirts and one pair of pants had gone missing. According to the grievance document the items were not found in the residents room or laundry. On 10/6/22 Resident #21 reported that four personally owned sheet sets and a blanket had been lost in the laundry. According to the grievance document, the items were not found. On 10/2/22 Resident #52 reported that all of his clothes had been lost in the laundry. According to the grievance document the items were never recovered. On 11/28/22 Resident #55 reported that three pairs of basketball shorts had gone missing and were never recovered. On 1/24/23 Resident #77 reported that three white shirts and three pairs of sweatpants had gone missing and never recovered. B. Other facility recordsAccording to facility reported incident (FRI) dated 12/20/22 of a resident's complaint for missing items of clothing and other personal items; the facility initiated a process to start using mesh laundry bags to transport resident laundry to the wash. The laundry would be washed and dried in the mesh bag then returned to the resident. This intervention was intended to prevent further loss. III. Observation Observation of the laundry room on 1/23/23 at 1:45 p.m., 1/25/23 at 12:48 p.m. and 1/25/23 at 4:28 p.m. revealed no mesh bags used in the laundry room while washing resident laundry. IV. Resident interviews A group interview with seven cognitively intact residents six (#52, #33, #6, #71, #21, #48 and #15), selected by the facility, was held on 1/25/23 at 10:00 a.m. The residents said there was a big problem with clothing and personal sheets and blankets going missing after being sent to the laundry room. This problem had been occurring for several months and they had given up on complaining. One resident said she was fearful she would not get her clothing back once it left her room. The resident council resident said one male resident had lost all of his clothing and was forced to wear a hospital gown. The resident was a larger person and had trouble finding clothing of the correct size. The resident group all agreed that the laundry service caused feelings of frustration because their clothes went to the laundry and did not come back; additionally, the facility did not resolve the issue satisfactorily. The residents said if it disappears it was gone. The resident's said replacing their missing clothing was getting expensive and some favorite clothing items could not be replaced. Some residents had given up complaining of missing clothing because the facility was not responsive to grievances for the problem to be corrected to put an end to the ongoing problem of lost clothing. The residents said that there was no laundry system with bags that kept each resident laundry contained and all together. V. Staff interviews Laundry aide (LA) #1 was interviewed on 1/24/23 at 2:15 p.m. LA #1 said it was difficult to distribute resident clothing when a resident had a room change, because they were not always notified of resident room changes. If they did not have an updated resident room list, clothing would be placed in the wrong resident closet. Some residents were not able to tell staff if they were dressed in someone else's clothes. LA #1 said they did try to confirm the resident laundry and room location match so the resident was getting their clothing back. However, when the name and the room number did not match she leaves the resident clothing in the laundry room for the certified nurse aides (CNA) to retrieve them for the residents; sometimes laundry hangs in the laundry room for a while before someone comes to claim it. LA #2 was interviewed on 1/26/23 at 10:45 a.m. LA #2 said the process of identifying missing clothes was to ask the CNAs who were familiar with the resident to assist in finding the owner; especially if the residents are unable to tell what belongs to them. If the CNAs were unable to assist in finding the owner of the clothing the laundry department would keep the laundry items for two weeks and then the items would be donated to whoever needs clothes.

Based on observation, record review, and interviews, the facility failed to ensure one (#55) of three residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and hygiene, out of 39 sample residents. Specifically, the facility failed to:-Provide timely incontinent care;-Provide timely consistent feeding assistance; and,-Update care plan for Resident #55 to reflect feeding assistance needs. Findings include:I. Facility policyThe Incontinence Care policy, undated, was provided by the nursing home administrator (NHA) on 2/26/23 at 2:08 p.m. It read in pertinent part: "Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible."The Activity of Daily Living (ADLs) policy, undated, was provided by the NHA on 2/26/23 at 2:08 p.m. It read in pertinent part: "Facility will based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living;-Eating to include meals and snacks."II. Resident #55 A. Resident statusResident #55, under the age of 65, was admitted on 9/17/21 and was readmitted on 11/10/22. According to the January 2023 computerized physician orders (CPO), diagnosis included traumatic brain injury, traumatic subdural hemorrhage (brain bleed) with loss of consciousness of unspecified duration, subsequent encounter, and convulsion (involuntary jerky movements). The minimum data set (MDS) assessment, dated 11/16/22 revealed the resident had severely impaired cognitive function with a brief interview for mental status (BIMS) score of two out of 15. The resident was dependent on staff for his ADL care and required extensive physical assistance with two staff. The resident had no display of behaviors during care and did not refuse care. The resident did not walk and needed physical support from staff and the use of a mechanical lift in order to complete transfer from surface to surface, with, toileting, and personal hygiene. The resident was always incontinent of both bowel and bladder and was at risk for developing pressure injuries. B. Resident interview and observationOn 1/24/23 from 9:15 a.m. to 12:00 p.m. Resident #55 was observed continuously. The resident was in bed with his breakfast placed on a bedside table across from his bed within the resident's reach. The resident had a strong smell of urine and was not eating the meal. -At 9:45 a.m., a certified nursing aide (CNA) #6 entered the room and picked up Resident #55 room tray for breakfast. The CNA did not encourage or assist the resident to eat his meal or ask the resident if he was done or wanted an alternative meal since he had not eaten any of the food provided. Additionally, the CNA left the room without providing Resident #55 with incontinent care. -At 9:55 a.m., CNA #6 came back to the resident's room to provide incontinence care and assist the resident into his wheelchair. The resident incontinent brief was observed to be heavily soaked with strong smelling brownish yellowish colored urine. - At 10:20 a.m. the resident was brought to the main dining room for an activity.- At 12:00 p.m. the dining room staff started serving lunch. Resident #55 was interviewed on 1/24/23 at 12:35 p.m. Resident #55 could not say what type of care assistance he needed. The resident had a smell of urine and feces.-At 1:15 p.m. the resident was assisted to his room in his wheelchair to watch television and later at 1:40 p.m. he was assisted into his bed. On 1/25/23 from 9:00 a.m. to 1:35 p.m., Resident #55 was observed continuously. Resident #55 was laying in bed on his back position with the head of his bed elevated.-At 9:10 a.m. CNA #7 delivered Resident #55 breakfast tray. CNA #7 did not stay to assist the resident with the meal. Resident #55 did not touch the meal or attempt to eat any of the meals.-At 9:35 a.m. CNA #7 came back to the resident's room, the CNA did not offer the resident any assistance or encouragement to eat the meal. The CNA removed the resident's tray and assisted him into his wheelchair after performing incontinent care. The resident was up in his wheelchair at approximately 9:45 a.m. -At 10:00 a.m. The resident was assisted to the dining room for musical activity. The resident was there for an hour and a half for the music activity. -At 11:30 a.m. when the activity was over, the resident remained in the dining room and was seated for lunch in the dining room. -At 11:45 a.m. the staff began serving lunch. Resident #55 lunch arrived at 12:05 p.m. and the staff set the tray up beside the resident but not in front of the resident. The resident did not make any attempt to feed himself and continued to just drink his juice. The dining room staff did not offer the resident any feeding assistance. -At 12:25 p.m. the director of nursing (DON) arrived at the dining room and asked the resident if the resident needed assistance with his food (the resident had not made any attempt to eat any of the meals). The resident responded yes. The DON began assisting the resident with his meal. The resident consumed all his meals on his plate, as the DON assisted him. -At 12:50 p.m., when lunch was over, the DON assisted the resident to an area where a few of the residents were gathered socializing. There was calm therapeutic music playing. -At 1:30 p.m., CNA #7 came to assist the resident to his room to lay him down on his bed to provide incontinence care. -At 1:35 p.m., it was three hours and 55 minutes since he was provided incontinence care earlier in the morning, with the assistance of another CNA, Resident#55 was laid down on his bed with the use of a mechanical lift, for incontinent care. During this time the staff left the room to collect new bed sheets as the resident was soaked with both feces and urine. CNA #7 said the resident was so soiled with urine and feces that the resident needed a complete bed change because the feces leaked out of the resident's brief during the incontinence brief change. Resident #55 was interviewed on 1/26/23 at 9:30 a.m. The resident said he did not know the reason he did not consume his breakfast. When asked if he would prefer a different meal he responded yes and said he would like some cookies. C. Record reviewThe resident comprehensive care plan documented a care focus for incontinent care last revised on 9/9/22. The care focus revealed Resident #55 was incontinent of bowel and bladder and had impaired mobility. The interventions included checking on the Resident every two hours and assisting the resident with incontinent care. The IDT (interdisciplinary team) Care Conference Summary dated 12/20/22 at 3:30 p.m. revealed the resident was on a regular diet, with regular texture with thin liquids. Per the restorative therapy summary, Resident #55 "needed assistance with feeding." Interventions included providing Resident #55 occupational therapy (OT) for self-feeding and training the resident on making successful hand to mouth movements while eating. Once the resident completed OT the resident would be transitioned to restorative dining. The comprehensive care plan was not updated after the 12/20/22 care conference meeting where it documented he needed assistance with eating. III. Staff interviewCNA #7 was interviewed on 1/25/23 at 4:16 p.m. CNA #7 said Resident #55 was a two-person mechanical lift transfer and had to be lifted into bed in order to provide incontinence care. Because there was only one CNA assigned to work the resident's hall it was difficult to meet the resident's needs for incontinence care. CNA #7 said the CNA assigned to Resident #55 checked the resident for incontinence every two hours and provided incontinence care to the resident; however, when only one staff was assigned to the unit it was difficult to meet that job expectation. CNA #7 acknowledged that because Resident #55 was not changed timely, the resident's incontinence brief was overflowing and soaked through to the resident's pants and the bedding when the resident was placed in bed for incontinence care (see observation above). CNA #1 was interviewed on 1/26/23 at 2:45 p.m. CNA #1 said Resident #55 was able to feed himself with some meals, but was on a restorative dining program and required feeding assistance during all meals. CNA #1 said the therapy department had developed the resident's feeding plan and when there are any modifications to the existing plan the therapy department would inform the restorative nurses and CNAs about the changes. Licensed practical nurse (LPN) #4 was interviewed on 1/26/23 at 3:00 p.m. LPN #4 said she was not aware that Resident #55 was not provided incontinent care between 9:45 a.m. to 1:35 p.m. LPN #4 said the CNAs checked residents every two hours and assisted them with incontinent care, as needed. LPN #4 said she would talk to the CNAs to make sure they were assisting the resident with incontinent care regularly based on the resident's toileting needs. LPN #4 said she had been away on vacation and had just returned the week of the survey and therefore did not know if Resident #55 required feeding assistance. The director of nursing (DON) was interviewed on 1/26/23 at 5:00 p.m. The DON said Resident #55 should be checked every two hours and as needed for incontinent care and repositioning. The DON said she would provide education to all the CNAs about incontinent care. The DON said she did not participate in the care conference in December 2022, so she was unable to provide any comment as to why Resident #55's care plan was not updated. The DON said the resident was able to feed himself with some meals and required assistance with other meals, especially meals that required cutting. The DON said the restorative nurses and CNAs were required to provide the resident needed assistance during all meals. The DON said she would provide staff education to offer Resident #55 assistance to make sure he was eating his meals. The director of rehabilitation (DOR) was interviewed on 1/26/23 at 5:20 p.m. The DOR said Resident #55's power of attorney (POA) brought up a concern during the care conference on 12/20/22 that the resident had food particles on him every time she visited the resident. The POA believed Resident #55 needed assistance with meals. The DOR said the facility staff should monitor Resident #55 food intake and provide assistance, as needed.

Based on record review, interview, and observation the facility failed to ensure the residents' environment remained as free from accident hazards as possible, for two (#20 and #42) of six residents reviewed for accident/hazards out of 39 sample residentsSpecifically, the facility failed to: -Provide effective monitoring and supervision of Resident #20's safety when the resident left the facility without notifying facility staff of an extended absence;.-Provide health assessment and document the assessment (if done) of Resident #20 upon the resident's return from extended and overnight absences for the facility when the resident was out in the community in potential unsafe conditions unsupervised by facility staff;-Provide Resident #20 with appropriate interventions and supervision to prevent the resident from eloping and being missing for hours before staff became aware of the resident's absence; and, -Ensure Resident #42 had a safe and appropriate mattress that was a compatible fit for the bed frame; so the mattress was not extending over the bed frame or slipping off the bed frame. Findings include:I. Resident #20A. Facility policy and procedureThe Elopement and Wandering Residents policy, undated, was received from the nursing home administrator (NHA) on 1/27/22 at 6:29 p.m. It read in pertinent part: "This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk."Elopement occurs when a resident leaves the premises or a safe area without authorization ( an order for discharge or leave of absence) and/or any necessary supervision to do so."The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement; implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary."A social service designee will re-assess the resident and make any referral for counseling or psychological/psychiatric consults."B. Resident statusResident #20, age 68, was admitted to the facility on 4/21/21. According to the January2023 computerized physician orders (CPO) the diagnoses include paranoid schizophrenia, major depressive disorder, recurrent, severe with psychotic symptoms, muscle weakness, and difficulty walking. The 11/3/22 minimum data set (MDS) assessment the resident did not participate in the brief interview for mental status (BIMS). Staff assessment of the resident's cognition revealed the resident's memory was ok she was able to recall the season, the location of her room, staffs names and faces, and that she was in a facility. The resident required extensive staff assistance with with transferring, toileting dressing and personal hygiene; and was incontinent of both bowel and bladder. The resident was unable to stand and walk but was independent with a manual wheelchair. The resident reject care daily. Additionally, the resident wandered daily. The resident had some difficulty in new situation and made decisions regarding tasks of daily life with modified independence. The resident had fluctuating disorganized and incoherent rambling thinking; conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. C. Resident interview and observationOn 1/23/23 at 2:18 p.m. during an attempted interview the resident was willing to engage but as she talked her answers became increasingly angry and paranoid; her answers during the interview were not relevant to the questions asked and provided no supportive information. On 1/24/23 at 4:05 p.m., Resident #20 was observed sitting in a manual wheelchair in front of the facility with a handbag around her neck and a rolling luggage; she had a cigarette and lighter in hand. On 1/25/23 at 7:45 a.m., 1/26/2 at 9:18 a.m., and 1/26/23 3:58 p.m., Resident #20 was observed sitting outside the front door of the facility alone smoking. D. Record reviewThe resident's comprehensive care plan for elopement initiated on 9/23/22 and revised on 10/3/22 documented that Resident #20 wandered and was an elopement risk due to a history of leaving the building without notifying staff or signing in or out as per facility policy related to impaired safety awareness. Interventions included distracting the resident away from wandering by offering pleasant diversion, structured activities, food, conversation, television, and books. Activities included toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. -The care focus had not been reviewed or updated since 10/3/22 and the comprehensive care plan did not have a care focus for interventions to provide staff guidance for supervision of Resident #20's whereabouts; when to notify facility leadership of Resident#20's absence; or assessment of risk for the resident to be alone unsupervised in the community panhandling or seeking chemically addictive substances.-Additionally, there was no care focus to address the resident substance use disorder or interventions for staff to follow if the resident left the facility and returned intoxicated. Progress notesResident #20's progress notes were reviewed, the note revealed Resident #20 eloped from the facility on at least 17 occasions between 9/5/22 and 1/26/23 without staff being aware of the resident's location/whereabouts. When staff did notice the resident was not in the building, usually several hours later they did not make attempts to locate the resident or check on the resident's safety. The resident record revealed that the resident found to be hanging out behind local business that were several miles from the facility, was without staff assistance to help the resident care for activity of care needs that she was assessed to need assistance with. The resident was found under the influence of a chemically addictive substance, heavily soiled with urine and feces and disheveled upon her return to the facility. On several occasions the resident's whereabouts was unknown to facility staff for hours at a time. On most occasions and no staff went to check on the resident's well being when they did discover the resident had been missing from the facility for hours at a time; particularly given that the resident was assessed to need long term care services with extensive assistance with activities of daily living tasks such as toileting, transferring, and personal hygiene. Additionally, the resident was known to the facility to have a substance use disorder. There were delays in reporting the resident's absence to leadership and in staff taking action to make sure the resident was in a safe situation and had not been victimized while being out for extended periods of time of up to 24 hours or more and with the potential to have been using chemically addictive substances. Notes revealed that on a couple of occasions the resident was observed to be intoxicated upon her return to the facility. There was no document assessment of the resident substance use or how that would impact her safety when in the community unsupervised for extended periods of time. The facility did not develop and implement interventions to respond to the resident substance use disorder. Progress notes were not detailed and failed to document if the resident was assessed for injuries or condition upon return from being out for hours at a time and overnight on several elopement occasions (see note below for more detail). Cross-reference F740 for the facility's failure to address the resident's mental health needs including substance abuse. Nursing note dated 9/5/22 at 10:50 p.m documented the resident had left the facility due to being upset by staff cleaning her room. The resident did not return to the facility until 11:50 p.m. Nursing notes dated9/6/22 at 12:10 p.m., documented the resident had been out of the building since 6:00 a.m. Nursing note dated 9/6/22 at 5:57 p.m. documented that the resident had been out of the building all day and was located at a shopping center in an extremely poor state of hygiene, and potentially dehydrated. The resident was panhandling and refused to return to the facility. Nursing note dated 9/10/22 at 9:26 p.m. documented that the resident left the facility earlier that morning and the staff had been unable to locate her. The police were called and found the resident in the community. Paramedics returned the resident to the facility. Nursing note dated 9/15/22 at 5:24 a.m. documented the resident left the facility on 9/14/22 and was returned back to the facility by the social services director who had followed her back from the convenience store until she arrived at the facility. The resident arrived rain soaked. Nursing note dated 9/17/22 at 5:38 p.m. documented the resident left the building after breakfast (served daily at 7:30 a.m.) and missed morning medications and still had not returned to the facility at the time the note was written. Nursing note dated 9/18/22 at 3:39 a.m. documented the resident's return. Nursing note dated 9/21/22 at 5:28 a.m. documented that the resident had been out of the facility all night and had been seen panhandling at a shopping center at midnight. The resident had refused to return.-The note did not document who saw the resident, what condition she was in or who attempted to get the resident to return to the facility. Nursing note dated 9/21/22 at 11:51 p.m. documented that the resident was still out of the facility. Nursing note dated 9/21/22 at 3:22 a.m. documented that the resident still had not returned. Nursing note dated 9/23/22 at 3:22 a.m. documented the resident was out of the facility, the resident was not in the building prior to the night shift. Nursing note dated 9/23/22 at 12:52 p.m. documented facility staff contacted police to report the resident missing. -It was not clear based on notes dated 9/23/22 and 9/23/22 if the resident was out of the facility that entire time or if she returned and came back in between the documented notes. Nursing note dated 9/23/22 at 10:27 a.m. documented an adult protective services (APS) report was filed due to the resident being out of the building and not returning. Behavior note dated 9/30/22 at 2:18 p.m. documented Resident #20 had been out of the facility and returned angry and yelling. The resident was slurring words and with dry heaves (almost vomiting). -The note did not indicate how long the resident was absent from the facility and did not indicate if the resident was assessed for condition upon her return. Nursing note dated 10/1/22 at 11:11 p.m. documented the resident had been out of the facility since the afternoon and was still not back.. Nursing note dated 10/3/22 at 12.32 p.m. the resident had left the facility and had returned around noon. The resident had been picked up by paramedics and had been taken to the hospital. Nursing note dated 10/6/22 at 5:50 a.m. documented the resident had been out of the facility until 1:40 a.m. Nursing note dated 10/9/22 at 1:31 p.m. documented the facility reported to the police that the resident had not been in the facility for two days. The police located her but she refused to return to the facility. Nursing note dated 10/9/22 at 5:28 p.m. documented the resident had returned to the facility with her family around 5:30 p.m.-The note did not document if the resident was with family the whole time or if the family went out to find the resident to bring her back to the facility. Nursing note dated 10/26/22 at 4:03 a.m. documented the resident had left the facility on 10/25/22 at 2:00 p.m., as reported by the day shift, without telling staff and the night shift staff had searched for the resident and the resident had not been found on the facility premises at 6:00 p.m. and had not returned at the time of the note. Nursing note dated 11/23/22 at 7:45 a.m. documented the resident left the facility on 11/22/22 at approximately 6:00 p.m. The resident was missing for approximately three hours when she was located and was picked up at 5:00 p.m. at a local Target store (2.2 miles away from the facility per a map application) by facility staff. The resident reported that she had slept at the gas station. -There was no documentation of a nursing assessment of the resident's health upon her return to the facility. A facility reported incident (FRI) report dated 11/27/22, documented the resident left the facility on 11/27/22 around 9:00 a.m. without signing out, and was not identified as missing until 6:45 p.m., later that day. The resident returned to the facility on her own after 14 hours. The staff attempted to perform an assessment but the resident refused to answer questions or allow a skin check. -A facility investigation was performed and unsubstantiated the alleged elopement because the resident failed to follow the pass policy. The resident was educated about signing out of the facility in the log book. The resident's care plan was to be updated. -The facility did not assess staff response to the resident being missing from the facility without staff's knowledge. Nursing note dated 1/2/23 at 4:57 a.m. documented the resident was not in the facility and had not been seen since 9:00 a.m. on 1/1/23 the day before the note was written. A missing person report was filed with the police at 5:00 a.m. on 1/2/23. The social services note dated 1/2/23 at 11:26 a.m. documented the resident was found at a local grocery store (1.9 miles away per a map application) at 9:15 a.m. on 1/2/23. Nursing note dated 1/11/23 at 3:25 a.m. documented the resident left the facility and had not been seen since 12:00 p.m. 1/10/23 the afternoon before. The resident had not signed out of the facility. The director of nursing (DON) was notified and filed a missing person report with the police. The resident was missing for over 15 hours. Preadmission screening and resident review (PASRR)Resident #20's PASRR evaluation dated 8/16/21 documented a behavioral health care provider for psychiatric monitoring, due to behavioral symptoms including mild verbal aggression weekly, moderate suspicion daily, weekly medication refusal. The behavioral health care provider was to assist the facility in psychiatric and behavioral monitoring including assessment as to severity of psychosis/mood symptoms. The PASRR also documented that the resident should continue with individual mental health treatment on a weekly basis to provide behavioral feedback. The behavioral management plan suggested the nursing facility staff, mental health therapist work with the resident on behaviors. Behavior management planOn 8/8/22 Resident #20 was provided a a behavior management plan that documented that Resident #20 had behaviors that interfere with the rights of others including: smoking in her room despite education as to the risks, leaving the facility unaccompanied and staying out past 12:00 a.m., taking things that did not belong to her, refusing care (bathing, medications) and a history of verbal and physical aggression towards others. -The contract went on the read: "You have identified the following areas to assist you with being successful in your interactions with others including: the ability to leave facility ground utilizing the pass program. As a resident of our community you are expected to do the following: not smoking in your room or out front of the facility. Smoking is to occur in designated smoking area only." -There was no mention of the resident use of chemically addictive substances. Psychosocial EvaluationA psychosocial evaluation dated 3/3/22 at 3:15 p.m. documented that Resident #20 was being followed by a specialist for psychological services. The resident had been on an M-1(mental health) hold due to threatening self harm and harm toward staff. The resident hoarded belongings on her person, refused to bathe, urinated on the floor, and refused to take medications. Community safety awareness summaryThe community safety awareness summary on 6/10/22 at 9:42 a.m. documented that Resident #20 was admitted to the facility due to the need for a higher level of care and supervision, needing 24 hour seven day a week care and supervision. Behavioral health clinical treatment plan reviewThe behavioral health clinical treatment plan review dated 3/14/22 documented the individual psychotherapy treatment plan with a frequency of one time per week had a goal for discussing mood and behavior concerns with the resident. Treatment was expected to result in an improvement in condition, emotional, cognitive, social, and behavioral functioning. The therapy was necessary to prevent decline or maintain current level of functioning. A psychiatric subsequent assessment dated 12/13/22 documented Resident #20 had depression, anxiety, agitation, psychosis, paranoia, hallucinations, delusions, confusion, and displayed high risk behavior. Additonal progress notesAccording to the nursing notes between 8/2/22 and 11/9/22 the resident refused care, weights, restorative therapy, blood sugar testing, showers, or medications 17 times. According to the nursing notes Resident #20 displayed aggressive or abusive behaviors on 8/8/22 and 12/12/22. According to the social services note dated 1/12/23 at 3:00 p.m. Resident #20 had an appointment scheduled with social services at 2:30 p.m. but the resident did not attend. F. Staff InterviewsThe director of nursing (DON) was interviewed on 1/25/23 at 9:32 a.m. The DON said that if the staff did not find a resident in their room or elsewhere in the facility staff were expected to check the resident's sign out book to see if the resident signed out. The resident sign out log book asks for the residents name; the time they left the facility; who they went with; when they were coming back, and a phone number to contact them. The DON said if the resident did not come back at the time they said they would be back by; facility staff were expected to call DON or NHA, to report the resident's absence. Facility staff should look in the usual places the resident goes to when they leave the facility. If the resident was not located, facility staff should then contact police. The DON said if Resident #20 went out overnight the resident was usually back by morning; and if the resident was back by morning the staff did not need to do any further searches. The staff provided education to any resident who leaves to facility for extended periods of time education about community safety and instruction about using the resident sign out book. The DON said the facility did not use the wander guard system or any other system for resident monitoring and the facility did not admit any residents who would not be safe out in the community while unsupervised. Registered nurse (RN) #1 was interviewed on 1/25/23 at 3:55 p.m. RN #1 said that most of the doors had alarms except for the door on the 400 hallway, that door leads to the smoking area which is fenced in. RN #1 said that nursing staff was expected to conduct safety checks on residents who were elopement risk every two (hours, and there was always someone at the front desk who could keep track of anyone who left the facility without signing out in the resident signout book. RN #1 said the staff knew who was allowed to leave and who was not able to leave based on prior behaviors. RN #1 said that each resident who was an elopement risk had a place in their medical record where the nurse would document that a visual assessment was performed to ensure residents were in the building. Certified nurse aide (CNA) #4 and CNA #5 were interviewed on 1/25/23 at 4:10 p.m. CNA #4 said Resident #20 did not need supervision when she went outside; the resident kept her belongings with her and was able to go out whenever and wherever she liked. The CNAs said Resident #20 liked togo to the local convenience store just up the block; staff were not required to follow the resident around. The receptionist/admissions director (AMD) was interviewed on 1/26/23 at 4:20 p.m. The AMD, said the facility had a list of residents who were elopement risks that was kept at the desk; Resident #20 was on that list. RN #1 was interviewed on 1/26/23 at 4:29 p.m. The nurse said there had always been a problem with Resident #20 going out the front door, and leaving the facility for long periods of time. The DON was interviewed again on 1/26/23 at 5:40 p.m. The DON said on 11/23/22 she received a call from the nurse reporting Resident #20 was not in the building. The nurse informed the DON they had checked the sign out binder, checked the residents room, and the perimeter of the building and the resident was not present. The staff drove around the neighborhood to search for the resident at the usual places the resident liked to go but they did not find the resident. The DON said the resident liked to go to certain stores and restaurants in the neighborhood; the staff drove around looking for the resident and the DON came in drove around looking and widened the search area. The resident was not located at any of the regular locations so the staff called the police to file a report. The police put out the BOLO (Be On Look Out) for the resident and were also searching for the resident. The resident was well known to the police; they have brought her back many times in the past. Sometimes the police would follow the resident to make sure she got back safely rather than pick her up. The DON said monitoring Resident #20's whereabouts was the residents would sign out in the resident sign out book prior to leaving the facility. The DON said Resident #20 was alert and knew what she was doing. Upon the resident's return, the resident was able to tell staff where she had been and who she had talked to. The DON said Resident #20 recently agreed to have an Apple Air Tag (GPS device) placed on her wheelchair. The DON said the facility had made an airplane style luggage tag with the device inside for the resident to put on her wheelchair. The resident chose instead to place the GPS device in the rolling luggage bags she kept with her at all times no matter when she was in the facility or in the community. Facility staff checked that the device was actively working on a regular basis and it was still showing active in the resident's rolling bag. The DON said the GPS device would not alert staff when the resident left the facility, however when staff recognized the resident was not present in the facility they could check the device for the resident's GPS location and go search for her. The device's location services were limited to being connected to only one iphone device. The facility made a decision to install the device location service on the (personal) call phone of the director of rehabilitation (DOR), because the facility did not have access to a facility iphone. The DON said if the resident goes missing the facility staff would have to call the DOR and ask the DOR to activate the device location services and give the facility staff the location of the GPS tracking device.-The DOR was not in the facility 24 hours seven days a week and the facility did not have a backup to access the resident GPS location device if staff could not reach the DOR after work hours or if the DOR was in a cell phone dead zone. The DOR was interviewed at 5:41 p.m. on 1/26/23 The DOR said the GPS device could only be registered on one device (iphone) with an Apple alert system. If the resident eloped and went missing nursing staff would call the DON; the DON would call him; and then he would look up the resident location on the location system. The facility started using the GPS location device on 11/28/22 with the resident's permission. The DOR said Resident #20 had been out of the facility but not longer than four hours.-The DOR's statement that the residenthad not been out of the facility for longer than four hours was not accurate (see nursing note above). The DOR said the staff conducted checks on Resident #20 at 6:00 a.m., 12:00 p.m., 6:00 p.m. and 12:00 a.m. The DOR said the cold weather was keeping the resident in the building, the staff told the resident that it was staying really cold outside and she needed to stay inside where it was warm. III. Resident #42A. Resident status Resident #42, younger than 65 years old, admitted on 1/27/21. According to the January 2023 computerized physician orders (CPO), the diagnosis included Guillain Barre syndrome (nervous system disorder), paraplegia (paralysis of lower legs) and type two diabetes (blood glucose abnormality). The 1/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. The resident required extensive two person assistance with bed mobility, dressing, toileting, and personal hygiene. The resident required set up assistance for eating. B. Record reviewResident #42 comprehensive care plans revealed Resident #42 refused to get out of bed and was at risk for developing moisture associated skin damage (MASD) and pressure ulcer. -However the resident was getting out of bed with therapy services giving the facility opportunity to adjust the resident bed and correct the continual sliding of the mattress (see therapy information below). Physical therapy (PT) note revealed Resident #42:- On 1/9/23 the resident completed a transfer training from sit to standing with max assistance (from staff);- On1/5/23 resident completed sit to stand training with three repetitions;- On 1/3/23 sit to stand mobility with moderate assistance of two (staff);- ON 12/29/22 resident was trained on the sit to stand from bed with assistance of two staff for two repetitions. Occupational therapy note dated 1/26/23 revealed assessment of patient mattress being partially askew (crooked) from bed frame upon entering the room. C.. Observations and interview On 1/23/23 at 2:37 p.m. Resident #42 was observed in bed. Resident #42's mattress was observed hanging off the frame on the right side by approximately ten inches and the frame was exposed by approximately four inches on the left side. Resident was laying on his back on an air mattress. Resident #42s body was not centered on the bed frame; he was positioned to the left side of the bed. Resident #42 was interviewed on 1/23/23 at 2:37 p.m. Resident #42 said he was told a few months ago that a new bed would come to accommodate his size and fit the mattress better, but no bed has ever come. On 1/24/23 at 10:00 a.m. Residents #42's mattress was observed hanging off the frame on the right side by approximately 12 inches and the frame was exposed on the left by approximately four inches. Resident #42 was interviewed on 1/24/23 at 1:00 p.m. Resident #42 said "I am afraid to roll in bed for care at times because I feel like I could fall out of bed."On 1/26/23 at 8:26 a.m. the director of rehabilitation (DOR) was interviewed. The DOR said specialty beds could be ordered by therapy or nursing. Beds were selected based on resident need, their weight and height. Specialty beds are audited monthly by the DOR. Residents also got mobility training with new beds. Licensed practical nurse (LPN) #4 was interviewed on 1/26/23 at 8:35 a.m. LPN #4 said Resident #42's mattress would hang to one side. LPN #4 looked at the resident's bed and acknowledged it was not centered on the frame, and the mattress was hanging off on the right side of the bed frame. LPN #4 said the placement of the mattress on the bed frame was a safety hazard for the resident due to the mattress hanging off the bed and the mattress not being supported. LPN #4 was interviewed on 1/26/23 at 11:10 a.m. LPN #4 acknowledged the mattress was hanging about 10 inches to the right off of the bed frame and frame exposed on the left five inches so that the right side of the mattress was not supported by the frame. LPN #4 said it took three to four staff members to get the resident mattress re-centered, but it needed to be done because when Resident #42's mattress was not centered and it could be dangerous for him. LPN #4 said Resident #42 could roll off the bed and get hurt. LPN #4 said Resident #42 has been complaining about his bed for a couple of months now about the bed not fitting properly to him. LPN #4 reviewed Resident #42's CPO and acknowledged the resident had a physician's order as follows: Specialty mattress settings: air mattress check function and setting and adjust, if needed every shift for routine monitoring. LPN#4 said this order reflects the mattress function and being inflated properly. This order would not prompt the nurse to look at the positioning of the mattress or fit on the frame of the mattress. The director of nursing (DON) was interviewed on 1/26/23 at 4:14 p.m. The DON said depending on a resident's individualized needs, specialty beds could be ordered either by nursing or the therapy department. Specialized beds have several factors taken into consideration like a person's height, weight, mobility, skin concerns, nutrition and hydration. The DON said a resident needed to be safe in bed and also feel safe while in bed. If a resident was not safe in bed they could be injured. D. Additional informationsOn 1/27/23 at 6:29 p.m. the clinical chief office (CCO) provided the following documents: An updated care plan for Resident #42 documenting the resident he "prefers to keep his bed mattress hanging over the frame of his bed in an elevated position, despite education as to the potential risks like falling, contusions, skin breakdown" revised on 1/27/23.-The revised care plan did not document why the resident wanted the mattress hanging over the bed frame or what interventions the facility planned to implement to keep the resident safe and free from being injured while lying (for extended periods of time), in a bed where the mattress did not properly fit the bed frame; where the mattress was hanging off the bed frame, and while the mattress continually slid around and off the bed frame. A durable medical equipment training dated 11/11/22 which read in part:"If durable medical equipment is broken or not fitting properly such as; bed frame broken/not working properly, mattress not fitting bed frame/or secured to bed frame staff are to notify nurse/nurse supervisor/DON/ administrator/maintenance immediately in the event that any of the above occur."

Based on record review, observation, and interview the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#20) out of one resident reviewed for a person-centered care plan that supports the resident's behavioral health needs, out of 39 sample residents. Specifically, the facility failed to:-Develop and follow a process to ensure a resident with a substance abuse history was properly monitored for unsafe addicting chemical substances use;-Ensure the facility staff monitored the resident for chemical substance withdrawals and documented concerns when the resident presented with intoxication; and, -Provide a person centered care plan to address Resident #20's mental health needs related to substance use disorder for monitoring and assessment when the resident was actively using an addictive substance, that include and support identified behavioral health care needs. Findings includeI. Facility policy and procedureThe Behavioral Health Services policy, undated, was received from the nursing home administrator (NHA) on 1/27/23 at 6:29 p.m. It reads in pertinent part: "It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning."Mental Disorder is a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects dysfunction in the psychosocial, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. "Substance use disorder (SUD) is defined as recurrent use of alcohol and/or drugs that cause clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. "Behavioral health encompasses a residents whole emotional and mental well-being, which includes but is not limited to, the prevention and treatment of mental and substance use disorders."The facility will ensure that necessary behavioral health care services are person-centered."Conditions that are frequently seen in nursing home residents and may require the facility to provide specialized services and supports based upon residents individual needs include but are not limited to: schizophrenia-is a serious mental disorder that may interfere with a person's ability to think clearly, manage emotions, make decisions and relate to others."II. Resident #20A. Resident statusResident #20, over the age of 65, was admitted to the facility on 4/21/21. According to the January 2023 computerized physician orders (CPO) the diagnoses include paranoid schizophrenia, major depressive disorder, recurrent, severe with psychotic symptoms, muscle weakness, and difficulty walking. The 11/3/22 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) of 15 out of 15. The resident was independent and wandered daily. III. Observations On 1/23/23 8:51 a.m. the resident was observed sitting in the doorway of her room yelling and swearing to herself. On 1/23/23 between 1:27 p.m. and 1:48 p.m. the resident was observed sitting in the lobby with her coat and bags. At 3:32 p.m. the resident was sitting outside of the NHA's office. On 1/24/23 at 5:10 p.m. the resident was observed sitting outside the NHA's office using swear words and yelling that she wanted her money, the resident was visibly agitated and upset. After a couple minutes of yelling, the corporate consultant came out of the front office to talk with the resident, but the resident continued to yell about her money. There were no other staff present to address the resident. IV. Record reviewResident #20'sprogress notes were reviewed, the note revealed Resident #20 eloped from the facility on at least 17 occasions between 9/5/22 and 1/26/23 without staff being aware of the resident's location/whereabouts. When staff did notice the resident was not in the building, usually several hours later they did not make attempts to locate the resident or check on the resident's safety. On several of the elopement events documented in nursing notes the resident was missing from the building for 12 or more hours without staff being aware of where she was or whom she was with. The resident's 1/3/22 MDS assessment revealed the needed extensive assistance with activities of daily living tasks such as toileting, transferring, and personal hygiene. The resident record revealed that the resident found to be hanging out behind local business that were several miles from the facility, was without staff assistance to help the resident care for activity of care needs that she was assessed to need assistance with. The resident was found under the influence of a chemically addictive substance, heavily soiled with urine and feces and disheveled upon her return to the facility.-The facility did not develop a care plan focus for the resident elopement behaviors driven by a desire to panhandle and seek out chemically addicting substances. Their comprehensive care plan failed to implement interventions to respond to the resident being in unsafe environments and how staff should respond to make sure the resident does not become a victim of a crime or how to monitor and assess the resident when she is found to be under the influence of a chemically addicting substance. Progress notes were not detailed and failed to document if the resident was assessed for injuries or condition upon return from being out for hours at a time and overnight on several elopement occasions and did not even give detail on the duration of the resident's absence. Cross-reference F689 for accident/hazards. Comprehensive care planThe resident care plan revealed a care focus for the resident's behaviors, initiated on 1/8/22 and revised on 1/8/22. The care focus documented that Resident #20 has behaviors including verbal agitation, anger, anxiety, yelling, screaming, physical aggression, manipulative behaviors, and making false accusations. Interventions include administer medication as ordered, caregivers to provide opportunities for positive interaction, attention, and frequent checks as needed when incidents occur. The resident's care plan also revealed a care focus for refusal of care assistance initiated on 1/5/22 and revised on 1/5/22. The care focus revealed that Resident #20 was sometimes resistant to care. This was attributed to the resident's diagnosis of paranoid schizophrenia, manipulative behaviors, memory loss and depression. The care focus revealed the resident could be resistant toward toileting, bathing, changing her clothes, hygiene tasks, and medications. The care plan documented that the resident was unable to transfer herself and was incontinent; when in public without staff to assist the resident would urinate so much that it went through her clothing and out of her wheelchair. Sometimes this occurred in the facility when the resident refused to let staff help her get cleaned up. Interventions include allowing the resident to make decisions about treatment regime, to provide a sense of control. -The comprehensive care plan failed to document a care focus for the resident use of chemical addicting substance or the resident's elopement from the facility and behaviors to seek out chemically addiction substance for personal use. Cross-reference to F689. Preadmission screening and resident review (PASRR)Resident #20's PASRR evaluation dated 8/16/21 documented a behavioral health care provider for psychiatric monitoring, due to behavioral symptoms including mild verbal aggression weekly, moderate suspicion daily, weekly medication refusal. The behavioral health care provider was to assist the facility in psychiatric and behavioral monitoring including assessment as to severity of psychosis/mood symptoms. The PASRR also documented that the resident should continue with individual mental health treatment on a weekly basis to provide behavioral feedback. The behavioral management plan suggested the nursing facility staff, mental health therapist work with the resident on behaviors. Behavioral health clinical treatment plan reviewThe behavioral health clinical treatment plan review dated 3/14/22 documented the individual psychotherapy treatment plan with a frequency of one time per week had a goal for discussing mood and behavior concerns with the resident. Treatment was expected to result in an improvement in condition, emotional, cognitive, social, and behavioral functioning. The therapy was necessary to prevent decline or maintain current level of functioning. A psychiatric subsequent assessment dated 12/13/22 documented Resident #20 had depression, anxiety, agitation, psychosis, paranoia, hallucinations, delusions, confusion, and displayed high risk behavior. -The resident was currently not seeing the mental health provider; the resident had two documented visits with the mental health provider and her substance abuse was not addressed. V. Staff InterviewsCertified nurse aide (CNA) #4 and CNA #5 were interviewed on 1/25/23 at 4:10 p.m. CNA #4 said that Resident #20 left the facility and went wherever she wanted to go, staff did not stop her from leaving. Registered nurse (RN) #1 was interviewed on 1/26/23 at 4:29 p.m. The RN said that Resident #20 was accustomed to moving around with her belongings with her at all times and that the resident had once been verbally aggressive at the nurses station with another resident over a use of the telephone. The NHA was interviewed on 1/26/23 at 6:40 p.m. The NHA said the resident left the building on several occasions without notifying facility staff. The resident was gone for long periods of time and the staff sometimes had to go out and search the neighborhood for the resident. The NHA said the resident had the right to leave the facility, and acknowledged the resident was sometime intoxicated upon her return. The nursing staff educated the resident about the safety of leaving the facility but the resident was not cooperative. The NHA acknowledged the facility had not found any effective interventions to prevent the resident from substance use and acknowledged it would be beneficial to have a conversation with the nursing staff about methods to monitor the resident's location and methods to monitor the resident when she returned intoxicated.

Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent for two residents (#29 and #45). Specifically, the facility had a medication error rate of 7.41%, which was two errors out of 27 opportunities for error. Findings includeI. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication."According to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed.(2020), Elsevier, St. Louis Missouri, pp. 608. "Medication errors occur when pills need to be split. Studies show that the accuracy of split tablets is questionable even if a tablet is scored."II. Facility policyThe Medication Administration policy, undated, received from the chief clinical officer (CCO) on 1/27/23 at 6:29 p.m. revealed in pertinent part, "medications are administered in accordance with professional standard of practice. Review medication administration record (MAR), identify the medication to be administered, compare medication source to MAR."III. Observations and interviewsOn 1/25/23 at 9:16 a.m. licensed practical nurse (LPN) #1 was observed preparing medications for Resident #29. Resident #29's physicians order read as follows: give two Senna (used for constipation) 8.6 milligrams (mg). LPN #1 dispensed two senna plus (sennoside and docusate sodium combination drug used for constipation) 8.6-50 mg into the medication cup. LPN #1 was ready to take the medication to the resident when the LPN was asked to review the medication order. LPN #1 compared the medication bottle to the resident's MAR and said the medication administered was the correct medication ordered (Senna 8.6 mg). LPN #1 failed to take into consideration the medication administered senna plus contained 50 mg of docusate and it was not the correct medication ordered (see order written above). The minimum data set coordinator (MDSC) was by the medication cart and educated LPN #1 about the specific differences between senna and senna plus and advised LPN #1 to dispense the correct senna medication tablets as the combined senna plus medication was not what the resident physician ordered for Resident #29. The correct medications were then administered to the resident. On 1/25/23 at 9:20 a.m. LPN #1 was observed preparing medications for Resident #45. Resident #45's physicians order read as follows: Cyanocobalamin (vitamin B12) 250 micrograms (mcg). LPN #1 was unable to find the correct dose of the medication and requested the MDSC go to the medication storage room to look for the correct dose. MDSC returned and advised LPN #1, the facility only had 100 mcg tablets in the storage room. The assistant director of nursing (ADON) was consulted by LPN #1 and asked what could be done to complete the dose administration. The ADON advised LPN #1 to use the three 100 mcg tablets on hand and cut one tablet in half, dispose of one half the tablet and it would make the 250 mcg dose. LPN #1 then dispensed three 100 mcg tablets, cut one in half and placed two and a half tablets into the medication cup for the resident. LPN #1 disposed of the other half tablet into the drug buster. The LPN then administered the medication to the resident. The cyanocobalamin tablets were not prescoured to indicate it could be cut in half. LPN #2 was interviewed on 1/26/23 at 11:05 a.m. LPN #2 said the cyanocobalamin tablet should not be cut in half as the tablet was not scored. If a tablet was not scored the resident may get too much or too little medication then ordered. The director of nursing (DON) was interviewed on 1/26/23 at 12:22 p.m. The DON said nurses were not to cut tablets in half unless they are scored. If they are not scored the resident may not get the correct dose. If the correct dose was not available a request should be sent to the pharmacy to obtain the correct dose.

Based on observation and interviews the facility failed to ensure medications and biologics were stored and labeled properly on two of four medications carts and one of two medication storage rooms. Specifically, the facility failed to ensure:-Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; -Vials of tubersol (used to test for Tuberculosis) were labeled appropriately with open dates;-Ensure the treatment cart was kept free from expired wound dressing supplies; and, -Medication carts were kept clean and free of loose pills. Findings include:I. Manufacturer recommendationsAccording to the Humalog package insert, retrieved 1/30/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf "In-use humalog vials, cartridges, pens, and humalog KwikPen should be stored at room temperature, below 86°F (30°C) and must be used within 28 days or be discarded, even if they still contain humalog. Unopened humalog should be stored in a refrigerator." According to the glargine insulin package insert, retrieved 1/30/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf " when not in use store in refrigerated temperatures of 36 to 46 degrees F. When in use, it can be kept at room temperature for up to 28 days."According to the Tubersol package insert, retrieved 1/30/22 from: https://www.fda.gov/media/74866/download, "A vial of tubersol which has been opened and in use for 30 days should be discarded."II. Facility policy and procedureThe Medication Storage policy, undated, received from the chief clinical officer (CCO) on 1/27/23 at 6:29 p.m. It revealed in pertinent part, "All drugs and biologics will be stored in the pharmacy and/or medications rooms according to the manufacturer's recommendations. In locked compartments like medication carts, cabinets and refrigerators under the proper temperature controls."III. Observations and interviewsOn 1/25/23 at 1:30 p.m. the treatment cart for the west side hall was reviewed. There were 14 purocol (collagen dressing for wounds) dressings that expired in March 2022; and one Hydrofera blue (wound dressing) that expired July 2021. Registered nurse (RN) #1 was interviewed at 1:39 p.m. RN #1 said expired dressings should be removed so a nurse did not use it for treatment on a resident. The director of nursing (DON) was interviewed at 1:41 p.m. The DON said the standard for the treatment carts to be reviewed was weekly by unit manager or DON; expired dressings should not be used on a resident; and should be removed from cart when expired. On 1/25/23 at 2:15 p.m. the 500 and 600 hall medication cart was reviewed. The review revealed 56 whole tabs and two half tabs loose in the cart. RN #1 was interviewed at 2:20 p.m. RN #1 said the medication carts were deep cleaned every two weeks by the night shift nurses. On 1/25/23 at 2:30 p.m the 400 hall medication cart was reviewed. It revealed two humalog insulin vials open with no open date on the box or the vial. One insulin glargine vial with no open date on box or vial. One insulin glargine pen injection device was not labeled with no open date. Additionally, there were two and a half loose tablets of medication loose in the cart. RN #1 was interviewed on 1/25/23 at 2:35 p.m. RN #1 said loose medications are to be disposed of in the drug buster (a device to discard medication). Insulins should be dated to know the date they were first accessed. Unopened insulin vials and pens should be stored in the refrigerator until ready to use. RN #1 said she would be checking the medication refrigerator to see if they had any insulin to replace the ones in the medication cart and if not she would contact the pharmacy to order the needed medications. The west medication storage room was reviewed on 1/25/23 at 2:40 p.m. It revealed one vial of open tubersol with no open date. The assistant director of nursing (ADON) was interviewed on 1/25/23 at 2:45 p.m. The ADON said tubersol vials were good for 30 days once accessed and should have an open date written on it. The date would ensure the medication was not used past its use by or expiration date. The DON was interviewed on 1/25/23 at 2:50 p.m. The DON said the medications carts were cleaned by the night shift nurse. Tubersol, insulin vials and insulin injection pens should be dated when opened and accessed to ensure they were not used past the 28 days after being accessed, to ensure the medication was safe for the resident.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in one of one facility kitchens. Specifically, the facility failed to:-Ensure the overall kitchen area were free from hanging dust; and -Ensure serving tables are free from chipped paint. Findings include:I. Professional referenceAccording to the Colorado Department of Public Health and Environment (CDPHE)The Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 2/5/23 from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. "Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues."According to The Colorado Department of Public Health and Environment (CDPHE)The Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 2/7/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, "Cleanability, multi use food-contact surfaces shall be, smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections, free of sharp internal angles, corners, and crevices. -Finished to have smooth welds and joints; durability and strength, cleanability, accuracy, functionality, acceptability accessible for cleaning and inspection by one of the following methods, without being disassembled, by disassembling without the use of tools, or by easy disassembling with the use of handheld tools commonly available for maintenance and cleaning personnel such as screwdrivers, pliers, open-end wrenches, and allen wrenches." II. Facility policy and proceduresThe Sanitation policy, last revised in 2022, was provided by the nursing home administrator (NHA) on 1/26/23 at 2:08 p.m. It read in pertinent part, "It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects. The department shall establish a sanitation program for food services based on applicable state and federal requirements. "The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations."C. ObservationsOn 1/23/23 at 10:00 a.m. the initial kitchen tour was conducted and the following was observed:-Beside the food preparation area and the cooking stove a hand sanitizer dispenser by the wall was covered with dirt, dust, and large particles of a white colored debris.-The post hooks above the stove had hanging cobwebs.-The upper wall above the kitchen stove had dirt and cobwebs hanging from the top leading to where cooking utensils were hanging.-The entire kitchen had pipes running along the ceiling. The pipes were covered with hanging dust. This included pipes over a food rack with rolls, a tray of soup bowls, the steam prep area, racks with cooking sheets and pans. -There were also multiple power outlet covers that were covered with dust and dirt.-The hanging light fixtures over the food prep areas were covered with dust on the top of the fixtures and along the chains that connected the light fixture to the ceiling. -The three food preparation tables had uneven surfaces with chipped paint. The tables were used for food prep and the bottom shelves stored baking sheets, pans, cutting boards, and other cooking equipment.-There were three food preparationtables that had chipped paint with uneven surfaces and there were cooking utensils and equipment being stored on the shelves with chipped and uneven surfaces. The above observation continued through the survey from 1/23/23 to 1/26/23. D. Staff interviewThe dietary manager (DM) and NHA were interviewed on 1/26/23 at 10:20 a.m. The DM said there was a daily and quarterly deep cleaning schedule for maintaining the kitchen in sanitary condition. The DM acknowledged the hanging dust could be problematic and was not sanitary. Once identified during the survey, the DM said he would ensure that the hanging dust would be removed as soon as the last meal of the day was completed. The DM acknowledged the chipped paint on the prep tables needed to be taken care of; and said he would take the tables outside to remove the paint as soon as reasonably possible. The NHA said that she would make sure the kitchen staff were educated on proper kitchen sanitation.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to:-Perform wound care in a sanitary manner for Resident #237; and,-Sanitize multiple use items after use; when providing wound care for Resident #237. Findings includeI. Professional referenceAccording to the Center for disease control (CDC) control and prevention, Hand Hygiene Basics retrieved on 2/2/23 from: http://www.cdc.gov/handhygiene/basics.html (2019), it read in pertinent part, "healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood,body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in a healthcare settings)."According to the Center for disease control (CDC) Core Practices retrieved on 2/2/23 from: https://www.cdc.gov/infectioncontrol/guidelines/core-practices/#anchor_1669138290983 (2022), it read in pertinent part, "Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered. The practices outlined in this document are intended to serve as a standard reference and reduce the need to repeatedly evaluate practices that are considered basic and accepted as standards of medical care. Medications safety if multidose medications are used on more then one patient, restrict the medication to a centralized medication area and do not bring them into the immediate treatment areas like patient rooms."According to the center for disease control (CDC) Implementation of Personal Protective Equipment (PPE) use in nursing homes to prevent spread of multidrug-resistant organisms (MDROs) retrieved on 2/2/23 from: https://www.cdc.gov/hai/pdfs/containment/PPE-Nursing-Homes-H.pdf (7/12/22), it read in pertinent part, "Enhanced Barrier Precautions expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of mulit-drug resistant organisms (MDRO) to staff hands and clothing. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of EBP wound care; any skin opening requiring a dressing." II. Facility policy The Hand Hygiene policy, undated, received from the chief clinical officer (CCO) on 1/27/23 at 6:29 p.m. revealed in pertinent part, "all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. The hand hygiene table indicated hand hygiene to be completed at but not limited to the following intervals; after handling contaminated objects, after handling items potentially contaminated with blood, body fluids, secretions, or excretions, during resident care when moving from contaminated body site to a clean body site."III. Resident #237A. Resident statusResident #237, age 74, was admitted on 1/5/23, according to the January 2023 computerized physician orders (CPO) the diagnosis include Methicillin-resistant Staphylococcus aureus (MRSA a bacterial infection ), hypertension(high blood pressure), and atrial fibrillation (irregular heart rhythm). The 1/9/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview of mental status (BIMs) score of three out of 15. The resident required extensive one person assistance for bed mobility, transfers, dressing, and toileting. He required setup assistance with meals. MDS skin conditions identified at risk for pressure ulcers and identified moisture associated skin damage. Skin treatments provided pressure reduction chair, mattress, turning/repositioning program, application on ointments/medications. B. Treatment orderResident #237's January 2023 CPO documented the following wound care order:"Right lateral ankle wound apply medi honey (wound ointment), calcium alginate (wound dressing), cover with abdominal pad (ABD) and kerlex (rolled gauze) one time a day for infection. Right shin wound care apply medi honey, calcium alginate, cover with abdominal pad and kerlex on time a day for infection."C. ObservationsOn 1/25/23 at 1:18 p.m. the director of nursing (DON) and registered nurse (RN) #1 entered Resident #237 room to provide wound care. RN #1 and DON used an alcohol based hand rub to sanitize their hands. RN #1 pulled a chair from the corner of Resident #237's room and removed personal items from the chair. The DON then placed all the dressing supplies on the unsanitized chair with no barrier pad. RN #1 and DON applied gloves. RN#1 failed to sanitize hands after touching personal items on the chair. The DON sat on the floor, lifted the resident's right pant leg up and removed the resident's right sock. Resident #237 sock was saturated in drainage. The DON's gloves were wet from the wound drainage. There was no date on the dressing. The DON said staff typically did not date dressings. Once the DON removed the old dressing, she used wound cleanser and gauze to clean the wound. The DON touched the wound cleanser bottle with the same gloves that touched the saturated dressing removed. RN #1 then applied a new dressing to the resident's leg using a large multiple dose medi honey tube and directly applied the ointment to the resident's wounds on the skin and then to the ankle wound. She closed tube and placed it back on chair. RN #1 then rubbed the medi honey onto the resident's shin with the same gloved hands that she had on and came in contact with the ointment tube and the unsanitized chair. After the RN removed her gloves, she failed to perform hand hygiene. The DON was still sitting on the floor and she removed soiled gloves and applied clean gloves without performing hand hygiene. RN #1 collected calcium alginate with her bare unwashed hands and cut a piece of the wound dressing pad to cover the shin wound; then she pressed the prepared dressing directly onto the resident's skin. RN #1 then cut another piece of calcium alginate the size to cover the wound on the resident's ankle and applied it directly on the wound with her bare unwashed hands. RN #1 then applied new gloves, without performing hand hygiene and opened two absorbent dressing (ABD) pads and placed them onto the resident's shin and one on his ankle. The DON held the ABD pads in place while RN #1 wrapped the lower leg from below the heel to below the knee with rolled gauze. They failed to bring in tape to secure the dressing. RN #1 exited to retrieve the tape and a new sock for the resident. Upon RN #1's return she failed to sanitize on entrance to the resident room after touching the door and door handle with her bare ungloved hands. RN #1 failed to apply gloves and proceeded to apply tape to the resident wound dressing to hold the dressing in place. RN#1 then handed the DON a new sock. The DON removed her gloves and applied the new sock to the resident. The DON applied hand sanitizer to her hands and exited the resident's room. RN #1 collected all the supplies from the room and returned to the treatment cart. RN #1 did not sanitize her hands on exit from the resident's room. RN #1 returned to the west treatment cart and placed the medi honey, wound cleanser and scissors on the top of the cart. The unsanitized multi resident use medi honey tube was placed into the top drawer of the communal treatment cart; and the unsanitized multi resident use wound cleanser was placed into the bottom drawer of the treatment cart. RN #1 still had not performed hand hygiene; RN #1 then applied gloves and sanitized the scissors just used for the resident's wound care procedure, with a sani cloth wipe (disinfectant wipe) and allowed to air dry before placing the scissors into a plastic bag labeled with the resident's name and placed into top drawer of the treatment cart. IV. Staff interviewsRN#1 was interviewed on 1/25/23 at 1:40 p.m. following wound care provided (above). RN #1 said the medi honey and the wound cleanser were house stock and not resident specific. RN #1 was interviewed on 1/25/23 at 4:01 p.m. RN #1 acknowledged she failed to disinfect the resident's chair or place a barrier pad down before setting up the resident's wound care supplies. RN #1 also acknowledged she did not perform proper hand hygiene when performing the observed resident wound care (see above); failing to perform hand hygiene prior to cutting and applying the wound dressing calcium alginate with bare hands or after removing gloves when moving from dirty to clean tasks; and failed to sanitize the wound cleanser and medi honey prior to placing back into the treatment cart. RN #1 acknowledged she should have disinfected the stock wound care supplies prior to placing them back into the treatment cart. The DON was interviewed on 1/15/23 at 4:05 p.m. The DON said the chair should have been sanitized prior to placing dressing items on it and a barrier pad should have been applied if the surface was used to set up wound treatment supplies, and wound care dressing material should not be touched with bare hands as it could lead to spread of infection. The DON said hand hygiene should be completed between glove changes and acknowledged she failed to perform hand hygiene between glove changes. The DON said the stocked wound cleanser and medi honey ointment were house stock and could be used on any resident; if the resident had an order for those items for wound care. The DON acknowledged that the medi honey ointment and the wound cleanser should have been disinfected prior to replacing them into the treatment cart with other clean dressing products. The DON said she would sanitize the west side cart immediately.